The public health crisis of child sexual abuse in low and middle income countries: An integrative review of the literature

Sexual Victimization and Sexually Transmitted Infections Among a Nationally Representative Sample of Adolescents and Young Adults in Haiti

Sexual assault victims are at major risk of being infected by sexually transmitted infections (STI). This article aims to examine and compare the prevalence of eight STIs (e.g., chlamydia, gonorrhea, hepatitis B, HIV/AIDS, human papillomavirus) among victims and non-victims of sexual abuse. A national cross-sectional study was conducted in Haiti, using a multistage sampling frame, stratified by geographical department, urban or rural setting, gender, and age groups (15-19 and 20-24 years). The final sample included 3586 household participants (47.6% female). A weighted sample of 3945 individuals was obtained and used in the following analyses. Overall, 21.75% (95% CI 19.91-23.59) of participants reported having been diagnosed with at least one STI in their lifetime, with a higher prevalence among men (25.70%; 95% CI 22.89-28.52), compared to women (18.11%; 95% CI 15.73-20.49), χ2 = 16.43; p < 0.001). Sexual abuse victims were more likely to report STIs (31.27%; 95% CI 29.21-33.34), compared to non-victims (18.40%; 95% CI 16.68-20.13), χ2 = 27.89; p < .001. Sexual abuse was associated to an increased risk of contracting at least one STI (OR = 1.74; 95% CI 1.35, 2.24). The results demonstrate that sexual abuse is associated with a general increase of reporting STIs. They indicate the need for national sexual abuse prevention programs at early ages. These programs should be implemented in schools and churches, focusing on the role of families in sexuality education. Finally, programs must be developed to eradicate community violence-especially in the cities-as increased political and social violence has always been associated with increased sexual abuse in Haiti.

Case conceptualization in child welfare: an underused resource to improve child, family, and provider outcomes

Case conceptualization, formally known as case formulation, is one tool that assists in determining the best course of action for children and families experiencing family violence that has been under-utilized in child welfare. In this article we present a step-by-step case conceptualization process that considers the child welfare context. We then present a hypothetical case example of a 10-year-old child referred by a child welfare worker to evidence-based treatment for mental health and behavioural concerns. Mental health services are not helpful for the child and further consultation is enlisted. To more effectively guide intervention and treatment planning and ultimately improve outcomes for the child, we present case conceptualization as a process that incorporates relevant aspects of the child and family's history and circumstance. We conclude with a succinct case conceptualization and treatment plan to show how the prognosis of the child can be improved when case conceptualization is employed.

A systematic review of the measurement properties of self-report screening tools to detect risk or exposure to child sexual abuse for children under 12

Child sexual abuse (CSA) is a substantial public health issue that is challenging to measure epidemiologically due to the "pact of silence" among those involved. Validated tools could contribute to early recognition or risk detection for CSA. We aimed to systematically assess self-report tools' measurement properties and methodological quality that detect risk or exposure to CSA for children under twelve. The search strategy, selection criteria, data extraction, data analysis, and synthesis followed the COSMIN methodology for systematic reviews (2018). PROSPERO 2021 registration CRD42021278465. MEDLINE, COCHRANE, EMBASE, CINAHL, SCOPUS, and ERIC were searched until August 2021, with an updated search on September 23, 2021, and unlimited by language. The inclusion criteria were: to assess risk or exposure to CSA under twelve years old by objective items and self-report tools; sexual violence risk or exposure in the domestic context; the application context should include health facilities (such as hospital emergency rooms, outpatient clinics, pediatric wards, psychology centers, social services), education (such as schools) and community; no language or date restriction. The exclusion criteria were: non-self-report tools studies, comprehensive articles, comments, editorials, expert opinions, and studies of projective techniques. The COSMIN risk of bias checklist was used to evaluate the methodological quality of the included studies. Feasibility aspects were assessed. This study had no funding source; 29 studies describing eight tools met eligibility criteria. No single instrument reported all nine measurement properties outlined by the COSMIN methodology. The strength of the evidence was moderate to high for six out of eight instruments. ICAST-C and JVQ were the tools that obtained the highest number of rated measurement properties and strength of evidence.

Lifetime and Child Sexual Violence, Risk Factors and Mental Health Correlates Among a Nationally Representative Sample of Adolescents and Young Adults in Haiti: A Public Health Emergency

Very little is known in Haiti and the Caribbean regarding child and lifetime sexual victimization. Using a nationally representative sample of adolescents and young adults aged 15-24, this study aimed to document the prevalence, risk factors and mental health correlates of lifetime and child sexual violence in Haiti. A national cross-sectional surrvey was conducted in Haiti, using a multistage sampling frame, stratified by geographical department, urban or rural setting, gender, and age groups (15-19 and 20-24 years). The final sample included 3586 household participants (47.6% female). A weighted sample of 3945 individuals was obtained and used in the following analyses. Overall rate of lifetime and child sexual violence was, respectively, 27.44% (95% CI 25.94-28.94) and 11.27% (95% CI 10.18-12.35). Lifetime sexual violence rate was significantly higher among female participants (29.02%; 95% CI 27.5-30.55) compared to male (25.73%, 95% CI 24.26-27.2), χ² = 4.63, p < .05, but there was no significant gender difference for child sexual victimization. Experiences of family physical violence, emotional abuse by mother and father, divorce of parents, and other physical violence were strongly associated with higher odds of sexual victimization. Participants who reported having experienced sexual violence are more at risk to meet criteria of PTSD (OR = 1.96, 95% CI 1.66-2.32; p < .0001), depression (OR = 1.73, 95% CI 1.47-2.02; p < .0001), psychological distress (OR =1.72, 95% CI 1.47-2.02; p < .0001), and substance abuse (OR = 1.33, 95% CI 1.13-1.57; p < .0001). Findings demonstrate that sexual violence is a public health emergency in Haiti. They provide evidence for the development of prevention and intervention programs.

Development and validation of a shortened version of the Child Abuse Self Report Scale (CASRS-12) in the Arabic language

BACKGROUND

All available scales to screen for child abuse may be challenging to administer due to their length. Indeed, a higher number of items is associated with more administration time and less motivation to engage in responding. We aimed through this study to examine the psychometric properties of a brief Arabic version of the Child Abuse Self Report Scale (CASRS-12) in terms of factorial structure, internal consistency, divergent validity, and correlations with measures of bullying victimization, eating attitudes and perceived social support.

METHODS

We performed a cross-sectional, web-based study among Community Lebanese adolescents; where two samples have been used (Sample 1: N = 852, aged 15.34 ± 1.18 years, 54.8% females; Sample 2: N = 404, aged 16.60 ± 1.51 years, 57.2% females). The construct validity was tested using both exploratory and confirmatory factor analyses.

RESULTS

Results revealed that both EFA and CFA yielded a four-factor structure for the CASRS-12 that mirrors the original four factors captured by the original CASRS. The scale also showed a good internal consistency as evidenced through McDonald's ω values ranging from 0.87 to 0.93 for the four subscales; and configural, metric, and scalar invariance across gender. Finally, we found that all CASRS-12 dimensions were significantly and positively correlated with more inappropriate eating attitudes and lower social support; and that psychological, physical, and sexual abuse correlated with higher bullying victimization CONCLUSION: In light of these findings, we potentially encourage clinicians and researchers to use this scale as a valid and reliable measure of child abuse among Arabic-speaking populations.

"What does that mean?": The content validity of the ISPCAN Child Abuse Screening Tool - Child version (ICAST-C) in Romania, South Africa, and the Philippines

BACKGROUND

The International Society for Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse Screening Tool (Children's Version), known as the ICAST-C Version 3, is used widely to assess violence against children, but there is limited psychometric evidence, especially on content validity.

OBJECTIVE

This study aimed to assess the content validity of the ICAST-C with adolescents in Romania, South Africa, and the Philippines.

METHODS

A purposive sample of adolescents (N = 53, 51 % female) were recruited from urban areas in Romania, the Eastern Cape Province of South Africa, and Metro Manila, Philippines. Semi-structured one-on-one in-depth cognitive interviews sought adolescent perspectives on the relevance, comprehensibility, and comprehensiveness of the ICAST-C. Data were analysed using template analysis.

RESULTS

The ICAST-C was broadly perceived to be relevant and comprehensive in measuring violence against children in all study locations. However, there were issues with the comprehensibility of the measure, described at three levels: interpreting items, undertaking coherent elaborations of relevant behaviors and places, and generating a coherent response to the questions.

CONCLUSIONS

Suggestions to revise the ICAST-C include, among others, adding a practice or how-to section on answering the survey, clarifying the intent of questions, especially on neglect and sexual abuse, emphasizing that questions cover all locations, and asking more positive questions. Pilot studies testing the content validity and cultural appropriateness are needed as a matter of practice in large self-report surveys.

Child Maltreatment and Intimate Partner Violence in Mental Health Settings

Intimate partner violence (IPV) and child maltreatment (physical, emotional, sexual abuse, neglect, and children's exposure to IPV) are two of the most common types of family violence; they are associated with a broad range of health consequences. We summarize evidence addressing the need for safe and culturally-informed clinical responses to child maltreatment and IPV, focusing on mental health settings. This considers clinical features of child maltreatment and IPV; applications of rights-based and trauma- and violence-informed care; how to ask about potential experiences of violence; safe responses to disclosures; assessment and interventions that include referral networks and resources developed in partnership with multidisciplinary and community actors; and the need for policy and practice frameworks, appropriate training and continuing professional development provisions and resources for mental health providers. Principles for a common approach to recognizing and safely responding to child maltreatment and IPV are discussed, recognizing the needs in well-resourced and scarce resource settings, and for marginalized groups in any setting.

Exploration of factors influencing court outcomes in cases involving minors as victims in Ghana

BACKGROUND

The factors that influence positive court outcomes for cases of child sexual abuse (CSA) have been studied in other contexts but very few such studies exist for Sub-Saharan countries. Knowledge of how such cases fare in these court systems is, however, important for a global assessment of such outcomes.

OBJECTIVE

The study explored the predictive effect of the victim, complainant; offender and offence characteristics, and length of the trial on case disposition and dropout.

METHODS, PARTICIPANTS AND SETTING

Three hundred and eighty-nine (389) closed court files related to child sexual abuse in Ghana were reviewed and analyzed.

RESULTS

The findings show that the number of court sittings (length of trial) and complainant characteristics predict negative outcomes for CSA cases in Ghana. Specifically, convictions were less likely to occur where caregivers were the complainants (OR = 0.45), and when there were longer court sittings (OR = 0.95). Victim, offender, and offence characteristics, however, did not influence case outcomes.

CONCLUSIONS

This study is one of the first studies using actual court data to predict the outcome of cases in CSA in Ghana, and makes recommendations for the support of children and caregivers through the court process.

Child Welfare Reform: A Scoping Review

While there have been ongoing calls to reform child welfare so that it better meets children's and families' needs, to date there have been no comprehensive summaries of child welfare reform strategies. For this systematic scoping review, we summarized authors' recommendations for improving child welfare. We conducted a systematic search (2010 to 2021) and included published reviews that addressed authors' recommendations for improving child welfare for children, youth, and families coming into contact with child welfare in high-income countries. A total of 4758 records was identified by the systematic search, 685 full-text articles were screened for eligibility, and 433 reviews were found to be eligible for this scoping review. Reviews were theoretically divided, with some review authors recommending reform efforts at the macro level (e.g., addressing poverty) and others recommending reform efforts at the practice level (e.g., implementing evidence-based parenting programs). Reform efforts across socioecological levels were summarized in this scoping review. An important next step is to formulate what policy solutions are likely to lead to the greatest improvement in safety and well-being for children and families involved in child welfare.

Foster children's perspectives on participation in child welfare processes: A meta-synthesis of qualitative studies

The objective of this meta-synthesis was to systematically synthesise qualitative research that explores foster children's perspectives on participation in child welfare processes. Searches were conducted in Medline (OVID), Embase, PsycINFO, and Social Science Citation Index. Children in non-kinship foster care in any setting (high-income, middle-income, low-income countries) who self-reported their experiences of care (removal from home, foster family processes, placement breakdown) were eligible for inclusion. Selected studies took place in 11 high-income countries. A total of 8436 citations were identified and 25 articles were included in this meta-synthesis. Studies summarized the views of 376 children. Children had been in foster care between two weeks and 17 years. Findings synthesize 'facets' of children's participation (e.g., being asked vs making decisions), as well as children's perceived barriers and facilitators to participation. A main priority for children was the quality of their relationships, especially in terms of values (e.g., fairness, honesty, inclusivity). No one way of participating in child welfare processes is better than another, as some children more clearly expressed a desire for passive listening roles and others indicated a desire for active roles in decision-making. However, meaningful adults in foster children's lives have a responsibility to act in a way that strengthens the emphasis on children's needs and voices.

Sexual Inviolability of Minors in Central Kazakhstan: A Forensic Medical Analysis

Abstract Child sexual abuse is a social phenomenon that requires special attention from society, as it leads to the suffering of the most vulnerable part of the world's population. Child sexual abuse around the world not only persists, but also continues to grow, despite the active measures of the world community against it. Taking into account the high latency of crimes against sexual inviolability and sexual freedom of the person, measures for their detection and prevention are of particular relevance. All this requires constant monitoring of the current situation not only in the world or in the country, but also in each region of the country separately. Forensic medical examination of victims of sexual violence plays an important role in the analysis of the situation on this problem, not only in the legal, but also in the medical aspect.  Research aim: Analysis of quantitative and qualitative indicators of crimes against the sexual inviolability of minors on the territory of Central Kazakhstan for the formation of indicators for assessing the current situation in the region and recommendations for the prevention of these types of crimes. Methods A retrospective analysis of the situation on the number and structure of sexual crimes committed against children from 2018 to 2021 was carried out, and their dynamics was studied. There were investigated 1252 forensic medical examinations on cases of sexual crimes against the sexual inviolability of the person on the territory of Central Kazakhstan. Methods of applied statistical analysis were used to analyz obtained results. Results A detailed analysis made it possible to assess the structure and peculiarities of sexual crimes committed against children on the territory of Central Kazakhstan over the specified period of time. The number of sexual crimes against minors in the region is increasing every year. Statistically significant age characteristics of victims and specific indicators characterizing the socio-psychological aspects of sexual crimes in the region were revealed. It has been established that in most cases the aggressor is part of the victim's family or is very close to it. The analysis of the age structure of children showed that boys from 6 to 14 years old and girls over 14 are more likely to become victims. In the studied territory, the number of sexual harassment of children is more often committed by one person, often known to them, and in most cases occurs in enclosed spaces than on the street. Conclusion The progressive growth of crimes against the sexual inviolability of children in the region requires strengthening measures to improve legal means of countering sexual crimes against minors. A detailed study of the issue made it possible to identify lacks (organizational, tactical, diagnostic) and give the forensic medical examination of sexual conditions a qualitatively new level. The strategy of combating sexual crimes against minors should be based on active preventive work. Key words: forensic medical examination, sexual violence, Central Kazakhstan, children, minors.

Pediatricians' Attitudes Toward Child Sexual Abuse in the Republic of Srpska

Child sexual abuse (CSA) affects all cultures and sociodemographic sections. As health professionals, pediatricians are often the first line of defense when it comes to CSA identification and reporting. Our previous study examined encounters, competence, beliefs, and reporting regarding CSA among pediatricians in countries of the former Yugoslavia, Serbia, and Montenegro. Following up on this work, we expanded our research to another neighboring country, the Republic of Srpska (RS). Sixty pediatricians were surveyed in 2020, comprising 30% of all practicing pediatricians in the Republic of Srpska. Compared to their colleagues from Serbia and Montenegro, RS pediatricians revealed an increased perception that children are often abused by someone they do know well, were more confident in their abilities to detect CSA, reported a higher number of CSA cases, and were more interested in further trainings on the subject of CSA. Despite this, the level of underreporting remained high (40%). To our knowledge, this is the first study to both assess and compare CSA-related attitudes in this part of the world. Key differences between RS, other two neighboring countries as well as from other countries worldwide are likely to stem from the level of pediatricians' training and education, as well as from the socio-cultural and legislation context. Although encouraging, our data indicate a need for further research in the countries of the former Yugoslavia.

Adverse childhood experiences and implications of perceived stress, anxiety and cortisol among women in Pakistan: a cross-sectional study

OBJECTIVES

Adverse childhood experiences (ACEs) are linked to poor maternal mental health. The goal of this study is to examine the associations between ACEs and multiple manifestations of stress (including perceived stress, anxiety and cortisol) among mothers in rural Pakistan.

DESIGN

This study used a cross-sectional design. Mothers were originally recruited during their third trimester of pregnancy and followed until 36 months post partum. Cortisol was collected at 12 months post partum, and self-report data were collected at 36 months post partum.

SETTING

All participants reside in rural villages in Rawalpindi, Pakistan. The measures were administered at home visits by field interviewers.

PARTICIPANTS

Data were collected from 889 mothers. All mothers in the sample provided data on ACEs and perceived stress, 623 provided data on anxiety and 90 provided hair cortisol.

PRIMARY AND SECONDARY OUTCOMES MEASURES

ACEs were captured retrospectively using an adapted version of the ACE International Questionnaire, and represented as a continuous variable and subdomains (neglect, home violence, family psychological distress, community violence). Primary outcomes included perceived stress measured with the Cohen Perceived Stress Scale (PSS) and anxiety measured with the Generalised Anxiety Disorder-7 scale (GAD-7). Hair-derived cortisol was included as a secondary outcome. Generalised linear models with cluster-robust SEs were used to estimate associations between ACEs and the outcome variables.

RESULTS

All models featured positive associations between ACE items and PSS. The continuous total ACE score (B=0.4; 95% CI 0.0 to 0.8) was associated with higher anxiety symptoms on the GAD-7. Home violence (B=6.7; 95% CI 2.7 to 10.8) and community violence (B=7.5; 95% CI 1.4 to 13.6) were associated with increased hair cortisol production.

CONCLUSIONS

All four ACE domains were associated with elevated levels of perceived stress, anxiety and cortisol, with varying precision and strength of estimates, indicating that the type of ACE has a differential impact. This study informed our understanding of the differential impact of specific ACEs on perceived stress, anxiety and hypothalamic pituitary adrenal-axis functioning, providing implications for future clinical intervention and research development.

Health care providers' responses to sexually abused children and adolescents: a systematic review

Background

Sexual abuse of children and adolescents is a significant health concern worldwide. Appropriate and timely health services for victims can prevent severe and long-term consequences. This study identified and categorized diagnostic and treatment services needed for sexually abused children and adolescents.

Methods

Several databases, including MEDLINE, Web of Science, Scopus, Science Direct, ProQuest, and Google Scholar, were searched to retrieve studies on the topic and clinical guidelines in English covering the literature from 2010 to 2020 using search terms. Primary studies and guidelines were reviewed to identify treatment strategies and medical interventions related to sexually abused children and adolescents.

Results

Twenty-one studies and guidelines were selected and analyzed narratively. The quality of evidence was relatively good. We identified that effective health care systems for sexually abused children include the following: interview and obtain medical history, physical and anogenital examination, collecting forensic and DNA evidence, documenting all the findings, prevention and termination of pregnancy, diagnostic tests, prophylaxis for HIV and other STIs, vaccinations, and psychological intervention.

Conclusions

This review provides up-to-date evidence about adequate health care services for children and adolescent victims of sexual abuse. We conclude that recent studies have focused more on prophylaxis against HIV and other STIs, studies on vaccinating against HPV for victims are still limited, and future research in this area is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07814-9.

Child Abuse as an Example of Coexistence of Emotional and Physical Trauma Among Children: An Academic Overview With Altmetric Perspective

Introduction: Child abuse combines emotional, physical, sexual, and neglect aspects of violence, thus diversifying the trauma for a child. Publications about child abuse had been discussed in academia for long years and evaluated by bibliometric analysis, frequently. This study aims to evaluate the most discussed/disseminated scientific publications about child abuse in electronic media such as social media accounts, blogs, podcasts, and media news sites using a new analysis method called altmetric analysis.

Methods: The data were obtained from the Altmetric Explorer database using the phrase “child abuse,” in 2021. After being ranked by altmetric attention score (AAS), descriptive statistics for all publications as well as detailed analyses for the first-100 publications were performed. Variables evaluated were AAS, dimensions-badge value, distribution of web sources, demographic/geographic-breakdown type distributions, main subject categories, and mesh terms. Kruskal Wallis test was used for AAS and dimensions-badge value comparisons while Spearman correlations and regression analysis were also performed. Analyses were performed by SPSS 23.0 (IBM SPSS, Inc., Chicago, IL, USA) and p<0.05 was considered statistically significant.

Results: Publications about child abuse were shared extensively on social media, mostly on Twitter. In terms of the main subject, sexual abuse was the trending topic, followed by physical abuse and maltreatment. Psychology, studies in human society, health sciences, and law/legal issues were the four main science categories about the subject. The United States was the major disseminator of publications while Child Abuse and Neglect was the most productive journal. There was a weak but significant (p<0.05) positive correlation between AAS and dimensions-badge values.

Conclusion: Child abuse is a multidimensional subject in social media. As the number of publications increases, the possibility of articles to be shared on different social media platforms also increases. The majority of the top-100 publications are the ones emphasizing the importance of child abuse in terms of the prevalence, individual/social burden, and negative consequences.

Sexual Abuse vs. Sexual Freedom? A Legal Approach to the Age of Sexual Consent in Adolescents in Spanish-Speaking Countries

Child and adolescent sexual abuse (CSA) is an international public health problem. Despite the importance of CSA, there is no consensus definition, and the lack of consensus is related to difficulties in conducting prevalence studies as well as research in other areas. To establish a consensual definition, legal aspects such as the age of sexual consent and the difference in age or power between victim and aggressor as well as aspects related to sexual freedom and sexual indemnity must be considered. Therefore, the main goal of this research was to analyze the age of sexual consent in the legal systems of Spanish-speaking countries and to examine whether the Romeo and Juliet clause is established. To achieve the proposed aims, we employed the legal interpretation method, and we analyzed the current Criminal Codes of the 21 Spanish-speaking countries. From the results, it is found that the age of sexual consent varies between countries, establishing valid sexual consent between 13 and 18 years. In addition, only six countries have the Romeo and Juliet clause that protects sexual freedom in adolescents. Finally, we discussed the lack of consensus on the age of sexual consent and the limitations presented by the Romeo and Juliet clause.

Boys should not be overlooked: Sexual violence victimization and associated factors among school-going adolescents in urban Ghana

BACKGROUND

Adolescent sexual violence victimization is still less researched in countries within sub-Saharan Africa, including Ghana.

OBJECTIVES

To estimate the 12-month prevalence of sexual violence victimization and describe the differences and commonalities in the associated factors between school-going boys and girls in urban Ghana.

PARTICIPANTS AND SETTING

Students (n = 1692) aged 13-19 years attending Second Cycle Schools in the Greater Accra Region of Ghana participated in this study.

METHODS

This is a cross-sectional survey involving the use of a self-report anonymous questionnaire. Items measuring sexual violence victimization and correlates were adopted from the 2012 WHO-Global School-based Student Health Survey. Data analysis involved bivariable and multivariable approaches.

RESULTS

Overall, 17.6% (95% confidence interval [CI] 15.7, 19.4) adolescents (males = 10.4% [95% CI 8.3, 13.6]; females = 24.3% [95% CI 21.5, 27.3]) reported sexual violence victimization during the previous 12 months. Girls (compared to boys) were nearly three times more likely to report sexual violence victimization (aOR = 2.74, 95% CI 2.01, 3.74, p < 0.001). Breakup, sexual minority status, and conflict with parents were uniquely associated with sexual violence victimization among females. Regardless of gender, adolescents who were in a romantic relationship (aOR = 1.63, 95% CI 1.19, 2.24, p = 0.002) and reported physical abuse victimization (aOR = 1.84, 95% CI 1.36, 2.49, p < 0.001) were more likely to report sexual violence victimization.

CONCLUSIONS

The prevalence of sexual violence victimization among school-going adolescents in urban Ghana compares with estimates from sub-Saharan Africa, but also warrants the need for universal and targeted prevention regimes against the offence in both boys and girls.

Factors associated with the prevalence of HIV, HSV-2, pregnancy, and reported sexual activity among adolescent girls in rural western Kenya: A cross-sectional analysis of baseline data in a cluster randomized controlled trial

BACKGROUND

Adolescence is a sensitive time for girls' sexual and reproductive health (SRH), as biological changes occur concurrently with heightening pressures for sexual activity. In western Kenya, adolescent girls are vulnerable to acquiring sexually transmitted infections (STIs), such as HIV and herpes simplex virus type 2 (HSV-2), and to becoming pregnant prior to reaching adulthood. This study examines associations between individual, household, and partner-related risk factors and the prevalence of sex, adolescent pregnancy, HIV, and HSV-2.

METHODS AND FINDINGS

We report baseline findings among 4,138 girls attending secondary school who were enrolled between 2017 and 2018 in the Cups or Cash for Girls (CCG) cluster randomized controlled trial in Siaya County, rural western Kenya. Laboratory confirmed biomarkers and survey data were utilized to assess the effects of girls' individual, household, and partner characteristics on the main outcome measures (adolescent reported sex, prior pregnancy, HIV, and HSV-2) through generalized linear model (GLM) analysis. Complete data were available for 3,998 girls (97%) with median age 17.1 years (interquartile range [IQR] 16.3 to 18.0 years); 17.2% were HSV-2 seropositive (n = 686) and 1.7% tested positive for HIV (n = 66). Sexual activity was reported by 27.3% girls (n = 1,090), of whom 12.2% had been pregnant (n = 133). After adjustment, orphanhood (adjusted risk ratio [aRR] 2.81, 95% confidence interval [CI] 1.18 to 6.71, p-value [p] = 0.020), low body mass index (BMI) (aRR 2.07; CI: 1.00 to 4.30, p = 0.051), and age (aRR 1.34, 1.18 to 1.53, p < 0.001) were all associated with HIV infection. Girls reporting light menstrual bleeding (aRR 2.42, 1.22 to 4.79, p = 0.012) for fewer than 3 days (aRR 2.81, 1.16 to 6.82, p = 0.023) were over twice as likely to have HIV. Early menarche (aRR 2.05, 1.33 to 3.17, p = 0.001) was associated with adolescent pregnancy and HSV-2-seropositive girls reported higher rates of pregnancy (aRR 1.62, CI: 1.16 to 2.27, p = 0.005). High BMI was associated with HSV-2 (aRR 1.24, 1.05 to 1.46, p = 0.010) and sexual activity (aRR 1.14, 1.02 to 1.28, p = 0.016). High levels of harassment were detected in the cohort (41.2%); being touched indecently conveyed the strongest association related to reported sexual activity (aRR 2.52, 2.26 to 2.81, p < 0.001). Study limitations include the cross-sectional design of the study, which informs on the SRH burdens found in this population but limits causal interpretation of associations, and the self-reported exposure ascertainment, which may have led to possible underreporting of risk factors, most notably prior sexual activity.

CONCLUSIONS

Our findings indicate that adolescent girls attending school in Kenya face frequent harassment for sex and are at high risk of pregnancy and HSV-2, with girls experiencing early menarche particularly vulnerable. Targeted interventions, such as earlier sexual education programs, are warranted to address their vulnerability to SRH harms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03051789.

A review of the literature on good practice considerations for initial health system response to child and adolescent sexual abuse

BACKGROUND

Healthcare workers play an important role in responding to the needs of the millions of children and adolescents who experience sexual abuse around the globe. A supportive child and adolescent-centered initial response is crucial for the physical and emotional wellbeing of survivors.

OBJECTIVE

In 2017, the World Health Organization (WHO) published clinical guidelines for responding to child and adolescent sexual abuse. The review described in this paper informed the development of good practice statements on how best to deliver health care to survivors.

PARTICIPANTS AND SETTING

This review examined the values and preferences of children and adolescents who were sexually abused, and of their caregivers and healthcare workers, regarding: 1) initial response to children and adolescents who have been sexually abused; and 2) obtaining medical history, conducting physical examination, and documenting examination findings.

METHODS

Searches were conducted in Scopus, Pubmed, and the WHO's Global Index Medicus (1 January, 1995-15 July 2016). All articles in English that indicated preferences of survivors, caregivers and/or healthcare workers in ensuring empathetic and trauma-informed care were included.

RESULTS

Sixty-two articles were included and analyzed thematically. Key findings included the importance of providing care to survivors in a manner that respects the child or adolescent's autonomy and wishes, ensures privacy and confidentiality, and makes services and facilities appropriate and welcoming.

CONCLUSIONS

Findings indicate how evidence-based recommendations can be delivered in a child or adolescent-centred and trauma-informed manner.

Self-Harm Among School-Going Adolescent Survivors of Sexual Violence Victimisation: A Cross-Sectional Study

Background: A growing body of evidence from high-income contexts suggests a strong association between sexual violence victimisation and self-harm and eventual suicide. However, both sexual violence and self-harm among adolescents are still less researched in sub-Saharan African countries, including Ghana. Objectives: To estimate the 12-month prevalence of self-harm, and to describe the associated factors and reported reasons for self-harm among school-going adolescent survivors of sexual violence victimisation during the previous 12 months in urban Ghana. Methods: Analytic data came from a regional-based representative cross-sectional survey including in-school youth (N = 1,723) conducted in 2017 within the Greater Accra Region of Ghana. Of these, 297 (17.2%) self-reported sexual violence victimisation in the previous 12 months; this proportion of the participants (n = 297) was the focus of the current study. Items measuring sexual violence victimisation, self-harm, and correlates were adopted from the 2012 Ghana WHO-Global School-based Student Health Survey and the Child and Adolescent Self-harm in Europe Study. Data analysis involved multivariable logistic regression models. Results: The estimate of self-harm ideation during the previous 12 months was 45.8% (95% CI: 40-52), whereas the estimate of self-harm behaviour was 38.7% (95% CI: 33-44). About two in five of the participants who reported self-harm wanted to die by their last episode of the behaviour. While bullying victimisation was associated with increased odds of self-harm ideation (aOR = 1.97, 95% CI 1.17, 3.31, p = 0.010) and behaviour (aOR = 2.76, 95% CI 1.59, 4.80, p < 0.001), weekly alcohol use (aOR = 2.56, 95% CI 1.32, 4.93, p = 0.005), conflict with parents (aOR = 2.30, 95% CI 1.28, 4.12, p = 0.005), and physical abuse victimisation (aOR = 1.80, 95% CI 1.03, 3.15, p = 0.037) showed strong associations with increased odds of self-harm behaviour in the past 12 months. Conclusions: The evidence underscores the need for both universal and targeted multi-level intervention and prevention programmes to mitigate the offence of sexual violence and reduce the chances of self-harm among adolescent survivors of sexual violence in urban Ghana.

Características da violência contra crianças no município de Porto Alegre: análise das notificações obrigatórias

RESUMO Objetivo caracterizar a violência notificada contra crianças no município de Porto Alegre. Método estudo retrospectivo, incluindo 5308 casos de violência contra crianças de zero a doze anos registrados no Sistema de Informação de Agravos de Notificação no município de Porto Alegre. Resultados idade média foi de 5,95 ± 3,86 anos, com predomínio de crianças do sexo feminino (61%). A violência sexual foi a mais notificada (53%). A maioria dos agressores eram do sexo masculino (68%) e 72% dos casos ocorreram no domicílio da vítima. As meninas são mais suscetíveis à violência sexual. Crianças do sexo masculino sofrem mais violência física e negligência. Conclusão e implicações para a prática os resultados demonstram a importância do conhecimento do perfil das violências para intervenção e elaboração de políticas públicas intersetoriais, assim como para a capacitação da equipe multiprofissional para o reconhecimento do problema no momento da assistência e o devido encaminhamento.

Male-On-Male Child and Adolescent Sexual Abuse in the Caribbean Region of Colombia: A Secondary Analysis of Medico-Legal Reports

Child and adolescent sexual abuse (CSA) is an important global health problem, especially in non-Western low- and middle-income countries. A number of studies have indicated that, in Latin American countries, male CSA is phenomenon of great concern. However, research on this topic is seriously lacking, and more specifically, on male-on-male CSA. We carried out a qualitative and quantitative secondary analysis of 680 cases of alleged male-on-male CSA that occurred between the years 2017 and 2018 in the Caribbean Region of Colombia. We analyzed the contents of forensic interviews with the alleged victims, conducted by professionals working at the Colombian Institute of Legal Medicine and Forensic Sciences. Our findings indicated a high prevalence of cases of alleged male-on-male CSA among young minors. Most of these cases were allegedly perpetrated by offenders known to the victim and involved high levels of violence. Evidence-based and culturally grounded preventative actions, such as training-based programs for teachers and parents among other public health initiatives are needed to address this type of CSA. Further research is also required to gain a more fine-grained understanding of the cultural and social context of CSA in the Caribbean Latin American countries.

Suffering whether You Tell or Don't Tell: Perceived Re-Victimization as a Barrier to Disclosing Child Sexual Abuse in Zimbabwe

Disclosing child sexual abuse (CSA) is a necessary first step to access the legal, health, and psycho-social services that survivors and their families need. However, disclosure rates are low: of young women who experienced CSA in Zimbabwe, only 9% disclosed the first incident. The purpose of this qualitative study was to explore and describe perceived barriers to disclosing CSA in Zimbabwe. We conducted focus group discussions with children aged 10-14 years (n = 40) and their parents/caregivers aged 20-62 years (n = 40), participating in an intervention trial in Chitungwiza, Zimbabwe. We found that potential retaliation against survivors and their families is a major barrier to disclosing CSA. These retaliatory acts, which we refer to as "re-victimization," arise from stigma or the victim feeling blamed or doubted and manifest through physical violence, emotional violence, and deprivation of family life and education. Our findings suggest that addressing social and cultural norms related to sex and strengthening legal protection for CSA survivors and their families could encourage CSA disclosure and could help end this violence. Our findings also highlight a need to increase children's awareness of their rights and to create safe systems for disclosure of sexual abuse.

Parents as Teachers: Mothers' Roles in Sexual Abuse Prevention Education in Gorgan, Iran

BACKGROUND

Parents play an important role in protecting their children from sexual abuse. Mothers, in particular, play key roles in the sexual socialization of their children and in educating their children about child sexual abuse (CSA).

OBJECTIVES

The purpose of this study was to determine whether preschool girls in Gorgan (a city in northern Iran) could learn personal safety skills when taught by their mothers.

PARTICIPANTS AND SETTING

Fifty-six participants (mother-daughter pairs) were recruited from patients visiting health centers. Mean age of girls was 6.34 years.

METHODS

Girls were pretested using Persian versions of the Personal Safety Questionnaire and 'What If' Situations Test, randomly assigned to either a mother-taught program or wait-list control, and post-tested. Mothers assigned to the education group participated in a two-hour workshop on preventing CSA and were given the Body Safety Training workbook to teach their daughters. Following the one-week training by their mothers, children in both groups were post-tested and follow-up tested one month later.

RESULTS

Children taught by their mothers demonstrated significant increases in knowledge about sexual abuse and higher levels of personal safety skills compared to controls, and these gains were maintained at the one-month follow-up.

CONCLUSION

Results suggest that mothers can effectively teach their young daughters personal safety skills. Difficulties female children have in recognizing appropriate-touch requests are discussed and compared to results in other developing countries. Advantages of home-based instruction for young children are described and suggestions for increasing parent participation are offered.

The Relevance of Certain Case Characteristics in the Successful Prosecution of Child Sexual Abuse Cases in Indonesia

Successful prosecution in child sexual abuse (CSA) cases is an essential purpose of law enforcement agencies to ensure accountability of perpetrators and children's safety. However, research has shown that legal prosecution of CSA cases is a highly complex endeavor resulting in only a limited percentage of cases being prosecuted and ultimately proven in court. Most attrition occurs at the stage of the police investigation. The current study is the first study of CSA prosecution in an Asian country. We aimed to identify factors, which contribute to Indonesian CSA cases prosecution. We examined police files of CSA cases (N = 179) from three police units in greater Jakarta. We found that only 32% (n = 58) of cases were prosecuted. The following factors increased the odds of prosecution: victim being threatened, the suspect confessed, medical examination report being present, duration of investigations between one to 2 months, and the case being charged under the Child Protection Law. These findings (threat, suspect confession, and the presence of a medical examination report) correspond to previous studies in other jurisdictions.

Evaluating the quality of meta-analytical reviews using the AMSTAR-2: A systematic review of meta-analytical reviews regarding child sexual abuse interventions

BACKGROUND

Effects of treatment for child sexual abuse (CSA) victims have important implications. Assessing Risk of Bias (RoB) is a vital step to inform interpretations of treatment effects for these victims. The AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) offers a comprehensive critical appraisal, allowing users to distinguish high quality reviews.

OBJECTIVE

The aim of this article is two-fold: 1) to provide an up-to-date systematic review of treatment program meta-analytical reviews on interventions for CSA victims; and 2) to evaluate the quality of meta-analytical reviews using the AMSTAR-2. This is the first systematic review to examine the quality of meta-analyses on the effectiveness of CSA interventions using the AMSTAR-2.

METHOD

Eight electronic databases were searched for articles published up to April 2019. Meta-analytical reviews that assessed the effectiveness of any treatment modality for sexually abused children and adolescents up to 18 years old were considered. Outcome measures included physical and mental symptoms, and disorders, measured through validated instruments. Of 2794 articles, nine meta-analyses met the eligibility criteria. There was a variety of interventions, including: trauma-focused cognitive-behavioral therapy CBT, psychodrama, play therapy, and eclectic interventions. The most common outcomes measured were post-traumatic stress disorder/trauma, externalizing, internalizing, and sexualized behaviors.

RESULTS

Although effect sizes were moderately significant, with treatment having a positive effect, all meta-analyses showed a high RoB.

CONCLUSIONS

To use the best available evidence in clinical decision-making for CSA victims, reviewers should conduct meta-analyses that employ RoB tools.

Parents' Knowledge, Attitudes, and Experiences in Child Sexual Abuse Prevention in El Salvador

Childhood sexual abuse (CSA), a global public health problem, is often underreported especially in low-income countries such as El Salvador, and prevention efforts are needed. The purpose of this study was to examine knowledge, attitudes and experiences of CSA prevention and characteristics related to greater knowledge and openness to engaging in child abuse prevention among Salvadoran parents. Salvadoran parents (N = 478) completed questionnaires regarding demographics, definition and signs and symptoms of child abuse, personal experiences of CSA, CSA prevention training, and knowledge, attitudes and practices about preventing CSA. Most parents were knowledgeable about CSA, viewed CSA prevention as their responsibility, and had talked with their children about CSA, although 65.7% incorrectly believed that children are more likely to be abused by strangers. Parents with lower income were less knowledgeable and willing to participate in CSA prevention. CSA programing needs to involve parents and specifically target low-income parents.

Childhood Sexual Violence in Indonesia: A Systematic Review

There has been relatively little research into the prevalence of childhood sexual violence (CSV) as well as the risk and protective factors for CSV in low- and middle-income countries including Indonesia. Systematic searches conducted in English and Bahasa Indonesia in this review identified 594 records published between 2006 and 2016 in peer-reviewed journals and other literature including 299 Indonesian records. Fifteen studies, including nine prevalence studies, met the quality appraisal criteria developed for this review. The review found that CSV research is scarce: Only one study included nationally representative prevalence estimates. Varying definitions for CSV, survey methods, and sample characteristics limited the generalizability of the data. The available evidence points to significant risk of sexual violence affecting both girls and boys across many geographical and institutional settings. Married adolescent girls are vulnerable to sexual violence by partners in their homes. Children in schools are vulnerable to CSV by peers and adults. Victims seldom disclose incidents and rarely seek support. In addition, early childhood experiences of trauma were strongly associated with later perpetration of sexual violence and revictimization. Limited information is available about protective factors. This review synthesizes evidence about what is currently known about CSV in Indonesia and identifies the strengths and weaknesses of the existing research. A more robust evidence base regarding CSV is required to better inform policy and justify investment into prevention programs.

Assessing gender differences in emotional, physical, and sexual violence against adolescents living in the districts of Pikine and Kolda, Senegal

BACKGROUND

Locally representative research and data on violence against children are important to understand the nature and scale of the issue and to inform effective prevention and response programs and policies. In Senegal, few population-level data estimating the prevalence of physical, emotional, or sexual violence against adolescents exist.

OBJECTIVE

This study assesses whether the gender of adolescents in two Senegalese districts is associated with having experienced emotional, physical, or sexual violence and whether such associations vary depending on district of residence and poverty status.

PARTICIPANTS AND SETTING

The sample comprised of 833 adolescents aged 13-18 residing in the peri-urban district of Pikine and rural district of Kolda.

METHODS

Cross-sectional population-based household survey data were analyzed using logistic regression models.

RESULTS

Adolescent boys had 1.6 times greater odds than adolescent girls of having experienced emotional abuse in the past month (adjusted OR = 1.6, 95 % CI 1.1, 2.5) in Pikine. Adolescents living in Pikine and in households with low poverty scores were more likely to have experienced physical abuse in the past month. Gender was a significant predictor of sexual abuse in Kolda, where the prevalence of sexual abuse among adolescent girls was twofold higher compared to boys (adjusted OR = 2.09, 95 % CI 1.03, 4.23).

CONCLUSIONS

Boys in Pikine were more likely to experience emotional violence, and girls in Kolda were at a significantly higher risk of experiencing sexual violence. Prevention and response programs must consider gender and geographic variation to maximize their potential to effectively reduce violence against children.

Preventing child sexual abuse: A systematic review of interventions and their efficacy in developing countries

BACKGROUND

Research on prevalence, risk factors, and prevention interventions for child sexual abuse has continued to focus on western and developed countries. Where country-level prevalence data or large-scale research exists, rates of child sexual abuse are consistently higher in developing and non-western countries than their western and developed counterparts.

OBJECTIVE

We systematically reviewed research on the nature of child sexual abuse interventions in developing countries, the settings and populations included to identify types of child sexual abuse prevention initiatives being implemented in developing countries and their effectiveness.

METHODS

Following PRISMA guidelines, we conducted a systematic search of six databases and identified eight studies to include in our analysis.

RESULTS

Most empirically evaluated interventions in developing countries have focused on preschool and primary school-aged children. Most have focused on interventions delivered in educational settings, with a lack of focus on population-level interventions to prevent child sexual abuse. Researchers have used outcomes measuring knowledge or skills for young people in self-protection and help-seeking, not deployment of those skills, actual reduction in prevalence of CSA, or improvements in conditions of safety in organizational contexts.

CONCLUSIONS

If the focus on school-based strategies to prevent child sexual abuse continues in developing countries, a significant gap in knowledge of the efficacy of population-level interventions outside of school contexts, and consistency across the application of interventions will remain. Evaluations are needed that address the efficacy of broader government-led or whole-of-community prevention interventions to reduce actual prevalence of child sexual abuse, or that can link increased knowledge and skill with reduced victimization.

Identifying children exposed to maltreatment: a systematic review update

Background

Child maltreatment affects a significant number of children globally. Strategies have been developed to identify children suspected of having been exposed to maltreatment with the aim of reducing further maltreatment and impairment. This systematic review evaluates the accuracy of strategies for identifying children exposed to maltreatment.

Methods

We conducted a systematic search of seven databases: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Cochrane Libraries, Sociological Abstracts and the Education Resources Information Center. We included studies published from 1961 to July 2, 2019 estimating the accuracy of instruments for identifying potential maltreatment of children, including neglect, physical abuse, emotional abuse, and sexual abuse. We extracted data about accuracy and narratively synthesised the evidence. For five studies—where the population and setting matched known prevalence estimates in an emergency department setting—we calculated false positives and negatives. We assessed risk of bias using QUADAS-2.

Results

We included 32 articles (representing 31 studies) that evaluated various identification strategies, including three screening tools (SPUTOVAMO checklist, Escape instrument, and a 6-item screening questionnaire for child sex trafficking). No studies evaluated the effects of identification strategies on important outcomes for children. All studies were rated as having serious risk of bias (often because of verification bias). The findings suggest that use of the SPUTOVAMO and Escape screening tools at the population level (per 100,000) would result in hundreds of children being missed and thousands of children being over identified.

Conclusions

There is low to very low certainty evidence that the use of screening tools may result in high numbers of children being falsely suspected or missed. These harms may outweigh the potential benefits of using such tools in practice (PROSPERO 2016:CRD42016039659).

"Everybody's responsibility": Conceptualization of youth mental health in Kenya

There is increasing interest in providing resilience-building interventions in low- and middle-income countries (LMIC), but limited evidence on how young people and their carers process mental health and related supports. The aim of this study was to establish stakeholders' conceptualization of youth mental health in a disadvantaged area of Kenya through focus groups with 7 young people aged 14-17 years and their parents, 9 teachers and 11 practitioners or community leads. The four identified themes related to definitions of both mental well-being and mental health problems; a range of contributing factors related to identity resolution, parenting, poverty and social media; attribution of responsibility at different socio-ecological levels; and required awareness, supports and interventions at these levels. Stakeholders, notably young people, are thus essential in the development and planning of user-led and culturally appropriate interventions in LMIC.

Perceived Skill and Willingness to Address Child Sexual Abuse: Assessing Serbian and Montenegrin Pediatricians

Most research on pediatricians' reporting of child sexual abuse (CSA) is based in western countries. Only recently have studies focused on low-income countries. We are the first to survey pediatricians in Serbia and Montenegro on their encounters, competence and beliefs regarding CSA. Pediatricians in Serbia (n = 358) were recruited during a professional conference; pediatricians in Montenegro (n = 121) were sent an online survey. Demographic information was not obtained. Frequencies and percentages were calculated. A quarter of pediatricians in both countries felt competent detecting medical evidence of CSA. Twenty-seven percent in Serbia and 7% in Montenegro felt adequately trained to assess and diagnose CSA. Forty percent believed that CSA occurs predominately in poor, unstable or disorganized families. Twenty-nine percent in Montenegro and 15% in Serbia believed that complete strangers perpetrate CSA. Both Serbian (23%) and Montenegrin (30%) pediatricians were uncomfortable asking questions about possible abuse. One third of pediatricians in both countries were interested in further training. CSA is underreported at a concerning rate in Serbia and Montenegro, yet only a third of pediatricians in both countries were interested in further training. Future studies should focus on barriers to reporting in these regions, to increase awareness and competencies related to CSA.

Child sexual abuse in Indonesia: A systematic review of literature, law and policy

BACKGROUND

Like many middle-income countries, knowledge about child sexual abuse (CSA) is limited in Indonesia. The national government has stated a commitment to protect children from the worst forms of abuse, yet the sensitivity of CSA along with the complexity of culture and law, present substantial challenges.

OBJECTIVE

This article reviews current knowledge about CSA in Indonesia, in the context of existing laws and policies that influence CSA prevention and intervention.

METHOD

A systematic review of this research was conducted in the following manner: a review of scholarly literature and grey literature in English (19 papers) and in Bahasa Indonesian (11 papers), and a review of CSA-related Indonesian laws (4 documents) and policies (5 documents).

RESULTS

This review finds that knowledge about CSA in Indonesia is still limited. The taboos on discussing sexual matters were identified as factors that impede reporting of CSA. Poverty also leads to increasing children's risk of sexual abuse. There was less attention to CSA occurring within family contexts and focus was more upon its occurrence outside of the family. The study identified that contradictory definitions of children within the law add to children's vulnerability to CSA; this is especially the case for girls. Current child protection strategies in prevention and intervention lack specific focus on CSA.

CONCLUSION

Further research is needed to enable the development of evidence-based approaches to better harmonize the development of law and policy with contemporary knowledge about CSA.

The Prevalence of Sexual Abuse in Adolescence in Suriname

Studies conducted to ascertain the prevalence of child sexual abuse (CSA) in the Caribbean are poorly synthesized. Present study reports on the lifetime and year prevalence of unwanted sexual experiences, the risk of CSA at different ages within adolescence, and differences between the three largest ethnic groups in Suriname. One thousand one hundred and twenty (1,120) adolescents completed a questionnaire on child maltreatment, including CSA. The study's stratified sample consisted of students (ages 12 to 17) from five districts in Suriname. More than 16% of all boys and 15% of all girls indicated that they had been exposed to some form of CSA in the past 12 months. Girls reported significantly more intrafamilial CSA by a minor than boys. Boys reported significantly more experiences of being touched or forced by a minor outside the family to look at/touch the abuser's private parts than girls. Besides, 16 and 17-year olds were the most vulnerable. An increased risk of CSA (year prevalence) was found as adolescence progresses. A significant portion of CSA constituted peer-to-peer sexual victimization. Afro Surinamese adolescents were found to report the highest rates of CSA. Appropriate legislation, policies, and services for prevention and recovery are needed in Suriname.

"I have the right to feel safe": Evaluation of a school-based child sexual abuse prevention program in Ecuador

BACKGROUND

Child sexual abuse (CSA) is a complex public health problem that has lifelong implications for children's wellbeing. Interventions may provide children strategies to protect themselves against CSA, but few have been studied in Latin America.

OBJECTIVE

Evaluate the immediate and medium-term impact of a 10-week educational program on children's knowledge of CSA self-protection strategies in Ecuador.

PARTICIPANTS AND SETTINGS

Children aged 7-12 years from six public elementary schools in Ecuador were cluster-randomized to either receive the intervention between October and November 2016 (Group 1, k = 4) or between March and April 2017 (Group 2, k = 2).

METHODS

To assess CSA knowledge, a random sample of students completed a questionnaire at three time points: 1) initial: before any group received the intervention, 2) intermediate: immediately after Group 1 completed the program but before Group 2 started it, and 3) final: after Group 2 completed the program. We evaluated changes in scores using mixed linear regression models with school as a clustering variable and adjusted degrees of freedom (df = 4).

RESULTS

Pre-post effect estimates at program completion adjusted for age, sex and clustering by school were 6.5% (95% CI: 2.9, 10.0) and 6.8% (95% CI 3.0, 10.7) for Groups 1 and 2, respectively. Scores did not change among children who had not yet received the intervention at intermediate evaluation (0.94%, 95%CI: -6.0, 7.9). Children in Group 1 maintained the scores six months after the program ended.

CONCLUSIONS

The self-protection program increased and maintained CSA knowledge six months after the intervention finished.

Children's and caregivers' perspectives about mandatory reporting of child maltreatment: a meta-synthesis of qualitative studies

OBJECTIVE

To systematically synthesise qualitative research that explores children's and caregivers' perceptions of mandatory reporting.

DESIGN

We conducted a meta-synthesis of qualitative studies.

DATA SOURCES

Searches were conducted in Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Criminal Justice Abstracts, Education Resources Information Center, Sociological Abstracts and Cochrane Libraries.

ELIGIBILITY CRITERIA

English-language, primary, qualitative studies that investigated children's or caregivers' perceptions of reporting child maltreatment were included. All healthcare and social service settings implicated by mandatory reporting laws were included.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal of included studies involved a modified checklist from the Critical Appraisal Skills Programme (CASP). Two independent reviewers extracted data, including direct quotations from children and caregivers (first-order constructs) and interpretations by study authors (second-order constructs). Third-order constructs (the findings of this meta-synthesis) involved synthesising second-order constructs that addressed strategies to improve the mandatory reporting processes for children or caregivers-especially when these themes addressed concerns raised by children or caregivers in relation to the reporting process.

RESULTS

Over 7935 citations were retrieved and 35 articles were included in this meta-synthesis. The studies represent the views of 821 caregivers, 50 adults with histories of child maltreatment and 28 children. Findings suggest that children and caregivers fear being reported, as well as the responses to reports. Children and caregivers identified a need for improvement in communication from healthcare providers about mandatory reporting, offering preliminary insight into child-driven and caregiver-driven strategies to mitigate potential harms associated with reporting processes.

CONCLUSION

Research on strategies to mitigate potential harms linked to mandatory reporting is urgently needed, as is research that explores children's experiences with this process.

Child Sexual Abuse: Toward a Conceptual Model and Definition

The problem of defining "child sexual abuse" (CSA), and the need to define this concept, has been recognized by major policy bodies and leading researchers since the 1970s. Recent demands for a more theoretically robust, explicit definition of CSA show this challenge remains urgent. In this article, we identify problems caused by variance in definitions of CSA for five domains: research and knowledge formation, legal frameworks and principles, prevention efforts, policy responses, and the establishment of social norms. We review and analyze definitions used in leading international epidemiological studies, national and international policy documents, social science literature, and legal systems in the United States, Canada, and Australia to demonstrate the continuing use of different concepts of CSA and identify key areas of conceptual disagreement. Informed by our literature review, we use a methodology of conceptual analysis to develop a conceptual model of CSA. The purpose of this model is to propose a more robust, theoretically sound concept of CSA, which clarifies its defining characteristics and distinguishes it from other concepts. Finally, we provide operational examples of the conceptual model to indicate how it would translate to a classificatory framework of typologies of acts and experiences. A sound conceptual model and classificatory system offers the prospect of more appropriate and effective methods of research, response, regulation, and prevention. While total consensus is unattainable, this analysis may assist in developing understanding and advancing more coherent approaches to the conceptual foundation of CSA and its operationalization.

Social determinants of child trafficking addressed by government and non-government strategies in South and Southeast Asia: an integrative review

Aims: Child trafficking in South and Southeast Asia is widespread and deeply troubling. While several agencies have initiated anti-child-trafficking interventions, it is unknown whether they address the 21 social determinants of child trafficking identified by Perry and McEwing (2013). The aim of this integrative review was to explore the anti-child-trafficking strategies employed by governments and non-governmental organizations (NGOs) that target the social determinants of child trafficking in South and Southeast Asia, and identify which levels of the socio-ecological model (SEM) they address. Methods: The authors performed a literature search for journal articles and reports by researchers, local or national governments, and international organizations on the prevention of child trafficking in eight South Asian and eight Southeast Asian nations. Identified manuscripts were analyzed to determine which social determinants and socio-ecological levels were addressed by the programs described. Results: Sixteen journal articles and 31 reports from the gray literature were identified. The government and NGO anti-child-trafficking strategies in 16 South and Southeast Asian nations addressed 15 and 12 of the 21 social determinants, respectively. Social determinants at the intrapersonal, interpersonal, community, and policy levels of SEM were addressed, but failed to address the organizational level. Conclusions: The gravity of child trafficking necessitates that interventions address all of the 21 social determinants of child trafficking at all levels of the SEM. The authors found no account on any anti-child-trafficking intervention from four South Asian and five Southeast Asian nations. Dissemination and continuous evaluation of anti-trafficking interventions are warranted.

The influence of self-reported childhood sexual abuse on psychological and behavioural risks in young adults at a university in Botswana

Globally, childhood sexual abuse is a public health problem that affects millions of people. Few studies have considered its long-term ramifications, especially among young adults in developing countries. This study assessed the influence of childhood sexual abuse on depression and behaviours in young adults. Data were obtained from 362 students enrolled at a university in Botswana (Age: M = 21.40, standard deviation = 2.48) using the Childhood Sexual Abuse Scale, the 21-item Beck’s Depression Inventory–II, Revised Sociosexual Orientation Inventory, and Alcohol Use Disorders Identification Test (AUDIT). The t test and chi-square test of independence were used to assess subgroup differences and regression analyses were used to assess the extent to which childhood sexual abuse predicted depression and risky behaviours. About 25% ( n = 90) reported childhood sexual abuse, 18% reported harmful alcohol use ( n = 66, 18.2%), 7.82% ( n = 28) reported severe depression, and 24% ( n = 101) reported failure to use contraceptives. Childhood sexual abuse significantly predicted depression and all the behavioural outcomes in the study. The effect sizes of the associations between childhood sexual abuse on the one hand and mental health and behavioural outcomes on the other were modest. Consequently, the current study is a precursor to further studies on the long-term outcomes of childhood sexual abuse in Botswana. Consequently, a history of childhood sexual abuse should be considered in planning interventions to mitigate depression and behavioural problems on university campuses.

The Characteristics of Child Sexual Abuse in the School Environment in Turkey

School may represent a protective factor, boosting the mental health of the student body, while also representing a risk factor that heightens the potential for mental health problems. The present study aims to identify the individual and familial characteristics associated with the incidents of child sexual abuse (CSA) in Turkey's school environment. The incidents involving school-related CSA constituted 5.6% (N = 125) of 2,238 cases. The following was discovered: an adult committed the majority (64%) of CSA in the school environment; most adult perpetrators were teachers (62.5%). This study determined that the perpetrators manipulated the victims via methods that included physical abuse (11.2%), threats (19.2%), tricks/deception (15.2%), and taking photographs/videos with sexual content (3.2%); and CSA incidents involved intercourse (15.2%); and almost three-quarter of the victims of CSA in the school environment reported the incident late. This study indicates that peer perpetrators abuse younger victims and a greater proportion of male victims relative to adult perpetrators. In light of these findings, school security must be improved, especially in public schools, and trainings aimed at preventing bullying and sexual abuse (SA) should be given to all school staff, students, and parents.

Incidence of depressive symptoms among sexually abused children in Kenya

BACKGROUND

Children who experience sexual abuse undergo various negative psychosocial outcomes such as depressive symptoms. Unfortunately, not many studies have been conducted on the incidence of depressive symptoms among sexually abused children in Kenya. This study sought to ascertain the incidence of depressive symptoms among children who have experienced sexual abuse in Kenya.

METHODS

This was a longitudinal study design. It was conducted at Kenyatta National Teaching and Referral Hospital and Nairobi Women's Hospitals in Kenya. One hundred and ninety-one children who had experienced sexual abuse and their parents/legal guardians were invited to participate in the study. The study administered the Becks Depression Inventory and the Child Depression Inventory to the children.

RESULTS

The incidence of depressive symptoms after 1 month of sexual abuse revealed that amongst children who were below 16 years old, 14.6% had minimal-mild depressive symptoms while 85.4% had moderate-severe depressive symptoms. In comparison, children who were 16 years or older, 6.4% had minimal-mild depressive symptoms while 93.6% had moderate-severe depressive symptoms. Children below 16 years old whose parents were separated were found to have depressive symptoms (p < 0.001) as well as those who were presented early for medical care (p < 0.004), while children aged 16 years and above who were abused by strangers were more likely to have depressive symptoms (p < 0.024) and those who were not attending school (p < 0.002).

CONCLUSION

Sexual abuse of children is world-wide and the Kenyan situation is comparable. Being the victim of sexual abuse as a child has major psychological and emotional sequlae which need to be addressed in Kenya. Children who experience sexual abuse have very high incidence of developing depressive symptoms. All the sexually abused children studied suffered from depressive symptoms and a large majority suffered from major depressive symptoms that should be promptly and effectively addressed to ameliorate psychological suffering among children.

A Bibliometric Analysis of the Global Research Trend in Child Maltreatment

Child maltreatment remains a major health threat globally that requires the understanding of socioeconomic and cultural contexts to craft effective interventions. However, little is known about research agendas globally and the development of knowledge-producing networks in this field of study. This study aims to explore the bibliometric overview on child maltreatment publications to understand their growth from 1916 to 2018. Data from the Web of Science Core Collection were collected in May 2018. Only research articles and reviews written in the English language were included, with no restrictions by publication date. We analyzed publication years, number of papers, journals, authors, keywords and countries, and presented the countries collaboration and co-occurrence keywords analysis. From 1916 to 2018, 47,090 papers (53.0% in 2010⁻2018) were published in 9442 journals. Child Abuse &amp; Neglect (2576 papers; 5.5%); Children and Youth Services Review (1130 papers; 2.4%) and Pediatrics (793 papers, 1.7%) published the most papers. The most common research areas were Psychology (16,049 papers, 34.1%), Family Studies (8225 papers, 17.5%), and Social Work (7367 papers, 15.6%). Among 192 countries with research publications, the most prolific countries were the United States (26,367 papers), England (4676 papers), Canada (3282 papers) and Australia (2664 papers). We identified 17 authors who had more than 60 scientific items. The most cited papers (with at least 600 citations) were published in 29 journals, headed by the Journal of the American Medical Association (JAMA) (7 papers) and the Lancet (5 papers). This overview of global research in child maltreatment indicated an increasing trend in this topic, with the world&rsquo;s leading centers located in the Western countries led by the United States. We called for interdisciplinary research approaches to evaluating and intervening on child maltreatment, with a focus on low-middle income countries (LMICs) settings and specific contexts.

The relationship between child protection contact and mental health outcomes among Canadian adults with a child abuse history

Despite being a primary response to child abuse, it is currently unknown whether contact with child protection services (CPS) does more good than harm. The aim of the current study was to examine whether contact with CPS is associated with improved mental health outcomes among adult respondents who reported experiencing child abuse, after adjusting for sociodemographic factors and abuse severity. The data were drawn from the 2012 Canadian Community Health Survey-Mental Health (CCHS-2012), which used a multistage stratified cluster design (household-level response rate = 79.8%). Included in this study were individuals aged 18 years and older living in the 10 Canadian provinces (N = 23,395). Child abuse included physical abuse, sexual abuse, and exposure to intimate partner violence (IPV). Mental health outcomes included lifetime mental disorders, lifetime and past year suicidal ideation, plans, and attempts, and current psychological well-being and functioning and distress. All models were adjusted for sociodemographic factors and severity of child abuse. For the majority of outcomes, there were no statistically significant differences between adults with a child abuse history who had CPS contact compared to those without CPS contact. However, those with CPS contact were more likely to report lifetime suicide attempts. These findings suggest that CPS contact is not associated with improved mental health outcomes. Implications are discussed.

A Nonrandom Sample of 55 Sexual Abuse Cases in Sivas

BACKGROUND Sexual abuse in childhood is a significant public health problem because of the destructive results both to the individual and to the community. The aim of this study was to examine the sociodemographic characteristics of children who were victims of sexual abuse, the relationship of the victim and abuser, and the findings of sexual abuse. MATERIAL AND METHODS An examination was made of the results of forensic medicine and psychiatric evaluations of child victims of sexual abuse. The sociodemographic characteristics of the cases and the characteristics of the incidents of sexual abuse were evaluated at the Forensic Medicine Department of Cumhuriyet University between 2013 and 2016. RESULTS A total of 55 cases were included in the study, comprising eight males (14.5%) and 47 females (85.5%) in the age range of 5-17 years. The vast majority of the cases were high school students. The place of the abuse incident was the home of the victim or the perpetrator in 29 cases (52.7%). The sexual abuse was determined to be bodily penetration in 32 cases (58.1%). In 32 cases (58.1%), the perpetrator was known to the victim. CONCLUSIONS The study findings that the perpetrator of the sexual abuse was known to the child, that predominantly female children were attacked, and the low sociocultural level of the cases were consistent with other studies reported in the literature. To prevent sexual abuse of children, to make an early diagnosis, and to provide rehabilitation for the abused children, it is essential that the evaluations of these cases are made using a professional multidisciplinary approach.

Challenges and Opportunities in Global Mental Health: a Research-to-Practice Perspective

PURPOSE OF REVIEW

Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap. In this review, we describe how health systems in low- and middle-income countries (LMICs) are addressing the mental health gap and further identify challenges and priority areas for future research.

RECENT FINDINGS

Common mental disorders are responsible for the largest proportion of the global burden of disease; yet, there is sound evidence that these disorders, as well as severe mental disorders, can be successfully treated using evidence-based interventions delivered by trained lay health workers in low-resource community or primary care settings. Stigma is a barrier to service uptake. Prevention, though necessary to address the mental health gap, has not solidified as a research or programmatic focus. Research-to-practice implementation studies are required to inform policies and scale-up services. Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scale up of public health systems to improve access to mental health treatment using evidence-based interventions.

Investigating the Self-Protective Potential of Immobility in Victims of Rape

Using a nationwide sample of reported rape cases collected by the Federal Bureau of Investigation (FBI; 389 victims; 89% stranger rapes), this study investigates assumptions about self-protective behaviors for rape victims. Past research on victim resistance strategies often specifies active resistance as self-protective, inadvertently underestimating the potential for biologically based reactions, such as tonic immobility, to be self-protective as well. Results confirm that rape victims who were verbally and physically immobile during the attack were less likely to be injured and have force used against them. In addition, victims who were verbally immobile suffered a less severe attack. The results indicate that immobility may protect the victim from increased injury, force, and severity of the attack. Implications for the legal and public definition of consent are discussed.