Children ’ s Knowledge of Sexual Abuse Prevention in El Salvador

Background: Child sexual abuse (CSA) remains a global health problem that must be addressed. In a country with limited resources such as El Salvador, we sought an alternative way to disseminate CSA prevention information to elementary school children. Objective: The aim of this study was to evaluate the effectiveness of a child sexual abuse (CSA) prevention exhibit at a children ’ s museum. Methods: We asked 189 children to answer a questionnaire about CSA prevention before entering a museum exhibit on the subject and then asked 59 different children to answer the questionnaire after visiting the exhibit. Findings: Children ’ s knowledge scores on CSA prevention significantly improved after visiting the exhibit ( P < .012). Conclusions: A museum exhibit that addresses CSA prevention is an effective way of communicating CSA prevention to children.


INTRODUCTION
Childhood is one of the most important times in human development. 1,2 It is during childhood that most of the foundation for one's personality develops. 1,2 Experiences and relationships throughout childhood shape how children will ultimately relate with others and how they will perceive themselves. [3][4][5] Often, these experiences go on to become internalized such that they affect a person's daily life experiences. One of the most devastating childhood events that has significant long-term and often lifelong consequences is child sexual abuse (CSA). A variety of adult psychiatric disorders, including major depression, personality disorders, and self-harming behaviors have been linked to childhood sexual abuse. [6][7][8] Rates of officially reported CSA often are related to social factors, including economic and family resources, housing instability, household and age structure, and geographic proximity of neighborhoods to poverty. Although abuse and poverty are not inescapably tied, the association between poverty and child abuse and neglect has been well documented. [9][10][11] El Salvador, one of seven Central American countries, has a population of 6.125 million. 12 In 1992, the signing of the Peace Accords ended a 12-year civil war that cost the lives of 75,000 Salvadorans. 13 Salvadoran migratory patterns have been shaped by both political and socioeconomic problems such as unemployment, chronic poverty, and fleeing the civil war. In 2008, there were about 1.1 million Salvadoran immigrants living in the United States. 14 Salvadorans are the sixth largest immigrant group in the United States after Mexican, Filipino, Indian, Chinese, and Vietnamese immigrants. Furthermore, about 1 in 5 Salvadorans lives in the United States. As a result of these migration patterns, 30% of all Salvadoran households are now headed by women, and approximately 39% of children in El Salvador live in extreme poverty. 15,16 Given that poverty is identified as a risk factor for CSA, we can only assume that Salvadoran children are at higher risk for abuse. 17 Recently, there has been increased attention to CSA as a global issue for which solutions must be devised in order to protect children from further harm and prevent others from becoming victims. Although CSA is a widespread phenomenon, it remains difficult to collect reliable prevalence data. A meta-analysis conducted by Stoltenborgh et al looking at worldwide data revealed that the prevalence of self-reported childhood sexual abuse cases was 11.8%, with an 18% prevalence for girls and 7.6% for boys between 1980 and 2008. 18 In another study using a self-administered questionnaire, 20% of sexually experienced Salvadoran girls aged 12 to 15 years reported that they had been forced to have sexual intercourse. 19 The devastating effects of CSA can be observed in the effect it has on Salvadoran daily life. For example, Speizer et al found that the proportion of sexually abused women reporting intimate partner violence was about twice as large as those who had not experienced child sexual abuse (5.7% vs 9.7%). 20 The risk for adolescent pregnancy also was found to be significantly higher among women who reported being abused as children. Women who were sexually abused had a 48% higher risk for adolescent pregnancy than those without a history of abuse. 21 In El Salvador, the number of teenage girls giving birth continues to increase. In 2008, 31.1% of all live births in El Salvador were recorded from women between the ages of 10 and 19. 22 According to reports from the U.S. Department of Health and Human Services, children younger than 1 year had the highest rate of child abuse and maltreatment in the United States. And overall, the percentage of victimization decreased with age. 23 In El Salvador, Speizer et al found that the mean age of abuse for women is 10.5 years. 20 Children are particularly vulnerable and sometimes simply do not know how to recognize unacceptable behaviors. Thus, an important step in approaching the issue of sexual abuse and preventing future CSA in particular is educating communities, as well as children at a young age.
Keeping in mind that the goal is to avoid future abuse, the United Nations Convention on the Rights of the Child recommends teaching children at a young age about their bodies and sexuality in an age-appropriate manner. One way to reach young children is through school-based community programs, which have proven effective in preventing CSA. 24,25 The Convention also found that children in preschool and early elementary school learned the most from prevention programs. Finkelhor et al found that children who were exposed to prevention education programs were more likely to disclose victimization and feel that they protected themselves rather than blame themselves. 26 In a metaanalysis, Rispens et al found considerable mean postintervention (d ¼ .71) and follow-up (d ¼ .62) effect sizes, thus concluding that school-based child abuse prevention programs are successful in teaching children abuse-prevention concepts. 27 Ko and Cosden found that high school students who participated in elementary school-based abuse-prevention programs have a greater understanding of issues around blame, the importance of reporting abuse, that abusers are usually not strangers, and that both boys and girls can be victims of abuse. 28 Furthermore, in recent years, there has been a significant increase in school attendance in El Salvador, where 90.7% of children living in urban areas and 76.07% in rural areas attend school. 22 Furthermore, secondary education enrollment has increased by 20% in urban areas and increased 3-fold in rural areas. 16 In brief, school-promoted CSA prevention programs should be able to reach a considerable portion of Salvadoran children and their families.
However, many challenges exist in prioritizing CSA prevention programs in a country with limited economic resources, a weak legal system, and a limited number of child protective agencies. A children's museum exhibit that school children can attend as part of a school trip, is an interactive, nonthreatening and fun manner to disseminate CSA prevention information to elementary school children and is the focus of this study. Our goal was to contribute to the furthering of a CSA prevention initiative by assessing whether this educational intervention, a museum exhibit that teaches about sexual abuse prevention to elementary school children, was indeed making an educational impact.

METHODS
This project was a collaboration between the Icahn School of Medicine at Mount Sinai and its Global Health Center, and the Tin Marin Children's Museum in San Salvador, El Salvador. This study was approved by the Icahn School of Medicine at Mount Sinai Institutional Review Board. The Tin Marin's Children's Museum at the time had a CSA exhibit based on a book entitled Mi Cuerpo Me Pertenece a Mi (My Body Belongs to Me), which addresses issues regarding body ownership, types of inappropriate touching, and escaping and reporting skills. This exhibit was part of a campaign to educate children about CSA initiated by the Salvadoran government and several nongovernmental organizations. The exhibit was interactive; children played along the way and watched and discussed a video with a trained museum guide.
To assess children's knowledge of CSA prevention themes, a questionnaire was administered to 189 children before they entered the museum and to 59 different children after they left the museum. Parents were asked if their child had completed the questionnaire before the museum visit, and if they had, they were not asked to fill out the questionnaire after the museum visit. The questionnaire consisted of 2 demographic questions (see Table 1 for participant sociodemographic profiles), and 5 multiplechoice questions to which answers were addressed at the exhibit (see Table 2 for the 5 questions). The questionnaire was translated into Spanish and back-translated and revised by 3 native Spanish speakers. Only 1 investigator distributed the questionnaire. Children and their parents were approached by the principal investigator, and verbal consent was obtained from at least 1 parent. The questionnaire was then read to all the children in Spanish, and the children then circled their own answers. To further ensure that a child was not tested twice, the child was asked if he or she had previously filled out the questionnaire or if he or she had seen the exhibit within the last year.

FINDINGS
In all, 248 children filled out the questionnaires. Of these, 189 answered the questionnaire before entering the museum and 59 after visiting the exhibit. We observed that parents were more willing to participate in this study at the start of the day before entering the museum than at the end after the museum visit. One questionnaire from a child who did not meet the age criteria (17 yearsold) was not used. Data from 247 children was used (Table 1).
On all questions, overall, a majority of children were able to answer questions correctly before viewing the museum exhibit. For example, >90% of children were able to correctly identify a boy's and girl's "private parts." However, children answered correctly at an even higher rate after visiting the "My Body Belongs to Me" museum exhibit (see Table 2 for details). Using Pearson's c 2 for analysis, there was a statistically significant improvement in the number of questions answered correctly after visiting the museum exhibit for all questions except question 5 (Q5), which asked to identify a boy's private parts (P ¼ .086). However, even for this question, all 59 children answered this questioned correctly after visiting the museum exhibit. For example, on Q2-"What should you do if someone tries to touch you or looks at you in a manner that scares or makes you feel bad"before entering the exhibit, 15% of children answered, "I would say nothing." However, after seeing the museum exhibit, only 2.4% gave the same response (see Table 2 for number of questions answered correctly pree and postemuseum exhibit visit). Based on the questionnaire's total score, children's scores improved after visiting the museum (P ¼ .012). When specific age groups were examined, younger children, aged 6 to 9, had a greater improvement in their scores after visiting the museum exhibit than children aged 10 to 14 years. For children aged 6 to 9, almost twice as many scored >60%. For children aged 10 to 14, only about 20% more children scored >60% after visiting the exhibit.

DISCUSSION
Children were unexpectedly knowledgeable before viewing the museum exhibit. It would be informative and relevant to learn where these children were able to obtain this knowledge, whether from home and/or school settings. The higher than expected knowledge from children might reflect that those brought to a museum by their parents are more likely to have involved parents or teachers from a higher socioeconomic class, who perhaps have spoken to the children about child abuse prevention. An overwhelming majority of the children studied were from the capital city of San Salvador, where there is a higher level of education and socioeconomic status (SES). Past research has found that SES does affect what children learn about child abuse prevention. Briggs and Hawkins found that children with lower SES started at a lower baseline of knowledge and, therefore, made more knowledge gains. 29 They also found that children with lower SES were less likely to receive personal safety education at home and school. 29 Nonetheless, 26.6% of children interviewed before seeing the museum exhibit chose "I would say nothing" or "I wouldn't tell someone until later" when asked to disclose being touched or scared by someone. The reasons why children do not disclose being sexually abused are many. Shaw et al found that victims of Hispanic background waited longer than black children to disclose such an incident. 30 One reason is that discussing sexuality remains taboo in many cultures, Latin American cultures in particular. Other cultural variables, such as shame and value placed on virginity and chastity in Latin American cultures, also may delay children from disclosing sexual abuse. 31,32 Studies suggest that Hispanic communities are more inclined to blame the victims of sexual abuse and that Hispanic victims report greater psychological distress. 32 Latinos' cultural constructs of family attachments (familismo) and respect (respeto) for authority figures suggest that it may be especially difficult for children from El Salvador to disclose sexual abuse perpetrated by family; Latino children may perceive disclosing as an act of disloyalty and disrespect. [33][34][35][36] However, despite their higher-thanexpected scores, children's knowledge of CSA prevention improved after being educated on CSA prevention.
Our findings support past research that children do gain knowledge about CSA prevention from educational programs. This was further replicated by Davis and Gidycz in a meta-analysis of 27 studies that found that children who participated in school-based child abuse programs performed 1.07 SD higher than the control group children in outcomes measured. 37 Specifically, we found that children can learn CSA prevention material from going to an exhibit at a museum that includes a short video about CSA prevention. Moreover, similar to Davis and Gidycz, we also found that younger children learned more. 37 As it was important to obtain parental consent, all participating children were accompanied by their parents at the museum. Therefore, our participant sample may have been over-represented by children of higher SES and thus access to better education. Our results may have been different if more Salvadoran children with lower SES, with limited access to education, were included. Another limitation in our study is that we were only able to test immediate increase in knowledge base and were unable to test how long children are able to retain this information after visiting the museum. We were also unable to test whether children are able to apply these lessons learned and thus reduce their chances of being sexually abused.

CONCLUSIONS
El Salvador is a country stricken by high rates of poverty and violence, resulting from years of war. It is integral that future studies examining child abuse prevalence and interventions explore these factors more systematically than we were able to do here. In conclusion, a museum exhibit that covers the topic of CSA prevention is an effective way of distributing an abuse prevention message to children.