Building the evidence base for school-based child sexual abuse prevention programs in China: Findings from a mixed-methods study

Background
Child sexual abuse (CSA) is a major public health concern and childhood exposure to sexual abuse is associated with a range of adverse physical, psychological, and behavioral consequences. In response, a range of strategies have been developed to prevent CSA. School-based CSA prevention programs are one such approach that has been developed and widely implemented across different countries, to teach children skills and knowledge aimed at enabling them to identify, respond to, and report CSA. Previous systematic reviews and meta-analyses have suggested that these programs are effective in improving participants’ knowledge of CSA and self-protective skills. To date, however, there has been little systematic examination with regard to the intervention components and underpinning mechanisms of school-based CSA prevention programs. As such, we do not currently know which intervention components in these programs appear to be linked to the most significant improvements in participants’ knowledge of CSA and self-protection skills. Identifying predictors for greater program effectiveness and integrating them into interventions is particularly important when delivering such interventions in lower- and middle-income countries (LMICs) facing economic hardship, severe resource restrictions, and service gaps.
China, which is home to the world’s second largest child population and an upper-middle income country with complex development needs, is no exception in this regard. Over the past decade, studies have been conducted to estimate the prevalence of CSA and evaluate the effectiveness of school-based CSA prevention programs in China. However, the development of a primary CSA prevention approach is still in its infancy and there is a paucity of evidence on the development of context-specific school-based CSA programs for Chinese children.
As such, this DPhil thesis aims to fill the evidence gap and contribute to building the evidence base for school-based CSA prevention programs in China. Specifically, this DPhil thesis utilizes an explanatory sequential mixed methods study design and consists of three stand-alone papers. The quantitative strand of the thesis comprises a systematic review and meta-analysis (DPhil Paper I) synthesizing the key intervention components and assessing the predictors of greater program effectiveness in existing school-based CSA prevention programs. The qualitative strand of the thesis (DPhil Paper II) comprises a qualitative study exploring stakeholders’ perspectives about these programs and CSA research in China, and a realist review (DPhil Paper III) to unpack how, for whom, and in what context(s) school-based CSA prevention programs work.
Methods and Results
DPhil Paper I – Methods
Building on the most comprehensive systematic review of this topic, a further systematic review and meta-analysis was conducted to examine the effectiveness of school-based CSA prevention programs. Systematic searches in both English-language databases from September 2014 to October 2020 and Chinese-language databases from inception to October 2020 were conducted. Intervention component analysis was utilized to identify intervention components in existing school-based CSA prevention programs. Meta-regression was performed to identify which of the components were associated with better outcomes.
Results: A total of 31 studies were included with a total sample size of 9,049 participants. Results from meta-analysis suggested that school-based CSA prevention programs are effective in increasing participants’ CSA knowledge as assessed via questionnaires (g = 0.72, 95% CI [0.52-0.93]) and vignette-based measures (g = 0.55, 95% CI [0.35-0.74]). Results from meta-regression revealed that programs with more than three sessions are more effective than programs with fewer sessions. Programs also appear to be more effective with children who are eight years and older than with younger children.
DPhil Paper II – Methods
DPhil Paper II builds on findings from DPhil Paper I and aims to enrich our understanding about stakeholders’ views with regard to school-based CSA prevention programs, and CSA research in China. Semi-structured interviews were conducted with 21 participants in Beijing and a county under Lanzhou City, China. Two authors systematically co-coded the interview transcripts and a thematic analysis was used for the data analysis.
Results: The findings indicated that while CSA prevention programs are on the whole regarded positively by key stakeholders in China, a number of important concerns were raised. Participants also identified factors that have both fostered the implementation of CSA research and prevented researchers from effectively conducting such research. The findings suggested a number of ways in which future school-based CSA prevention programs could be strengthened and adapted to a Chinese context.
DPhil Paper III – Methods
Existing efforts to understand school-based CSA prevention programs in a global and Chinese context mainly focus on the effectiveness of these programs in increasing participants’ CSA knowledge and skills regarding self-protection. No attempt has been made to date, to explore how and in what contexts these programs work. As such, building on the findings from DPhil Papers I and II, a realist review was conducted to explore how, for whom, and in what contexts school-based CSA prevention programs work. An iterative search of English-language and Chinese-language databases was conducted, supplemented with citation tracking to locate relevant literature.
Results: A total of 62 studies were included, from which data were extracted and thematic content analysis were conducted to synthesize data. Five Context-Strategy-Mechanism-Outcome configurations (CSMOs) that contributed to the success of school-based CSA prevention programs were identified, including: tailoring programs to participants’ cognitive developmental levels, repeated exposure of key concepts and skills, utilization of interactive delivery methods and positive feedback, delivery of positive information, and application of the “train-the-trainer” model.
Conclusion
This DPhil thesis provided context-specific evidence regarding school-based CSA prevention programs in China. Findings from both the quantitative and qualitative strands of the DPhil thesis contributed to the development of a comprehensive picture of evidence with regard to school-based CSA prevention programs. Implications for research include integrating factors that contribute to better program effectiveness into the development of school-based CSA prevention programs, improving the reporting of future studies, and strengthening the context-specific evidence base in the field of CSA prevention in China. Implications for practice and policy include engaging the wider community and parents in the CSA prevention process and reducing existing barriers to CSA research implementation and collaboration.

Keywords: child protection
child sexual abuse prevention
child sexual abuse
school-based interventions
Advisor: Barlow, J
Meinck, F