1. CRICOS No. 00213J Key messages from a Cochrane review of school-based programs for the prevention of child sexual abuse Kerryann Walsh 1, Karen Zwi 2, Sue Woolfenden 3 & Aron Shlonsky 4 1 Queensland University of Technology, Brisbane, Australia 2 University of New South Wales & Sydney Children's Hospital, Sydney, Australia 3 Sydney Children's Hospitals Network, Sydney Children's Community Health Centre, Randwick, Australia 4 The University of Melbourne, Melbourne, Australia

2. CRICOS No. 00213J a university for the world real R Cochrane is a global independent network of researchers, professionals, patients, carers and people interested in promoting evidence informed health care Produce and maintain high quality systematic reviews to inform decision making Cochrane library has 6000+ reviews 40 new reviews / 45 updates per month Who/what is ? Trusted evidence. Informed decisions. Better health.

3. CRICOS No. 00213J a university for the world real R Cochrane reviews: top of the evidence pyramid Other systematic reviews RCT replications RCTs Uncontrolled trials Uncontrolled observational studies Case studies, case reports Expert opinion, clinical wisdom Cochrane/Campbell systematic reviews Adapted from CDC (2011), NHMRC (2000)

4. CRICOS No. 00213J a university for the world real R Review types: key differences Systematic review Narrative review Pre-defined objectives Clear inclusion / exclusion criteria  Explicit, replicable, exhaustive search strategy (including unpublished/grey literature)  Systematic coding and analysis of included studies  Quality appraisal  Meta-analysis  Peer-reviewed protocol  At least 2 reviewers - independently & compare results  Peer and editorial review

5. CRICOS No. 00213J a university for the world real R Review process Obtains all the high quality evidence More “power” and “precision” Built in assessment of “quality” Cochrane exists so that program decision making gets better Information in practical format What are systematic reviews? 5 min podcast What are systematic reviews

6. CRICOS No. 00213J a university for the world real R Questions or comments

7. CRICOS No. 00213J a university for the world real R Background Child sexual abuse is a significant problem: 10-20% of girls & 5-10% of boys worldwide (Barth et al, 2013; Pereda et al., 2009; Stoltenborgh, 2011) School-based programs are the most widely-used strategy for prevention of child sexual abuse Schools are a logical place for prevention initiatives

8. CRICOS No. 00213J a university for the world real R Why this review was needed To synthesise highest quality evidence about: –Programs’ effectiveness in preventing child sexual abuse –Programs’ negative effects Several previous reviews of different types –Different inclusion criteria –Some similar findings Systematic review of reviews Systematic review & meta-analyses Systematic reviews Narrative reviews 1 (2009)5 (1992, 1994, 1997, 2000, 2007) 5 (1994, 2000, 2002, 2008, 2009) 16 (1986 – 2007)

9. CRICOS No. 00213J a university for the world real R Key messages School-based programs for prevention of child sexual abuse: –Seem to be effective in both increasing children’s knowledge about child sexual abuse and teaching them the types of skills considered necessary for recognizing and reporting child sexual abuse –Knowledge gains seem to not be significantly eroded 1-6 months later for either intervention or control groups –Do not increase (nor decrease) children’s anxiety or fear about child sexual abuse, nor are there any other reported adverse effects –Children exposed to these school based programs were more likely to disclose their abuse than children who had not been exposed

10. CRICOS No. 00213J a university for the world real R Key messages Many of the included studies are now dated. More rigorous evaluations of child sexual abuse prevention programs are needed –With longitudinal follow up –And more precise measurement –And more complete reporting This review supports the provision of high quality, rigorously evaluated school-based programs to protect children against sexual abuse

11. CRICOS No. 00213J a university for the world real R Objective To systematically assess evidence of the effectiveness of school- based education programs for the prevention of child sexual abuse

12. CRICOS No. 00213J a university for the world real R Outcomes 1. Self-protective skills (as measured by an independently- scored simulation test) 2. Knowledge of child sexual abuse prevention concepts (as measured by questionnaires or vignettes) 3. Retention of self- protective skills over time 4. Retention of knowledge over time 5. Parental or child anxiety or fear (parent and/or child report) 6. Disclosures (school records, CPS, police)

13. CRICOS No. 00213J a university for the world real R Study characteristics 24 studies; 5802 participants (98.8% primary school age) 15 discrete programs RCTs (7), cluster RCTs (11), & quasi-RCTs (6) Countries: United States (16), Canada (3), China (1), Germany (1), Spain (1), Taiwan (1), and Turkey (1) Period: 1986-2013 Mean age at baseline: 5.8 – 13.44 years Ethnicity data: (2 x 100% Chinese; 6 x mixed with non-White participants 32-66%; others not reported) Not reported / not well reported: Parental SES, religious background, school achievement at baseline

14. CRICOS No. 00213J a university for the world real R Education programs Program duration: 1 x 45 min – 8 x 20 min lessons Common program elements: safety rules, body ownership, private parts of the body, distinguishing types of touches and types of secrets, and who to tell Common program formats: film, video/DVD, theatrical plays, multimedia presentations, use of songs, puppets, comics, and colouring books Common teaching methods: rehearsal, practice, role play, discussion, and feedback

15. CRICOS No. 00213J a university for the world real R Quality of the evidence = moderate Why? 1. 2. Incorrect data analysis in primary studies – did not adjust for effect of clustering of students in classes or schools (statistical procedures now recommended in CONSORT statement)

16. CRICOS No. 00213J a university for the world real R A closer look at outcomes

17. Protective behaviours (self-protective skills) OR 5.71 (1.98 to 16.51) Odds of “pass” were higher for intervention group Control group: 390 per 1000 Intervention group: 795 per 1000 (range 559 - 914 per 1000)

18. Knowledge (factual) SMD 0.61 (0.45 to 0.78) Intervention group knowledge scores were 0.61 standard deviations higher than control group

19. Hattie, 2009; 2012

20. Knowledge (applied) SMD 0.45 (0.24 to 0.65 ) Intervention group knowledge scores were 0.45 standard deviations higher than control group

21. Hattie, 2009; 2012

22. Retention of skills over time – insufficient data More research needed

23. Retention of factual knowledge over time SMD 0.78 (0.38 to 1.17) SMD 0.69 (0.51 to 0.87) Effects of intervention persisted for at least 6 months

24. Hattie, 2009; 2012

25. Retention of applied knowledge over time – insufficient data More research needed

26. Harm SMD -0.08 (-0.22 to 0.07) No increase or decrease in anxiety/fear in intervention or control groups

27. Disclosure OR 3.56 (1.13 to 11.24) Children who had received programme more likely to tell Control group: 4 per 1000 Intervention group: 14 per 1000 (range 5 - 45 per 1000)

28. CRICOS No. 00213J a university for the world real R What the studies could not tell us Long-term outcomes Outcomes for different groups. Why? Data not reported

29. CRICOS No. 00213J a university for the world real R Key messages 1 School-based programs for prevention of child sexual abuse: –Seem to be effective in both increasing children’s knowledge about child sexual abuse and teaching them the types of skills considered necessary for recognizing and reporting child sexual abuse –Knowledge gains seem to not be significantly eroded 1-6 months later for either intervention or control groups –Do not increase (nor decrease) children’s anxiety or fear about child sexual abuse, nor are there any other reported adverse effects –Children exposed to these school based programs were more likely to disclose their abuse than children who had not been exposed

30. CRICOS No. 00213J a university for the world real R Key messages 2 Many of the included studies are now dated. More rigorous evaluations of child sexual abuse prevention programs are needed –With longitudinal follow up –And more precise measurement –And more complete reporting This review supports the provision of high quality, rigorously evaluated school-based programs to protect children against sexual abuse

31. CRICOS No. 00213J a university for the world real R References Original protocol Zwi K., Woolfenden S., Wheeler D.M., O'Brien T.A., Tait P., & Williams K.J. (2003). School-based education programs for the prevention of child sexual abuse [Protocol]. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CD004380.pub2. Original review Zwi, K. J., Woolfenden, S. R., Wheeler, D. M., O'Brien, T. A., Tait, P., & Williams, K. J. (2007). School-based education programs for prevention of child sexual abuse [Review]. Cochrane Database of Systematic Reviews, DOI:10.1002/14651858.CD004380.pub2. Review update Walsh, K., Zwi, K., Woolfenden, S., & Shlonsky, A. (2015). School-based education programs for prevention of child sexual abuse [Review]. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD004380. DOI: 10.1002/14651858.CD004380.pub3.

32. CRICOS No. 00213J a university for the world real R Questions & comments

33. CRICOS No. 00213J a university for the world real R Take home messages School-based prevention programs –Are effective in increasing knowledge and self-protective skills –Knowledge gains are not eroded 1-6 months later –Do not appear to have adverse effects –Direct links between teaching / program provision and actual changes in behaviour and actual prevention is lacking We need better and more rigorous evaluations of Australian school programs –That use the randomised controlled trial method –Are registered on international trials registers –With longitudinal follow up –And more precise measurement –And more complete reporting using CONSORT guidelines

34. CRICOS No. 00213J a university for the world real R Contact details Dr Kerryann Walsh School of Early Childhood Faculty of Education Queensland University of Technology Email :k.walsh@qut.edu.au Phone: 07 3138 3174 Details: http://staff.qut.edu.au/staff/walshk/http://staff.qut.edu.au/staff/walshk/