School-based education programmes for the prevention of child sexual abuse (Review)
Walsh K, Zwi K, Woolfenden S, Shlonsky A
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2015, Issue 4
http://www.thecochranelibrary.com
School-based education programmes for the prevention of child sexual abuse (Review)
T A B L E O F C O N T E N T S
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 1.1. Comparison 1 Protective behaviours, Outcome 1 Protective behaviours, no correction for clustering. . 93
Analysis 1.2. Comparison 1 Protective behaviours, Outcome 2 Protective behaviours, ICC=0.1. . . . . . . . . 93
Analysis 1.3. Comparison 1 Protective behaviours, Outcome 3 Protective behaviours, ICC=0.2. . . . . . . . . 94
Analysis 2.1. Comparison 2 Knowledge, Outcome 1 Questionnaire-based knowledge, no correction for clustering. . 95
Analysis 2.2. Comparison 2 Knowledge, Outcome 2 Questionnaire-based knowledge, ICC = 0.1. . . . . . . . 96
Analysis 2.3. Comparison 2 Knowledge, Outcome 3 Questionnaire-based knowledge, ICC = 0.2. . . . . . . . 97
Analysis 2.4. Comparison 2 Knowledge, Outcome 4 Vignette-based knowledge, no correction for clustering. . . . 98
Analysis 2.5. Comparison 2 Knowledge, Outcome 5 Vignette-based knowledge, ICC = 0.1. . . . . . . . . . 99
Analysis 2.6. Comparison 2 Knowledge, Outcome 6 Vignette-based knowledge, ICC = 0.2. . . . . . . . . . 100
Analysis 3.1. Comparison 3 Retention over time, Outcome 1 Questionnaire-based knowledge, no correction for
clustering. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Analysis 3.2. Comparison 3 Retention over time, Outcome 2 Questionnaire-based knowledge, ICC = 0.1. . . . . 102
Analysis 3.3. Comparison 3 Retention over time, Outcome 3 Questionnaire-based knowledge, ICC = 0.2. . . . . 103
Analysis 4.1. Comparison 4 Harm, Outcome 1 Harm, no correction for clustering. . . . . . . . . . . . . 104
Analysis 4.2. Comparison 4 Harm, Outcome 2 Harm, ICC=0.1. . . . . . . . . . . . . . . . . . . 105
Analysis 4.3. Comparison 4 Harm, Outcome 3 Harm, ICC=0.2. . . . . . . . . . . . . . . . . . . 106
Analysis 5.1. Comparison 5 Disclosures, Outcome 1 Disclosures, no correction for clustering. . . . . . . . . 107
Analysis 5.2. Comparison 5 Disclosures, Outcome 2 Disclosures, ICC=0.1. . . . . . . . . . . . . . . . 107
Analysis 5.3. Comparison 5 Disclosures, Outcome 3 Disclosures, ICC=0.2. . . . . . . . . . . . . . . . 108
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
109
118
119
119
119
120
120
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School-based education programmes for the prevention of child sexual abuse (Review) i
[Intervention Review]
School-based education programmes for the prevention of child sexual abuse
Kerryann Walsh1, Karen Zwi2 , Susan Woolfenden3, Aron Shlonsky4
1Faculty of Education, Queensland University of Technology, Brisbane, Australia. 2 School of Women’s and Children’s Health, University of New South Wales & Sydney Children’s Hospital, Sydney, Australia. 3Sydney Children’s Hospitals Network, Sydney Children’s Community Health Centre, Randwick, Australia. 4Department of Social Work, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia
Contact address: Kerryann Walsh, Faculty of Education, Queensland University of Technology, Victoria Park Road, Brisbane, Queens- land, 4059, Australia. k.walsh@qut.edu.au.
Editorial group: Cochrane Developmental, Psychosocial and Learning Problems Group.
Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 4, 2015.
Review content assessed as up-to-date: 8 September 2014.
Citation: Walsh K, Zwi K, Woolfenden S, Shlonsky A. School-based education programmes for the prevention of child sexual abuse.
Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD004380. DOI: 10.1002/14651858.CD004380.pub3. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Child sexual abuse is a significant global problem in both magnitude and sequelae. The most widely used primary prevention strategy has been the provision of school-based education programmes. Although programmes have been taught in schools since the 1980s, their effectiveness requires ongoing scrutiny.
Objectives
To systematically assess evidence of the effectiveness of school-based education programmes for the prevention of child sexual abuse. Specifically, to assess whether: programmes are effective in improving students’ protective behaviours and knowledge about sexual abuse prevention; behaviours and skills are retained over time; and participation results in disclosures of sexual abuse, produces harms, or both.
Search methods
In September 2014, we searched CENTRAL, Ovid MEDLINE, EMBASE and 11 other databases. We also searched two trials registers and screened the reference lists of previous reviews for additional trials.
Selection criteria
We selected randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of school-based education interventions for the prevention of child sexual abuse compared with another intervention or no intervention.
Data collection and analysis
Two review authors independently assessed the eligibility of trials for inclusion, extracted data, and assessed risk of bias. We summarised data for six outcomes: protective behaviours; knowledge of sexual abuse or sexual abuse prevention concepts; retention of protective behaviours over time; retention of knowledge over time; harm; and disclosures of sexual abuse.
Main results
This is an update of a Cochrane Review that included 15 trials (up to August 2006). We identified 10 additional trials for the period to September 2014. We excluded one trial from the original review. Therefore, this update includes a total of 24 trials (5802 participants). We conducted several meta-analyses. More than half of the trials in each meta-analysis contained unit of analysis errors.
1. Meta-analysis of two trials (n = 102) evaluating protective behaviours favoured intervention (odds ratio (OR) 5.71, 95% confidence interval (CI) 1.98 to 16.51), with borderline low to moderate heterogeneity (Chi² = 1.37, df = 1, P value = 0.24, I² = 27%, Tau² = 0.16). The results did not change when we made adjustments using intraclass correlation coefficients (ICCs) to correct errors made in studies where data were analysed without accounting for the clustering of students in classes or schools.
2. Meta-analysis of 18 trials (n = 4657) evaluating questionnaire-based knowledge favoured intervention (standardised mean difference (SMD) 0.61, 95% CI 0.45 to 0.78), but there was substantial heterogeneity (Chi² = 104.76, df = 17, P value < 0.00001, I² = 84%, Tau² = 0.10). The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.66, 95% CI 0.51 to 0.81; ICC: 0.2 SMD 0.63, 95% CI 0.50 to 0.77).
3. Meta-analysis of 11 trials (n =1688) evaluating vignette-based knowledge favoured intervention (SMD 0.45, 95% CI 0.24 to 0.65), but there was substantial heterogeneity (Chi² = 34.25, df = 10, P value < 0.0002, I² = 71%, Tau² = 0.08). The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.53, 95% CI 0.32 to 0.74; ICC: 0.2 SMD 0.60, 95% CI 0.31 to 0.89).
4. We included four trials in the meta-analysis for retention of knowledge over time. The effect of intervention seemed to persist beyond the immediate assessment (SMD 0.78, 95% CI 0.38 to 1.17; I² = 84%, Tau² = 0.13, P value = 0.0003; n = 956) to six months (SMD 0.69, 95% CI 0.51 to 0.87; I² = 25%; Tau² = 0.01, P value = 0.26; n = 929). The results did not change when adjustments were made using ICCs.
5. We included three studies in the meta-analysis for adverse effects (harm) manifesting as child anxiety or fear. The results showed no increase or decrease in anxiety or fear in intervention participants (SMD -0.08, 95% CI -0.22 to 0.07; n = 795) and there was no heterogeneity (I² = 0%, P value = 0.79; n=795). The results did not change when adjustments were made using ICCs.
6. We included three studies (n = 1788) in the meta-analysis for disclosure of previous or current sexual abuse. The results favoured intervention (OR 3.56, 95% CI 1.13 to 11.24), with no heterogeneity (I² = 0%, P value = 0.84). However, adjusting for the effect of clustering had the effect of widening the confidence intervals around the OR (ICC: 0.1 OR 3.04, 95% CI 0.75 to 12.33; ICC: 0.2 OR 2.95, 95% CI 0.69 to 12.61).
Insufficient information was provided in the included studies to conduct planned subgroup analyses and there were insufficient studies to conduct meaningful analyses.
The quality of evidence for all outcomes included in the meta-analyses was moderate owing to unclear risk of selection bias across most studies, high or unclear risk of detection bias across over half of included studies, and high or unclear risk of attrition bias across most studies. The results should be interpreted cautiously.
Authors’ conclusions
The studies included in this review show evidence of improvements in protective behaviours and knowledge among children exposed to school-based programmes, regardless of the type of programme. The results might have differed had the true ICCs or cluster-adjusted results been available. There is evidence that children’s knowledge does not deteriorate over time, although this requires further research with longer-term follow-up. Programme participation does not generate increased or decreased child anxiety or fear, however there is a need for ongoing monitoring of both positive and negative short- and long-term effects. The results show that programme participation may increase the odds of disclosure, however there is a need for more programme evaluations to routinely collect such data. Further investigation of the moderators of programme effects is required along with longitudinal or data linkage studies that can assess actual prevention of child sexual abuse.
P L A I N L A N G U A G E S U M M A R Y
School-based programmes for the prevention of child sexual abuse Background and review question
School-based education programmes for the prevention of child sexual abuse (Review) 2
School-based education programmes for the prevention of child sexual abuse have been implemented on a large scale in some countries. We reviewed the evidence for the effectiveness of these programmes in the following areas: (i) children’s skills in protective behaviours;
(ii) children’s knowledge of child sexual abuse prevention concepts; (iii) children’s retention of protective behaviours over time; (iv) children’s retention of knowledge over time; (v) parental or child anxiety or fear as a result of programme participation; and (vi) disclosures of past or current child sexual abuse during or after programmes. The evidence is current to September 2014.
Study characteristics
This review included 24 studies, conducted with a total of 5802 participants in primary (elementary) and secondary (high) schools in the United States, Canada, China, Germany, Spain, Taiwan, and Turkey. The duration of interventions ranged from a single 45-minute session to eight 20-minute sessions on consecutive days. Although a wide range of programmes were used, there were many common elements, including the teaching of safety rules, body ownership, private parts of the body, distinguishing types of touches and types of secrets, and who to tell. Programme delivery formats included film, video or DVD, theatrical plays, and multimedia presentations. Other resources used included songs, puppets, comics, and colouring books. Teaching methods used in delivery included rehearsal, practice, role-play, discussion, and feedback.
Key results
This review found evidence that school-based sexual abuse prevention programmes were effective in increasing participants’ skills in protective behaviours and knowledge of sexual abuse prevention concepts (measured via questionnaires or vignettes). Knowledge gains (measured via questionnaires) were not significantly eroded one to six months after the intervention for either intervention or control groups. In terms of harm, there was no evidence that programmes increased or decreased children’s anxiety or fear. No studies measured parental anxiety or fear. Children exposed to a child sexual abuse prevention programme had greater odds of disclosing their abuse than children who had not been exposed, however we were more uncertain about this effect when the analysis was adjusted to account for the grouping of participants in classes or schools. Studies have not yet adequately measured the long-term benefits of programmes in terms of reducing the incidence or prevalence (or both) of child sexual abuse in programme participants.
Quality of the evidence
The quality of the evidence for all outcomes included in the meta-analyses (combining of data) was moderate. Study quality was compromised in about half of the included studies, due to suboptimal data collection methods for study outcomes and inappropriate data analysis.
S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
School-based programme for the prevention of child sexual abuse compared with no intervention or standard school curriculum Patient or population: children (aged 5 to 12) and adolescents (aged 13 to 18)
Settings: primary (elementary) or secondary (high) schools
Intervention: school-based education programmes for the prevention of child sexual abuse
Comparison: no intervention or standard school curriculum
Outcomes Illustrative comparative risks* (95% CI) Relative effect
(95% CI)
Assumed risk Corresponding risk
Control group Intervention group
Number of participants (studies)
Quality of the evidence (GRADE)
Comments
Protective
behaviours (self protec- tive events measured us- ing a stranger simulation test immediately post in- tervention)
390 per 1000 795 per 1000
(559 to 914)
OR 5.71
(1.98 to 16.51)
102
(2 studies)
⊕⊕⊕§
moderate1
Results favoured inter- vention
Questionnaire-
based knowledge (fac- tual knowledge measured by assessing responses to items on a question- naire or multi-choice test, immediately post inter- vention)
(higher score = higher knowledge)
The mean knowledge score measured using a variety of scales across control groups ranged from 3 to 64
The mean knowledge score in the intervention groups was
0.61 standard deviations higher (0.45 higher to 0. 78 higher)
4657
(18)
⊕⊕⊕§
moderate2
Results favoured inter- vention
Vignette-based knowl- edge (applied knowledge measured by assessing responses to hypothet- ical scenarios, immedi- ately post intervention) (higher score = higher knowledge)
Harm (measured using anxiety or fear question- naires)
The mean knowledge score measured using a variety of instruments across control groups ranged from
1 to 42
The mean anxiety or fear score measured using a variety of scales across control groups ranged from 2 to 7
The mean knowledge score in the intervention groups was
0.45 standard deviations higher (0.24 higher to 0. 65 higher)
The mean anxiety or fear score in the intervention groups was
0.08 standard deviations lower (0.22 lower to 0.07 higher)
1688
(11)
795
(3)
⊕⊕⊕§
moderate2
⊕⊕⊕§
moderate3
Results favoured inter- vention
Results showed no in- crease or decrease in anxiety or fear
Disclosures (of past or current child sexual abuse made during or after pro- gramme completion)
4 per 1000 14 per 1000
(5 to 45)
OR 3.56
(1.13 to 11.24)
1788
(3)
⊕⊕⊕§
moderate4
Results favoured inter- vention, however when adjusted for unit of analy- sis errors, this effect dis- appeared
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; OR: odds ratio
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
1Downgraded one level due to imprecision (wide confidence intervals).
2Downgraded one level due to risk of bias: unclear or high risk of bias for randomisation and allocation concealment, and blinding of participants or personnel
3Downgraded one level due to imprecision: 95% CIs around pooled estimate include both effect and no effect.
4 Downgraded one level following sensitivity analysis using ICCs of 0.1 and 0.2 to adjust for the effect of clustering on the results.
B A C K G R O U N D
Description of the condition
Child sexual abuse is a problem of considerable magnitude with short- and long-term repercussions for those victimised. There is no universal definition of child sexual abuse (Macdonald 2001; Trickett 2006). It is a term used to describe a range of experiences involving a child in unwanted, inappropriate, coercive, and un- lawful sexual exploitation by an adult or older child. The World Health Organization (WHO) definition states that “child sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed con- sent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society” (WHO 1999, p 15). Child sexual abuse is categorised along a continuum according to the type of abuse experienced by the child: involving physical body contact (using the term ’contact child sexual abuse’) or not involving physical body contact (us- ing the term “non-contact child sexual abuse”). Contact acts in- clude unwanted touching, fondling, masturbation, frottage, oral- genital contact, and vaginal or anal penetration by a penis, fin- ger or other object. Non-contact acts include making sexual com- ments, voyeurism (’peeping’), exhibitionism (’flashing’), exposing a child to pornography, or making pornography (Finkelhor 2008; Putnam 2003). Recent meta-analyses of data collected from ret- rospective studies of adults in countries and cultures worldwide estimate that 10% to 20% of female children, and 5% to 10% of male children, have experienced child sexual abuse on a spec- trum from exposure through unwanted touching to penetrative assault before the age of 18 years (Barth 2013; Ji 2013; Pereda 2009; Stoltenborgh 2011). These data are likely to underestimate its true prevalence because two-thirds of individuals never disclose their victimisation (London 2005) and most cases go unreported to authorities (Wyatt 1999). The WHO estimates that child sexual abuse contributes to seven to eight per cent of the global burden of disease for females, and four to five per cent for males (Andrews 2004).
Child sexual abuse is associated with adverse psychosocial out- comes such as depression (Roosa 1999), post-traumatic stress dis- order (Widom 1999), antisocial and suicidal behaviours (Bensley 1999), eating disorders (Perkins 1999), alcohol and substance abuse (Spak 1998), post-partum depression and parenting diffi- culties (Buist 1998), sexual re-victimisation, and sexual dysfunc- tion (Fleming 1999). A recent meta-analysis found child sexual abuse was also associated with higher rates of physical health con- ditions, including gastrointestinal, gynaecological, and cardiovas- cular problems, and obesity (Irish 2010). A longitudinal analysis of the association between childhood sexual abuse and educational achievement found a clear linear relationship between increasing severity of child sexual abuse and poorer educational achievement, however the relationship was confounded by sociodemographic
characteristics (e.g. lower maternal age and qualifications) and family functioning variables (e.g. inter-parental violence) known to be associated with child maltreatment (Boden 2007). These consequences are far-reaching into families and communities, with significant costs for institutions in terms of primary and rehabili- tative health care, education and welfare assistance, child protec- tion, and justice system costs (Fang 2012).
Given the retrospective nature of many studies, it is unclear what proportion of survivors go on to experience adverse outcomes and how sexual abuse interacts with other potential risk factors for these adverse outcomes. However, outcomes are known to vary for individuals according to: child age and gender; perpetrator age and gender; the relationship between child and perpetrator; the severity, duration, and/or frequency of the abusive act(s); ac- companying physical or emotional violence and/or force; and the presence of other forms of victimisation (Putnam 2003; Trickett 1997). Sexual abuse has been reported across all socioeconomic and ethnic groups, in both males and females, and perpetrators can include those outside the family as well as within it (Finkelhor 1993); they can be adults or other young people (Turner 2011). However, all children are not at equal risk. Risk factors for child sexual abuse, mainly identified in Western countries, include be- ing female (Fergusson 1996), having a physical or mental disabil- ity (Westcott 1999), living without a natural parent (Finkelhor 1986; Finkelhor 1990), parental mental illness, parental alcohol or drug dependency, and young maternal age (Fergusson 1996; Holmes 1998; MacMillan 2013). Girls appear to be more likely to be sexually abused by family members and boys by non-family members (Finkelhor 1990). The time of greatest vulnerability for child sexual abuse is between 7 and 12 years of age (Finkelhor 1986).
Description of the intervention
This review focuses on the most widely used strategy for the prevention of child sexual abuse: the provision of school-based programmes. Some terms commonly used to describe these pro- grammes include: personal safety education (NCMEC 1999); pro- tective behaviours (Flandreau-West 1984); personal body safety (Miller-Perrin 1990); body safety (Wurtele 2007); and child assault prevention and child protection education (NSW Department of School Education 1998). These programmes target children and adolescents aged 5 to 18 years who are students in primary (ele- mentary) or secondary (high) schools. Support for interventions of this type can be found in Article 19 of the United Nations Con- vention on the Rights of the Child, an international law, which states that governments should “take all appropriate legislative, admin- istrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse” (United Nations 1989).
Education programmes to reduce the occurrence of sexual abuse in children and adolescents were first developed by women’s rape prevention collectives in the United States of America (USA) in the 1970s (Berrick 1991). School-based programmes for the pre- vention of child sexual abuse were rapidly and widely adopted across the USA, assisted in some states by policy mandates, and by the mid 1990s it was estimated that two-thirds of 10- to 16-year olds in the USA had participated in such programmes (Finkelhor 1995c). Schools are a logical choice for teaching children about sexual abuse and its prevention, given their primary function is to educate (Wurtele 2009), and the content of prevention pro- grammes aligns with proscribed school health curricula (Walsh 2013). Hence, schools have emerged as an important primary and secondary prevention setting providing access to large populations of children and adolescents, and relatively economical service de- livery, without stigmatising those who may be at particular risk (Wurtele 2010).
School-based child sexual abuse prevention programmes are typi- cally presented to groups of students and are tailored to ages and cognitive levels. Programme content covers themes such as body ownership; distinguishing types of touches; identifying potential abuse situations; avoiding, resisting, or escaping such situations; secrecy; and how and whom to tell if abuse has occurred (Duane 2002; Topping 2009). Many programmes also stress that the child or adolescent is not to blame. Programmes vary in the number of, and extent to which these themes are covered. There is con- siderable variability in programme delivery formats and teaching methods. Formats such as books, comics, dramatic plays, puppet shows, films, lectures, and discussions have been used with some programmes employing single formats, whereas others use combi- nations of formats (Duane 2002; Topping 2009; Wurtele 1987a). Programme teaching methods have been conceptualised on a con- tinuum from those employing purely didactic approaches, such as a speech, address, or talk, stressing students’ passive listening and acquisition of knowledge, to those employing behavioural ap- proaches, such as modelling, and emphasising students’ active par- ticipation in role-play, rehearsing, or practising new self protec- tion skills (Wurtele 1987a). The duration and frequency of pro- grammes is diverse, with 30 minutes being a common length as this fits with a standard school lesson period. Programmes also vary in their scope with some programmes dealing only with child sex- ual abuse, whereas others integrate these themes into programmes covering broader issues such as general safety education, social and emotional learning, mental health and well being, respectful rela- tionships, and sexuality education. This review focuses only upon interventions in which prevention of child sexual abuse is the main goal.
How the intervention might work
The ultimate goal of child sexual abuse prevention education is to prevent children from ever experiencing abuse. It is also impor-
tant, in cases where children have experienced abuse, for adults to respond quickly and effectively to disclosures, to protect them from further victimisation, and to limit the harm caused. From a public health perspective (Rosenberg 1991), comprehensive ap- proaches to child sexual abuse would involve multiple “preven- tion targets”, including (i) offenders and potential offenders, (ii) children and adolescents, (iii) situations, and (iv) communities (Smallbone 2008, p 47). Although not yet rigorously researched, it appears that school-based programmes may also work to enhance community capacity for sexual abuse prevention by raising aware- ness and delivering information to multiple members of children’s social systems (Duane 2002), via provision of information pack- ages to parents, training for teachers, and family participation in homework activities.
School-based sexual abuse prevention programmes focus on chil- dren and adolescents as prevention targets. They seek to prevent child sexual abuse by providing students with knowledge and skills to recognise and avoid potentially sexually abusive situations, and with strategies to physically and verbally repel sexual approaches by offenders. They endeavour to minimise harm by disseminating messages about appropriate help seeking in the event of abuse or attempted abuse. Interventions aim to transfer the knowledge and skills learned by the child or adolescent in the classroom to real- life situations. Interventions work by capitalising on principles used by classroom teachers, most notably social cognitive learning theories (Bandura 1986; Vygotsky 1986), which stress the social context of learning via the use of instruction, modelling, rehearsal, reinforcement, and feedback (Wurtele 1987a).
Do programmes actually prevent child sexual abuse? There is some evidence from a small group of studies, all of which have been conducted in the USA, that participation in school-based child sexual abuse prevention programmes may decrease the occurrence of child sexual abuse. A study of 2000 10- to 16-year olds found that those exposed to more comprehensive prevention education were more knowledgeable about sexual abuse, more likely to re- port using self protection strategies, more likely to report protec- tive efficacy, more likely to have disclosed their victimisation, and less likely to engage in self blame (Finkelhor 1995a). In a follow- up study, the same individuals were more likely to use the protec- tive strategies they had been taught when confronted with threats and assaults (Finkelhor 1995b). Two studies with high-school (Ko 2001) and college students (Gibson 2000) showed programmes were associated with reduced incidence of child sexual abuse. How- ever these studies harbour the limitations of retrospective recall and have not been replicated with larger and more diverse samples. Research with sexual offenders on their perceptions of the efficacy of children’s self protection strategies in actual abuse situations has found the most effective strategy, reported by three-quarters of offenders, was to tell the offender they did not want to participate in sexual activities. Girls under the age of 12 years effectively used six strategies to avoid abuse: demanding to be left alone, saying they would tell someone, crying, saying they were scared, saying
the they did not want to, and saying “no” (Leclerc 2011). These strategies are key content in school-based child sexual abuse pre- vention programmes (Duane 2002).
Why it is important to do this review
Despite widespread adoption into the school curriculum in many countries, conclusions about the effectiveness of school-based pro- grammes for the prevention of child sexual abuse remain tentative. A number of research synthesis studies have been conducted on this topic in the form of meta-analyses, and systematic and nar- rative reviews (see Table 1: Previous reviews). However the find- ings have been limited by methodological weaknesses in the re- views (e.g. including non-randomised as well as randomised stud- ies; aggregation of diverse outcomes; inappropriate analytical ap- proaches), and in the individual studies included in the reviews (e.g. use of diverse measures; inadequate measurement of pro- gramme fidelity). Additionally, previous meta-analyses have dif- fered in their parameters and have not been replicated. Further, there are historical distinctions in previous reviews, for example, the classification of programmes as primarily active or passive, be- havioural or instructional, that warrant further exploration; this particular distinction seems artificial from an educational perspec- tive because many programmes are, in practice, multifaceted, in- volving a number of teaching methods that are used in integrated ways to deliver programme content (MacMillan 1994). What is needed is a way of identifying, more precisely, the range of child, programme, and study design characteristics that may moderate programme effectiveness.
Evaluations of discrete programmes have been limited to authors assessing and reporting on one or more of five measures: (i) knowl- edge gains, (ii) skills gains, (iii) sexual abuse disclosures, (iv) neg- ative programme effects or harms, and (v) subsequent incidence of child sexual abuse (Smallbone 2008). Consistent with previ- ous reviews, the original Cochrane review found improvements in knowledge and protective behaviours (skills) among children who had received school-based programmes (Zwi 2007). Find- ings on disclosures, harm, and retention of knowledge over time were inconclusive. As this was the most rigorous of the reviews ever conducted (Mikton 2009), and is the only review to include risk of bias analyses, the review also uncovered many methodolog- ical quality issues that warrant ongoing monitoring and review. This is important because the historical controversy over school- based child sexual abuse prevention programmes is concentrated on two outcomes: programmes’ actual effectiveness in preventing child sexual abuse, and concerns over negative programme effects (Finkelhor 2007). Evidence on programmes’ effectiveness with re- gard to the fifth and arguably the most important measure, the degree to which programmes actually reduce the incidence of child sexual abuse, remains a pressing and unanswered empirical ques- tion that requires ongoing review.
It has been suggested that education programmes can cause harm to participating children and adolescents (Taal 1997). This is re- ported to be a common parental concern (Finkelhor 2007; Tutty 1993). Some studies report few or no evaluated negative effects on children (Tutty 1997), whereas others suggest potentially harm- ful sequelae. For example, some children report increased worry following programme participation (Finkelhor 1995c) and older children have been found to experience more negative feelings about non-sexual physical touch (Taal 1997). Therefore, there is a need to rigorously evaluate the evidence for these programmes, both in terms of beneficial and harmful outcomes, and to update the current evidence base on programme effectiveness.
O B J E C T I V E S
To systematically assess evidence of the effectiveness of school- based education programmes for the prevention of child sexual abuse. Specifically, to assess whether: programmes are effective in improving students’ protective behaviours and knowledge about sexual abuse prevention; behaviours and skills are retained over time; and participation results in disclosures of sexual abuse, pro- duces harms, or both.
The original review and the current update do not address whether these programmes or other interventions have reduced the inci- dence and/or prevalence of child sexual abuse at the population level as reported by official records (e.g. from statutory child pro- tection services, law enforcement, primary care, or hospital data), and/or community prevalence data (e.g. from self report surveys repeated at regular intervals). This objective may be incorporated in future review updates as research advances in this field.
M E T H O D S
Criteria for considering studies for this review
Types of studies
We included studies in the original review, and in this update, if they were randomised controlled trials (RCTs), cluster-RCTs, or quasi-RCTs where participants were allocated to the intervention or control group by day of the week, alphabetical order, or other sequential allocation such as class or school. In decision making for inclusion in the review, we focused on features of study design rather than design labels.
Types of participants
The study population comprised children (aged 5 to 12 years) and adolescents (aged 13 to 18 years) attending primary (elementary) or secondary (high) schools.
Types of interventions
Included interventions were school-based education programmes focusing on knowledge of sexual abuse and sexual abuse prevention concepts, or skill acquisition in protective behaviours, or both, compared with no intervention or the standard school curricu- lum. For this update, we excluded: interventions for preventing relationship and dating violence, and sexually coercive peer re- lationships, as these were reviewed in another Cochrane review (Fellmeth 2013); interventions for abduction prevention, the aims of which did not clearly refer to prevention of child sexual abuse; interventions aimed broadly at child protection or personal safety in which it was not possible to isolate the effects of the sexual abuse component; and interventions set entirely in before- and after- school programmes, and early childhood programmes that were not in schools (e.g. day-care settings).
Types of outcome measures
Child outcome measures were:
1. protective behaviours (as measured by an independently scored simulation test);
2. knowledge of sexual abuse or knowledge of sexual abuse prevention concepts, or both (as measured by questionnaires or vignettes);
3. retention of protective behaviours over time;
4. retention of knowledge over time;
5. harm, manifest as parental or child anxiety or fear (as measured by questionnaires); and
6. disclosure of sexual abuse by child or adolescent during or after programmes (as measured by official records of student self reports to school staff, child protective services, or police). Outcomes measured did not form criteria for inclusion in the review. We included studies meeting the inclusion criteria for types of study, participants, and interventions only.
Search methods for identification of studies
Electronic searches
We completed the most recent searches for this review update on 8 September 2014. We incorporated new search terms to describe recent concepts, such as child sexual abuse in online contexts, and the increasing use of terms such as ’exploitation’ and ’victimisation’ by researchers when describing child sexual abuse. Searches for the previous review were completed in August 2006. Where possible,
we focused on finding new studies and identifying older studies added to databases since that time. We added five new sources (two trials registers, two conference proceedings indexes, and one source of open access dissertations), and searched these for all available years (see Appendix 1). Search strategies used for the original review are in Appendix 2. The list of the databases searched and the time period they cover (for the original review and for this review update) are listed below:
• Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 8);
• Ovid MEDLINE(R), 1946 to August Week 4, 2014;
• EMBASE (OVID), 1980 to 2014 Week 36;
• PsycINFO (OVID),1967 to September Week 1 2014;
• CINAHL (EBSCOhost), 1937 to current;
• Social Science Citation Index (SSCI), 1970 to 29 August 2014;
• ERIC (EBSCOhost), 1966 to current;
• Sociological Abstracts (ProQuest), 1952 to current;
• Conference Proceedings Citation Index - Science (CPCI-S), 1990 to 29 August 2014;
• Conference Proceedings Citation Index - Social Sciences & Humanities (CPCI-SSH), 1990 to 29 August 2014;
• Database of Abstracts of Reviews of Effects (DARE) 2014, Issue 3, part of theCochrane Library;
• ClinicalTrials.gov (clinicaltrials.gov/);
• ICTRP (apps.who.int/trialsearch/);
• Australasian Theses (via TROVE) (trove.nla.gov.au/);
• Networked Digital Library of Theses and Dissertations (NDLTD) (via SCIRUS) (ndltd.org/serviceproviders/scirus-etd- search); last searched September 2013, not available in September 2014.
Searching other resources
Other sources of information searched included the reference lists of previous systematic and narrative reviews, and reference lists of included studies. We also searched databases of programme evalua- tions such as the Promising Practices Network (RAND Corporation 2013), and Blueprints for Healthy Youth Development (CSPV 2013). To identify unpublished studies, we circulated requests via email to relevant listservs (e.g. Child-Maltreatment-Research-Lis- terv).
Data collection and analysis
Selection of studies
We conducted selection of studies in three phases. In phase one, we imported titles and abstracts of articles identified in the searches into reference management software and review authors KZ and SW (2007 and 2009 searches), KW and KZ (2013 searches), and
KW and AS (2014 searches) independently screened them. We excluded papers if they clearly did not meet the inclusion crite- ria (i.e. study design, participants, type of intervention, types of comparisons). In phase two, two review authors (KZ and SW in 2007; KZ and KW in 2013; KW and AS in 2014) independently screened the titles, abstracts, and methodology sections of papers appearing to meet inclusion criteria. In phase three, we retrieved the full text of studies meeting all inclusion criteria for data ex- traction and we linked together multiple reports of the same study (e.g. Blumberg 1991). One study was translated into English (Del Campo Sanchez 2006). In cases where agreement could not be reached during screening, we asked a third and fourth review au- thor to independently assess the study against the inclusion crite- ria, and we resolved these cases via discussion and consensus.
Data extraction and management
For this update, we used an electronic data extraction proforma adapted from the checklist of items specified in the Cochrane Hand- book for Systematic Reviews of Interventions (Higgins 2011, Table 7.3a). Two review authors (KZ and SW in 2007) independently performed data extraction. KW repeated data extraction for all 24 studies in 2013, with KZ extracting data independently for new studies in 2013. No data extraction was required in 2014 as no fur- ther studies met the inclusion criteria. The data were entered into RevMan by KZ (Review Manager 4.2 in 2007) and KW (Review Manager 5.2 in 2013), and independently checked for accuracy by a research assistant who was not involved in the review. We resolved discrepancies via discussion. We asked authors of stud- ies in which methods of sequence generation, allocation conceal- ment, or blinding were unclear to provide additional information (see Assessment of risk of bias in included studies). We contacted corresponding authors of studies with insufficient information to allow inclusion in meta-analyses (Harvey 1988; Saslawsky 1986 in 2007; Chen 2012; Kraizer 1991 in 2013) and studies that used cluster-randomisation (Dake 2003; see Unit of analysis issues) via
email with a request to provide additional data. In some instances, authors were able to provide data as requested, however, the ma- jority did not respond to requests. It is not possible to know for sure that all authors received our correspondence.
Assessment of risk of bias in included studies
In the original review, two review authors (KZ, SW) independently assessed each included study. In the review update, the procedure was repeated by one review author (KW) who independently as- sessed risk of bias for all included studies and compared these re- sults to those obtained in the original review, with KZ assessing risk of bias independently for new studies in 2013. KW repeated assessment of risk of bias after a six-month interval. There were no discrepancies. We undertook no ’Risk of bias’ assessment in 2014 as no further studies met the inclusion criteria. Review authors assessing risk of bias were not blinded to the names of the authors, institutions, journals, or results of studies.
We assessed risk of bias using the seven domains on the Cochrane revised ’Risk of bias’ assessment tool (Higgins 2011, Table 8.5a):
(i) random sequence generation; (ii) allocation concealment; (iii) blinding of participants and personnel; (iv) blinding of outcome assessment; (v) incomplete outcome data; (vi) selective reporting; and (vii) other sources of bias. We assessed included studies on each domain as ’low risk’, ’high risk’, or ’unclear risk’ of bias. We made judgements by answering ’yes’ (assessed as low risk of bias), ’no’ (assessed as high risk of bias) or ’uncertain’ (assessed as unclear risk of bias) to pre-specified questions for each domain. We used verbatim text from study reports as support for each judgement of risk wherever possible. We entered information into RevMan and summarised it in a ’Risk of bias’ table for each included study. We generated two summary figures: a ’Risk of bias’ summary (Figure
1) visually depicting judgements across all studies, and a ’Risk of bias’ graph (Figure 2) illustrating the proportion of studies for each risk of bias criterion. Risk of bias domains are detailed below.
Figure 1. ’Risk of bias’ summary: review authors’ judgements about each risk of bias item for each included study
Figure 2. ’Risk of bias’ graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies
Random sequence generation (selection bias)
Description: The method used to generate the allocation sequence was described in sufficient detail to enable assessment of the extent to which it could produce comparable groups. In other words, a rule, based on some chance process, was adequately applied.
Questions: Do study authors make an explicit statement about random assignment? What methods were used to randomly assign participants to intervention and control groups?
Judgement: Was the allocation sequence adequately generated?
Allocation concealment (selection bias)
Description: The method used to conceal the allocation sequence was described in sufficient detail to enable assessment of whether the assignment of participants to groups could have been predicted ahead of time, or during the assignment process. Upcoming alloca- tions were concealed from those allocating participants to groups. Questions: Do the study authors report a method of concealing allocation of participants to intervention or control groups? Is there evidence that the method was potentially unconcealed?
Judgement: Was allocation adequately concealed?
Blinding of participants and personnel (performance bias)
Description: The measures used to blind study participants and personnel (such as programme facilitators or teachers) from knowl- edge of participant intervention or control group membership was
described in sufficient detail to enable assessment of the effects of this knowledge on study outcomes.
Questions: Do study authors reportprocedures for blinding? What specific blinding procedures were used? Was blinding achievable for this type of intervention?
Judgement: Was participant and personnel knowledge of the allo- cation to intervention or control group adequately withheld?
Blinding of outcome assessment (detection bias)
Description: The measures used to blind outcome assessors from knowledge of participant intervention or control group member- ship were described in sufficient detail to enable assessment of the effects of this knowledge on outcome assessment or data collec- tion, or both.
Questions: Do study authors report procedures for blinding of in- dividuals responsible for outcome assessment or data collection, or both? What specific blinding procedures were used? Was blinding achievable for this type of intervention?
Judgement: Was outcome assessors’ knowledge of the allocation to intervention or control group adequately withheld?
Incomplete outcome data (attrition bias)
Description: Complete outcome data are reported for each main outcome in sufficient detail to enable assessment of group differ- ences owing to missing data. Complete outcome data include: at- trition, exclusions, numbers of participants in each intervention
and control group compared with the total number of participants randomised, and reasons for attrition and exclusions.
Questions: Do study authors report attrition, exclusions, numbers of participants in each intervention and control group compared with the total number of participants randomised, and reasons for attrition and exclusions? Are imputation methods explained?
Judgement: Were outcome data adequately addressed?
Selective reporting (reporting bias)
Description: The extent of outcome reporting is sufficient to en- able assessment of the possibility of selective outcome reporting, that is, reporting of some outcomes and not others depending on the nature and direction of results.
Questions: Do study authors report complete outcome data that
match the aims or hypotheses of the study? Do study authors report on all pre-specified outcomes of interest?
Judgement: Are reports of the study free of suggestion of selective outcome reporting?
Other sources of bias
Description: Any other important concerns about bias not ad- dressed in other domains.
Questions: Do study authors report studies in sufficient detail to enable assessment of other important risks of bias (e.g. related to the specific study design, extreme baseline imbalances, or contam- ination effects)?
Judgement: Was the study free of other problems that could put it at a high risk of bias?
Measures of treatment effect
According to the review protocol (Zwi 2003), for individual trials we planned to report the risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CI) for dichotomous outcomes and mean differences (MD) with 95% CI for continuous variables. For the meta-analysis, where possible, we planned to report the RR and RD with 95% CI for dichotomous outcomes and MD with 95% CI for continuous variables. Elsewhere in the protocol (e.g. p 4) odds ratios (OR) are also mentioned.
In the original review, and in this review update, we reported the summary of effect for dichotomous outcomes as an OR with 95% CI. Odds ratios are the statistic used most often in this field. For continuous outcomes this was to be reported as the standardised mean difference (SMD) with 95% CI. Standardised mean differ- ences are appropriate for data synthesis where different outcome measures are used across studies.
Unit of analysis issues
In the review protocol (Zwi 2003), in the case of cluster-RCTs, we planned to adjust for unit of analysis errors where the intr- aclass correlation coefficient (ICC) was available. In the original review, and in this review update, some included studies involved cluster-randomisation at the level of the class, school, or district. However, ICCs were not reported in the studies, nor were they available from study authors. No published ICC for school-based child sexual abuse prevention interventions could be found. We noted that estimates of 0.1 and 0.2 had been used in a review of school-based violence prevention programmes (Mytton 2006), based on the rationale for a published ICC of 0.15 for similar trials (CPPRG 1999b in Mytton 2006), and was considered a plausible yet conservative estimate for the impact of clustering at the class- room level (Schochet 2008). We reasoned that a suitably conser- vative approach would be to use the extremes of ICC 0.1 and 0.2 to calculate a design effect for each cluster-RCT according to the formula given in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section 16.3.4) which is: 1 + (mean cluster size - 1) ICC. We weighted these using the generic inverse variance function and used random-effect models.
Some studies included in this review had multiple intervention groups (Blumberg 1991; Crowley 1989; Dawson 1987; Krahé 2009; Poche 1988). In these cases, we combined all relevant inter- vention groups into a single group, and all relevant control groups into a single group. Using the tools available in Review Manager 5.2, we combined means and standard deviations (SD) for con- tinuous outcomes, and summed sample sizes and number of out- comes across groups for dichotomous outcomes. This enabled us to make comparisons between groups using pair-wise comparisons without risk of double-counting participants.
Dealing with missing data
Requirements for dealing with missing data in Cochrane Reviews have changed since the protocol for this review was written (Zwi 2003). We identified several types of missing data in this review update: missing outcomes, missing summary data, and missing participants. For missing outcomes (e.g. disclosures, adverse out- comes) and missing summary data (i.e. group size totals, means, SDs), we contacted corresponding study authors to provide the outstanding data. Some authors responded helpfully to these re- quests, but data could only be provided for the most recent studies; in other cases, data had been collected over two decades ago and were no longer available. In some cases, authors did not respond. If data remained unavailable after these processes, we excluded these studies from the analyses. For missing participants, we reported the attrition rate wherever possible in the ’Risk of bias’ tables be- neath the Characteristics of included studies table.
Assessment of heterogeneity
We assessed heterogeneity (study diversity) visually and by exam- ining the I² statistic (Higgins 2002), a quantity which describes
the proportion of variation in point estimates that is due to het- erogeneity rather than sampling error. We supplemented this with a statistical test of homogeneity to determine the strength of ev- idence for genuine heterogeneity using a significance level of P value > 0.05.
Assessment of reporting biases
To assess reporting biases, we used two approaches to investigate the relationship between effect size and sample size (Borenstein 2009). We drew fixed-effect forest plots with studies plotted ac- cording to weight (i.e. from most to least precise). We noted any trend towards greater effect sizes at the bottom of the plots indica- tive of bias attributable to missing studies. We also drew fixed-ef- fect funnel plots and checked them for asymmetry indicating the presence of publication bias. In both approaches, trends or asym- metry could be due to publication or related biases (e.g. language bias, availability bias, citation bias) or due to genuine differences between small and large trials (Borenstein 2009; Egger 1997). If a relationship was identified, we further examined differences be- tween studies as a possible explanation along with comparisons by source (e.g. peer-reviewed journals; theses). We planned to con- duct these analyses only when there was a reasonable number of studies (more than 10) and a reasonable amount of dispersion in sample sizes. To reduce the effects of publication bias, in the review update, we made efforts to retrieve the full texts of unpublished trials (e.g. theses). This was made easier by virtue of the fact that many had been made available on electronic databases since our previous searches were conducted and document delivery services had improved.
Data synthesis
We synthesised the data using tools provided in Review Manger (RevMan) 5.2 (RevMan 2012). We assessed the appropriateness of combining studies based on sufficient comparability with respect to: the type of intervention, the type of outcome measures, and the nominated data collection points pre- and post-intervention. We calculated summary statistics (OR for dichotomous data and SMD for continuous data) with 95% CIs for each study. We had intended to use a fixed effect model to combine data in the first instance and then to adopt a random effects model where the I square value exceeded 30%. On further consideration of the differences between the included studies in terms of their setting and intervention, we decided instead to adopt a random effects model to combine data. In all cases, we generated pooled estimates for those studies for which complete statistical data were available or could be derived (i.e. counts and proportions for dichotomous data, and means and SDs for continuous data). Forest plots are presented for each of the pooled estimates. In all cases, we corrected for small sample size bias by using Hedges’ g, which is the default in Review Manager (RevMan) 5.2 (RevMan 2012).
We planned to conduct analyses on the six outcomes nominated above: (i) protective behaviours; (ii) knowledge of sexual abuse or knowledge of sexual abuse prevention concepts, or both; (iii) re- tention of protective behaviours over time; (iv) retention of knowl- edge over time; (v) parental or child anxiety or fear; (vi) disclosure of sexual abuse. To manage subtle differences in outcome mea- surement for (ii) (knowledge), we created subgroups according to the category of measurement instrument used (i.e. questionnaire- based knowledge or vignette-based knowledge). There were insuf- ficient data to proceed with analysis for retention of protective be- haviours over time. No studies measured parental anxiety or fear.
Subgroup analysis and investigation of heterogeneity
In the review protocol (Zwi 2003), we specified the conduct of subgroup analyses to assess the impact of clinically relevant differ- ences: (i) in the interventions (e.g. passive or active involvement of participants); and (ii) between groups of participants (e.g. gen- der, school setting). We did not conduct subgroup analyses be- cause there was insufficient information provided in the included studies about issues that were hypothesised as being relevant for subgroup analysis, for example, studies did not always provide a breakdown of studentgender by intervention group. Further, upon close scrutiny, interventions did not appear to fit an active/pas- sive dichotomy with many having multiple components of both active and passive types (e.g. a video or DVD presentation may at times require children to sit still and listen, and at other times, to respond, chant, sing, or move). Further, there were insufficient numbers of studies to allow for meaningful comparisons. This will be elaborated further below.
Sensitivity analysis
We conducted sensitivity analysis to explore the extent to which results were influenced by risk of bias. We conducted a series of sen- sitivity analyses removing from the analyses studies with high risk of bias for: (i) allocation concealment (selection bias); (ii) blinding of outcome assessors (detection bias); (iii) incomplete outcome data (attrition of over 20%), and (iv) selective reporting (reporting bias). We also conducted sensitivity analyses to determine the im- pact of unit of analysis errors, arising from inadequate adjustment for cluster-randomisation in published results.
Rating the quality of the evidence
We rated the quality of the evidence for our main outcomes ac- cording to methods for rating evidence from randomised con- trolled trial developed by the GRADE working group (http:// www.gradeworkinggroup.org/). For each outcome of interest the evidence started at high quality and could be downgraded to mod- erate, low or very low quality after consideration of the possible impact of risk of bias, imprecision, inconsistency, indirectness and publication bias on our confidence in the effects of intervention.
We have presented results for the primary analyses, quality ratings, and explanations for downgrading any decisions for the following outcomes in a ’Summary of Findings’ table:
• Protective behaviours (self protective events measured using a stranger simulation test immediately post intervention)
• Questionnaire-based knowledge (factual knowledge measured by assessing responses to items on a questionnaire or multi-choice test, immediately post intervention)
• Vignette-based knowledge (applied knowledge measured by assessing responses to hypothetical scenarios, immediately post intervention)
• Harm (measured using anxiety or fear questionnaires)
• Disclosures (of past or current child sexual abuse made during or after programme completion)
R E S U L T S
Description of studies
Results of the search
For this update, we searched the period from August 2006 to September 2014 (see Appendix 1). We identified a total of 12,969 records through database searching and a further 58 records from other sources. After duplicates were removed, we screened 10,218 records and excluded 10,161 records. We retrieved and evaluated the full-text reports of the remaining 57 records for eligibility. Of these, we excluded 43 reports, with reasons reported in the Characteristics of excluded studies table. From the remaining pa- pers, we identified: 10 new included studies, one of which was translated from Spanish into English (Del Campo Sanchez 2006); three additional reports of two included studies from the previous review (Blumberg 1991; Fryer 1987b); and one ongoing study (NCT02181647).
Searches for the original review covered the period up to August 2006 (Appendix 2). The previous review was based on 15 included studies. We excluded one of the previously included studies from this update (Pacifici 2001), because we reassessed it as not meet- ing the eligibility criterion for type of intervention, being focused on sexual violence prevention in the context of dating relation- ships for adolescents (see Fellmeth 2013), rather than explicitly on knowledge of child sexual abuse and its prevention. In total, this updated review reports on a total of 24 unique trials reported in 29 papers (Figure 3).
Figure 3. Study flow diagram for searches 2006-2014
Included studies
The Characteristics of included studies table summarise details for each of the 24 included studies.
Design
Of the 24 included studies, seven were randomised controlled tri- als (RCTs) (Chen 2012; Fryer 1987a; Harvey 1988; Lee 1998; Tutty 1997; Wurtele 1986; e en-Ero ul 2013), 11 were clus-
ter-RCTs (Blumberg 1991; Dake 2003; Dawson 1987; Grendel
1991; Hazzard 1991; Kolko 1989; Krahé 2009; Kraizer 1991; Oldfield 1996; Poche 1988; Wolfe 1986), and six were quasi-RCTs (Crowley 1989; Daigneault 2012; Del Campo Sanchez 2006;
Hébert 2001; Saslawsky 1986; Snyder 1986). Of the quasi-RCTs, all but Del Campo Sanchez 2006 used a Solomon four-group de- sign (Campbell 1963; Solomon 1949).
The unit of randomisation in 14 studies was clusters (classrooms,
schools, or districts). Of these, 11 were cluster-RCTs (as above) and three were quasi-RCTs (Crowley 1989; Daigneault 2012; Hébert 2001). In 10 trials the unit of randomisation was individual school students. Of these, seven were RCTs (as above) and three were quasi-RCTs (Del Campo Sanchez 2006; Saslawsky 1986; Snyder 1986).
Eighteen studies allocated participants to one of two groups, the intervention (school-based sexual abuse prevention programme) and a control group (no programme or wait-listed). Four stud- ies allocated participants to one of three groups, two of which were intervention groups comprising slight variations of the same programme (Krahé 2009; Kraizer 1991), or different programmes (Blumberg 1991; Del Campo Sanchez 2006). Three studies al- located participants to one of four groups, three of which were intervention groups comprising programme variations (Hazzard 1991; Poche 1988; Wurtele 1986).
Location
Sixteen studies were conducted in the USA. Three studies were conducted in Canada (Daigneault 2012; Hébert 2001; Tutty 1997). One study apiece was conducted in China (Lee 1998), Ger- many (Krahé 2009), Spain (Del Campo Sanchez 2006), Taiwan (Chen 2012), and Turkey ( e en-Ero ul 2013).
Sample sizes
The total number of participants randomised in cluster-RCTs ranged from 74 (Poche 1988) to 1269 (Oldfield 1996). The total number of students randomised in trials with individuals as the unit of randomisation ranged from 46 (Chen 2012) to 382 (Del
Campo Sanchez 2006). The number of participants in the 13 clus- ter-RCTs ranged from 74 (Poche 1988) to 1269 (Oldfield 1996), and in the nine RCTs in which participants were randomised as individuals, ranged from 36 ( e en-Ero ul 2013) to 231 (Tutty 1997). Eleven studies (including nine cluster-RCTs and two stud- ies in which participants were randomised as individuals) each in- cluded more than 200 participants.
Settings
All studies were conducted in school settings: 23 in primary (elementary) schools and one in a special school for adoles- cents with intellectual disabilities. Only six studies were under- taken in single grades: one in kindergarten (Harvey 1988), one in grade one (Grendel 1991), two in grade three (Dake 2003; Kolko 1989), and two in grade four (Snyder 1986; e en-Ero ul 2013). All other studies involved various combinations of grades to which there was no discernable pattern. It is possible to cate- gorise the studies into three broad age group blocks as follows: (i) 10 studies with younger participants from kindergarten to grade three (Blumberg 1991; Dake 2003; Fryer 1987a; Grendel 1991;
Harvey 1988; Hébert 2001; Kolko 1989; Krahé 2009; Kraizer 1991; Poche 1988); (ii) eight studies with older participants from grade four upwards (Crowley 1989; Dawson 1987; Del Campo Sanchez 2006; Hazzard 1991; Lee 1998; Snyder 1986; Wolfe 1986; e en-Ero ul 2013); and (iii) six studies with younger and older participants together (Chen 2012; Daigneault 2012; Oldfield 1996; Saslawsky 1986; Tutty 1997; Wurtele 1986).
None of the included studies were conducted in secondary (high) school settings.
Participants
A total of 5802 school-aged participants were included in the 24 trials. Study participants’ mean ages at baseline in the included studies ranged from 5.8 years (Harvey 1988) to 13.44 years (Lee 1998). Authors of eight studies did not report the mean age of participants at baseline (Crowley 1989; Del Campo Sanchez 2006; Fryer 1987a; Hazzard 1991; Kraizer 1991; Oldfield 1996; Tutty 1997; e en-Ero ul 2013).
The proportion of females in the included studies ranged from 45% (Poche 1988; e en-Ero ul 2013) to 55% (Crowley 1989). One trial enrolled female participants only (Lee 1998). Gender- specific proportions were not reported in five studies (Chen 2012; Daigneault 2012; Fryer 1987a; Harvey 1988; Kraizer 1991).
Ethnicity data were reported in 13 studies. Two studies reported 100% Chinese participants (Chen 2012; Lee 1998). In five studies the predominant ethnicity reported was White or Caucasian com- prising 74% to 97% of participants (Grendel 1991; Oldfield 1996;
Poche 1988; Snyder 1986; Tutty 1997). Six studies reported di- verse samples comprising participants from different combinations of White or Caucasian, Black or African, Hispanic, Asian, Mid- dle Eastern, or ’other’ backgrounds (Blumberg 1991; Daigneault 2012; Dake 2003; Dawson 1987; Harvey 1988; Hazzard 1991). In these six studies, the proportion of non-White participants ranged from 32% (Hazzard 1991) to 66% (Dake 2003). One of these studies reported country of birth rather than ethnicity (Daigneault 2012). Ethnicity data were not reported in the 10 remaining stud- ies (Del Campo Sanchez 2006; Fryer 1987a; Hébert 2001; Kolko 1989; Krahé 2009; Kraizer 1991; Saslawsky 1986; Wolfe 1986;
Wurtele 1986; e en-Ero ul 2013).
Parental socioeconomic position was not reported in any study. Non-empirical markers for study locations were used such as “low socioeconomic” (e.g. Daigneault 2012), “middle income” (Grendel 1991; Hébert 2001; Poche 1988), or “lower to middle income” (Saslawsky 1986; Wolfe 1986; Wurtele 1986).
Religious background of study participants was not reported in any study. One study reported data collection in religious schools in Spain (Del Campo Sanchez 2006).
Participants’ school achievement data (e.g. grades) at baseline were notreported in any study. In one study, the Peabody Picture Vocab- ulary Test (PPVT) (Dunn 1981) was used to assess children’s recep- tive and expressive language ability at baseline (Fryer 1987a), and, in another study, Raven’s Standard Progressive Matrices (RSPM) (Raven 1960) was used as a measure of general intellectual ability at baseline (Lee 1998); in this study, participants were adolescent Chinese females with mild intellectual disabilities from four spe- cial schools in Hong Kong, China.
None of the studies enrolled participants on the basis of previously reported abuse.
Interventions
In all 24 trials, interventions focused specifically on child sexual abuse prevention. The targets of the interventions were school- aged children who were taught knowledge of sexual abuse, sexual abuse prevention concepts, and/or skill acquisition in self protec- tive behaviours.
A wide range of previously published, modified, and new pre- vention programmes were used in the trials. Fifteen discrete programmes were identified including: Behavioural Skills Train- ing (BST) (Lee 1998; Wurtele 1986), Good Touch/Bad Touch (Crowley 1989; Harvey 1988; e en-Ero ul 2013), Red Flag/ Green Flag (Chen 2012; Kolko 1989), Child Abuse Primary Prevention Program (CAPPP) (Blumberg 1991), Child Sexual Abuse Prevention Program (Grendel 1991), Children Need to Know Personal Safety Training Programme (Fryer 1987a), ES- PACE (Daigneault 2012; Hébert 2001), Good Secrets/Bad Se- crets (Snyder 1986), No Child’s Play (Krahé 2009), Prevention of Child Sexual Abuse Program (Del Campo Sanchez 2006), Project TRUST (Oldfield 1996), Safe Child Program (Kraizer 1991),
Stop, Tell someone, Own your body, Protect yourself (STOP!) (Blumberg 1991), TOUCH (Saslawsky 1986), and Who Do You Tell? (Tutty 1997).
In two trials, combinations of programmes were used in interven- tions: TOUCH plus BST (Wurtele 1986), and Feeling Yes, Feel- ing No plus Spiderman and Power Pack Comic Book (Hazzard 1991). Four trials did not identify the programme used (Dake 2003; Dawson 1987; Poche 1988; Wolfe 1986).
Contents of or topics covered in the intervention programmes were not consistently reported in the majority of trials. We could discern that programmes were multifaceted with integrated con- tent, including teaching of safety rules ranging from two to six rules (e.g. Grendel 1991; Poche 1988), with the most common be- ing four rules (Blumberg 1991; Fryer 1987a; Lee 1998; Saslawsky 1986; Wurtele 1986), and prevention concepts such as body own- ership, private parts, distinguishing appropriate and inappropriate touches, distinguishing types of secrets, and whom to tell. Pro- gramme content was not detailed in eight studies (Crowley 1989; Dake 2003; Dawson 1987; Del Campo Sanchez 2006; Hazzard
1991; Krahé 2009; Snyder 1986; Tutty 1997). Four studies also included abduction prevention content (Chen 2012; Fryer 1987a; Kraizer 1991; Poche 1988).
Teaching methods were more clearly reported than programme contents. Rehearsal, practice, or role-play was mentioned in 12 studies (Blumberg 1991; Daigneault 2012; Fryer 1987a; Harvey 1988; Hébert 2001; Kraizer 1991; Lee 1998; Poche 1988; Snyder
1986; Tutty 1997; Wurtele 1986; e en-Ero ul 2013), discus-
sion in 10 studies (Blumberg 1991; Grendel 1991; Hazzard 1991;
Hébert 2001; Oldfield 1996; Saslawsky 1986; Snyder 1986; Tutty 1997; Wolfe 1986; Wurtele 1986), and modelling in six stud- ies (Daigneault 2012; Hébert 2001; Lee 1998; Saslawsky 1986; Wurtele 1986; e en-Ero ul 2013). A specific suite of teaching strategies was designated in four studies, including instruction, modelling, rehearsal, social reinforcement, shaping, feedback, and group mastery (Chen 2012; Lee 1998; Saslawsky 1986; Wurtele 1986). The strategy review, which involved revisiting previous con- tent and summarising new content, was nominated in one study (Grendel 1991). Three studies did not report teaching methods (Crowley 1989; Dake 2003; Del Campo Sanchez 2006).
Programme delivery formats were reported in the majority of stud- ies. These included film, video, and DVD formats in 12 stud- ies (Blumberg 1991; Dawson 1987; Grendel 1991; Harvey 1988;
Hazzard 1991; Kolko 1989; Krahé 2009; Poche 1988; Saslawsky 1986; Tutty 1997; Wurtele 1986; e en-Ero ul 2013), plays in three studies (Krahé 2009; Oldfield 1996; Wolfe 1986), and mul- timedia in two studies (Blumberg 1991; Hazzard 1991). Addi- tional resources included songs (Blumberg 1991; Harvey 1988; Krahé 2009), puppets (Blumberg 1991; Harvey 1988), comics (Dawson 1987; Hazzard 1991), a colouring book (Kolko 1989), a storybook (Harvey 1988), and games (Harvey 1988). Three stud- ies did not nominate programme delivery formats (Crowley 1989; Dake 2003; Del Campo Sanchez 2006).
No programmes were delivered electronically in web- or computer- based formats.
The duration of the intervention programmes in the included trials ranged from a single 45-minute session (Oldfield 1996) to eight 20-minute sessions on consecutive days (Fryer 1987a). Fourteen interventions were brief (i.e. less than 90 minutes total duration) (Blumberg 1991; Crowley 1989; Dawson 1987; Grendel 1991;
Harvey 1988; Hébert 2001; Kolko 1989; Krahé 2009; Lee 1998;
Oldfield 1996; Poche 1988; Saslawsky 1986; Wolfe 1986; Wurtele 1986), and the remainder were longer, lasting from 90 to 180 minutes in total duration.
In 17 trials, the effectiveness of prevention programmes was com- pared to that of a wait-listed control group. In the seven remaining studies, the control group interventions were as follows: discus- sion about self concept (Saslawsky 1986; Wurtele 1986); multi- media presentation with no child abuse content (Harvey 1988); fire safety (Blumberg 1991); fire or water safety (Hazzard 1991); attention control programme (Lee 1998); and a game of hangman (Snyder 1986).
All programmes were delivered on school premises and during school hours, apart from one study in which the programme was delivered in the morning, before school classes began (Chen 2012).
Outcomes
In this section we summarise six outcome measures of interest that were addressed in the included studies: (i) protective be- haviours; (ii) knowledge (questionnaire-based knowledge and vi- gnette-based knowledge); (iii) retention of protective behaviours over time; (iv) retention of knowledge over time; (v) harm (man- ifest as parent or child anxiety or fear); and (vi) disclosures. This information is presented in the Characteristics of included studies tables.
Protective behaviours
Three studies measured change in behaviour using a simulated abuse situation and scored the child’s response to the situation (Fryer 1987a; Kraizer 1991; Poche 1988). All three studies used a version of a stranger simulation test to assess children’s self protec- tive skills (i.e. whether children could follow the rules they were taught and not interact if approached by a stranger).
Knowledge
Knowledge outcome measures varied between studies. Knowledge measures used were: (i) questionnaire-based measures, or (ii) vi- gnette-based measures that used scenarios or visual prompts to elicit a response from the child about safe behaviour in that situ- ation. Only one study did not measure knowledge (Poche 1988), and one study used a vignette-based measure only (Krahé 2009). Ten studies used both vignette- and questionnaire-based measures (Blumberg 1991; Chen 2012; Daigneault 2012; Grendel 1991;
Harvey 1988; Hazzard 1991; Hébert 2001; Lee 1998; Saslawsky 1986; Wurtele 1986). Three studies used a second questionnaire- based measure to establish construct validity (Chen 2012; Crowley 1989; Del Campo Sanchez 2006).
The use of more than one measure by studies to assess knowledge gain was not anticipated at the outset of this systematic review. The two types of measures were administered differently. Question- naire-based measures were administered as self completed mea- sures via individual or group administration. Vignette measures were administered by interview. The different methods of admin- istration and the type of response required from the child means that these two outcomes may measure different aspects of children’s knowledge; therefore, we considered them as separate knowledge outcomes.
Knowledge - questionnaire-based measures
Questionnaire-based knowledge measures were used in 21 stud- ies. The Personal Safety Questionnaire (PSQ) was used in six (Crowley 1989; Grendel 1991; Hébert 2001; Lee 1998; Saslawsky 1986; Wurtele 1986). The Children’s Knowledge of Abuse Ques- tionnaire (CKAQ) and versions thereof (CKAQ-R, CKAQ-IIIR) were used in five studies (Daigneault 2012; Del Campo Sanchez 2006; Hébert 2001; Oldfield 1996; Tutty 1997), and the Chil- dren Need to Know Knowledge/Attitude Test (CNTKKAT) was used in two (Fryer 1987a; Kraizer 1981). Other custom-made knowledge scales were also used (Blumberg 1991; Chen 2012; Crowley 1989; Dake 2003; Dawson 1987; Del Campo Sanchez
2006; Harvey 1988; Hazzard 1991; Kolko 1989; Snyder 1986;
Wolfe 1986; e en-Ero ul 2013).
Knowledge - vignette-based measures
Vignette-based knowledge measures were used in 11 studies. The What If Situations Test (WIST), comprising six brief ver- bal vignettes, was used in four studies (Grendel 1991; Lee 1998; Saslawsky 1986; Wurtele 1986). A Chinese version of the WIST was used in one study (Chen 2012), and a French version in an- other (Daigneault 2012). The Touch Discrimination Task (TDT), based on the WIST and comprising seven verbal vignettes, was used in one study (Blumberg 1991), and an unnamed measure comprising 10 picture vignettes featuring good touch and sex- ually abusive touch were used in another study (Harvey 1988). Eight cartoon picture vignettes and stories were used in Krahé 2009. Video vignettes entitled What Would You Do? (WWYD) and comprising six 30-second scenes were used by Hazzard 1991, and an unnamed video measure with five situations was used by Hébert 2001.
Retention of protective behaviours over time
Retention of self protective skills was measured in three studies at one month (Poche 1988), and six months (Fryer 1987a; Kraizer
1991). In Fryer 1987a, no comparison with the control group was available at follow-up because the control groups had been exposed to the intervention. In Kraizer 1991, data were not reported. In Poche 1988, there was substantial loss to follow-up.
All three studies measured post-test protective behaviours within one to two days following the intervention. One study reported following up with assessment of protective behaviours one month after the intervention (Poche 1988), and the two other studies reported following up six months after the intervention (Fryer 1987a; Kraizer 1991). However, follow-up data were published only for Fryer 1987a; data were not published for Kraizer 1991, and Poche 1988 reported significant loss to follow-up with only nine of 23 children available for measurement.
Retention of knowledge over time
All of the 21 studies measuring post-test questionnaire-based knowledge did so within a two-week period following inter- vention. Ten studies also reported short-term knowledge out- comes one to three months following intervention (Crowley 1989; Dawson 1987; Harvey 1988; Hazzard 1991; Hébert 2001; Lee
1998; Poche 1988; Saslawsky 1986; Wurtele 1986; e en-Ero ul 2013). One study reported knowledge outcomes at five months (Blumberg 1991), three studies at six months (Fryer 1987a; Kolko 1989; Kraizer 1991), and two studies at eight months (Del Campo Sanchez 2006; Krahé 2009). One study measured long-term out- comes at 12 months (Hazzard 1991). One study measured long- term outcomes in “the second year of the study” (Daigneault 2012, p 527), however the precise timing was not reported.
For most studies, no comparison with the control group was avail- able at follow-up because the control groups had been exposed to the intervention by then. Complete data (for intervention and control groups) were reported in only four studies (Dawson 1987; Hazzard 1991; Kolko 1989; Lee 1998).
Harm - parental or child anxiety or fear
No studies measured parental anxiety or fear. Parent satisfaction questionnaires were used in five studies (Grendel 1991; Hazzard 1991; Hébert 2001; Tutty 1997; Wurtele 1986).
Six studies measured child anxiety or fear via child report (Blumberg 1991; Daigneault 2012; Dawson 1987; Hazzard 1991; Kraizer 1991; Lee 1998), and four studies via parent report (Del Campo Sanchez 2006; Hazzard 1991; Hébert 2001; Tutty 1997). Instruments used with children were the State-Trait Anxiety In- ventory for Children (STAIC) (Dawson 1987; Hazzard 1991; Oldfield 1996), the Revised Children’s Manifest Anxiety Scale (RCMAS) (Oldfield 1996), and the Fear Assessment Thermome- ter Scale (Lee 1998). One study used a “children’s feelings of sa- fety” measure (Daigneault 2012, p 530). Instruments used with parents were adapted from the Parental Perception Questionnaire (PPQ) (Miller-Perrin 1986), a 16-item measure in which parents
rate how often they observed negative and positive behaviours. Included studies variously referred to the measure as a ’parent ob- servation’ measure (e.g. Tutty 1997) and a ’side effects’ scale (e.g. Del Campo Sanchez 2006).
Disclosures
Children’s disclosures of child sexual abuse during or follow- ing intervention were reported by five studies (Blumberg 1991; Del Campo Sanchez 2006; Hazzard 1991; Kolko 1989; Oldfield 1996). To record disclosures, two studies used a data collection form completed by staff at the school (Hazzard 1991; Oldfield 1996). Two other studies conducted child protective services (CPS) file searches (Blumberg 1991; Kolko 1989). Blumberg 1991 conducted follow-up CPS searches at 15 months post-interven- tion.
Excluded studies
We excluded 55 studies because they did not meet the inclusion criteria. We excluded 36 studies on the basis of study type (13 pre- test and post-test studies without control groups; 11 controlled before-and-after studies without random assignment; five post- test only studies; five quasi-experimental studies without random assignment; one cross-sectional comparative study; and one com- parative group design). We excluded 14 studies because the inter- vention was not primarily about child sexual abuse prevention, but was about dating and relationship violence, gendered violence, or sexual harassment in the context of partner relationships (seven of these studies were cited in the Cochrane Review by Fellmeth 2013, including Pacifici 2001, which was included in the original review) or abduction prevention, the aims of which did not men- tion prevention of child sexual abuse. We excluded four studies because they were not school-based and one study because partic- ipants were outside the age criteria.
Reasons for exclusion are detailed in the Characteristics of excluded studies table.
Risk of bias in included studies
Allocation
Random sequence generation
Twenty studies stated that individuals or groups (classes, schools, or districts) were “randomised”, “randomly allocated”, or “ran- domly assigned” to groups, but provided no detail about how the random sequence was generated. Three further studies described a classic experimental design, but did not report details about ran- dom assignment (Dake 2003; Kolko 1989; Kraizer 1991). We classified all of these studies as unclear risk of bias. One study
reported a random component in the sequence generation, coin tossing (Snyder 1986), and we classified it as low risk of bias. In one study, evidence of computerised randomisation was provided after author contact (Dake 2003). We re-classified this study as low risk of bias.
Allocation concealment
No studies provided information on methods used to conceal al- location. In all instances we concluded that procedures were po- tentially unconcealed such that assignment to groups could rea- sonably have been predicted prior to or during the process. Twelve studies reported tests of baseline imbalances showing no statistical differences between groups, potentially indicating successful ran- domisation. However, we classified these studies as unclear risk of bias because the method of concealment was not described in sufficient detail for an adequate assessment to be made. Ten stud- ies provided no baseline comparisons and we also classified them as unclear risk of bias. We classified two studies as high risk of bias: one study reported important differences between groups at baseline and concluded failure of randomisation (Crowley 1989, pp 60-1) and another study revealed school officials were involved in the process (Kraizer 1991, p 27).
Blinding
Blinding of participants and personnel
The school-based nature of the interventions made blinding of participants receiving the intervention and personnel delivering the intervention impossible. In 14 studies intervention and con- trol groups were located within the same school. In these cases, it was possible that participants experienced ’contamination’ effects via contact with each other in the playground or their siblings at home, and/or inadvertent ’exposure’ to programme concepts via teachers and other school staff. This is likely to have biased the results towards an underestimation of programme effects, particu- larly on knowledge outcomes, which would be more susceptible to such contamination and exposure. Personnel delivering the inter- ventions were various study authors, programme facilitators, and classroom teachers. None of these 14 studies described a means by which programme fidelity or integrity was addressed (e.g. via the use of scripts or standardised lesson plans) or measured (e.g. via observation, audio, or video recordings). We classified these 14 studies as high risk of bias. Seven further studies provided no information on blinding procedures and we classified them as un- clear risk of bias (Chen 2012; Dake 2003; Del Campo Sanchez 2006; Saslawsky 1986; Wolfe 1986; Wurtele 1986; e en-Ero ul 2013). We classified three studies as low risk of bias: one study re- ported that instructors were blind to group conditions (Daigneault 2012), one study reported measures to control for contamination and the use of narrative scripts (Lee 1998), and another study
reported that the programme and testing were conducted on the same day to minimise the risk of contamination between groups in the school (Snyder 1986).
Blinding of outcome assessment
Blinding was not reported in seven studies (Del Campo Sanchez 2006; Harvey 1988; Kolko 1989; Lee 1998; Tutty 1997; Wolfe 1986; e en-Ero ul 2013), which we classified as unclear risk of bias.
We classified 10 studies as low risk of bias (Blumberg 1991; Daigneault 2012; Fryer 1987a; Grendel 1991; Krahé 2009;
Kraizer 1991; Oldfield 1996; Poche 1988; Saslawsky 1986; Wurtele 1986). Some studies used multiple strategies for min- imising outcome assessment bias. In eight studies, authors re- ported that outcome assessors were blind to group membership, study hypotheses, or both (Blumberg 1991; Daigneault 2012; Fryer 1987a; Grendel 1991; Krahé 2009; Oldfield 1996; Saslawsky 1986; Wurtele 1986). In three studies, authors noted that partici- pants were not informed that the outcome assessment was related to the intervention (Blumberg 1991; Fryer 1987a; Poche 1988), and in three studies outcome assessors were reported to be differ- ent to the personnel delivering the interventions (Blumberg 1991; Fryer 1987a; Kraizer 1991). In two studies, video monitoring was used to collect observational data on the protective behaviours outcome, and coders’ inter-rater reliability was reported (Fryer 1987a; Kraizer 1991). One study reported that participants were assessed only once (either pre-test or post-test) by the same out- come assessor to control for potential effects of rapport building (Blumberg 1991). Of these 10 studies, Fryer 1987a implemented more strategies than any other study and we considered it to be at lowest risk of bias in this domain.
We classified seven studies as high risk of bias. In these studies outcome assessment was administered in group format (in class or with a number of children) and there were no strategies in place to blind outcome assessors to group membership or to ensure children completed the assessment independently (Chen 2012; Crowley 1989; Dake 2003; Dawson 1987; Hazzard 1991; Hébert 2001; Snyder 1986). This risk was further heightened when the outcome assessors were the same individuals as those delivering the programme (e.g. Dawson 1987).
Incomplete outcome data
Attrition rates for individual studies are reported in the ’Risk of bias’ tables beneath the Characteristics of included studies table. Twelve studies did not report attrition rates (Daigneault 2012; Del Campo Sanchez 2006; Hazzard 1991; Hébert 2001; Krahé 2009;
Oldfield 1996; Poche 1988; Saslawsky 1986; Tutty 1997; Wolfe 1986; Wurtele 1986; e en-Ero ul 2013). We classified these studies as unclear risk of bias. One study reported no attrition or loss to follow-up (Chen 2012) and we classified it as low risk of
bias. We classified four further studies as low risk of bias, reporting attrition rates of less than 10% (Dawson 1987; Kraizer 1991; Lee 1998; Snyder 1986). Seven studies reported attrition rates of more than 10%, ranging from 12% to 24%, all of which we classified as high risk of bias (Blumberg 1991; Crowley 1989; Dake 2003; Fryer 1987a; Grendel 1991; Harvey 1988; Kolko 1989).
Only four studies reported results in such a way that loss to follow-
up for intervention and control groups could be differentiated: Blumberg 1991 (14.1% role-play, 8.1% multimedia, 3.8% con-
trol), Dawson 1987 (7.3% intervention, 2.6% control 1, 3.1%
control 2), Fryer 1987a (4% intervention, 12% control), and
Grendel 1991 (19% intervention, 22% control).
Reasons for attrition were reported in nine studies (Crowley 1989; Dake 2003; Dawson 1987; Grendel 1991; Harvey 1988; Kraizer
1991; Lee 1998; Poche 1988; Snyder 1986) and included student absence, withdrawal, vacation, illness, and school change, as well as missing or incomplete data on forms, and unmatchable pre- and post-tests.
No study reported analysis on an intention-to-treat (ITT) basis.
Selective reporting
Most studies reported complete outcome data that matched the stated aims or hypothesis of the study, and reported on pre-spec- ified outcomes of interest. We initially classified these studies as low risk of bias. We classified two studies as high risk of bias (Fryer 1987a; Wolfe 1986), because not all measures discussed in the methods section of the paper were also reported in the results. This may be an artefact of publication word limits.
On closer inspection, however, we noted that outcome report- ing was incomplete in five studies. One study did not provide a breakdown of data for intervention and control groups (Kraizer 1991). In four studies, outcomes were reported as summary statis- tics (e.g. F-tests or T-tests) without including means and SDs for continuous outcomes (Del Campo Sanchez 2006; Chen 2012, Harvey 1988; Kraizer 1991). Where data were not reported, we contacted study authors with an open-ended request to provide further information. We received helpful replies from Chen 2012 (additional data provided; study classified as low risk of bias) and Kraizer 1991 (data unable to be retrieved; study classified as high risk of bias).
We classified no studies as unclear risk of bias.
In summary we considered five studies as high risk of bias on this domain (Del Campo Sanchez 2006; Fryer 1987a; Harvey 1988;
Kraizer 1991; Wolfe 1986), and we considered the remaining 19 studies low risk of bias.
Other potential sources of bias
The unit of randomisation in 14 studies was clusters. Eleven of these were cluster-RCTs (Blumberg 1991; Dake 2003; Dawson 1987; Grendel 1991; Hazzard 1991; Kolko 1989; Krahé 2009;
Kraizer 1991; Oldfield 1996; Poche 1988; Wolfe 1986), where the unit of allocation was a group (e.g. classroom or school). Three quasi-RCTs also used groups as the unit of randomisation (Crowley 1989; Daigneault 2012; Hébert 2001). None of these studies reported appropriate analyses accounting for clustering ef- fects. Therefore, we assumed unit of analysis errors in all cases, meaning the original P values would be artificially small. In the subsequent meta-analysis, studies with unadjusted unit of analy- sis errors would be incorrectly and more highly weighted than is, in reality, appropriate. This risks biasing results in favour of the intervention.
As noted above, to diminish the risk of publication bias, in the review update we made concerted efforts to retrieve the full texts of unpublished trials (e.g. theses). Seven of 29 records included in this review were unpublished theses (Blumberg 1987; Chadwick 1989; Crowley 1989; Dawson 1987; Grendel 1991; Kraizer 1991; Snyder 1986). We assessed the risk of publication bias by draw- ing fixed-effect forest and funnel plots for the two meta-analy- ses involving 10 or more trials (questionnaire-based knowledge, 18 trials; vignette-based knowledge, 11 trials). Visual inspection of fixed-effect forest plots revealed no discernable trend towards greater effect sizes in smaller studies. However, our subjective im- pression of the fixed-effect funnel plots suggested the presence of slight asymmetry on the lower right (here we found smaller stud- ies with greater effect sizes) indicating the possibility that some studies are missing from the lower left (here we should have found smaller studies with smaller effect sizes) (see Figure 4 and Figure 5). There is also the possibility that smaller studies were of poorer methodological quality (although this is not evident in the ’Risk of bias’ assessments), or there may have been genuine differences between studies (e.g. unreported sample differences at baseline; differences in programme duration) (Borenstein 2009). Due to poor reporting of variables that may be responsible for heterogene- ity, it was not possible to further explore the sources of variation, for example, via the use of meta-regression.
Figure 4. Funnel plot of studies included in meta-analysis for questionnaire-based knowledge
Figure 5. Funnel plot of studies included in meta-analysis for vignette-based knowledge
Effects of interventions
See: Summary of findings for the main comparison
This review sought to assess the evidence of effectiveness of school- based education programmes for the prevention of child sexual abuse. Specifically, we sought to assess whether: programmes were effective in improving students’ protective behaviours and knowl- edge about sexual abuse prevention; behaviours and skills were re- tained over time; and programme participation resulted in disclo- sures of sexual abuse, produced harm, or both. In this section, we present the main findings on the effects of the interventions for six outcomes: (i) protective behaviours; (ii) knowledge (question- naire-based knowledge and vignette-based knowledge); (iii) reten- tion of protective behaviours over time; (iv) retention of knowl- edge over time; (v) harm (parental or child anxiety or fear); and
(vi) disclosures. The analysis results and our GRADE ratings are presented in Summary of findings for the main comparison.
Protective behaviours
Of the 24 included studies, three studies reported collecting data on protective behaviours (Fryer 1987a; Kraizer 1991; Poche 1988). All used a version of a stranger simulation test involving staging of a simulated abuse or grooming situation with each individual
child where a research assistant, posing as a stranger, requested the child’s help with a task that required them to go with the stranger (e.g. accompany the stranger to the stranger’s car to do a special task). Children’s responses were recorded by independent assessors using contemporaneous video monitoring (Fryer 1987a; Kraizer 1991), or by the research assistant (Poche 1988). Scoring was pass or fail. All three studies were conducted with children in lower primary school (kindergarten to grade three).
Only the Fryer 1987a (n = 48; randomised controlled trial (RCT)) and Poche 1988 (n = 74; cluster-RCT) studies could be included in the meta-analysis for protective behaviours, as Kraizer 1991 (n
= 670; cluster-RCT) did not report a breakdown of pass or fail scores for intervention and control groups. For the Poche 1988 study, we combined two intervention groups as the self protective knowledge and skills received were considered sufficiently similar to those in Fryer 1987a: teaching rules, group discussion, and practice through role-play and rehearsal. Data were available for 102 participants. Comparison was with a control group.
In the analysis, heterogeneity approached the moderate range (I² = 27%; Tau² = 0.16) and was non-significant (P value = 0.24). Pro- tective behaviours were greatly enhanced in intervention groups compared to control groups immediately post-intervention (odds ratio (OR) 5.71, 95% confidence interval (CI) 1.98 to 16.51; two
studies; n = 102) (see Analysis 1.1).
We performed sensitivity analyses to assess the effects of adjust- ing the Poche 1988 study for cluster-randomisation. Using this method and an intraclass correlation coefficient (ICC) of 0.1 pro- duced an OR of 5.43 (95% CI 1.88 to 15.65; Analysis 1.2) and
an ICC of 0.2 produced an OR of 5.16 (95% CI 1.81 to 14.70; Analysis 1.3). These analyses indicate that adjusting for the effect of clustering have minimal effects on our results.
Taken together, results of the more conservative adjustment for clustering show the short-term (i.e. immediately post-interven- tion) superiority of the interventions over control group effects. That is, children who received a school-based sexual abuse pre- vention programme were substantially more likely to demonstrate protective behaviours in a simulated situation that was adminis- tered immediately after the programme ended.
In addition to the above assessment, Fryer 1987a and Kraizer 1991 assessed the impact of knowledge and self esteem on the use of pro- tective behaviours. Fryer 1987a used the Harter Perceived Compe- tence Scale for Children (HPCS) (Harter 1982), commonly used as a measure of self esteem. Kraizer 1991 used the Battle Culture Free Self-esteem Inventory (Battle 1981) and the Children Need to Know Knowledge/Attitude Test (CNKKAT) (Kraizer 1981). Results of these measures were reported only for the intervention groups. In both studies, children with high self esteem who had improved knowledge scores post-intervention were more likely to exhibit protective behaviours. These studies did not report effect sizes to enable assessment of the magnitude of the relationships between self esteem, knowledge, and protective behaviours, al- though self esteem was identified as a potential “critical path” or moderating variable, which was recommended for further research (Fryer 1987a, p 177).
Knowledge
Questionnaire-based knowledge
Of the 24 included studies, 21 reported questionnaire-based knowledge using a range of different measures detailed above. Three of the 21 studies did not provide data in a way that could be included in meta-analysis (Del Campo Sanchez 2006; Harvey 1988; Kraizer 1991). In three trials, with multiple intervention groups in which interventions were judged to be sufficiently com- parable, we combined intervention groups into a single interven- tion group in the meta-analysis (Blumberg 1991; Crowley 1989; Dawson 1987). Eighteen studies were included in the meta-anal- ysis comprising a total of 4657 participants.
In the meta-analysis, there was evidence of substantial heterogene- ity (I² = 84%; Tau² = 0.10). The high Chi² statistic (104.76; df
= 17) and low P value (< 0.00001) indicated variation of effect estimates beyond chance. The SMD was 0.61 (95% CI 0.45 to 0.78), reflecting an average 0.61 standard deviation (SD) increase
in factual knowledge, across various measures, for the intervention group. These results suggest that children exposed to the inter- ventions tend to display increased factual knowledge about sexual abuse and its prevention, when measured immediately after com- pletion of the programme, and the effect is of a moderate size (see Analysis 2.1).
Of the 18 studies included in this meta-analysis, 12 were cluster-
randomised studies and all were analysed with unit of analysis errors. Of the cluster-randomised studies, one was randomised by school district (Kolko 1989), four were randomised by school (Daigneault 2012; Dake 2003; Hazzard 1991; Hébert 2001), and seven by classroom (Blumberg 1991; Crowley 1989; Dawson 1987; Grendel 1991; Oldfield 1996; Snyder 1986; Wolfe 1986). We estimated ICCs, as described above, in sensitivity analyses to adjust for unit of analysis errors. We applied the same ICC to district, school, and class cluster-RCTs. When adjusted, an ICC of 0.1 produced a SMD of 0.66 (95% CI 0.51 to 0.81; Analysis
2.2) and an ICC of 0.2 produced a SMD of 0.63 (95% CI 0.50 to 0.77; Analysis 2.3). These analyses indicate that adjusting for clustering has very minimal effects on results.
We also conducted sensitivity analyses to assess the effects of study exclusion for risk of bias in the two most relevant domains for school-based studies. First, we examined risk of bias on the blind- ing of outcome assessment domain. When studies at high risk of bias were excluded (Chen 2012; Crowley 1989; Dake 2003; Dawson 1987; Hazzard 1991; Hébert 2001; Snyder 1986), the
SMD was reduced to 0.47 (95% CI 0.29 to 0.66). These results indicate that knowledge scores in these studies may be influenced by assessor bias or contamination from group assessment, or both, such that better controlled studies may generate lower effect sizes in this domain. Second, we examined risk of bias on the attri- tion bias domain. When studies at high risk of bias were excluded (Blumberg 1991; Crowley 1989; Daigneault 2012; Dake 2003;
Grendel 1991; Kolko 1989), the SMD was 0.69 (95% CI 0.59 to 0.88), indicating that children from studies with better follow-up tended to score somewhat higher in this domain.
We conducted subgroup analyses to assess the effects of participant age. We examined studies in two age-based subgroups as follows:
(i) six studies with only younger participants from kindergarten to grade three (Blumberg 1991; Daigneault 2012; Dake 2003; Grendel 1991; Hébert 2001; Kolko 1989); and (ii) seven studies with only older participants from grade four upwards (Crowley 1989; Dawson 1987; Hazzard 1991; Lee 1998; Snyder 1986; Wolfe 1986; e en-Ero ul 2013). The SMD was 0.42 (95% CI
0.08 to 0.77) for the younger group and 0.89 (95% CI 0.59 to 1.19) for the older group. The test for subgroup differences was just below the statistically significant cut-off of 0.05 (Chi² = 4.04, df = 1; P value = 0.04). These results indicate that knowledge may be better gained immediately after the intervention by older children.
Vignette-based knowledge
Twelve studies used vignette-based measures in various formats, including verbal, picture, and video vignettes. One study did not report SDs and thus could not be included in a meta-analysis (Harvey 1988). One study did not report SDs but these could be derived by review authors from other reported statistics to enable inclusion in meta-analysis (Saslawsky 1986). In Blumberg 1991 and Krahé 2009, we combined two intervention groups into a sin- gle intervention group based on our assessment that the interven- tions were sufficiently similar when compared with other studies. Eleven studies were included in the meta-analysis with a total of 1688 participants.
There was evidence of substantial heterogeneity (I² = 71%; Tau²
= 0.08) in the meta-analysis. The high Chi² statistic (34.25, df
= 10) and low P value (< 0.0002) provide further evidence of variation in effect estimates beyond chance. The SMD was 0.45 (95% CI 0.24 to 0.65) (see Analysis 2.4), indicating that those receiving treatment had an average 0.45 SD increase in applied knowledge as reflected in their responses to vignettes administered post-intervention, a gain of moderate effect size.
Of the 11 studies included in the meta-analysis, seven studies were
of cluster-randomised design (Blumberg 1991; Daigneault 2012; Grendel 1991; Hazzard 1991; Hébert 2001; Kolko 1989; Krahé 2009). To assess the impact of unit of analysis errors, we conducted sensitivity analyses for estimated ICCs (as above). For an ICC of 0.1, the SMD was 0.53, (95% CI 0.32 to 0.74; Analysis 2.5) and
for an ICC of 0.2, the SMD was 0.60 (95% CI 0.31 to 0.89;
Analysis 2.6). These analyses suggest that adjusting for clustering has only slight effects on results.
We conducted sensitivity analyses to assess the effects of study exclusion for risk of bias. First, we examined risk of bias on the blinding of outcome assessment domain. When we excluded three studies (Chen 2012; Hazzard 1991; Hébert 2001), the SMD was reduced to 0.36 (95% CI 0.17 to 0.56), indicating a slight testing effect. Second, we examined risk of bias on the attrition bias do- main. When we excluded studies at high risk of bias (Blumberg 1991; Daigneault 2012; Grendel 1991; Kolko 1989), the SMD
increased to 0.57 (95% CI 0.25 to 0.89), indicating that chil- dren from studies with better follow-up tended to score somewhat higher in this domain.
We conducted subgroup analyses to assess the effects of participant age. We examined studies in two groups: (i) six studies including only participants in kindergarten to grade three (Blumberg 1991; Daigneault 2012; Grendel 1991; Hébert 2001; Kolko 1989; Krahé 2009); and (ii) three studies including only participants in grade four upwards (Chen 2012; Hazzard 1991; Lee 1998). The SMD was 0.39 (95% CI 0.09 to 0.69) for the younger group and 0.56 (95% CI 0.03 to 1.08) for the older group. Thus, older children, on average, may score somewhat better than younger children when they complete these measures of applied knowledge immediately after the intervention. However, the test for subgroup differences was not significant (Chi² = 0.29, df = 1; P value = 0.59).
Retention of protective behaviours over time
Three of the 24 included studies measured retention of protective behaviours over time. Complete data were not available for any of these studies and a meta-analysis could not be conducted.
Retention of knowledge over time
Questionnaire-based measures were used in 21 of the 24 included studies. Ten of these studies reported on retention of knowledge over time. Complete data were available for four studies (956 par- ticipants) (Dawson 1987; Hazzard 1991; Kolko 1989; Lee 1998). All studies used unique knowledge scales. In three studies, follow- up periods were one to three months post-intervention (Dawson 1987; Hazzard 1991; Lee 1998), and in one study, six months post-intervention (Kolko 1989). These four studies were included in meta-analysis using a random-effects model. For comparative purposes we generated two meta-analyses: one estimating effects for the four studies immediately post-intervention and one esti- mating effects at follow-up. Results suggest that knowledge ap- peared to deteriorate slightly over time as demonstrated by a de- cline in the SMD from 0.78 (95% CI 0.38 to 1.17; I² = 84%, Tau² = 0.13, P value = 0.0003) immediately post-intervention to SMD 0.69 (95% CI 0.51 to 0.87; I² = 25%; Tau² = 0.01, P value
= 0.26) at one to three months follow-up (see Analysis 3.1). How- ever, the test for subgroup differences was not significant (Chi² = 0.14, df = 1; P value = 0.71), suggesting knowledge scores did not deteriorate significantly for intervention or control groups within the one- to six-month follow-up period.
Of the four studies included in this meta-analysis, three were cluster-randomised studies (Dawson 1987; Hazzard 1991; Kolko 1989). Sensitivity analyses, adjusting for clustering yielded very similar results. When adjusted with an ICC of 0.1, knowledge de- creased slightly over time as demonstrated by a small decline in the SMD from 0.86 (95% CI 0.53 to 1.20) immediately post-inter-
vention to 0.73 (95% CI 0.41 to 1.06) at follow-up (Analysis 3.2). When adjusted with an ICC of 0.2, knowledge decreased slightly over time as demonstrated by a small decline in the SMD from SMD 0.86 (95% CI 0.53 to 1.20) immediately post-intervention
to 0.72 (95% CI 0.32 to 1.11) at follow-up (Analysis 3.3).
Vignette-based measures were used in 12 of the 24 included stud- ies. Nine of these studies reported on retention of knowledge over time. None of these studies could be included in a meta-analysis. The reasons for this are twofold: (i) the wait-list control design of the study meant that the control group received the interven- tion immediately after the experimental group had finished and, therefore, follow-up data were unavailable for the control group (Blumberg 1991; Daigneault 2012; Grendel 1991; Hazzard 1991; Saslawsky 1986; Wurtele 1986); or (ii) the study did not provide data in a form useable in meta-analysis, for example, the study pro- vided a narrative statement or reported summary statistics with- out providing means and SDs (Hébert 2001; Krahé 2009; Lee 1998). As a narrative synthesis, six studies provided intervention
group data only: two studies reported no knowledge gains between post-test and follow-up (at five months, Blumberg 1991; at one year, Hazzard 1991), two studies reported maintenance of knowl- edge gains at two-month follow-up (Hébert 2001; Lee 1998), and three studies reported small, but unimportant additional knowl- edge gains between post-test and follow-up (six months, Kolko 1989; three months, Saslawsky 1986; Wurtele 1986).
Harm
A total of six studies had measured harm, but three did not report data in a form that could be used in meta-analysis (Daigneault 2012; Hazzard 1991; Kraizer 1991). We included three studies (795 participants) in the meta-analysis for harm in relation to participation in school-based child sexual abuse prevention pro- grammes (Blumberg 1991; Dawson 1987; Lee 1998). In these studies, harm was measured via child self report anxiety or fear scales, with all studies using unique measures: Dawson 1987 used the State-Trait Anxiety Inventory for Children (STAIC), Lee 1998 used the Fear Assessment Thermometer Scale (FATS), and Blumberg 1991 used a custom-made scale. There was no hetero- geneity (I² = 0%, P value = 0.79). The SMD was -0.08 (95% CI
-0.22 to 0.07) (see Analysis 4.1). This result reveals evidence of no increases or decreases in anxiety or fear in intervention partic- ipants.
Two of these three studies were cluster-randomised studies ( Blumberg 1991; Dawson 1987). To assess the impact of unit of analysis errors, we conducted sensitivity analyses for estimated ICCs as above, showing little change in point estimates and slightly widening CIs. For an ICC of 0.1, the SMD was -0.04 (95% CI -
0.42 to 0.33; Analysis 4.2) and for an ICC of 0.2, the SMD was
-0.03 (95% CI -0.46 to 0.40; Analysis 4.3).
A narrative synthesis of the studies not included in the meta-analy- sis shows that seven studies reported on adverse effects with either child (Hazzard 1991; Kraizer 1991; Oldfield 1996) or parent self reports (Del Campo Sanchez 2006; Hazzard 1991; Hébert 2001; Tutty 1997). Using child self report measures, Hazzard 1991 and Oldfield 1996 reported no important differences in STAIC scores between intervention and control groups (Hazzard 1991, treat- ment mean 29.7, control mean 29.9; Oldfield 1996, F(1, 593)
= 0.05, P value = 0.825). Hazzard 1991 did not report SDs and ANCOVA results. Oldfield 1996 did not report means and SDs. Oldfield 1996 also found no important differences between ex- perimental and control group anxiety scores using the Revised Children’s Manifest Anxiety Scale (RCMAS) with younger partic- ipants, F(1, 653) = 1.40, P value = 0.248. In one study (Kraizer 1991), children in the intervention group participated in an exit interview (n = 332): 14.8% of the children experienced some anxi- ety or fear initially but none on programme completion, and 4.5% experienced some anxiety or fear initially and remained a little worried on programme completion.
Using parent self report measures of perceived changes in chil-
dren’s behaviour, Del Campo Sanchez 2006 (n = 193) reported the following in children exposed to the intervention: fear of adults (1%) and increased fighting with peers (1%), but no sleep prob- lems, or rejection of normal affection. Similarly, in intervention group children, Tutty 1997 (n = 231) found worry about scary things happening (1.7%), but no bedwetting, nightmares, cry- ing, rejection of normal affection, or attention seeking behaviour. Hébert 2001 (n = 133) reported intervention group children hav- ing increased dependency behaviours (13%), more aggressiveness towards peers (15%) and siblings (29%), and more fearfulness of strangers (25%). Hazzard 1991 (n = 399) reported no important differences between intervention and control group children on parental perceptions of anxiety or fear (summary data not pro- vided).
Disclosure
We included three studies (1788 participants) in the meta-analysis for disclosures of previous or current sexual abuse (Del Campo Sanchez 2006; Kolko 1989; Oldfield 1996). There was no hetero- geneity (I² = 0%, P value = 0.84). Disclosure occurred more often in the intervention group (OR 3.56, 95% CI 1.13 to 11.24). The odds of disclosure were as much as 3.5 times higher in participants exposed to the intervention (see Analysis 5.1).
We performed sensitivity analyses to assess the effects of adjusting the Kolko 1989 and Oldfield 1996 studies for cluster-randomi- sation. Using this method and an ICC of 0.1 produced a non- significant OR of 3.04, 95% CI 0.75 to 12.33; Analysis 5.2) and
an ICC of 0.2 produced an OR of 2.95, 95% CI 0.69 to 12.61; see Analysis 5.3). These analyses, adjusted for unit of analysis errors, indicate that the effect of intervention programmes on disclosure was sensitive to different assumptions regarding the effect of clus- tering on the results.
Of the studies not included in meta-analysis, disclosure of past or current abuse was recorded in two studies (Blumberg 1991; Hazzard 1991). One study conducted a search of the files of Child Protective Services (CPS) for names of children in the classrooms who were part of the study (Blumberg 1991). Data event counts were not provided, however the study reported that risk ratios (RR) were calculated for experimental against control conditions. Both ratios “approached 1.0 which one would expect by chance” (Chadwick 1989, p 61). One further study measured disclosures, but was unable to distinguish between treatment and control groups due to data reporting methods (Hazzard 1991). Eight of 526 participants (1.5%) reported ongoing sexual abuse and 20 (3.8%) reported past sexual abuse.
Subgroup analyses
Subgroup analyses are used to compare the mean effect for different subgroups of studies where there are sufficient numbers of studies to allow for meaningful comparisons. We were able to conduct
subgroup analyses for age, but only for knowledge outcomes, by categorising studies into two broad groups: younger children and older children as described above. This was because programmes were often delivered to children across multiple consecutive and non-consecutive school grades. We did not conduct other sub- group analyses in this review because the included studies provided insufficient information about issues that were hypothesised as be- ing relevant for subgroup analysis. In the original study protocol we planned to conduct subgroup analyses for participant age and gender, and programme type and setting (Zwi 2003). We were unable to conduct subgroup analyses for gender owing to poor reporting. We did not conduct subgroup analyses for active or pas- sive involvement as it was not possible to categorise programmes in this way; most were multifaceted, involving both active and passive approaches. What is needed is a way of identifying, more precisely, the range of child, programme, and study design charac- teristics that may moderate programme effectiveness. We explain this in more detail in the discussion below.
D I S C U S S I O N
Summary of main results
This updated review reported on 24 trials (29 reports) examining the effectiveness of school-based programmes for the prevention of child sexual abuse. The studies reporton data for 5802 child partic- ipants of whom 5730 (almost 98.8%) were from primary (elemen- tary) schools. In this review, we assessed programme effectiveness according to six outcomes: (i) protective behaviours; (ii) knowl- edge (questionnaire-based knowledge and vignette-based knowl- edge); (iii) retention of protective behaviours over time; (iv) reten- tion of knowledge over time; (v) harm manifesting as parental or child anxiety or fear; and (vi) disclosures of past or current child sexual abuse. Below we report on: (i) protective behaviours; (ii) knowledge; (iii) harm; and (iv) disclosures.
Protective behaviours
Meta-analysis of data from two studies showed significant im- provements in protective behaviours in simulated at-risk situa- tions, measured immediately (up to two weeks) post-intervention. Follow-up assessment of protective behaviours was not reported in either of the studies. Simulated situations, used in three of the included studies, were a form of in vivo assessment, which exposed children to potentially stressful situations such as an invitation to go with an unknown adult (Fryer 1987a; Kraizer 1991; Poche 1988). The use of these simulation techniques is difficult to jus- tify and raises important ethical questions about balancing risks against potential benefits for participants. Research of this type also presents significant challenges for voluntary consent where there
is active concealment via role-playing. Although this is arguably as close as researchers can get to testing whether participants’ learned skills can be translated into appropriate behaviour, three salient issues must be considered. First, the generalisation of responses from simulated to actual settings cannot be assumed. Second, it is not known if skills taught in the context of approaches from strangers help children deal with threats from familiar adults, who are the most common perpetrators of child sexual abuse. Third, there is the possibility that this type of outcome assessment may desensitise children to similar occurrences in the future. Outcome assessment of this type, therefore, must be rigorously conducted and monitored.
The results of one study suggest that children with greater self esteem (Fryer 1987a), as measured by the Harter Perceived Com- petence Scale (HPCS) (Harter 1982), exhibited better protective behaviours following intervention. Since self esteem is clinically relevant in child sexual abuse, this finding warrants further in- vestigation to determine whether self esteem training should be included as a component of child sexual abuse prevention inter- ventions. It may be that children with greater self esteem are more likely to display protective behaviours regardless of exposure to programmes. Unfortunately, the psychological literature has been hampered by the use of a confusing array of terms encompassing self esteem (e.g. self belief, self concept, self efficacy, self worth), and there has been extensive debate in the educational psychology literature about its role in children’s learning (Valentine 2004). Greater levels of precision in definition and measurement are re- quired in future research.
Knowledge
Meta-analysis of data from 18 studies for questionnaire-based knowledge and 11 studies for vignette-based knowledge suggested gains in factual and applied knowledge immediately (up to two weeks) post-intervention. Follow-up assessment of factual knowl- edge was limited to four studies with our meta-analyses show- ing that factual knowledge scores did not deteriorate for either intervention or control groups one to six months after interven- tions. Follow-up assessment of applied knowledge was conducted in some studies, however data were incomplete and not suitable for meta-analysis. Across all of the included studies, less than half of the studies (10 of 24) reported on short-term knowledge out- comes (within three months of the intervention), three studies reported medium-term outcomes (up to 12 months post-inter- vention), and only one study measured retention of knowledge beyond 12 months. A methodological problem in these studies was data completeness because, at the time of follow-up, control groups had already been exposed to the programmes and it is un- ethical to withhold programme delivery. Well-designed and timely follow-up is required to determine whether factual and applied knowledge can be sustained over time with the use of boosters and other maintenance strategies (such as reiteration of programme
messages by parents and teachers).
An important source of heterogeneity across studies is the knowl- edge measure used. For the 24 studies included in this review, 15 discrete questionnaire-based measures and six discrete vignette- based measures were used to measure children’s factual and applied knowledge respectively. For studies included in the meta-analyses, there were 10 unique questionnaire-based measures and six unique vignette-based measures represented. These were pooled using the standardised mean difference (SMD) as a summary statistic. In us- ing SMDs, we treated the different assessment measures as though they were one standardised measure with comparable standard de- viations (SDs). It is then difficult to relate this abstract figure back to the original measures to determine what this means in real life. For example, it is not clear what a 0.61 SD increase in factual knowledge or a 0.45 SDincrease in applied knowledge translates to in practical knowledge terms. Are these findings sufficient to offer protective effects under threats of sexual abuse? Further research is required to address the magnitude of knowledge improvement re- quired to produce clinically important protective effects. Research would be improved by the use of standardised rather than custom- made instruments.
Harm
Adverse or negative effects in the form of harm to participants were assessed via measures of child anxiety or fear. Studies examining participants’ anxiety or fear were based on child self report and parent report. Meta-analysis of three studies found no evidence of increased or decreased anxiety or fear in those exposed to pro- grammes and this did not change when adjusted for clustering. Narrative synthesis of included studies revealed that a small pro- portion of programme participants experienced anxiety or fear but these (anxieties or fears) were mild rather than severe, and short- rather than long-term. There was insufficient information to assess whether harms varied according to participant age or grade level. Although parent satisfaction data were collected in some studies, parental anxiety or fear was not measured in any study. This may be important in future studies for determining the role of parents in moderating programme effects.
Disclosures
The only direct measure of programme effects was participants’ disclosures of past or current sexual abuse that were made fol- lowing interventions. Disclosures were poorly reported or not re- ported in most studies. Our meta-analysis of three studies showed greater odds of disclosures by children receiving interventions. However, such disclosures cannot really be considered an adverse event since: (i) the onset of the alleged abuse would have occurred prior to the intervention; (ii) disclosing abuse, while potentially traumatic, can also prompt the provision of treatment; and (iii) the identification and reporting of perpetrators may prevent harm
to other children. Details of how disclosures were dealt with were not reported in any of the studies. Appropriate systems for dealing with disclosures are important and must reflect jurisdictional legal reporting obligations (also known as mandatory reporting laws), and school policies for child maltreatment recognition, reporting, and response. Future studies should consider methods for record- ing and responding to disclosures; data linkage to child protection or police records, or both; and/or interviewing or surveying par- ticipants at repeated follow-up intervals.
Subgroup effects
Demographic characteristics (e.g. participant age, gender, ethnic- ity, socioeconomic position, and ability level) are potential sources of heterogeneity, and potential effect moderators. If studies do not account for these characteristics, important subgroup effects may be missed. Genuine but unidentified differences in study samples at baseline are potential sources of heterogeneity within and across studies. Baseline characteristics of intervention and control groups were inconsistently and poorly reported in the included studies. Control for baseline characteristics within individual studies is particularly important for criteria that are most relevant to learn- ing such as academic ability, or reading age. These data were not reported or were absent by study design, therefore we were not able to explore whether programme effectiveness varied according to key baseline criteria. These issues have implications for pro- gramme delivery.
Demographic characteristics, such as participant age, would ap- pear to be straightforward variables, however, mean age was not reported in eight of 24 included studies and in others was con- flated with grade level. Few studies were undertaken with single grades, and most (18 of 24) studies were undertaken with multi- ple grade levels together. This study design limited the pooling of results across studies in meta-analysis. Subgroup analyses showed that older children (grades four and above) made greater knowl- edge gains than younger children (grades kindergarten to three) immediately post-intervention; results that are congruent with de- velopmental and maturation theories. However, we do not know if younger children would respond differently with differentiated approaches (e.g. reinforcement of skills and knowledge by par- ents or teachers, or both). We were unable to assess programme effectiveness according to other potentially important participant variables (e.g. child gender, ethnicity, socioeconomic position, and ability level) as few studies reported on these data or provided sub- group effects.
Characteristics of effective programmes
Insufficient data were provided to evaluate the specific effects of programme type, duration, frequency, or setting. These pro- gramme characteristics have implications for delivery in schools and the ideal constellation of programme characteristics, which
is not yet known. Although there was insufficient information to develop programme typologies and compare effects, we noted that approximately half of the programmes in included studies used content, such as the teaching of safety rules (e.g. “my body belongs to me”), and prevention concepts (e.g. distinguishing appropriate and inappropriate touches), and the use of delivery methods such as discussion, modelling, role-play, rehearsal, and feedback. Our narrative synthesis of included studies documented multidimen- sionality in intervention contents, methods, and delivery. This is an important finding in itself. To date, programmes have been cat- egorised dichotomously as active or passive or behavioural or in- structional. Our descriptive analysis shows this categorisation to be somewhat artificial as most programmes in this review were mul- tifaceted with multiple components. Programmes covered multi- ple topics (e.g. body safety rules, distinguishing types of touches, reporting abuse to adults who can help), used teaching strategies in combination (e.g. discussion, modelling, role-play, rehearsal, and feedback), and integrated active or passive and behavioural or instructional approaches in one session (e.g. a video or DVD presentation encouraged children to listen and then partake in ac- tivities). The contribution to effectiveness of programme content, methods, and delivery will require documentation using standard- ised data collection tools in future studies.
The duration and frequency (dose) of programme interventions varied from one single 45-minute session to eight 20-minute ses- sions. There were insufficient studies to create subgroup analyses for total programme hours, or total number of sessions, or for the presence or absence of booster sessions or reinforcement strategies. While interventions appear to increase protective behaviours and knowledge about sexual abuse, it is important that this learning is not seen as a replacement for adult responsibility to ensure child safety. Nor should education replace the need for appropriate med- ical and legal handling of those affected by child sexual abuse. We do not have evidence that these programmes reduce the inci- dence of child sexual abuse. The findings of this review need to be considered in the context of complementary prevention ini- tiatives. Current child sexual abuse prevention frameworks sug- gest that strategies must not only target children, but must work on multiple elements of children’s social systems to prevent abuse from occurring in the first place, namely at the level of the family, community, and society (Smallbone 2008).
Overall completeness and applicability of evidence
Studies were conducted in countries with high and upper-middle income economies according to the World Bank’s analytical in- come categories (The World Bank 2013). Most (16 of 24) were conducted in North America, the remainder in Europe, East Asia, and Central Asia. Ethnicity data were poorly or not reported in 10 of the 24 studies. Where data were reported, participants were from a diverse range of ethnicities, increasing the generalisability of
the evidence, and also suggesting that concern about child sexual abuse prevention and the delivery of programmes in schools is a wide-spread phenomenon. Whether similar effects would be seen when programmes are implemented in countries not included is unknown.
All but one of the included studies was conducted in primary (ele- mentary) school settings. There are several possible reasons for this. First, policy makers and school authorities may truly recognise that the age of greatest vulnerability is within the earlier school years (7 to 12 years according to Finkelhor 1986). Second, from our searches, we gleaned that programmes for secondary (high) school students tended to be broader in scope and focused on the pre- vention of relationship and dating violence, sexually coercive peer relationships, sexual harassment, or sexual assault (see Fellmeth 2013). The purpose of these programmes was not predominantly prevention of child sexual abuse, the focus of this review. In our searches we noted a sizeable group of studies based in preschool settings, the effectiveness of which requires further scrutiny in a separate systematic review given that these programmes have qual- itatively different delivery methods and contents, including greater parental participation, which we infer may have a mediating ef- fect.
None of the included studies investigated the effectiveness of a web-based or online programme. This may be because rigorous programme evaluations have not yet been developed, conducted, or published. Online programmes offer the potential for technol- ogy to capture real-time evaluation data from children as they ex- perience online interventions.
As noted above, the completeness and applicability of evidence was limited by methodology and failure to report the full range of child, intervention, and study design characteristics that could possibly account for variations in programme effects. In the period since the original review was conducted (Zwi 2007), Cochrane Reviews have become more rigorous in identifying methodological limitations in trials via risk of bias analyses, and the CONSORT statementhas been developed to provide guidance on the reporting of randomised controlled trials (Shulz 2010). Nevertheless, the methodological quality of trials has not improved substantially. No study in this area has yet published a study protocol, and we found no clinical trials register records pertaining to studies of this type. Researchers must continue testing these interventions, but use study design methodology, data collection tools, registration, and reporting guidelines that enable rigorous scientific evaluation.
Quality of the evidence
Summary of findings for the main comparison presents the qual- ity of evidence for each outcome of interest. We downgraded the quality of evidence to moderate quality either due to risk of bias, imprecision, or because of the impact of adjusting for the effect of clustering within some of the studies. Most studies in this review were at an unclear risk of selection bias as illustrated in Figure
1 and Figure 2, due to inadequate information regarding meth- ods of random sequence generation and allocation concealment. Studies which randomised classes within a single school to inter- vention and control groups were at high risk of contamination effects owing to the interaction of children in school playgrounds, friendship groups and families, and also from chance exposure to programme concepts via teachers and other school staff familiar with programme contents. In addition, there was detection bias due to inadequate or unclear assessor, participant and personnel blinding, and inadequate or unclear reporting of attrition for as- sessments at post-test and follow-up. Double-blinding to min- imise performance bias is seldom possible in school-based trials as group membership is obvious to participants, programme facili- tators, and school staff. Blinding of staff responsible for assessing study outcomes can be controlled with careful planning and im- plementation. This would be particularly effective where outcome assessments are administered with children individually. However, group administration of self report questionnaires or vignette mea- sures may be more susceptible to bias when used with younger participants who are not yet able to read independently. Alterna- tive administration methods, including the use of digital devices and animations, may go some distance to minimising detection bias.
In 14 of the included studies children were randomised in groups of classrooms, schools, or school districts for ease of implementa- tion. However, the appropriate analysis for cluster-randomisation was not used in any of the studies resulting in potential for over- estimation of the effects of interventions. Initial analyses do not take account of unit of analysis errors that occurred in at least half of the studies in each meta-analysis. ICCs used in the meta-anal- ysis are imputed and may not be appropriate for all of the stud- ies included. Therefore, results might have differed had the true ICCs from these studies been available, or had cluster-adjusted results been provided by the authors. Furthermore, the same ICC was used for studies that had undertaken cluster-randomisation at class, school, and district level, which could further overestimate the magnitude of the findings.
Potential biases in the review process
In producing this review our aim was to provide an unbiased ap- praisal of the evidence available. We have attempted, therefore, to be comprehensive in our reporting and transparent in our method- ology. The review was conducted in line with criteria in the pub- lished protocol (Zwi 2003), and where we deviated from these criteria to accommodate updates in Cochrane review methods or advances in the field, we have documented this in the subsection on Differences between protocol and review. The methodological decision to produce each meta-analysis was complex, involving a balance between the quest for an easily digestible summary of the information, and the danger of applying results when significant methodological caveats exist. We present the meta-analyses with
accompanying cautions as outlined above, and invite debate and comments regarding the route we have chosen.
Agreements and disagreements with other studies or reviews
Five previous meta-analyses of sexual abuse prevention pro- grammes exist as noted in Table 1, including the original ver- sion of this review (Zwi 2007). Our review differs from previous reviews in that it assesses a broader range of outcomes, applies more rigorous inclusion criteria to select high quality studies, and excludes preschool programmes. Further, all previous reviews in- cluded studies with control groups but did not apply randomi- sation criteria, therefore unlike our review, previous reviews in- cluded controlled before-and-after studies. All previous reviews have found medium to large effects for knowledge outcomes in favour of intervention groups. These effect sizes ranged from 0.57 (Heidotting 1994, 18 studies), through 0.71 (Rispens 1997, 16
studies) and 0.90 (Berrick 1992, 13 studies) to 1.07 (Davis 2000, 27 studies). Our previous review found a SMD of 0.59 (95% con- fidence interval (CI) 0.44 to 0.74; nine studies, n = 3022) for the questionnaire-based knowledge outcome, which is the outcome most comparable to the outcomes reported in previous reviews. The current review found a SMD of 0.61 (95% CI 0.45 to 0.78;
18 studies, n = 4657).
Davis 2000 attempted subgroup analyses to examine moderator effects: age (mean age was divided into three groups: three to five years, 5.1 to eight years, older than eight years of age), level of participation (participation was analysed at three different levels: physical participation, verbal participation, no participation), and number of sessions (three subsets: one session, two to three ses- sions, more than three sessions). Due to inadequate reporting of study data, we were unable to replicate these meta-analyses, and would caution against using the broad variable of participation as the only marker for programme variation. Given that most pro- grammes include multiple participatory opportunities, often in combination, it may be more informative to develop and explore the effects of multidimensional programme typologies as noted above.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
Our overall interpretation is that there is moderate quality evi- dence that school-based programmes for the prevention of child sexual abuse, of the types described in this review, are effective in increasing primary (elementary) school-aged children’s protec- tive behaviours and knowledge immediately post-intervention. Knowledge scores did not deteriorate for intervention participants
one to six months after programme participation, signalling that booster sessions or other maintenance strategies for reinforcement of key messages remain appropriate follow-up strategies. Retention of knowledge should be measured beyond six months. It appears that older children make greater knowledge gains than younger children when tested using questionnaire-based measures, but not when using vignette-based measures, indicating the need for cau- tion when interpreting study findings. None of the included stud- ies evaluated programmes delivered via electronic means. On bal- ance of evidence, programmes do not appear to increase or de- crease children’s fear or anxiety, and may result in greater odds of disclosures of past or current sexual abuse from children who have been programme participants, however results are uncertain be- cause of inappropriate data analysis in individual studies. Hence, there is a need for ongoing monitoring of both positive and nega- tive short- and long-term effects of programmes in more rigorous studies with more detailed reporting of potential moderators of programme effects in the form of child, programme, and contex- tual characteristics.
Currently, schools implement a variety of interventions aimed at preventing child sexual abuse. It is likely that these interventions will be most useful as part of wider community initiatives pro- moting the safety of children, the contents, processes, and out- comes of which must be clearly defined and measured in rigorous evaluation designs. Furthermore, children’s increased knowledge of abuse should not be seen as a replacement for society’s responsi- bility to ensure child safety. It must be emphasised that increasing children’s knowledge in this area does not mean they are in any way responsible for abuse, which might then occur by their not being able to apply this knowledge in an actual abuse situation. Even if successful in only a small proportion of situations, given the prevalence of child sexual abuse, it is possible that the skills and knowledge learned in prevention programmes may be of as- sistance to a considerable number of children.
Implications for research
Further evidence is required to assess the effectiveness of school- based programmes for the prevention of child sexual abuse. The current evidence is primarily focused on improvements in partic- ipants’ skills (protective behaviours) and knowledge (both factual and applied knowledge), and to a lesser extent on assessing harm (child anxiety or fear) and disclosures of past or current child sexual abuse. Further research is needed to investigate the links (if any) between programme participation and actual prevention of child sexual abuse. This will require large cohort studies with repeated follow-up into adulthood. However, even large cohort studies may not provide definitive evidence for changes in child sexual abuse incidence, as it is under-identified and difficult to prove. Further research is also required to address uncertainties about the mag- nitude of skill or knowledge improvement (or both) that can (if at all) translate to clinically important protective effects. Such ev-
idence is a necessary precursor to assessing programmes’ cost-ef- fectiveness.
Ongoing research is needed to more rigorously evaluate pro- grammes. Research to date suggests several categories of factors that may influence programme effectiveness, such as child fac- tors, including family microsystem factors; programme factors, including school contextual factors; and evaluation design factors (Heidotting 1994; Rispens 1997). These require further investi- gation in well-designed experimental studies. Many demographic and other independent variables were poorly reported in the in- cluded studies. Reliable evidence of this type will advance assess- ment of programmes’ cultural sensitivity, and the appropriateness of programmes for groups of children considered at greater risk. Future evaluations must be more comprehensive, use valid, reli- able, standardised measures, and be more precisely reported, ac- cording to evidence-based guidelines for reporting of clinical tri- als such as the CONSORT (Consolidated Standards of Reporting Trials) Statement (Shulz 2010).
Further investigation of programme contents, methods, and de- livery is required with a view to developing programme typolo- gies that can incorporate the programmes’ multidimensionality. To this end, typologies should be developed that capture variables emerging as important in newly developed frameworks for child sexual abuse prevention (Smallbone 2008), such as the extent and nature of parent, teacher, and community education components within programmes.
Future studies should address problems with study design, in par- ticular unit of analysis errors in cluster-randomised trials. Studies where cluster-randomisation is used should adjust results with ap- propriate statistical methods, and publish intra-class correlation coefficients (ICCs) (Campbell 2004). It may then be possible for meta-analyses to be more robust, and to overcome inadequate sam- ple size and study power to test for differences in child character- istics and intervention types. Other design features that warrant particular attention in future studies include those domains asso- ciated with risk of bias: randomisation of study participants, allo- cation concealment, blinding of outcome assessors, reporting of attrition, and analysis based on intention-to-treat (ITT). Longer follow-up periods for measurement of study outcomes beyond six months are essential to monitor maintenance effects.
A C K N O W L E D G E M E N T S
In the original review, Danielle M Wheeler acknowledged sup- port from the Financial Markets Foundation for Children and the Nordic Campbell Centre. Dr Andrew Hayen (Australia) and Dr Roger Harbord (UK) provided much valued statistical advice.
In the review update, Kerryann Walsh was funded by a Queens- land University of Technology Vice Chancellor’s Research Fellow-
ship (2010 to 2012) and acknowledges the Australian Research Council Discovery Projects scheme (DP1093717). Pauline Mulli- gan and Leisa Brandon provided much valued research assistance. The Australasian Cochrane Centre provided training and review completion workshops.
The authors are especially grateful for the comments of exter- nal Cochrane reviewers and statisticians, and for the expert ad- vice from the Cochrane Developmental, Psychosocial and Learn-
ing Problems Group editorial base: Professor Geraldine MacDon- ald (Co-ordinating Editor), Dr Joanne Wilson (Managing Edi- tor), Gemma O’Loughlin (Assistant Managing Editor), and Mar- garet Anderson (Trials Search Co-ordinator) who conducted the searches for this review update. The authors also wish to thank Laura MacDonald, former Managing Editor, Cochrane Develop- mental, Psychosocial, and Learning Problems Group, for her sup- port during development of the update of this review.
References to studies included in this review
Blumberg 1991 {publisfted and unpublisfted data}
R E F E R E N C E S
Fryer 1987a {publisfted data only}
∗ Fryer Jr GE, Kraizer SK, Miyoshi T. Measuring actual reduction of risk to child abuse: a new approach. Child
Blumberg EJ. The Effects of Two Sexual Abuse Prevention
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∗ Blumberg EJ, Chadwick MW, Fogarty LA, Speth TW, Chadwick DL. The touch discrimination component of sexual abuse prevention training: unanticipated positive consequences. Journal of Interpersonal Violence 1991;6(1): 12–28.
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Chen 2012 {publisfted and unpublisfted data}
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Crowley 1989 {unpublisfted data only}
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Dawson 1987 {unpublisfted data only}
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Grendel 1991 {unpublisfted data only}
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Harvey 1988 {publisfted data only}
Harvey P, Forehand R, Brown C, Holmes T. The prevention of sexual abuse: examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy 1988;19(3):429–35.
Hazzard 1991 {publisfted data only}
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Krahé 2009 {publisfted data only}
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primary school children in Germany. Journal of Community & Applied Social Psychology 2009;19(4):321–9.
Kraizer 1991 {publisfted and unpublisfted data}
∗ Kraizer S. The Safe Child Program for the Prevention of Child Abuse: Development and Evaluation of a School-Based
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Lee 1998 {publisfted data only}
Lee YK, Tang CS. Evaluation of a sexual abuse prevention program for female Chinese adolescents with mild mental retardation. American Journal of Mental Retardation 1998; 103(2):105–16.
Oldfield 1996 {publisfted data only}
Oldfield D, Hays BJ, Megel ME. Evaluation of the effectiveness of Project Trust: an elementary school-based victimization prevention strategy. Child Abuse & Neglect 1996;20(9):821–32.
Poche 1988 {publisfted data only}
Poche C, Yoder P, Miltenberger R. Teaching self-protection to children using television techniques. Journal of Applied Behavior Analysis 1988;21(3):253–61.
Saslawsky 1986 {publisfted data only}
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Snyder 1986 {unpublisfted data only}
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Tutty 1997 {publisfted data only}
∗ Tutty LM. Child sexual abuse prevention programs: evaluating ’Who do you tell’. Child Abuse & Neglect 1997; 21(9):869–81.
Tutty LM. What children learn from sexual abuse prevention programs: difficult concept and developmental issues.
Research on Social Work Practice 2000;10(3):275–300.
Wolfe 1986 {publisfted data only}
Wolfe DA, MacPherson T, Blount R, Wolfe VV. Evaluation of a brief intervention for educating school children in awareness of physical and sexual abuse. Child Abuse & Neglect 1986;10(1):85–92.
Wurtele 1986 {publisfted data only}
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e en-Ero ul 2013 {publisfted data only}
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Ages 1991 {publisfted data only}
Ages SE. An Evaluation of the Maintenance of Changes in Knowledge and Behaviour Skills Effected by a School-Based Personal Safety Program for the Primary Grades [PhD thesis]. Ottawa, Canada: Carleton University, 1991.
Alexander 1998 {publisfted data only}
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Toronto, Canada: University of Toronto, 1998.
Araji 1995 {publisfted data only}
Araji SK, Fenton R, Straugh T. Child sexual abuse: description and evaluation of a K-6 prevention curriculum. Journal of Primary Prevention 1995;16(2):149–64.
Bae 2009 {publisfted data only}
Bae J, Panuncio R. Development of computer-assisted instruction program for child sexual abuse prevention. International Journal of Computer Science and Network Security 2009;9(3):142–7.
Baker 2013 {publisfted data only}
∗ Baker CK, Gleason K, Naai R, Mitchell J, Trecker
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Deretzotes 1989 {publisfted data only}
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Dhooper 1995 {publisfted data only}
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Foshee 1996 {publisfted data only}
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Garbarino 1987 {publisfted data only}
Garbarino J. Children’s response to a sexual abuse prevention program: a study of the Spiderman comic. Child Abuse & Neglect 1987;11(1):143–8.
Herman 1987 {publisfted data only}
Herman P. Evaluation of a Sexual Abuse Curriculum/ Prevention Program [PhD thesis]. Washington, United States: Washington State University, 1987.
Jacobs 1995 {publisfted data only}
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Kindt 1995 {publisfted data only}
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Madak 1992 {publisfted data only}
Madak PR, Berg DH. The prevention of sexual abuse: an evaluation of “Talking About Touching”. Canadian Journal of Counselling 1992;26(1):29–40.
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Michaelson 2001 {publisfted data only}
Michaelson R. Development, Evaluation and Revision of the School-Based Child Sexual Abuse Prevention Program (CSAPP Project) [PhD Thesis]. St Alban’s, Australia: Victoria University of Technology, 2001.
Miller 2011 {publisfted data only}
Miller E, McCauley H, Virata MC, Decker M, Trancredi D, Moideen F, et al. Coaching boys into men: preliminary success of a sexual violence prevention program. Journal of Adolescent Health 2011;48(2 Suppl):S85–6.
Miller 2012 {publisfted data only}
Miller E, Tancredi DJ, McCauley HL, Decker MR, Virata MCD, Anderson HA, et al. Coaching boys into men: a cluster-randomized controlled trial of a dating violence
prevention program. Journal of Adolescent Health 2012;51 (5):431–8.
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Moreno-Manso 2014 {publisfted data only}
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Ogunfowokan 2012 {publisfted data only}
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Pacifici 2001 {publisfted data only}
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Peraino 1990 {publisfted data only}
Peraino JM. Evaluation of a preschool antivictimization prevention program. Journal of Interpersonal Violence 1990; 5(4):520–8.
Pohl 1990 {publisfted data only}
Pohl JD, Hazzard A. Reactions of children, parents, and teachers to child sexual abuse prevention programs. Education 1990;110(3):337–4.
Smothers 2011 {publisfted data only}
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Taal 1997 {publisfted data only}
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Taylor 1991 {publisfted data only}
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Taylor 2010a {publisfted data only}
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Tutty 1991 {publisfted data only}
Tutty LM. An Investigation of the Ability of Elementary School-Aged Children to Learn Child Sexual Abuse Prevention Concepts [PhD thesis]. Alberta, Canada: University of Calgary, 1991.
Tutty 1992 {publisfted data only}
Tutty LM. The ability of elementary school children to learn child sexual abuse prevention concepts. Child Abuse & Neglect 1992;16(3):369–84.
Volpe 1984 {publisfted data only}
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References to ongoing studies
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∗ Indicates the major publication for the study
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Blumberg 1991
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 264 kindergarten, 1st, 2nd, and 3rd grade students
Mean age: 7.2 years
Gender: 53% male; 47% female
Ethnicity: 51% Caucasian; 18% Black; 17% Hispanic; 7% Asian; 7% Other Setting: 3 city elementary schools in San Diego unified school district, California Country: USA
Attrition: intervention group 14/99 = 14.1%; intervention group 7/86 = 8.1%; control
group 3/79 = 3.8%
Interventions Intervention 1: role-play programme (“Stop, Tell someone, Own your body, Protect yourself ” (STOP))
• Content: body ownership/body rights; body openings needing protection (eyes, ears, private places); appropriate and inappropriate touches; safety rules (Stop, Go, Tell, tell, tell and keep telling until somebody listens); perpetrators are usually someone known to the child; sexual abuse is not the child’s fault; appropriate and inappropriate secrets
• Methods: role-play, modelling, rehearsal, and discussion
• Delivery: by volunteers trained by a licensed social worker with expertise in child sexual abuse
Intervention 2: multimedia programme (“Child Abuse Primary Prevention Program” (CAPPP))
• Content: discriminating types of touches based on feelings; they have the right to say no; safety rules “Say No,” “Go,” and “Tell”; no one should touch private areas unless you need help; “touching secrets” or secrets that hurt should never be kept;
sexual abuse is never the child’s fault
• Methods: younger children were taught concepts through use of teddy bear and viewed a film; older children were taught through a puppet show and discussion
• Delivery: by educators, counsellor, school nurse, teachers, all trained by the school nurse
Control: fire prevention programme Duration: 1 x 1-hour session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): yes, reported in Chadwick 1989 Knowledge (vignette-based knowledge): Touch Discrimination Task, comprising 7 vi- gnettes in which an adult touched a child in some way
Disclosures: child protective services file search at 15 months post intervention
Harm: not reported
Other: fear survey, sexual abuse knowledge index, and measure of behavioural acquisition,
Blumberg 1991 (Continued)
reported in Chadwick 1989
Last outcome assessment: 3 to 94 days post intervention
Notes Author contact: yes
This study was part of a larger study (n = 486) reported in Blumberg 1987 and Chadwick 1989
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Classrooms were randomly allocated for treatments. Student participation was based on parental consent” (p 15). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Students within the same school received 1 of 3 interventions (role-play programme, multimedia programme, or control fire sa- fety). It is possible that children may have been aware of this or exposed to other factors/information apart from the inter- vention they were receiving, or both (e.g. through treatment-control contamination via playground, siblings, or friendships). Blinding of key personnel (e.g. teachers) may not have been possible in the school delivery context
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “The children were not informed that the interviews were related to the presenta- tions” (p 20). Outcome assessors were dif- ferent to the persons providing the inter- ventions. “Interviewers were blind to the group membership of the children, and no child was interviewed more than once by the same interviewer to control for poten- tial effects of rapport building” (p 19)
Incomplete outcome data (attrition bias) All outcomes
High risk Attrition: intervention group 1 14/99 = 14. 1%; intervention group 2 7/86 = 8.1%; control group 3/79 = 3.8%. Reasons for at- trition were not reported
Blumberg 1991 (Continued)
Chen 2012
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat: no Adjustment for clustering: no
Participants Total number randomised: 46 students in grades 1 through 6
Mean age: 9.02 years Gender: not reported Ethnicity: 100% Taiwanese
Setting: 1 public elementary school in a rural area in southern Taiwan Country: Taiwan
Attrition: 0%
Interventions Intervention: child sexual abuse prevention training based on Red Flag/Green Flag People (Rape and Abuse Crisis Center 2008) and Red Flag/Green Flag People II (Grimm 1994)
• Content: body ownership; distinguishing appropriate from inappropriate touches and requests; distinguishing types of secrets; and abduction prevention training based on the book “Who Is a Stranger and What Should I Do?” (Girard 1985)
• Methods: instruction; modelling, role-play, rehearsal, practice, feedback, and reinforcement
• Delivery: details not reported Control: wait list control
Duration: 2 x 50-minute sessions delivered “at the beginning of the school day… before children began their regular academic classes” (p 628)
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Children’s Sexual Knowledge Question- naire (CSKQ), a 6-item self report knowledge questionnaire with response items correct/ incorrect/I don’t know
Knowledge (questionnaire-based knowledge): Children’s Awareness of Scary Secrets (CASSQ), a 6-item self report measure to distinguish okay from not okay secrets. Items
Chen 2012 (Continued)
scored correct/incorrect
Knowledge (vignette-based knowledge): Chinese What If Situations Test (CWIST), comprising 6 hypothetical situations (3 appropriate and 3 inappropriate) to which chil- dren respond okay or not okay and then answer to a standard list of 4 further questions Disclosures: not reported
Harm: not reported Other: no
Last outcome assessment: 2 to 3 weeks after programme completion
Notes Author contact: yes
This study is reported as a “pilot” programme
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Children in each group then were ran- domly assigned to the skills-based CSA pre- vention program (n = 23) or the WLC con- dition (n = 23)…” (p 625). Method of ran- domisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. No significant differences between the groups were observed “on the demographic variables (e.g. gender, race, age) or on other measures administered at pretest” (p 632)
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported
Blinding of outcome assessment (detection bias)
All outcomes
High risk Outcome assessment was administered in group format but no further information was reported. The identities of the out- come assessors were not specifically re- ported however we assume the outcome as- sessors were the same personnel as those de- livering the programme
Incomplete outcome data (attrition bias) All outcomes
Low risk The study reported “all children enrolled in the study completed the pre- and post- assessment instruments and completed the treatment” (p 632)
Chen 2012 (Continued)
Crowley 1989
Methods Design: quasi-experimental randomised Solomon 4-group design Unit of allocation: classes or homerooms
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 293 4th and 5th grade students
Mean age: not reported; data provided for grade level only Gender: 45% male; 55% female
Ethnicity: not reported
Setting: 4 elementary schools in the Bedford Central School District, Westchester County, New York
Country: USA
Attrition: the study consisted of 367 “potential participants” (p 45). Data on 74 par- ticipants (20%) were excluded due to missing or incomplete data, or absence during a portion of the study
Interventions Intervention: “Good Touches/Bad Touches: A Program to Prevent Child Sexual Abuse” devised by the MHAWC 1984 (group 1 and group 3)
• Content: individuals are unique and special; feelings are special and important; different kinds of touches; body ownership; touching; saying no; distinguishing types of secrets; identifying trusted adults; how to tell
• Methods: discussion; structured activities, including active participation and rehearsal; film; review
• Delivery: by school psychologists, school social worker, school nurse, and teacher who received 2 training sessions by programme developers (5 hours) plus departmental training (2 hours)
Control: wait-list control (group 2 and group 4)
Duration: 2 x 45-minute sessions, once per week for 2 weeks
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Sexual Abuse Knowledge Inventory (SAKI), a 27-item multiple choice format test
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ) (
Saslawsky 1986), a 13-item test. Used to establish construct validity of the SAKI Knowledge (vignette-based knowledge): no
Disclosures: not reported Harm: not reported Other: no
Last outcome assessment: 3 months after programme completion
Crowley 1989 (Continued)
Notes Author contact: no
Solomon 4-group design consisted of: group 1: pre-tested treatment; group 2: pre-tested control; group 3: unpre-tested treatment; group 4: unpre-tested control
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Fourth and fifth grade children (n = 293) were randomly assigned to one of four groups” (p iii). Method of randomisation was not reported
Allocation concealment (selection bias) High risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances were conducted: “suc- cessful randomisation of Groups 1 & 2 did not occur” (pp 60 - 61). There were differ- ences in pre-test mean scores for groups 1 and 2. Group 1 had higher scores on the pre-test SAKI than group 2. Group 3 had higher scores on the SAKI and PSQ than group 4
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. It did not seem that the intervention groups were blinded to their own con- dition. Homeroom teachers were present during programme delivery, so it was not possible for them to be blinded to the stu- dents’ conditions
Blinding of outcome assessment (detection bias)
All outcomes
High risk Group administration of the outcome as- sessment meant that outcome assessors would need to be blinded to the condition of each entire class or homeroom. Given that the assessors were school staff, blinding was not possible. On some occasions the outcome assessor was the researcher who was not blinded to the groups. On some other occasions the outcome assessor was the programme presenter who was also not blinded to the groups
Incomplete outcome data (attrition bias) All outcomes
High risk Data on 74 participants (20%) were ex- cluded due to missing or incomplete data, or absence during a portion of the study
Crowley 1989 (Continued)
Daigneault 2012
Methods Design: quasi-experimental design with random assignment of participants to groups Unit of allocation: schools
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Participants: 160 1st, 2nd, 3rd, and 4th grade students Mean age: 7.75 years
Gender: not reported
Ethnicity: reported as country of birth. 48% Canada; 14.5% Middle East; 13% Asia; 10% Africa; 7% Europe; 4% South America; 3% North America; 0.5% Oceania Setting: 3 public schools in low socioeconomic areas of Montreal, Canada
Country: Canada Attrition: not reported
Interventions Intervention: ESPACE child sexual abuse prevention programme, “a French adaptation of the CAP workshop (Cooper 1991)” (p 525) for children aged 3 to 12 years
• Content: awareness of personal rights; (safe, strong, secure), self assertion skills (self defence yell), and appropriate responses to instances of abuse (seeking out peer support, confiding in a trusted adult). Also included prevention of verbal and physical violence
• Methods: role-playing, guided discussions, behaviour modelling, and rehearsals
• Delivery: 3 trained community workers from diverse ethnic backgrounds Booster: Confidence, Solidarity, Respect (CSR) based on ESPACE (p 526)
• Content: revision of prevention knowledge; definitions of aggression and violence; cycle of violence; ways of using power positively; impact of behaviour on others
• Methods: guided discussions, behaviour modelling, role-playing and rehearsals.
• Delivery: “instructors” not otherwise specified (p 526) Control: wait-list control (table 2)
Duration: 1 x 90 minute workshop
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): French translation of 24-item CKAQ ( Tutty 1995)
Knowledge (vignette-based knowledge): adaptation of the WIST (Wurtele 1998) com- prising 3 vignettes matching ESPACE content with response options (yes/no) to 4 pos- sible behaviours for each vignette (12 items in total)
Disclosures: not reported
Harm: children’s feelings of safety, an 11-item measure adapted from Schwab-Stone 1995 Other: children’s peer victimisation over the past week, a 10-item measure adapted from Orpinas 1995
Last outcome assessment: “in the second year of the study” (p 530)
Daigneault 2012 (Continued)
Notes Author contact: yes
Study reports on booster componentwith 4 additional outcome measures: general knowl- edge about violence; confidence in others; empathic concern; and respect towards others
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Schools were randomly assigned to condi- tions across two years of the study” (p 527)
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Low risk “Interviewers (n = 7) and ESPACE instruc- tors (n = 4) were blind to school status at T1 and T2. Only interviewers were blind to school status at T4 and T5” (p 527). Blinding procedures were not described
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “Interviewers (n = 7) and ESPACE instruc- tors (n = 4) were blind to school status at T1 and T2. Only interviewers were blind to school status at T4 and T5” (p 527). Blinding procedures were not described
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition was not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article are reported in the results
Dake 2003
Dake 2003 (Continued)
Interventions Intervention: child abuse prevention curriculum modified from an existing curriculum (title not reported)
• Content: abuse problems children may encounter; people in family and community support systems that children can turn to in abuse situations; 3 types of touches; personal safety rules regarding potential child abuse; child abuse is never a
child’s fault; child abuse should never be kept secret; empathy for others who find themselves in abusive situations
• Methods: role-play, video, discussion
• Delivery: by employees of a child abuse prevention agency and trained volunteers (all had attended a 30-hour training programme)
Control: wait-list control Duration: 2 x 1-hour sessions
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): custom made 26-item questionnaire in- cluding: 16 knowledge items; 5 efficacy expectation items (confidence take action in abuse situations); 4 demographic items; and 1 item that determined if the children knew an extra familial adult they could talk to about abuse
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported Other: no
Last outcome assessment: 3 months after programme completion
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Low risk Method of randomisation was not re- ported. Evidence of computer randomisa- tion provided after author contact (Zwi 2007)
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. No statistical differences were evident be- tween intervention and control groups on outcome measures for knowledge or effi- cacy expectations
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported
Dake 2003 (Continued)
Dawson 1987
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment of clustering: no
Participants Total number randomised: 237 4th, 5th, and 6th grade students Mean age: 10.6 years
Gender: 54% male; 46% female
Ethnicity: 53.2% White; 46.8% Black Setting: 2 Memphis City public schools Country: USA
Attrition: intervention group, 7/96 (7.3%); control group 1, 2/76 (2.6%); control group 2, 2/65 (3.1%)
Interventions Intervention: child sexual abuse prevention programme presentation, including the ap- propriate grade level film from the series “Child Sexual Abuse: A Solution” (Adams 1984)
• Content: definitions; session standards; purpose of session; discriminate appropriate and inappropriate touches; trusting feelings; talking with a trusted adult; offender characteristics and approaches; offenders are likely to be someone they know; personal safety rules; distinguishing appropriate and inappropriate secrets; child sexual
abuse is against the law; children are not to blame; skills for resisting or avoiding abuse; identifying support systems
• Methods: film; role-play; modelling; problem-solving activities (“what if ” situations); questions and answers
• Delivery: by school district sexual abuse co-ordinator Control 1: no presentation (same school as intervention group) Control 2: no presentation (different school)
Duration: 1 x 60-minute session
Dawson 1987 (Continued)
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Issues Test, a 10-item mul- tiple choice test
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported Other: no
Other: State-Trait Anxiety Inventory for Children (STAIC) (Speilberger 1966), 20 state-
ments designed to measure transitory anxiety
Last outcome assessment: 6 weeks post intervention
Notes Author contact: no
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Classes in the selected schools were ran- domly assigned to the different treatment groups” (p 45). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances were conducted. Age, race, and gender ratios were not sig- nificantly different among groups. How- ever, results showed that the mean pre-test knowledge test score for group B (control
1) was significantly higher than A (inter- vention) or C (control 2) on the pre-test (p 82)
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within one school were receiv- ing both treatment and control conditions. Authors indicate that children may have been exposed to “grapevine” effect (p 51) whereby information was transmitted in- formally throughoutthe school, or between siblings in a family or across families hav- ing contact with each other outside of school. School personnel did not appear to be blinded to group or class membership so there is risk of differential treatment of groups
Dawson 1987 (Continued)
Del Campo Sanchez 2006
Del Campo Sanchez 2006 (Continued)
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): questionnaire on knowledge about sexual abuse, a 35-item test comprising 33 knowledge and skill items and 2 items on commu- nication with parents about child sexual abuse
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ) ( Saslawsky 1986), a 13-item test. Used to establish construct validity of the questionnaire on knowledge about sexual abuse
Knowledge (vignette-based knowledge): no
Disclosures: spontaneous child disclosures reported (8/277 or 2.9% in experimental groups; 2/105 or 1.9% in control group)
Harm: information on programme side effects was collected in a questionnaire for parents (12-item version) and educators (9-item version) asking for observations of positive and negative changes in children’s behaviour after programme completion
Other: qualitative assessment of children’s participation in the programme during deliv-
ery. These data were collected using an observation sheet completed by educators acting as “participant observers” (p 2)
Last outcome assessment: 8 months after programme completion
Notes Author contact: yes
The curriculum evaluated in this study is the 1st elementary school curriculum of its type developed for delivery in Spain
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Subjects were randomly assigned” (p 2). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. There were no baseline imbalances regard- ing pre-treatment knowledge and skills in groups
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk The method of assessment (group or in- dividual administration) was not reported. The measures used to blind outcome asses- sors from knowledge of which intervention participants received was not reported
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not reported
Del Campo Sanchez 2006 (Continued)
Fryer 1987a
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 48 kindergarten, 1st, and 2nd grade students
Mean age: not reported Gender: not reported Ethnicity: not reported
Setting: 1 mid-town Denver elementary school
Country: USA Attrition: < 10%
Interventions Intervention: “Children Need to Know Personal Safety Training Program” (Kraizer 1981)
• Content: 4 safety rules to follow when they were not with care-taking adults: stay an arm’s reach away from strangers; don’t talk to them; don’t take anything from them; don’t go anywhere with them
• Methods: role-play
• Delivery: details not reported Control: wait-list control
Duration: 1 x 20-minute presentation, once per day for 8 days
Outcomes Protective behaviours simulation: yes. Involved staging of actual simulations used to record children’s responses indicating their “degree of vulnerability to abuse” (p 175) Knowledge (questionnaire-based knowledge): Children Need to Know Knowledge At- titude Test, a 20-item examination (results not reported)
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: discussed but not measured
Other: Harter Perceived Competence Scale for Children (Harter 1982) used to measure self esteem (results not reported)
Last outcome assessment: for the simulation “the day after the classroom program” (p 175); for the questionnaire measures “immediately following the instruction” (p 177)
Notes Author contact: yes
The results of this study are also reported in Fryer 1987b
Risk of bias
Fryer 1987a (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Twenty-four each were randomly assigned to the experimental and control groups tested” (p 174). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances revealed “pretest scores on each of the three tests administered were very nearly the same for the two study groups” (p 177)
Blinding of participants and personnel (performance bias)
All outcomes
High risk As there was only 1 intervention group, there was no possibility for systematic dif- ferences between groups in the way in which the programme was delivered. How- ever, as the control group were from the same school, they may have experienced some contamination or exposure to the programme via other students in the play- ground, or friends, or siblings outside of the study setting
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Children were blinded to the simulation test. “A research assistant, posing as a stranger” (p 175) conducted the outcome assessment. The blinding of the assessor (if any) is not reported. “A hidden camera and wireless microphone produced an audio- visual record of the encounter which was later reviewed and scored by research team members” (p 176). Interrater reliability was established as 1.0 (total reliability)
Incomplete outcome data (attrition bias) All outcomes
High risk Missing data were reported for 1/24 in ex- perimental group (4%) and 3/24 for the control group (12.5%). Data were gathered only from children present on both testing days
Selective reporting (reporting bias) High risk Not all measures discussed in the methods section of the article were also reported in the results. The results reported in the pa- pers refer only to the simulation
Grendel 1991
Methods Design: cluster-RCT
Unit of allocation: classrooms and individuals Intention-to-treat analysis: no
Adjustment for clustering: no, although in some analyses ANCOVA was used to enable adjustment for confounding because of the influence of intact groups
Participants Total number randomised: 100 1st grade students
Mean age: 6.9 years
Gender: 48% male; 52% female
Ethnicity: 84.3% White; 15.7% African-American (intervention group); 79.6% White; 18.4% African-American (control group)
Setting: “2 public schools serving a middle income, predominantly white population
from a large school district in the northern part of the Greater Cincinnati area” (p 66) Country: USA
Attrition: intervention group, 12/62 (19%); control group, 14/63 (22%)
Interventions Intervention: “Child Sexual Abuse Prevention Program” (developed by Women Helping Women, Ohio)
• Content: what is a stranger?; public versus private parts of the body; happy versus sad touches; trusting your feelings or inner voices; 3 body safety rules (say no, get away, tell someone); what if situations/concrete examples; who could you trust to tell?
• Methods: film, discussion, and review
• Delivery: by Women Helping Women education programme co-ordinator Control: wait-list control
Duration: 1 x 50-minute session
Outcomes Protective behaviours simulation: no
Knowledge (Questionnaire-based knowledge): Personal Safety Questionnaire (PSQ) ( Saslawsky 1986), 15 items. “A few minor changes were made in the wording of the PSQ fort his study, but the meaning of the questions remained unchanged” (p 80) Knowledge (vignette-based knowledge): “What If ” Situations Test (Wurtele 1989), 6 hypothetical situations, including 3 appropriate and 3 inappropriate touch situations. After each vignette there are 5 questions
Disclosures: not reported Harm: not reported
Other: Parent Perception Questionnaire (Wurtele 1989); Teacher Perception Question- naire (Wurtele 1989); Children’s Reactions to Prevention Program (adapted from Binder 1987b; Hazzard 1991)
Last outcome assessment: 1-day post intervention
Notes Author contact: no
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “In each school one intact class was ran- domly assigned to the treatment group, a second intact class was randomly assigned
Grendel 1991 (Continued)
to the control group, and the students in the third class were randomly assigned to ether the treatment or control group” (p 69). Method of randomisation was not re- ported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances were conducted: “the results of the demographic data indicate that the treatment and control groups were very similar on the variables assessed... both groups demonstrated comparable knowl- edge about sexual abuse and sexual abuse prevention skills” (pp 88-90)
Blinding of participants and personnel (performance bias)
All outcomes
High risk The intervention groups were not blinded to their own condition and school person- nel were not blinded to group or class con- ditions since teachers attended training and completed measures. Since both interven- tion and control groups were from the same school, there is a possibility of treatment- control contamination effects
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Outcome assessment was conducted indi- vidually with each participant. “Every ef- fort was made to keep the assistants naive to the hypotheses and to the group mem- bership of the subjects” (p 72)
Incomplete outcome data (attrition bias) All outcomes
High risk Incomplete outcome data, mainly in the form of “missing data due to students’ absence, withdrawal from school, unwill- ingness to participate” (p 70). This is high: 19% intervention group; 22% con- trol group
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article were also reported in the results
Harvey 1988
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 90 kindergarten children
Mean age: 5.8 years (70 months) Gender: not reported
Ethnicity: 56.3% Caucasian; 43.7% Black Setting: 4 schools in a rural area near Georgia Country: USA
Attrition: 21%
Interventions Intervention: “Good Touch-Bad Touch” programme (citation not reported)
• Content: defining sexual abuse; differentiating between good, bad, and sexually abusive touches; identifying who can sexually abuse children; 5 body safety rules (I can decide with whom I want to share my body; recognising when “something wrong” is happening to me; learning to say “no” and get away; learning to tell someone what happened; and recognising that, if abuse occurs, it is never my fault)
• Methods: storybook, game, film, song, and role-plays. Utilising modelling, rehearsal, and social reinforcement as teaching procedures
• Delivery: by 2 members of the research team who were experienced programme presenters
Control: story, discussion, film, and song not related to child sexual abuse Duration: 3 x 30-minute sessions across 3 consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): basic knowledge, a 5-item test Knowledge (vignette-based knowledge): good touch/sexually abusive touch pictures, comprising 10 pictures of young children interacting with an adult. 5 pictures represented good touches, and 5 pictures represented sexually abusive touches
Knowledge (vignette-based knowledge): direct test, comprising 2 scenes (taught as part of the programme) followed by 6 questions
Knowledge (vignette-based knowledge): generalisation test, comprising 2 scenes (not taught as part of the programme) followed by 6 questions
Disclosures: not reported Harm: not reported Other: no
Last outcome assessment: 7 weeks after programme completion
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Children in each of the four schools were randomly assigned (with the restriction that at the pre intervention assessment
Harvey 1988 (Continued)
there was approximately an equal num- ber of black and white boys and girls per group) to one of two groups: an experimen- tal group and a placebo control group” (p 432). Method of randomisation was not re- ported
Allocation concealment (selection bias) Unclear risk Method of concealment was not de- scribed. Potentially unconcealed proce- dure. In terms of baseline imbalances, re- sults indicated no significant differences in the age of children, family socioeconomic status, gender, or race between experimen- tal and control groups
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. 2 “experimenters” delivered the intervention programme (p 431). “Each experimenter conducted experimental and placebo con- trol sessions in two schools” (p 431). These individuals could not have been blinded to study conditions, however the use of 2 in- dividuals increases the risk that compared groups received different interventions
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk Outcome assessment was conducted “indi- vidually for each child at pre intervention, postintervention, and follow up” (pp 431- 2). The measures used to blind outcome as- sessors from knowledge of which interven- tion participants received was not reported
Incomplete outcome data (attrition bias) All outcomes
High risk Attrition was reported only for the study overall, and not specified for intervention and control groups. Attrition and miss- ing data were attributed to student absence during the programme or testing, and mov- ing from the school. Attrition was calcu- lated overall as 19/90 (21%)
Selective reporting (reporting bias) High risk Not all measures discussed in the methods section of the article were also reported in the results. Means and SDs for knowledge outcomes were measured but not reported
Hazzard 1991
Methods Design: cluster-RCT
Unit of allocation: schools Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 399 3rd and 4th grade students
Mean age: not reported Gender: 50% male; 50% female
Ethnicity: 68% Caucasian; 23% Black; 4% Hispanic; 3% Asian; 2% Other
Setting: 27 classrooms (14 x 3rd grade and 13 x 4th grade) in 8 city elementary schools from a suburban school district in a large southeastern city
Country: USA
Attrition: not reported
Interventions Intervention 1: teacher and child training comprising a 6-hour workshop for teachers and adaptation of “Feeling Yes, Feeling No” (National Film Board of Canada 1985) sexual abuse prevention curriculum for children and homework handouts
• Content: touches can give children positive or negative feelings; children can say no, leave, and tell a trusted adult; sexual abuse is when a grown-up or older child touches the private parts of your body or asks you to touch or look at their private parts; children can problem-solve (use “3 stranger questions”) to avoid dangerous
situations with strangers; sometimes children are sexually abused by someone they know; there are many adults who can help sexually abused children so keep telling if the first adult you tell does not believe you; and sexual abuse is never the child’s fault
• Methods: video tape, discussion, and role-play, plus Spiderman and Power Pack comic book (Marvel Comics 1984) and homework handouts
• Delivery: by female mental health professional with expertise in child sexual abuse Intervention 2: child training only as per intervention 1
Intervention 3: teacher training only as per intervention 1
Control: fire or water safety programme, and wait-listed to receive the programme after follow-up testing was completed
Duration: 3 x 1-hour sessions
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): What I Know About Touching scale, a 25-item measure testing knowledge of concepts, including: definitions of sexual abuse, characteristics of abusers, who can be abused, it’s ok to say no, it’s okay to tell about abuse, and sexual abuse is not the child’s fault
Knowledge (vignette-based knowledge): What Would You Do? A video tape measure
comprising 6 x 30-second scenarios, which were not shown or discussed in the prevention programme. This outcome assessment was administered to 4 to 6 randomly selected children from each treatment group at post-test and follow-up
Disclosures: yes Harm: not reported
Other: State-Trait Anxiety Inventory for Children (STAIC) (Spielberger 1973); parent measure (adapted from Miller-Perrin 1986)
Last outcome assessment: 1-year follow-up
Notes Author contact: yes
Hazzard 1991 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “One school from each set was randomly assigned to one of four conditions” (p 125). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk “All teachers were aware that different schools were receiving different services and were told that we were evaluating the effec- tiveness of different models of sexual abuse prevention training” (pp 125-6). “Since the child prevention program was presented by professional trainers rather than teach- ers themselves, the teacher training com- ponent was not expected to have a major impact on children’s gains at post-testing. However, it was expected that if Condition 1 teachers became more knowledgeable and supportive of prevention education as a re- sult of their own training, their students might demonstrate continued increases in prevention knowledge and skills over the 6- week follow-up period” (p 126)
Blinding of outcome assessment (detection bias)
All outcomes
High risk Outcome assessments were conducted via group administration by a research assis- tant who read the scripts to participating children in each class. However, the video measure was administered at post-test and follow-up to a random sample of 4 to 6 children from each group. The video mea- sure was “administered by a trained re- search assistant to each child as an individ- ual structured interview. Interviewers were not blind to subjects’ treatment condition since schools were assigned to condition” (p 128)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition between pre- and post-test was not re- ported. However, complete data were re- ported for 103/399 at 1-year follow-up (25. 8%)
Hazzard 1991 (Continued)
Hébert 2001
Methods Design: quasi-experimental randomised Solomon 4-group design Unit of allocation: schools
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Participants: 133 1st and 3rd grade students Mean age: 7 years 2 months
Gender: 50% male; 50% female Ethnicity: not reported
Setting: 2 primary schools in Quebec City situated in middle-income areas Country: Canada
Attrition: not reported
Interventions Intervention: ESPACE child sexual abuse prevention program, “an adaptation of the widely implemented American Child Assault Prevention Program [CAPP] (Cooper 1991)” (p 508)
• Content: enhance children’s awareness of their personal rights; basic prevention concepts and skills; self assertion skills; self defence yell; children are encouraged to ask friends for help and to tell a trusted adult if abuse occurs; covers issues relating verbal and physical abuse and bullying; workshops for parents and teachers are included
• Methods: role-playing, guided discussions, behaviour modelling, and rehearsal
• Delivery: by female community workers
Control: wait-list control, scheduled to receive the programme in the next calendar year
Duration: 1 x 60- to 75-minute workshop
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): knowledge questionnaire, an 11-item measure derived from the CKAQ (Tutty 1995) and the PSQ (Saslawsky 1986) Knowledge (vignette-based knowledge): vignette measure of skills, comprising 5 video vignettes (4 depicting abuse situations; 1 non-abusive situation)
Disclosures: not reported
Harm: data on potential side effects of the programme were gathered from parents who completed the PPQ 2 weeks after programme completion
Other: children’s programme satisfaction measure; parent questionnaire adapted from the PPQ (Wurtele 1989); programme fidelity measure
Last outcome assessment: 2 months after programme completion
Notes Author contact: yes
Solomon 4-group design consisted of: group 1 treatment group (pre-test, post-test and follow-up); group 2 control group (pre-test and post-test); group 3 treatment group (post-test and follow-up only); group 4 control group (post-test only)
Hébert 2001 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Assignment of schools to conditions was determined randomly” (p 509). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. There were no significant differences be- tween intervention and control groups with respect to “exposure to prevention informa- tion prior to their participation in the pro- gram” (p 512)
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students in the same school received the same intervention. It is likely that partici- pants were not blinded to their condition. School personnel were not blinded to the conditions of children within the school as teachers received training as part of the pro- gramme
Blinding of outcome assessment (detection bias)
All outcomes
High risk “The program was delivered in class by three female community workers. Six grad- uate students were recruited as interview- ers, all of whom had extensive experience with children in school settings” (p 511). “The questionnaire was administered col- lectively in class” (p 509) meaning that out- come assessors would need to have been blinded to the condition of whole schools. This is unlikely under the circumstances. The video vignettes were watched in small groups of 4 or 5 children and questions were answered individually
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article were also reported in the results section
Kolko 1989
Methods Design: cluster-RCT
Unit of allocation: school districts Intention-to-treat analysis: no Adjustment for clustering: no
Participants Participants: 337 3rd grade students
Mean age: 8.3 years (experimental group); 8.5 years (control group)
Gender: 52% male, 48% female (experimental group); 57% male, 43% female (control group)
Ethnicity: not reported
Setting: elementary schools in Washington County, Pennsylvania Country: USA
Attrition: from enrolment to 2-week post-test 16.2%; from enrolment to 6-month fol- low-up 25.3%
Interventions Intervention: Red Flag/Green Flag programme (Williams 1980)
• Content: defining sexual abuse; differences between good and bad, touching from strangers, familiar people, and family members; prevention rules; potentially helpful adults; discussion of personal experiences, and training in prevention skills (say no, get away quickly, tell adult immediately); includes classroom training for children, a parent orientation session, and in-service training for teachers and volunteers
• Methods: use of a programme colouring book presenting concepts about abuse, and a film “Better Safe Than Sorry II” (citation not reported)
• Delivery: by trained volunteers Control: wait-list control
Duration: 2 x 45-minute sessions
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): child self report, a 25-item questionnaire comprising 4 scales (awareness, subjective disturbance, likelihood of talking, programme concepts/skills). The programme concepts/skills scale comprised 11 items derived from the programme training manual in multiple choice format
Knowledge (vignette-based knowledge): no
Disclosure: data collected from school guidance counsellor incident reports
Harm: discussed. No adverse reactions were reported by children, parents, teachers, or volunteers
Other: programme integrity monitored using a rating scale completed by volunteers Last outcome assessment: 6 months after the second classroom training session and less than 1 month before the end of the school year
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk Method of randomisation was not reported
Kolko 1989 (Continued)
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. No baseline imbalances were detected between groups. There were 6 intervention schools and only 1 control school meaning that the groups were not equivalent. Adjust- ment procedures to address these imbal- ances were not reported
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. However, it is likely that participants were not blinded to their condition. Blinding of key personnel within the school was not possible as they were involved in pro- gramme delivery
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk It was not clear if outcome assessment was administered individually to children, or in group format with the whole class. The identities of outcome assessors were not re- ported. Methods of blinding were not re- ported
Incomplete outcome data (attrition bias) All outcomes
High risk Attrition was high (as noted above). Rea- sons for attrition were not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion were reported in the results section
Krahé 2009
Krahé 2009 (Continued)
uneasy; promoting confidence in their ability to seek help
• Methods: theatrical performance
• Delivery: play performed by the Berlin Police
Intervention 2: DVD(i.e. performance captured on DVD), participants watched a filmed
performance of the theatre play as above, on DVD Control: wait-list control
Duration: 1 x 60-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): no
Knowledge (vignette-based knowledge): self protective skills, comprising 8 short scenar- ios depicting “interactions of a child with an adult where the child was uneasy about the adult’s behaviour or uncertain as to the adult’s intention” (p 324). Scenarios presented with a simple cartoon, followed by a set of up to 4 questions
Disclosures: not reported
Harm: 1 vignette assessed possible negative side effects (fear of adults) Other: no
Last outcome assessment: 30 weeks post intervention
Notes Author contact: no
Intervention 1 (LIVE) was accompanied by a 3-hour training session for teachers and a 3-hour information evening for parents
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk Schools thatwere “first to sign up for partic- ipation in the (No) Child’s Play prevention programme offered by Berlin police were randomly assigned to three conditions” (p 323). Method of randomisation was not re- ported
Allocation concealment (selection bias) Unclear risk Method of concealment was not de- scribed. Potentially unconcealed proce- dure. In terms of baseline imbalances, de- mographic characteristics of each group were not reported. Results showed that the mean knowledge scores of students in the 3 study conditions did not differ significantly at baseline
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. In- tervention schools were notblinded to their own condition by virtue of the fact that they volunteered to receive the programme or were wait-listed to receive it. Schools may or may not have been blinded to other
Krahé 2009 (Continued)
schools’ conditions, that is, they may or may nothave been aware that they were get- ting/not getting something equivalent to other groups (e.g. via correspondence with the Berlin Police). It is possible that stu- dents were blinded, but teachers were not. It is possible that teaching staff in the DVD group may have compensated for not hav- ing the live performance which may have altered results
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Group administration of the outcome as- sessment meant that outcome assessors would need to be blinded to the condition of whole schools. 4 interviewers conducted the outcome assessments. “One of them was the second author, who was not blind with regard to the hypotheses and experi- mental conditions. Half of the sessions in each school were conducted by the second author, the remaining sessions were con- ducted by the three additional interview- ers who were blind as to the hypotheses of the study and the group membership of the children they tested. In this way, the same number of sessions was run by the second author and the additional interviewers in each condition. No differences between the conditions were found in relation to differ- ent interviewers” (p 325 footnote 3)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion were reported in the results section
Kraizer 1991
Kraizer 1991 (Continued)
+ 1 additional preschool) Country: USA
Attrition: 26/670 (3.8%)
Interventions Intervention 1: “The Safe Child Program” (written by Kraizer for this PhD) for children aged 3 to 10 years. Phase 1 is teacher training; phase 2 is parent training; phase 3 is training with the children
• Content (of the child component): your body belongs to you; you have a right to say who touches you and how; if someone touches you in a way that you do not like, in a way that makes you feel funny or uncomfortable, or in a way that you think is wrong, it’s okay to say no; if the person does not stop, say “I’m going to tell”; if you have a
problem, or if something like this is happening to you, tell and keep telling until someone helps you; adults cannot read your mind, you need to communicate clearly and fully; touch should never have to be a secret. Programme also includes: prevention of abuse and abduction by strangers (as in Fryer 1987a above); prevention of physical and emotional abuse; safety in self care
• Methods: the video tape teaches concepts, skills and words. Classroom teachers use role-play and classroom activities used to “turn the concepts into skills for each child” (p 17)
• Delivery: via videotape by classroom teachers Intervention 2: the Safe Child Program (revised version) Control: wait-list control
Duration: preschool and kindergarten, 1 session per day for 10 days. 1st to 3rd grade, 1
session per day for 5 days
Outcomes Protective behaviours simulation: stranger simulation, involved staging of actual simula- tions to evaluate children’s “degree of vulnerability to abduction and abuse by strangers” (p 175)
Protective behaviours simulation: yes. Role-play, a protocol used as the “basis for measur- ing behavioural change and actual mastery of skills associated with prevention of sexual abuse... the role play measures the child’s ability and willingness to terminate unwanted touch effectively and appropriately in the face of flattery, emotional coercion, rejection, bribery, and secrecy” (p 29)
Knowledge (questionnaire-based knowledge): Children Need to Know Knowledge At-
titude Test, comprising a 20-item self report instrument “measuring a child’s cognitive awareness, understanding and attitudes” (p 31)
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported
Other: Battle Culture Free Self Esteem Inventory (Battle 1981); The Children’s Nowicki- Strickland Internal External Locus of Control Inventory (Nowicki 1973); self care sim- ulation; Teacher Knowledge/Attitude Questionnaire and Demographics Sheet; Teacher Questionnaire
Last outcome assessment: 6 months after the programme
Notes Author contact: yes
An overview of this study is reported in Kraizer 1989
Risk of bias
Kraizer 1991 (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk Method of randomisation was not reported
Allocation concealment (selection bias) High risk Method of concealment was not reported. Potentially unconcealed procedure. The following statement: “student samples were selected, in cooperation with school offi- cials, to meet the following research objec- tives and criteria...” (p 27) indicates there was not adequate allocation concealment and therefore high risk of bias
Blinding of participants and personnel (performance bias)
All outcomes
High risk Teachers, as key personnel, could not have
been blinded to group allocation as they de- livered the video tape intervention. It is not clear if children from the same school were allocated to treatment and control groups as this detail is not reported
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “Role-plays were conducted by a research team member trained in child development and the prevention of child abuse who was not associated with the prevention pro- gram being conducted in the school” (p.30)
. “Scoring was completed by an observer via
contemporaneous video monitoring rather than the person conducting the role-play” (p 30). It is not clear if these outcome asses- sors were blinded to study condition and hypotheses
Incomplete outcome data (attrition bias) All outcomes
Low risk Attrition for the study overall was reported as 3.8% and was attributed to student with- drawals or exclusions or both. Attrition was not specified for intervention and control groups
Selective reporting (reporting bias) High risk Not all measures discussed in the methods section of the article were also reported in the results. Means and SDs for knowledge outcomes were measured but not reported
Lee 1998
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 77 female students attending schools for children with mental
retardation
Mean age: 13.44 years
Gender: 0% male; 100% female
Ethnicity: 100% Chinese
Setting: 4 special schools in Hong Kong Country: China
Attrition: 6.3%
Interventions Intervention: Behavioral Skills Training Program (Wurtele 1990) encompassing 7 safety rules, 1 personal body safety rule, and 4 self protection skills
• Content: we are the bosses of our bodies; the locations of “private parts”; touching your own private parts is acceptable when done in private; it is appropriate for doctors, nurses, or parents to touch children’s private parts for health or hygiene reasons; otherwise, it is not okay to have private parts touched or looked at by a bigger person;
it is wrong to be forced to touch a bigger person’s private parts; a bigger person’s inappropriate touching of a child’s private parts is never the child’s fault; personal body safety rule “It’s not okay for a bigger person to touch or look at my private parts” (unless they need help as in situations when their private parts get hurt)
• Methods: “taught via instruction, modelling, behavioral rehearsal (practice), shaping, social reinforcement, and feedback” (p 109)
• Delivery: by the first author
Control: Attention Control Program (Wurtele 1992) covering safety skills unrelated to
sexual abuse
Duration: 2 x 45-minute sessions on consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (Wurtele 1990) comprising 15 items covering personal safety and 3 control questions Knowledge (vignette-based knowledge): What If Situations Test (Wurtele 1990) com- prising 6 brief vignettes (3 appropriate and 3 inappropriate touch requests)
Disclosure: not reported
Harm: discussed. Lower levels of fear reported at 2-month follow-up compared with pre-test and post-test
Other: baseline assessment of intellectual ability using Raven’s Standard Progressive Ma- trices (Raven 1960); Fear Assessment Thermometer Scale (Wurtele 1986b), 12 items collecting data on fear of objects, people and situations
Last outcome assessment: 2 months after programme implementation
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Lee 1998 (Continued)
Random sequence generation (selection bias)
Unclear risk “The 72 completers were randomly as- signed to either the treatment (n = 38) or control group (n = 34)” (p 107). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Low risk “To control for intergroup contamination, we assigned participants from the same school to the same program. Both programs were led by the first author, who read from narrative scripts with pictures as visual aids” (p 108). Blinding of school personnel (e.g. teachers) would not be possible under the circumstances. Analysis of baseline data in- dicated no significant differences between groups on outcome measures, intellectual ability, or age
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk All outcome assessments were individually administered “by one of three female inter- viewers, who read the questions aloud in a standardized format and recorded the par- ticipants’ exact responses” (p 108). Base- line assessment of intellectual ability was administered to groups of 8 to 10. Mea- sures used to blind outcome assessors were not reported
Incomplete outcome data (attrition bias) All outcomes
Low risk Attrition was reported as 2/38 (5.3%) for the intervention group and 3/34 (8.8%) for the control group (p 109). Reasons for at- trition were failure to attend the interven- tion programme after pre-testing or failing to take part in the post-test
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the paper were also discussed in the results
Oldfield 1996
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 1269 1st to 6th grade students
Mean age: not reported
Gender: 47% male; 53 % female
Ethnicity: 86% Caucasian; 7% African American; 3% Hispanic; 3% Asian American;
1% Native American
Setting: 4 public schools in a Midwestern city Country: USA
Attrition: not reported
Interventions Intervention: Project TRUST (Anderson 1990)
• Content: the touch continuum (nurturing, confusing, exploitative); the right to question or refuse exploitative touch; the way to say “no” to uncomfortable situations; the fact that perpetrators can be either people you know or strangers
• Method: an optional pre-play discussion; a 30-minute play comprising vignettes covering prevention topics; and a 15-minute post-play discussion and question/ response period
• Delivery: pre-play discussion by teachers; play by trained performers; post-play discussion by Project TRUST facilitators and play performers
Control: wait-list control, received the programme after all data were collected Duration: 1 x 45-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Children’s Knowledge of Abuse Question- naire-Revised (CKAQ-R) (Tutty 1995) comprising 33 true/false items
Knowledge (vignette-based knowledge): no
Disclosure: Maltreatment Disclosure Report Form was used to record information about student disclosures (date, type of disclosure, nature of the report, student age, gender, race, and socioeconomic status)
Harm: discussed. No significant difference in anxiety between intervention and control groups
Other: Revised Children’s Manifest Anxiety Scale (RCMAS) (Reynolds 1985), a 37- item self report anxiety measure for children in grades 1 to 3; The State-Trait Anxiety Inventory for Children (STAIC) (Spielberger 1973) a 20-item self report measure for children in grades 4 to 6
Last outcome assessment: within 2 days after viewing the play
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Classrooms at each grade level were ran- domly assigned to the treatment or control
Oldfield 1996 (Continued)
conditions” (p 822). Method of randomi- sation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions. There was a possibility of treatment-control con- tamination of information transmitted in- formally throughout the school. School personnel did not appear to be blinded to group or class membership so there is risk of differential treatment of groups
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “Data were collected by assigned evalua- tors from subjects in both treatment and control groups on the same day... All data were collected in a blind assessment format with the evaluators unaware of which class- rooms were assigned to treatment or con- trol conditions” (p 824). Outcome assess- ments were administered in group format in classrooms
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not was reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the paper were also discussed in the results
Poche 1988
Poche 1988 (Continued)
Interventions Intervention 1: videotape only
• Content: several child abduction scenes in which adults approach children in a friendly manner and entice them; child actors demonstrate 2 safety rules (no further detail reported)
• Methods: videotape presentation; questioning children for responses; direct articulation of child actors’ strategies; feedback about correct responses; guiding of viewer’s attention; praise for correct responses; and using the child’s viewpoint Intervention 2 (videotape plus behaviour rehearsal): as above with the addition of be-
haviour rehearsal conducted in the classroom with a trainer playing the role of a friendly abductor
• Delivery: by police officer
Intervention 3 (standard programme): a presentation of 2 safety rules, discussion of
several abduction situations, and a brief film on personal safety
Control: wait-list control, who received the programme at the end of the study Duration: video only (25 minutes); videotape plus behaviour rehearsal (45 minutes); standard programme (60 minutes)
Outcomes Protective behaviours simulation: yes. Staging of scenarios in which an adult male (a doctoral student) “posed as a potential abductor, approached each child in a friendly manner, and attempted to entice the child to go with him. The child’s responses (verbal and motor) to the enticements were directly observed and recorded on a data sheet” (p 256). At follow-up the simulation was conducted in an identical manner, at or near the child’s home (with parental permission)
Knowledge (questionnaire-based knowledge): no Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported Other: no
Last outcome assessment: 1 month after training
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Each kindergarten and each first-grade class were randomly assigned to one of four conditions” (p 257). Method of randomi- sation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions there- fore there was a possibility of treatment-
Poche 1988 (Continued)
control contamination. It was not possi- ble for school personnel (e.g. teachers) to be blinded to the study condition of their classes
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “The adult portraying an abductor served as the primary observer and recorded each child’s verbal and motor responses as soon as the simulation was over. This observer was blind to the experimental condition of each subject” (p 257). Another adult “served as a reliability observer” (p 257). Agreement between the two observers was 100% (total reliability)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Attrition between pre- and post-test was not reported. At 1-month follow-up, only 23/74 children (31%) met the criteria for outcome assessment (pp 256-7). Of these only 9 were available to partake (12%). Reasons for attrition were “summer vaca- tions, disconnected phones, illnesses and accidents” (p 257)
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the paper were also discussed in the results
Saslawsky 1986
Saslawsky 1986 (Continued)
knowledge gained, and review of key messages
• Delivery: by female graduate student
Control: discussion about self concept and personal values with no mention of sexual
abuse
Duration: 1 x 50-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ), a 15-item measure with 2 practice questions and 13 personal safety questions covering topics typically taught in child sexual abuse prevention programmes
Knowledge (vignette-based knowledge): What If Situations Test (WIST), comprising 6 hypothetical situations (2 non-threatening and 4 threatening situations) after which children respond to a standard list of 4 questions
Disclosure: not reported Harm: not reported Other: no
Last outcome assessment: 3 months post intervention
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Subjects in schools A and B were assigned randomly, balanced for sex and grade, to one of two conditions” (p 240). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions there- fore there was a possibility of treatment- control contamination. It was not possi- ble for school personnel (e.g. teachers) to be blinded to the study condition of their classes
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Research assistants conducted the outcome assessments. They were blind to each child’s group assignment (p 240). PSQ was ad- ministered in group format to children in classes. WIST was individually adminis- tered to children in an interview format
Saslawsky 1986 (Continued)
Snyder 1986
Methods Design: quasi-experimental Solomon 4-group design Unit of allocation: classes
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 177 4th grade students
Mean age: 9.6 years
Gender: 40.7% male; 49.3% female
Ethnicity: 97% White; 3% Black, Asian, Hispanic-American, Other Setting: 7 elementary schools in Erie county, Pennsylvania
Country: USA
Attrition: 8/177 (4.5%)
Interventions Intervention: “Good Secrets, Bad Secrets” (citation not reported) sexual abuse prevention programme
• Content: general safety; distinguishing appropriate and inappropriate touching; assertiveness; help seeking and action planning
• Methods: role-plays; discussions; story-like situations
• Delivery: by a sexual assault counsellor trained in delivering the programme Control: students played hangman between pre-test and post-test, and were wait-listed to receive the programme
Duration: 1 x 45-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Good Secrets Bad Secrets Quiz, a 35-item covering general safety skills, distinguishing appropriate touching from sexual touching, knowing sexual touches can come from known people, recognising assertive responses for dealing with persuasive adults, recognising how to obtain help in an assault situation, recognising the appropriate course of action for dealing with a potentially dangerous situation. Criterion referenced standard of 80% was applied
Knowledge (vignette-based knowledge): no
Disclosures: not reported Harm: not reported Other: no
Last outcome assessment: 1-day post intervention
Notes Author contact: no
Risk of bias
Snyder 1986 (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Low risk “A coin was tossed to determine group as- signments” (p 45). No other information was provided
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Low risk Blinding procedures were not reported. Children may not have been blinded to their condition. Blinding of key personnel (e.g. teachers) may not have been possible in the school delivery context. The pro- gramme and testing were conducted on the same day in an attempt to control for con- tamination effects
Blinding of outcome assessment (detection bias)
All outcomes
High risk Group administration of outcome assess- ment meant that outcome assessors would have to be blinded to the condition of entire classes. This was not possible as outcome assessors were also programme presenters
Incomplete outcome data (attrition bias) All outcomes
Low risk Missing data were noted for 8/177 partic- ipants (4.5%) owing to parental omissions on the child data sheet. Attrition from the study is not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion were also reported in the results sec- tion
Tutty 1997
Tutty 1997 (Continued)
Interventions Intervention: “Who Do You Tell” programme developed by the Calgary Sexual Assault Centre in 1983 (citation not reported)
• Content: prevention concepts; giving information; permission to say no to unwanted touch; whether children should be suspicious of all touches or adults; also included are a parent information evening and a teacher in-service workshop
• Methods: discussion, pictures, short videos, and role-plays. Following presentations, children are given opportunity to talk individually to the presenters
• Delivery: by 2 trainers Control: wait-list control
Duration: 2 x 45- to 60-minute sessions on consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Children’s Knowledge of Abuse Question- naire-Revised (CKAQ-R) (Tutty 1995) comprising 9-item Appropriate Touch subscale, and 24-item Inappropriate Touch subscale (33 items in all) testing concepts taught in the programme
Knowledge (vignette-based knowledge): no Disclosure: not reported
Harm: parent questionnaire gathered data on children’s reactions to the programme Other: no
Last outcome assessment: “shortly after” programme completion (p 284)
Notes Author contact: yes, no reply
Secondary analysis comparing younger (5 to 7 years) and older children (8 to 13 years) was presented in Tutty 2000
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Children
were randomly assigned (matched by age) to participate in the program (N = 117) or in a wait-list control condition (N = 114)” (p 869). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not reported.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within the same school were re- ceiving the intervention or participating in the wait-listed control group. There is risk of treatment-control contamination ef- fects. It is likely that children were not blinded to their condition. Teachers par- ticipated in a training workshop, therefore
Tutty 1997 (Continued)
Wolfe 1986
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 290 students (214 4th grade and 76 5th grade students)
Mean age: 10.3 years
Gender: 49% male; 51% female Ethnicity: not reported
Setting: 3 public schools comprising children from middle- and lower-income families in the central area of a Southeastern city
Country: USA Attrition: not reported
Interventions Intervention: 2 x 5-minute plays written and performed by volunteer medical students who consulted with child abuse specialists
• Content: 5 themes: abuse can be perpetrated by someone you love and trust; feelings generated in such circumstances; importance of telling someone, even if unsure of what is happening; abuse is not your fault; and getting help right away is the best way to respond
• Methods: theatrical skits depict “a child at school who was upset about (abusive) events that had happened at home on the previous evening” (p 88); followed by 1-hour discussion
• Delivery: by volunteer medical students who consulted with a child abuse specialist
Control: wait-list control
Duration: 1 x 70-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): a brief 10-item true/false questionnaire focusing on programme objectives
Wolfe 1986 (Continued)
Knowledge (vignette-based knowledge): no Disclosure: not reported
Harm: not reported Other: no
Last outcome assessment: 3 to 5 days following the presentation
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “The 12 classrooms participating in the study were randomly assigned to a control or treatment condition” (p 88). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. It is not known whether whole schools were allocated to conditions or whether schools comprised classes allocated to both treat- ment and control conditions. The latter presents a higher risk of treatment-control contamination
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk Method of assessment (group or individ- ual administration) was not specified. The measures used to blind outcome assessors from knowledge of group membership was not reported
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition was not reported
Selective reporting (reporting bias) High risk “Three items were dropped from the final questionnaire due to their inability to con- tribute to the validity of the measure” (p 89)
, therefore outcome data for only 7 ques- tionnaire items are reported
Wurtele 1986
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 71 students (28 kindergarten and 1st grade students and 43
5th and 6th grade students) Mean age: 6.1 years; 11.0 years
Gender: 50% male; 50% female Ethnicity: not reported
Setting: 1 public school serving a lower to middle class population in a small rural town in eastern Washington
Country: USA Attrition: not reported
Interventions Intervention 1: 35-minute film entitled ”Touch“ (Illusion Theater Company 1984)
• Content: 4 body safety rules (saying ”No¡‘; yelling for help; getting away; telling someone and keep telling until someone believes you)
• Methods: film, 15-minute discussion, review
• Delivery: by female graduate student
Intervention 2: Body Safety Training (BST) (Wurtele 1986a)
• Content: 3 specific self protective skills (being able to identify the location of one’s ”private parts; knowing when it is “okay” or “not okay” to have their private parts touched; developing verbal responses (e.g. saying “No!” in a big voice) and motoric
responses (e.g. getting away, telling someone) in potential abuse situations. Methods: “instruction, modelling, rehearsal, social reinforcement, shaping and feedback” (p 690)
. Group mastery of skills was also a feature
• Delivery: by a female graduate student
Intervention 3: combined group (film and BST). Children viewed the “Touch” film
followed by a shortened discussion led by the first graduate student and a shortened version of the BST led by the second graduate student
Control: 50-minute discussion of self concept and personal values with no sexual abuse content
Duration: groups 1 and 2: 1 x 50-minute session; group 3: 1 x 60-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ), a 15-item measure with 2 practice questions and 13 personal safety questions covering topics typically taught in child sexual abuse prevention programmes
Knowledge (vignette-based knowledge): What If Situations Test (WIST), comprising 6 hypothetical situations (2 non-threatening and 4 threatening situations) after which children respond to a standard list of 4 questions
Disclosure: not reported Harm: not reported Other: no
Last outcome assessment: 3 months later
Notes Author contact: yes
Children gave verbal and written consent for their participation in the study
Wurtele 1986 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Subjects were randomly assigned, in bal- anced numbers for sex and grade, to one of four experimental conditions” (p 689). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions there- fore there was a possibility of treatment- control contamination. It was not possi- ble for school personnel (e.g. teachers) to be blinded to the study condition of their classes
Blinding of outcome assessment (detection bias)
All outcomes
Low risk PSQ was administered in group format to children in classes. WIST was individually administered to children in an interview format. Interviewers “were unaware of each child’s group assignment” (p 690)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition was not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article are reported in the results
e en-Ero ul 2013 (Continued)
Interventions Intervention: “Preventing child sexual abuse psycho-educational training program” (p 727) based on the Good Touch Bad Touch (GTBT) program (Childhelp 2011) adapted for the Turkish culture
• Content: my body belongs to me; discriminating good touch/bad touch; promises; body safety rules; saying No; secrets; talking with adults; and abuse is never a child’s fault
• Methods: video, lecture, role-play, modelling, rehearsal
• Delivery: not reported Control: no programme
Duration: 4 x 60-minute sessions on consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Good Touch Bad Touch Curriculum Test (Church 1988), a 10-item measure covering touch differentiation, knowledge of coping with sexual abuse and application to situations. Response options correct, incorrect, don’t know. In this study test/retest reliability (0.80) and internal consistency (0.78) Knowledge (vignette-based knowledge): no
Disclosure: not reported Harm: not reported Other: no
Last outcome assessment: 8 weeks after post-test
Notes Author contact: pending
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “The subjects consisted of 36 fourth grade students; 18 randomly assigned to the ex- perimental and 18 randomly to the control group” (p 725, abstract). Method of ran- domisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. It was not clear if some students within a single school participated the intervention while others received no intervention. This would increase the risk of contamination
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk Method of assessment (group or individ- ual administration) was not specified. The measures used to blind outcome assessors from knowledge of group membership was not reported
e en-Ero ul 2013 (Continued)
ANCOVA: analysis of covariance
CKAQ: Children’s Knowledge of Abuse Questionnaire CSA: child sexual abuse
RCT: randomised controlled trial
PPQ: Parental Perception Questionnaire PSQ: Personal Safety Questionnaire WIST: What If Situations Test
WLC: wait list control
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Ages 1991 Pre-test and post-test study. No control group
Alexander 1998 Post-test only study. No control group. No random allocation of students or classes to groups
Araji 1995 Pre-test and post-test study. No control group
Bae 2009 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Baker 2013 Quasi-experimental study. No random allocation of students or classes to groups
Baker 2014 Intervention is about sexual violence in peer dating relationships. Quasi-experimental study. No random allocation of students or classes to groups
Barron 2013 Quasi-experimental study. No random allocation of students or classes to groups
Binder 1987a Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Bodzy 1988 Controlled before-and-after study. No random allocation of students or classes to groups
Boyle 2005 Not school-based
Briggs 1994 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Briggs 1996 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
(Continued)
Casper 1999 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Conte 1985 Not school-based
Counts 2003 Controlled before-and-after study. No random allocation of students or classes to groups Students’ results selected randomly from an archival pool
Currier 1996 Comparative group design (abused versus non-abused children). Not school-based
Deretzotes 1989 Quasi-experimental study. No random allocation of students or classes to groups
Dhooper 1995 Controlled before-and-after study. No random allocation of students or classes to groups
Foshee 1996 Intervention is about dating and relationship violence prevention. Reports baseline findings for Foshee 1998
Foshee 1998 Intervention is about dating and relationship violence prevention. This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Garbarino 1987 Post-test only study. No control group
Herman 1987 Pre-test and post-test with multiple baseline study. No control group. No random allocation of students or classes to groups
Jacobs 1995 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Johnson 1994 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Johnson 2006 Intervention is about abduction prevention. Not school-based
Kernsmith 2011 Intervention is about rape and sexual relationship victimisation prevention. Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Kindt 1995 Controlled before-and-after study. No random allocation of students or classes to groups
Kolko 1987 Controlled before-and-after study. No random allocation of students or classes to groups
MacIntyre 1999a Controlled before-and-after study. No random allocation of students or classes to groups
MacIntyre 1999b Cross-sectional comparative study
Madak 1992 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Martin 2012 Intervention is about coercive sexual relationships prevention. Controlled before-and-after study. No random allocation of students or classes to groups
(Continued)
Michaelson 2001 Controlled before-and-after study + Solomon 4-group design. No random allocation of students or classes to groups
Miller 2011 Intervention is about sexual violence prevention in the context of partner relationships
This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Miller 2012 Intervention is about sexual violence prevention in the context of partner relationships
This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Miller 2013 Intervention is about sexual violence prevention in the context of partner relationships
This study provides follow-up data for Miller 2012, which is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Moreno-Manso 2014 Intervention is about prevention of physical neglect and emotional abuse (i.e. broader focus than prevention of child sexual abuse). Quasi-experimental study. No random allocation of students or classes to groups
Ogunfowokan 2012 Participants outside age criteria (13 to 24 years of age)
Pacifici 2001 Intervention is about coercive sexual relationships prevention. This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Peraino 1990 Not school-based (preschool)
Pohl 1990 Post-test only design. No control group. No random allocation of students or classes to groups
Smothers 2011 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Taal 1997 Controlled before-and-after study. No random allocation of students or classes to groups
Taylor 1991 Post-test only design. No random allocation of students or classes to groups
Taylor 2010a Intervention is about gender violence and harassment. This study was excluded in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013) on the basis of participant age
Taylor 2010b Intervention is about gender violence and harassment. This study was excluded in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013) on the basis of participant age
Telljohann 1997 Controlled before-and-after study. No random allocation of students or classes to groups
Tutty 1991 Quasi-experimental study. No random allocation of students or classes to groups
(Continued)
RCT: randomised controlled trial
Characteristics of ongoing studies [ordered by study ID]
NCT02181647
D A T A A N D A N A L Y S E S
Comparison 1. Protective behaviours
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Protective behaviours, no correction for clustering
2 102 Odds Ratio (M-H, Random, 95% CI) 5.71 [1.98, 16.51]
2 Protective behaviours, ICC=0.1 2 102 Odds Ratio (Random, 95% CI) 5.43 [1.88, 15.65]
3 Protective behaviours, ICC=0.2 2 102 Odds Ratio (Random, 95% CI) 5.16 [1.81, 14.70]
Comparison 2. Knowledge
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Questionnaire-based knowledge, no correction for clustering
2 Questionnaire-based knowledge,
ICC = 0.1
3 Questionnaire-based knowledge,
ICC = 0.2
4 Vignette-based knowledge, no correction for clustering
5 Vignette-based knowledge, ICC
= 0.1
6 Vignette-based knowledge, ICC
= 0.2
18 4657 Std. Mean Difference (IV, Random, 95% CI) 0.61 [0.45, 0.78]
18 Std. Mean Difference (Random, 95% CI) 0.66 [0.51, 0.81]
18 Std. Mean Difference (Random, 95% CI) 0.63 [0.50, 0.77]
11 1688 Std. Mean Difference (IV, Random, 95% CI) 0.45 [0.24, 0.65]
11 Std. Mean Difference (Random, 95% CI) 0.53 [0.32, 0.74]
11 Std. Mean Difference (Random, 95% CI) 0.60 [0.31, 0.89]
Comparison 3. Retention over time
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Questionnaire-based knowledge, no correction for clustering
1.1 Questionnaire-based knowledge (post-test)
1.2 Questionnaire-based knowledge (follow-up)
2 Questionnaire-based knowledge,
ICC = 0.1
4 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
4 956 Std. Mean Difference (IV, Random, 95% CI) 0.78 [0.38, 1.17]
4 929 Std. Mean Difference (IV, Random, 95% CI) 0.69 [0.51, 0.87]
4 Std. Mean Difference (Random, 95% CI) Subtotals only
2.1 Questionnaire-based knowledge (post-test) 4 Std. Mean Difference (Random, 95% CI) 0.86 [0.53, 1.20]
2.2 Questionnaire-based
knowledge (follow-up) 4 Std. Mean Difference (Random, 95% CI) 0.73 [0.41, 1.06]
3 Questionnaire-based knowledge,
ICC = 0.2 4 Std. Mean Difference (Random, 95% CI) Subtotals only
3.1 Questionnaire-based
knowledge (post-test) 4 Std. Mean Difference (Random, 95% CI) 0.86 [0.53, 1.20]
3.2 Questionnaire-based
knowledge (follow-up) 4 Std. Mean Difference (Random, 95% CI) 0.72 [0.32, 1.11]
Comparison 4. Harm
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Harm, no correction for clustering
3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
1.1 Anxiety or fear 3 795 Std. Mean Difference (IV, Random, 95% CI) -0.08 [-0.22, 0.07] 2 Harm, ICC=0.1 3 Std. Mean Difference (Random, 95% CI) Subtotals only
2.1 Anxiety or fear 3 Std. Mean Difference (Random, 95% CI) -0.04 [-0.42, 0.33] 3 Harm, ICC=0.2 3 Std. Mean Difference (Random, 95% CI) Subtotals only
3.1 Anxiety or fear 3 Std. Mean Difference (Random, 95% CI) -0.03 [-0.46, 0.40]
Comparison 5. Disclosures
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Disclosures, no correction for clustering
3 1788 Odds Ratio (M-H, Random, 95% CI) 3.56 [1.13, 11.24]
2 Disclosures, ICC=0.1 3 1788 Odds Ratio (Random, 95% CI) 3.04 [0.75, 12.33]
3 Disclosures, ICC=0.2 3 1788 Odds Ratio (Random, 95% CI) 2.95 [0.69, 12.61]
School-based education programmes for the prevention of child sexual abuse (Review) 92
Analysis 1.1. Comparison 1 Protective behaviours, Outcome 1 Protective behaviours, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 1 Protective behaviours
Outcome: 1 Protective behaviours, no correction for clustering
Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Fryer 1987a 18/23 11/21 48.5 % 3.27 [ 0.88, 12.12 ]
Poche 1988 29/38 5/20 51.5 % 9.67 [ 2.75, 34.03 ]
Total (95% CI) 61 41 100.0 % 5.71 [ 1.98, 16.51 ]
Total events: 47 (Intervention), 16 (Control)
Heterogeneity: Tau2 = 0.16; Chi2 = 1.37, df = 1 (P = 0.24); I2 =27% Test for overall effect: Z = 3.22 (P = 0.0013)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours control Favours intervention
Analysis 1.2. Comparison 1 Protective behaviours, Outcome 2 Protective behaviours, ICC=0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 1 Protective behaviours
Outcome: 2 Protective behaviours, ICC=0.1
Study or subgroup Intervention Control log [Odds Ratio] Odds Ratio Weight Odds Ratio N N (SE) IV,Random,95% CI IV,Random,95% CI
Fryer 1987a 23 21 1.1856 (0.6682) 53.3 % 3.27 [ 0.88, 12.12 ]
Poche 1988 38 20 2.2687 (0.7236) 46.7 % 9.67 [ 2.34, 39.92 ]
Total (95% CI) 61 41 100.0 % 5.43 [ 1.88, 15.65 ]
Heterogeneity: Tau2 = 0.10; Chi2 = 1.21, df = 1 (P = 0.27); I2 =17% Test for overall effect: Z = 3.13 (P = 0.0017)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours control Favours intervention
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Analysis 1.3. Comparison 1 Protective behaviours, Outcome 3 Protective behaviours, ICC=0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 1 Protective behaviours
Outcome: 3 Protective behaviours, ICC=0.2
S 4
Analysis 2.1. Comparison 2 Knowledge, Outcome 1 Questionnaire-based knowledge, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 1 Questionnaire-based knowledge, no correction for clustering
Std. Mean
Std. Mean
e en-Ero ul 2013
Heterogeneity: Tau2 = 0.10; Chi2 = 104.76, df = 17 (P<0.00001); I2 =84% Test for overall effect: Z = 7.26 (P < 0.00001)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 2.2. Comparison 2 Knowledge, Outcome 2 Questionnaire-based knowledge, ICC = 0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 2 Questionnaire-based knowledge, ICC = 0.1
Std. Mean Difference
Std. Mean
Std. Mean
e en-Ero ul 2013
Total (95% CI) 100.0 % 0.66 [ 0.51, 0.81 ]
Heterogeneity: Tau2 = 0.02; Chi2 = 22.19, df = 17 (P = 0.18); I2 =23% Test for overall effect: Z = 8.47 (P < 0.00001)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 2.3. Comparison 2 Knowledge, Outcome 3 Questionnaire-based knowledge, ICC = 0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 3 Questionnaire-based knowledge, ICC = 0.2
Std. Mean Difference
Std. Mean
Std. Mean
e en-Ero ul 2013
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Analysis 2.4. Comparison 2 Knowledge, Outcome 4 Vignette-based knowledge, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 4 Vignette-based knowledge, no correction for clustering
S 8
C
Analysis 2.5. Comparison 2 Knowledge, Outcome 5 Vignette-based knowledge, ICC = 0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 5 Vignette-based knowledge, ICC = 0.1
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
Blumberg 1991 0.13572133 (0.4091979) 6.7 % 0.14 [ -0.67, 0.94 ]
Chen 2012 0.70577457 (0.30475898) 12.1 % 0.71 [ 0.11, 1.30 ]
Daigneault 2012 0.09314352 (0.4624079) 5.3 % 0.09 [ -0.81, 1.00 ]
Grendel 1991 0.6075004 (0.52561535) 4.1 % 0.61 [ -0.42, 1.64 ]
Hazzard 1991 0.17045685 (0.26459481) 16.1 % 0.17 [ -0.35, 0.69 ]
H bert 2001 1.11872408 (0.7808566) 1.8 % 1.12 [ -0.41, 2.65 ]
Kolko 1989 0.33231604 (0.81308542) 1.7 % 0.33 [ -1.26, 1.93 ]
Krah 2009 0.13799652 (1.02000413) 1.1 % 0.14 [ -1.86, 2.14 ]
Lee 1998 0.91724207 (0.24881393) 18.2 % 0.92 [ 0.43, 1.40 ]
Saslawsky 1986 0.60571515 (0.25024759) 18.0 % 0.61 [ 0.12, 1.10 ]
Wurtele 1986 0.48110613 (0.27595157) 14.8 % 0.48 [ -0.06, 1.02 ]
Total (95% CI) 100.0 % 0.53 [ 0.32, 0.74 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 7.34, df = 10 (P = 0.69); I2 =0.0% Test for overall effect: Z = 4.96 (P < 0.00001)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 2.6. Comparison 2 Knowledge, Outcome 6 Vignette-based knowledge, ICC = 0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 6 Vignette-based knowledge, ICC = 0.2
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
Blumberg 1991 0.13572133 (0.6819965) 3.9 % 0.14 [ -1.20, 1.47 ]
Chen 2012 0.70577457 (0.30475898) 11.3 % 0.71 [ 0.11, 1.30 ]
Daigneault 2012 0.09314352 (0.7653648) 3.2 % 0.09 [ -1.41, 1.59 ]
Grendel 1991 0.6075004 (0.50513683) 6.2 % 0.61 [ -0.38, 1.60 ]
Hazzard 1991 0.17045685 (0.11127819) 19.0 % 0.17 [ -0.05, 0.39 ]
H bert 2001 1.11872408 (0.19400164) 15.6 % 1.12 [ 0.74, 1.50 ]
Kolko 1989 0.33231604 (1.28106706) 1.3 % 0.33 [ -2.18, 2.84 ]
Krah 2009 0.13799652 (1.8651504) 0.6 % 0.14 [ -3.52, 3.79 ]
Lee 1998 0.91724207 (0.24881393) 13.3 % 0.92 [ 0.43, 1.40 ]
Saslawsky 1986 0.60571515 (0.25024759) 13.3 % 0.61 [ 0.12, 1.10 ]
Wurtele 1986 0.48110613 (0.27595157) 12.3 % 0.48 [ -0.06, 1.02 ]
Total (95% CI) 100.0 % 0.60 [ 0.31, 0.89 ]
Heterogeneity: Tau2 = 0.10; Chi2 = 23.05, df = 10 (P = 0.01); I2 =57% Test for overall effect: Z = 4.03 (P = 0.000057)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
Favours control Favours intervention
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Analysis 3.1. Comparison 3 Retention over time, Outcome 1 Questionnaire-based knowledge, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 3 Retention over time
Outcome: 1 Questionnaire-based knowledge, no correction for clustering
Study or subgroup Intervention Control
Std. Mean
Difference Weight
Std. Mean Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Questionnaire-based knowledge (post-test)
Dawson 1987 96 78.75 (18.71) 141 64.68 (18.58) 26.8 % 0.75 [ 0.48, 1.02 ]
Hazzard 1991 286 20.6 (3.67) 113 15.4 (5.18) 27.6 % 1.25 [ 1.02, 1.48 ]
Kolko 1989 213 12.4 (2.4) 35 11.5 (2.1) 24.4 % 0.38 [ 0.02, 0.74 ]
Lee 1998 38 8.97 (1.82) 34 7.79 (1.77) 21.2 % 0.65 [ 0.17, 1.13 ]
Subtotal (95% CI) 633 323 100.0 % 0.78 [ 0.38, 1.17 ]
Heterogeneity: Tau2 = 0.13; Chi2 = 18.77, df = 3 (P = 0.00030); I2 =84% Test for overall effect: Z = 3.84 (P = 0.00012)
2 Questionnaire-based knowledge (follow-up)
Dawson 1987 96 77.29 (19.17) 141 63.76 (20.37) 31.2 % 0.68 [ 0.41, 0.94 ]
Hazzard 1991 286 20.5 (4.19) 113 16.7 (5.17) 38.6 % 0.85 [ 0.62, 1.07 ]
Kolko 1989 191 12 (2.3) 30 11.1 (2.1) 17.8 % 0.39 [ 0.01, 0.78 ]
Lee 1998 38 9.03 (1.98) 34 7.71 (1.8) 12.4 % 0.69 [ 0.21, 1.17 ]
Subtotal (95% CI) 611 318 100.0 % 0.69 [ 0.51, 0.87 ]
Heterogeneity: Tau2 = 0.01; Chi2 = 4.00, df = 3 (P = 0.26); I2 =25% Test for overall effect: Z = 7.55 (P < 0.00001)
-2 -1 0
1 2
Favours control Favours intervention
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Analysis 3.2. Comparison 3 Retention over time, Outcome 2 Questionnaire-based knowledge, ICC = 0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 3 Retention over time
Outcome: 2 Questionnaire-based knowledge, ICC = 0.1
S 2
C
Analysis 3.3. Comparison 3 Retention over time, Outcome 3 Questionnaire-based knowledge, ICC = 0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 3 Retention over time
Outcome: 3 Questionnaire-based knowledge, ICC = 0.2
Std. Mean Difference
Study or subgroup (SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
1 Questionnaire-based knowledge (post-test)
Dawson 1987 0.75271304 (0.48349098) 12.3 % 0.75 [ -0.19, 1.70 ]
Hazzard 1991 1.25004636 (0.28457694) 35.2 % 1.25 [ 0.69, 1.81 ]
Kolko 1989 0.38006195 (0.81393081) 4.4 % 0.38 [ -1.22, 1.98 ]
Lee 1998 0.64973314 (0.24254667) 48.2 % 0.65 [ 0.17, 1.13 ]
Subtotal (95% CI)
Heterogeneity: Tau2 = 0.00; Chi2 = 3.03, df = 3 (P = 0.39); I2 =1% 100.0 % 0.86 [ 0.53, 1.20 ]
Test for overall effect: Z = 5.07 (P < 0.00001)
2 Questionnaire-based knowledge (follow-up)
Dawson 1987 0.67794492 (0.8250421) 6.1 % 0.68 [ -0.94, 2.29 ]
Hazzard 1991 0.84506507 (0.43229517) 22.1 % 0.85 [ 0.00, 1.69 ]
Kolko 1989 0.39433013 (1.40364558) 2.1 % 0.39 [ -2.36, 3.15 ]
Lee 1998 0.68825484 (0.24332598) 69.7 % 0.69 [ 0.21, 1.17 ]
Subtotal (95% CI)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.16, df = 3 (P = 0.98); I2 =0.0% 100.0 % 0.72 [ 0.32, 1.11 ]
Test for overall effect: Z = 3.52 (P = 0.00042)
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 4.1. Comparison 4 Harm, Outcome 1 Harm, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 4 Harm
Outcome: 1 Harm, no correction for clustering
Std. Mean
Std. Mean
Study or subgroup Intervention
N
Mean(SD) Control
N
Mean(SD) Difference
IV,Random,95% CI Weight Difference
IV,Random,95% CI
1 Anxiety or fear
Blumberg 1991 322 43.32 (7.75) 164 43.71 (7.73) 59.2 % -0.05 [ -0.24, 0.14 ]
Dawson 1987 96 28.51 (6.51) 141 29.46 (6) 31.0 % -0.15 [ -0.41, 0.11 ]
Lee 1998 38 4.71 (1.99) 34 4.74 (2.22) 9.8 % -0.01 [ -0.48, 0.45 ]
Subtotal (95% CI) 456 339 100.0 % -0.08 [ -0.22, 0.07 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.47, df = 2 (P = 0.79); I2 =0.0% Test for overall effect: Z = 1.06 (P = 0.29)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 4.2. Comparison 4 Harm, Outcome 2 Harm, ICC=0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 4 Harm
Outcome: 2 Harm, ICC=0.1
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
1 Anxiety or fear
Blumberg 1991 -0.0502882 (0.47493631) 16.5 % -0.05 [ -0.98, 0.88 ]
Dawson 1987 -0.1524605 (0.46819977) 16.9 % -0.15 [ -1.07, 0.77 ]
Lee 1998 -0.0141216 (0.23606995) 66.6 % -0.01 [ -0.48, 0.45 ]
Subtotal (95% CI) 100.0 % -0.04 [ -0.42, 0.33 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.07, df = 2 (P = 0.97); I2 =0.0% Test for overall effect: Z = 0.23 (P = 0.82)
Test for subgroup differences: Not applicable
-1 -0.5 0 0.5 1
Favours control Favours intervention
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Analysis 4.3. Comparison 4 Harm, Outcome 3 Harm, ICC=0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 4 Harm
Outcome: 3 Harm, ICC=0.2
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
1 Anxiety or fear
Blumberg 1991 -0.0502882 (0.8539259) 6.6 % -0.05 [ -1.72, 1.62 ]
Dawson 1987 -0.1524605 (0.80389018) 7.4 % -0.15 [ -1.73, 1.42 ]
Lee 1998 -0.0141216 (0.23606995) 86.0 % -0.01 [ -0.48, 0.45 ]
Subtotal (95% CI) 100.0 % -0.03 [ -0.46, 0.40 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.03, df = 2 (P = 0.99); I2 =0.0% Test for overall effect: Z = 0.12 (P = 0.90)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 5.1. Comparison 5 Disclosures, Outcome 1 Disclosures, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 5 Disclosures
Outcome: 1 Disclosures, no correction for clustering
Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Del Campo Sanchez 2006 10/193 2/105 56.0 % 2.81 [ 0.60, 13.09 ]
Kolko 1989 20/191 0/30 16.5 % 7.29 [ 0.43, 123.77 ]
Oldfield 1996 4/658 1/611 27.5 % 3.73 [ 0.42, 33.47 ]
Total (95% CI) 1042 746 100.0 % 3.56 [ 1.13, 11.24 ]
Total events: 34 (Intervention), 3 (Control)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.36, df = 2 (P = 0.84); I2 =0.0% Test for overall effect: Z = 2.16 (P = 0.031)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours control Favours intervention
Analysis 5.2. Comparison 5 Disclosures, Outcome 2 Disclosures, ICC=0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 5 Disclosures
Outcome: 2 Disclosures, ICC=0.1
Study or subgroup Intervention Control log [Odds Ratio] Odds Ratio Weight Odds Ratio N N (SE) IV,Random,95% CI IV,Random,95% CI
Del Campo Sanchez 2006 193 105 1.0347 (0.7843) 83.0 % 2.81 [ 0.61, 13.09 ]
Kolko 1989 191 30 1.9865 (3.4542) 4.3 % 7.29 [ 0.01, 6352.52 ]
Oldfield 1996 658 611 1.3166 (2.0048) 12.7 % 3.73 [ 0.07, 189.79 ]
Total (95% CI) 1042 746 100.0 % 3.04 [ 0.75, 12.33 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.08, df = 2 (P = 0.96); I2 =0.0% Test for overall effect: Z = 1.56 (P = 0.12)
Test for subgroup differences: Not applicable
0.001 0.01 0.1 1 10 100 1000
Favours control Favours intervention
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Analysis 5.3. Comparison 5 Disclosures, Outcome 3 Disclosures, ICC=0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 5 Disclosures
Outcome: 3 Disclosures, ICC=0.2
Study or subgroup Intervention Control log [Odds Ratio] Odds Ratio Weight Odds Ratio N N (SE) IV,Random,95% CI IV,Random,95% CI
Del Campo Sanchez 2006 193 105 1.0347 (0.7843) 89.4 % 2.81 [ 0.61, 13.09 ]
Kolko 1989 191 30 1.9865 (4.6663) 2.5 % 7.29 [ 0.00, 68342.01 ]
Oldfield 1996 658 611 1.3166 (2.6049) 8.1 % 3.73 [ 0.02, 615.30 ]
Total (95% CI) 1042 746 100.0 % 2.95 [ 0.69, 12.61 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.05, df = 2 (P = 0.98); I2 =0.0% Test for overall effect: Z = 1.46 (P = 0.14)
Test for subgroup differences: Not applicable
0.001 0.01 0.1 1 10 100 1000
Favours control Favours intervention
A D D I T I O N A L T A B L E S
Table 1. Previous reviews
Meta-analyses Systematic reviews Narrative reviews Systematic reviews of reviews
Berrick 1992
Davis 2000
Heidotting 1994
Rispens 1997
Zwi 2007
Duane 2002
Kenny 2008
MacIntyre 2000
MacMillan 1994
Topping 2009
Albers 1991
Carroll 1992
Conte 1986
Daro 1991
Daro 1994
Finkelhor 2007
Finkelhor 1992
Hébert 2004
Kolko 1988
O’Donohue 1992
Reppucci 2005
Mikton 2009
School-based education programmes for the prevention of child sexual abuse (Review) 108
Table 1. Previous reviews (Continued)
A P P E N D I C E S
Appendix 1. Search strategies for the period 2006 to 2014
CENTRAL 2014, Issue 8, last searched 8 September 2014, limited to publication years 2013 to 2014 (47 records) Previous searches
CENTRAL 2013(9), searched 2 September 2013, limited to publication years 2012 to 2013 (19 records)
CENTRAL 2012(3), searched 4 April 2012, limited to publication years 2006 to 2012 (160 records)
#1 MeSH descriptor Child Abuse, Sexual, this term only
#2 MeSH descriptor Rape, this term only
#3 MeSH descriptor Incest, this term only
#4 MeSH descriptor Sex Offenses, this term only
#5 molest* or rape* or incest*
#6 sex* near/3 (crim* or abuse* or assault* or offen* or exploit* or victim* or coerc* or maltreat*)
#7 (groom* near/3 (child* or online or sex*))
#8 (online near/3 solicit)
#9 (#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8)
#10 MeSH descriptor Adolescent, this term only
#11 child NEAR MEsh
#12 (child* or boy* or girl* or adolescen* or teen* or youth* or young NEXT people or young NEXT person* OR school* or pupil* or student* or college*)
#13 (#10 OR #11 OR #12)
#14 (#9 AND #13)
#15 (#1 OR #14)
Ovid MEDLINE(R) 1946 to August Week 4 2014, last searched 8 September 2014 (160 records) Previous searches
1946 to August Week 3 2013, searched 2 September 2013 (258 records)
1946 to March Week 3 2012, searched 4 April 2012 (757 records) 1 Child Abuse, Sexual/
2 sex offenses/
3 rape/
4 incest/
5 molest$.tw.
6 rape$.tw.
7 incest$.tw.
8 (sex$ adj3 crim$).tw. 9 (sex$ adj3 abuse$).tw.
10 (sex$ adj3 assault$).tw. 11 (sex$ adj3 offen$).tw.
12 (sex$ adj3 exploit$).tw. 13 (sex$ adj3 victim$).tw. 14 (sex$ adj3 coerc$).tw. 15 (sex$ adj3 maltreat$).tw.
16 (groom$ adj3 (online or child$ or sex$)).tw. 17 (online adj3 solicit$).tw.
18 or/2-17
19 exp child/
20 adolescent/
21 (child$ or boy$ or girl$ or adolescen$ or teen$ or youth$ or young people or young person$ or pupil$ or student$ or school$ or college$).tw.
22 or/19-21
23 18 and 22
24 1 or 23
25 randomized controlled trial.pt. 26 controlled clinical trial.pt.
27 randomi#ed.ab.
28 placebo$.ab.
29 drug therapy.fs.
30 randomly.ab.
31 trial.ab.
32 groups.ab.
33 or/25-32
34 exp animals/ not humans.sh. 35 33 not 34
36 24 and 35
37 limit 36 to yr=“2006 -Current” [limits applied April 2012]
38 limit 36 to ed=20120301-20130902 [limits applied Sept 2013]
39 limit 36 to ed=ed=20130901-20140908 [limits applied Sept 2014]
EMBASE (OVID) 1980 to 2014 Week 36, searched 8 September 2014 (320 records) Previous searches
1980 to 2013 Week 35, searched 2 September 2013 (400 records)
1980 to 2012 Week 13, searched 4 April 2012 (1118 records) 1 child sexual abuse/
2 exp sexual crime/ 3 rape$.tw.
4 incest$.tw.
5 (sex$ adj3 offen$).tw. 6 (sex$ adj3 abus$).tw.
7 (sex$ adj3 assault$).tw. 8 (sex$ adj3 molest$).tw. 9 (sex$ adj3 coerc$).tw. 10 (sex$ adj3 crim$).tw. 11 (sex$ adj3 victim$).tw. 12 (sex$ adj3 exploit$).tw.
13 (sex$ adj3 maltreat$).tw.
14 (groom$ adj3 (online or child$ or sex$)).tw. 15 (online adj3 solicit$).tw.
16 or/2-15
17 exp child/
18 adolescent/
19 (child$ or school$ or boy$ or girl$ or adolescen$ or teen$ or youth$ or young people or young person$ or pupil$ or student$ or college$).tw.
20 17 or 18 or 19
21 16 and 20
22 1 or 21
23 exp Clinical trial/
24 Randomized controlled trial/ 25 Randomization/
26 Single blind procedure/ 27 Double blind procedure/ 28 Crossover procedure/
29 Placebo/
30 Randomi#ed.tw.
31 RCT.tw.
32 (random$ adj3 (allocat$ or assign$)).tw. 33 randomly.ab.
34 groups.ab.
35 trial.ab.
36 ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw. 37 Placebo$.tw.
38 Prospective study/ (248367) 39 (crossover or cross-over).tw. 40 prospective.tw.
41 or/23-40
42 22 and 41
43 limit 42 to yr=“2006 -Current” [limits applied April 2012] 44 limit 42 to em=201214-201335 [limits applied Sept 2013]
45 limit 42 to em=201335-201436 [limits applied Sept 2014]
PsycINFO (OVID) 1967 to September Week 1 2014 (102 records) Previous searches
1967 to August Week 4 2013, last searched 2 September 2013 (118 records)
1967 to March Week 4, searched 4 April 2012 ( 378 records) 1 exp sexual abuse/
2 sex offenses/
3 molest$.tw.
4 rape$.tw.
5 incest$.tw.
6 (sex$ adj3 crim$).tw. 7 (sex$ adj3 abuse$).tw. 8 (sex$ adj3 assault$).tw. 9 (sex$ adj3 offen$).tw.
10 (sex$ adj3 exploit$).tw. 11 (sex$ adj3 victim$).tw. 12 (sex$ adj3 coerc$).tw. 13 (sex$ adj3 maltreat$).tw.
14 (groom$ adj3 (online or child$ or sex$)).tw.
15 (online adj3 solicit$).tw. 16 or/1-15
17 (“100” or “160” or “180” or “200”).ag.
18 (child$ or boy$ or girl$ or adolescen$ or teen$ or youth$ or young people or young person$ or pupil$ or student$ or school$ or college$).tw.
19 17 or 18
20 16 and 19
21 clinical trials/
22 (randomis$ or randomiz$).tw.
23 (random$ adj3 (allocat$ or assign$)).tw. 24 ((clinic$ or control$) adj trial$).tw.
25 ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw. 26 (crossover$ or “cross over$”).tw.
27 random sampling/
28 Experiment Controls/
29 Placebo/
30 placebo$.tw.
31 exp program evaluation/
32 treatment effectiveness evaluation/
33 ((effectiveness or evaluat$) adj3 (stud$ or research$)).tw. 34 school based intervention/
35 or/21-34
36 20 and 35
37 limit 36 to yr=“2006 -Current” [limits applied April 2012]
38 limit 36 to up=20120301-20130902 [limits applied Sept 2013]
39 limit 36 to up=20130901-20140908 [limits applied Sept 2014]
CINAHL (EBSCOhost) 1937 to current, last searched 8 September 2014 and limited to EM 20130901 onwards (98 records) Previous searches
1937 to current, searched 2 September 2013 and limited to EM 20120301 onwards (201 records)
1937 to current, searched 4 April 2012 and limited to EM 20060801 onwards (526 records) S38 S19 and S37
S37 S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36 S36 (MH “Evaluation Research”) OR (MH “Summative Evaluation Research”) OR (MH “Program Evaluation”)
S35 (MH “Treatment Outcomes”) S34 (MH “Comparative Studies”)
S33 TI (compar* stud* or compar* research*) or AB (compar* stud* or compar* research*) or TI (evaluat* study or evaluat* research) or AB (evaluate* study or evaluat* research) or TI (effectiv* study or effectiv* research) or AB (effectiv* study or effectiv* research) OR TI (prospectiv* study or prospectiv* research) or AB(prospectiv* study or prospectiv* research) or TI (follow-up study or follow-up research) or AB (follow-up study or follow-up research)
S32 “cross over*” S31 crossover*
S30 (MH “Crossover Design”)
S29 (tripl* N3 mask*) or (tripl* N3 blind*) S28 (trebl* N3 mask*) or (trebl* N3 blind*) S27 (doubl* N3 mask*) or (doubl* N3 blind*) S26 (singl* N3 mask*) or (singl* N3 blind*) S25 (clinic* N3 trial*) or (control* N3 trial*)
S24 (random* N3 allocat* ) or (random* N3 assign*) S23 randomis* or randomiz*
S22 (MH “Meta Analysis”) S21 (MH “Clinical Trials+”) S20 MH random assignment S19 S1 or S18
S18 S14 and S17 S17 S15 or S16
S16 (child* or schoolchild* or schoolboy* or schoolgirl* or adolescen* or teen* or youth* or young people or young person* or pre- school* or preschool* or pupil* or student* or kindergarten*)
S15 AG adolescent or AG child
S14 S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 S13 (groom* N3 online) or (groom* N3 child*) or (groom* N3 sex*)
S12 (online N3 solicit*) S11 (sex* N3 maltreat*)
S10 (sex* N3 coerc*) S9 (sex* N3 victim*) S8 (sex* N3 exploit*) S7 (sex* N3 offen*) S6 (sex* N3 assault*) S5 (sex* N3 abuse*) S4 (sex* N3 crim*)
S3 rape* or incest* or molest*
S2 (MH “Rape”) OR (MH “Incest”) S1 (MH “Child Abuse, Sexual”)
Social Science Citation Index (SSCI), 1970 to 29 August 2014, last searched 8 September 2014, limited to publication years 2013 to 2014 (777 records)
Previous searches
1970 to 30 August 2013, last searched 2 September 2013, limited by Processing Date 2012-03-01 to 2013-09-02 (661 records) 1970 to 30 March 2012, searched 4 April 2012, no limits applied as not searched for original review (4543 records)
# 7 #6 AND #5 AND #4
# 6 TS=(random* or control* or trial* or group* or blind* or RCT )
# 5 TS= (child* or boy* or girl* or adolescen* or teen* or youth* or “young person*” or “young people” OR school* or college* OR pupil* or student*)
# 4 #3 OR #2 OR #1
# 3 TS=(online* NEAR/3 solicit*)
# 2 TS=((groom*) NEAR/3 (online* OR child* or sex*))
# 1 TS= ((sex*) NEAR/3 (crime or crimes or abus* OR assault* or offenc* or offens* or exploit* or victim* or coerc* or maltreat*)) Sociological Abstracts (ProQuest), 1952 to current, last searched 3 September 2013, limited by publication year 2012 to current (91 records)
Previous searches
25 July 2012, limited to publication year 2006 to 2012 ( 242 records)
(TI(molest* OR rape* OR incest*) OR AB(molest* OR rape* OR incest*) OR TI((groom* NEAR/3 (child* OR online OR sex*)) OR (online NEAR/3 solicit)) OR AB((groom* NEAR/3 (child* OR online OR sex*)) OR (online NEAR/3 solicit)) OR AB (sex* NEAR/3 (crim* OR abuse* OR assault* OR offen* OR exploit* OR victim* OR coerc* OR maltreat*)) OR TI(sex* NEAR/3 (crim* OR abuse* OR assault* OR offen* OR exploit* OR victim* OR coerc* OR maltreat*)) OR SU.EXACT(Child Sexual Abuse) OR SU.EXACT(“Incest”)) AND (AB(child* OR school* OR kindergarten* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young people” OR “young person*” OR preschool* OR “pre-school*” OR pupil* OR student* OR college*) OR TI(child* OR school* OR kindergarten* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young people” OR “young person*” OR preschool* OR “pre-school*” OR pupil* OR student* OR college*)) AND (AB(random* OR group* OR trial* OR control* OR placebo* OR prospective OR “cross over” OR crossover OR blind* OR RCT) OR TI(random* OR group* OR trial* OR control* OR placebo* OR prospective OR “cross over” OR crossover OR blind* OR RCT))
Conference Proceedings Citation Indexes (CPCI-S and CPCI-SSH), 1990 to 29 August 2014, last searched 8 September 2014 (7 records)
Previous searches
1990 to 30 August 2013, searched 2 September 2013 (15 records)
1970 to 30 March 2012, searched 4 April 2012, no limits applied as not searched for original review. (221 records)
#7 #6 AND #5 AND #4
# 6 TS=(random* or control* or trial* or group* or blind* or RCT )
# 5 TS= (child* or boy* or girl* or adolescen* or teen* or youth* or “young person*” or “young people” OR school* or college* OR pupil* or student*)
# 4 #1 OR #2 OR #1
# 3 TS=(online* NEAR/3 solicit*)
# 2 TS=((groom*) NEAR/3 (online* OR child* or sex*))
# 1 TS= ((sex*) NEAR/3 (crime or crimes or abus* OR assault* or offenc* or offens* or exploit* or victim* or coerc* or maltreat*)) ERIC (EBSCOhost), 1966 to current, last searched 8 September 2014, limited by entry date = 1 January 2013 or later ( 206 records) S22 S12 AND S15 AND S21
S21 S16 OR S17 OR S18 OR S19 OR S20
S20 random* OR intervention* OR experiment* OR trial*
S19 ((evaluat* OR compar* OR blind*) N5 (study OR studies OR research)) S18 “follow up” or followup
S17 prospective
S16 ((DE “Control Groups” OR DE “Longitudinal Studies” OR DE “Program Effectiveness” OR DE “Program Evaluation” OR DE “Experimental Groups”) OR (DE “Followup Studies”)) OR (DE “Comparative Analysis”)
S15 S13 OR S14
S14 (child* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young person*” OR “young people” OR school* OR college* OR pupil* OR student*)
S13 DE “Children” OR DE “Preadolescents” OR DE “Young Children” OR DE “Preschool Children” OR DE “Adolescents” S12 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11
S11 (groom* N3 online) or (groom* N3 child*) or (groom* N3 sex*) S10 (online N3 solicit*)
S9 (sex* N3 maltreat*)
S8 (sex* N3 coerc*) S7 (sex* N3 victim*) S6 (sex* N3 exploit*) S5 sex* N3 offen*
S4 (sex* N3 assault*) S3 (sex* N3 abuse*) S2 (sex* N3 crim*)
S1 (DE “Sexual Abuse” OR DE “Child Abuse” OR DE “Rape”)
ERIC (ProQuest), 1966 to current, last searched 3 September 2013, limited by PY=2012-2013 ( 206 records) Previous searches
1966 to current, searched 15 May 2012, limited to entry date 2006 or later, (1357 records)
((“sex* coerc*” OR “sex* crim*” OR “sex* molest*” OR “sex* assault*” OR “sex* abus*” OR “sex* offen*” OR “sex* victim*” OR “sex* maltreat*” OR incest* OR rape*) OR (SU.EXACT(“Sexual Abuse”) OR SU.EXACT(“Child Abuse”) OR SU.EXACT(“Rape”))) AND (SU.EXACT(“Longitudinal Studies”) OR SU.EXACT(“Control Groups”) OR SU.EXACT(“Program Effectiveness”) OR SU.EXACT(“Experimental Groups”) OR SU.EXACT(“Followup Studies”) OR SU.EXACT(“Comparative Analysis”) OR prospective OR “follow up” OR ((evaluat* OR compar* OR blind*) NEAR/5 (study OR studies OR research)) OR ((compar* OR control*) NEAR/5 group*) OR random* OR intervention* OR experiment* OR trial*) AND (child* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young person*” OR “young people” OR school* OR college* OR pupil* OR student*)
DARE, 2014 (3), part of Tfte Cocftrane Library , last searched 8 September 2014 (6 records) Previous searches
DARE 2013(3), searched 2 September 2013 (5 records)
DARE 2012(2), searched 4 April 2012 ( 2 records)
#1 MeSH descriptor Child Abuse, Sexual, this term only
#2 MeSH descriptor Rape, this term only
#3 MeSH descriptor Incest, this term only
#4 MeSH descriptor Sex Offenses, this term only
#5 molest* or rape* or incest*
#6 sex* near/3 (crim* or abuse* or assault* or offen* or exloit* or victim* or coerc* or maltreat*)
#7 (groom* near/3 (child* or online or sex*))
#8 (online near/3 solicit)
#9 (#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8)
#10 MeSH descriptor Adolescent, this term only
#11 child NEAR MEsh
#12 (child* or boy* or girl* or adolescen* or teen* or youth* or young NEXT people or young NEXT person* OR school* or pupil* or student* or college*)
#13 (#10 OR #11 OR #12)
#14 (#9 AND #13)
#15 (#1 OR #14)
NDLTD (SCIRUS) ndltd.org/serviceproviders/scirus-etd-search, last searched 3 September 2013 (no new records). Not available in September 2014 and no longer available via SCIRUS
Previous searches
4 April 2013, all available years (9 records)
title:sex* AND title:abuse* AND (title:school* OR title:college*) Limited to Theses and dissertations and by year 2012 to 2013
ClinicalTrials.gov, clinicaltrials.gov/, searched 9 September 2014, limited to records added since 1 September 2013 (15 records) Previous searches
3 September 2013, limited to records added since 1 March 2012 (9 records)
5 April 2012, searched all years as not searched for original review (22 records) Sex abuse school | Interventional Studies | Child |
ICTRP apps.who.int/trialsearch/, last searched searched 9 September 2014, limited to records registered since 1 September 2013 (1 record)
Previous searches
3 September 2013 (no new records)
3 April 2012, no limits applied as not searched for original review (no records) Condition: sex abuse
Intervention: School
Australasian Theses (via TROVE) trove.nla.gov.au/, last searched 9 September 2014, limited to publication year 2013 to 2014 (no new records)
Previous searches
3 September 2013, limited to publication year 2012 to 2013 (no new records) 3 April 2012, no limits applied as not searched for original review (9 records) All words: SEX* ABUSE* SCHOOL* in TITLE and limited to Dissertations
Appendix 2. Search strategies up to August 2006
Cochrane Central Register of Controlled Trials (CENTRAL) (2006, Issue 3) CHILD
CHILD* TEENAGE* ADOLESCEN*
(((#1 or #2) or #3) or #4) SEX OFFENSES
RAPE INCEST*
(SEX* near OFFENCE*)
(SEX* near OFFENSE*) (SEX* near ABUS*) (SEX* near ASSAULT*) (SEX* near MOLEST*) (SEX* near CRIM*) (SEX* near COERC*)
(((((((((#6 or #7) or #8) or #9) or #10) or #11) or #12) or #13) or #14) or #15
(#5 and #16)
MEDLINE (via OVID) searched 1966 to August 2006 1 exp child/
2 child$.tw.
3 adolescen$.tw.
4 teenage$.tw.
5 1 or 2 or 3 or 4 6 exp Sex offenses/
7 Incest/
8 (sex$ adj5 offen$).tw. 9 (sex$ adj5 abus$).tw.
10 (sex$ adj5 assault$).tw. 11 (sex$ adj5 molest$).tw. 12 (sex$ adj5 coerc$).tw. 13 (sex$ adj5 crim$).tw. 14 incest$.tw.
15 rape.tw.
16 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15
17 5 and 16
18 randomized controlled trial.pt. 19 controlled clinical trial.pt.
20 Randomized controlled trials/
21 random allocation.sh. 22 double blind method.sh. 23 single-blind method.sh.
24 or/18-23
25 (animal not human).sh. 26 24 not 25
27 clinical trial.pt. 28 exp Clinical trials/
29 (clin$ adj25 trial$).ti,ab.
30 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).ti,ab.
31 placebos.sh.
32 placebo08
33 random$.ti,ab.
34 research design.sh.
35 or/27-34
36 35 not 25
37 36 not 26
38 comparative study.sh. 39 exp evaluation studies/ 40 follow up studies.sh. 41 prospective studies.sh.
42 (control$ or prospectiv$ or volunteer$).ti,ab. 43 or/38-42
44 43 not 25
45 44 not (26 or 37)
46 26 or 37 or 45
47 17 and 46
EMBASE (via OVID) searched 1980 to August 2006 1 Controlled study/
2 Clinical trial/
3 Major clinical study/ 4 random$.tw.
5 Randomized controlled trial/ 6 trial$.tw.
7 compar$.tw.
8 control$.tw.
9 study.tw.
10 follow-up.tw.
11 clinic$.tw.
12 blind$.tw.
13 Double blind procedure/ 14 placebo$.tw.
15 Clinical article/
16 Placebo/
17 doubl$.tw.
18 or/1-17
19 exp child/
20 exp adolescent/
21 child$.tw.
22 adolescen$.tw.
23 teenage$.tw.
24 19 or 20 or 21 or 22 or 23 25 exp sexual abuse/
26 exp Child abuse/ 27 exp sexual crime/ 28 rape$.tw.
29 incest$.tw.
30 (sex$ adj5 offen$).tw. 31 (sex$ adj5 abus$).tw. 32 (sex$ adj5 assault$).tw. 33 (sex$ adj5 molest$).tw. 34 (sex$ adj5 coerc$).tw. 35 (sex$ adj5 crim$).tw.
36 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35
37 24 and 36
38 37 and 18
CINAHL (via OVID) searched 1982 to August 2006
1 Experimental Studies/ 2 exp Clinical trials/
3 ((control$ or clinic$ or prospectiv$) adj5 (trial$ or study or studies)).tw.
4 ((allocat$ or assign$ or divid$) adj5 (condition$ or experiment$ or treatment$ or control$ or group$)).tw. 5 ((singl$ or doubl$) adj (blind$ or mask$)).tw.
6 cross?over$.tw.
7 placebo$.tw.
8 (compar$ adj5 (trial$ or study or studies)).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 9 exp Clinical research/
10 Comparative studies/ 11 exp Evaluation research/
12 exp “control (research)”/ 13 Random assignment/
14 exp Prospective studies/ 15 exp Evaluation research/ 16 random$.tw.
17 exp Sexual abuse/ 18 rape.tw.
19 incest$.tw.
20 (sex$ adj5 offen$).tw. 21 (sex$ adj5 abus$).tw. 22 (sex$ adj5 assault$).tw. 23 (sex$ adj5 molest$).tw. 24 (sex$ adj5 coerc$).tw.
25 (sex$ adj5 crim$).tw. 26 or/17-25
27 exp Child/
28 child$.tw.
29 adolescen$.tw.
30 teenage$.tw.
31 or/27-30
32 26 and 31
33 or/1-16
34 32 and 33
PsycINFO searched 1984 to August 2006
1 “RANDOM$”.mp.
2 (random$ adj (alloc$ or assign$ or divid$)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers] 3 (random$ adj (trial$ or study or studies)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers]
4 ((control$ or clinic$ or prospectiv$) adj5 (trial$ or study or studies)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers]
5 ((allocat$ or assign$ or divid$) adj5 (condition$ or experiment$ or treatment$ or control$ or group$)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers]
6 ((singl$ or double$) adj (blind$ or mask$)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers] 7 “CROSS?OVER”.mp.
8 exp placebo/
9 (compar$ adj5 (trial$ or study or studies)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers] 10 (health or medicine or illness).sh.
11 8 and 9
12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 11
13 “child”/
14 “CHILD$”.mp.
15 exp adolescents/ or “teenager”.mp. 16 14 or 15
17 exp sexual abuse/
18 exp incest/ or exp rape/ or exp sex offenses/ or exp victimization/ or “sexual assault”.mp. 19 17 or 18
20 12 and 16 and 19
Sociological Abstracts (via Cambridge Scientific Abstracts) searched 1963 to August 2006
((sex* near3 coerc*) or (sex* near3 crim*) or (sex* near3 assault*) or (sex* near3 abus*) or (sex* near3 molest*) or (sex* near3 offense*) or (sex* near3 offence*) or (“Incest-” in DE) or (incest*) or (“Rape-” in DE) or (rape) or (explode “Child-Sexual-Abuse” in DE)) and ((( ((control* or clinic* or prospectiv*) near5 (trial* or study or studies)) in AB )or( ((control* or clinic* or prospectiv*) near5 (trial* or study or studies)) in TI )) or (( (random*) in AB )or( (random*) in TI )) or (( (random* near (trial* or study or studies)) in AB )or( (random* near (trial* or study or studies)) in TI )) or (( (random* near (allocat* or assign* or divid*)) in AB )or( (random* near (allocat* or assign* or divid*)) in TI )) or (( (compar* near5 (trial* or study or studies)) in AB )and( compar* near5 (trial* or study or studies) )) or (placebo*) or (( (cross?over) in AB )and( (cross?over) in TI )) or (( ((singl* or doubl*) near (blind* or mask*)) in AB )and( ((singl* or doubl*) near (blind* or mask*)) in TI )) or (( ((allocat* or assign* or divid*) near5 (condition* or experiment* or treatment* or control* or group*)) in AB )and( ((allocat* or assign* or divid*) near5 (condition* or experiment* or treatment* or control* or group*)) in TI
))) and ((adolescen*) or (teen*) or (child*) or (explode “Children-” in DE) or (explode “Adolescents-” in DE))
W H A T ’ S N E W
Last assessed as up-to-date: 8 September 2014.
H I S T O R Y
Protocol first published: Issue 3, 2003
Review first published: Issue 3, 2007
C O N T R I B U T I O N S O F A U T H O R S
The original protocol and review was developed and written by Karen Zwi, Susan Woolfenden, Danielle M Wheeler, Tracey O’Brien, Paul Tait, and Katrina J Williams. Danielle Wheeler and Joanne Abbott (TSC for the Cochrane Developmental, Psychosocial and Learning Problems Group) conducted searches for the review.
Trial selection was performed by KW, KZ, SW, and AS. Data extraction and assessment of risk of bias were performed by KW, KZ, SW, and AS. Building on the original review, KW led the re-writing of results, discussion, and conclusions with input from all authors.
D E C L A R A T I O N S O F I N T E R E S T
Kerryann Walsh - acknowledges the Australian Research Council Discovery Projects Scheme (DP1093717) funding for research about sexual abuse prevention programmes in Australia that was conducted in parallel to this review.
Karen Zwi and Susan Woolfenden have access to ’training, education, and study leave’ (TESL) funds from their organisation, to attend conferences to present or to learn. This pays for travel, accommodation, per diem allowance, and registration fees.
Aron Shlonsky - none known.
S O U R C E S O F S U P P O R T
Internal sources
• No sources of support supplied
External sources
• Financial Markets Foundation for Children, Australia.
• Nordic Campbell Centre, Denmark.
• Queensland University of Technology Vice Chancellor’s Research Fellowship, Australia.
D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W
There are five main differences between the protocol, Zwi 2003, and the review update.
1. Types of outcome measures. On p 2 of the review protocol, five outcomes were specified: (i) the development of protective behaviours; (ii) knowledge of sexual abuse and abuse prevention concepts; (iii) retention of knowledge over time; (iv) parental or child anxiety; and (v) disclosure of sexual abuse by child or adolescent during or after participating in programmes. In this review update we reported on six more precise outcomes: (i) protective behaviours; (ii) knowledge (questionnaire-based knowledge and vignette-based knowledge); (iii) retention of protective behaviours over time; (iv) retention of knowledge over time; (v) harm manifesting as parental or child anxiety or fear; and (vi) disclosures of past or current child sexual abuse.
2. Measures of treatment effect. On p 4 of the review protocol, calculation of odds ratios (OR) for dichotomous outcomes was specified in strategies for data synthesis, while relative risk (RR) and risk difference (RD) were specified for reporting on dichotomous measures of treatment effects. In this review update, we used the OR as this is the statistic used most often in this field and for ease of interpretation.
3. Unit of analysis issues. On p 4 of the review protocol, we indicated we would adjust for unit of analysis errors where the ICC was available. However, ICCs were not reported in the studies or available from study authors. Instead, we used estimates of 0.1 and 0.2 that had been previously used in a review of school-based violence prevention programmes (Mytton 2006).
4. Dealing with missing data. Requirements for Cochrane Reviews have changed since this study’s protocol was written. In this review update we identified the following types of missing data: missing outcomes, missing summary data, and missing participants. For missing outcomes (e.g. disclosures, adverse outcomes) and missing summary data (i.e. group size totals, means, standard deviations (SDs)), we contacted corresponding study authors to provide outstanding data.
5. Data synthesis. Before starting the 2015 update of this review we had intended to combine data with a fixed effect model in the absence of moderate statistical heterogeneity (I square <30%) and to adopt a random effects model where I square exceeded this threshold. Further consideration of the differences between the characteristics of the included studies prompted us to revise this approach. We decided to use a random effects model throughout the review in the expectation that variation between the results of the studies represented a distribution of related intervention effects.
6. Subgroup analyses. On p 4 of the review protocol, we specified the conduct of subgroup analyses to determine differential effects according to participant age, gender and previous reported abuse, and intervention type (passive or active involvement of
participants). Subgroup analyses were only conducted for age, but not for other variables, as there was insufficient information provided in the included studies.
N O T E S
This review is co-registered within the Campbell Collaboration.
I N D E X T E R M S
Medical Subject Headings (MeSH)
∗Schools; Child Abuse, Sexual [∗prevention & control]; Health Knowledge, Attitudes, Practice; Program Evaluation; Randomized Controlled Trials as Topic
MeSH check words
Adolescent; Child; Humans
Walsh K, Zwi K, Woolfenden S, Shlonsky A
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2015, Issue 4
http://www.thecochranelibrary.com
School-based education programmes for the prevention of child sexual abuse (Review)
T A B L E O F C O N T E N T S
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 1.1. Comparison 1 Protective behaviours, Outcome 1 Protective behaviours, no correction for clustering. . 93
Analysis 1.2. Comparison 1 Protective behaviours, Outcome 2 Protective behaviours, ICC=0.1. . . . . . . . . 93
Analysis 1.3. Comparison 1 Protective behaviours, Outcome 3 Protective behaviours, ICC=0.2. . . . . . . . . 94
Analysis 2.1. Comparison 2 Knowledge, Outcome 1 Questionnaire-based knowledge, no correction for clustering. . 95
Analysis 2.2. Comparison 2 Knowledge, Outcome 2 Questionnaire-based knowledge, ICC = 0.1. . . . . . . . 96
Analysis 2.3. Comparison 2 Knowledge, Outcome 3 Questionnaire-based knowledge, ICC = 0.2. . . . . . . . 97
Analysis 2.4. Comparison 2 Knowledge, Outcome 4 Vignette-based knowledge, no correction for clustering. . . . 98
Analysis 2.5. Comparison 2 Knowledge, Outcome 5 Vignette-based knowledge, ICC = 0.1. . . . . . . . . . 99
Analysis 2.6. Comparison 2 Knowledge, Outcome 6 Vignette-based knowledge, ICC = 0.2. . . . . . . . . . 100
Analysis 3.1. Comparison 3 Retention over time, Outcome 1 Questionnaire-based knowledge, no correction for
clustering. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Analysis 3.2. Comparison 3 Retention over time, Outcome 2 Questionnaire-based knowledge, ICC = 0.1. . . . . 102
Analysis 3.3. Comparison 3 Retention over time, Outcome 3 Questionnaire-based knowledge, ICC = 0.2. . . . . 103
Analysis 4.1. Comparison 4 Harm, Outcome 1 Harm, no correction for clustering. . . . . . . . . . . . . 104
Analysis 4.2. Comparison 4 Harm, Outcome 2 Harm, ICC=0.1. . . . . . . . . . . . . . . . . . . 105
Analysis 4.3. Comparison 4 Harm, Outcome 3 Harm, ICC=0.2. . . . . . . . . . . . . . . . . . . 106
Analysis 5.1. Comparison 5 Disclosures, Outcome 1 Disclosures, no correction for clustering. . . . . . . . . 107
Analysis 5.2. Comparison 5 Disclosures, Outcome 2 Disclosures, ICC=0.1. . . . . . . . . . . . . . . . 107
Analysis 5.3. Comparison 5 Disclosures, Outcome 3 Disclosures, ICC=0.2. . . . . . . . . . . . . . . . 108
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
109
118
119
119
119
120
120
121
121
School-based education programmes for the prevention of child sexual abuse (Review) i
[Intervention Review]
School-based education programmes for the prevention of child sexual abuse
Kerryann Walsh1, Karen Zwi2 , Susan Woolfenden3, Aron Shlonsky4
1Faculty of Education, Queensland University of Technology, Brisbane, Australia. 2 School of Women’s and Children’s Health, University of New South Wales & Sydney Children’s Hospital, Sydney, Australia. 3Sydney Children’s Hospitals Network, Sydney Children’s Community Health Centre, Randwick, Australia. 4Department of Social Work, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia
Contact address: Kerryann Walsh, Faculty of Education, Queensland University of Technology, Victoria Park Road, Brisbane, Queens- land, 4059, Australia. k.walsh@qut.edu.au.
Editorial group: Cochrane Developmental, Psychosocial and Learning Problems Group.
Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 4, 2015.
Review content assessed as up-to-date: 8 September 2014.
Citation: Walsh K, Zwi K, Woolfenden S, Shlonsky A. School-based education programmes for the prevention of child sexual abuse.
Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD004380. DOI: 10.1002/14651858.CD004380.pub3. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Child sexual abuse is a significant global problem in both magnitude and sequelae. The most widely used primary prevention strategy has been the provision of school-based education programmes. Although programmes have been taught in schools since the 1980s, their effectiveness requires ongoing scrutiny.
Objectives
To systematically assess evidence of the effectiveness of school-based education programmes for the prevention of child sexual abuse. Specifically, to assess whether: programmes are effective in improving students’ protective behaviours and knowledge about sexual abuse prevention; behaviours and skills are retained over time; and participation results in disclosures of sexual abuse, produces harms, or both.
Search methods
In September 2014, we searched CENTRAL, Ovid MEDLINE, EMBASE and 11 other databases. We also searched two trials registers and screened the reference lists of previous reviews for additional trials.
Selection criteria
We selected randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of school-based education interventions for the prevention of child sexual abuse compared with another intervention or no intervention.
Data collection and analysis
Two review authors independently assessed the eligibility of trials for inclusion, extracted data, and assessed risk of bias. We summarised data for six outcomes: protective behaviours; knowledge of sexual abuse or sexual abuse prevention concepts; retention of protective behaviours over time; retention of knowledge over time; harm; and disclosures of sexual abuse.
Main results
This is an update of a Cochrane Review that included 15 trials (up to August 2006). We identified 10 additional trials for the period to September 2014. We excluded one trial from the original review. Therefore, this update includes a total of 24 trials (5802 participants). We conducted several meta-analyses. More than half of the trials in each meta-analysis contained unit of analysis errors.
1. Meta-analysis of two trials (n = 102) evaluating protective behaviours favoured intervention (odds ratio (OR) 5.71, 95% confidence interval (CI) 1.98 to 16.51), with borderline low to moderate heterogeneity (Chi² = 1.37, df = 1, P value = 0.24, I² = 27%, Tau² = 0.16). The results did not change when we made adjustments using intraclass correlation coefficients (ICCs) to correct errors made in studies where data were analysed without accounting for the clustering of students in classes or schools.
2. Meta-analysis of 18 trials (n = 4657) evaluating questionnaire-based knowledge favoured intervention (standardised mean difference (SMD) 0.61, 95% CI 0.45 to 0.78), but there was substantial heterogeneity (Chi² = 104.76, df = 17, P value < 0.00001, I² = 84%, Tau² = 0.10). The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.66, 95% CI 0.51 to 0.81; ICC: 0.2 SMD 0.63, 95% CI 0.50 to 0.77).
3. Meta-analysis of 11 trials (n =1688) evaluating vignette-based knowledge favoured intervention (SMD 0.45, 95% CI 0.24 to 0.65), but there was substantial heterogeneity (Chi² = 34.25, df = 10, P value < 0.0002, I² = 71%, Tau² = 0.08). The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.53, 95% CI 0.32 to 0.74; ICC: 0.2 SMD 0.60, 95% CI 0.31 to 0.89).
4. We included four trials in the meta-analysis for retention of knowledge over time. The effect of intervention seemed to persist beyond the immediate assessment (SMD 0.78, 95% CI 0.38 to 1.17; I² = 84%, Tau² = 0.13, P value = 0.0003; n = 956) to six months (SMD 0.69, 95% CI 0.51 to 0.87; I² = 25%; Tau² = 0.01, P value = 0.26; n = 929). The results did not change when adjustments were made using ICCs.
5. We included three studies in the meta-analysis for adverse effects (harm) manifesting as child anxiety or fear. The results showed no increase or decrease in anxiety or fear in intervention participants (SMD -0.08, 95% CI -0.22 to 0.07; n = 795) and there was no heterogeneity (I² = 0%, P value = 0.79; n=795). The results did not change when adjustments were made using ICCs.
6. We included three studies (n = 1788) in the meta-analysis for disclosure of previous or current sexual abuse. The results favoured intervention (OR 3.56, 95% CI 1.13 to 11.24), with no heterogeneity (I² = 0%, P value = 0.84). However, adjusting for the effect of clustering had the effect of widening the confidence intervals around the OR (ICC: 0.1 OR 3.04, 95% CI 0.75 to 12.33; ICC: 0.2 OR 2.95, 95% CI 0.69 to 12.61).
Insufficient information was provided in the included studies to conduct planned subgroup analyses and there were insufficient studies to conduct meaningful analyses.
The quality of evidence for all outcomes included in the meta-analyses was moderate owing to unclear risk of selection bias across most studies, high or unclear risk of detection bias across over half of included studies, and high or unclear risk of attrition bias across most studies. The results should be interpreted cautiously.
Authors’ conclusions
The studies included in this review show evidence of improvements in protective behaviours and knowledge among children exposed to school-based programmes, regardless of the type of programme. The results might have differed had the true ICCs or cluster-adjusted results been available. There is evidence that children’s knowledge does not deteriorate over time, although this requires further research with longer-term follow-up. Programme participation does not generate increased or decreased child anxiety or fear, however there is a need for ongoing monitoring of both positive and negative short- and long-term effects. The results show that programme participation may increase the odds of disclosure, however there is a need for more programme evaluations to routinely collect such data. Further investigation of the moderators of programme effects is required along with longitudinal or data linkage studies that can assess actual prevention of child sexual abuse.
P L A I N L A N G U A G E S U M M A R Y
School-based programmes for the prevention of child sexual abuse Background and review question
School-based education programmes for the prevention of child sexual abuse (Review) 2
School-based education programmes for the prevention of child sexual abuse have been implemented on a large scale in some countries. We reviewed the evidence for the effectiveness of these programmes in the following areas: (i) children’s skills in protective behaviours;
(ii) children’s knowledge of child sexual abuse prevention concepts; (iii) children’s retention of protective behaviours over time; (iv) children’s retention of knowledge over time; (v) parental or child anxiety or fear as a result of programme participation; and (vi) disclosures of past or current child sexual abuse during or after programmes. The evidence is current to September 2014.
Study characteristics
This review included 24 studies, conducted with a total of 5802 participants in primary (elementary) and secondary (high) schools in the United States, Canada, China, Germany, Spain, Taiwan, and Turkey. The duration of interventions ranged from a single 45-minute session to eight 20-minute sessions on consecutive days. Although a wide range of programmes were used, there were many common elements, including the teaching of safety rules, body ownership, private parts of the body, distinguishing types of touches and types of secrets, and who to tell. Programme delivery formats included film, video or DVD, theatrical plays, and multimedia presentations. Other resources used included songs, puppets, comics, and colouring books. Teaching methods used in delivery included rehearsal, practice, role-play, discussion, and feedback.
Key results
This review found evidence that school-based sexual abuse prevention programmes were effective in increasing participants’ skills in protective behaviours and knowledge of sexual abuse prevention concepts (measured via questionnaires or vignettes). Knowledge gains (measured via questionnaires) were not significantly eroded one to six months after the intervention for either intervention or control groups. In terms of harm, there was no evidence that programmes increased or decreased children’s anxiety or fear. No studies measured parental anxiety or fear. Children exposed to a child sexual abuse prevention programme had greater odds of disclosing their abuse than children who had not been exposed, however we were more uncertain about this effect when the analysis was adjusted to account for the grouping of participants in classes or schools. Studies have not yet adequately measured the long-term benefits of programmes in terms of reducing the incidence or prevalence (or both) of child sexual abuse in programme participants.
Quality of the evidence
The quality of the evidence for all outcomes included in the meta-analyses (combining of data) was moderate. Study quality was compromised in about half of the included studies, due to suboptimal data collection methods for study outcomes and inappropriate data analysis.
S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
School-based programme for the prevention of child sexual abuse compared with no intervention or standard school curriculum Patient or population: children (aged 5 to 12) and adolescents (aged 13 to 18)
Settings: primary (elementary) or secondary (high) schools
Intervention: school-based education programmes for the prevention of child sexual abuse
Comparison: no intervention or standard school curriculum
Outcomes Illustrative comparative risks* (95% CI) Relative effect
(95% CI)
Assumed risk Corresponding risk
Control group Intervention group
Number of participants (studies)
Quality of the evidence (GRADE)
Comments
Protective
behaviours (self protec- tive events measured us- ing a stranger simulation test immediately post in- tervention)
390 per 1000 795 per 1000
(559 to 914)
OR 5.71
(1.98 to 16.51)
102
(2 studies)
⊕⊕⊕§
moderate1
Results favoured inter- vention
Questionnaire-
based knowledge (fac- tual knowledge measured by assessing responses to items on a question- naire or multi-choice test, immediately post inter- vention)
(higher score = higher knowledge)
The mean knowledge score measured using a variety of scales across control groups ranged from 3 to 64
The mean knowledge score in the intervention groups was
0.61 standard deviations higher (0.45 higher to 0. 78 higher)
4657
(18)
⊕⊕⊕§
moderate2
Results favoured inter- vention
Vignette-based knowl- edge (applied knowledge measured by assessing responses to hypothet- ical scenarios, immedi- ately post intervention) (higher score = higher knowledge)
Harm (measured using anxiety or fear question- naires)
The mean knowledge score measured using a variety of instruments across control groups ranged from
1 to 42
The mean anxiety or fear score measured using a variety of scales across control groups ranged from 2 to 7
The mean knowledge score in the intervention groups was
0.45 standard deviations higher (0.24 higher to 0. 65 higher)
The mean anxiety or fear score in the intervention groups was
0.08 standard deviations lower (0.22 lower to 0.07 higher)
1688
(11)
795
(3)
⊕⊕⊕§
moderate2
⊕⊕⊕§
moderate3
Results favoured inter- vention
Results showed no in- crease or decrease in anxiety or fear
Disclosures (of past or current child sexual abuse made during or after pro- gramme completion)
4 per 1000 14 per 1000
(5 to 45)
OR 3.56
(1.13 to 11.24)
1788
(3)
⊕⊕⊕§
moderate4
Results favoured inter- vention, however when adjusted for unit of analy- sis errors, this effect dis- appeared
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; OR: odds ratio
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
1Downgraded one level due to imprecision (wide confidence intervals).
2Downgraded one level due to risk of bias: unclear or high risk of bias for randomisation and allocation concealment, and blinding of participants or personnel
3Downgraded one level due to imprecision: 95% CIs around pooled estimate include both effect and no effect.
4 Downgraded one level following sensitivity analysis using ICCs of 0.1 and 0.2 to adjust for the effect of clustering on the results.
B A C K G R O U N D
Description of the condition
Child sexual abuse is a problem of considerable magnitude with short- and long-term repercussions for those victimised. There is no universal definition of child sexual abuse (Macdonald 2001; Trickett 2006). It is a term used to describe a range of experiences involving a child in unwanted, inappropriate, coercive, and un- lawful sexual exploitation by an adult or older child. The World Health Organization (WHO) definition states that “child sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed con- sent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society” (WHO 1999, p 15). Child sexual abuse is categorised along a continuum according to the type of abuse experienced by the child: involving physical body contact (using the term ’contact child sexual abuse’) or not involving physical body contact (us- ing the term “non-contact child sexual abuse”). Contact acts in- clude unwanted touching, fondling, masturbation, frottage, oral- genital contact, and vaginal or anal penetration by a penis, fin- ger or other object. Non-contact acts include making sexual com- ments, voyeurism (’peeping’), exhibitionism (’flashing’), exposing a child to pornography, or making pornography (Finkelhor 2008; Putnam 2003). Recent meta-analyses of data collected from ret- rospective studies of adults in countries and cultures worldwide estimate that 10% to 20% of female children, and 5% to 10% of male children, have experienced child sexual abuse on a spec- trum from exposure through unwanted touching to penetrative assault before the age of 18 years (Barth 2013; Ji 2013; Pereda 2009; Stoltenborgh 2011). These data are likely to underestimate its true prevalence because two-thirds of individuals never disclose their victimisation (London 2005) and most cases go unreported to authorities (Wyatt 1999). The WHO estimates that child sexual abuse contributes to seven to eight per cent of the global burden of disease for females, and four to five per cent for males (Andrews 2004).
Child sexual abuse is associated with adverse psychosocial out- comes such as depression (Roosa 1999), post-traumatic stress dis- order (Widom 1999), antisocial and suicidal behaviours (Bensley 1999), eating disorders (Perkins 1999), alcohol and substance abuse (Spak 1998), post-partum depression and parenting diffi- culties (Buist 1998), sexual re-victimisation, and sexual dysfunc- tion (Fleming 1999). A recent meta-analysis found child sexual abuse was also associated with higher rates of physical health con- ditions, including gastrointestinal, gynaecological, and cardiovas- cular problems, and obesity (Irish 2010). A longitudinal analysis of the association between childhood sexual abuse and educational achievement found a clear linear relationship between increasing severity of child sexual abuse and poorer educational achievement, however the relationship was confounded by sociodemographic
characteristics (e.g. lower maternal age and qualifications) and family functioning variables (e.g. inter-parental violence) known to be associated with child maltreatment (Boden 2007). These consequences are far-reaching into families and communities, with significant costs for institutions in terms of primary and rehabili- tative health care, education and welfare assistance, child protec- tion, and justice system costs (Fang 2012).
Given the retrospective nature of many studies, it is unclear what proportion of survivors go on to experience adverse outcomes and how sexual abuse interacts with other potential risk factors for these adverse outcomes. However, outcomes are known to vary for individuals according to: child age and gender; perpetrator age and gender; the relationship between child and perpetrator; the severity, duration, and/or frequency of the abusive act(s); ac- companying physical or emotional violence and/or force; and the presence of other forms of victimisation (Putnam 2003; Trickett 1997). Sexual abuse has been reported across all socioeconomic and ethnic groups, in both males and females, and perpetrators can include those outside the family as well as within it (Finkelhor 1993); they can be adults or other young people (Turner 2011). However, all children are not at equal risk. Risk factors for child sexual abuse, mainly identified in Western countries, include be- ing female (Fergusson 1996), having a physical or mental disabil- ity (Westcott 1999), living without a natural parent (Finkelhor 1986; Finkelhor 1990), parental mental illness, parental alcohol or drug dependency, and young maternal age (Fergusson 1996; Holmes 1998; MacMillan 2013). Girls appear to be more likely to be sexually abused by family members and boys by non-family members (Finkelhor 1990). The time of greatest vulnerability for child sexual abuse is between 7 and 12 years of age (Finkelhor 1986).
Description of the intervention
This review focuses on the most widely used strategy for the prevention of child sexual abuse: the provision of school-based programmes. Some terms commonly used to describe these pro- grammes include: personal safety education (NCMEC 1999); pro- tective behaviours (Flandreau-West 1984); personal body safety (Miller-Perrin 1990); body safety (Wurtele 2007); and child assault prevention and child protection education (NSW Department of School Education 1998). These programmes target children and adolescents aged 5 to 18 years who are students in primary (ele- mentary) or secondary (high) schools. Support for interventions of this type can be found in Article 19 of the United Nations Con- vention on the Rights of the Child, an international law, which states that governments should “take all appropriate legislative, admin- istrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse” (United Nations 1989).
Education programmes to reduce the occurrence of sexual abuse in children and adolescents were first developed by women’s rape prevention collectives in the United States of America (USA) in the 1970s (Berrick 1991). School-based programmes for the pre- vention of child sexual abuse were rapidly and widely adopted across the USA, assisted in some states by policy mandates, and by the mid 1990s it was estimated that two-thirds of 10- to 16-year olds in the USA had participated in such programmes (Finkelhor 1995c). Schools are a logical choice for teaching children about sexual abuse and its prevention, given their primary function is to educate (Wurtele 2009), and the content of prevention pro- grammes aligns with proscribed school health curricula (Walsh 2013). Hence, schools have emerged as an important primary and secondary prevention setting providing access to large populations of children and adolescents, and relatively economical service de- livery, without stigmatising those who may be at particular risk (Wurtele 2010).
School-based child sexual abuse prevention programmes are typi- cally presented to groups of students and are tailored to ages and cognitive levels. Programme content covers themes such as body ownership; distinguishing types of touches; identifying potential abuse situations; avoiding, resisting, or escaping such situations; secrecy; and how and whom to tell if abuse has occurred (Duane 2002; Topping 2009). Many programmes also stress that the child or adolescent is not to blame. Programmes vary in the number of, and extent to which these themes are covered. There is con- siderable variability in programme delivery formats and teaching methods. Formats such as books, comics, dramatic plays, puppet shows, films, lectures, and discussions have been used with some programmes employing single formats, whereas others use combi- nations of formats (Duane 2002; Topping 2009; Wurtele 1987a). Programme teaching methods have been conceptualised on a con- tinuum from those employing purely didactic approaches, such as a speech, address, or talk, stressing students’ passive listening and acquisition of knowledge, to those employing behavioural ap- proaches, such as modelling, and emphasising students’ active par- ticipation in role-play, rehearsing, or practising new self protec- tion skills (Wurtele 1987a). The duration and frequency of pro- grammes is diverse, with 30 minutes being a common length as this fits with a standard school lesson period. Programmes also vary in their scope with some programmes dealing only with child sex- ual abuse, whereas others integrate these themes into programmes covering broader issues such as general safety education, social and emotional learning, mental health and well being, respectful rela- tionships, and sexuality education. This review focuses only upon interventions in which prevention of child sexual abuse is the main goal.
How the intervention might work
The ultimate goal of child sexual abuse prevention education is to prevent children from ever experiencing abuse. It is also impor-
tant, in cases where children have experienced abuse, for adults to respond quickly and effectively to disclosures, to protect them from further victimisation, and to limit the harm caused. From a public health perspective (Rosenberg 1991), comprehensive ap- proaches to child sexual abuse would involve multiple “preven- tion targets”, including (i) offenders and potential offenders, (ii) children and adolescents, (iii) situations, and (iv) communities (Smallbone 2008, p 47). Although not yet rigorously researched, it appears that school-based programmes may also work to enhance community capacity for sexual abuse prevention by raising aware- ness and delivering information to multiple members of children’s social systems (Duane 2002), via provision of information pack- ages to parents, training for teachers, and family participation in homework activities.
School-based sexual abuse prevention programmes focus on chil- dren and adolescents as prevention targets. They seek to prevent child sexual abuse by providing students with knowledge and skills to recognise and avoid potentially sexually abusive situations, and with strategies to physically and verbally repel sexual approaches by offenders. They endeavour to minimise harm by disseminating messages about appropriate help seeking in the event of abuse or attempted abuse. Interventions aim to transfer the knowledge and skills learned by the child or adolescent in the classroom to real- life situations. Interventions work by capitalising on principles used by classroom teachers, most notably social cognitive learning theories (Bandura 1986; Vygotsky 1986), which stress the social context of learning via the use of instruction, modelling, rehearsal, reinforcement, and feedback (Wurtele 1987a).
Do programmes actually prevent child sexual abuse? There is some evidence from a small group of studies, all of which have been conducted in the USA, that participation in school-based child sexual abuse prevention programmes may decrease the occurrence of child sexual abuse. A study of 2000 10- to 16-year olds found that those exposed to more comprehensive prevention education were more knowledgeable about sexual abuse, more likely to re- port using self protection strategies, more likely to report protec- tive efficacy, more likely to have disclosed their victimisation, and less likely to engage in self blame (Finkelhor 1995a). In a follow- up study, the same individuals were more likely to use the protec- tive strategies they had been taught when confronted with threats and assaults (Finkelhor 1995b). Two studies with high-school (Ko 2001) and college students (Gibson 2000) showed programmes were associated with reduced incidence of child sexual abuse. How- ever these studies harbour the limitations of retrospective recall and have not been replicated with larger and more diverse samples. Research with sexual offenders on their perceptions of the efficacy of children’s self protection strategies in actual abuse situations has found the most effective strategy, reported by three-quarters of offenders, was to tell the offender they did not want to participate in sexual activities. Girls under the age of 12 years effectively used six strategies to avoid abuse: demanding to be left alone, saying they would tell someone, crying, saying they were scared, saying
the they did not want to, and saying “no” (Leclerc 2011). These strategies are key content in school-based child sexual abuse pre- vention programmes (Duane 2002).
Why it is important to do this review
Despite widespread adoption into the school curriculum in many countries, conclusions about the effectiveness of school-based pro- grammes for the prevention of child sexual abuse remain tentative. A number of research synthesis studies have been conducted on this topic in the form of meta-analyses, and systematic and nar- rative reviews (see Table 1: Previous reviews). However the find- ings have been limited by methodological weaknesses in the re- views (e.g. including non-randomised as well as randomised stud- ies; aggregation of diverse outcomes; inappropriate analytical ap- proaches), and in the individual studies included in the reviews (e.g. use of diverse measures; inadequate measurement of pro- gramme fidelity). Additionally, previous meta-analyses have dif- fered in their parameters and have not been replicated. Further, there are historical distinctions in previous reviews, for example, the classification of programmes as primarily active or passive, be- havioural or instructional, that warrant further exploration; this particular distinction seems artificial from an educational perspec- tive because many programmes are, in practice, multifaceted, in- volving a number of teaching methods that are used in integrated ways to deliver programme content (MacMillan 1994). What is needed is a way of identifying, more precisely, the range of child, programme, and study design characteristics that may moderate programme effectiveness.
Evaluations of discrete programmes have been limited to authors assessing and reporting on one or more of five measures: (i) knowl- edge gains, (ii) skills gains, (iii) sexual abuse disclosures, (iv) neg- ative programme effects or harms, and (v) subsequent incidence of child sexual abuse (Smallbone 2008). Consistent with previ- ous reviews, the original Cochrane review found improvements in knowledge and protective behaviours (skills) among children who had received school-based programmes (Zwi 2007). Find- ings on disclosures, harm, and retention of knowledge over time were inconclusive. As this was the most rigorous of the reviews ever conducted (Mikton 2009), and is the only review to include risk of bias analyses, the review also uncovered many methodolog- ical quality issues that warrant ongoing monitoring and review. This is important because the historical controversy over school- based child sexual abuse prevention programmes is concentrated on two outcomes: programmes’ actual effectiveness in preventing child sexual abuse, and concerns over negative programme effects (Finkelhor 2007). Evidence on programmes’ effectiveness with re- gard to the fifth and arguably the most important measure, the degree to which programmes actually reduce the incidence of child sexual abuse, remains a pressing and unanswered empirical ques- tion that requires ongoing review.
It has been suggested that education programmes can cause harm to participating children and adolescents (Taal 1997). This is re- ported to be a common parental concern (Finkelhor 2007; Tutty 1993). Some studies report few or no evaluated negative effects on children (Tutty 1997), whereas others suggest potentially harm- ful sequelae. For example, some children report increased worry following programme participation (Finkelhor 1995c) and older children have been found to experience more negative feelings about non-sexual physical touch (Taal 1997). Therefore, there is a need to rigorously evaluate the evidence for these programmes, both in terms of beneficial and harmful outcomes, and to update the current evidence base on programme effectiveness.
O B J E C T I V E S
To systematically assess evidence of the effectiveness of school- based education programmes for the prevention of child sexual abuse. Specifically, to assess whether: programmes are effective in improving students’ protective behaviours and knowledge about sexual abuse prevention; behaviours and skills are retained over time; and participation results in disclosures of sexual abuse, pro- duces harms, or both.
The original review and the current update do not address whether these programmes or other interventions have reduced the inci- dence and/or prevalence of child sexual abuse at the population level as reported by official records (e.g. from statutory child pro- tection services, law enforcement, primary care, or hospital data), and/or community prevalence data (e.g. from self report surveys repeated at regular intervals). This objective may be incorporated in future review updates as research advances in this field.
M E T H O D S
Criteria for considering studies for this review
Types of studies
We included studies in the original review, and in this update, if they were randomised controlled trials (RCTs), cluster-RCTs, or quasi-RCTs where participants were allocated to the intervention or control group by day of the week, alphabetical order, or other sequential allocation such as class or school. In decision making for inclusion in the review, we focused on features of study design rather than design labels.
Types of participants
The study population comprised children (aged 5 to 12 years) and adolescents (aged 13 to 18 years) attending primary (elementary) or secondary (high) schools.
Types of interventions
Included interventions were school-based education programmes focusing on knowledge of sexual abuse and sexual abuse prevention concepts, or skill acquisition in protective behaviours, or both, compared with no intervention or the standard school curricu- lum. For this update, we excluded: interventions for preventing relationship and dating violence, and sexually coercive peer re- lationships, as these were reviewed in another Cochrane review (Fellmeth 2013); interventions for abduction prevention, the aims of which did not clearly refer to prevention of child sexual abuse; interventions aimed broadly at child protection or personal safety in which it was not possible to isolate the effects of the sexual abuse component; and interventions set entirely in before- and after- school programmes, and early childhood programmes that were not in schools (e.g. day-care settings).
Types of outcome measures
Child outcome measures were:
1. protective behaviours (as measured by an independently scored simulation test);
2. knowledge of sexual abuse or knowledge of sexual abuse prevention concepts, or both (as measured by questionnaires or vignettes);
3. retention of protective behaviours over time;
4. retention of knowledge over time;
5. harm, manifest as parental or child anxiety or fear (as measured by questionnaires); and
6. disclosure of sexual abuse by child or adolescent during or after programmes (as measured by official records of student self reports to school staff, child protective services, or police). Outcomes measured did not form criteria for inclusion in the review. We included studies meeting the inclusion criteria for types of study, participants, and interventions only.
Search methods for identification of studies
Electronic searches
We completed the most recent searches for this review update on 8 September 2014. We incorporated new search terms to describe recent concepts, such as child sexual abuse in online contexts, and the increasing use of terms such as ’exploitation’ and ’victimisation’ by researchers when describing child sexual abuse. Searches for the previous review were completed in August 2006. Where possible,
we focused on finding new studies and identifying older studies added to databases since that time. We added five new sources (two trials registers, two conference proceedings indexes, and one source of open access dissertations), and searched these for all available years (see Appendix 1). Search strategies used for the original review are in Appendix 2. The list of the databases searched and the time period they cover (for the original review and for this review update) are listed below:
• Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 8);
• Ovid MEDLINE(R), 1946 to August Week 4, 2014;
• EMBASE (OVID), 1980 to 2014 Week 36;
• PsycINFO (OVID),1967 to September Week 1 2014;
• CINAHL (EBSCOhost), 1937 to current;
• Social Science Citation Index (SSCI), 1970 to 29 August 2014;
• ERIC (EBSCOhost), 1966 to current;
• Sociological Abstracts (ProQuest), 1952 to current;
• Conference Proceedings Citation Index - Science (CPCI-S), 1990 to 29 August 2014;
• Conference Proceedings Citation Index - Social Sciences & Humanities (CPCI-SSH), 1990 to 29 August 2014;
• Database of Abstracts of Reviews of Effects (DARE) 2014, Issue 3, part of theCochrane Library;
• ClinicalTrials.gov (clinicaltrials.gov/);
• ICTRP (apps.who.int/trialsearch/);
• Australasian Theses (via TROVE) (trove.nla.gov.au/);
• Networked Digital Library of Theses and Dissertations (NDLTD) (via SCIRUS) (ndltd.org/serviceproviders/scirus-etd- search); last searched September 2013, not available in September 2014.
Searching other resources
Other sources of information searched included the reference lists of previous systematic and narrative reviews, and reference lists of included studies. We also searched databases of programme evalua- tions such as the Promising Practices Network (RAND Corporation 2013), and Blueprints for Healthy Youth Development (CSPV 2013). To identify unpublished studies, we circulated requests via email to relevant listservs (e.g. Child-Maltreatment-Research-Lis- terv).
Data collection and analysis
Selection of studies
We conducted selection of studies in three phases. In phase one, we imported titles and abstracts of articles identified in the searches into reference management software and review authors KZ and SW (2007 and 2009 searches), KW and KZ (2013 searches), and
KW and AS (2014 searches) independently screened them. We excluded papers if they clearly did not meet the inclusion crite- ria (i.e. study design, participants, type of intervention, types of comparisons). In phase two, two review authors (KZ and SW in 2007; KZ and KW in 2013; KW and AS in 2014) independently screened the titles, abstracts, and methodology sections of papers appearing to meet inclusion criteria. In phase three, we retrieved the full text of studies meeting all inclusion criteria for data ex- traction and we linked together multiple reports of the same study (e.g. Blumberg 1991). One study was translated into English (Del Campo Sanchez 2006). In cases where agreement could not be reached during screening, we asked a third and fourth review au- thor to independently assess the study against the inclusion crite- ria, and we resolved these cases via discussion and consensus.
Data extraction and management
For this update, we used an electronic data extraction proforma adapted from the checklist of items specified in the Cochrane Hand- book for Systematic Reviews of Interventions (Higgins 2011, Table 7.3a). Two review authors (KZ and SW in 2007) independently performed data extraction. KW repeated data extraction for all 24 studies in 2013, with KZ extracting data independently for new studies in 2013. No data extraction was required in 2014 as no fur- ther studies met the inclusion criteria. The data were entered into RevMan by KZ (Review Manager 4.2 in 2007) and KW (Review Manager 5.2 in 2013), and independently checked for accuracy by a research assistant who was not involved in the review. We resolved discrepancies via discussion. We asked authors of stud- ies in which methods of sequence generation, allocation conceal- ment, or blinding were unclear to provide additional information (see Assessment of risk of bias in included studies). We contacted corresponding authors of studies with insufficient information to allow inclusion in meta-analyses (Harvey 1988; Saslawsky 1986 in 2007; Chen 2012; Kraizer 1991 in 2013) and studies that used cluster-randomisation (Dake 2003; see Unit of analysis issues) via
email with a request to provide additional data. In some instances, authors were able to provide data as requested, however, the ma- jority did not respond to requests. It is not possible to know for sure that all authors received our correspondence.
Assessment of risk of bias in included studies
In the original review, two review authors (KZ, SW) independently assessed each included study. In the review update, the procedure was repeated by one review author (KW) who independently as- sessed risk of bias for all included studies and compared these re- sults to those obtained in the original review, with KZ assessing risk of bias independently for new studies in 2013. KW repeated assessment of risk of bias after a six-month interval. There were no discrepancies. We undertook no ’Risk of bias’ assessment in 2014 as no further studies met the inclusion criteria. Review authors assessing risk of bias were not blinded to the names of the authors, institutions, journals, or results of studies.
We assessed risk of bias using the seven domains on the Cochrane revised ’Risk of bias’ assessment tool (Higgins 2011, Table 8.5a):
(i) random sequence generation; (ii) allocation concealment; (iii) blinding of participants and personnel; (iv) blinding of outcome assessment; (v) incomplete outcome data; (vi) selective reporting; and (vii) other sources of bias. We assessed included studies on each domain as ’low risk’, ’high risk’, or ’unclear risk’ of bias. We made judgements by answering ’yes’ (assessed as low risk of bias), ’no’ (assessed as high risk of bias) or ’uncertain’ (assessed as unclear risk of bias) to pre-specified questions for each domain. We used verbatim text from study reports as support for each judgement of risk wherever possible. We entered information into RevMan and summarised it in a ’Risk of bias’ table for each included study. We generated two summary figures: a ’Risk of bias’ summary (Figure
1) visually depicting judgements across all studies, and a ’Risk of bias’ graph (Figure 2) illustrating the proportion of studies for each risk of bias criterion. Risk of bias domains are detailed below.
Figure 1. ’Risk of bias’ summary: review authors’ judgements about each risk of bias item for each included study
Figure 2. ’Risk of bias’ graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies
Random sequence generation (selection bias)
Description: The method used to generate the allocation sequence was described in sufficient detail to enable assessment of the extent to which it could produce comparable groups. In other words, a rule, based on some chance process, was adequately applied.
Questions: Do study authors make an explicit statement about random assignment? What methods were used to randomly assign participants to intervention and control groups?
Judgement: Was the allocation sequence adequately generated?
Allocation concealment (selection bias)
Description: The method used to conceal the allocation sequence was described in sufficient detail to enable assessment of whether the assignment of participants to groups could have been predicted ahead of time, or during the assignment process. Upcoming alloca- tions were concealed from those allocating participants to groups. Questions: Do the study authors report a method of concealing allocation of participants to intervention or control groups? Is there evidence that the method was potentially unconcealed?
Judgement: Was allocation adequately concealed?
Blinding of participants and personnel (performance bias)
Description: The measures used to blind study participants and personnel (such as programme facilitators or teachers) from knowl- edge of participant intervention or control group membership was
described in sufficient detail to enable assessment of the effects of this knowledge on study outcomes.
Questions: Do study authors reportprocedures for blinding? What specific blinding procedures were used? Was blinding achievable for this type of intervention?
Judgement: Was participant and personnel knowledge of the allo- cation to intervention or control group adequately withheld?
Blinding of outcome assessment (detection bias)
Description: The measures used to blind outcome assessors from knowledge of participant intervention or control group member- ship were described in sufficient detail to enable assessment of the effects of this knowledge on outcome assessment or data collec- tion, or both.
Questions: Do study authors report procedures for blinding of in- dividuals responsible for outcome assessment or data collection, or both? What specific blinding procedures were used? Was blinding achievable for this type of intervention?
Judgement: Was outcome assessors’ knowledge of the allocation to intervention or control group adequately withheld?
Incomplete outcome data (attrition bias)
Description: Complete outcome data are reported for each main outcome in sufficient detail to enable assessment of group differ- ences owing to missing data. Complete outcome data include: at- trition, exclusions, numbers of participants in each intervention
and control group compared with the total number of participants randomised, and reasons for attrition and exclusions.
Questions: Do study authors report attrition, exclusions, numbers of participants in each intervention and control group compared with the total number of participants randomised, and reasons for attrition and exclusions? Are imputation methods explained?
Judgement: Were outcome data adequately addressed?
Selective reporting (reporting bias)
Description: The extent of outcome reporting is sufficient to en- able assessment of the possibility of selective outcome reporting, that is, reporting of some outcomes and not others depending on the nature and direction of results.
Questions: Do study authors report complete outcome data that
match the aims or hypotheses of the study? Do study authors report on all pre-specified outcomes of interest?
Judgement: Are reports of the study free of suggestion of selective outcome reporting?
Other sources of bias
Description: Any other important concerns about bias not ad- dressed in other domains.
Questions: Do study authors report studies in sufficient detail to enable assessment of other important risks of bias (e.g. related to the specific study design, extreme baseline imbalances, or contam- ination effects)?
Judgement: Was the study free of other problems that could put it at a high risk of bias?
Measures of treatment effect
According to the review protocol (Zwi 2003), for individual trials we planned to report the risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CI) for dichotomous outcomes and mean differences (MD) with 95% CI for continuous variables. For the meta-analysis, where possible, we planned to report the RR and RD with 95% CI for dichotomous outcomes and MD with 95% CI for continuous variables. Elsewhere in the protocol (e.g. p 4) odds ratios (OR) are also mentioned.
In the original review, and in this review update, we reported the summary of effect for dichotomous outcomes as an OR with 95% CI. Odds ratios are the statistic used most often in this field. For continuous outcomes this was to be reported as the standardised mean difference (SMD) with 95% CI. Standardised mean differ- ences are appropriate for data synthesis where different outcome measures are used across studies.
Unit of analysis issues
In the review protocol (Zwi 2003), in the case of cluster-RCTs, we planned to adjust for unit of analysis errors where the intr- aclass correlation coefficient (ICC) was available. In the original review, and in this review update, some included studies involved cluster-randomisation at the level of the class, school, or district. However, ICCs were not reported in the studies, nor were they available from study authors. No published ICC for school-based child sexual abuse prevention interventions could be found. We noted that estimates of 0.1 and 0.2 had been used in a review of school-based violence prevention programmes (Mytton 2006), based on the rationale for a published ICC of 0.15 for similar trials (CPPRG 1999b in Mytton 2006), and was considered a plausible yet conservative estimate for the impact of clustering at the class- room level (Schochet 2008). We reasoned that a suitably conser- vative approach would be to use the extremes of ICC 0.1 and 0.2 to calculate a design effect for each cluster-RCT according to the formula given in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section 16.3.4) which is: 1 + (mean cluster size - 1) ICC. We weighted these using the generic inverse variance function and used random-effect models.
Some studies included in this review had multiple intervention groups (Blumberg 1991; Crowley 1989; Dawson 1987; Krahé 2009; Poche 1988). In these cases, we combined all relevant inter- vention groups into a single group, and all relevant control groups into a single group. Using the tools available in Review Manager 5.2, we combined means and standard deviations (SD) for con- tinuous outcomes, and summed sample sizes and number of out- comes across groups for dichotomous outcomes. This enabled us to make comparisons between groups using pair-wise comparisons without risk of double-counting participants.
Dealing with missing data
Requirements for dealing with missing data in Cochrane Reviews have changed since the protocol for this review was written (Zwi 2003). We identified several types of missing data in this review update: missing outcomes, missing summary data, and missing participants. For missing outcomes (e.g. disclosures, adverse out- comes) and missing summary data (i.e. group size totals, means, SDs), we contacted corresponding study authors to provide the outstanding data. Some authors responded helpfully to these re- quests, but data could only be provided for the most recent studies; in other cases, data had been collected over two decades ago and were no longer available. In some cases, authors did not respond. If data remained unavailable after these processes, we excluded these studies from the analyses. For missing participants, we reported the attrition rate wherever possible in the ’Risk of bias’ tables be- neath the Characteristics of included studies table.
Assessment of heterogeneity
We assessed heterogeneity (study diversity) visually and by exam- ining the I² statistic (Higgins 2002), a quantity which describes
the proportion of variation in point estimates that is due to het- erogeneity rather than sampling error. We supplemented this with a statistical test of homogeneity to determine the strength of ev- idence for genuine heterogeneity using a significance level of P value > 0.05.
Assessment of reporting biases
To assess reporting biases, we used two approaches to investigate the relationship between effect size and sample size (Borenstein 2009). We drew fixed-effect forest plots with studies plotted ac- cording to weight (i.e. from most to least precise). We noted any trend towards greater effect sizes at the bottom of the plots indica- tive of bias attributable to missing studies. We also drew fixed-ef- fect funnel plots and checked them for asymmetry indicating the presence of publication bias. In both approaches, trends or asym- metry could be due to publication or related biases (e.g. language bias, availability bias, citation bias) or due to genuine differences between small and large trials (Borenstein 2009; Egger 1997). If a relationship was identified, we further examined differences be- tween studies as a possible explanation along with comparisons by source (e.g. peer-reviewed journals; theses). We planned to con- duct these analyses only when there was a reasonable number of studies (more than 10) and a reasonable amount of dispersion in sample sizes. To reduce the effects of publication bias, in the review update, we made efforts to retrieve the full texts of unpublished trials (e.g. theses). This was made easier by virtue of the fact that many had been made available on electronic databases since our previous searches were conducted and document delivery services had improved.
Data synthesis
We synthesised the data using tools provided in Review Manger (RevMan) 5.2 (RevMan 2012). We assessed the appropriateness of combining studies based on sufficient comparability with respect to: the type of intervention, the type of outcome measures, and the nominated data collection points pre- and post-intervention. We calculated summary statistics (OR for dichotomous data and SMD for continuous data) with 95% CIs for each study. We had intended to use a fixed effect model to combine data in the first instance and then to adopt a random effects model where the I square value exceeded 30%. On further consideration of the differences between the included studies in terms of their setting and intervention, we decided instead to adopt a random effects model to combine data. In all cases, we generated pooled estimates for those studies for which complete statistical data were available or could be derived (i.e. counts and proportions for dichotomous data, and means and SDs for continuous data). Forest plots are presented for each of the pooled estimates. In all cases, we corrected for small sample size bias by using Hedges’ g, which is the default in Review Manager (RevMan) 5.2 (RevMan 2012).
We planned to conduct analyses on the six outcomes nominated above: (i) protective behaviours; (ii) knowledge of sexual abuse or knowledge of sexual abuse prevention concepts, or both; (iii) re- tention of protective behaviours over time; (iv) retention of knowl- edge over time; (v) parental or child anxiety or fear; (vi) disclosure of sexual abuse. To manage subtle differences in outcome mea- surement for (ii) (knowledge), we created subgroups according to the category of measurement instrument used (i.e. questionnaire- based knowledge or vignette-based knowledge). There were insuf- ficient data to proceed with analysis for retention of protective be- haviours over time. No studies measured parental anxiety or fear.
Subgroup analysis and investigation of heterogeneity
In the review protocol (Zwi 2003), we specified the conduct of subgroup analyses to assess the impact of clinically relevant differ- ences: (i) in the interventions (e.g. passive or active involvement of participants); and (ii) between groups of participants (e.g. gen- der, school setting). We did not conduct subgroup analyses be- cause there was insufficient information provided in the included studies about issues that were hypothesised as being relevant for subgroup analysis, for example, studies did not always provide a breakdown of studentgender by intervention group. Further, upon close scrutiny, interventions did not appear to fit an active/pas- sive dichotomy with many having multiple components of both active and passive types (e.g. a video or DVD presentation may at times require children to sit still and listen, and at other times, to respond, chant, sing, or move). Further, there were insufficient numbers of studies to allow for meaningful comparisons. This will be elaborated further below.
Sensitivity analysis
We conducted sensitivity analysis to explore the extent to which results were influenced by risk of bias. We conducted a series of sen- sitivity analyses removing from the analyses studies with high risk of bias for: (i) allocation concealment (selection bias); (ii) blinding of outcome assessors (detection bias); (iii) incomplete outcome data (attrition of over 20%), and (iv) selective reporting (reporting bias). We also conducted sensitivity analyses to determine the im- pact of unit of analysis errors, arising from inadequate adjustment for cluster-randomisation in published results.
Rating the quality of the evidence
We rated the quality of the evidence for our main outcomes ac- cording to methods for rating evidence from randomised con- trolled trial developed by the GRADE working group (http:// www.gradeworkinggroup.org/). For each outcome of interest the evidence started at high quality and could be downgraded to mod- erate, low or very low quality after consideration of the possible impact of risk of bias, imprecision, inconsistency, indirectness and publication bias on our confidence in the effects of intervention.
We have presented results for the primary analyses, quality ratings, and explanations for downgrading any decisions for the following outcomes in a ’Summary of Findings’ table:
• Protective behaviours (self protective events measured using a stranger simulation test immediately post intervention)
• Questionnaire-based knowledge (factual knowledge measured by assessing responses to items on a questionnaire or multi-choice test, immediately post intervention)
• Vignette-based knowledge (applied knowledge measured by assessing responses to hypothetical scenarios, immediately post intervention)
• Harm (measured using anxiety or fear questionnaires)
• Disclosures (of past or current child sexual abuse made during or after programme completion)
R E S U L T S
Description of studies
Results of the search
For this update, we searched the period from August 2006 to September 2014 (see Appendix 1). We identified a total of 12,969 records through database searching and a further 58 records from other sources. After duplicates were removed, we screened 10,218 records and excluded 10,161 records. We retrieved and evaluated the full-text reports of the remaining 57 records for eligibility. Of these, we excluded 43 reports, with reasons reported in the Characteristics of excluded studies table. From the remaining pa- pers, we identified: 10 new included studies, one of which was translated from Spanish into English (Del Campo Sanchez 2006); three additional reports of two included studies from the previous review (Blumberg 1991; Fryer 1987b); and one ongoing study (NCT02181647).
Searches for the original review covered the period up to August 2006 (Appendix 2). The previous review was based on 15 included studies. We excluded one of the previously included studies from this update (Pacifici 2001), because we reassessed it as not meet- ing the eligibility criterion for type of intervention, being focused on sexual violence prevention in the context of dating relation- ships for adolescents (see Fellmeth 2013), rather than explicitly on knowledge of child sexual abuse and its prevention. In total, this updated review reports on a total of 24 unique trials reported in 29 papers (Figure 3).
Figure 3. Study flow diagram for searches 2006-2014
Included studies
The Characteristics of included studies table summarise details for each of the 24 included studies.
Design
Of the 24 included studies, seven were randomised controlled tri- als (RCTs) (Chen 2012; Fryer 1987a; Harvey 1988; Lee 1998; Tutty 1997; Wurtele 1986; e en-Ero ul 2013), 11 were clus-
ter-RCTs (Blumberg 1991; Dake 2003; Dawson 1987; Grendel
1991; Hazzard 1991; Kolko 1989; Krahé 2009; Kraizer 1991; Oldfield 1996; Poche 1988; Wolfe 1986), and six were quasi-RCTs (Crowley 1989; Daigneault 2012; Del Campo Sanchez 2006;
Hébert 2001; Saslawsky 1986; Snyder 1986). Of the quasi-RCTs, all but Del Campo Sanchez 2006 used a Solomon four-group de- sign (Campbell 1963; Solomon 1949).
The unit of randomisation in 14 studies was clusters (classrooms,
schools, or districts). Of these, 11 were cluster-RCTs (as above) and three were quasi-RCTs (Crowley 1989; Daigneault 2012; Hébert 2001). In 10 trials the unit of randomisation was individual school students. Of these, seven were RCTs (as above) and three were quasi-RCTs (Del Campo Sanchez 2006; Saslawsky 1986; Snyder 1986).
Eighteen studies allocated participants to one of two groups, the intervention (school-based sexual abuse prevention programme) and a control group (no programme or wait-listed). Four stud- ies allocated participants to one of three groups, two of which were intervention groups comprising slight variations of the same programme (Krahé 2009; Kraizer 1991), or different programmes (Blumberg 1991; Del Campo Sanchez 2006). Three studies al- located participants to one of four groups, three of which were intervention groups comprising programme variations (Hazzard 1991; Poche 1988; Wurtele 1986).
Location
Sixteen studies were conducted in the USA. Three studies were conducted in Canada (Daigneault 2012; Hébert 2001; Tutty 1997). One study apiece was conducted in China (Lee 1998), Ger- many (Krahé 2009), Spain (Del Campo Sanchez 2006), Taiwan (Chen 2012), and Turkey ( e en-Ero ul 2013).
Sample sizes
The total number of participants randomised in cluster-RCTs ranged from 74 (Poche 1988) to 1269 (Oldfield 1996). The total number of students randomised in trials with individuals as the unit of randomisation ranged from 46 (Chen 2012) to 382 (Del
Campo Sanchez 2006). The number of participants in the 13 clus- ter-RCTs ranged from 74 (Poche 1988) to 1269 (Oldfield 1996), and in the nine RCTs in which participants were randomised as individuals, ranged from 36 ( e en-Ero ul 2013) to 231 (Tutty 1997). Eleven studies (including nine cluster-RCTs and two stud- ies in which participants were randomised as individuals) each in- cluded more than 200 participants.
Settings
All studies were conducted in school settings: 23 in primary (elementary) schools and one in a special school for adoles- cents with intellectual disabilities. Only six studies were under- taken in single grades: one in kindergarten (Harvey 1988), one in grade one (Grendel 1991), two in grade three (Dake 2003; Kolko 1989), and two in grade four (Snyder 1986; e en-Ero ul 2013). All other studies involved various combinations of grades to which there was no discernable pattern. It is possible to cate- gorise the studies into three broad age group blocks as follows: (i) 10 studies with younger participants from kindergarten to grade three (Blumberg 1991; Dake 2003; Fryer 1987a; Grendel 1991;
Harvey 1988; Hébert 2001; Kolko 1989; Krahé 2009; Kraizer 1991; Poche 1988); (ii) eight studies with older participants from grade four upwards (Crowley 1989; Dawson 1987; Del Campo Sanchez 2006; Hazzard 1991; Lee 1998; Snyder 1986; Wolfe 1986; e en-Ero ul 2013); and (iii) six studies with younger and older participants together (Chen 2012; Daigneault 2012; Oldfield 1996; Saslawsky 1986; Tutty 1997; Wurtele 1986).
None of the included studies were conducted in secondary (high) school settings.
Participants
A total of 5802 school-aged participants were included in the 24 trials. Study participants’ mean ages at baseline in the included studies ranged from 5.8 years (Harvey 1988) to 13.44 years (Lee 1998). Authors of eight studies did not report the mean age of participants at baseline (Crowley 1989; Del Campo Sanchez 2006; Fryer 1987a; Hazzard 1991; Kraizer 1991; Oldfield 1996; Tutty 1997; e en-Ero ul 2013).
The proportion of females in the included studies ranged from 45% (Poche 1988; e en-Ero ul 2013) to 55% (Crowley 1989). One trial enrolled female participants only (Lee 1998). Gender- specific proportions were not reported in five studies (Chen 2012; Daigneault 2012; Fryer 1987a; Harvey 1988; Kraizer 1991).
Ethnicity data were reported in 13 studies. Two studies reported 100% Chinese participants (Chen 2012; Lee 1998). In five studies the predominant ethnicity reported was White or Caucasian com- prising 74% to 97% of participants (Grendel 1991; Oldfield 1996;
Poche 1988; Snyder 1986; Tutty 1997). Six studies reported di- verse samples comprising participants from different combinations of White or Caucasian, Black or African, Hispanic, Asian, Mid- dle Eastern, or ’other’ backgrounds (Blumberg 1991; Daigneault 2012; Dake 2003; Dawson 1987; Harvey 1988; Hazzard 1991). In these six studies, the proportion of non-White participants ranged from 32% (Hazzard 1991) to 66% (Dake 2003). One of these studies reported country of birth rather than ethnicity (Daigneault 2012). Ethnicity data were not reported in the 10 remaining stud- ies (Del Campo Sanchez 2006; Fryer 1987a; Hébert 2001; Kolko 1989; Krahé 2009; Kraizer 1991; Saslawsky 1986; Wolfe 1986;
Wurtele 1986; e en-Ero ul 2013).
Parental socioeconomic position was not reported in any study. Non-empirical markers for study locations were used such as “low socioeconomic” (e.g. Daigneault 2012), “middle income” (Grendel 1991; Hébert 2001; Poche 1988), or “lower to middle income” (Saslawsky 1986; Wolfe 1986; Wurtele 1986).
Religious background of study participants was not reported in any study. One study reported data collection in religious schools in Spain (Del Campo Sanchez 2006).
Participants’ school achievement data (e.g. grades) at baseline were notreported in any study. In one study, the Peabody Picture Vocab- ulary Test (PPVT) (Dunn 1981) was used to assess children’s recep- tive and expressive language ability at baseline (Fryer 1987a), and, in another study, Raven’s Standard Progressive Matrices (RSPM) (Raven 1960) was used as a measure of general intellectual ability at baseline (Lee 1998); in this study, participants were adolescent Chinese females with mild intellectual disabilities from four spe- cial schools in Hong Kong, China.
None of the studies enrolled participants on the basis of previously reported abuse.
Interventions
In all 24 trials, interventions focused specifically on child sexual abuse prevention. The targets of the interventions were school- aged children who were taught knowledge of sexual abuse, sexual abuse prevention concepts, and/or skill acquisition in self protec- tive behaviours.
A wide range of previously published, modified, and new pre- vention programmes were used in the trials. Fifteen discrete programmes were identified including: Behavioural Skills Train- ing (BST) (Lee 1998; Wurtele 1986), Good Touch/Bad Touch (Crowley 1989; Harvey 1988; e en-Ero ul 2013), Red Flag/ Green Flag (Chen 2012; Kolko 1989), Child Abuse Primary Prevention Program (CAPPP) (Blumberg 1991), Child Sexual Abuse Prevention Program (Grendel 1991), Children Need to Know Personal Safety Training Programme (Fryer 1987a), ES- PACE (Daigneault 2012; Hébert 2001), Good Secrets/Bad Se- crets (Snyder 1986), No Child’s Play (Krahé 2009), Prevention of Child Sexual Abuse Program (Del Campo Sanchez 2006), Project TRUST (Oldfield 1996), Safe Child Program (Kraizer 1991),
Stop, Tell someone, Own your body, Protect yourself (STOP!) (Blumberg 1991), TOUCH (Saslawsky 1986), and Who Do You Tell? (Tutty 1997).
In two trials, combinations of programmes were used in interven- tions: TOUCH plus BST (Wurtele 1986), and Feeling Yes, Feel- ing No plus Spiderman and Power Pack Comic Book (Hazzard 1991). Four trials did not identify the programme used (Dake 2003; Dawson 1987; Poche 1988; Wolfe 1986).
Contents of or topics covered in the intervention programmes were not consistently reported in the majority of trials. We could discern that programmes were multifaceted with integrated con- tent, including teaching of safety rules ranging from two to six rules (e.g. Grendel 1991; Poche 1988), with the most common be- ing four rules (Blumberg 1991; Fryer 1987a; Lee 1998; Saslawsky 1986; Wurtele 1986), and prevention concepts such as body own- ership, private parts, distinguishing appropriate and inappropriate touches, distinguishing types of secrets, and whom to tell. Pro- gramme content was not detailed in eight studies (Crowley 1989; Dake 2003; Dawson 1987; Del Campo Sanchez 2006; Hazzard
1991; Krahé 2009; Snyder 1986; Tutty 1997). Four studies also included abduction prevention content (Chen 2012; Fryer 1987a; Kraizer 1991; Poche 1988).
Teaching methods were more clearly reported than programme contents. Rehearsal, practice, or role-play was mentioned in 12 studies (Blumberg 1991; Daigneault 2012; Fryer 1987a; Harvey 1988; Hébert 2001; Kraizer 1991; Lee 1998; Poche 1988; Snyder
1986; Tutty 1997; Wurtele 1986; e en-Ero ul 2013), discus-
sion in 10 studies (Blumberg 1991; Grendel 1991; Hazzard 1991;
Hébert 2001; Oldfield 1996; Saslawsky 1986; Snyder 1986; Tutty 1997; Wolfe 1986; Wurtele 1986), and modelling in six stud- ies (Daigneault 2012; Hébert 2001; Lee 1998; Saslawsky 1986; Wurtele 1986; e en-Ero ul 2013). A specific suite of teaching strategies was designated in four studies, including instruction, modelling, rehearsal, social reinforcement, shaping, feedback, and group mastery (Chen 2012; Lee 1998; Saslawsky 1986; Wurtele 1986). The strategy review, which involved revisiting previous con- tent and summarising new content, was nominated in one study (Grendel 1991). Three studies did not report teaching methods (Crowley 1989; Dake 2003; Del Campo Sanchez 2006).
Programme delivery formats were reported in the majority of stud- ies. These included film, video, and DVD formats in 12 stud- ies (Blumberg 1991; Dawson 1987; Grendel 1991; Harvey 1988;
Hazzard 1991; Kolko 1989; Krahé 2009; Poche 1988; Saslawsky 1986; Tutty 1997; Wurtele 1986; e en-Ero ul 2013), plays in three studies (Krahé 2009; Oldfield 1996; Wolfe 1986), and mul- timedia in two studies (Blumberg 1991; Hazzard 1991). Addi- tional resources included songs (Blumberg 1991; Harvey 1988; Krahé 2009), puppets (Blumberg 1991; Harvey 1988), comics (Dawson 1987; Hazzard 1991), a colouring book (Kolko 1989), a storybook (Harvey 1988), and games (Harvey 1988). Three stud- ies did not nominate programme delivery formats (Crowley 1989; Dake 2003; Del Campo Sanchez 2006).
No programmes were delivered electronically in web- or computer- based formats.
The duration of the intervention programmes in the included trials ranged from a single 45-minute session (Oldfield 1996) to eight 20-minute sessions on consecutive days (Fryer 1987a). Fourteen interventions were brief (i.e. less than 90 minutes total duration) (Blumberg 1991; Crowley 1989; Dawson 1987; Grendel 1991;
Harvey 1988; Hébert 2001; Kolko 1989; Krahé 2009; Lee 1998;
Oldfield 1996; Poche 1988; Saslawsky 1986; Wolfe 1986; Wurtele 1986), and the remainder were longer, lasting from 90 to 180 minutes in total duration.
In 17 trials, the effectiveness of prevention programmes was com- pared to that of a wait-listed control group. In the seven remaining studies, the control group interventions were as follows: discus- sion about self concept (Saslawsky 1986; Wurtele 1986); multi- media presentation with no child abuse content (Harvey 1988); fire safety (Blumberg 1991); fire or water safety (Hazzard 1991); attention control programme (Lee 1998); and a game of hangman (Snyder 1986).
All programmes were delivered on school premises and during school hours, apart from one study in which the programme was delivered in the morning, before school classes began (Chen 2012).
Outcomes
In this section we summarise six outcome measures of interest that were addressed in the included studies: (i) protective be- haviours; (ii) knowledge (questionnaire-based knowledge and vi- gnette-based knowledge); (iii) retention of protective behaviours over time; (iv) retention of knowledge over time; (v) harm (man- ifest as parent or child anxiety or fear); and (vi) disclosures. This information is presented in the Characteristics of included studies tables.
Protective behaviours
Three studies measured change in behaviour using a simulated abuse situation and scored the child’s response to the situation (Fryer 1987a; Kraizer 1991; Poche 1988). All three studies used a version of a stranger simulation test to assess children’s self protec- tive skills (i.e. whether children could follow the rules they were taught and not interact if approached by a stranger).
Knowledge
Knowledge outcome measures varied between studies. Knowledge measures used were: (i) questionnaire-based measures, or (ii) vi- gnette-based measures that used scenarios or visual prompts to elicit a response from the child about safe behaviour in that situ- ation. Only one study did not measure knowledge (Poche 1988), and one study used a vignette-based measure only (Krahé 2009). Ten studies used both vignette- and questionnaire-based measures (Blumberg 1991; Chen 2012; Daigneault 2012; Grendel 1991;
Harvey 1988; Hazzard 1991; Hébert 2001; Lee 1998; Saslawsky 1986; Wurtele 1986). Three studies used a second questionnaire- based measure to establish construct validity (Chen 2012; Crowley 1989; Del Campo Sanchez 2006).
The use of more than one measure by studies to assess knowledge gain was not anticipated at the outset of this systematic review. The two types of measures were administered differently. Question- naire-based measures were administered as self completed mea- sures via individual or group administration. Vignette measures were administered by interview. The different methods of admin- istration and the type of response required from the child means that these two outcomes may measure different aspects of children’s knowledge; therefore, we considered them as separate knowledge outcomes.
Knowledge - questionnaire-based measures
Questionnaire-based knowledge measures were used in 21 stud- ies. The Personal Safety Questionnaire (PSQ) was used in six (Crowley 1989; Grendel 1991; Hébert 2001; Lee 1998; Saslawsky 1986; Wurtele 1986). The Children’s Knowledge of Abuse Ques- tionnaire (CKAQ) and versions thereof (CKAQ-R, CKAQ-IIIR) were used in five studies (Daigneault 2012; Del Campo Sanchez 2006; Hébert 2001; Oldfield 1996; Tutty 1997), and the Chil- dren Need to Know Knowledge/Attitude Test (CNTKKAT) was used in two (Fryer 1987a; Kraizer 1981). Other custom-made knowledge scales were also used (Blumberg 1991; Chen 2012; Crowley 1989; Dake 2003; Dawson 1987; Del Campo Sanchez
2006; Harvey 1988; Hazzard 1991; Kolko 1989; Snyder 1986;
Wolfe 1986; e en-Ero ul 2013).
Knowledge - vignette-based measures
Vignette-based knowledge measures were used in 11 studies. The What If Situations Test (WIST), comprising six brief ver- bal vignettes, was used in four studies (Grendel 1991; Lee 1998; Saslawsky 1986; Wurtele 1986). A Chinese version of the WIST was used in one study (Chen 2012), and a French version in an- other (Daigneault 2012). The Touch Discrimination Task (TDT), based on the WIST and comprising seven verbal vignettes, was used in one study (Blumberg 1991), and an unnamed measure comprising 10 picture vignettes featuring good touch and sex- ually abusive touch were used in another study (Harvey 1988). Eight cartoon picture vignettes and stories were used in Krahé 2009. Video vignettes entitled What Would You Do? (WWYD) and comprising six 30-second scenes were used by Hazzard 1991, and an unnamed video measure with five situations was used by Hébert 2001.
Retention of protective behaviours over time
Retention of self protective skills was measured in three studies at one month (Poche 1988), and six months (Fryer 1987a; Kraizer
1991). In Fryer 1987a, no comparison with the control group was available at follow-up because the control groups had been exposed to the intervention. In Kraizer 1991, data were not reported. In Poche 1988, there was substantial loss to follow-up.
All three studies measured post-test protective behaviours within one to two days following the intervention. One study reported following up with assessment of protective behaviours one month after the intervention (Poche 1988), and the two other studies reported following up six months after the intervention (Fryer 1987a; Kraizer 1991). However, follow-up data were published only for Fryer 1987a; data were not published for Kraizer 1991, and Poche 1988 reported significant loss to follow-up with only nine of 23 children available for measurement.
Retention of knowledge over time
All of the 21 studies measuring post-test questionnaire-based knowledge did so within a two-week period following inter- vention. Ten studies also reported short-term knowledge out- comes one to three months following intervention (Crowley 1989; Dawson 1987; Harvey 1988; Hazzard 1991; Hébert 2001; Lee
1998; Poche 1988; Saslawsky 1986; Wurtele 1986; e en-Ero ul 2013). One study reported knowledge outcomes at five months (Blumberg 1991), three studies at six months (Fryer 1987a; Kolko 1989; Kraizer 1991), and two studies at eight months (Del Campo Sanchez 2006; Krahé 2009). One study measured long-term out- comes at 12 months (Hazzard 1991). One study measured long- term outcomes in “the second year of the study” (Daigneault 2012, p 527), however the precise timing was not reported.
For most studies, no comparison with the control group was avail- able at follow-up because the control groups had been exposed to the intervention by then. Complete data (for intervention and control groups) were reported in only four studies (Dawson 1987; Hazzard 1991; Kolko 1989; Lee 1998).
Harm - parental or child anxiety or fear
No studies measured parental anxiety or fear. Parent satisfaction questionnaires were used in five studies (Grendel 1991; Hazzard 1991; Hébert 2001; Tutty 1997; Wurtele 1986).
Six studies measured child anxiety or fear via child report (Blumberg 1991; Daigneault 2012; Dawson 1987; Hazzard 1991; Kraizer 1991; Lee 1998), and four studies via parent report (Del Campo Sanchez 2006; Hazzard 1991; Hébert 2001; Tutty 1997). Instruments used with children were the State-Trait Anxiety In- ventory for Children (STAIC) (Dawson 1987; Hazzard 1991; Oldfield 1996), the Revised Children’s Manifest Anxiety Scale (RCMAS) (Oldfield 1996), and the Fear Assessment Thermome- ter Scale (Lee 1998). One study used a “children’s feelings of sa- fety” measure (Daigneault 2012, p 530). Instruments used with parents were adapted from the Parental Perception Questionnaire (PPQ) (Miller-Perrin 1986), a 16-item measure in which parents
rate how often they observed negative and positive behaviours. Included studies variously referred to the measure as a ’parent ob- servation’ measure (e.g. Tutty 1997) and a ’side effects’ scale (e.g. Del Campo Sanchez 2006).
Disclosures
Children’s disclosures of child sexual abuse during or follow- ing intervention were reported by five studies (Blumberg 1991; Del Campo Sanchez 2006; Hazzard 1991; Kolko 1989; Oldfield 1996). To record disclosures, two studies used a data collection form completed by staff at the school (Hazzard 1991; Oldfield 1996). Two other studies conducted child protective services (CPS) file searches (Blumberg 1991; Kolko 1989). Blumberg 1991 conducted follow-up CPS searches at 15 months post-interven- tion.
Excluded studies
We excluded 55 studies because they did not meet the inclusion criteria. We excluded 36 studies on the basis of study type (13 pre- test and post-test studies without control groups; 11 controlled before-and-after studies without random assignment; five post- test only studies; five quasi-experimental studies without random assignment; one cross-sectional comparative study; and one com- parative group design). We excluded 14 studies because the inter- vention was not primarily about child sexual abuse prevention, but was about dating and relationship violence, gendered violence, or sexual harassment in the context of partner relationships (seven of these studies were cited in the Cochrane Review by Fellmeth 2013, including Pacifici 2001, which was included in the original review) or abduction prevention, the aims of which did not men- tion prevention of child sexual abuse. We excluded four studies because they were not school-based and one study because partic- ipants were outside the age criteria.
Reasons for exclusion are detailed in the Characteristics of excluded studies table.
Risk of bias in included studies
Allocation
Random sequence generation
Twenty studies stated that individuals or groups (classes, schools, or districts) were “randomised”, “randomly allocated”, or “ran- domly assigned” to groups, but provided no detail about how the random sequence was generated. Three further studies described a classic experimental design, but did not report details about ran- dom assignment (Dake 2003; Kolko 1989; Kraizer 1991). We classified all of these studies as unclear risk of bias. One study
reported a random component in the sequence generation, coin tossing (Snyder 1986), and we classified it as low risk of bias. In one study, evidence of computerised randomisation was provided after author contact (Dake 2003). We re-classified this study as low risk of bias.
Allocation concealment
No studies provided information on methods used to conceal al- location. In all instances we concluded that procedures were po- tentially unconcealed such that assignment to groups could rea- sonably have been predicted prior to or during the process. Twelve studies reported tests of baseline imbalances showing no statistical differences between groups, potentially indicating successful ran- domisation. However, we classified these studies as unclear risk of bias because the method of concealment was not described in sufficient detail for an adequate assessment to be made. Ten stud- ies provided no baseline comparisons and we also classified them as unclear risk of bias. We classified two studies as high risk of bias: one study reported important differences between groups at baseline and concluded failure of randomisation (Crowley 1989, pp 60-1) and another study revealed school officials were involved in the process (Kraizer 1991, p 27).
Blinding
Blinding of participants and personnel
The school-based nature of the interventions made blinding of participants receiving the intervention and personnel delivering the intervention impossible. In 14 studies intervention and con- trol groups were located within the same school. In these cases, it was possible that participants experienced ’contamination’ effects via contact with each other in the playground or their siblings at home, and/or inadvertent ’exposure’ to programme concepts via teachers and other school staff. This is likely to have biased the results towards an underestimation of programme effects, particu- larly on knowledge outcomes, which would be more susceptible to such contamination and exposure. Personnel delivering the inter- ventions were various study authors, programme facilitators, and classroom teachers. None of these 14 studies described a means by which programme fidelity or integrity was addressed (e.g. via the use of scripts or standardised lesson plans) or measured (e.g. via observation, audio, or video recordings). We classified these 14 studies as high risk of bias. Seven further studies provided no information on blinding procedures and we classified them as un- clear risk of bias (Chen 2012; Dake 2003; Del Campo Sanchez 2006; Saslawsky 1986; Wolfe 1986; Wurtele 1986; e en-Ero ul 2013). We classified three studies as low risk of bias: one study re- ported that instructors were blind to group conditions (Daigneault 2012), one study reported measures to control for contamination and the use of narrative scripts (Lee 1998), and another study
reported that the programme and testing were conducted on the same day to minimise the risk of contamination between groups in the school (Snyder 1986).
Blinding of outcome assessment
Blinding was not reported in seven studies (Del Campo Sanchez 2006; Harvey 1988; Kolko 1989; Lee 1998; Tutty 1997; Wolfe 1986; e en-Ero ul 2013), which we classified as unclear risk of bias.
We classified 10 studies as low risk of bias (Blumberg 1991; Daigneault 2012; Fryer 1987a; Grendel 1991; Krahé 2009;
Kraizer 1991; Oldfield 1996; Poche 1988; Saslawsky 1986; Wurtele 1986). Some studies used multiple strategies for min- imising outcome assessment bias. In eight studies, authors re- ported that outcome assessors were blind to group membership, study hypotheses, or both (Blumberg 1991; Daigneault 2012; Fryer 1987a; Grendel 1991; Krahé 2009; Oldfield 1996; Saslawsky 1986; Wurtele 1986). In three studies, authors noted that partici- pants were not informed that the outcome assessment was related to the intervention (Blumberg 1991; Fryer 1987a; Poche 1988), and in three studies outcome assessors were reported to be differ- ent to the personnel delivering the interventions (Blumberg 1991; Fryer 1987a; Kraizer 1991). In two studies, video monitoring was used to collect observational data on the protective behaviours outcome, and coders’ inter-rater reliability was reported (Fryer 1987a; Kraizer 1991). One study reported that participants were assessed only once (either pre-test or post-test) by the same out- come assessor to control for potential effects of rapport building (Blumberg 1991). Of these 10 studies, Fryer 1987a implemented more strategies than any other study and we considered it to be at lowest risk of bias in this domain.
We classified seven studies as high risk of bias. In these studies outcome assessment was administered in group format (in class or with a number of children) and there were no strategies in place to blind outcome assessors to group membership or to ensure children completed the assessment independently (Chen 2012; Crowley 1989; Dake 2003; Dawson 1987; Hazzard 1991; Hébert 2001; Snyder 1986). This risk was further heightened when the outcome assessors were the same individuals as those delivering the programme (e.g. Dawson 1987).
Incomplete outcome data
Attrition rates for individual studies are reported in the ’Risk of bias’ tables beneath the Characteristics of included studies table. Twelve studies did not report attrition rates (Daigneault 2012; Del Campo Sanchez 2006; Hazzard 1991; Hébert 2001; Krahé 2009;
Oldfield 1996; Poche 1988; Saslawsky 1986; Tutty 1997; Wolfe 1986; Wurtele 1986; e en-Ero ul 2013). We classified these studies as unclear risk of bias. One study reported no attrition or loss to follow-up (Chen 2012) and we classified it as low risk of
bias. We classified four further studies as low risk of bias, reporting attrition rates of less than 10% (Dawson 1987; Kraizer 1991; Lee 1998; Snyder 1986). Seven studies reported attrition rates of more than 10%, ranging from 12% to 24%, all of which we classified as high risk of bias (Blumberg 1991; Crowley 1989; Dake 2003; Fryer 1987a; Grendel 1991; Harvey 1988; Kolko 1989).
Only four studies reported results in such a way that loss to follow-
up for intervention and control groups could be differentiated: Blumberg 1991 (14.1% role-play, 8.1% multimedia, 3.8% con-
trol), Dawson 1987 (7.3% intervention, 2.6% control 1, 3.1%
control 2), Fryer 1987a (4% intervention, 12% control), and
Grendel 1991 (19% intervention, 22% control).
Reasons for attrition were reported in nine studies (Crowley 1989; Dake 2003; Dawson 1987; Grendel 1991; Harvey 1988; Kraizer
1991; Lee 1998; Poche 1988; Snyder 1986) and included student absence, withdrawal, vacation, illness, and school change, as well as missing or incomplete data on forms, and unmatchable pre- and post-tests.
No study reported analysis on an intention-to-treat (ITT) basis.
Selective reporting
Most studies reported complete outcome data that matched the stated aims or hypothesis of the study, and reported on pre-spec- ified outcomes of interest. We initially classified these studies as low risk of bias. We classified two studies as high risk of bias (Fryer 1987a; Wolfe 1986), because not all measures discussed in the methods section of the paper were also reported in the results. This may be an artefact of publication word limits.
On closer inspection, however, we noted that outcome report- ing was incomplete in five studies. One study did not provide a breakdown of data for intervention and control groups (Kraizer 1991). In four studies, outcomes were reported as summary statis- tics (e.g. F-tests or T-tests) without including means and SDs for continuous outcomes (Del Campo Sanchez 2006; Chen 2012, Harvey 1988; Kraizer 1991). Where data were not reported, we contacted study authors with an open-ended request to provide further information. We received helpful replies from Chen 2012 (additional data provided; study classified as low risk of bias) and Kraizer 1991 (data unable to be retrieved; study classified as high risk of bias).
We classified no studies as unclear risk of bias.
In summary we considered five studies as high risk of bias on this domain (Del Campo Sanchez 2006; Fryer 1987a; Harvey 1988;
Kraizer 1991; Wolfe 1986), and we considered the remaining 19 studies low risk of bias.
Other potential sources of bias
The unit of randomisation in 14 studies was clusters. Eleven of these were cluster-RCTs (Blumberg 1991; Dake 2003; Dawson 1987; Grendel 1991; Hazzard 1991; Kolko 1989; Krahé 2009;
Kraizer 1991; Oldfield 1996; Poche 1988; Wolfe 1986), where the unit of allocation was a group (e.g. classroom or school). Three quasi-RCTs also used groups as the unit of randomisation (Crowley 1989; Daigneault 2012; Hébert 2001). None of these studies reported appropriate analyses accounting for clustering ef- fects. Therefore, we assumed unit of analysis errors in all cases, meaning the original P values would be artificially small. In the subsequent meta-analysis, studies with unadjusted unit of analy- sis errors would be incorrectly and more highly weighted than is, in reality, appropriate. This risks biasing results in favour of the intervention.
As noted above, to diminish the risk of publication bias, in the review update we made concerted efforts to retrieve the full texts of unpublished trials (e.g. theses). Seven of 29 records included in this review were unpublished theses (Blumberg 1987; Chadwick 1989; Crowley 1989; Dawson 1987; Grendel 1991; Kraizer 1991; Snyder 1986). We assessed the risk of publication bias by draw- ing fixed-effect forest and funnel plots for the two meta-analy- ses involving 10 or more trials (questionnaire-based knowledge, 18 trials; vignette-based knowledge, 11 trials). Visual inspection of fixed-effect forest plots revealed no discernable trend towards greater effect sizes in smaller studies. However, our subjective im- pression of the fixed-effect funnel plots suggested the presence of slight asymmetry on the lower right (here we found smaller stud- ies with greater effect sizes) indicating the possibility that some studies are missing from the lower left (here we should have found smaller studies with smaller effect sizes) (see Figure 4 and Figure 5). There is also the possibility that smaller studies were of poorer methodological quality (although this is not evident in the ’Risk of bias’ assessments), or there may have been genuine differences between studies (e.g. unreported sample differences at baseline; differences in programme duration) (Borenstein 2009). Due to poor reporting of variables that may be responsible for heterogene- ity, it was not possible to further explore the sources of variation, for example, via the use of meta-regression.
Figure 4. Funnel plot of studies included in meta-analysis for questionnaire-based knowledge
Figure 5. Funnel plot of studies included in meta-analysis for vignette-based knowledge
Effects of interventions
See: Summary of findings for the main comparison
This review sought to assess the evidence of effectiveness of school- based education programmes for the prevention of child sexual abuse. Specifically, we sought to assess whether: programmes were effective in improving students’ protective behaviours and knowl- edge about sexual abuse prevention; behaviours and skills were re- tained over time; and programme participation resulted in disclo- sures of sexual abuse, produced harm, or both. In this section, we present the main findings on the effects of the interventions for six outcomes: (i) protective behaviours; (ii) knowledge (question- naire-based knowledge and vignette-based knowledge); (iii) reten- tion of protective behaviours over time; (iv) retention of knowl- edge over time; (v) harm (parental or child anxiety or fear); and
(vi) disclosures. The analysis results and our GRADE ratings are presented in Summary of findings for the main comparison.
Protective behaviours
Of the 24 included studies, three studies reported collecting data on protective behaviours (Fryer 1987a; Kraizer 1991; Poche 1988). All used a version of a stranger simulation test involving staging of a simulated abuse or grooming situation with each individual
child where a research assistant, posing as a stranger, requested the child’s help with a task that required them to go with the stranger (e.g. accompany the stranger to the stranger’s car to do a special task). Children’s responses were recorded by independent assessors using contemporaneous video monitoring (Fryer 1987a; Kraizer 1991), or by the research assistant (Poche 1988). Scoring was pass or fail. All three studies were conducted with children in lower primary school (kindergarten to grade three).
Only the Fryer 1987a (n = 48; randomised controlled trial (RCT)) and Poche 1988 (n = 74; cluster-RCT) studies could be included in the meta-analysis for protective behaviours, as Kraizer 1991 (n
= 670; cluster-RCT) did not report a breakdown of pass or fail scores for intervention and control groups. For the Poche 1988 study, we combined two intervention groups as the self protective knowledge and skills received were considered sufficiently similar to those in Fryer 1987a: teaching rules, group discussion, and practice through role-play and rehearsal. Data were available for 102 participants. Comparison was with a control group.
In the analysis, heterogeneity approached the moderate range (I² = 27%; Tau² = 0.16) and was non-significant (P value = 0.24). Pro- tective behaviours were greatly enhanced in intervention groups compared to control groups immediately post-intervention (odds ratio (OR) 5.71, 95% confidence interval (CI) 1.98 to 16.51; two
studies; n = 102) (see Analysis 1.1).
We performed sensitivity analyses to assess the effects of adjust- ing the Poche 1988 study for cluster-randomisation. Using this method and an intraclass correlation coefficient (ICC) of 0.1 pro- duced an OR of 5.43 (95% CI 1.88 to 15.65; Analysis 1.2) and
an ICC of 0.2 produced an OR of 5.16 (95% CI 1.81 to 14.70; Analysis 1.3). These analyses indicate that adjusting for the effect of clustering have minimal effects on our results.
Taken together, results of the more conservative adjustment for clustering show the short-term (i.e. immediately post-interven- tion) superiority of the interventions over control group effects. That is, children who received a school-based sexual abuse pre- vention programme were substantially more likely to demonstrate protective behaviours in a simulated situation that was adminis- tered immediately after the programme ended.
In addition to the above assessment, Fryer 1987a and Kraizer 1991 assessed the impact of knowledge and self esteem on the use of pro- tective behaviours. Fryer 1987a used the Harter Perceived Compe- tence Scale for Children (HPCS) (Harter 1982), commonly used as a measure of self esteem. Kraizer 1991 used the Battle Culture Free Self-esteem Inventory (Battle 1981) and the Children Need to Know Knowledge/Attitude Test (CNKKAT) (Kraizer 1981). Results of these measures were reported only for the intervention groups. In both studies, children with high self esteem who had improved knowledge scores post-intervention were more likely to exhibit protective behaviours. These studies did not report effect sizes to enable assessment of the magnitude of the relationships between self esteem, knowledge, and protective behaviours, al- though self esteem was identified as a potential “critical path” or moderating variable, which was recommended for further research (Fryer 1987a, p 177).
Knowledge
Questionnaire-based knowledge
Of the 24 included studies, 21 reported questionnaire-based knowledge using a range of different measures detailed above. Three of the 21 studies did not provide data in a way that could be included in meta-analysis (Del Campo Sanchez 2006; Harvey 1988; Kraizer 1991). In three trials, with multiple intervention groups in which interventions were judged to be sufficiently com- parable, we combined intervention groups into a single interven- tion group in the meta-analysis (Blumberg 1991; Crowley 1989; Dawson 1987). Eighteen studies were included in the meta-anal- ysis comprising a total of 4657 participants.
In the meta-analysis, there was evidence of substantial heterogene- ity (I² = 84%; Tau² = 0.10). The high Chi² statistic (104.76; df
= 17) and low P value (< 0.00001) indicated variation of effect estimates beyond chance. The SMD was 0.61 (95% CI 0.45 to 0.78), reflecting an average 0.61 standard deviation (SD) increase
in factual knowledge, across various measures, for the intervention group. These results suggest that children exposed to the inter- ventions tend to display increased factual knowledge about sexual abuse and its prevention, when measured immediately after com- pletion of the programme, and the effect is of a moderate size (see Analysis 2.1).
Of the 18 studies included in this meta-analysis, 12 were cluster-
randomised studies and all were analysed with unit of analysis errors. Of the cluster-randomised studies, one was randomised by school district (Kolko 1989), four were randomised by school (Daigneault 2012; Dake 2003; Hazzard 1991; Hébert 2001), and seven by classroom (Blumberg 1991; Crowley 1989; Dawson 1987; Grendel 1991; Oldfield 1996; Snyder 1986; Wolfe 1986). We estimated ICCs, as described above, in sensitivity analyses to adjust for unit of analysis errors. We applied the same ICC to district, school, and class cluster-RCTs. When adjusted, an ICC of 0.1 produced a SMD of 0.66 (95% CI 0.51 to 0.81; Analysis
2.2) and an ICC of 0.2 produced a SMD of 0.63 (95% CI 0.50 to 0.77; Analysis 2.3). These analyses indicate that adjusting for clustering has very minimal effects on results.
We also conducted sensitivity analyses to assess the effects of study exclusion for risk of bias in the two most relevant domains for school-based studies. First, we examined risk of bias on the blind- ing of outcome assessment domain. When studies at high risk of bias were excluded (Chen 2012; Crowley 1989; Dake 2003; Dawson 1987; Hazzard 1991; Hébert 2001; Snyder 1986), the
SMD was reduced to 0.47 (95% CI 0.29 to 0.66). These results indicate that knowledge scores in these studies may be influenced by assessor bias or contamination from group assessment, or both, such that better controlled studies may generate lower effect sizes in this domain. Second, we examined risk of bias on the attri- tion bias domain. When studies at high risk of bias were excluded (Blumberg 1991; Crowley 1989; Daigneault 2012; Dake 2003;
Grendel 1991; Kolko 1989), the SMD was 0.69 (95% CI 0.59 to 0.88), indicating that children from studies with better follow-up tended to score somewhat higher in this domain.
We conducted subgroup analyses to assess the effects of participant age. We examined studies in two age-based subgroups as follows:
(i) six studies with only younger participants from kindergarten to grade three (Blumberg 1991; Daigneault 2012; Dake 2003; Grendel 1991; Hébert 2001; Kolko 1989); and (ii) seven studies with only older participants from grade four upwards (Crowley 1989; Dawson 1987; Hazzard 1991; Lee 1998; Snyder 1986; Wolfe 1986; e en-Ero ul 2013). The SMD was 0.42 (95% CI
0.08 to 0.77) for the younger group and 0.89 (95% CI 0.59 to 1.19) for the older group. The test for subgroup differences was just below the statistically significant cut-off of 0.05 (Chi² = 4.04, df = 1; P value = 0.04). These results indicate that knowledge may be better gained immediately after the intervention by older children.
Vignette-based knowledge
Twelve studies used vignette-based measures in various formats, including verbal, picture, and video vignettes. One study did not report SDs and thus could not be included in a meta-analysis (Harvey 1988). One study did not report SDs but these could be derived by review authors from other reported statistics to enable inclusion in meta-analysis (Saslawsky 1986). In Blumberg 1991 and Krahé 2009, we combined two intervention groups into a sin- gle intervention group based on our assessment that the interven- tions were sufficiently similar when compared with other studies. Eleven studies were included in the meta-analysis with a total of 1688 participants.
There was evidence of substantial heterogeneity (I² = 71%; Tau²
= 0.08) in the meta-analysis. The high Chi² statistic (34.25, df
= 10) and low P value (< 0.0002) provide further evidence of variation in effect estimates beyond chance. The SMD was 0.45 (95% CI 0.24 to 0.65) (see Analysis 2.4), indicating that those receiving treatment had an average 0.45 SD increase in applied knowledge as reflected in their responses to vignettes administered post-intervention, a gain of moderate effect size.
Of the 11 studies included in the meta-analysis, seven studies were
of cluster-randomised design (Blumberg 1991; Daigneault 2012; Grendel 1991; Hazzard 1991; Hébert 2001; Kolko 1989; Krahé 2009). To assess the impact of unit of analysis errors, we conducted sensitivity analyses for estimated ICCs (as above). For an ICC of 0.1, the SMD was 0.53, (95% CI 0.32 to 0.74; Analysis 2.5) and
for an ICC of 0.2, the SMD was 0.60 (95% CI 0.31 to 0.89;
Analysis 2.6). These analyses suggest that adjusting for clustering has only slight effects on results.
We conducted sensitivity analyses to assess the effects of study exclusion for risk of bias. First, we examined risk of bias on the blinding of outcome assessment domain. When we excluded three studies (Chen 2012; Hazzard 1991; Hébert 2001), the SMD was reduced to 0.36 (95% CI 0.17 to 0.56), indicating a slight testing effect. Second, we examined risk of bias on the attrition bias do- main. When we excluded studies at high risk of bias (Blumberg 1991; Daigneault 2012; Grendel 1991; Kolko 1989), the SMD
increased to 0.57 (95% CI 0.25 to 0.89), indicating that chil- dren from studies with better follow-up tended to score somewhat higher in this domain.
We conducted subgroup analyses to assess the effects of participant age. We examined studies in two groups: (i) six studies including only participants in kindergarten to grade three (Blumberg 1991; Daigneault 2012; Grendel 1991; Hébert 2001; Kolko 1989; Krahé 2009); and (ii) three studies including only participants in grade four upwards (Chen 2012; Hazzard 1991; Lee 1998). The SMD was 0.39 (95% CI 0.09 to 0.69) for the younger group and 0.56 (95% CI 0.03 to 1.08) for the older group. Thus, older children, on average, may score somewhat better than younger children when they complete these measures of applied knowledge immediately after the intervention. However, the test for subgroup differences was not significant (Chi² = 0.29, df = 1; P value = 0.59).
Retention of protective behaviours over time
Three of the 24 included studies measured retention of protective behaviours over time. Complete data were not available for any of these studies and a meta-analysis could not be conducted.
Retention of knowledge over time
Questionnaire-based measures were used in 21 of the 24 included studies. Ten of these studies reported on retention of knowledge over time. Complete data were available for four studies (956 par- ticipants) (Dawson 1987; Hazzard 1991; Kolko 1989; Lee 1998). All studies used unique knowledge scales. In three studies, follow- up periods were one to three months post-intervention (Dawson 1987; Hazzard 1991; Lee 1998), and in one study, six months post-intervention (Kolko 1989). These four studies were included in meta-analysis using a random-effects model. For comparative purposes we generated two meta-analyses: one estimating effects for the four studies immediately post-intervention and one esti- mating effects at follow-up. Results suggest that knowledge ap- peared to deteriorate slightly over time as demonstrated by a de- cline in the SMD from 0.78 (95% CI 0.38 to 1.17; I² = 84%, Tau² = 0.13, P value = 0.0003) immediately post-intervention to SMD 0.69 (95% CI 0.51 to 0.87; I² = 25%; Tau² = 0.01, P value
= 0.26) at one to three months follow-up (see Analysis 3.1). How- ever, the test for subgroup differences was not significant (Chi² = 0.14, df = 1; P value = 0.71), suggesting knowledge scores did not deteriorate significantly for intervention or control groups within the one- to six-month follow-up period.
Of the four studies included in this meta-analysis, three were cluster-randomised studies (Dawson 1987; Hazzard 1991; Kolko 1989). Sensitivity analyses, adjusting for clustering yielded very similar results. When adjusted with an ICC of 0.1, knowledge de- creased slightly over time as demonstrated by a small decline in the SMD from 0.86 (95% CI 0.53 to 1.20) immediately post-inter-
vention to 0.73 (95% CI 0.41 to 1.06) at follow-up (Analysis 3.2). When adjusted with an ICC of 0.2, knowledge decreased slightly over time as demonstrated by a small decline in the SMD from SMD 0.86 (95% CI 0.53 to 1.20) immediately post-intervention
to 0.72 (95% CI 0.32 to 1.11) at follow-up (Analysis 3.3).
Vignette-based measures were used in 12 of the 24 included stud- ies. Nine of these studies reported on retention of knowledge over time. None of these studies could be included in a meta-analysis. The reasons for this are twofold: (i) the wait-list control design of the study meant that the control group received the interven- tion immediately after the experimental group had finished and, therefore, follow-up data were unavailable for the control group (Blumberg 1991; Daigneault 2012; Grendel 1991; Hazzard 1991; Saslawsky 1986; Wurtele 1986); or (ii) the study did not provide data in a form useable in meta-analysis, for example, the study pro- vided a narrative statement or reported summary statistics with- out providing means and SDs (Hébert 2001; Krahé 2009; Lee 1998). As a narrative synthesis, six studies provided intervention
group data only: two studies reported no knowledge gains between post-test and follow-up (at five months, Blumberg 1991; at one year, Hazzard 1991), two studies reported maintenance of knowl- edge gains at two-month follow-up (Hébert 2001; Lee 1998), and three studies reported small, but unimportant additional knowl- edge gains between post-test and follow-up (six months, Kolko 1989; three months, Saslawsky 1986; Wurtele 1986).
Harm
A total of six studies had measured harm, but three did not report data in a form that could be used in meta-analysis (Daigneault 2012; Hazzard 1991; Kraizer 1991). We included three studies (795 participants) in the meta-analysis for harm in relation to participation in school-based child sexual abuse prevention pro- grammes (Blumberg 1991; Dawson 1987; Lee 1998). In these studies, harm was measured via child self report anxiety or fear scales, with all studies using unique measures: Dawson 1987 used the State-Trait Anxiety Inventory for Children (STAIC), Lee 1998 used the Fear Assessment Thermometer Scale (FATS), and Blumberg 1991 used a custom-made scale. There was no hetero- geneity (I² = 0%, P value = 0.79). The SMD was -0.08 (95% CI
-0.22 to 0.07) (see Analysis 4.1). This result reveals evidence of no increases or decreases in anxiety or fear in intervention partic- ipants.
Two of these three studies were cluster-randomised studies ( Blumberg 1991; Dawson 1987). To assess the impact of unit of analysis errors, we conducted sensitivity analyses for estimated ICCs as above, showing little change in point estimates and slightly widening CIs. For an ICC of 0.1, the SMD was -0.04 (95% CI -
0.42 to 0.33; Analysis 4.2) and for an ICC of 0.2, the SMD was
-0.03 (95% CI -0.46 to 0.40; Analysis 4.3).
A narrative synthesis of the studies not included in the meta-analy- sis shows that seven studies reported on adverse effects with either child (Hazzard 1991; Kraizer 1991; Oldfield 1996) or parent self reports (Del Campo Sanchez 2006; Hazzard 1991; Hébert 2001; Tutty 1997). Using child self report measures, Hazzard 1991 and Oldfield 1996 reported no important differences in STAIC scores between intervention and control groups (Hazzard 1991, treat- ment mean 29.7, control mean 29.9; Oldfield 1996, F(1, 593)
= 0.05, P value = 0.825). Hazzard 1991 did not report SDs and ANCOVA results. Oldfield 1996 did not report means and SDs. Oldfield 1996 also found no important differences between ex- perimental and control group anxiety scores using the Revised Children’s Manifest Anxiety Scale (RCMAS) with younger partic- ipants, F(1, 653) = 1.40, P value = 0.248. In one study (Kraizer 1991), children in the intervention group participated in an exit interview (n = 332): 14.8% of the children experienced some anxi- ety or fear initially but none on programme completion, and 4.5% experienced some anxiety or fear initially and remained a little worried on programme completion.
Using parent self report measures of perceived changes in chil-
dren’s behaviour, Del Campo Sanchez 2006 (n = 193) reported the following in children exposed to the intervention: fear of adults (1%) and increased fighting with peers (1%), but no sleep prob- lems, or rejection of normal affection. Similarly, in intervention group children, Tutty 1997 (n = 231) found worry about scary things happening (1.7%), but no bedwetting, nightmares, cry- ing, rejection of normal affection, or attention seeking behaviour. Hébert 2001 (n = 133) reported intervention group children hav- ing increased dependency behaviours (13%), more aggressiveness towards peers (15%) and siblings (29%), and more fearfulness of strangers (25%). Hazzard 1991 (n = 399) reported no important differences between intervention and control group children on parental perceptions of anxiety or fear (summary data not pro- vided).
Disclosure
We included three studies (1788 participants) in the meta-analysis for disclosures of previous or current sexual abuse (Del Campo Sanchez 2006; Kolko 1989; Oldfield 1996). There was no hetero- geneity (I² = 0%, P value = 0.84). Disclosure occurred more often in the intervention group (OR 3.56, 95% CI 1.13 to 11.24). The odds of disclosure were as much as 3.5 times higher in participants exposed to the intervention (see Analysis 5.1).
We performed sensitivity analyses to assess the effects of adjusting the Kolko 1989 and Oldfield 1996 studies for cluster-randomi- sation. Using this method and an ICC of 0.1 produced a non- significant OR of 3.04, 95% CI 0.75 to 12.33; Analysis 5.2) and
an ICC of 0.2 produced an OR of 2.95, 95% CI 0.69 to 12.61; see Analysis 5.3). These analyses, adjusted for unit of analysis errors, indicate that the effect of intervention programmes on disclosure was sensitive to different assumptions regarding the effect of clus- tering on the results.
Of the studies not included in meta-analysis, disclosure of past or current abuse was recorded in two studies (Blumberg 1991; Hazzard 1991). One study conducted a search of the files of Child Protective Services (CPS) for names of children in the classrooms who were part of the study (Blumberg 1991). Data event counts were not provided, however the study reported that risk ratios (RR) were calculated for experimental against control conditions. Both ratios “approached 1.0 which one would expect by chance” (Chadwick 1989, p 61). One further study measured disclosures, but was unable to distinguish between treatment and control groups due to data reporting methods (Hazzard 1991). Eight of 526 participants (1.5%) reported ongoing sexual abuse and 20 (3.8%) reported past sexual abuse.
Subgroup analyses
Subgroup analyses are used to compare the mean effect for different subgroups of studies where there are sufficient numbers of studies to allow for meaningful comparisons. We were able to conduct
subgroup analyses for age, but only for knowledge outcomes, by categorising studies into two broad groups: younger children and older children as described above. This was because programmes were often delivered to children across multiple consecutive and non-consecutive school grades. We did not conduct other sub- group analyses in this review because the included studies provided insufficient information about issues that were hypothesised as be- ing relevant for subgroup analysis. In the original study protocol we planned to conduct subgroup analyses for participant age and gender, and programme type and setting (Zwi 2003). We were unable to conduct subgroup analyses for gender owing to poor reporting. We did not conduct subgroup analyses for active or pas- sive involvement as it was not possible to categorise programmes in this way; most were multifaceted, involving both active and passive approaches. What is needed is a way of identifying, more precisely, the range of child, programme, and study design charac- teristics that may moderate programme effectiveness. We explain this in more detail in the discussion below.
D I S C U S S I O N
Summary of main results
This updated review reported on 24 trials (29 reports) examining the effectiveness of school-based programmes for the prevention of child sexual abuse. The studies reporton data for 5802 child partic- ipants of whom 5730 (almost 98.8%) were from primary (elemen- tary) schools. In this review, we assessed programme effectiveness according to six outcomes: (i) protective behaviours; (ii) knowl- edge (questionnaire-based knowledge and vignette-based knowl- edge); (iii) retention of protective behaviours over time; (iv) reten- tion of knowledge over time; (v) harm manifesting as parental or child anxiety or fear; and (vi) disclosures of past or current child sexual abuse. Below we report on: (i) protective behaviours; (ii) knowledge; (iii) harm; and (iv) disclosures.
Protective behaviours
Meta-analysis of data from two studies showed significant im- provements in protective behaviours in simulated at-risk situa- tions, measured immediately (up to two weeks) post-intervention. Follow-up assessment of protective behaviours was not reported in either of the studies. Simulated situations, used in three of the included studies, were a form of in vivo assessment, which exposed children to potentially stressful situations such as an invitation to go with an unknown adult (Fryer 1987a; Kraizer 1991; Poche 1988). The use of these simulation techniques is difficult to jus- tify and raises important ethical questions about balancing risks against potential benefits for participants. Research of this type also presents significant challenges for voluntary consent where there
is active concealment via role-playing. Although this is arguably as close as researchers can get to testing whether participants’ learned skills can be translated into appropriate behaviour, three salient issues must be considered. First, the generalisation of responses from simulated to actual settings cannot be assumed. Second, it is not known if skills taught in the context of approaches from strangers help children deal with threats from familiar adults, who are the most common perpetrators of child sexual abuse. Third, there is the possibility that this type of outcome assessment may desensitise children to similar occurrences in the future. Outcome assessment of this type, therefore, must be rigorously conducted and monitored.
The results of one study suggest that children with greater self esteem (Fryer 1987a), as measured by the Harter Perceived Com- petence Scale (HPCS) (Harter 1982), exhibited better protective behaviours following intervention. Since self esteem is clinically relevant in child sexual abuse, this finding warrants further in- vestigation to determine whether self esteem training should be included as a component of child sexual abuse prevention inter- ventions. It may be that children with greater self esteem are more likely to display protective behaviours regardless of exposure to programmes. Unfortunately, the psychological literature has been hampered by the use of a confusing array of terms encompassing self esteem (e.g. self belief, self concept, self efficacy, self worth), and there has been extensive debate in the educational psychology literature about its role in children’s learning (Valentine 2004). Greater levels of precision in definition and measurement are re- quired in future research.
Knowledge
Meta-analysis of data from 18 studies for questionnaire-based knowledge and 11 studies for vignette-based knowledge suggested gains in factual and applied knowledge immediately (up to two weeks) post-intervention. Follow-up assessment of factual knowl- edge was limited to four studies with our meta-analyses show- ing that factual knowledge scores did not deteriorate for either intervention or control groups one to six months after interven- tions. Follow-up assessment of applied knowledge was conducted in some studies, however data were incomplete and not suitable for meta-analysis. Across all of the included studies, less than half of the studies (10 of 24) reported on short-term knowledge out- comes (within three months of the intervention), three studies reported medium-term outcomes (up to 12 months post-inter- vention), and only one study measured retention of knowledge beyond 12 months. A methodological problem in these studies was data completeness because, at the time of follow-up, control groups had already been exposed to the programmes and it is un- ethical to withhold programme delivery. Well-designed and timely follow-up is required to determine whether factual and applied knowledge can be sustained over time with the use of boosters and other maintenance strategies (such as reiteration of programme
messages by parents and teachers).
An important source of heterogeneity across studies is the knowl- edge measure used. For the 24 studies included in this review, 15 discrete questionnaire-based measures and six discrete vignette- based measures were used to measure children’s factual and applied knowledge respectively. For studies included in the meta-analyses, there were 10 unique questionnaire-based measures and six unique vignette-based measures represented. These were pooled using the standardised mean difference (SMD) as a summary statistic. In us- ing SMDs, we treated the different assessment measures as though they were one standardised measure with comparable standard de- viations (SDs). It is then difficult to relate this abstract figure back to the original measures to determine what this means in real life. For example, it is not clear what a 0.61 SD increase in factual knowledge or a 0.45 SDincrease in applied knowledge translates to in practical knowledge terms. Are these findings sufficient to offer protective effects under threats of sexual abuse? Further research is required to address the magnitude of knowledge improvement re- quired to produce clinically important protective effects. Research would be improved by the use of standardised rather than custom- made instruments.
Harm
Adverse or negative effects in the form of harm to participants were assessed via measures of child anxiety or fear. Studies examining participants’ anxiety or fear were based on child self report and parent report. Meta-analysis of three studies found no evidence of increased or decreased anxiety or fear in those exposed to pro- grammes and this did not change when adjusted for clustering. Narrative synthesis of included studies revealed that a small pro- portion of programme participants experienced anxiety or fear but these (anxieties or fears) were mild rather than severe, and short- rather than long-term. There was insufficient information to assess whether harms varied according to participant age or grade level. Although parent satisfaction data were collected in some studies, parental anxiety or fear was not measured in any study. This may be important in future studies for determining the role of parents in moderating programme effects.
Disclosures
The only direct measure of programme effects was participants’ disclosures of past or current sexual abuse that were made fol- lowing interventions. Disclosures were poorly reported or not re- ported in most studies. Our meta-analysis of three studies showed greater odds of disclosures by children receiving interventions. However, such disclosures cannot really be considered an adverse event since: (i) the onset of the alleged abuse would have occurred prior to the intervention; (ii) disclosing abuse, while potentially traumatic, can also prompt the provision of treatment; and (iii) the identification and reporting of perpetrators may prevent harm
to other children. Details of how disclosures were dealt with were not reported in any of the studies. Appropriate systems for dealing with disclosures are important and must reflect jurisdictional legal reporting obligations (also known as mandatory reporting laws), and school policies for child maltreatment recognition, reporting, and response. Future studies should consider methods for record- ing and responding to disclosures; data linkage to child protection or police records, or both; and/or interviewing or surveying par- ticipants at repeated follow-up intervals.
Subgroup effects
Demographic characteristics (e.g. participant age, gender, ethnic- ity, socioeconomic position, and ability level) are potential sources of heterogeneity, and potential effect moderators. If studies do not account for these characteristics, important subgroup effects may be missed. Genuine but unidentified differences in study samples at baseline are potential sources of heterogeneity within and across studies. Baseline characteristics of intervention and control groups were inconsistently and poorly reported in the included studies. Control for baseline characteristics within individual studies is particularly important for criteria that are most relevant to learn- ing such as academic ability, or reading age. These data were not reported or were absent by study design, therefore we were not able to explore whether programme effectiveness varied according to key baseline criteria. These issues have implications for pro- gramme delivery.
Demographic characteristics, such as participant age, would ap- pear to be straightforward variables, however, mean age was not reported in eight of 24 included studies and in others was con- flated with grade level. Few studies were undertaken with single grades, and most (18 of 24) studies were undertaken with multi- ple grade levels together. This study design limited the pooling of results across studies in meta-analysis. Subgroup analyses showed that older children (grades four and above) made greater knowl- edge gains than younger children (grades kindergarten to three) immediately post-intervention; results that are congruent with de- velopmental and maturation theories. However, we do not know if younger children would respond differently with differentiated approaches (e.g. reinforcement of skills and knowledge by par- ents or teachers, or both). We were unable to assess programme effectiveness according to other potentially important participant variables (e.g. child gender, ethnicity, socioeconomic position, and ability level) as few studies reported on these data or provided sub- group effects.
Characteristics of effective programmes
Insufficient data were provided to evaluate the specific effects of programme type, duration, frequency, or setting. These pro- gramme characteristics have implications for delivery in schools and the ideal constellation of programme characteristics, which
is not yet known. Although there was insufficient information to develop programme typologies and compare effects, we noted that approximately half of the programmes in included studies used content, such as the teaching of safety rules (e.g. “my body belongs to me”), and prevention concepts (e.g. distinguishing appropriate and inappropriate touches), and the use of delivery methods such as discussion, modelling, role-play, rehearsal, and feedback. Our narrative synthesis of included studies documented multidimen- sionality in intervention contents, methods, and delivery. This is an important finding in itself. To date, programmes have been cat- egorised dichotomously as active or passive or behavioural or in- structional. Our descriptive analysis shows this categorisation to be somewhat artificial as most programmes in this review were mul- tifaceted with multiple components. Programmes covered multi- ple topics (e.g. body safety rules, distinguishing types of touches, reporting abuse to adults who can help), used teaching strategies in combination (e.g. discussion, modelling, role-play, rehearsal, and feedback), and integrated active or passive and behavioural or instructional approaches in one session (e.g. a video or DVD presentation encouraged children to listen and then partake in ac- tivities). The contribution to effectiveness of programme content, methods, and delivery will require documentation using standard- ised data collection tools in future studies.
The duration and frequency (dose) of programme interventions varied from one single 45-minute session to eight 20-minute ses- sions. There were insufficient studies to create subgroup analyses for total programme hours, or total number of sessions, or for the presence or absence of booster sessions or reinforcement strategies. While interventions appear to increase protective behaviours and knowledge about sexual abuse, it is important that this learning is not seen as a replacement for adult responsibility to ensure child safety. Nor should education replace the need for appropriate med- ical and legal handling of those affected by child sexual abuse. We do not have evidence that these programmes reduce the inci- dence of child sexual abuse. The findings of this review need to be considered in the context of complementary prevention ini- tiatives. Current child sexual abuse prevention frameworks sug- gest that strategies must not only target children, but must work on multiple elements of children’s social systems to prevent abuse from occurring in the first place, namely at the level of the family, community, and society (Smallbone 2008).
Overall completeness and applicability of evidence
Studies were conducted in countries with high and upper-middle income economies according to the World Bank’s analytical in- come categories (The World Bank 2013). Most (16 of 24) were conducted in North America, the remainder in Europe, East Asia, and Central Asia. Ethnicity data were poorly or not reported in 10 of the 24 studies. Where data were reported, participants were from a diverse range of ethnicities, increasing the generalisability of
the evidence, and also suggesting that concern about child sexual abuse prevention and the delivery of programmes in schools is a wide-spread phenomenon. Whether similar effects would be seen when programmes are implemented in countries not included is unknown.
All but one of the included studies was conducted in primary (ele- mentary) school settings. There are several possible reasons for this. First, policy makers and school authorities may truly recognise that the age of greatest vulnerability is within the earlier school years (7 to 12 years according to Finkelhor 1986). Second, from our searches, we gleaned that programmes for secondary (high) school students tended to be broader in scope and focused on the pre- vention of relationship and dating violence, sexually coercive peer relationships, sexual harassment, or sexual assault (see Fellmeth 2013). The purpose of these programmes was not predominantly prevention of child sexual abuse, the focus of this review. In our searches we noted a sizeable group of studies based in preschool settings, the effectiveness of which requires further scrutiny in a separate systematic review given that these programmes have qual- itatively different delivery methods and contents, including greater parental participation, which we infer may have a mediating ef- fect.
None of the included studies investigated the effectiveness of a web-based or online programme. This may be because rigorous programme evaluations have not yet been developed, conducted, or published. Online programmes offer the potential for technol- ogy to capture real-time evaluation data from children as they ex- perience online interventions.
As noted above, the completeness and applicability of evidence was limited by methodology and failure to report the full range of child, intervention, and study design characteristics that could possibly account for variations in programme effects. In the period since the original review was conducted (Zwi 2007), Cochrane Reviews have become more rigorous in identifying methodological limitations in trials via risk of bias analyses, and the CONSORT statementhas been developed to provide guidance on the reporting of randomised controlled trials (Shulz 2010). Nevertheless, the methodological quality of trials has not improved substantially. No study in this area has yet published a study protocol, and we found no clinical trials register records pertaining to studies of this type. Researchers must continue testing these interventions, but use study design methodology, data collection tools, registration, and reporting guidelines that enable rigorous scientific evaluation.
Quality of the evidence
Summary of findings for the main comparison presents the qual- ity of evidence for each outcome of interest. We downgraded the quality of evidence to moderate quality either due to risk of bias, imprecision, or because of the impact of adjusting for the effect of clustering within some of the studies. Most studies in this review were at an unclear risk of selection bias as illustrated in Figure
1 and Figure 2, due to inadequate information regarding meth- ods of random sequence generation and allocation concealment. Studies which randomised classes within a single school to inter- vention and control groups were at high risk of contamination effects owing to the interaction of children in school playgrounds, friendship groups and families, and also from chance exposure to programme concepts via teachers and other school staff familiar with programme contents. In addition, there was detection bias due to inadequate or unclear assessor, participant and personnel blinding, and inadequate or unclear reporting of attrition for as- sessments at post-test and follow-up. Double-blinding to min- imise performance bias is seldom possible in school-based trials as group membership is obvious to participants, programme facili- tators, and school staff. Blinding of staff responsible for assessing study outcomes can be controlled with careful planning and im- plementation. This would be particularly effective where outcome assessments are administered with children individually. However, group administration of self report questionnaires or vignette mea- sures may be more susceptible to bias when used with younger participants who are not yet able to read independently. Alterna- tive administration methods, including the use of digital devices and animations, may go some distance to minimising detection bias.
In 14 of the included studies children were randomised in groups of classrooms, schools, or school districts for ease of implementa- tion. However, the appropriate analysis for cluster-randomisation was not used in any of the studies resulting in potential for over- estimation of the effects of interventions. Initial analyses do not take account of unit of analysis errors that occurred in at least half of the studies in each meta-analysis. ICCs used in the meta-anal- ysis are imputed and may not be appropriate for all of the stud- ies included. Therefore, results might have differed had the true ICCs from these studies been available, or had cluster-adjusted results been provided by the authors. Furthermore, the same ICC was used for studies that had undertaken cluster-randomisation at class, school, and district level, which could further overestimate the magnitude of the findings.
Potential biases in the review process
In producing this review our aim was to provide an unbiased ap- praisal of the evidence available. We have attempted, therefore, to be comprehensive in our reporting and transparent in our method- ology. The review was conducted in line with criteria in the pub- lished protocol (Zwi 2003), and where we deviated from these criteria to accommodate updates in Cochrane review methods or advances in the field, we have documented this in the subsection on Differences between protocol and review. The methodological decision to produce each meta-analysis was complex, involving a balance between the quest for an easily digestible summary of the information, and the danger of applying results when significant methodological caveats exist. We present the meta-analyses with
accompanying cautions as outlined above, and invite debate and comments regarding the route we have chosen.
Agreements and disagreements with other studies or reviews
Five previous meta-analyses of sexual abuse prevention pro- grammes exist as noted in Table 1, including the original ver- sion of this review (Zwi 2007). Our review differs from previous reviews in that it assesses a broader range of outcomes, applies more rigorous inclusion criteria to select high quality studies, and excludes preschool programmes. Further, all previous reviews in- cluded studies with control groups but did not apply randomi- sation criteria, therefore unlike our review, previous reviews in- cluded controlled before-and-after studies. All previous reviews have found medium to large effects for knowledge outcomes in favour of intervention groups. These effect sizes ranged from 0.57 (Heidotting 1994, 18 studies), through 0.71 (Rispens 1997, 16
studies) and 0.90 (Berrick 1992, 13 studies) to 1.07 (Davis 2000, 27 studies). Our previous review found a SMD of 0.59 (95% con- fidence interval (CI) 0.44 to 0.74; nine studies, n = 3022) for the questionnaire-based knowledge outcome, which is the outcome most comparable to the outcomes reported in previous reviews. The current review found a SMD of 0.61 (95% CI 0.45 to 0.78;
18 studies, n = 4657).
Davis 2000 attempted subgroup analyses to examine moderator effects: age (mean age was divided into three groups: three to five years, 5.1 to eight years, older than eight years of age), level of participation (participation was analysed at three different levels: physical participation, verbal participation, no participation), and number of sessions (three subsets: one session, two to three ses- sions, more than three sessions). Due to inadequate reporting of study data, we were unable to replicate these meta-analyses, and would caution against using the broad variable of participation as the only marker for programme variation. Given that most pro- grammes include multiple participatory opportunities, often in combination, it may be more informative to develop and explore the effects of multidimensional programme typologies as noted above.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
Our overall interpretation is that there is moderate quality evi- dence that school-based programmes for the prevention of child sexual abuse, of the types described in this review, are effective in increasing primary (elementary) school-aged children’s protec- tive behaviours and knowledge immediately post-intervention. Knowledge scores did not deteriorate for intervention participants
one to six months after programme participation, signalling that booster sessions or other maintenance strategies for reinforcement of key messages remain appropriate follow-up strategies. Retention of knowledge should be measured beyond six months. It appears that older children make greater knowledge gains than younger children when tested using questionnaire-based measures, but not when using vignette-based measures, indicating the need for cau- tion when interpreting study findings. None of the included stud- ies evaluated programmes delivered via electronic means. On bal- ance of evidence, programmes do not appear to increase or de- crease children’s fear or anxiety, and may result in greater odds of disclosures of past or current sexual abuse from children who have been programme participants, however results are uncertain be- cause of inappropriate data analysis in individual studies. Hence, there is a need for ongoing monitoring of both positive and nega- tive short- and long-term effects of programmes in more rigorous studies with more detailed reporting of potential moderators of programme effects in the form of child, programme, and contex- tual characteristics.
Currently, schools implement a variety of interventions aimed at preventing child sexual abuse. It is likely that these interventions will be most useful as part of wider community initiatives pro- moting the safety of children, the contents, processes, and out- comes of which must be clearly defined and measured in rigorous evaluation designs. Furthermore, children’s increased knowledge of abuse should not be seen as a replacement for society’s responsi- bility to ensure child safety. It must be emphasised that increasing children’s knowledge in this area does not mean they are in any way responsible for abuse, which might then occur by their not being able to apply this knowledge in an actual abuse situation. Even if successful in only a small proportion of situations, given the prevalence of child sexual abuse, it is possible that the skills and knowledge learned in prevention programmes may be of as- sistance to a considerable number of children.
Implications for research
Further evidence is required to assess the effectiveness of school- based programmes for the prevention of child sexual abuse. The current evidence is primarily focused on improvements in partic- ipants’ skills (protective behaviours) and knowledge (both factual and applied knowledge), and to a lesser extent on assessing harm (child anxiety or fear) and disclosures of past or current child sexual abuse. Further research is needed to investigate the links (if any) between programme participation and actual prevention of child sexual abuse. This will require large cohort studies with repeated follow-up into adulthood. However, even large cohort studies may not provide definitive evidence for changes in child sexual abuse incidence, as it is under-identified and difficult to prove. Further research is also required to address uncertainties about the mag- nitude of skill or knowledge improvement (or both) that can (if at all) translate to clinically important protective effects. Such ev-
idence is a necessary precursor to assessing programmes’ cost-ef- fectiveness.
Ongoing research is needed to more rigorously evaluate pro- grammes. Research to date suggests several categories of factors that may influence programme effectiveness, such as child fac- tors, including family microsystem factors; programme factors, including school contextual factors; and evaluation design factors (Heidotting 1994; Rispens 1997). These require further investi- gation in well-designed experimental studies. Many demographic and other independent variables were poorly reported in the in- cluded studies. Reliable evidence of this type will advance assess- ment of programmes’ cultural sensitivity, and the appropriateness of programmes for groups of children considered at greater risk. Future evaluations must be more comprehensive, use valid, reli- able, standardised measures, and be more precisely reported, ac- cording to evidence-based guidelines for reporting of clinical tri- als such as the CONSORT (Consolidated Standards of Reporting Trials) Statement (Shulz 2010).
Further investigation of programme contents, methods, and de- livery is required with a view to developing programme typolo- gies that can incorporate the programmes’ multidimensionality. To this end, typologies should be developed that capture variables emerging as important in newly developed frameworks for child sexual abuse prevention (Smallbone 2008), such as the extent and nature of parent, teacher, and community education components within programmes.
Future studies should address problems with study design, in par- ticular unit of analysis errors in cluster-randomised trials. Studies where cluster-randomisation is used should adjust results with ap- propriate statistical methods, and publish intra-class correlation coefficients (ICCs) (Campbell 2004). It may then be possible for meta-analyses to be more robust, and to overcome inadequate sam- ple size and study power to test for differences in child character- istics and intervention types. Other design features that warrant particular attention in future studies include those domains asso- ciated with risk of bias: randomisation of study participants, allo- cation concealment, blinding of outcome assessors, reporting of attrition, and analysis based on intention-to-treat (ITT). Longer follow-up periods for measurement of study outcomes beyond six months are essential to monitor maintenance effects.
A C K N O W L E D G E M E N T S
In the original review, Danielle M Wheeler acknowledged sup- port from the Financial Markets Foundation for Children and the Nordic Campbell Centre. Dr Andrew Hayen (Australia) and Dr Roger Harbord (UK) provided much valued statistical advice.
In the review update, Kerryann Walsh was funded by a Queens- land University of Technology Vice Chancellor’s Research Fellow-
ship (2010 to 2012) and acknowledges the Australian Research Council Discovery Projects scheme (DP1093717). Pauline Mulli- gan and Leisa Brandon provided much valued research assistance. The Australasian Cochrane Centre provided training and review completion workshops.
The authors are especially grateful for the comments of exter- nal Cochrane reviewers and statisticians, and for the expert ad- vice from the Cochrane Developmental, Psychosocial and Learn-
ing Problems Group editorial base: Professor Geraldine MacDon- ald (Co-ordinating Editor), Dr Joanne Wilson (Managing Edi- tor), Gemma O’Loughlin (Assistant Managing Editor), and Mar- garet Anderson (Trials Search Co-ordinator) who conducted the searches for this review update. The authors also wish to thank Laura MacDonald, former Managing Editor, Cochrane Develop- mental, Psychosocial, and Learning Problems Group, for her sup- port during development of the update of this review.
References to studies included in this review
Blumberg 1991 {publisfted and unpublisfted data}
R E F E R E N C E S
Fryer 1987a {publisfted data only}
∗ Fryer Jr GE, Kraizer SK, Miyoshi T. Measuring actual reduction of risk to child abuse: a new approach. Child
Blumberg EJ. The Effects of Two Sexual Abuse Prevention
Training Programs on the Evaluation of Touches [MA Psych thesis]. San Diego: San Diego State University, 1987.
∗ Blumberg EJ, Chadwick MW, Fogarty LA, Speth TW, Chadwick DL. The touch discrimination component of sexual abuse prevention training: unanticipated positive consequences. Journal of Interpersonal Violence 1991;6(1): 12–28.
Chadwick MW. A Comparative Evaluation of Two Sexual Abuse Prevention Programs for Children [PhD thesis]. Irvine, United States: University of California, 1989.
Chen 2012 {publisfted and unpublisfted data}
Chen YI, Fortson BL, Tseng KW. Pilot evaluation of a sexual abuse prevention program for Taiwanese children. Journal of Child Sexual Abuse 2012;21(6):621–45.
Crowley 1989 {unpublisfted data only}
Crowley KJ. Evaluation of Good Touches/Bad Touches: A Program to Prevent Child Sexual Abuse in School Age Children [Psy.D. thesis]. New York, United States: Pace University, 1989.
Daigneault 2012 {publisfted data only}
Daigneault I, Hébert M, McDuff P, Frappier JY. Evaluation of a sexual abuse prevention workshop in a multicultural, impoverished urban area. Journal of Child Sexual Abuse 2012;21(5):521–42.
Dake 2003 {publisfted data only}
Dake JA, Price JH, Murnan J. Evaluation of a child abuse prevention curriculum for third-grade students: assessment of knowledge and efficacy expectations. Journal of School Health 2003;73(2):76–82.
Dawson 1987 {unpublisfted data only}
Dawson GF. An Evaluation of Cognitive and Affective Outcomes of a Prevention Program for Childhood Sexual Abuse [EdD thesis]. Tennessee, United States: Memphis State University, 1987.
Del Campo Sanchez 2006 {publisfted data only}
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Abuse & Neglect 1987;11(2):173–9.
Fryer Jr GE, Kraizer SK, Miyoshi T. Measuring children’s retention of skills to resist stranger abduction: use of the simulation technique. Child Abuse & Neglect 1987;11(2): 181–5.
Grendel 1991 {unpublisfted data only}
Grendel MA. Cognitive and Emotional Effects of a Brief Child Sexual Abuse Prevention Program for First Graders [EdD thesis]. Ohio, United States: University of Cincinnati, 1991.
Harvey 1988 {publisfted data only}
Harvey P, Forehand R, Brown C, Holmes T. The prevention of sexual abuse: examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy 1988;19(3):429–35.
Hazzard 1991 {publisfted data only}
Hazzard A, Webb C, Kleemeier C, Angert L, Pohl J. Child sexual abuse prevention: evaluation and one-year follow-up. Child Abuse & Neglect 1991;15(1-2):123–38.
Hébert 2001 {publisfted data only}
Hébert M, Lavoie F, Piche C, Poitras M. Proximate effects of a child sexual abuse prevention program in elementary school children. Child Abuse & Neglect 2001;25(4):505–22.
Kolko 1989 {publisfted data only}
Kolko DJ, Moser JT, Hughes J. Classroom training in sexual victimization awareness and prevention skills: an extension of the Red Flag/Green Flag people program. Journal of Family Violence 1989;4(1):25–45.
Krahé 2009 {publisfted data only}
Krahé B, Knappert L. A group-randomized evaluation of a theatre-based sexual abuse prevention programme for
primary school children in Germany. Journal of Community & Applied Social Psychology 2009;19(4):321–9.
Kraizer 1991 {publisfted and unpublisfted data}
∗ Kraizer S. The Safe Child Program for the Prevention of Child Abuse: Development and Evaluation of a School-Based
Curriculum [PhD thesis]. Ohio, United States: The Union Institute, 1991.
Kraizer S, Witte SS, Fryer GE. Child sexual abuse prevention programs: what makes them effective in protecting children?. Children Today 1989;18(5):23–7.
Lee 1998 {publisfted data only}
Lee YK, Tang CS. Evaluation of a sexual abuse prevention program for female Chinese adolescents with mild mental retardation. American Journal of Mental Retardation 1998; 103(2):105–16.
Oldfield 1996 {publisfted data only}
Oldfield D, Hays BJ, Megel ME. Evaluation of the effectiveness of Project Trust: an elementary school-based victimization prevention strategy. Child Abuse & Neglect 1996;20(9):821–32.
Poche 1988 {publisfted data only}
Poche C, Yoder P, Miltenberger R. Teaching self-protection to children using television techniques. Journal of Applied Behavior Analysis 1988;21(3):253–61.
Saslawsky 1986 {publisfted data only}
Saslawsky DA, Wurtele SK. Educating children about sexual abuse: implications for pediatric intervention and possible prevention. Journal of Pediatric Psychology 1986;11(2): 235–45.
Snyder 1986 {unpublisfted data only}
Snyder CM. An Evaluation of the “Good Secrets, Bad Secrets” Assault Prevention Program [PhD thesis]. California, United States: International University, 1986.
Tutty 1997 {publisfted data only}
∗ Tutty LM. Child sexual abuse prevention programs: evaluating ’Who do you tell’. Child Abuse & Neglect 1997; 21(9):869–81.
Tutty LM. What children learn from sexual abuse prevention programs: difficult concept and developmental issues.
Research on Social Work Practice 2000;10(3):275–300.
Wolfe 1986 {publisfted data only}
Wolfe DA, MacPherson T, Blount R, Wolfe VV. Evaluation of a brief intervention for educating school children in awareness of physical and sexual abuse. Child Abuse & Neglect 1986;10(1):85–92.
Wurtele 1986 {publisfted data only}
Wurtele SK, Saslawsky DA, Miller CL, Marrs SR, Britcher JC. Teaching personal safety skills for potential prevention of sexual abuse: a comparison of treatments. Journal of Consulting and Clinical Psychology 1986;54(5):688–92.
e en-Ero ul 2013 {publisfted data only}
e en-Ero ul AR, Kaf Hasirci . The effectiveness of psycho-educational school-based child sexual abuse prevention training program on Turkish elementary
students. Educational Sciences, Theory & Practice 2013;13 (2):725–9.
References to studies excluded from this review
Ages 1991 {publisfted data only}
Ages SE. An Evaluation of the Maintenance of Changes in Knowledge and Behaviour Skills Effected by a School-Based Personal Safety Program for the Primary Grades [PhD thesis]. Ottawa, Canada: Carleton University, 1991.
Alexander 1998 {publisfted data only}
Alexander AD. The Assessment of a School-Based Intervention for the Prevention of Child Sexual Abuse [EdD thesis].
Toronto, Canada: University of Toronto, 1998.
Araji 1995 {publisfted data only}
Araji SK, Fenton R, Straugh T. Child sexual abuse: description and evaluation of a K-6 prevention curriculum. Journal of Primary Prevention 1995;16(2):149–64.
Bae 2009 {publisfted data only}
Bae J, Panuncio R. Development of computer-assisted instruction program for child sexual abuse prevention. International Journal of Computer Science and Network Security 2009;9(3):142–7.
Baker 2013 {publisfted data only}
∗ Baker CK, Gleason K, Naai R, Mitchell J, Trecker
C. Increasing knowledge of sexual abuse: a study with elementary school children in Hawai’i. Research on Social Work Practice 2013;23(2):167–78.
Baker 2014 {publisfted data only}
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Barron 2013 {publisfted data only}
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Binder 1987a {publisfted data only}
Binder RL, McNiel DE. Evaluation of a school-based sexual abuse prevention program: cognitive and emotional effects. Child Abuse & Neglect 1987;11(4):497–506.
Bodzy 1988 {publisfted data only}
Bodzy LL. The Effects of a Personal Safety Program on Affective Measures of Child Development [EdD thesis]. Tennessee, United States: Peabody College for Teachers of Vanderbilt University, 1988.
Boyle 2005 {publisfted data only}
Boyle CL, Lutzker JR. Teaching young children to discriminate abusive from nonabusive situations using multiple exemplars in a modified discrete trial teaching format. Journal of Family Violence 2005;20(2):55–69.
Briggs 1994 {publisfted data only}
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Briggs 1996 {publisfted data only}
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Casper 1999 {publisfted data only}
Casper R. Characteristics of children who experience positive or negative reactions to a sexual abuse prevention program. Journal of Child Sexual Abuse 1999;7(4):97–112.
Conte 1985 {publisfted data only}
Conte JR, Rosen C, Saperstein L, Shermack R. An evaluation of a program to prevent the sexual victimization of young children. Child Abuse & Neglect 1985;9(3): 319–28.
Counts 2003 {publisfted data only}
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Currier 1996 {publisfted data only}
Currier LL, Wurtele SK. A pilot study of previously abused and non-sexually abused children’s responses to a personal safety program. Journal of Child Sexual Abuse 1996;5(1): 71–87.
Deretzotes 1989 {publisfted data only}
Deretzotes DS. Evaluation of High School Level CAPTA Child Abuse Prevention Programs [PhD thesis]. Berkeley, California, United States: University of California, 1989.
Dhooper 1995 {publisfted data only}
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Foshee 1996 {publisfted data only}
Foshee VA, Linder GF, Bauman KE, Langwick SA, Arriaga XB, Heath JL, et al. The Safe Dates Project: theoretical basis, evaluation design, and selected baseline findings.
American Journal of Preventive Medicine 1996;12(5 Suppl): 39–47.
Foshee 1998 {publisfted data only}
Foshee VA, Bauman KE, Arriaga XB, Helms RW, Koch GG, Linder GF. An evaluation of Safe Dates, an adolescent dating violence prevention program. American Journal of Public Health 1998;88(1):45–50.
Garbarino 1987 {publisfted data only}
Garbarino J. Children’s response to a sexual abuse prevention program: a study of the Spiderman comic. Child Abuse & Neglect 1987;11(1):143–8.
Herman 1987 {publisfted data only}
Herman P. Evaluation of a Sexual Abuse Curriculum/ Prevention Program [PhD thesis]. Washington, United States: Washington State University, 1987.
Jacobs 1995 {publisfted data only}
Jacobs JE, Hashima PY, Kenning M. Children’s perceptions of the risk of sexual abuse. Child Abuse & Neglect 1995;19 (12):1443–56.
Johnson 1994 {publisfted data only}
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Kernsmith 2011 {publisfted data only}
Kernsmith PD, Hernandez-Jozefowicz DM. A gender- sensitive peer education program for sexual assault prevention in the schools. Children & Schools 2011;33(3): 146–57.
Kindt 1995 {publisfted data only}
Kindt MT. Evaluation of an Adolescent Sexual Abuse Prevention Program [PhD Thesis]. Ohio, United States: Bowling Green State University, 1995.
Kolko 1987 {publisfted data only}
Kolko DJ, Moser JT, Litz J, Hughes J. Promoting awareness and prevention of child sexual victimization using the Red Flag/Green Flag program: an evaluation with follow-up. Journal of Family Violence 1987;2(1):11–35.
MacIntyre 1999a {publisfted data only}
MacIntyre D, Carr A. Evaluation of the effectiveness of the stay safe primary prevention programme for child sexual abuse. Child Abuse & Neglect 1999;23(12):1307–25.
MacIntyre 1999b {publisfted data only}
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Madak 1992 {publisfted data only}
Madak PR, Berg DH. The prevention of sexual abuse: an evaluation of “Talking About Touching”. Canadian Journal of Counselling 1992;26(1):29–40.
Martin 2012 {publisfted data only}
Martin AF, Baz M, Vicario-Molina I, Martinez Alvarez JL, Fuertes AF, Gonzalez RJ. Assessment of a sexual coercion prevention program for adolescents. Spanish Journal of Psychology 2012;15(2):560–70.
Michaelson 2001 {publisfted data only}
Michaelson R. Development, Evaluation and Revision of the School-Based Child Sexual Abuse Prevention Program (CSAPP Project) [PhD Thesis]. St Alban’s, Australia: Victoria University of Technology, 2001.
Miller 2011 {publisfted data only}
Miller E, McCauley H, Virata MC, Decker M, Trancredi D, Moideen F, et al. Coaching boys into men: preliminary success of a sexual violence prevention program. Journal of Adolescent Health 2011;48(2 Suppl):S85–6.
Miller 2012 {publisfted data only}
Miller E, Tancredi DJ, McCauley HL, Decker MR, Virata MCD, Anderson HA, et al. Coaching boys into men: a cluster-randomized controlled trial of a dating violence
prevention program. Journal of Adolescent Health 2012;51 (5):431–8.
Miller 2013 {publisfted data only}
Miller E, Tancredi DJ, McCauley HL, Decker MR, Virata MCD, Anderson HA, et al. One-year follow-up of a coach- delivered dating violence prevention program: a cluster randomized controlled trial. American Journal of Preventive Medicine 2013;45(1):108–12.
Moreno-Manso 2014 {publisfted data only}
Moreno-Manso J, Garcia-Baamonde E, Blazquez-Alonso M, Pozueco-Romero JM. Application of a child abuse prevention programme in an educational context. Anales de Psicologia 2014;30(3):1014–24.
Ogunfowokan 2012 {publisfted data only}
Ogunfowokan AA, Fajemilehin RB. Impact of a school- based sexual abuse prevention education program on the knowledge and attitude of high school girls. Journal of School Nursing 2012;28(6):459–68.
Pacifici 2001 {publisfted data only}
Pacifici C, Stoolmiller M, Nelson C. Evaluating a prevention program for teenagers on sexual coercion: a differential effectiveness approach. Journal of Consulting and Clinical Psychology 2001;69(3):552–9.
Peraino 1990 {publisfted data only}
Peraino JM. Evaluation of a preschool antivictimization prevention program. Journal of Interpersonal Violence 1990; 5(4):520–8.
Pohl 1990 {publisfted data only}
Pohl JD, Hazzard A. Reactions of children, parents, and teachers to child sexual abuse prevention programs. Education 1990;110(3):337–4.
Smothers 2011 {publisfted data only}
Smothers MK, Smothers DB. A sexual assault primary prevention model with diverse urban youth. Journal of Child Sexual Abuse 2011;20(6):708–27.
Taal 1997 {publisfted data only}
Taal M, Edelaar M. Positive and negative effects of a child sexual abuse prevention program. Child Abuse & Neglect 1997;21(4):399–410.
Taylor 1991 {publisfted data only}
Taylor S. An Evaluative Study of the Child Abuse Research and Education Program [Med Thesis]. Newfoundland and Labrador, Canada: Memorial University of Newfoundland, 1991.
Taylor 2010a {publisfted data only}
Taylor B, Stein N, Burden F. The effects of gender violence/ harassment prevention programming in middle schools: a randomized experimental evaluation. Violence and Victims 2010;25(2):202–23.
Taylor 2010b {publisfted data only}
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Telljohann 1997 {publisfted data only}
Telljohann SK, Everett SA, Price JH. Evaluation of a third grade sexual abuse curriculum. Journal of School Health 1997;67(4):149–53.
Tutty 1991 {publisfted data only}
Tutty LM. An Investigation of the Ability of Elementary School-Aged Children to Learn Child Sexual Abuse Prevention Concepts [PhD thesis]. Alberta, Canada: University of Calgary, 1991.
Tutty 1992 {publisfted data only}
Tutty LM. The ability of elementary school children to learn child sexual abuse prevention concepts. Child Abuse & Neglect 1992;16(3):369–84.
Volpe 1984 {publisfted data only}
Volpe R. A psychoeducational program dealing with child abuse for elementary school children. Child Abuse & Neglect 1984;8(4):511–7.
Warden 1997 {publisfted data only}
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Webb 1997 {publisfted data only}
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Weisz 2001 {publisfted data only}
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Wurtele 1987a {publisfted data only}
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References to ongoing studies
NCT02181647 {publisfted data only}
NCT02181647. Safe touches: a rigorous evaluation of a sexual abuse prevention program for children. https:/
/clinicaltrials.gov/ct2/show/NCT02181647 (accessed 8
February 2015).
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∗ Indicates the major publication for the study
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Blumberg 1991
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 264 kindergarten, 1st, 2nd, and 3rd grade students
Mean age: 7.2 years
Gender: 53% male; 47% female
Ethnicity: 51% Caucasian; 18% Black; 17% Hispanic; 7% Asian; 7% Other Setting: 3 city elementary schools in San Diego unified school district, California Country: USA
Attrition: intervention group 14/99 = 14.1%; intervention group 7/86 = 8.1%; control
group 3/79 = 3.8%
Interventions Intervention 1: role-play programme (“Stop, Tell someone, Own your body, Protect yourself ” (STOP))
• Content: body ownership/body rights; body openings needing protection (eyes, ears, private places); appropriate and inappropriate touches; safety rules (Stop, Go, Tell, tell, tell and keep telling until somebody listens); perpetrators are usually someone known to the child; sexual abuse is not the child’s fault; appropriate and inappropriate secrets
• Methods: role-play, modelling, rehearsal, and discussion
• Delivery: by volunteers trained by a licensed social worker with expertise in child sexual abuse
Intervention 2: multimedia programme (“Child Abuse Primary Prevention Program” (CAPPP))
• Content: discriminating types of touches based on feelings; they have the right to say no; safety rules “Say No,” “Go,” and “Tell”; no one should touch private areas unless you need help; “touching secrets” or secrets that hurt should never be kept;
sexual abuse is never the child’s fault
• Methods: younger children were taught concepts through use of teddy bear and viewed a film; older children were taught through a puppet show and discussion
• Delivery: by educators, counsellor, school nurse, teachers, all trained by the school nurse
Control: fire prevention programme Duration: 1 x 1-hour session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): yes, reported in Chadwick 1989 Knowledge (vignette-based knowledge): Touch Discrimination Task, comprising 7 vi- gnettes in which an adult touched a child in some way
Disclosures: child protective services file search at 15 months post intervention
Harm: not reported
Other: fear survey, sexual abuse knowledge index, and measure of behavioural acquisition,
Blumberg 1991 (Continued)
reported in Chadwick 1989
Last outcome assessment: 3 to 94 days post intervention
Notes Author contact: yes
This study was part of a larger study (n = 486) reported in Blumberg 1987 and Chadwick 1989
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Classrooms were randomly allocated for treatments. Student participation was based on parental consent” (p 15). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Students within the same school received 1 of 3 interventions (role-play programme, multimedia programme, or control fire sa- fety). It is possible that children may have been aware of this or exposed to other factors/information apart from the inter- vention they were receiving, or both (e.g. through treatment-control contamination via playground, siblings, or friendships). Blinding of key personnel (e.g. teachers) may not have been possible in the school delivery context
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “The children were not informed that the interviews were related to the presenta- tions” (p 20). Outcome assessors were dif- ferent to the persons providing the inter- ventions. “Interviewers were blind to the group membership of the children, and no child was interviewed more than once by the same interviewer to control for poten- tial effects of rapport building” (p 19)
Incomplete outcome data (attrition bias) All outcomes
High risk Attrition: intervention group 1 14/99 = 14. 1%; intervention group 2 7/86 = 8.1%; control group 3/79 = 3.8%. Reasons for at- trition were not reported
Blumberg 1991 (Continued)
Chen 2012
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat: no Adjustment for clustering: no
Participants Total number randomised: 46 students in grades 1 through 6
Mean age: 9.02 years Gender: not reported Ethnicity: 100% Taiwanese
Setting: 1 public elementary school in a rural area in southern Taiwan Country: Taiwan
Attrition: 0%
Interventions Intervention: child sexual abuse prevention training based on Red Flag/Green Flag People (Rape and Abuse Crisis Center 2008) and Red Flag/Green Flag People II (Grimm 1994)
• Content: body ownership; distinguishing appropriate from inappropriate touches and requests; distinguishing types of secrets; and abduction prevention training based on the book “Who Is a Stranger and What Should I Do?” (Girard 1985)
• Methods: instruction; modelling, role-play, rehearsal, practice, feedback, and reinforcement
• Delivery: details not reported Control: wait list control
Duration: 2 x 50-minute sessions delivered “at the beginning of the school day… before children began their regular academic classes” (p 628)
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Children’s Sexual Knowledge Question- naire (CSKQ), a 6-item self report knowledge questionnaire with response items correct/ incorrect/I don’t know
Knowledge (questionnaire-based knowledge): Children’s Awareness of Scary Secrets (CASSQ), a 6-item self report measure to distinguish okay from not okay secrets. Items
Chen 2012 (Continued)
scored correct/incorrect
Knowledge (vignette-based knowledge): Chinese What If Situations Test (CWIST), comprising 6 hypothetical situations (3 appropriate and 3 inappropriate) to which chil- dren respond okay or not okay and then answer to a standard list of 4 further questions Disclosures: not reported
Harm: not reported Other: no
Last outcome assessment: 2 to 3 weeks after programme completion
Notes Author contact: yes
This study is reported as a “pilot” programme
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Children in each group then were ran- domly assigned to the skills-based CSA pre- vention program (n = 23) or the WLC con- dition (n = 23)…” (p 625). Method of ran- domisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. No significant differences between the groups were observed “on the demographic variables (e.g. gender, race, age) or on other measures administered at pretest” (p 632)
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported
Blinding of outcome assessment (detection bias)
All outcomes
High risk Outcome assessment was administered in group format but no further information was reported. The identities of the out- come assessors were not specifically re- ported however we assume the outcome as- sessors were the same personnel as those de- livering the programme
Incomplete outcome data (attrition bias) All outcomes
Low risk The study reported “all children enrolled in the study completed the pre- and post- assessment instruments and completed the treatment” (p 632)
Chen 2012 (Continued)
Crowley 1989
Methods Design: quasi-experimental randomised Solomon 4-group design Unit of allocation: classes or homerooms
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 293 4th and 5th grade students
Mean age: not reported; data provided for grade level only Gender: 45% male; 55% female
Ethnicity: not reported
Setting: 4 elementary schools in the Bedford Central School District, Westchester County, New York
Country: USA
Attrition: the study consisted of 367 “potential participants” (p 45). Data on 74 par- ticipants (20%) were excluded due to missing or incomplete data, or absence during a portion of the study
Interventions Intervention: “Good Touches/Bad Touches: A Program to Prevent Child Sexual Abuse” devised by the MHAWC 1984 (group 1 and group 3)
• Content: individuals are unique and special; feelings are special and important; different kinds of touches; body ownership; touching; saying no; distinguishing types of secrets; identifying trusted adults; how to tell
• Methods: discussion; structured activities, including active participation and rehearsal; film; review
• Delivery: by school psychologists, school social worker, school nurse, and teacher who received 2 training sessions by programme developers (5 hours) plus departmental training (2 hours)
Control: wait-list control (group 2 and group 4)
Duration: 2 x 45-minute sessions, once per week for 2 weeks
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Sexual Abuse Knowledge Inventory (SAKI), a 27-item multiple choice format test
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ) (
Saslawsky 1986), a 13-item test. Used to establish construct validity of the SAKI Knowledge (vignette-based knowledge): no
Disclosures: not reported Harm: not reported Other: no
Last outcome assessment: 3 months after programme completion
Crowley 1989 (Continued)
Notes Author contact: no
Solomon 4-group design consisted of: group 1: pre-tested treatment; group 2: pre-tested control; group 3: unpre-tested treatment; group 4: unpre-tested control
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Fourth and fifth grade children (n = 293) were randomly assigned to one of four groups” (p iii). Method of randomisation was not reported
Allocation concealment (selection bias) High risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances were conducted: “suc- cessful randomisation of Groups 1 & 2 did not occur” (pp 60 - 61). There were differ- ences in pre-test mean scores for groups 1 and 2. Group 1 had higher scores on the pre-test SAKI than group 2. Group 3 had higher scores on the SAKI and PSQ than group 4
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. It did not seem that the intervention groups were blinded to their own con- dition. Homeroom teachers were present during programme delivery, so it was not possible for them to be blinded to the stu- dents’ conditions
Blinding of outcome assessment (detection bias)
All outcomes
High risk Group administration of the outcome as- sessment meant that outcome assessors would need to be blinded to the condition of each entire class or homeroom. Given that the assessors were school staff, blinding was not possible. On some occasions the outcome assessor was the researcher who was not blinded to the groups. On some other occasions the outcome assessor was the programme presenter who was also not blinded to the groups
Incomplete outcome data (attrition bias) All outcomes
High risk Data on 74 participants (20%) were ex- cluded due to missing or incomplete data, or absence during a portion of the study
Crowley 1989 (Continued)
Daigneault 2012
Methods Design: quasi-experimental design with random assignment of participants to groups Unit of allocation: schools
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Participants: 160 1st, 2nd, 3rd, and 4th grade students Mean age: 7.75 years
Gender: not reported
Ethnicity: reported as country of birth. 48% Canada; 14.5% Middle East; 13% Asia; 10% Africa; 7% Europe; 4% South America; 3% North America; 0.5% Oceania Setting: 3 public schools in low socioeconomic areas of Montreal, Canada
Country: Canada Attrition: not reported
Interventions Intervention: ESPACE child sexual abuse prevention programme, “a French adaptation of the CAP workshop (Cooper 1991)” (p 525) for children aged 3 to 12 years
• Content: awareness of personal rights; (safe, strong, secure), self assertion skills (self defence yell), and appropriate responses to instances of abuse (seeking out peer support, confiding in a trusted adult). Also included prevention of verbal and physical violence
• Methods: role-playing, guided discussions, behaviour modelling, and rehearsals
• Delivery: 3 trained community workers from diverse ethnic backgrounds Booster: Confidence, Solidarity, Respect (CSR) based on ESPACE (p 526)
• Content: revision of prevention knowledge; definitions of aggression and violence; cycle of violence; ways of using power positively; impact of behaviour on others
• Methods: guided discussions, behaviour modelling, role-playing and rehearsals.
• Delivery: “instructors” not otherwise specified (p 526) Control: wait-list control (table 2)
Duration: 1 x 90 minute workshop
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): French translation of 24-item CKAQ ( Tutty 1995)
Knowledge (vignette-based knowledge): adaptation of the WIST (Wurtele 1998) com- prising 3 vignettes matching ESPACE content with response options (yes/no) to 4 pos- sible behaviours for each vignette (12 items in total)
Disclosures: not reported
Harm: children’s feelings of safety, an 11-item measure adapted from Schwab-Stone 1995 Other: children’s peer victimisation over the past week, a 10-item measure adapted from Orpinas 1995
Last outcome assessment: “in the second year of the study” (p 530)
Daigneault 2012 (Continued)
Notes Author contact: yes
Study reports on booster componentwith 4 additional outcome measures: general knowl- edge about violence; confidence in others; empathic concern; and respect towards others
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Schools were randomly assigned to condi- tions across two years of the study” (p 527)
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Low risk “Interviewers (n = 7) and ESPACE instruc- tors (n = 4) were blind to school status at T1 and T2. Only interviewers were blind to school status at T4 and T5” (p 527). Blinding procedures were not described
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “Interviewers (n = 7) and ESPACE instruc- tors (n = 4) were blind to school status at T1 and T2. Only interviewers were blind to school status at T4 and T5” (p 527). Blinding procedures were not described
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition was not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article are reported in the results
Dake 2003
Dake 2003 (Continued)
Interventions Intervention: child abuse prevention curriculum modified from an existing curriculum (title not reported)
• Content: abuse problems children may encounter; people in family and community support systems that children can turn to in abuse situations; 3 types of touches; personal safety rules regarding potential child abuse; child abuse is never a
child’s fault; child abuse should never be kept secret; empathy for others who find themselves in abusive situations
• Methods: role-play, video, discussion
• Delivery: by employees of a child abuse prevention agency and trained volunteers (all had attended a 30-hour training programme)
Control: wait-list control Duration: 2 x 1-hour sessions
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): custom made 26-item questionnaire in- cluding: 16 knowledge items; 5 efficacy expectation items (confidence take action in abuse situations); 4 demographic items; and 1 item that determined if the children knew an extra familial adult they could talk to about abuse
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported Other: no
Last outcome assessment: 3 months after programme completion
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Low risk Method of randomisation was not re- ported. Evidence of computer randomisa- tion provided after author contact (Zwi 2007)
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. No statistical differences were evident be- tween intervention and control groups on outcome measures for knowledge or effi- cacy expectations
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported
Dake 2003 (Continued)
Dawson 1987
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment of clustering: no
Participants Total number randomised: 237 4th, 5th, and 6th grade students Mean age: 10.6 years
Gender: 54% male; 46% female
Ethnicity: 53.2% White; 46.8% Black Setting: 2 Memphis City public schools Country: USA
Attrition: intervention group, 7/96 (7.3%); control group 1, 2/76 (2.6%); control group 2, 2/65 (3.1%)
Interventions Intervention: child sexual abuse prevention programme presentation, including the ap- propriate grade level film from the series “Child Sexual Abuse: A Solution” (Adams 1984)
• Content: definitions; session standards; purpose of session; discriminate appropriate and inappropriate touches; trusting feelings; talking with a trusted adult; offender characteristics and approaches; offenders are likely to be someone they know; personal safety rules; distinguishing appropriate and inappropriate secrets; child sexual
abuse is against the law; children are not to blame; skills for resisting or avoiding abuse; identifying support systems
• Methods: film; role-play; modelling; problem-solving activities (“what if ” situations); questions and answers
• Delivery: by school district sexual abuse co-ordinator Control 1: no presentation (same school as intervention group) Control 2: no presentation (different school)
Duration: 1 x 60-minute session
Dawson 1987 (Continued)
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Issues Test, a 10-item mul- tiple choice test
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported Other: no
Other: State-Trait Anxiety Inventory for Children (STAIC) (Speilberger 1966), 20 state-
ments designed to measure transitory anxiety
Last outcome assessment: 6 weeks post intervention
Notes Author contact: no
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Classes in the selected schools were ran- domly assigned to the different treatment groups” (p 45). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances were conducted. Age, race, and gender ratios were not sig- nificantly different among groups. How- ever, results showed that the mean pre-test knowledge test score for group B (control
1) was significantly higher than A (inter- vention) or C (control 2) on the pre-test (p 82)
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within one school were receiv- ing both treatment and control conditions. Authors indicate that children may have been exposed to “grapevine” effect (p 51) whereby information was transmitted in- formally throughoutthe school, or between siblings in a family or across families hav- ing contact with each other outside of school. School personnel did not appear to be blinded to group or class membership so there is risk of differential treatment of groups
Dawson 1987 (Continued)
Del Campo Sanchez 2006
Del Campo Sanchez 2006 (Continued)
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): questionnaire on knowledge about sexual abuse, a 35-item test comprising 33 knowledge and skill items and 2 items on commu- nication with parents about child sexual abuse
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ) ( Saslawsky 1986), a 13-item test. Used to establish construct validity of the questionnaire on knowledge about sexual abuse
Knowledge (vignette-based knowledge): no
Disclosures: spontaneous child disclosures reported (8/277 or 2.9% in experimental groups; 2/105 or 1.9% in control group)
Harm: information on programme side effects was collected in a questionnaire for parents (12-item version) and educators (9-item version) asking for observations of positive and negative changes in children’s behaviour after programme completion
Other: qualitative assessment of children’s participation in the programme during deliv-
ery. These data were collected using an observation sheet completed by educators acting as “participant observers” (p 2)
Last outcome assessment: 8 months after programme completion
Notes Author contact: yes
The curriculum evaluated in this study is the 1st elementary school curriculum of its type developed for delivery in Spain
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Subjects were randomly assigned” (p 2). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. There were no baseline imbalances regard- ing pre-treatment knowledge and skills in groups
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk The method of assessment (group or in- dividual administration) was not reported. The measures used to blind outcome asses- sors from knowledge of which intervention participants received was not reported
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not reported
Del Campo Sanchez 2006 (Continued)
Fryer 1987a
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 48 kindergarten, 1st, and 2nd grade students
Mean age: not reported Gender: not reported Ethnicity: not reported
Setting: 1 mid-town Denver elementary school
Country: USA Attrition: < 10%
Interventions Intervention: “Children Need to Know Personal Safety Training Program” (Kraizer 1981)
• Content: 4 safety rules to follow when they were not with care-taking adults: stay an arm’s reach away from strangers; don’t talk to them; don’t take anything from them; don’t go anywhere with them
• Methods: role-play
• Delivery: details not reported Control: wait-list control
Duration: 1 x 20-minute presentation, once per day for 8 days
Outcomes Protective behaviours simulation: yes. Involved staging of actual simulations used to record children’s responses indicating their “degree of vulnerability to abuse” (p 175) Knowledge (questionnaire-based knowledge): Children Need to Know Knowledge At- titude Test, a 20-item examination (results not reported)
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: discussed but not measured
Other: Harter Perceived Competence Scale for Children (Harter 1982) used to measure self esteem (results not reported)
Last outcome assessment: for the simulation “the day after the classroom program” (p 175); for the questionnaire measures “immediately following the instruction” (p 177)
Notes Author contact: yes
The results of this study are also reported in Fryer 1987b
Risk of bias
Fryer 1987a (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Twenty-four each were randomly assigned to the experimental and control groups tested” (p 174). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances revealed “pretest scores on each of the three tests administered were very nearly the same for the two study groups” (p 177)
Blinding of participants and personnel (performance bias)
All outcomes
High risk As there was only 1 intervention group, there was no possibility for systematic dif- ferences between groups in the way in which the programme was delivered. How- ever, as the control group were from the same school, they may have experienced some contamination or exposure to the programme via other students in the play- ground, or friends, or siblings outside of the study setting
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Children were blinded to the simulation test. “A research assistant, posing as a stranger” (p 175) conducted the outcome assessment. The blinding of the assessor (if any) is not reported. “A hidden camera and wireless microphone produced an audio- visual record of the encounter which was later reviewed and scored by research team members” (p 176). Interrater reliability was established as 1.0 (total reliability)
Incomplete outcome data (attrition bias) All outcomes
High risk Missing data were reported for 1/24 in ex- perimental group (4%) and 3/24 for the control group (12.5%). Data were gathered only from children present on both testing days
Selective reporting (reporting bias) High risk Not all measures discussed in the methods section of the article were also reported in the results. The results reported in the pa- pers refer only to the simulation
Grendel 1991
Methods Design: cluster-RCT
Unit of allocation: classrooms and individuals Intention-to-treat analysis: no
Adjustment for clustering: no, although in some analyses ANCOVA was used to enable adjustment for confounding because of the influence of intact groups
Participants Total number randomised: 100 1st grade students
Mean age: 6.9 years
Gender: 48% male; 52% female
Ethnicity: 84.3% White; 15.7% African-American (intervention group); 79.6% White; 18.4% African-American (control group)
Setting: “2 public schools serving a middle income, predominantly white population
from a large school district in the northern part of the Greater Cincinnati area” (p 66) Country: USA
Attrition: intervention group, 12/62 (19%); control group, 14/63 (22%)
Interventions Intervention: “Child Sexual Abuse Prevention Program” (developed by Women Helping Women, Ohio)
• Content: what is a stranger?; public versus private parts of the body; happy versus sad touches; trusting your feelings or inner voices; 3 body safety rules (say no, get away, tell someone); what if situations/concrete examples; who could you trust to tell?
• Methods: film, discussion, and review
• Delivery: by Women Helping Women education programme co-ordinator Control: wait-list control
Duration: 1 x 50-minute session
Outcomes Protective behaviours simulation: no
Knowledge (Questionnaire-based knowledge): Personal Safety Questionnaire (PSQ) ( Saslawsky 1986), 15 items. “A few minor changes were made in the wording of the PSQ fort his study, but the meaning of the questions remained unchanged” (p 80) Knowledge (vignette-based knowledge): “What If ” Situations Test (Wurtele 1989), 6 hypothetical situations, including 3 appropriate and 3 inappropriate touch situations. After each vignette there are 5 questions
Disclosures: not reported Harm: not reported
Other: Parent Perception Questionnaire (Wurtele 1989); Teacher Perception Question- naire (Wurtele 1989); Children’s Reactions to Prevention Program (adapted from Binder 1987b; Hazzard 1991)
Last outcome assessment: 1-day post intervention
Notes Author contact: no
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “In each school one intact class was ran- domly assigned to the treatment group, a second intact class was randomly assigned
Grendel 1991 (Continued)
to the control group, and the students in the third class were randomly assigned to ether the treatment or control group” (p 69). Method of randomisation was not re- ported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests of baseline imbalances were conducted: “the results of the demographic data indicate that the treatment and control groups were very similar on the variables assessed... both groups demonstrated comparable knowl- edge about sexual abuse and sexual abuse prevention skills” (pp 88-90)
Blinding of participants and personnel (performance bias)
All outcomes
High risk The intervention groups were not blinded to their own condition and school person- nel were not blinded to group or class con- ditions since teachers attended training and completed measures. Since both interven- tion and control groups were from the same school, there is a possibility of treatment- control contamination effects
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Outcome assessment was conducted indi- vidually with each participant. “Every ef- fort was made to keep the assistants naive to the hypotheses and to the group mem- bership of the subjects” (p 72)
Incomplete outcome data (attrition bias) All outcomes
High risk Incomplete outcome data, mainly in the form of “missing data due to students’ absence, withdrawal from school, unwill- ingness to participate” (p 70). This is high: 19% intervention group; 22% con- trol group
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article were also reported in the results
Harvey 1988
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 90 kindergarten children
Mean age: 5.8 years (70 months) Gender: not reported
Ethnicity: 56.3% Caucasian; 43.7% Black Setting: 4 schools in a rural area near Georgia Country: USA
Attrition: 21%
Interventions Intervention: “Good Touch-Bad Touch” programme (citation not reported)
• Content: defining sexual abuse; differentiating between good, bad, and sexually abusive touches; identifying who can sexually abuse children; 5 body safety rules (I can decide with whom I want to share my body; recognising when “something wrong” is happening to me; learning to say “no” and get away; learning to tell someone what happened; and recognising that, if abuse occurs, it is never my fault)
• Methods: storybook, game, film, song, and role-plays. Utilising modelling, rehearsal, and social reinforcement as teaching procedures
• Delivery: by 2 members of the research team who were experienced programme presenters
Control: story, discussion, film, and song not related to child sexual abuse Duration: 3 x 30-minute sessions across 3 consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): basic knowledge, a 5-item test Knowledge (vignette-based knowledge): good touch/sexually abusive touch pictures, comprising 10 pictures of young children interacting with an adult. 5 pictures represented good touches, and 5 pictures represented sexually abusive touches
Knowledge (vignette-based knowledge): direct test, comprising 2 scenes (taught as part of the programme) followed by 6 questions
Knowledge (vignette-based knowledge): generalisation test, comprising 2 scenes (not taught as part of the programme) followed by 6 questions
Disclosures: not reported Harm: not reported Other: no
Last outcome assessment: 7 weeks after programme completion
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Children in each of the four schools were randomly assigned (with the restriction that at the pre intervention assessment
Harvey 1988 (Continued)
there was approximately an equal num- ber of black and white boys and girls per group) to one of two groups: an experimen- tal group and a placebo control group” (p 432). Method of randomisation was not re- ported
Allocation concealment (selection bias) Unclear risk Method of concealment was not de- scribed. Potentially unconcealed proce- dure. In terms of baseline imbalances, re- sults indicated no significant differences in the age of children, family socioeconomic status, gender, or race between experimen- tal and control groups
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. 2 “experimenters” delivered the intervention programme (p 431). “Each experimenter conducted experimental and placebo con- trol sessions in two schools” (p 431). These individuals could not have been blinded to study conditions, however the use of 2 in- dividuals increases the risk that compared groups received different interventions
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk Outcome assessment was conducted “indi- vidually for each child at pre intervention, postintervention, and follow up” (pp 431- 2). The measures used to blind outcome as- sessors from knowledge of which interven- tion participants received was not reported
Incomplete outcome data (attrition bias) All outcomes
High risk Attrition was reported only for the study overall, and not specified for intervention and control groups. Attrition and miss- ing data were attributed to student absence during the programme or testing, and mov- ing from the school. Attrition was calcu- lated overall as 19/90 (21%)
Selective reporting (reporting bias) High risk Not all measures discussed in the methods section of the article were also reported in the results. Means and SDs for knowledge outcomes were measured but not reported
Hazzard 1991
Methods Design: cluster-RCT
Unit of allocation: schools Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 399 3rd and 4th grade students
Mean age: not reported Gender: 50% male; 50% female
Ethnicity: 68% Caucasian; 23% Black; 4% Hispanic; 3% Asian; 2% Other
Setting: 27 classrooms (14 x 3rd grade and 13 x 4th grade) in 8 city elementary schools from a suburban school district in a large southeastern city
Country: USA
Attrition: not reported
Interventions Intervention 1: teacher and child training comprising a 6-hour workshop for teachers and adaptation of “Feeling Yes, Feeling No” (National Film Board of Canada 1985) sexual abuse prevention curriculum for children and homework handouts
• Content: touches can give children positive or negative feelings; children can say no, leave, and tell a trusted adult; sexual abuse is when a grown-up or older child touches the private parts of your body or asks you to touch or look at their private parts; children can problem-solve (use “3 stranger questions”) to avoid dangerous
situations with strangers; sometimes children are sexually abused by someone they know; there are many adults who can help sexually abused children so keep telling if the first adult you tell does not believe you; and sexual abuse is never the child’s fault
• Methods: video tape, discussion, and role-play, plus Spiderman and Power Pack comic book (Marvel Comics 1984) and homework handouts
• Delivery: by female mental health professional with expertise in child sexual abuse Intervention 2: child training only as per intervention 1
Intervention 3: teacher training only as per intervention 1
Control: fire or water safety programme, and wait-listed to receive the programme after follow-up testing was completed
Duration: 3 x 1-hour sessions
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): What I Know About Touching scale, a 25-item measure testing knowledge of concepts, including: definitions of sexual abuse, characteristics of abusers, who can be abused, it’s ok to say no, it’s okay to tell about abuse, and sexual abuse is not the child’s fault
Knowledge (vignette-based knowledge): What Would You Do? A video tape measure
comprising 6 x 30-second scenarios, which were not shown or discussed in the prevention programme. This outcome assessment was administered to 4 to 6 randomly selected children from each treatment group at post-test and follow-up
Disclosures: yes Harm: not reported
Other: State-Trait Anxiety Inventory for Children (STAIC) (Spielberger 1973); parent measure (adapted from Miller-Perrin 1986)
Last outcome assessment: 1-year follow-up
Notes Author contact: yes
Hazzard 1991 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “One school from each set was randomly assigned to one of four conditions” (p 125). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk “All teachers were aware that different schools were receiving different services and were told that we were evaluating the effec- tiveness of different models of sexual abuse prevention training” (pp 125-6). “Since the child prevention program was presented by professional trainers rather than teach- ers themselves, the teacher training com- ponent was not expected to have a major impact on children’s gains at post-testing. However, it was expected that if Condition 1 teachers became more knowledgeable and supportive of prevention education as a re- sult of their own training, their students might demonstrate continued increases in prevention knowledge and skills over the 6- week follow-up period” (p 126)
Blinding of outcome assessment (detection bias)
All outcomes
High risk Outcome assessments were conducted via group administration by a research assis- tant who read the scripts to participating children in each class. However, the video measure was administered at post-test and follow-up to a random sample of 4 to 6 children from each group. The video mea- sure was “administered by a trained re- search assistant to each child as an individ- ual structured interview. Interviewers were not blind to subjects’ treatment condition since schools were assigned to condition” (p 128)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition between pre- and post-test was not re- ported. However, complete data were re- ported for 103/399 at 1-year follow-up (25. 8%)
Hazzard 1991 (Continued)
Hébert 2001
Methods Design: quasi-experimental randomised Solomon 4-group design Unit of allocation: schools
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Participants: 133 1st and 3rd grade students Mean age: 7 years 2 months
Gender: 50% male; 50% female Ethnicity: not reported
Setting: 2 primary schools in Quebec City situated in middle-income areas Country: Canada
Attrition: not reported
Interventions Intervention: ESPACE child sexual abuse prevention program, “an adaptation of the widely implemented American Child Assault Prevention Program [CAPP] (Cooper 1991)” (p 508)
• Content: enhance children’s awareness of their personal rights; basic prevention concepts and skills; self assertion skills; self defence yell; children are encouraged to ask friends for help and to tell a trusted adult if abuse occurs; covers issues relating verbal and physical abuse and bullying; workshops for parents and teachers are included
• Methods: role-playing, guided discussions, behaviour modelling, and rehearsal
• Delivery: by female community workers
Control: wait-list control, scheduled to receive the programme in the next calendar year
Duration: 1 x 60- to 75-minute workshop
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): knowledge questionnaire, an 11-item measure derived from the CKAQ (Tutty 1995) and the PSQ (Saslawsky 1986) Knowledge (vignette-based knowledge): vignette measure of skills, comprising 5 video vignettes (4 depicting abuse situations; 1 non-abusive situation)
Disclosures: not reported
Harm: data on potential side effects of the programme were gathered from parents who completed the PPQ 2 weeks after programme completion
Other: children’s programme satisfaction measure; parent questionnaire adapted from the PPQ (Wurtele 1989); programme fidelity measure
Last outcome assessment: 2 months after programme completion
Notes Author contact: yes
Solomon 4-group design consisted of: group 1 treatment group (pre-test, post-test and follow-up); group 2 control group (pre-test and post-test); group 3 treatment group (post-test and follow-up only); group 4 control group (post-test only)
Hébert 2001 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Assignment of schools to conditions was determined randomly” (p 509). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. Tests for baseline imbalances were conducted. There were no significant differences be- tween intervention and control groups with respect to “exposure to prevention informa- tion prior to their participation in the pro- gram” (p 512)
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students in the same school received the same intervention. It is likely that partici- pants were not blinded to their condition. School personnel were not blinded to the conditions of children within the school as teachers received training as part of the pro- gramme
Blinding of outcome assessment (detection bias)
All outcomes
High risk “The program was delivered in class by three female community workers. Six grad- uate students were recruited as interview- ers, all of whom had extensive experience with children in school settings” (p 511). “The questionnaire was administered col- lectively in class” (p 509) meaning that out- come assessors would need to have been blinded to the condition of whole schools. This is unlikely under the circumstances. The video vignettes were watched in small groups of 4 or 5 children and questions were answered individually
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article were also reported in the results section
Kolko 1989
Methods Design: cluster-RCT
Unit of allocation: school districts Intention-to-treat analysis: no Adjustment for clustering: no
Participants Participants: 337 3rd grade students
Mean age: 8.3 years (experimental group); 8.5 years (control group)
Gender: 52% male, 48% female (experimental group); 57% male, 43% female (control group)
Ethnicity: not reported
Setting: elementary schools in Washington County, Pennsylvania Country: USA
Attrition: from enrolment to 2-week post-test 16.2%; from enrolment to 6-month fol- low-up 25.3%
Interventions Intervention: Red Flag/Green Flag programme (Williams 1980)
• Content: defining sexual abuse; differences between good and bad, touching from strangers, familiar people, and family members; prevention rules; potentially helpful adults; discussion of personal experiences, and training in prevention skills (say no, get away quickly, tell adult immediately); includes classroom training for children, a parent orientation session, and in-service training for teachers and volunteers
• Methods: use of a programme colouring book presenting concepts about abuse, and a film “Better Safe Than Sorry II” (citation not reported)
• Delivery: by trained volunteers Control: wait-list control
Duration: 2 x 45-minute sessions
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): child self report, a 25-item questionnaire comprising 4 scales (awareness, subjective disturbance, likelihood of talking, programme concepts/skills). The programme concepts/skills scale comprised 11 items derived from the programme training manual in multiple choice format
Knowledge (vignette-based knowledge): no
Disclosure: data collected from school guidance counsellor incident reports
Harm: discussed. No adverse reactions were reported by children, parents, teachers, or volunteers
Other: programme integrity monitored using a rating scale completed by volunteers Last outcome assessment: 6 months after the second classroom training session and less than 1 month before the end of the school year
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk Method of randomisation was not reported
Kolko 1989 (Continued)
Allocation concealment (selection bias) Unclear risk Method of concealment was not described. Potentially unconcealed procedure. No baseline imbalances were detected between groups. There were 6 intervention schools and only 1 control school meaning that the groups were not equivalent. Adjust- ment procedures to address these imbal- ances were not reported
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. However, it is likely that participants were not blinded to their condition. Blinding of key personnel within the school was not possible as they were involved in pro- gramme delivery
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk It was not clear if outcome assessment was administered individually to children, or in group format with the whole class. The identities of outcome assessors were not re- ported. Methods of blinding were not re- ported
Incomplete outcome data (attrition bias) All outcomes
High risk Attrition was high (as noted above). Rea- sons for attrition were not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion were reported in the results section
Krahé 2009
Krahé 2009 (Continued)
uneasy; promoting confidence in their ability to seek help
• Methods: theatrical performance
• Delivery: play performed by the Berlin Police
Intervention 2: DVD(i.e. performance captured on DVD), participants watched a filmed
performance of the theatre play as above, on DVD Control: wait-list control
Duration: 1 x 60-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): no
Knowledge (vignette-based knowledge): self protective skills, comprising 8 short scenar- ios depicting “interactions of a child with an adult where the child was uneasy about the adult’s behaviour or uncertain as to the adult’s intention” (p 324). Scenarios presented with a simple cartoon, followed by a set of up to 4 questions
Disclosures: not reported
Harm: 1 vignette assessed possible negative side effects (fear of adults) Other: no
Last outcome assessment: 30 weeks post intervention
Notes Author contact: no
Intervention 1 (LIVE) was accompanied by a 3-hour training session for teachers and a 3-hour information evening for parents
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk Schools thatwere “first to sign up for partic- ipation in the (No) Child’s Play prevention programme offered by Berlin police were randomly assigned to three conditions” (p 323). Method of randomisation was not re- ported
Allocation concealment (selection bias) Unclear risk Method of concealment was not de- scribed. Potentially unconcealed proce- dure. In terms of baseline imbalances, de- mographic characteristics of each group were not reported. Results showed that the mean knowledge scores of students in the 3 study conditions did not differ significantly at baseline
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. In- tervention schools were notblinded to their own condition by virtue of the fact that they volunteered to receive the programme or were wait-listed to receive it. Schools may or may not have been blinded to other
Krahé 2009 (Continued)
schools’ conditions, that is, they may or may nothave been aware that they were get- ting/not getting something equivalent to other groups (e.g. via correspondence with the Berlin Police). It is possible that stu- dents were blinded, but teachers were not. It is possible that teaching staff in the DVD group may have compensated for not hav- ing the live performance which may have altered results
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Group administration of the outcome as- sessment meant that outcome assessors would need to be blinded to the condition of whole schools. 4 interviewers conducted the outcome assessments. “One of them was the second author, who was not blind with regard to the hypotheses and experi- mental conditions. Half of the sessions in each school were conducted by the second author, the remaining sessions were con- ducted by the three additional interview- ers who were blind as to the hypotheses of the study and the group membership of the children they tested. In this way, the same number of sessions was run by the second author and the additional interviewers in each condition. No differences between the conditions were found in relation to differ- ent interviewers” (p 325 footnote 3)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion were reported in the results section
Kraizer 1991
Kraizer 1991 (Continued)
+ 1 additional preschool) Country: USA
Attrition: 26/670 (3.8%)
Interventions Intervention 1: “The Safe Child Program” (written by Kraizer for this PhD) for children aged 3 to 10 years. Phase 1 is teacher training; phase 2 is parent training; phase 3 is training with the children
• Content (of the child component): your body belongs to you; you have a right to say who touches you and how; if someone touches you in a way that you do not like, in a way that makes you feel funny or uncomfortable, or in a way that you think is wrong, it’s okay to say no; if the person does not stop, say “I’m going to tell”; if you have a
problem, or if something like this is happening to you, tell and keep telling until someone helps you; adults cannot read your mind, you need to communicate clearly and fully; touch should never have to be a secret. Programme also includes: prevention of abuse and abduction by strangers (as in Fryer 1987a above); prevention of physical and emotional abuse; safety in self care
• Methods: the video tape teaches concepts, skills and words. Classroom teachers use role-play and classroom activities used to “turn the concepts into skills for each child” (p 17)
• Delivery: via videotape by classroom teachers Intervention 2: the Safe Child Program (revised version) Control: wait-list control
Duration: preschool and kindergarten, 1 session per day for 10 days. 1st to 3rd grade, 1
session per day for 5 days
Outcomes Protective behaviours simulation: stranger simulation, involved staging of actual simula- tions to evaluate children’s “degree of vulnerability to abduction and abuse by strangers” (p 175)
Protective behaviours simulation: yes. Role-play, a protocol used as the “basis for measur- ing behavioural change and actual mastery of skills associated with prevention of sexual abuse... the role play measures the child’s ability and willingness to terminate unwanted touch effectively and appropriately in the face of flattery, emotional coercion, rejection, bribery, and secrecy” (p 29)
Knowledge (questionnaire-based knowledge): Children Need to Know Knowledge At-
titude Test, comprising a 20-item self report instrument “measuring a child’s cognitive awareness, understanding and attitudes” (p 31)
Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported
Other: Battle Culture Free Self Esteem Inventory (Battle 1981); The Children’s Nowicki- Strickland Internal External Locus of Control Inventory (Nowicki 1973); self care sim- ulation; Teacher Knowledge/Attitude Questionnaire and Demographics Sheet; Teacher Questionnaire
Last outcome assessment: 6 months after the programme
Notes Author contact: yes
An overview of this study is reported in Kraizer 1989
Risk of bias
Kraizer 1991 (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk Method of randomisation was not reported
Allocation concealment (selection bias) High risk Method of concealment was not reported. Potentially unconcealed procedure. The following statement: “student samples were selected, in cooperation with school offi- cials, to meet the following research objec- tives and criteria...” (p 27) indicates there was not adequate allocation concealment and therefore high risk of bias
Blinding of participants and personnel (performance bias)
All outcomes
High risk Teachers, as key personnel, could not have
been blinded to group allocation as they de- livered the video tape intervention. It is not clear if children from the same school were allocated to treatment and control groups as this detail is not reported
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “Role-plays were conducted by a research team member trained in child development and the prevention of child abuse who was not associated with the prevention pro- gram being conducted in the school” (p.30)
. “Scoring was completed by an observer via
contemporaneous video monitoring rather than the person conducting the role-play” (p 30). It is not clear if these outcome asses- sors were blinded to study condition and hypotheses
Incomplete outcome data (attrition bias) All outcomes
Low risk Attrition for the study overall was reported as 3.8% and was attributed to student with- drawals or exclusions or both. Attrition was not specified for intervention and control groups
Selective reporting (reporting bias) High risk Not all measures discussed in the methods section of the article were also reported in the results. Means and SDs for knowledge outcomes were measured but not reported
Lee 1998
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 77 female students attending schools for children with mental
retardation
Mean age: 13.44 years
Gender: 0% male; 100% female
Ethnicity: 100% Chinese
Setting: 4 special schools in Hong Kong Country: China
Attrition: 6.3%
Interventions Intervention: Behavioral Skills Training Program (Wurtele 1990) encompassing 7 safety rules, 1 personal body safety rule, and 4 self protection skills
• Content: we are the bosses of our bodies; the locations of “private parts”; touching your own private parts is acceptable when done in private; it is appropriate for doctors, nurses, or parents to touch children’s private parts for health or hygiene reasons; otherwise, it is not okay to have private parts touched or looked at by a bigger person;
it is wrong to be forced to touch a bigger person’s private parts; a bigger person’s inappropriate touching of a child’s private parts is never the child’s fault; personal body safety rule “It’s not okay for a bigger person to touch or look at my private parts” (unless they need help as in situations when their private parts get hurt)
• Methods: “taught via instruction, modelling, behavioral rehearsal (practice), shaping, social reinforcement, and feedback” (p 109)
• Delivery: by the first author
Control: Attention Control Program (Wurtele 1992) covering safety skills unrelated to
sexual abuse
Duration: 2 x 45-minute sessions on consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (Wurtele 1990) comprising 15 items covering personal safety and 3 control questions Knowledge (vignette-based knowledge): What If Situations Test (Wurtele 1990) com- prising 6 brief vignettes (3 appropriate and 3 inappropriate touch requests)
Disclosure: not reported
Harm: discussed. Lower levels of fear reported at 2-month follow-up compared with pre-test and post-test
Other: baseline assessment of intellectual ability using Raven’s Standard Progressive Ma- trices (Raven 1960); Fear Assessment Thermometer Scale (Wurtele 1986b), 12 items collecting data on fear of objects, people and situations
Last outcome assessment: 2 months after programme implementation
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Lee 1998 (Continued)
Random sequence generation (selection bias)
Unclear risk “The 72 completers were randomly as- signed to either the treatment (n = 38) or control group (n = 34)” (p 107). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Low risk “To control for intergroup contamination, we assigned participants from the same school to the same program. Both programs were led by the first author, who read from narrative scripts with pictures as visual aids” (p 108). Blinding of school personnel (e.g. teachers) would not be possible under the circumstances. Analysis of baseline data in- dicated no significant differences between groups on outcome measures, intellectual ability, or age
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk All outcome assessments were individually administered “by one of three female inter- viewers, who read the questions aloud in a standardized format and recorded the par- ticipants’ exact responses” (p 108). Base- line assessment of intellectual ability was administered to groups of 8 to 10. Mea- sures used to blind outcome assessors were not reported
Incomplete outcome data (attrition bias) All outcomes
Low risk Attrition was reported as 2/38 (5.3%) for the intervention group and 3/34 (8.8%) for the control group (p 109). Reasons for at- trition were failure to attend the interven- tion programme after pre-testing or failing to take part in the post-test
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the paper were also discussed in the results
Oldfield 1996
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 1269 1st to 6th grade students
Mean age: not reported
Gender: 47% male; 53 % female
Ethnicity: 86% Caucasian; 7% African American; 3% Hispanic; 3% Asian American;
1% Native American
Setting: 4 public schools in a Midwestern city Country: USA
Attrition: not reported
Interventions Intervention: Project TRUST (Anderson 1990)
• Content: the touch continuum (nurturing, confusing, exploitative); the right to question or refuse exploitative touch; the way to say “no” to uncomfortable situations; the fact that perpetrators can be either people you know or strangers
• Method: an optional pre-play discussion; a 30-minute play comprising vignettes covering prevention topics; and a 15-minute post-play discussion and question/ response period
• Delivery: pre-play discussion by teachers; play by trained performers; post-play discussion by Project TRUST facilitators and play performers
Control: wait-list control, received the programme after all data were collected Duration: 1 x 45-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Children’s Knowledge of Abuse Question- naire-Revised (CKAQ-R) (Tutty 1995) comprising 33 true/false items
Knowledge (vignette-based knowledge): no
Disclosure: Maltreatment Disclosure Report Form was used to record information about student disclosures (date, type of disclosure, nature of the report, student age, gender, race, and socioeconomic status)
Harm: discussed. No significant difference in anxiety between intervention and control groups
Other: Revised Children’s Manifest Anxiety Scale (RCMAS) (Reynolds 1985), a 37- item self report anxiety measure for children in grades 1 to 3; The State-Trait Anxiety Inventory for Children (STAIC) (Spielberger 1973) a 20-item self report measure for children in grades 4 to 6
Last outcome assessment: within 2 days after viewing the play
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Classrooms at each grade level were ran- domly assigned to the treatment or control
Oldfield 1996 (Continued)
conditions” (p 822). Method of randomi- sation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions. There was a possibility of treatment-control con- tamination of information transmitted in- formally throughout the school. School personnel did not appear to be blinded to group or class membership so there is risk of differential treatment of groups
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “Data were collected by assigned evalua- tors from subjects in both treatment and control groups on the same day... All data were collected in a blind assessment format with the evaluators unaware of which class- rooms were assigned to treatment or con- trol conditions” (p 824). Outcome assess- ments were administered in group format in classrooms
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition not was reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the paper were also discussed in the results
Poche 1988
Poche 1988 (Continued)
Interventions Intervention 1: videotape only
• Content: several child abduction scenes in which adults approach children in a friendly manner and entice them; child actors demonstrate 2 safety rules (no further detail reported)
• Methods: videotape presentation; questioning children for responses; direct articulation of child actors’ strategies; feedback about correct responses; guiding of viewer’s attention; praise for correct responses; and using the child’s viewpoint Intervention 2 (videotape plus behaviour rehearsal): as above with the addition of be-
haviour rehearsal conducted in the classroom with a trainer playing the role of a friendly abductor
• Delivery: by police officer
Intervention 3 (standard programme): a presentation of 2 safety rules, discussion of
several abduction situations, and a brief film on personal safety
Control: wait-list control, who received the programme at the end of the study Duration: video only (25 minutes); videotape plus behaviour rehearsal (45 minutes); standard programme (60 minutes)
Outcomes Protective behaviours simulation: yes. Staging of scenarios in which an adult male (a doctoral student) “posed as a potential abductor, approached each child in a friendly manner, and attempted to entice the child to go with him. The child’s responses (verbal and motor) to the enticements were directly observed and recorded on a data sheet” (p 256). At follow-up the simulation was conducted in an identical manner, at or near the child’s home (with parental permission)
Knowledge (questionnaire-based knowledge): no Knowledge (vignette-based knowledge): no Disclosures: not reported
Harm: not reported Other: no
Last outcome assessment: 1 month after training
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Each kindergarten and each first-grade class were randomly assigned to one of four conditions” (p 257). Method of randomi- sation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions there- fore there was a possibility of treatment-
Poche 1988 (Continued)
control contamination. It was not possi- ble for school personnel (e.g. teachers) to be blinded to the study condition of their classes
Blinding of outcome assessment (detection bias)
All outcomes
Low risk “The adult portraying an abductor served as the primary observer and recorded each child’s verbal and motor responses as soon as the simulation was over. This observer was blind to the experimental condition of each subject” (p 257). Another adult “served as a reliability observer” (p 257). Agreement between the two observers was 100% (total reliability)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Attrition between pre- and post-test was not reported. At 1-month follow-up, only 23/74 children (31%) met the criteria for outcome assessment (pp 256-7). Of these only 9 were available to partake (12%). Reasons for attrition were “summer vaca- tions, disconnected phones, illnesses and accidents” (p 257)
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the paper were also discussed in the results
Saslawsky 1986
Saslawsky 1986 (Continued)
knowledge gained, and review of key messages
• Delivery: by female graduate student
Control: discussion about self concept and personal values with no mention of sexual
abuse
Duration: 1 x 50-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ), a 15-item measure with 2 practice questions and 13 personal safety questions covering topics typically taught in child sexual abuse prevention programmes
Knowledge (vignette-based knowledge): What If Situations Test (WIST), comprising 6 hypothetical situations (2 non-threatening and 4 threatening situations) after which children respond to a standard list of 4 questions
Disclosure: not reported Harm: not reported Other: no
Last outcome assessment: 3 months post intervention
Notes Author contact: yes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Subjects in schools A and B were assigned randomly, balanced for sex and grade, to one of two conditions” (p 240). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions there- fore there was a possibility of treatment- control contamination. It was not possi- ble for school personnel (e.g. teachers) to be blinded to the study condition of their classes
Blinding of outcome assessment (detection bias)
All outcomes
Low risk Research assistants conducted the outcome assessments. They were blind to each child’s group assignment (p 240). PSQ was ad- ministered in group format to children in classes. WIST was individually adminis- tered to children in an interview format
Saslawsky 1986 (Continued)
Snyder 1986
Methods Design: quasi-experimental Solomon 4-group design Unit of allocation: classes
Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 177 4th grade students
Mean age: 9.6 years
Gender: 40.7% male; 49.3% female
Ethnicity: 97% White; 3% Black, Asian, Hispanic-American, Other Setting: 7 elementary schools in Erie county, Pennsylvania
Country: USA
Attrition: 8/177 (4.5%)
Interventions Intervention: “Good Secrets, Bad Secrets” (citation not reported) sexual abuse prevention programme
• Content: general safety; distinguishing appropriate and inappropriate touching; assertiveness; help seeking and action planning
• Methods: role-plays; discussions; story-like situations
• Delivery: by a sexual assault counsellor trained in delivering the programme Control: students played hangman between pre-test and post-test, and were wait-listed to receive the programme
Duration: 1 x 45-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Good Secrets Bad Secrets Quiz, a 35-item covering general safety skills, distinguishing appropriate touching from sexual touching, knowing sexual touches can come from known people, recognising assertive responses for dealing with persuasive adults, recognising how to obtain help in an assault situation, recognising the appropriate course of action for dealing with a potentially dangerous situation. Criterion referenced standard of 80% was applied
Knowledge (vignette-based knowledge): no
Disclosures: not reported Harm: not reported Other: no
Last outcome assessment: 1-day post intervention
Notes Author contact: no
Risk of bias
Snyder 1986 (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Low risk “A coin was tossed to determine group as- signments” (p 45). No other information was provided
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Low risk Blinding procedures were not reported. Children may not have been blinded to their condition. Blinding of key personnel (e.g. teachers) may not have been possible in the school delivery context. The pro- gramme and testing were conducted on the same day in an attempt to control for con- tamination effects
Blinding of outcome assessment (detection bias)
All outcomes
High risk Group administration of outcome assess- ment meant that outcome assessors would have to be blinded to the condition of entire classes. This was not possible as outcome assessors were also programme presenters
Incomplete outcome data (attrition bias) All outcomes
Low risk Missing data were noted for 8/177 partic- ipants (4.5%) owing to parental omissions on the child data sheet. Attrition from the study is not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion were also reported in the results sec- tion
Tutty 1997
Tutty 1997 (Continued)
Interventions Intervention: “Who Do You Tell” programme developed by the Calgary Sexual Assault Centre in 1983 (citation not reported)
• Content: prevention concepts; giving information; permission to say no to unwanted touch; whether children should be suspicious of all touches or adults; also included are a parent information evening and a teacher in-service workshop
• Methods: discussion, pictures, short videos, and role-plays. Following presentations, children are given opportunity to talk individually to the presenters
• Delivery: by 2 trainers Control: wait-list control
Duration: 2 x 45- to 60-minute sessions on consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Children’s Knowledge of Abuse Question- naire-Revised (CKAQ-R) (Tutty 1995) comprising 9-item Appropriate Touch subscale, and 24-item Inappropriate Touch subscale (33 items in all) testing concepts taught in the programme
Knowledge (vignette-based knowledge): no Disclosure: not reported
Harm: parent questionnaire gathered data on children’s reactions to the programme Other: no
Last outcome assessment: “shortly after” programme completion (p 284)
Notes Author contact: yes, no reply
Secondary analysis comparing younger (5 to 7 years) and older children (8 to 13 years) was presented in Tutty 2000
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Children
were randomly assigned (matched by age) to participate in the program (N = 117) or in a wait-list control condition (N = 114)” (p 869). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not reported.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
High risk Blinding procedures were not reported. Students within the same school were re- ceiving the intervention or participating in the wait-listed control group. There is risk of treatment-control contamination ef- fects. It is likely that children were not blinded to their condition. Teachers par- ticipated in a training workshop, therefore
Tutty 1997 (Continued)
Wolfe 1986
Methods Design: cluster-RCT
Unit of allocation: classrooms Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 290 students (214 4th grade and 76 5th grade students)
Mean age: 10.3 years
Gender: 49% male; 51% female Ethnicity: not reported
Setting: 3 public schools comprising children from middle- and lower-income families in the central area of a Southeastern city
Country: USA Attrition: not reported
Interventions Intervention: 2 x 5-minute plays written and performed by volunteer medical students who consulted with child abuse specialists
• Content: 5 themes: abuse can be perpetrated by someone you love and trust; feelings generated in such circumstances; importance of telling someone, even if unsure of what is happening; abuse is not your fault; and getting help right away is the best way to respond
• Methods: theatrical skits depict “a child at school who was upset about (abusive) events that had happened at home on the previous evening” (p 88); followed by 1-hour discussion
• Delivery: by volunteer medical students who consulted with a child abuse specialist
Control: wait-list control
Duration: 1 x 70-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): a brief 10-item true/false questionnaire focusing on programme objectives
Wolfe 1986 (Continued)
Knowledge (vignette-based knowledge): no Disclosure: not reported
Harm: not reported Other: no
Last outcome assessment: 3 to 5 days following the presentation
Notes Author contact: yes, no reply
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “The 12 classrooms participating in the study were randomly assigned to a control or treatment condition” (p 88). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. It is not known whether whole schools were allocated to conditions or whether schools comprised classes allocated to both treat- ment and control conditions. The latter presents a higher risk of treatment-control contamination
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk Method of assessment (group or individ- ual administration) was not specified. The measures used to blind outcome assessors from knowledge of group membership was not reported
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition was not reported
Selective reporting (reporting bias) High risk “Three items were dropped from the final questionnaire due to their inability to con- tribute to the validity of the measure” (p 89)
, therefore outcome data for only 7 ques- tionnaire items are reported
Wurtele 1986
Methods Design: RCT
Unit of allocation: individuals Intention-to-treat analysis: no Adjustment for clustering: no
Participants Total number randomised: 71 students (28 kindergarten and 1st grade students and 43
5th and 6th grade students) Mean age: 6.1 years; 11.0 years
Gender: 50% male; 50% female Ethnicity: not reported
Setting: 1 public school serving a lower to middle class population in a small rural town in eastern Washington
Country: USA Attrition: not reported
Interventions Intervention 1: 35-minute film entitled ”Touch“ (Illusion Theater Company 1984)
• Content: 4 body safety rules (saying ”No¡‘; yelling for help; getting away; telling someone and keep telling until someone believes you)
• Methods: film, 15-minute discussion, review
• Delivery: by female graduate student
Intervention 2: Body Safety Training (BST) (Wurtele 1986a)
• Content: 3 specific self protective skills (being able to identify the location of one’s ”private parts; knowing when it is “okay” or “not okay” to have their private parts touched; developing verbal responses (e.g. saying “No!” in a big voice) and motoric
responses (e.g. getting away, telling someone) in potential abuse situations. Methods: “instruction, modelling, rehearsal, social reinforcement, shaping and feedback” (p 690)
. Group mastery of skills was also a feature
• Delivery: by a female graduate student
Intervention 3: combined group (film and BST). Children viewed the “Touch” film
followed by a shortened discussion led by the first graduate student and a shortened version of the BST led by the second graduate student
Control: 50-minute discussion of self concept and personal values with no sexual abuse content
Duration: groups 1 and 2: 1 x 50-minute session; group 3: 1 x 60-minute session
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Personal Safety Questionnaire (PSQ), a 15-item measure with 2 practice questions and 13 personal safety questions covering topics typically taught in child sexual abuse prevention programmes
Knowledge (vignette-based knowledge): What If Situations Test (WIST), comprising 6 hypothetical situations (2 non-threatening and 4 threatening situations) after which children respond to a standard list of 4 questions
Disclosure: not reported Harm: not reported Other: no
Last outcome assessment: 3 months later
Notes Author contact: yes
Children gave verbal and written consent for their participation in the study
Wurtele 1986 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “Subjects were randomly assigned, in bal- anced numbers for sex and grade, to one of four experimental conditions” (p 689). Method of randomisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. Students within 1 school were receiving treatment and control conditions there- fore there was a possibility of treatment- control contamination. It was not possi- ble for school personnel (e.g. teachers) to be blinded to the study condition of their classes
Blinding of outcome assessment (detection bias)
All outcomes
Low risk PSQ was administered in group format to children in classes. WIST was individually administered to children in an interview format. Interviewers “were unaware of each child’s group assignment” (p 690)
Incomplete outcome data (attrition bias) All outcomes
Unclear risk Missing data were not reported. Attrition was not reported
Selective reporting (reporting bias) Low risk All measures discussed in the methods sec- tion of the article are reported in the results
e en-Ero ul 2013 (Continued)
Interventions Intervention: “Preventing child sexual abuse psycho-educational training program” (p 727) based on the Good Touch Bad Touch (GTBT) program (Childhelp 2011) adapted for the Turkish culture
• Content: my body belongs to me; discriminating good touch/bad touch; promises; body safety rules; saying No; secrets; talking with adults; and abuse is never a child’s fault
• Methods: video, lecture, role-play, modelling, rehearsal
• Delivery: not reported Control: no programme
Duration: 4 x 60-minute sessions on consecutive days
Outcomes Protective behaviours simulation: no
Knowledge (questionnaire-based knowledge): Good Touch Bad Touch Curriculum Test (Church 1988), a 10-item measure covering touch differentiation, knowledge of coping with sexual abuse and application to situations. Response options correct, incorrect, don’t know. In this study test/retest reliability (0.80) and internal consistency (0.78) Knowledge (vignette-based knowledge): no
Disclosure: not reported Harm: not reported Other: no
Last outcome assessment: 8 weeks after post-test
Notes Author contact: pending
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection bias)
Unclear risk “The subjects consisted of 36 fourth grade students; 18 randomly assigned to the ex- perimental and 18 randomly to the control group” (p 725, abstract). Method of ran- domisation was not reported
Allocation concealment (selection bias) Unclear risk Method of concealment was not described.
Potentially unconcealed procedure
Blinding of participants and personnel (performance bias)
All outcomes
Unclear risk Blinding procedures were not reported. It was not clear if some students within a single school participated the intervention while others received no intervention. This would increase the risk of contamination
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk Method of assessment (group or individ- ual administration) was not specified. The measures used to blind outcome assessors from knowledge of group membership was not reported
e en-Ero ul 2013 (Continued)
ANCOVA: analysis of covariance
CKAQ: Children’s Knowledge of Abuse Questionnaire CSA: child sexual abuse
RCT: randomised controlled trial
PPQ: Parental Perception Questionnaire PSQ: Personal Safety Questionnaire WIST: What If Situations Test
WLC: wait list control
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Ages 1991 Pre-test and post-test study. No control group
Alexander 1998 Post-test only study. No control group. No random allocation of students or classes to groups
Araji 1995 Pre-test and post-test study. No control group
Bae 2009 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Baker 2013 Quasi-experimental study. No random allocation of students or classes to groups
Baker 2014 Intervention is about sexual violence in peer dating relationships. Quasi-experimental study. No random allocation of students or classes to groups
Barron 2013 Quasi-experimental study. No random allocation of students or classes to groups
Binder 1987a Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Bodzy 1988 Controlled before-and-after study. No random allocation of students or classes to groups
Boyle 2005 Not school-based
Briggs 1994 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Briggs 1996 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
(Continued)
Casper 1999 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Conte 1985 Not school-based
Counts 2003 Controlled before-and-after study. No random allocation of students or classes to groups Students’ results selected randomly from an archival pool
Currier 1996 Comparative group design (abused versus non-abused children). Not school-based
Deretzotes 1989 Quasi-experimental study. No random allocation of students or classes to groups
Dhooper 1995 Controlled before-and-after study. No random allocation of students or classes to groups
Foshee 1996 Intervention is about dating and relationship violence prevention. Reports baseline findings for Foshee 1998
Foshee 1998 Intervention is about dating and relationship violence prevention. This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Garbarino 1987 Post-test only study. No control group
Herman 1987 Pre-test and post-test with multiple baseline study. No control group. No random allocation of students or classes to groups
Jacobs 1995 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Johnson 1994 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Johnson 2006 Intervention is about abduction prevention. Not school-based
Kernsmith 2011 Intervention is about rape and sexual relationship victimisation prevention. Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Kindt 1995 Controlled before-and-after study. No random allocation of students or classes to groups
Kolko 1987 Controlled before-and-after study. No random allocation of students or classes to groups
MacIntyre 1999a Controlled before-and-after study. No random allocation of students or classes to groups
MacIntyre 1999b Cross-sectional comparative study
Madak 1992 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Martin 2012 Intervention is about coercive sexual relationships prevention. Controlled before-and-after study. No random allocation of students or classes to groups
(Continued)
Michaelson 2001 Controlled before-and-after study + Solomon 4-group design. No random allocation of students or classes to groups
Miller 2011 Intervention is about sexual violence prevention in the context of partner relationships
This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Miller 2012 Intervention is about sexual violence prevention in the context of partner relationships
This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Miller 2013 Intervention is about sexual violence prevention in the context of partner relationships
This study provides follow-up data for Miller 2012, which is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Moreno-Manso 2014 Intervention is about prevention of physical neglect and emotional abuse (i.e. broader focus than prevention of child sexual abuse). Quasi-experimental study. No random allocation of students or classes to groups
Ogunfowokan 2012 Participants outside age criteria (13 to 24 years of age)
Pacifici 2001 Intervention is about coercive sexual relationships prevention. This study is included in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013)
Peraino 1990 Not school-based (preschool)
Pohl 1990 Post-test only design. No control group. No random allocation of students or classes to groups
Smothers 2011 Pre-test and post-test study. No control group. No random allocation of students or classes to groups
Taal 1997 Controlled before-and-after study. No random allocation of students or classes to groups
Taylor 1991 Post-test only design. No random allocation of students or classes to groups
Taylor 2010a Intervention is about gender violence and harassment. This study was excluded in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013) on the basis of participant age
Taylor 2010b Intervention is about gender violence and harassment. This study was excluded in the Cochrane Review of Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults (Fellmeth 2013) on the basis of participant age
Telljohann 1997 Controlled before-and-after study. No random allocation of students or classes to groups
Tutty 1991 Quasi-experimental study. No random allocation of students or classes to groups
(Continued)
RCT: randomised controlled trial
Characteristics of ongoing studies [ordered by study ID]
NCT02181647
D A T A A N D A N A L Y S E S
Comparison 1. Protective behaviours
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Protective behaviours, no correction for clustering
2 102 Odds Ratio (M-H, Random, 95% CI) 5.71 [1.98, 16.51]
2 Protective behaviours, ICC=0.1 2 102 Odds Ratio (Random, 95% CI) 5.43 [1.88, 15.65]
3 Protective behaviours, ICC=0.2 2 102 Odds Ratio (Random, 95% CI) 5.16 [1.81, 14.70]
Comparison 2. Knowledge
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Questionnaire-based knowledge, no correction for clustering
2 Questionnaire-based knowledge,
ICC = 0.1
3 Questionnaire-based knowledge,
ICC = 0.2
4 Vignette-based knowledge, no correction for clustering
5 Vignette-based knowledge, ICC
= 0.1
6 Vignette-based knowledge, ICC
= 0.2
18 4657 Std. Mean Difference (IV, Random, 95% CI) 0.61 [0.45, 0.78]
18 Std. Mean Difference (Random, 95% CI) 0.66 [0.51, 0.81]
18 Std. Mean Difference (Random, 95% CI) 0.63 [0.50, 0.77]
11 1688 Std. Mean Difference (IV, Random, 95% CI) 0.45 [0.24, 0.65]
11 Std. Mean Difference (Random, 95% CI) 0.53 [0.32, 0.74]
11 Std. Mean Difference (Random, 95% CI) 0.60 [0.31, 0.89]
Comparison 3. Retention over time
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Questionnaire-based knowledge, no correction for clustering
1.1 Questionnaire-based knowledge (post-test)
1.2 Questionnaire-based knowledge (follow-up)
2 Questionnaire-based knowledge,
ICC = 0.1
4 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
4 956 Std. Mean Difference (IV, Random, 95% CI) 0.78 [0.38, 1.17]
4 929 Std. Mean Difference (IV, Random, 95% CI) 0.69 [0.51, 0.87]
4 Std. Mean Difference (Random, 95% CI) Subtotals only
2.1 Questionnaire-based knowledge (post-test) 4 Std. Mean Difference (Random, 95% CI) 0.86 [0.53, 1.20]
2.2 Questionnaire-based
knowledge (follow-up) 4 Std. Mean Difference (Random, 95% CI) 0.73 [0.41, 1.06]
3 Questionnaire-based knowledge,
ICC = 0.2 4 Std. Mean Difference (Random, 95% CI) Subtotals only
3.1 Questionnaire-based
knowledge (post-test) 4 Std. Mean Difference (Random, 95% CI) 0.86 [0.53, 1.20]
3.2 Questionnaire-based
knowledge (follow-up) 4 Std. Mean Difference (Random, 95% CI) 0.72 [0.32, 1.11]
Comparison 4. Harm
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Harm, no correction for clustering
3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
1.1 Anxiety or fear 3 795 Std. Mean Difference (IV, Random, 95% CI) -0.08 [-0.22, 0.07] 2 Harm, ICC=0.1 3 Std. Mean Difference (Random, 95% CI) Subtotals only
2.1 Anxiety or fear 3 Std. Mean Difference (Random, 95% CI) -0.04 [-0.42, 0.33] 3 Harm, ICC=0.2 3 Std. Mean Difference (Random, 95% CI) Subtotals only
3.1 Anxiety or fear 3 Std. Mean Difference (Random, 95% CI) -0.03 [-0.46, 0.40]
Comparison 5. Disclosures
Outcome or subgroup title
No. of studies
No. of
participants Statistical method Effect size
1 Disclosures, no correction for clustering
3 1788 Odds Ratio (M-H, Random, 95% CI) 3.56 [1.13, 11.24]
2 Disclosures, ICC=0.1 3 1788 Odds Ratio (Random, 95% CI) 3.04 [0.75, 12.33]
3 Disclosures, ICC=0.2 3 1788 Odds Ratio (Random, 95% CI) 2.95 [0.69, 12.61]
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Analysis 1.1. Comparison 1 Protective behaviours, Outcome 1 Protective behaviours, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 1 Protective behaviours
Outcome: 1 Protective behaviours, no correction for clustering
Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Fryer 1987a 18/23 11/21 48.5 % 3.27 [ 0.88, 12.12 ]
Poche 1988 29/38 5/20 51.5 % 9.67 [ 2.75, 34.03 ]
Total (95% CI) 61 41 100.0 % 5.71 [ 1.98, 16.51 ]
Total events: 47 (Intervention), 16 (Control)
Heterogeneity: Tau2 = 0.16; Chi2 = 1.37, df = 1 (P = 0.24); I2 =27% Test for overall effect: Z = 3.22 (P = 0.0013)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours control Favours intervention
Analysis 1.2. Comparison 1 Protective behaviours, Outcome 2 Protective behaviours, ICC=0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 1 Protective behaviours
Outcome: 2 Protective behaviours, ICC=0.1
Study or subgroup Intervention Control log [Odds Ratio] Odds Ratio Weight Odds Ratio N N (SE) IV,Random,95% CI IV,Random,95% CI
Fryer 1987a 23 21 1.1856 (0.6682) 53.3 % 3.27 [ 0.88, 12.12 ]
Poche 1988 38 20 2.2687 (0.7236) 46.7 % 9.67 [ 2.34, 39.92 ]
Total (95% CI) 61 41 100.0 % 5.43 [ 1.88, 15.65 ]
Heterogeneity: Tau2 = 0.10; Chi2 = 1.21, df = 1 (P = 0.27); I2 =17% Test for overall effect: Z = 3.13 (P = 0.0017)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours control Favours intervention
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Analysis 1.3. Comparison 1 Protective behaviours, Outcome 3 Protective behaviours, ICC=0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 1 Protective behaviours
Outcome: 3 Protective behaviours, ICC=0.2
S 4
Analysis 2.1. Comparison 2 Knowledge, Outcome 1 Questionnaire-based knowledge, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 1 Questionnaire-based knowledge, no correction for clustering
Std. Mean
Std. Mean
e en-Ero ul 2013
Heterogeneity: Tau2 = 0.10; Chi2 = 104.76, df = 17 (P<0.00001); I2 =84% Test for overall effect: Z = 7.26 (P < 0.00001)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 2.2. Comparison 2 Knowledge, Outcome 2 Questionnaire-based knowledge, ICC = 0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 2 Questionnaire-based knowledge, ICC = 0.1
Std. Mean Difference
Std. Mean
Std. Mean
e en-Ero ul 2013
Total (95% CI) 100.0 % 0.66 [ 0.51, 0.81 ]
Heterogeneity: Tau2 = 0.02; Chi2 = 22.19, df = 17 (P = 0.18); I2 =23% Test for overall effect: Z = 8.47 (P < 0.00001)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 2.3. Comparison 2 Knowledge, Outcome 3 Questionnaire-based knowledge, ICC = 0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 3 Questionnaire-based knowledge, ICC = 0.2
Std. Mean Difference
Std. Mean
Std. Mean
e en-Ero ul 2013
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Analysis 2.4. Comparison 2 Knowledge, Outcome 4 Vignette-based knowledge, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 4 Vignette-based knowledge, no correction for clustering
S 8
C
Analysis 2.5. Comparison 2 Knowledge, Outcome 5 Vignette-based knowledge, ICC = 0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 5 Vignette-based knowledge, ICC = 0.1
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
Blumberg 1991 0.13572133 (0.4091979) 6.7 % 0.14 [ -0.67, 0.94 ]
Chen 2012 0.70577457 (0.30475898) 12.1 % 0.71 [ 0.11, 1.30 ]
Daigneault 2012 0.09314352 (0.4624079) 5.3 % 0.09 [ -0.81, 1.00 ]
Grendel 1991 0.6075004 (0.52561535) 4.1 % 0.61 [ -0.42, 1.64 ]
Hazzard 1991 0.17045685 (0.26459481) 16.1 % 0.17 [ -0.35, 0.69 ]
H bert 2001 1.11872408 (0.7808566) 1.8 % 1.12 [ -0.41, 2.65 ]
Kolko 1989 0.33231604 (0.81308542) 1.7 % 0.33 [ -1.26, 1.93 ]
Krah 2009 0.13799652 (1.02000413) 1.1 % 0.14 [ -1.86, 2.14 ]
Lee 1998 0.91724207 (0.24881393) 18.2 % 0.92 [ 0.43, 1.40 ]
Saslawsky 1986 0.60571515 (0.25024759) 18.0 % 0.61 [ 0.12, 1.10 ]
Wurtele 1986 0.48110613 (0.27595157) 14.8 % 0.48 [ -0.06, 1.02 ]
Total (95% CI) 100.0 % 0.53 [ 0.32, 0.74 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 7.34, df = 10 (P = 0.69); I2 =0.0% Test for overall effect: Z = 4.96 (P < 0.00001)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 2.6. Comparison 2 Knowledge, Outcome 6 Vignette-based knowledge, ICC = 0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 2 Knowledge
Outcome: 6 Vignette-based knowledge, ICC = 0.2
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
Blumberg 1991 0.13572133 (0.6819965) 3.9 % 0.14 [ -1.20, 1.47 ]
Chen 2012 0.70577457 (0.30475898) 11.3 % 0.71 [ 0.11, 1.30 ]
Daigneault 2012 0.09314352 (0.7653648) 3.2 % 0.09 [ -1.41, 1.59 ]
Grendel 1991 0.6075004 (0.50513683) 6.2 % 0.61 [ -0.38, 1.60 ]
Hazzard 1991 0.17045685 (0.11127819) 19.0 % 0.17 [ -0.05, 0.39 ]
H bert 2001 1.11872408 (0.19400164) 15.6 % 1.12 [ 0.74, 1.50 ]
Kolko 1989 0.33231604 (1.28106706) 1.3 % 0.33 [ -2.18, 2.84 ]
Krah 2009 0.13799652 (1.8651504) 0.6 % 0.14 [ -3.52, 3.79 ]
Lee 1998 0.91724207 (0.24881393) 13.3 % 0.92 [ 0.43, 1.40 ]
Saslawsky 1986 0.60571515 (0.25024759) 13.3 % 0.61 [ 0.12, 1.10 ]
Wurtele 1986 0.48110613 (0.27595157) 12.3 % 0.48 [ -0.06, 1.02 ]
Total (95% CI) 100.0 % 0.60 [ 0.31, 0.89 ]
Heterogeneity: Tau2 = 0.10; Chi2 = 23.05, df = 10 (P = 0.01); I2 =57% Test for overall effect: Z = 4.03 (P = 0.000057)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
Favours control Favours intervention
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Analysis 3.1. Comparison 3 Retention over time, Outcome 1 Questionnaire-based knowledge, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 3 Retention over time
Outcome: 1 Questionnaire-based knowledge, no correction for clustering
Study or subgroup Intervention Control
Std. Mean
Difference Weight
Std. Mean Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Questionnaire-based knowledge (post-test)
Dawson 1987 96 78.75 (18.71) 141 64.68 (18.58) 26.8 % 0.75 [ 0.48, 1.02 ]
Hazzard 1991 286 20.6 (3.67) 113 15.4 (5.18) 27.6 % 1.25 [ 1.02, 1.48 ]
Kolko 1989 213 12.4 (2.4) 35 11.5 (2.1) 24.4 % 0.38 [ 0.02, 0.74 ]
Lee 1998 38 8.97 (1.82) 34 7.79 (1.77) 21.2 % 0.65 [ 0.17, 1.13 ]
Subtotal (95% CI) 633 323 100.0 % 0.78 [ 0.38, 1.17 ]
Heterogeneity: Tau2 = 0.13; Chi2 = 18.77, df = 3 (P = 0.00030); I2 =84% Test for overall effect: Z = 3.84 (P = 0.00012)
2 Questionnaire-based knowledge (follow-up)
Dawson 1987 96 77.29 (19.17) 141 63.76 (20.37) 31.2 % 0.68 [ 0.41, 0.94 ]
Hazzard 1991 286 20.5 (4.19) 113 16.7 (5.17) 38.6 % 0.85 [ 0.62, 1.07 ]
Kolko 1989 191 12 (2.3) 30 11.1 (2.1) 17.8 % 0.39 [ 0.01, 0.78 ]
Lee 1998 38 9.03 (1.98) 34 7.71 (1.8) 12.4 % 0.69 [ 0.21, 1.17 ]
Subtotal (95% CI) 611 318 100.0 % 0.69 [ 0.51, 0.87 ]
Heterogeneity: Tau2 = 0.01; Chi2 = 4.00, df = 3 (P = 0.26); I2 =25% Test for overall effect: Z = 7.55 (P < 0.00001)
-2 -1 0
1 2
Favours control Favours intervention
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Analysis 3.2. Comparison 3 Retention over time, Outcome 2 Questionnaire-based knowledge, ICC = 0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 3 Retention over time
Outcome: 2 Questionnaire-based knowledge, ICC = 0.1
S 2
C
Analysis 3.3. Comparison 3 Retention over time, Outcome 3 Questionnaire-based knowledge, ICC = 0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 3 Retention over time
Outcome: 3 Questionnaire-based knowledge, ICC = 0.2
Std. Mean Difference
Study or subgroup (SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
1 Questionnaire-based knowledge (post-test)
Dawson 1987 0.75271304 (0.48349098) 12.3 % 0.75 [ -0.19, 1.70 ]
Hazzard 1991 1.25004636 (0.28457694) 35.2 % 1.25 [ 0.69, 1.81 ]
Kolko 1989 0.38006195 (0.81393081) 4.4 % 0.38 [ -1.22, 1.98 ]
Lee 1998 0.64973314 (0.24254667) 48.2 % 0.65 [ 0.17, 1.13 ]
Subtotal (95% CI)
Heterogeneity: Tau2 = 0.00; Chi2 = 3.03, df = 3 (P = 0.39); I2 =1% 100.0 % 0.86 [ 0.53, 1.20 ]
Test for overall effect: Z = 5.07 (P < 0.00001)
2 Questionnaire-based knowledge (follow-up)
Dawson 1987 0.67794492 (0.8250421) 6.1 % 0.68 [ -0.94, 2.29 ]
Hazzard 1991 0.84506507 (0.43229517) 22.1 % 0.85 [ 0.00, 1.69 ]
Kolko 1989 0.39433013 (1.40364558) 2.1 % 0.39 [ -2.36, 3.15 ]
Lee 1998 0.68825484 (0.24332598) 69.7 % 0.69 [ 0.21, 1.17 ]
Subtotal (95% CI)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.16, df = 3 (P = 0.98); I2 =0.0% 100.0 % 0.72 [ 0.32, 1.11 ]
Test for overall effect: Z = 3.52 (P = 0.00042)
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 4.1. Comparison 4 Harm, Outcome 1 Harm, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 4 Harm
Outcome: 1 Harm, no correction for clustering
Std. Mean
Std. Mean
Study or subgroup Intervention
N
Mean(SD) Control
N
Mean(SD) Difference
IV,Random,95% CI Weight Difference
IV,Random,95% CI
1 Anxiety or fear
Blumberg 1991 322 43.32 (7.75) 164 43.71 (7.73) 59.2 % -0.05 [ -0.24, 0.14 ]
Dawson 1987 96 28.51 (6.51) 141 29.46 (6) 31.0 % -0.15 [ -0.41, 0.11 ]
Lee 1998 38 4.71 (1.99) 34 4.74 (2.22) 9.8 % -0.01 [ -0.48, 0.45 ]
Subtotal (95% CI) 456 339 100.0 % -0.08 [ -0.22, 0.07 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.47, df = 2 (P = 0.79); I2 =0.0% Test for overall effect: Z = 1.06 (P = 0.29)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 4.2. Comparison 4 Harm, Outcome 2 Harm, ICC=0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 4 Harm
Outcome: 2 Harm, ICC=0.1
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
1 Anxiety or fear
Blumberg 1991 -0.0502882 (0.47493631) 16.5 % -0.05 [ -0.98, 0.88 ]
Dawson 1987 -0.1524605 (0.46819977) 16.9 % -0.15 [ -1.07, 0.77 ]
Lee 1998 -0.0141216 (0.23606995) 66.6 % -0.01 [ -0.48, 0.45 ]
Subtotal (95% CI) 100.0 % -0.04 [ -0.42, 0.33 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.07, df = 2 (P = 0.97); I2 =0.0% Test for overall effect: Z = 0.23 (P = 0.82)
Test for subgroup differences: Not applicable
-1 -0.5 0 0.5 1
Favours control Favours intervention
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Analysis 4.3. Comparison 4 Harm, Outcome 3 Harm, ICC=0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 4 Harm
Outcome: 3 Harm, ICC=0.2
Study or subgroup Std. Mean Difference
(SE) Std. Mean Difference
Weight Std. Mean Difference
IV,Random,95% CI IV,Random,95% CI
1 Anxiety or fear
Blumberg 1991 -0.0502882 (0.8539259) 6.6 % -0.05 [ -1.72, 1.62 ]
Dawson 1987 -0.1524605 (0.80389018) 7.4 % -0.15 [ -1.73, 1.42 ]
Lee 1998 -0.0141216 (0.23606995) 86.0 % -0.01 [ -0.48, 0.45 ]
Subtotal (95% CI) 100.0 % -0.03 [ -0.46, 0.40 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.03, df = 2 (P = 0.99); I2 =0.0% Test for overall effect: Z = 0.12 (P = 0.90)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours control Favours intervention
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Analysis 5.1. Comparison 5 Disclosures, Outcome 1 Disclosures, no correction for clustering.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 5 Disclosures
Outcome: 1 Disclosures, no correction for clustering
Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Del Campo Sanchez 2006 10/193 2/105 56.0 % 2.81 [ 0.60, 13.09 ]
Kolko 1989 20/191 0/30 16.5 % 7.29 [ 0.43, 123.77 ]
Oldfield 1996 4/658 1/611 27.5 % 3.73 [ 0.42, 33.47 ]
Total (95% CI) 1042 746 100.0 % 3.56 [ 1.13, 11.24 ]
Total events: 34 (Intervention), 3 (Control)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.36, df = 2 (P = 0.84); I2 =0.0% Test for overall effect: Z = 2.16 (P = 0.031)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours control Favours intervention
Analysis 5.2. Comparison 5 Disclosures, Outcome 2 Disclosures, ICC=0.1.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 5 Disclosures
Outcome: 2 Disclosures, ICC=0.1
Study or subgroup Intervention Control log [Odds Ratio] Odds Ratio Weight Odds Ratio N N (SE) IV,Random,95% CI IV,Random,95% CI
Del Campo Sanchez 2006 193 105 1.0347 (0.7843) 83.0 % 2.81 [ 0.61, 13.09 ]
Kolko 1989 191 30 1.9865 (3.4542) 4.3 % 7.29 [ 0.01, 6352.52 ]
Oldfield 1996 658 611 1.3166 (2.0048) 12.7 % 3.73 [ 0.07, 189.79 ]
Total (95% CI) 1042 746 100.0 % 3.04 [ 0.75, 12.33 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.08, df = 2 (P = 0.96); I2 =0.0% Test for overall effect: Z = 1.56 (P = 0.12)
Test for subgroup differences: Not applicable
0.001 0.01 0.1 1 10 100 1000
Favours control Favours intervention
School-based education programmes for the prevention of child sexual abuse (Review) Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
107
Analysis 5.3. Comparison 5 Disclosures, Outcome 3 Disclosures, ICC=0.2.
Review: School-based education programmes for the prevention of child sexual abuse Comparison: 5 Disclosures
Outcome: 3 Disclosures, ICC=0.2
Study or subgroup Intervention Control log [Odds Ratio] Odds Ratio Weight Odds Ratio N N (SE) IV,Random,95% CI IV,Random,95% CI
Del Campo Sanchez 2006 193 105 1.0347 (0.7843) 89.4 % 2.81 [ 0.61, 13.09 ]
Kolko 1989 191 30 1.9865 (4.6663) 2.5 % 7.29 [ 0.00, 68342.01 ]
Oldfield 1996 658 611 1.3166 (2.6049) 8.1 % 3.73 [ 0.02, 615.30 ]
Total (95% CI) 1042 746 100.0 % 2.95 [ 0.69, 12.61 ]
Heterogeneity: Tau2 = 0.0; Chi2 = 0.05, df = 2 (P = 0.98); I2 =0.0% Test for overall effect: Z = 1.46 (P = 0.14)
Test for subgroup differences: Not applicable
0.001 0.01 0.1 1 10 100 1000
Favours control Favours intervention
A D D I T I O N A L T A B L E S
Table 1. Previous reviews
Meta-analyses Systematic reviews Narrative reviews Systematic reviews of reviews
Berrick 1992
Davis 2000
Heidotting 1994
Rispens 1997
Zwi 2007
Duane 2002
Kenny 2008
MacIntyre 2000
MacMillan 1994
Topping 2009
Albers 1991
Carroll 1992
Conte 1986
Daro 1991
Daro 1994
Finkelhor 2007
Finkelhor 1992
Hébert 2004
Kolko 1988
O’Donohue 1992
Reppucci 2005
Mikton 2009
School-based education programmes for the prevention of child sexual abuse (Review) 108
Table 1. Previous reviews (Continued)
A P P E N D I C E S
Appendix 1. Search strategies for the period 2006 to 2014
CENTRAL 2014, Issue 8, last searched 8 September 2014, limited to publication years 2013 to 2014 (47 records) Previous searches
CENTRAL 2013(9), searched 2 September 2013, limited to publication years 2012 to 2013 (19 records)
CENTRAL 2012(3), searched 4 April 2012, limited to publication years 2006 to 2012 (160 records)
#1 MeSH descriptor Child Abuse, Sexual, this term only
#2 MeSH descriptor Rape, this term only
#3 MeSH descriptor Incest, this term only
#4 MeSH descriptor Sex Offenses, this term only
#5 molest* or rape* or incest*
#6 sex* near/3 (crim* or abuse* or assault* or offen* or exploit* or victim* or coerc* or maltreat*)
#7 (groom* near/3 (child* or online or sex*))
#8 (online near/3 solicit)
#9 (#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8)
#10 MeSH descriptor Adolescent, this term only
#11 child NEAR MEsh
#12 (child* or boy* or girl* or adolescen* or teen* or youth* or young NEXT people or young NEXT person* OR school* or pupil* or student* or college*)
#13 (#10 OR #11 OR #12)
#14 (#9 AND #13)
#15 (#1 OR #14)
Ovid MEDLINE(R) 1946 to August Week 4 2014, last searched 8 September 2014 (160 records) Previous searches
1946 to August Week 3 2013, searched 2 September 2013 (258 records)
1946 to March Week 3 2012, searched 4 April 2012 (757 records) 1 Child Abuse, Sexual/
2 sex offenses/
3 rape/
4 incest/
5 molest$.tw.
6 rape$.tw.
7 incest$.tw.
8 (sex$ adj3 crim$).tw. 9 (sex$ adj3 abuse$).tw.
10 (sex$ adj3 assault$).tw. 11 (sex$ adj3 offen$).tw.
12 (sex$ adj3 exploit$).tw. 13 (sex$ adj3 victim$).tw. 14 (sex$ adj3 coerc$).tw. 15 (sex$ adj3 maltreat$).tw.
16 (groom$ adj3 (online or child$ or sex$)).tw. 17 (online adj3 solicit$).tw.
18 or/2-17
19 exp child/
20 adolescent/
21 (child$ or boy$ or girl$ or adolescen$ or teen$ or youth$ or young people or young person$ or pupil$ or student$ or school$ or college$).tw.
22 or/19-21
23 18 and 22
24 1 or 23
25 randomized controlled trial.pt. 26 controlled clinical trial.pt.
27 randomi#ed.ab.
28 placebo$.ab.
29 drug therapy.fs.
30 randomly.ab.
31 trial.ab.
32 groups.ab.
33 or/25-32
34 exp animals/ not humans.sh. 35 33 not 34
36 24 and 35
37 limit 36 to yr=“2006 -Current” [limits applied April 2012]
38 limit 36 to ed=20120301-20130902 [limits applied Sept 2013]
39 limit 36 to ed=ed=20130901-20140908 [limits applied Sept 2014]
EMBASE (OVID) 1980 to 2014 Week 36, searched 8 September 2014 (320 records) Previous searches
1980 to 2013 Week 35, searched 2 September 2013 (400 records)
1980 to 2012 Week 13, searched 4 April 2012 (1118 records) 1 child sexual abuse/
2 exp sexual crime/ 3 rape$.tw.
4 incest$.tw.
5 (sex$ adj3 offen$).tw. 6 (sex$ adj3 abus$).tw.
7 (sex$ adj3 assault$).tw. 8 (sex$ adj3 molest$).tw. 9 (sex$ adj3 coerc$).tw. 10 (sex$ adj3 crim$).tw. 11 (sex$ adj3 victim$).tw. 12 (sex$ adj3 exploit$).tw.
13 (sex$ adj3 maltreat$).tw.
14 (groom$ adj3 (online or child$ or sex$)).tw. 15 (online adj3 solicit$).tw.
16 or/2-15
17 exp child/
18 adolescent/
19 (child$ or school$ or boy$ or girl$ or adolescen$ or teen$ or youth$ or young people or young person$ or pupil$ or student$ or college$).tw.
20 17 or 18 or 19
21 16 and 20
22 1 or 21
23 exp Clinical trial/
24 Randomized controlled trial/ 25 Randomization/
26 Single blind procedure/ 27 Double blind procedure/ 28 Crossover procedure/
29 Placebo/
30 Randomi#ed.tw.
31 RCT.tw.
32 (random$ adj3 (allocat$ or assign$)).tw. 33 randomly.ab.
34 groups.ab.
35 trial.ab.
36 ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw. 37 Placebo$.tw.
38 Prospective study/ (248367) 39 (crossover or cross-over).tw. 40 prospective.tw.
41 or/23-40
42 22 and 41
43 limit 42 to yr=“2006 -Current” [limits applied April 2012] 44 limit 42 to em=201214-201335 [limits applied Sept 2013]
45 limit 42 to em=201335-201436 [limits applied Sept 2014]
PsycINFO (OVID) 1967 to September Week 1 2014 (102 records) Previous searches
1967 to August Week 4 2013, last searched 2 September 2013 (118 records)
1967 to March Week 4, searched 4 April 2012 ( 378 records) 1 exp sexual abuse/
2 sex offenses/
3 molest$.tw.
4 rape$.tw.
5 incest$.tw.
6 (sex$ adj3 crim$).tw. 7 (sex$ adj3 abuse$).tw. 8 (sex$ adj3 assault$).tw. 9 (sex$ adj3 offen$).tw.
10 (sex$ adj3 exploit$).tw. 11 (sex$ adj3 victim$).tw. 12 (sex$ adj3 coerc$).tw. 13 (sex$ adj3 maltreat$).tw.
14 (groom$ adj3 (online or child$ or sex$)).tw.
15 (online adj3 solicit$).tw. 16 or/1-15
17 (“100” or “160” or “180” or “200”).ag.
18 (child$ or boy$ or girl$ or adolescen$ or teen$ or youth$ or young people or young person$ or pupil$ or student$ or school$ or college$).tw.
19 17 or 18
20 16 and 19
21 clinical trials/
22 (randomis$ or randomiz$).tw.
23 (random$ adj3 (allocat$ or assign$)).tw. 24 ((clinic$ or control$) adj trial$).tw.
25 ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw. 26 (crossover$ or “cross over$”).tw.
27 random sampling/
28 Experiment Controls/
29 Placebo/
30 placebo$.tw.
31 exp program evaluation/
32 treatment effectiveness evaluation/
33 ((effectiveness or evaluat$) adj3 (stud$ or research$)).tw. 34 school based intervention/
35 or/21-34
36 20 and 35
37 limit 36 to yr=“2006 -Current” [limits applied April 2012]
38 limit 36 to up=20120301-20130902 [limits applied Sept 2013]
39 limit 36 to up=20130901-20140908 [limits applied Sept 2014]
CINAHL (EBSCOhost) 1937 to current, last searched 8 September 2014 and limited to EM 20130901 onwards (98 records) Previous searches
1937 to current, searched 2 September 2013 and limited to EM 20120301 onwards (201 records)
1937 to current, searched 4 April 2012 and limited to EM 20060801 onwards (526 records) S38 S19 and S37
S37 S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36 S36 (MH “Evaluation Research”) OR (MH “Summative Evaluation Research”) OR (MH “Program Evaluation”)
S35 (MH “Treatment Outcomes”) S34 (MH “Comparative Studies”)
S33 TI (compar* stud* or compar* research*) or AB (compar* stud* or compar* research*) or TI (evaluat* study or evaluat* research) or AB (evaluate* study or evaluat* research) or TI (effectiv* study or effectiv* research) or AB (effectiv* study or effectiv* research) OR TI (prospectiv* study or prospectiv* research) or AB(prospectiv* study or prospectiv* research) or TI (follow-up study or follow-up research) or AB (follow-up study or follow-up research)
S32 “cross over*” S31 crossover*
S30 (MH “Crossover Design”)
S29 (tripl* N3 mask*) or (tripl* N3 blind*) S28 (trebl* N3 mask*) or (trebl* N3 blind*) S27 (doubl* N3 mask*) or (doubl* N3 blind*) S26 (singl* N3 mask*) or (singl* N3 blind*) S25 (clinic* N3 trial*) or (control* N3 trial*)
S24 (random* N3 allocat* ) or (random* N3 assign*) S23 randomis* or randomiz*
S22 (MH “Meta Analysis”) S21 (MH “Clinical Trials+”) S20 MH random assignment S19 S1 or S18
S18 S14 and S17 S17 S15 or S16
S16 (child* or schoolchild* or schoolboy* or schoolgirl* or adolescen* or teen* or youth* or young people or young person* or pre- school* or preschool* or pupil* or student* or kindergarten*)
S15 AG adolescent or AG child
S14 S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 S13 (groom* N3 online) or (groom* N3 child*) or (groom* N3 sex*)
S12 (online N3 solicit*) S11 (sex* N3 maltreat*)
S10 (sex* N3 coerc*) S9 (sex* N3 victim*) S8 (sex* N3 exploit*) S7 (sex* N3 offen*) S6 (sex* N3 assault*) S5 (sex* N3 abuse*) S4 (sex* N3 crim*)
S3 rape* or incest* or molest*
S2 (MH “Rape”) OR (MH “Incest”) S1 (MH “Child Abuse, Sexual”)
Social Science Citation Index (SSCI), 1970 to 29 August 2014, last searched 8 September 2014, limited to publication years 2013 to 2014 (777 records)
Previous searches
1970 to 30 August 2013, last searched 2 September 2013, limited by Processing Date 2012-03-01 to 2013-09-02 (661 records) 1970 to 30 March 2012, searched 4 April 2012, no limits applied as not searched for original review (4543 records)
# 7 #6 AND #5 AND #4
# 6 TS=(random* or control* or trial* or group* or blind* or RCT )
# 5 TS= (child* or boy* or girl* or adolescen* or teen* or youth* or “young person*” or “young people” OR school* or college* OR pupil* or student*)
# 4 #3 OR #2 OR #1
# 3 TS=(online* NEAR/3 solicit*)
# 2 TS=((groom*) NEAR/3 (online* OR child* or sex*))
# 1 TS= ((sex*) NEAR/3 (crime or crimes or abus* OR assault* or offenc* or offens* or exploit* or victim* or coerc* or maltreat*)) Sociological Abstracts (ProQuest), 1952 to current, last searched 3 September 2013, limited by publication year 2012 to current (91 records)
Previous searches
25 July 2012, limited to publication year 2006 to 2012 ( 242 records)
(TI(molest* OR rape* OR incest*) OR AB(molest* OR rape* OR incest*) OR TI((groom* NEAR/3 (child* OR online OR sex*)) OR (online NEAR/3 solicit)) OR AB((groom* NEAR/3 (child* OR online OR sex*)) OR (online NEAR/3 solicit)) OR AB (sex* NEAR/3 (crim* OR abuse* OR assault* OR offen* OR exploit* OR victim* OR coerc* OR maltreat*)) OR TI(sex* NEAR/3 (crim* OR abuse* OR assault* OR offen* OR exploit* OR victim* OR coerc* OR maltreat*)) OR SU.EXACT(Child Sexual Abuse) OR SU.EXACT(“Incest”)) AND (AB(child* OR school* OR kindergarten* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young people” OR “young person*” OR preschool* OR “pre-school*” OR pupil* OR student* OR college*) OR TI(child* OR school* OR kindergarten* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young people” OR “young person*” OR preschool* OR “pre-school*” OR pupil* OR student* OR college*)) AND (AB(random* OR group* OR trial* OR control* OR placebo* OR prospective OR “cross over” OR crossover OR blind* OR RCT) OR TI(random* OR group* OR trial* OR control* OR placebo* OR prospective OR “cross over” OR crossover OR blind* OR RCT))
Conference Proceedings Citation Indexes (CPCI-S and CPCI-SSH), 1990 to 29 August 2014, last searched 8 September 2014 (7 records)
Previous searches
1990 to 30 August 2013, searched 2 September 2013 (15 records)
1970 to 30 March 2012, searched 4 April 2012, no limits applied as not searched for original review. (221 records)
#7 #6 AND #5 AND #4
# 6 TS=(random* or control* or trial* or group* or blind* or RCT )
# 5 TS= (child* or boy* or girl* or adolescen* or teen* or youth* or “young person*” or “young people” OR school* or college* OR pupil* or student*)
# 4 #1 OR #2 OR #1
# 3 TS=(online* NEAR/3 solicit*)
# 2 TS=((groom*) NEAR/3 (online* OR child* or sex*))
# 1 TS= ((sex*) NEAR/3 (crime or crimes or abus* OR assault* or offenc* or offens* or exploit* or victim* or coerc* or maltreat*)) ERIC (EBSCOhost), 1966 to current, last searched 8 September 2014, limited by entry date = 1 January 2013 or later ( 206 records) S22 S12 AND S15 AND S21
S21 S16 OR S17 OR S18 OR S19 OR S20
S20 random* OR intervention* OR experiment* OR trial*
S19 ((evaluat* OR compar* OR blind*) N5 (study OR studies OR research)) S18 “follow up” or followup
S17 prospective
S16 ((DE “Control Groups” OR DE “Longitudinal Studies” OR DE “Program Effectiveness” OR DE “Program Evaluation” OR DE “Experimental Groups”) OR (DE “Followup Studies”)) OR (DE “Comparative Analysis”)
S15 S13 OR S14
S14 (child* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young person*” OR “young people” OR school* OR college* OR pupil* OR student*)
S13 DE “Children” OR DE “Preadolescents” OR DE “Young Children” OR DE “Preschool Children” OR DE “Adolescents” S12 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11
S11 (groom* N3 online) or (groom* N3 child*) or (groom* N3 sex*) S10 (online N3 solicit*)
S9 (sex* N3 maltreat*)
S8 (sex* N3 coerc*) S7 (sex* N3 victim*) S6 (sex* N3 exploit*) S5 sex* N3 offen*
S4 (sex* N3 assault*) S3 (sex* N3 abuse*) S2 (sex* N3 crim*)
S1 (DE “Sexual Abuse” OR DE “Child Abuse” OR DE “Rape”)
ERIC (ProQuest), 1966 to current, last searched 3 September 2013, limited by PY=2012-2013 ( 206 records) Previous searches
1966 to current, searched 15 May 2012, limited to entry date 2006 or later, (1357 records)
((“sex* coerc*” OR “sex* crim*” OR “sex* molest*” OR “sex* assault*” OR “sex* abus*” OR “sex* offen*” OR “sex* victim*” OR “sex* maltreat*” OR incest* OR rape*) OR (SU.EXACT(“Sexual Abuse”) OR SU.EXACT(“Child Abuse”) OR SU.EXACT(“Rape”))) AND (SU.EXACT(“Longitudinal Studies”) OR SU.EXACT(“Control Groups”) OR SU.EXACT(“Program Effectiveness”) OR SU.EXACT(“Experimental Groups”) OR SU.EXACT(“Followup Studies”) OR SU.EXACT(“Comparative Analysis”) OR prospective OR “follow up” OR ((evaluat* OR compar* OR blind*) NEAR/5 (study OR studies OR research)) OR ((compar* OR control*) NEAR/5 group*) OR random* OR intervention* OR experiment* OR trial*) AND (child* OR boy* OR girl* OR adolescen* OR teen* OR youth* OR “young person*” OR “young people” OR school* OR college* OR pupil* OR student*)
DARE, 2014 (3), part of Tfte Cocftrane Library , last searched 8 September 2014 (6 records) Previous searches
DARE 2013(3), searched 2 September 2013 (5 records)
DARE 2012(2), searched 4 April 2012 ( 2 records)
#1 MeSH descriptor Child Abuse, Sexual, this term only
#2 MeSH descriptor Rape, this term only
#3 MeSH descriptor Incest, this term only
#4 MeSH descriptor Sex Offenses, this term only
#5 molest* or rape* or incest*
#6 sex* near/3 (crim* or abuse* or assault* or offen* or exloit* or victim* or coerc* or maltreat*)
#7 (groom* near/3 (child* or online or sex*))
#8 (online near/3 solicit)
#9 (#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8)
#10 MeSH descriptor Adolescent, this term only
#11 child NEAR MEsh
#12 (child* or boy* or girl* or adolescen* or teen* or youth* or young NEXT people or young NEXT person* OR school* or pupil* or student* or college*)
#13 (#10 OR #11 OR #12)
#14 (#9 AND #13)
#15 (#1 OR #14)
NDLTD (SCIRUS) ndltd.org/serviceproviders/scirus-etd-search, last searched 3 September 2013 (no new records). Not available in September 2014 and no longer available via SCIRUS
Previous searches
4 April 2013, all available years (9 records)
title:sex* AND title:abuse* AND (title:school* OR title:college*) Limited to Theses and dissertations and by year 2012 to 2013
ClinicalTrials.gov, clinicaltrials.gov/, searched 9 September 2014, limited to records added since 1 September 2013 (15 records) Previous searches
3 September 2013, limited to records added since 1 March 2012 (9 records)
5 April 2012, searched all years as not searched for original review (22 records) Sex abuse school | Interventional Studies | Child |
ICTRP apps.who.int/trialsearch/, last searched searched 9 September 2014, limited to records registered since 1 September 2013 (1 record)
Previous searches
3 September 2013 (no new records)
3 April 2012, no limits applied as not searched for original review (no records) Condition: sex abuse
Intervention: School
Australasian Theses (via TROVE) trove.nla.gov.au/, last searched 9 September 2014, limited to publication year 2013 to 2014 (no new records)
Previous searches
3 September 2013, limited to publication year 2012 to 2013 (no new records) 3 April 2012, no limits applied as not searched for original review (9 records) All words: SEX* ABUSE* SCHOOL* in TITLE and limited to Dissertations
Appendix 2. Search strategies up to August 2006
Cochrane Central Register of Controlled Trials (CENTRAL) (2006, Issue 3) CHILD
CHILD* TEENAGE* ADOLESCEN*
(((#1 or #2) or #3) or #4) SEX OFFENSES
RAPE INCEST*
(SEX* near OFFENCE*)
(SEX* near OFFENSE*) (SEX* near ABUS*) (SEX* near ASSAULT*) (SEX* near MOLEST*) (SEX* near CRIM*) (SEX* near COERC*)
(((((((((#6 or #7) or #8) or #9) or #10) or #11) or #12) or #13) or #14) or #15
(#5 and #16)
MEDLINE (via OVID) searched 1966 to August 2006 1 exp child/
2 child$.tw.
3 adolescen$.tw.
4 teenage$.tw.
5 1 or 2 or 3 or 4 6 exp Sex offenses/
7 Incest/
8 (sex$ adj5 offen$).tw. 9 (sex$ adj5 abus$).tw.
10 (sex$ adj5 assault$).tw. 11 (sex$ adj5 molest$).tw. 12 (sex$ adj5 coerc$).tw. 13 (sex$ adj5 crim$).tw. 14 incest$.tw.
15 rape.tw.
16 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15
17 5 and 16
18 randomized controlled trial.pt. 19 controlled clinical trial.pt.
20 Randomized controlled trials/
21 random allocation.sh. 22 double blind method.sh. 23 single-blind method.sh.
24 or/18-23
25 (animal not human).sh. 26 24 not 25
27 clinical trial.pt. 28 exp Clinical trials/
29 (clin$ adj25 trial$).ti,ab.
30 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).ti,ab.
31 placebos.sh.
32 placebo08
33 random$.ti,ab.
34 research design.sh.
35 or/27-34
36 35 not 25
37 36 not 26
38 comparative study.sh. 39 exp evaluation studies/ 40 follow up studies.sh. 41 prospective studies.sh.
42 (control$ or prospectiv$ or volunteer$).ti,ab. 43 or/38-42
44 43 not 25
45 44 not (26 or 37)
46 26 or 37 or 45
47 17 and 46
EMBASE (via OVID) searched 1980 to August 2006 1 Controlled study/
2 Clinical trial/
3 Major clinical study/ 4 random$.tw.
5 Randomized controlled trial/ 6 trial$.tw.
7 compar$.tw.
8 control$.tw.
9 study.tw.
10 follow-up.tw.
11 clinic$.tw.
12 blind$.tw.
13 Double blind procedure/ 14 placebo$.tw.
15 Clinical article/
16 Placebo/
17 doubl$.tw.
18 or/1-17
19 exp child/
20 exp adolescent/
21 child$.tw.
22 adolescen$.tw.
23 teenage$.tw.
24 19 or 20 or 21 or 22 or 23 25 exp sexual abuse/
26 exp Child abuse/ 27 exp sexual crime/ 28 rape$.tw.
29 incest$.tw.
30 (sex$ adj5 offen$).tw. 31 (sex$ adj5 abus$).tw. 32 (sex$ adj5 assault$).tw. 33 (sex$ adj5 molest$).tw. 34 (sex$ adj5 coerc$).tw. 35 (sex$ adj5 crim$).tw.
36 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35
37 24 and 36
38 37 and 18
CINAHL (via OVID) searched 1982 to August 2006
1 Experimental Studies/ 2 exp Clinical trials/
3 ((control$ or clinic$ or prospectiv$) adj5 (trial$ or study or studies)).tw.
4 ((allocat$ or assign$ or divid$) adj5 (condition$ or experiment$ or treatment$ or control$ or group$)).tw. 5 ((singl$ or doubl$) adj (blind$ or mask$)).tw.
6 cross?over$.tw.
7 placebo$.tw.
8 (compar$ adj5 (trial$ or study or studies)).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 9 exp Clinical research/
10 Comparative studies/ 11 exp Evaluation research/
12 exp “control (research)”/ 13 Random assignment/
14 exp Prospective studies/ 15 exp Evaluation research/ 16 random$.tw.
17 exp Sexual abuse/ 18 rape.tw.
19 incest$.tw.
20 (sex$ adj5 offen$).tw. 21 (sex$ adj5 abus$).tw. 22 (sex$ adj5 assault$).tw. 23 (sex$ adj5 molest$).tw. 24 (sex$ adj5 coerc$).tw.
25 (sex$ adj5 crim$).tw. 26 or/17-25
27 exp Child/
28 child$.tw.
29 adolescen$.tw.
30 teenage$.tw.
31 or/27-30
32 26 and 31
33 or/1-16
34 32 and 33
PsycINFO searched 1984 to August 2006
1 “RANDOM$”.mp.
2 (random$ adj (alloc$ or assign$ or divid$)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers] 3 (random$ adj (trial$ or study or studies)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers]
4 ((control$ or clinic$ or prospectiv$) adj5 (trial$ or study or studies)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers]
5 ((allocat$ or assign$ or divid$) adj5 (condition$ or experiment$ or treatment$ or control$ or group$)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers]
6 ((singl$ or double$) adj (blind$ or mask$)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers] 7 “CROSS?OVER”.mp.
8 exp placebo/
9 (compar$ adj5 (trial$ or study or studies)).mp. [mp=title, abstract, heading word, table of contents, key phrase identifiers] 10 (health or medicine or illness).sh.
11 8 and 9
12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 11
13 “child”/
14 “CHILD$”.mp.
15 exp adolescents/ or “teenager”.mp. 16 14 or 15
17 exp sexual abuse/
18 exp incest/ or exp rape/ or exp sex offenses/ or exp victimization/ or “sexual assault”.mp. 19 17 or 18
20 12 and 16 and 19
Sociological Abstracts (via Cambridge Scientific Abstracts) searched 1963 to August 2006
((sex* near3 coerc*) or (sex* near3 crim*) or (sex* near3 assault*) or (sex* near3 abus*) or (sex* near3 molest*) or (sex* near3 offense*) or (sex* near3 offence*) or (“Incest-” in DE) or (incest*) or (“Rape-” in DE) or (rape) or (explode “Child-Sexual-Abuse” in DE)) and ((( ((control* or clinic* or prospectiv*) near5 (trial* or study or studies)) in AB )or( ((control* or clinic* or prospectiv*) near5 (trial* or study or studies)) in TI )) or (( (random*) in AB )or( (random*) in TI )) or (( (random* near (trial* or study or studies)) in AB )or( (random* near (trial* or study or studies)) in TI )) or (( (random* near (allocat* or assign* or divid*)) in AB )or( (random* near (allocat* or assign* or divid*)) in TI )) or (( (compar* near5 (trial* or study or studies)) in AB )and( compar* near5 (trial* or study or studies) )) or (placebo*) or (( (cross?over) in AB )and( (cross?over) in TI )) or (( ((singl* or doubl*) near (blind* or mask*)) in AB )and( ((singl* or doubl*) near (blind* or mask*)) in TI )) or (( ((allocat* or assign* or divid*) near5 (condition* or experiment* or treatment* or control* or group*)) in AB )and( ((allocat* or assign* or divid*) near5 (condition* or experiment* or treatment* or control* or group*)) in TI
))) and ((adolescen*) or (teen*) or (child*) or (explode “Children-” in DE) or (explode “Adolescents-” in DE))
W H A T ’ S N E W
Last assessed as up-to-date: 8 September 2014.
H I S T O R Y
Protocol first published: Issue 3, 2003
Review first published: Issue 3, 2007
C O N T R I B U T I O N S O F A U T H O R S
The original protocol and review was developed and written by Karen Zwi, Susan Woolfenden, Danielle M Wheeler, Tracey O’Brien, Paul Tait, and Katrina J Williams. Danielle Wheeler and Joanne Abbott (TSC for the Cochrane Developmental, Psychosocial and Learning Problems Group) conducted searches for the review.
Trial selection was performed by KW, KZ, SW, and AS. Data extraction and assessment of risk of bias were performed by KW, KZ, SW, and AS. Building on the original review, KW led the re-writing of results, discussion, and conclusions with input from all authors.
D E C L A R A T I O N S O F I N T E R E S T
Kerryann Walsh - acknowledges the Australian Research Council Discovery Projects Scheme (DP1093717) funding for research about sexual abuse prevention programmes in Australia that was conducted in parallel to this review.
Karen Zwi and Susan Woolfenden have access to ’training, education, and study leave’ (TESL) funds from their organisation, to attend conferences to present or to learn. This pays for travel, accommodation, per diem allowance, and registration fees.
Aron Shlonsky - none known.
S O U R C E S O F S U P P O R T
Internal sources
• No sources of support supplied
External sources
• Financial Markets Foundation for Children, Australia.
• Nordic Campbell Centre, Denmark.
• Queensland University of Technology Vice Chancellor’s Research Fellowship, Australia.
D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W
There are five main differences between the protocol, Zwi 2003, and the review update.
1. Types of outcome measures. On p 2 of the review protocol, five outcomes were specified: (i) the development of protective behaviours; (ii) knowledge of sexual abuse and abuse prevention concepts; (iii) retention of knowledge over time; (iv) parental or child anxiety; and (v) disclosure of sexual abuse by child or adolescent during or after participating in programmes. In this review update we reported on six more precise outcomes: (i) protective behaviours; (ii) knowledge (questionnaire-based knowledge and vignette-based knowledge); (iii) retention of protective behaviours over time; (iv) retention of knowledge over time; (v) harm manifesting as parental or child anxiety or fear; and (vi) disclosures of past or current child sexual abuse.
2. Measures of treatment effect. On p 4 of the review protocol, calculation of odds ratios (OR) for dichotomous outcomes was specified in strategies for data synthesis, while relative risk (RR) and risk difference (RD) were specified for reporting on dichotomous measures of treatment effects. In this review update, we used the OR as this is the statistic used most often in this field and for ease of interpretation.
3. Unit of analysis issues. On p 4 of the review protocol, we indicated we would adjust for unit of analysis errors where the ICC was available. However, ICCs were not reported in the studies or available from study authors. Instead, we used estimates of 0.1 and 0.2 that had been previously used in a review of school-based violence prevention programmes (Mytton 2006).
4. Dealing with missing data. Requirements for Cochrane Reviews have changed since this study’s protocol was written. In this review update we identified the following types of missing data: missing outcomes, missing summary data, and missing participants. For missing outcomes (e.g. disclosures, adverse outcomes) and missing summary data (i.e. group size totals, means, standard deviations (SDs)), we contacted corresponding study authors to provide outstanding data.
5. Data synthesis. Before starting the 2015 update of this review we had intended to combine data with a fixed effect model in the absence of moderate statistical heterogeneity (I square <30%) and to adopt a random effects model where I square exceeded this threshold. Further consideration of the differences between the characteristics of the included studies prompted us to revise this approach. We decided to use a random effects model throughout the review in the expectation that variation between the results of the studies represented a distribution of related intervention effects.
6. Subgroup analyses. On p 4 of the review protocol, we specified the conduct of subgroup analyses to determine differential effects according to participant age, gender and previous reported abuse, and intervention type (passive or active involvement of
participants). Subgroup analyses were only conducted for age, but not for other variables, as there was insufficient information provided in the included studies.
N O T E S
This review is co-registered within the Campbell Collaboration.
I N D E X T E R M S
Medical Subject Headings (MeSH)
∗Schools; Child Abuse, Sexual [∗prevention & control]; Health Knowledge, Attitudes, Practice; Program Evaluation; Randomized Controlled Trials as Topic
MeSH check words
Adolescent; Child; Humans
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