Preventing Child Sexual Abuse Early

This study is aimed to examine preschool teachers’ knowledge of, attitudes about, and training related to child sexual abuse (CSA) prevention in Beijing, China. Two hundred and forty-five preschool teachers were administered the 16-item questionnaire that contained questions on CSA prevention knowledge, attitudes, and teacher training. Results showed that Chinese preschool teachers had limited knowledge on CSA prevention (M = 4.86, SD = 2.12). Less than 5% of the teachers ever attended CSA prevention training programs. Preschool teachers’ training on CSA prevention was the significant factor for their knowledge and attitudes. To help protect children against sexual abuse, there is an urgent need to develop appropriate prevention training programs for preschool teachers in China.


Introduction
Child sexual abuse (CSA) is a widespread public health problem with negative consequences for child victims. Previous studies have showed that the consequences of CSA include a wide range of mental, physical, and social problems, such as chronic pelvic pain, depression, anxiety, behavioral problems, drug abuse, and interpersonal sensitivity (Chen, Dunne, & Han, 2006;Homma, Wang, Saewyc, & Kishor, 2012;Hornor, 2010;Lin, Li, Fan, & Fang, 2011;Maniglio, 2009;Tsutsumi, Izutsu, & Matsumoto, 2012). Although estimates vary depending on the sample and definition of sexual abuse used, research suggests that CSA is not uncommon in China Chen, Han, Lian, & Dunne, 2010;Sun, Dong, Yi, & Sun, 2006;Tang, 2002). In China, there is also no official definition for CSA to date. Most Chinese researchers have chosen to use the World Health Organization's definition for CSA. According to this definition, CSA is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. (World Health Organization, 1999) In a recent cross-sectional study conducted among 2,508 college students from six colleges/universities in Beijing, Hebei, Shanxi, Jiangsu, Shaanxi, and Anhui provinces of China, it was found that the prevalence of unwanted physical contact sexual experiences before the age of 16 years was 11.2% (Chen et al., 2010). Similar to the studies in other cultures, several population-based studies in China have demonstrated that preschool-aged children may also suffer from sexual abuse Chen et al., 2010;Lu, 1997;Sun et al., 2006). In another case-based study of Forensic Medicine, it was reported that the youngest child victim in China was only 2 years old (Lu, 1997).
In response to the growing awareness of the scope and outcomes of CSA in China, Ministry of Education, Ministry of Public Security, Central Committee of the Communist Youth League of China, and All-China Women's Federation jointly issued the "opinions" on CSA prevention in September 2013. The first "opinion" is that all local Education Departments should develop appropriate school-based CSA prevention education programs to inform children, teachers, and parents about sexual abuse knowledge and skills related to CSA prevention (e.g., What is CSA and how to ask for help if the abuse occurs). The first "opinion" may match up with the Strengths Approach Models in child protection education. The Strengths Approach as a model of practice is grounded in a specific way of viewing the world and valuing the child as opposed to espousing the specific knowledge and skills base to be taught (Fenton, 2008).
A solid body of studies has demonstrated that schoolbased programs are able to increase children's knowledge (e.g., knowing personal boundaries and that it is not the child's fault if the abuse occurs) and skills related to CSA prevention (e.g., recognizing, resisting, and reporting inappropriate touch requests; Baker, Gleason, Naai, Mitchell, & Trecker, 2012;Chen, 2012;Chen, Du, & Zhang, 2013;Finkelhor, 2007;Rispens, Aleman, & Goudena, 1997;Topping & Barron, 2009;Tutty, 1997;Weatherley et al., 2012;Wurtele & Owens, 1997;W. Zhang et al., 2014). Especially, recent research has indicated that beginning primary prevention with preschoolers is feasible, and that children as young as 3 years old can learn to recognize inappropriate touching and acquire self-protection skills (Kenny, Wurtele, & Alonso, 2012;Wurtele & Owens, 1997;W. Zhang et al., 2014). In the United States, Wurtele and Owens (1997) employed data from five studies with preschool-aged children and found that preschool-aged children who had participated in a 5-day Behavioral Skills Training (BST) program had significant improvement in their selfprotection skills. In another recent study in China, W. Zhang et al. (2014) found that Chinese preschool-aged children increased their scores on knowledge of sexual abuse and skills related to CSA prevention after participating in a childdirected prevention program.
In the school-based programs, the teacher plays an important role in instructing children about CSA prevention knowledge and self-protection skills (Baker et al., 2012;Kong & Chen, 2012), and the teacher also can provide protective behaviors for young children (Baginsky & Macpherson, 2005). Teachers, especially in children's preschool years, often perform similar caregiving functions as parents (X. Zhang, 2011). For example, in urban areas (e.g., Beijing) of China, preschools usually provide full-day care or education for children 2 to 5 years old. Preschool teachers, especially classroom teachers, usually take the responsibility for feeding children, handling children's daily routines, and teaching children (X. Zhang, 2011). In child protection education using a Strengths Approach, the preschool teacher then would learn to be able to identify and enable their own and children's strengths and resources as a way of addressing child protection issues (Fenton, 2008). Therefore, early childhood teachers' knowledge and understanding of child abuse and protection have far-reaching implications for young children (Feng, Huang, & Wang, 2010;McKee & Dillenburger, 2009, 2012. Given that the teacher plays a professional role that is ideally placed to contribute to CSA prevention, a series of studies with student-teachers or teachers has been conducted in many countries around the world. Many studies have showed that teachers or student-teachers often feel inadequately prepared to handle the issue of child abuse, including CSA (Chen, 2009;Goldman, 2007;Goldman & Padayachi, 2005;Kenny, 2004;Kong & Chen, 2012;Li, 2010;McKee & Dillenburger, 2009;Walsh & Farrell, 2008). For instance, in Queensland, Australia, Goldman (2007) conducted a survey among 81 student-teachers by questionnaire and found that the respondents lacked confidence in their ability to identify CSA and to respond appropriately to suspicions of sexual abuse. Similar findings have been reported in the United Kingdom and in the United States. In a survey of 200 teachers in Miami-Dade county of the United States, Kenny (2004) found that only 14.5% respondents reported being aware of the signs of CSA. In another study conducted among 216 first-year student-teachers in the United Kingdom, it was reported that about 51% of the student-teachers knew how to define and recognize CSA, and that only 13% had the knowledge of causes of CSA (McKee & Dillenburger, 2009).
The findings are similar to that found in China. Previous studies have showed that Chinese teachers had limited knowledge on CSA prevention (Chen, 2009;Han & Chen, 2009;Kong & Chen, 2012;Li, 2010). In a study based in Fuxin city, China, Kong and Chen (2012) found that less than one third of the primary school teachers believed that children usually have no obvious physical signs when sexual abuse occurred and that less than two thirds of the teachers believed that children can be sexually abused by females. In addition, in a study based in Zhejiang province, China, Li (2010) found that less than 60% of the teachers believed that children may be sexually abused by familiar persons (e.g., fathers, mothers, and other relatives). Encouragingly, recent studies have showed that most teachers have positive attitudes toward child-focused CSA prevention in China (Kong & Chen, 2012;Li, 2010). For instance, in a study among 117 teachers in Zhejiang province of China, it was reported that approximately 90% respondents agreed that it is important for teachers to take part in CSA prevention education programs and agreed that teaching students about the knowledge of CSA prevention is important (Li, 2010). In another survey conducted in Fuxin of China, it was found that about 84% of 174 primary school teachers agreed to develop school-based CSA prevention programs (Kong & Chen, 2012).
In China, preschool teachers should have the Teacher's Qualification Certificate (TQC) before they work with preschool-aged children. In a normal college or university in China, the student-teachers receive 2 or 3 years training on child pedagogy and psychology, and preschool teacher preparation in child protection was "minimal." Although some professionals (e.g., school health workers and child protection workers) have advocated that CSA prevention should be started from preschool period in China (Chen, 2009;Chen et al., 2008), yet research with preschool teachers is still very rare. In one study in Zhejiang province of China, it was reported that only one fourth of the teachers came from preschool and that preschool teachers' knowledge on CSA prevention was significantly lower than primary teachers' (Li, 2010). In another study based on qualitative data, Han and Chen (2009) found that only three teachers came from preschools and that the preschool teachers lacked CSA prevention awareness. Previous studies in China, which include preschool teachers, had small sample sizes and lacked system statistical analysis. Until now, we know very little of preschool teachers' knowledge and understanding of issues pertaining to CSA prevention education in China.
In addition, previous studies conducted in the developed countries have indicated that some prevention programs with student-teachers can be effective in improving participants' knowledge on child abuse (including CSA) as well as in enhancing their confidence in dealing with child abuse or sexual abuse (Goldman & Bradley, 2011;Goldman & Torrisi-Steele, 2004;Kenny, 2007;McKee & Dillenburger, 2012). In one exploratory study among 105 student-teachers in the United States, it was reported that student-teachers' posttest scores were significantly higher than pretest scores on knowledge of child abuse (including CSA), after participating in a relatively short web-based training (Kenny, 2007). In the United Kingdom, McKee and Dillenburger (2012) found that student-teachers' knowledge on CSA increases significantly after participation in a child protection training program. It is important to provide CSA prevention training for teachers or student-teachers (Baginsky & Macpherson, 2005;Feng et al., 2010;Goldman & Torrisi-Steele, 2004;Kenny, 2004); thus, researchers should pay more attention to conduct CSA prevention studies with teachers or studentteachers. Few studies have the sample of teachers and very few studies provide the evidence to describe the relationships between teachers' training education and awareness of CSA prevention in China.
Accordingly, the present study had two aims. The first aim is to examine preschool teachers' attitudes and knowledge of CSA prevention as well as their training education on CSA prevention in Beijing, China. Second, this study aimed to explore the associations between teachers' CSA prevention education and their knowledge and attitudes of CSA prevention in China. Findings of the current study will not only point to the importance of sexual abuse prevention education for Chinese preschool teachers but will also reflect on aspects of inadequacy that are of particular relevance to Chinese to facilitate the design of school-based prevention programs.

Procedure
The current study was approved by Peking University Biomedical Ethics Committee. During the school years 2012-2013, a total of 312 preschool teachers who worked with 3-to 5-year-old children were invited to participate in the survey while they attended teacher education workshops offered in their school districts, making this a sample of convenience. After the conclusion of the teacher education workshops, the participants took about 10 to 15 min to complete the questionnaires anonymously and voluntarily in the teachers' workroom. The teachers were asked to complete the questionnaire independently and not to discuss it with others before or during data collection. Definitions of CSA and the survey aims and questionnaire response instructions were explained in the first page. The completed questionnaire was sealed by each participant before returning it to the research group.

Participants
Among this population, 261 preschool teachers participated in this self-administered questionnaire survey and returned their completed questionnaires. Of these, 16 questionnaires were rejected due to the fact that the respondents missed over one third of the questions (11), or they gave clearly fictitious or inconsistent answers (5). A final 245 eligible questionnaires remained. The response rate was 93.9% among the 261 participants who were given the questionnaire (83.7% among the 312 enrolled preschool teachers). The respondents included 240 females (98%) and 2 males (0.8%), with 3 respondents not providing their gender. The participants ranged in age from 17 to 55 years (M age = 28.93, SD = 8.42). Of 244 respondents, 51.2% held a college degree or lower and 48.8% held a bachelor's degree or higher. Seventyseven percent of the preschool teachers worked in the urban area and 23% worked in the rural area in Beijing. The mean number of years teaching in the sample was 8.50 (SD = 8.45, range = 0-36 years).

Measure
The 16-item questionnaire was based on the research objectives and the findings from a series of published studies and reviews (Baginsky & Macpherson, 2005;Chen, Dunne, & Han, 2007;Deblinger, Thakkar-Kolar, Berry, & Schroeder, 2010;Goldman & Bradley, 2011;Kenny, 2004;Walsh, Brandon, & Chirio, 2012). The questionnaire included four sections: teachers' general demographics, and CSA prevention education-related knowledge (e.g., "Preschool-aged children can be sexually abused?" and "Child sexual abuse is the child's fault"), attitudes (e.g., "Are you afraid that CSA prevention education may induce the child to know too much about 'sex?'" and "Do you agree to CSA prevention education curricula should be taught in the preschool?"), and training education (e.g., "Did you ever attend the training program of child sexual abuse prevention education?" and "Did you ever attend the training programs that may include information on CSA prevention?"). There were 9 items on CSA knowledge subscale. Correct responses to each knowledge item were scored 1, while incorrect and "unsure" responses were scored as 0 (range = 0-9). Four items were compiled regarding attitudes toward CSA prevention education. The response choices to the items were simply "agree," "disagree," and "undecided," with "agree" being scored as 1 and "disagree" or "undecided" as 0 (range = 0-4). The teacher training education subscale included 3 items and teachers were asked the following questions: "Did you ever attend the training program of CSA prevention education?" "Did you ever attend any training programs that may include information regarding CSA prevention education?" and "Would you like to attend teacher training programs about CSA prevention education?" (Response options were "yes" or "no"). Affirmative responses were scored as 1 and negative responses were scored as 0 (range = 0-3). Internal consistency analyses of the 16-item questionnaire produced alpha level of .78 in the present study.

Data Analysis
The program Epidata was used for data entry, and the Statistical Package for Social Sciences software was used for data analysis. Frequency, percentage, and mean score of relative indicators were computed to describe the status of knowledge, attitudes, and training of CSA prevention education in preschool teachers. Then, the statistics analysis was performed using the chi-square, independent sample t test, and one-way ANOVA to identify possible associated factors for teachers' knowledge and attitudes of CSA prevention education.

Preschool Teachers' Knowledge of CSA Prevention
As shown Table 1, less than 4% of the preschool teachers believed that there are usually no obvious physical signs when CSA occurred, and only 25% of the teachers believed that children can be sexually abused by females; in addition, less than 40% of the respondents believed that preschoolaged children can be sexually abused and only 50% of the respondents knew that children most often are sexually abused by familiar persons. Not one preschool teacher could provide the correct responses to all nine items of the CSA knowledge subscale. On average, preschool teachers had limited knowledge on CSA prevention (M = 4.86, SD = 2.12). Table 2 shows that some 68% of the preschool teachers agreed that CSA prevention education curricula should be taught in preschools and 66% of the preschool teachers agreed that it is appropriate to develop CSA prevention programs in the local area. But, only one third of the preschool teachers believed that CSA prevention education will help prevent CSA. In addition, 72% of the preschool teachers worried that CSA prevention education may induce children to know too much about "sex" (see Table 2). As a whole, although most of the preschool teachers supported CSA prevention education in China, they lacked confidence in effectiveness of CSA prevention education.

Preschool Teachers' Training Education in Relation to CSA Prevention
About 15% of the preschool teachers ever attended the training programs that may include information regarding CSA prevention education, and less than 5% of the preschool teachers ever attended the training program of CSA prevention education (see Table 3). Encouragingly, a majority of teachers (85%) reported that they would like to participate in CSA prevention training programs. Table 4 displays the associations between demographics variables and teachers' scores on the knowledge, attitudes, and training of CSA prevention. The results indicated that teachers' gender was not associated with differences in knowledge, attitudes, and training. Similarly, teachers' educational level was not significantly related to their scores of the knowledge, attitudes, and training subscales. Results also showed that urban teachers and rural teachers had similar levels on the knowledge, attitudes, and training, and that there were no associations between teaching years and the CSA prevention knowledge, attitudes, and training. Then, we grouped the preschool teachers into two categories as either attending any training programs that may include information regarding CSA prevention education or not attending the training. One-way analyses of variance revealed that there were significant positive associations between training types (yes/no) and the teachers' knowledge (F = 9.22, p = .003) and attitudes (F = 11.79, p = .001). Teachers who ever attended the training programs had higher scores on CSA prevention knowledge (M = 5.81, SD = 2.11 vs. M = 4.68, SD = 2.08) and had more positive attitudes toward CSA prevention education (M = 2.20, SD = 1.02 vs. M = 1.61, SD = .93), compared with the preschool teachers who did not attend the training programs.

Discussion
The findings of this study provide insight into substantial barriers to CSA prevention in preschools in China. Preschool teachers lacked basic knowledge on CSA prevention. Less than 4% of the preschool teachers knew that if CSA occurs, there will be no obvious physical signs, much lower than previous research with Chinese parents (about 28% in Chen et al., 2007) and the research with Chinese primary school teachers (about 30% in Kong & Chen, 2012). The majority of preschool teachers appeared not to believe that preschoolers can be sexually abused, and most teachers were unaware that children most often are sexually molested by a familiar person. In addition, only few believed that females are also on the list of the potential abusers. These findings are consistent with previous studies in China (Chen, 2009;Kong & Chen, 2012) and in other cultures (Goldman & Padayachi, 2005;Kenny, 2004;McKee & Dillenburger, 2009). Teachers lacking CSA prevention knowledge probably find it difficult to quickly identify the CSA incident and provide support for child victims as soon as possible (Baginsky & Macpherson, 2005;Kenny, 2004;Kong & Chen, 2012;Walsh & Farrell, 2008). Moreover, teachers without basic knowledge may not convey the critical CSA prevention information and selfprotection skills (e.g., how to recognize, avert, or disclose sexual abuse) to children (Chen, 2009;Kong & Chen, 2012;Li, 2010). It is also worth highlighting the fact that such a  large percentage of preschool teachers (30%) believed that sexual abuse is a child's fault. It is important to let children know that even if someone does touch their private parts, it is never the child's fault (Tutty, 1997;Wurtele & Owens, 1997). This knowledge is helpful in the child's recovery from the abuse incident (Finkelhor, 2007). If the preschool teacher cannot acquire the knowledge, they would have limited ability to protect a child against sexual abuse. Therefore, to protect children better and supply a safer environment for children, educating teachers, especially preschool teachers, about CSA prevention knowledge is an important part of teacher education in China in future.
Previous research provides strong evidence to support that school-based prevention can be helpful in preventing CSA as a whole (Finkelhor, 2007;Topping & Barron, 2009), and that beginning primary CSA prevention with preschoolaged children is important and feasible (Berrick & Barth, 1992;Finkelhor, 2007;Wurtele & Owens, 1997;W. Zhang et al., 2014). Yet, in the current study, only some teachers (30%) had confidence in the effectiveness of prevention education programs for children and approximately 30% of the preschool teachers disagreed (or undecided) to develop CSA prevention in the preschool. The findings are consistent with the previous studies. For example, in a study based in Jilin province, China, it was reported that about 39% of the student-teachers disagreed to develop sexual health programs in preschools (Tian, 2013). Moreover, in the current study, more than 70% of the preschool teachers worried that the CSA prevention education might induce children to know too much about "sex." In fact, previous studies among preschoolers have shown that young children often report positive feelings about their genitals, including that it was okay to touch one's own private parts (Kenny et al., 2012;Wurtele & Owens, 1997). The findings indicate that not like the teachers in western culture (Larsson & Svedin, 2002), Chinese teachers' attitudes toward child sexuality might not be quite open. One of the reasons is that sex has been a very sensitive topic in Chinese culture for a long time, and preschool teachers may have little confidence in instructing young children on sexual issues openly because of the Chinese tradition of sexual conservatism. Contrary to the stated support for CSA prevention education in preschools, such programs will meet some resistance in China. The findings also suggest that the curriculum for young children in preschools should be designed very carefully to address teachers' sensitivities.
Training educators about appropriate knowledge, behaviors, and skills to deal effectively with CSA is an important part of CSA prevention education (Baginsky & Macpherson, 2005;Goldman & Torrisi-Steele, 2004). In the current study, a majority of the preschool teachers would like to participate in CSA prevention training programs. This is consistent with the research in Fuxin city (Kong & Chen, 2012), and Zhejiang province (Li, 2010), in China. Nevertheless, in fact, most of the preschool teachers never attended the CSA prevention training program (about 95%) and the training program that may include the content of CSA prevention (about 85%) in the current study. In addition, similar to the previous studies with student-teachers in the United States (Kenny, 2007), United Kingdom (McKee & Dillenburger, 2012), and Australia (Goldman & Torrisi-Steele, 2004), the current study found that the preschool teachers' knowledge and attitudes of CSA prevention were significantly associated with their training education. Compared with teachers who never attended the training programs that may include information of CSA prevention, trained teachers had more CSA knowledge and more positive attitudes toward CSA prevention education. The findings suggest that Chinese preschool teachers had poor training on CSA prevention and that teacher CSA prevention education is able to improve teachers' awareness and understanding of CSA prevention. Preschool teachers must be equipped with more accurate CSA knowledge (e.g., outline of CSA statistics, types of CSA, indictors and signs of CSA) and need to be provided education materials to promote teachers' training on child protection (e.g., how to discuss with children about sexuality and personal boundaries, and how to teach children to identify the threat of sexual abuse and to tell an adult if it occurs). According to the Strengths Approach Model, the types of teacher training may include formal lecture presentations, small group and individual tutorials, and workshop sessions supported with texts, readings, a subject website, and discussion board (Fenton, 2008). In summary, in the future, CSA prevention education should be one important part of routine teacher training.
As is true of all investigations, there are some limitations to the investigation that are important to note. First, the participants in the study are only from three school districts of Beijing. Thus, caution should be used in generalizing these findings due to the lack of representative sampling. Second, because the information of the study was cross-sectional, causation between teachers' education and their knowledge and attitudes of CSA prevention cannot be inferred from the current study. Finally, as the teacher questionnaire was designed to be simple, the measurement of the CSA knowledge and training education was relatively superficial. For example, there were only three items on teacher education on CSA prevention, thus the authors could not get specific information on teacher CSA prevention.

Conclusion
Overall, the findings from preschool teachers in the current study indicated that their knowledge about CSA was not strong. These preschool teachers in China appeared to lack sufficient preparation for their child protection role, which may consequently limit their ability to teach the young children an accurate picture of CSA. Encouragingly, most of preschool teachers gave a positive attitude toward participation in CSA training education. The study also has highlighted the need to enhance teacher preparation in this area and that an ideal method of child protection preparation is one that is integrated throughout the teacher training (Baginsky & Macpherson, 2005). As receiving training education is a good way to improve participants' knowledge and attitudes of CSA prevention (Goldman & Bradley, 2011;Kenny, 2007;McKee & Dillenburger, 2012), it is important to develop appropriate training programs for Chinese preschool teachers. In addition, because of the sensitive nature of CSA in China, there must be official support for teachers and trained professionals to cooperate together in developing the prevention curriculum that will meet the needs of young children. Chinese policy makers are aware of the importance of CSA prevention and should start to encourage each social member (e.g., teachers, parents, and professionals) to prevent CSA together.