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Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rgph20
Teachers' knowledge, attitudes and experience in sexual abuse prevention education in El Salvador a
Alicia Hurtado , Craig Katz
abc
, Dianne Ciro
ad
& Daniel Guttfreund
a
Department of Psychiatry, Mount Sinai School of Medicine, NY, USA b
Global Health Center, Mount Sinai School of Medicine, NY, USA
c
Department of Medical Education, Mount Sinai School of Medicine, NY, USA d
Department of Preventive Medicine, Mount Sinai School of Medicine, NY, USA Published online: 31 Oct 2013.
To cite this article: Alicia Hurtado, Craig Katz, Dianne Ciro & Daniel Guttfreund (2013) Teachers' knowledge, attitudes and experience in sexual abuse prevention education in El Salvador, Global Public Health: An International Journal for Research, Policy and Practice, 8:9, 1075-1086, DOI: 10.1080/17441692.2013.839729 To link to this article: http://dx.doi.org/10.1080/17441692.2013.839729
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Global Public Health, 2013 Vol. 8, No. 9, 1075–1086, http://dx.doi.org/10.1080/17441692.2013.839729
Teachers’ knowledge, attitudes and experience in sexual abuse prevention education in El Salvador
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Alicia Hurtadoa*, Craig Katza,b,c, Dianne Ciroa,d and Daniel Guttfreund a Department of Psychiatry, Mount Sinai School of Medicine, NY, USA; bGlobal Health Center, Mount Sinai School of Medicine, NY, USA; cDepartment of Medical Education, Mount Sinai School of Medicine, NY, USA; dDepartment of Preventive Medicine, Mount Sinai School of Medicine, NY, USA
(Received 30 November 2012; accepted 17 June 2013) Research on how to prevent child sexual abuse (CSA) in developing nations is practically non-existent. We sought to determine Salvadoran teachers’ knowledge, attitudes, experience and barriers to CSA detection and reporting to assess the need for a CSA prevention programme and to assess barriers in conducting such a programme. One hundred teachers completed a questionnaire while they visited the Tin Marin Children’s Museum in San Salvador. Nineteen of these teachers also participated in a focus group. We found that 89% of teachers reported at least two signs and symptoms of child abuse. One hundred per cent of teachers agreed that it is their responsibility to teach students about sexual abuse. Unusual for a study of this kind, parental migration was mentioned as making children vulnerable to CSA, and fear of gang violence and retribution was identified as interfering with teachers’ ability to protect children. We conclude that Salvadoran teachers were knowledgeable about CSA detection and reporting and would support a programme in which they are trained to speak to their students about this topic. Barriers to reporting child abuse, such as teachers’ safety and fear, need to be addressed in future CSA prevention programmes. Keywords: child sexual abuse prevention; teachers; El Salvador
Introduction When children are subjected to traumatic events during childhood, such as child sexual abuse (CSA), the mental health consequences are particularly impactful and long-lasting (Johnson, 2004; Molnar, Buka, & Kessler, 2001; Putnam, 2003). However, despite the lasting effects CSA has on people’s well-being, there is minimal research on how to prevent CSA. This is even more true in developing nations, where research on how to prevent CSA is practically non-existent. Community-based research, however, has identified risk factors of CSA, including poverty, weak legal systems, breakdown of family and armed conflicts (WHO, 2004). El Salvador, one of seven Central American countries, with a population of 6.1 million in 2011, has many of these risk factors. In 1992, the signing of the Peace Accords ended a 12-year civil war that cost the lives of about 75,000 Salvadorans (US Department of State, 2012). Political and socio-economic problems, such as limited job opportunities, persistent poverty and outmigration during the civil war, have resulted in 1 out of every *Corresponding author. Email: [email protected] © 2013 Taylor & Francis
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five Salvadorans living in the USA, 30% of all Salvadoran households being headed by females (Edwards, 2008), 67% of Salvadoran children living with only one parent or no parent (Ruiz, 2010) and 21.3% of Salvadoran families receiving remittances (monetary allowances sent to family members) (US Department of State, 2012). In post-civil war El Salvador, a country where 47% of the population lives in poverty, and where the mean age is under 20 (Pan American Health Organisation, 2005), Salvadoran children are at high risk for CSA. Childhood sexual abuse is defined by the World Health Organisation (WHO) in part as: ‘The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared…’ (WHO, 1999). International studies reveal that approximately 20% of women and 5–10% of men report being sexually abused as children, while 25–50% of all children report being physically abused (WHO, 2010). Twelve and sixtenths per cent of Salvadoran women reported being abused at any age and the mean age of abuse was 10.5 years (Speizer, Goodwin, Whittle, Clyde, & Rogers, 2008). Of these women, 11.4% reported that their father was the perpetrator; in Guatemala and Honduras 2.1% and 3.3% reported that their fathers were the perpetrators, respectively (Speizer et al., 2008). Young children are particularly vulnerable to CSA, as they may lack the cognitive ability to process what has happened to them and do not know how to recognise unacceptable behaviours. Thus, a key step in preventing CSA is educating children at a young age. One way to reach young children is through school-based community programmes, which have been proven to be effective in preventing CSA (Finkelhor, 2007; Gibson & Leitenberg, 2000). In a meta-analysis, Davis and Gidycz (2000) found that children who participated in prevention programmes performed 1.07 SD higher than control group children. This effect size can be interpreted as improvements in the prevention-related knowledge and skills of children who participated in programmes. Further, Ko and Cosden (2001) found that high school students who participated as children in school-based abuse prevention programmes have greater understanding of issues around blame, that abusers can be people who are close to the victim, that boys and girls can be victims, and of the need to report the abuse. However, in order to launch a CSA programme targeting elementary schoolchildren in El Salvador, an initial study is required to ensure that its development and implementation are informed, relevant and practical. Although epidemiological research exists on the prevalence of CSA in El Salvador, there are no studies that we know of that have researched teachers’ knowledge, attitudes, experiences and barriers to CSA detection and reporting. Objectives First, this study will assess teachers’ knowledge and attitudes of detection and prevention of CSA in order to determine the need and interest for a CSA prevention programme. Second, this study will assess experiences and barriers associated with teaching CSA prevention and with reporting CSA.
Methodology This project was a collaboration between the Mount Sinai School of Medicine and its Global Health Center, and the Tin Marin Children’s Museum in San Salvador, El Salvador. This study was approved by the Institutional Review Board of the Mount Sinai
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School of Medicine and the Salvadoran Ministry of Education. The Tin Marin’s Children’s Museum, in 2008, had a CSA exhibit based on a book entitled Mi Cuerpo Me Pertenece a Mi (My Body Belongs To Me), which addresses issues regarding body ownership, types of inappropriate touching and escaping and reporting skills. This exhibit was part of a campaign to educate children about CSA that was spearheaded by the Salvadoran Government and several non-governmental organisations (NGOs). Children from both urban and rural El Salvador were invited to the museum along with their teachers. Verbal consent to participate in this project was received from all teachers. Teachers were asked to anonymously complete a 28-item questionnaire entitled Teacher’s Questionnaire, while they visited the Tin Marin Children’s Museum exhibit with their students. The questionnaire was created by the research team in Spanish. It was divided into four sections: Demographics, Knowledge, Attitudes and Experiences. A total of 105 teachers were approached to participate and complete the questionnaire, and a total of 101 agreed to participate. One questionnaire was excluded as it was left unanswered (see Table 1 for participant sociodemographic profile). To assess teachers’ knowledge about CSA prevention and detection, teachers were asked five closed-ended questions and two open-ended questions. Answers on the five closed-ended questions were scored (K1–K5) (see Table 2 for details). To assess teachers’ opinions regarding CSA and their roles as teachers in protecting children, teachers were asked a series of seven closed-ended questions (A1–A7) (see Table 2 for details). To assess teachers experiences in providing child abuse prevention education, they were asked five questions (E1–E5) (see Table 2 for details). During their same museum visit, teachers were also asked to participate in 45-minute focus groups facilitated by the principal investigator in fluent Spanish. A total of 29 Table 1. Sociodemographic profile of teachers. Characteristics Full sample = 100 Mean age (± SD) Gender Female Male Unknown School setting Urban Rural Private or Public schoolteacher Private Public Missing information Mean years teaching (± SD) Educational level Some college College graduate Postgraduate education Received formal training in child abuse detection Yes No
38.2 (± 7.6) 61% 21% 18% 63% 34% N=7 N = 69 N = 24 12.93 (± 7.09) 77% 20% 1% 27% 70%
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Table 2. Teachers’ knowledge, attitudes and experiences of child abuse prevention (n = 100). Knowledge questions
True
False
Blank
K1. Adolescents are more likely to be victims of abuse than pre-adolescents. K2. Children who live in homes with domestic violence are more likely to become victims of sexual abuse. K3. Children are more likely to be abused by strangers. K4. If a child is being abused physically, I know who to inform. K5. If a child is being abused sexually, I know who to inform.
27%
70%a
3%
83%a
17%
0%
61% 92% 96%
39%a 5% 4%
0% 3% 0%
Agree
Disagree
Blank
31%
68%
1%
100%
0%
0%
99% 63%
1% 35%
0% 2%
95%
1%
4%
90%
3%
7%
95%
1%
4%
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Attitudes questions A1. Child sexual abuse is a problem in El Salvador that is being addressed adequately. A2. It is my responsibility as a teacher to educate my students about sexual abuse. A3. Learning about sexual abuse prevention is worth my time. A4. If I disclose a child abuse case to the authorities, I am sure that the child will be protected. A5. I would support legislation that would encourage teachers to report anonymously cases were they suspected child abuse. A6. I would agree to participate in an educational session about child sexual abuse prevention. A7. I would like to develop a class lesson after visiting the museum with my students about the prevention of sexual abuse. Experience questions E1. If I suspected that a child was being physically or sexually abused in his/her home, I would tell someone. E2. In the past I have spoken to a class of children about sexual abuse. E3. In the past I have spoken to a class of children about physical abuse. E4. In the past I have spoken to an individual child about sexual abuse. E5. In the past I have spoken to an individual child about physical abuse.
Agree
Disagree
Blank
92%
5%
3%
58% 72%
41% 26%
1% 2%
44% 58%
54% 41%
2% 1%
a
Correct answer.
teachers, who also filled out questionnaires, were invited to participate in focus groups, and 19 agreed to participate. In total, five focus groups were conducted with three to four teachers per group. Focus groups took place during lunch break in a conference room, while museum guides supervised children while they ate lunch. During the start of the focus group, a script was read to obtain the verbal consent of participants. Keeping in mind cultural sensitivity and political climate, participants were reminded that participation was voluntary, that their role with the public school system and the museum would not be impacted by participation, and that they could stop participation at any point during the study. Furthermore, as we believed that recording group interviews would be too threatening given the political climate at that time, we chose not to audio record the sessions. Instead, careful notes were taken, which were then translated back to English. Participants were also reassured that none of the information collected during the focus group would be shared with anyone from the museum or in the Ministry of Education
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until after the study was completed. During each focus group, the number of participants, approximate age ranges, general area of where teachers worked (rural or urban) and gender breakdown were recorded. Three open-ended questions were asked to encourage discussion during the focus groups: (1) Do you believe that CSA is a problem that needs to be addressed in El Salvador? (2) What role can you play as a teacher in preventing CSA? (3) If you were to become aware of a case of CSA, what resources currently exist in El Salvador to protect the child? The facilitator did her best not to lead participants, so as to get broad, nonbiased information. Data obtained during each focus group was summarised at the end of each group in a narrative form that was then read back to participants to ensure accuracy.
Results Teachers’ questionnaire Schoolteachers’ knowledge Of the five knowledge questions (K1–K5) (see Table 2 for details), 69% of teachers answered at least four of these five questions correctly. However, when asked: ‘True or False, Children are more likely to be abused by strangers’, approximately 60% of teachers answered this question incorrectly. The first open-ended question asked teachers to define ‘child abuse’ in their own words. In general, most teachers were able to provide an appropriate definition. One teacher wrote, ‘Child sexual abuse is the inappropriate manipulation of a child’s body without consent. It includes speaking to them dirty, showing them inappropriate images that are not age appropriate’. Another teacher answered, ‘It is when an adult person takes advantage of a child’s innocence to satisfy their basic instincts’. The second open-ended question asked teachers to describe two signs, emotional or physical, that a child is being physically or sexually mistreated. Eighty-nine per cent of teachers were able to provide two or more signs or symptoms that a child is being abused. Signs and symptoms reported included: ‘aggressive behaviour’, ‘socially withdrawn’, ‘afraid of adults’, ‘distracted’, ‘uses inappropriate sexually explicit words’, ‘bruises on the body’ and ‘sadness’. Schoolteachers’ attitudes In general, of the teachers surveyed, an overwhelming majority felt that as teachers they had a role in protecting children. For example, 100% of the teachers believed that it is ‘my responsibility as a teacher to educate my students about sexual abuse’. Ninety-nine per cent of the teachers felt that ‘learning about sexual abuse prevention is worth my time’. Furthermore, in order to assess whether teachers would be interested in participating in an initiative to provide education on CSA prevention, teachers were asked to agree or disagree with the following statements: ‘I would agree to participate in an educational session about child sexual abuse prevention’ and ‘I would like to develop a class lesson after visiting the museum with my students about the prevention of sexual abuse’. Ninety and ninety-five per cent of the teachers surveyed, respectively, stated that they would agree (see Table 2 for details). Sixty-eight per cent of the schoolteachers surveyed felt that CSA is a problem that is not being addressed appropriately in El Salvador. This opinion did not differ between men and women nor between teachers teaching in rural versus urban settings.
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Schoolteachers’ experiences Twenty-seven per cent of the teachers surveyed reported receiving formal training in child abuse prevention (see Table 1). In response to the statement ‘In the past I have spoken to a class of children about sexual abuse’, 58% of respondents indicated they had, while 41% indicated that they had not; 1% did not respond. In response to the statement ‘In the past I have spoken to a class of children about physical abuse’, 72% of respondents indicated they had, while 26% indicated they had not. Of those teachers who reported that they had spoken to children about physical abuse in a classroom setting, 92% reported that they had received training in child abuse prevention (chi square p < 0.008). Furthermore, of those teachers who reported receiving formal training, 73% reported that they had spoken to children about sexual abuse in a classroom setting. Although this finding did not reach significance with a chi square of p < 0.057, a trend can be observed. Interestingly, the longer a teacher had been teaching, the more likely she was to report that she had spoken to a child individually about both sexual and physical abuse (T-test = 0.007 and 0.022, respectively). Furthermore, more teachers who taught in rural settings reported that they had spoken to children about both sexual (chi square p < 0.036) and physical abuse in a class room setting (chi square p < 0.035). There was no significant difference in the number of urban versus rural teachers, who had received training in sexual abuse prevention. Teachers were also asked to agree or disagree with the statement: ‘If I suspected that a child was being physically or sexually abused in his/her home, I would tell someone.’ Ninety-two per cent of teachers agreed while 5% disagreed; 3% did not respond. Teachers were asked to select whom they would inform if they suspected that a child was being physically or sexually mistreated in his home. Most teachers selected the school’s director or principal (n = 39), followed by the National Police (n = 35) and ISNA (Institute for the Integral Development of Children and Adolescents) (n = 31). Many teachers also selected the child’s mother, father or guardian (n = 22). Few teachers selected a pastor (n = 1) or doctor (n = 3). Teachers’ focus groups In general, focus groups were lively and all individuals participated in the discussions. Several themes arose during the discussions, including barriers to reporting, such as the safety of the person reporting; to whom to report abuse cases; the purpose of reporting; and the role of teacher as a reporter. Of all the themes, teachers’ safety was the most frequently discussed. Teachers expressed serious doubts that reporting sexual abuse could be done anonymously. Teachers emphasised that this is particularly difficult in rural areas where teachers live in the community and often teach their own family members. One teacher explained, ‘There is no mechanism in place that protects a teacher if threatened. There is no support for them’. Teachers expressed concern of retribution by angry parents or others in the community. One teacher explained, ‘We are trained to see ourselves as teachers, as mediators; however, the biggest challenge is having the courage to get involved’. Another teacher who works in a rural setting stated: As a teacher and Christian, I love my students. It hurts me when I find out about a case. However, because of where the school is located, I cannot do anything about it. To report it would cost us our lives.
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Another teacher reported, ‘In rural areas where there is heavy gang activity, the police will not protect you’. And yet another teacher explained, ‘In this country witnesses are not protected. Gangs are a big problem…and if they hear that you are a witness…you [will be found] dead the next morning’. Some teachers expressed fear of being accused of making a false report as retribution. In general, teachers agreed that they know where to report a case of CSA. One teacher explained, ‘Everyone knows that these agencies exist, because the ISNA and ISDEMU (Salvadoran Institute for the Development of Women) are new and well identified’. Teachers also expressed distrust of Salvadoran institutions. One teacher stated, ‘I think there is more trust in these international organisations than in Salvadoran organisations. There is no such thing as national security, not even for government officials. How can we think there is national security for us?’ Doubts were expressed among some teachers about what reporting can accomplish. Some expressed concern that taking a child out of the home and placing him under the care of governmental or child protective agencies is not necessarily better for the child. Others expressed concern that there is no point in identifying abuse if laws do not exist to prosecute perpetrators. One teacher explained, ‘If we want to do something we have to improve the law. What is the point if the laws are weak and the perpetrators never get prosecuted?’ Another teacher reported: …and this is even more of a problem in the interior of the country. Even when parents are informed of the situation they do nothing. We had a big problem in one of our (rural) communities…There was a child whose father was abusing her. The mother supported the situation. I mean we knew that the mother would tie her children up as punishment and since I knew the father did worse, I called the ISNA. They did an investigation and they couldn’t tell me anything, but all I know is that nothing was done. I feel better because later on I discovered that the mother separated from that man.
Two teachers questioned the appropriateness of the role of educators in sexual abuse prevention. They expressed concern that they would be disrespecting parents’ religious beliefs by talking about sexual abuse prevention. As one of them stated, ‘Some parents don’t want issues of sex being discussed with their children’. Another teacher offered a different perspective: But I [don’t] think that we are… talking about sexual education; …actually we are talking about protecting children. Sexual reproduction is different than …[sexual abuse]. I agree that sexual reproduction is something that needs to be addressed in the home. The church is right.
Other teachers expressed resentment towards having to fill in for parents ‘who do not want to educate their children’. One teacher explained, ‘Parents just don’t give their children any importance. That is why we as teachers need to be involved’. However, other participants reported being eager to help parent a child who has been neglected at home. One teacher identified migration as one of the factors contributing to the incidence of CSA. She stated: It is a reality for our country that so many parents leave their children behind… [to be] raised by grandparents, aunts and uncles who sometimes don’t look after these children in the same manner that a parent would.
Despite expressing concern over the added responsibility that screening for child abuse would entail, teachers were nonetheless willing to take on that extra role. One teacher
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stated, ‘Our students trust us and if parents are abusing their children then we are the next closest to these children. For some of these children, we are the only educated individuals, the only ones that are aware of what the laws are’. Another teacher expressed, ‘But we do have a role as teachers. This is part of the education we provide to our students. We have an obligation to our children’.
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Discussion From teachers’ questionnaires In response to the Teachers’ Questionnaire, an overwhelming majority of teachers agreed that it is their responsibility to teach children about child abuse prevention, that they have a role in protecting children and that learning about child abuse prevention is worth their time. Despite the taboo nature of this subject, an overwhelming number of teachers affirmed that they ‘would like to develop a class lesson after visiting the museum with my students about the prevention of sexual abuse’. The willingness to participate in child abuse prevention programme among these teachers was much higher than expected. This overwhelming response to participation may have been influenced by teachers’ eagerness to please the investigator distributing the Teachers’ Questionnaire. It is also possible that this reflects the extent to which teachers believe that child abuse is a problem that needs to be addressed, as shown by the 68% of teachers who reported that CSA is a problem not being adequately addressed in El Salvador. A majority of teachers reported that they had spoken to children both individually and as a group about physical and sexual abuse. However, we were surprised that these numbers were so high among Salvadoran teachers, as only 27% of the teachers reported having received training in CSA prevention. Again, it is possible that teachers overreported having spoken to children about abuse as they wanted to please the investigators or were too ashamed to say that they had not. It is also important to note that we do not know the content of these discussions, nor if they were educational and helpful in preventing CSA. This high number of teachers reporting that they had spoken to children about abuse prevention could also reflect the number of years of teaching experience. The mean number of years teaching was about 13 years, and from our data, teachers with more experience reported talking with children about sexual abuse at a higher rate than those with less experience. Surprisingly, teachers were much more knowledgeable about the subject of CSA prevention despite the low percentage of teachers reporting formal training. Among the teachers surveyed, 89% of teachers were able to identify at least two symptoms of physical or sexual abuse. We did not ask teachers to identify separate symptoms for sexual and physical abuse, but even so, these numbers are higher than expected. It is possible that even though formal training in abuse prevention had not taken place, teachers have learned about child abuse prevention through other mediums, such as college courses, the media or NGOs. Furthermore, while most of the teachers surveyed indicated that they believe that a child would be protected if they reported a case of abuse to authorities, a large percentage (35%) did not. This trend is similar to that expressed during focus groups, where teachers expressed concern that child protective agencies and other authorities are not able to provide safety for children, their families or informants. Based on our survey, an overwhelming majority of teachers reported that they would inform someone if they believed a child was being physically or sexually abused.
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However, it is important to note that we did not ask if cases had actually been reported, but rather whether they would inform someone if they suspected that a child was being physically or sexually abused.
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From teachers’ focus groups Focus groups provided further information regarding barriers to reporting and potential consequences of reporting. They touched on the dilemma that exists between the desire to take action and protect a child when a case of abuse is identified and the reality of the sociopolitical environment in which Salvadorans live. Although 90% of the teachers surveyed reported that they would inform someone, focus groups elicited the dangerous sociopolitical context in which reporting occurs. Consistent with what was reported in the Teachers’ Questionnaire, where teachers reported knowing whom to inform about physical and sexual abuse at the rates of 92% and 96%, respectively, teachers in the focus groups reported that they knew whom to inform about both physical and sexual abuse. From the focus groups and Teachers’ Questionnaires, it appears that the person to whom teachers would most likely report abuse is the school principal. In many states in the USA, it is mandatory for teachers to report cases of child abuse directly to authorities, even if they already informed their principal. This is particularly important as it is up to authorities to determine whether an incident is deemed child abuse or not, and the principal may have reasons for wanting to keep reported child abuse cases low. Mistrust by Salvadoran teachers of the government or the authorities is not surprising given the fact that during the civil war in El Salvador many lost faith in the Salvadoran government and relied more on NGOs for protection and services. Furthermore, during the civil war, many teachers suffered persecution or death by the Salvadoran government and authorities for joining the teacher’s union (Flaitz, 2006). It is perhaps for this reason that teachers most frequently identified the principal before the police or a child protective agency as the person they would inform if a child was being abused. However, this question merits further research in order to ensure that teachers are informed about the most appropriate protocol to protect children under the current Salvadoran political system. Past research has also noted that an obstacle identified by teachers in reporting is their lack of knowledge about the legal procedures in reporting (Hinkelman & Bruno, 2008; Kenny, 2001) and fear of legal ramifications of making false allegations (Abrahams, Casey, & Daro, 1992). This was not an identified barrier to reporting in our study group. This may reflect the sentiment expressed by teachers in focus groups that the legal system in El Salvador is ‘weak’, and as a result legal proceedings are not seen as a major obstacle. However, it does appear that there was an ongoing theme from statements provided in the focus groups that part of the dissatisfaction with the way that CSA is being addressed is the lack of legal protection for both teachers and children. From this data, it also appears that teachers living in rural parts of El Salvador are more afraid of retribution for reporting cases, such as retribution from family members affiliated with gangs. These fears are not unfounded given that authorities estimate that there are 800,000 firearms in the hands of civilians and gang members in El Salvador, many of which are left over from the civil war (FESPAD, 2010). El Salvador is one of the most violent countries in the world with a homicide rate of 51.9 per 100,000 population in 2008 and, more recently in 2011, a homicide rate of 69.2 per 100,000 (UNDOC, 2012). In the USA, the homicide rate was 4.6 per 100,000 population in 2008 (UNDOC,
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2012). However, from Teachers’ Questionnaires, it appears that more teachers in rural settings reported having spoken to children about both sexual and physical abuse in a classroom setting. This finding may reflect that even though there is more resistance to reporting in rural areas, more teachers feel compelled to teach their students how to protect themselves. Based on reports from the ISNA, in 2010, there were more reports of child abuse made to ISNA from outside the urban area of San Salvador (1613) than from San Salvador (1050), even though the population of San Salvador is greater (ISNA, 2010). This fear of retribution may also explain why 95% of Salvadoran teachers surveyed reported that they would support legislation that would encourage teachers to report child abuse cases anonymously.
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Limitations It is important to recognise the limitations of our study. Only 4 out of 105 individuals approached to complete the survey refused. However, 10 out of 29 approached to participate in the focus groups refused. Thus, this increases the chances of bias in the focus groups. Most teachers stated that their reason for refusing to participate was not wanting to give up their lunch hour in order to participate in the focus group. However, we suspect that a reason for refusing to participate in focus groups was fear of identification, retribution or, at worst, losing their jobs for making comments that may be perceived as critical of the current education system. It is important to note that during the time that this project took place, there was an ongoing national debate about sex education in the classroom; a strong conservative opposition was spearheaded by the Catholic Church. The majority of the population in El Salvador, like most Latin American countries, is Catholic (Central Intelligence Agency, 2013). We suspect that some teachers fearing identification and its repercussions were concerned that a discussion on sexual abuse prevention in public schools would be too controversial. Interestingly, teachers participating in the focus groups had no difficulty discussing topics, such as gang violence and fear of retribution. It may be that teachers felt more comfortable disclosing in focus groups with a Spanish-speaking Salvadoran researcher, while the surveys may have been more threatening. Another limitation is that we do not know how representative this sample of teachers and students is of the Salvadoran population, thus potentially limiting generalisability of the findings. Finally, El Salvador is a country stricken by high rates of poverty and violence resulting from years of war. It is integral that future studies examining child abuse prevalence and interventions explore these factors more systematically than we were able to do here. However, as identified by teachers interviewed, a programme educating children and teachers about prevention and identification is insufficient when victims and those brave enough to disclose are not sufficiently protected from further violence and retribution. In 2009, a new Salvadoran government was elected. According to UNFPA, this new government has demonstrated a commitment to social inclusion, reproductive health and gender equality. This commitment led to the passing of the Special Law for Integral Life Free of Violence Against Women, which took effect on 1 January 2012. This law provides harsher penalties for violence against women, including not only physical violence, but also pornography and psychological abuse (UNDP, 2011). Furthermore, in 2011, the Law for the Protection of Children and Adolescents (LEPINA) took effect. This law establishes a comprehensive framework for protecting children, directly addresses physical and sexual abuse, and commits the state to protecting children. Unfortunately, a
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lack of resources is preventing fulfilment of the provisions established by this law (Global Issues, Ayala, 2011). Currently the Salvadoran Ministry of Education is working with Oxfam on ‘La Ruta del Arte’, a project in which thousands of schoolchildren will watch a performance intended to empower them to say no to child abuse and encourage them to disclose their perpetrators (Oxfam, 2010). These changes are a step in the right direction towards removing some of the barriers to protecting Salvadoran children. However, these legislative changes do not directly address the need to protect those who report child physical or sexual abuse. In conclusion, a CSA prevention programme where teachers are trained to speak to their students about issues regarding body ownership, types of inappropriate touching, and escaping and reporting skills would be supported by Salvadoran teachers. Furthermore, it is imperative for future CSA prevention programmes to focus on not only identification and reporting, but also how to protect children without risking teachers’ safety given the current sociopolitical climate. Acknowledgements The authors would like to thank the staff of El Tin Marin Children’s Museum, namely Celeste de Trabanino and Ricardo Granada, for being so welcoming and accommodating. We also thank the Mount Sinai School of Medicine Centre for Multicultural and Community Affairs, including Dr Butts, Ray Cornbill and Ann-Gel Palermo for their encouragement and guidance. Finally, we thank Drs Sharma and Ozbay, and Kathryn Marrone for facilitating the writing of this paper; and Mary Rojas, Dr Adriana Feder and Bertille Gaigbe-Togbe for their contributions.
References Abrahams, N., Casey, K., & Daro, D. (1992). Teachers’ knowledge, attitudes, and beliefs about child abuse and its prevention. Child Abuse and Neglect, 16, 229–238. doi:10.1016/0145-2134 (92)90030-U Ayala, E. (2011). El Salvador: New child protection law starved of resources. Global Issues [online]. Retrived from http://www.globalissues.org/news/2011/08/04/10740 Central Intelligence Agency. (2013). The world factbook: El Salvador [online]. Retrived from https://www.cia.gov/library/publications/the-world-factbook/geos/es.html Davis, M. K., & Gidycz, C. A. (2000). Child sexual abuse prevention programmes: A metaanalysis. Journal of Clinical Child Psychology, 29, 257–265. doi:10.1207/S15374424jccp 2902_11 Edwards, F. (2008). Remittances from international migration: A comparison of El Salvador and Nicaragua. The Review of Economics and Statistics, 77(1), 137–146. Retrived from http://www. jstor.org/stable/2109999 FESPAD. (2010). Human rights and confrontation in Central America 2010–2011, Regional human rights monitoring and analysis team in Central America. San Salvador, El Salvador: FESPAD. Finkelhor, D. (2007). Prevention of sexual abuse through educational programmes directed toward children. Pediatrics, 120, 640–645. doi:10.1542/peds.2007-0754 Flaitz, J. (2006). Understanding your refugee and immigrant students: An educational, cultural and linguistic guide. Ann Arbor: University of Michigan Press. Gibson, L. E., & Leitenberg, H. (2000). Child sexual abuse prevention programmes: Do they decrease the occurrence of child sexual abuse? Child Abuse and Neglect, 24, 1115–1125. doi:10.1016/S0145-2134(00)00179-4 Hinkelman, L., & Bruno, M. (2008). Identification and reporting of child sexual abuse: The role of elementary school pofessionals. The Elementary School Journal, 108, 376–391. doi:10.1086/ 589468 ISNA. (2010). Informe de rendicion de cuentas de gestion. San Salvador, El Salvador: ISNA. Johnson, C. F. (2004). Child sexual abuse. Lancet, 64, 462–470. doi:10.1016/S0140-6736(04) 16771-8 Kenny, M. C. (2001). Child abuse reporting: Teacher’s perceived deterrents. Child Abuse and Neglect, 25(1), 81–92. doi:10.1016/S0145-2134(00)00218-0
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Ko, S. F., & Cosden, M. A. (2001). Do elementary school-based child abuse prevention programmes work? A high-school follow-up. Psychology in the Schools, 38(1), 57–66. doi:10.1002/1520-6807(200101)38:13.0.CO;2-W Molnar, B. E., Buka, S. L., & Kessler, R. C. (2001). Child sexual abuse and subsequent psychopathology: Results from the National Comorbidity Survey. American Journal of Public Health, 91, 753–760. doi:10.2105/AJPH.91.5.753 Oxfam. (2010). La ruta del arte – an artistic way to end gender-based violence [online]. Retrived from http://www.oxfamamerica.org/articles/la-ruta-del-arte-an-artistic-way-to-prevent-genderbased-violence Pan American Health Organisation. (2005). PAHO basic health indicator database [online]. Retrived from http://www.paho.org/english/dd/ais/cp_222.htm Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 269–278. doi:10.1097/00004583200303000-00006 Ruiz, L. C. (2010). El Salvador 1989–2009, Estudios sobre migraciones y Salvadoreños en Estados Unidos desde las categorías de Segundo Montes [Migration studies and Salvadorans in the United States since Segundo Montes categories]. San Salvador: PNUD/UCA. Speizer, I. S., Goodwin, M., Whittle, L., Clyde, M., & Rogers, J. (2008). Dimensions of child sexual abuse before age 15 in three Central American countries: Honduras, El Salvador and Guatemala. Child Abuse and Neglect, 32, 455–462. doi:10.1016/j.chiabu.2007.03.026 UNDP. (2011). El Salvador women in parliament unite on new law against violence [online]. Retrived from http://content.undp.org/go/newsroom/2011/march/el-salvador-women-in-parliamentunite-on-new-law-against-violence.en UNDOC. (2012). UN data – a world of information [online]. Retrived from http://data.un.org US Department of State. (2012). US relations with El Salvador [online]. Retrived from http://www. state.gov/r/pa/ei/bgn/2033.htm World Health Organisation. (1999). Report of the consultation on child abuse prevention (pp. 13– 17), 29–31 March 1999. Geneva: World Health Organisation, Social Change and Mental Health, Violence and Injury Prevention. World Health Organisation. (2004). WHO suggests guidelines for child and sexual abuse prevention and management in Africa [online]. Retrived from http://www.afro.who.int/en/media-centre/press releases/item/586-who-suggests-guidelines-for-child-and-sexual-abuse-prevention-and-managementin-africa.html World Health Organisation. (2010). Child maltreatment [online]. Retrived from http://www.who.int/ mediacentre/factsheets/fs150/en/index.html
Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rgph20
Teachers' knowledge, attitudes and experience in sexual abuse prevention education in El Salvador a
Alicia Hurtado , Craig Katz
abc
, Dianne Ciro
ad
& Daniel Guttfreund
a
Department of Psychiatry, Mount Sinai School of Medicine, NY, USA b
Global Health Center, Mount Sinai School of Medicine, NY, USA
c
Department of Medical Education, Mount Sinai School of Medicine, NY, USA d
Department of Preventive Medicine, Mount Sinai School of Medicine, NY, USA Published online: 31 Oct 2013.
To cite this article: Alicia Hurtado, Craig Katz, Dianne Ciro & Daniel Guttfreund (2013) Teachers' knowledge, attitudes and experience in sexual abuse prevention education in El Salvador, Global Public Health: An International Journal for Research, Policy and Practice, 8:9, 1075-1086, DOI: 10.1080/17441692.2013.839729 To link to this article: http://dx.doi.org/10.1080/17441692.2013.839729
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Global Public Health, 2013 Vol. 8, No. 9, 1075–1086, http://dx.doi.org/10.1080/17441692.2013.839729
Teachers’ knowledge, attitudes and experience in sexual abuse prevention education in El Salvador
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Alicia Hurtadoa*, Craig Katza,b,c, Dianne Ciroa,d and Daniel Guttfreund a Department of Psychiatry, Mount Sinai School of Medicine, NY, USA; bGlobal Health Center, Mount Sinai School of Medicine, NY, USA; cDepartment of Medical Education, Mount Sinai School of Medicine, NY, USA; dDepartment of Preventive Medicine, Mount Sinai School of Medicine, NY, USA
(Received 30 November 2012; accepted 17 June 2013) Research on how to prevent child sexual abuse (CSA) in developing nations is practically non-existent. We sought to determine Salvadoran teachers’ knowledge, attitudes, experience and barriers to CSA detection and reporting to assess the need for a CSA prevention programme and to assess barriers in conducting such a programme. One hundred teachers completed a questionnaire while they visited the Tin Marin Children’s Museum in San Salvador. Nineteen of these teachers also participated in a focus group. We found that 89% of teachers reported at least two signs and symptoms of child abuse. One hundred per cent of teachers agreed that it is their responsibility to teach students about sexual abuse. Unusual for a study of this kind, parental migration was mentioned as making children vulnerable to CSA, and fear of gang violence and retribution was identified as interfering with teachers’ ability to protect children. We conclude that Salvadoran teachers were knowledgeable about CSA detection and reporting and would support a programme in which they are trained to speak to their students about this topic. Barriers to reporting child abuse, such as teachers’ safety and fear, need to be addressed in future CSA prevention programmes. Keywords: child sexual abuse prevention; teachers; El Salvador
Introduction When children are subjected to traumatic events during childhood, such as child sexual abuse (CSA), the mental health consequences are particularly impactful and long-lasting (Johnson, 2004; Molnar, Buka, & Kessler, 2001; Putnam, 2003). However, despite the lasting effects CSA has on people’s well-being, there is minimal research on how to prevent CSA. This is even more true in developing nations, where research on how to prevent CSA is practically non-existent. Community-based research, however, has identified risk factors of CSA, including poverty, weak legal systems, breakdown of family and armed conflicts (WHO, 2004). El Salvador, one of seven Central American countries, with a population of 6.1 million in 2011, has many of these risk factors. In 1992, the signing of the Peace Accords ended a 12-year civil war that cost the lives of about 75,000 Salvadorans (US Department of State, 2012). Political and socio-economic problems, such as limited job opportunities, persistent poverty and outmigration during the civil war, have resulted in 1 out of every *Corresponding author. Email: [email protected] © 2013 Taylor & Francis
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five Salvadorans living in the USA, 30% of all Salvadoran households being headed by females (Edwards, 2008), 67% of Salvadoran children living with only one parent or no parent (Ruiz, 2010) and 21.3% of Salvadoran families receiving remittances (monetary allowances sent to family members) (US Department of State, 2012). In post-civil war El Salvador, a country where 47% of the population lives in poverty, and where the mean age is under 20 (Pan American Health Organisation, 2005), Salvadoran children are at high risk for CSA. Childhood sexual abuse is defined by the World Health Organisation (WHO) in part as: ‘The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared…’ (WHO, 1999). International studies reveal that approximately 20% of women and 5–10% of men report being sexually abused as children, while 25–50% of all children report being physically abused (WHO, 2010). Twelve and sixtenths per cent of Salvadoran women reported being abused at any age and the mean age of abuse was 10.5 years (Speizer, Goodwin, Whittle, Clyde, & Rogers, 2008). Of these women, 11.4% reported that their father was the perpetrator; in Guatemala and Honduras 2.1% and 3.3% reported that their fathers were the perpetrators, respectively (Speizer et al., 2008). Young children are particularly vulnerable to CSA, as they may lack the cognitive ability to process what has happened to them and do not know how to recognise unacceptable behaviours. Thus, a key step in preventing CSA is educating children at a young age. One way to reach young children is through school-based community programmes, which have been proven to be effective in preventing CSA (Finkelhor, 2007; Gibson & Leitenberg, 2000). In a meta-analysis, Davis and Gidycz (2000) found that children who participated in prevention programmes performed 1.07 SD higher than control group children. This effect size can be interpreted as improvements in the prevention-related knowledge and skills of children who participated in programmes. Further, Ko and Cosden (2001) found that high school students who participated as children in school-based abuse prevention programmes have greater understanding of issues around blame, that abusers can be people who are close to the victim, that boys and girls can be victims, and of the need to report the abuse. However, in order to launch a CSA programme targeting elementary schoolchildren in El Salvador, an initial study is required to ensure that its development and implementation are informed, relevant and practical. Although epidemiological research exists on the prevalence of CSA in El Salvador, there are no studies that we know of that have researched teachers’ knowledge, attitudes, experiences and barriers to CSA detection and reporting. Objectives First, this study will assess teachers’ knowledge and attitudes of detection and prevention of CSA in order to determine the need and interest for a CSA prevention programme. Second, this study will assess experiences and barriers associated with teaching CSA prevention and with reporting CSA.
Methodology This project was a collaboration between the Mount Sinai School of Medicine and its Global Health Center, and the Tin Marin Children’s Museum in San Salvador, El Salvador. This study was approved by the Institutional Review Board of the Mount Sinai
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School of Medicine and the Salvadoran Ministry of Education. The Tin Marin’s Children’s Museum, in 2008, had a CSA exhibit based on a book entitled Mi Cuerpo Me Pertenece a Mi (My Body Belongs To Me), which addresses issues regarding body ownership, types of inappropriate touching and escaping and reporting skills. This exhibit was part of a campaign to educate children about CSA that was spearheaded by the Salvadoran Government and several non-governmental organisations (NGOs). Children from both urban and rural El Salvador were invited to the museum along with their teachers. Verbal consent to participate in this project was received from all teachers. Teachers were asked to anonymously complete a 28-item questionnaire entitled Teacher’s Questionnaire, while they visited the Tin Marin Children’s Museum exhibit with their students. The questionnaire was created by the research team in Spanish. It was divided into four sections: Demographics, Knowledge, Attitudes and Experiences. A total of 105 teachers were approached to participate and complete the questionnaire, and a total of 101 agreed to participate. One questionnaire was excluded as it was left unanswered (see Table 1 for participant sociodemographic profile). To assess teachers’ knowledge about CSA prevention and detection, teachers were asked five closed-ended questions and two open-ended questions. Answers on the five closed-ended questions were scored (K1–K5) (see Table 2 for details). To assess teachers’ opinions regarding CSA and their roles as teachers in protecting children, teachers were asked a series of seven closed-ended questions (A1–A7) (see Table 2 for details). To assess teachers experiences in providing child abuse prevention education, they were asked five questions (E1–E5) (see Table 2 for details). During their same museum visit, teachers were also asked to participate in 45-minute focus groups facilitated by the principal investigator in fluent Spanish. A total of 29 Table 1. Sociodemographic profile of teachers. Characteristics Full sample = 100 Mean age (± SD) Gender Female Male Unknown School setting Urban Rural Private or Public schoolteacher Private Public Missing information Mean years teaching (± SD) Educational level Some college College graduate Postgraduate education Received formal training in child abuse detection Yes No
38.2 (± 7.6) 61% 21% 18% 63% 34% N=7 N = 69 N = 24 12.93 (± 7.09) 77% 20% 1% 27% 70%
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Table 2. Teachers’ knowledge, attitudes and experiences of child abuse prevention (n = 100). Knowledge questions
True
False
Blank
K1. Adolescents are more likely to be victims of abuse than pre-adolescents. K2. Children who live in homes with domestic violence are more likely to become victims of sexual abuse. K3. Children are more likely to be abused by strangers. K4. If a child is being abused physically, I know who to inform. K5. If a child is being abused sexually, I know who to inform.
27%
70%a
3%
83%a
17%
0%
61% 92% 96%
39%a 5% 4%
0% 3% 0%
Agree
Disagree
Blank
31%
68%
1%
100%
0%
0%
99% 63%
1% 35%
0% 2%
95%
1%
4%
90%
3%
7%
95%
1%
4%
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Attitudes questions A1. Child sexual abuse is a problem in El Salvador that is being addressed adequately. A2. It is my responsibility as a teacher to educate my students about sexual abuse. A3. Learning about sexual abuse prevention is worth my time. A4. If I disclose a child abuse case to the authorities, I am sure that the child will be protected. A5. I would support legislation that would encourage teachers to report anonymously cases were they suspected child abuse. A6. I would agree to participate in an educational session about child sexual abuse prevention. A7. I would like to develop a class lesson after visiting the museum with my students about the prevention of sexual abuse. Experience questions E1. If I suspected that a child was being physically or sexually abused in his/her home, I would tell someone. E2. In the past I have spoken to a class of children about sexual abuse. E3. In the past I have spoken to a class of children about physical abuse. E4. In the past I have spoken to an individual child about sexual abuse. E5. In the past I have spoken to an individual child about physical abuse.
Agree
Disagree
Blank
92%
5%
3%
58% 72%
41% 26%
1% 2%
44% 58%
54% 41%
2% 1%
a
Correct answer.
teachers, who also filled out questionnaires, were invited to participate in focus groups, and 19 agreed to participate. In total, five focus groups were conducted with three to four teachers per group. Focus groups took place during lunch break in a conference room, while museum guides supervised children while they ate lunch. During the start of the focus group, a script was read to obtain the verbal consent of participants. Keeping in mind cultural sensitivity and political climate, participants were reminded that participation was voluntary, that their role with the public school system and the museum would not be impacted by participation, and that they could stop participation at any point during the study. Furthermore, as we believed that recording group interviews would be too threatening given the political climate at that time, we chose not to audio record the sessions. Instead, careful notes were taken, which were then translated back to English. Participants were also reassured that none of the information collected during the focus group would be shared with anyone from the museum or in the Ministry of Education
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until after the study was completed. During each focus group, the number of participants, approximate age ranges, general area of where teachers worked (rural or urban) and gender breakdown were recorded. Three open-ended questions were asked to encourage discussion during the focus groups: (1) Do you believe that CSA is a problem that needs to be addressed in El Salvador? (2) What role can you play as a teacher in preventing CSA? (3) If you were to become aware of a case of CSA, what resources currently exist in El Salvador to protect the child? The facilitator did her best not to lead participants, so as to get broad, nonbiased information. Data obtained during each focus group was summarised at the end of each group in a narrative form that was then read back to participants to ensure accuracy.
Results Teachers’ questionnaire Schoolteachers’ knowledge Of the five knowledge questions (K1–K5) (see Table 2 for details), 69% of teachers answered at least four of these five questions correctly. However, when asked: ‘True or False, Children are more likely to be abused by strangers’, approximately 60% of teachers answered this question incorrectly. The first open-ended question asked teachers to define ‘child abuse’ in their own words. In general, most teachers were able to provide an appropriate definition. One teacher wrote, ‘Child sexual abuse is the inappropriate manipulation of a child’s body without consent. It includes speaking to them dirty, showing them inappropriate images that are not age appropriate’. Another teacher answered, ‘It is when an adult person takes advantage of a child’s innocence to satisfy their basic instincts’. The second open-ended question asked teachers to describe two signs, emotional or physical, that a child is being physically or sexually mistreated. Eighty-nine per cent of teachers were able to provide two or more signs or symptoms that a child is being abused. Signs and symptoms reported included: ‘aggressive behaviour’, ‘socially withdrawn’, ‘afraid of adults’, ‘distracted’, ‘uses inappropriate sexually explicit words’, ‘bruises on the body’ and ‘sadness’. Schoolteachers’ attitudes In general, of the teachers surveyed, an overwhelming majority felt that as teachers they had a role in protecting children. For example, 100% of the teachers believed that it is ‘my responsibility as a teacher to educate my students about sexual abuse’. Ninety-nine per cent of the teachers felt that ‘learning about sexual abuse prevention is worth my time’. Furthermore, in order to assess whether teachers would be interested in participating in an initiative to provide education on CSA prevention, teachers were asked to agree or disagree with the following statements: ‘I would agree to participate in an educational session about child sexual abuse prevention’ and ‘I would like to develop a class lesson after visiting the museum with my students about the prevention of sexual abuse’. Ninety and ninety-five per cent of the teachers surveyed, respectively, stated that they would agree (see Table 2 for details). Sixty-eight per cent of the schoolteachers surveyed felt that CSA is a problem that is not being addressed appropriately in El Salvador. This opinion did not differ between men and women nor between teachers teaching in rural versus urban settings.
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Schoolteachers’ experiences Twenty-seven per cent of the teachers surveyed reported receiving formal training in child abuse prevention (see Table 1). In response to the statement ‘In the past I have spoken to a class of children about sexual abuse’, 58% of respondents indicated they had, while 41% indicated that they had not; 1% did not respond. In response to the statement ‘In the past I have spoken to a class of children about physical abuse’, 72% of respondents indicated they had, while 26% indicated they had not. Of those teachers who reported that they had spoken to children about physical abuse in a classroom setting, 92% reported that they had received training in child abuse prevention (chi square p < 0.008). Furthermore, of those teachers who reported receiving formal training, 73% reported that they had spoken to children about sexual abuse in a classroom setting. Although this finding did not reach significance with a chi square of p < 0.057, a trend can be observed. Interestingly, the longer a teacher had been teaching, the more likely she was to report that she had spoken to a child individually about both sexual and physical abuse (T-test = 0.007 and 0.022, respectively). Furthermore, more teachers who taught in rural settings reported that they had spoken to children about both sexual (chi square p < 0.036) and physical abuse in a class room setting (chi square p < 0.035). There was no significant difference in the number of urban versus rural teachers, who had received training in sexual abuse prevention. Teachers were also asked to agree or disagree with the statement: ‘If I suspected that a child was being physically or sexually abused in his/her home, I would tell someone.’ Ninety-two per cent of teachers agreed while 5% disagreed; 3% did not respond. Teachers were asked to select whom they would inform if they suspected that a child was being physically or sexually mistreated in his home. Most teachers selected the school’s director or principal (n = 39), followed by the National Police (n = 35) and ISNA (Institute for the Integral Development of Children and Adolescents) (n = 31). Many teachers also selected the child’s mother, father or guardian (n = 22). Few teachers selected a pastor (n = 1) or doctor (n = 3). Teachers’ focus groups In general, focus groups were lively and all individuals participated in the discussions. Several themes arose during the discussions, including barriers to reporting, such as the safety of the person reporting; to whom to report abuse cases; the purpose of reporting; and the role of teacher as a reporter. Of all the themes, teachers’ safety was the most frequently discussed. Teachers expressed serious doubts that reporting sexual abuse could be done anonymously. Teachers emphasised that this is particularly difficult in rural areas where teachers live in the community and often teach their own family members. One teacher explained, ‘There is no mechanism in place that protects a teacher if threatened. There is no support for them’. Teachers expressed concern of retribution by angry parents or others in the community. One teacher explained, ‘We are trained to see ourselves as teachers, as mediators; however, the biggest challenge is having the courage to get involved’. Another teacher who works in a rural setting stated: As a teacher and Christian, I love my students. It hurts me when I find out about a case. However, because of where the school is located, I cannot do anything about it. To report it would cost us our lives.
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Another teacher reported, ‘In rural areas where there is heavy gang activity, the police will not protect you’. And yet another teacher explained, ‘In this country witnesses are not protected. Gangs are a big problem…and if they hear that you are a witness…you [will be found] dead the next morning’. Some teachers expressed fear of being accused of making a false report as retribution. In general, teachers agreed that they know where to report a case of CSA. One teacher explained, ‘Everyone knows that these agencies exist, because the ISNA and ISDEMU (Salvadoran Institute for the Development of Women) are new and well identified’. Teachers also expressed distrust of Salvadoran institutions. One teacher stated, ‘I think there is more trust in these international organisations than in Salvadoran organisations. There is no such thing as national security, not even for government officials. How can we think there is national security for us?’ Doubts were expressed among some teachers about what reporting can accomplish. Some expressed concern that taking a child out of the home and placing him under the care of governmental or child protective agencies is not necessarily better for the child. Others expressed concern that there is no point in identifying abuse if laws do not exist to prosecute perpetrators. One teacher explained, ‘If we want to do something we have to improve the law. What is the point if the laws are weak and the perpetrators never get prosecuted?’ Another teacher reported: …and this is even more of a problem in the interior of the country. Even when parents are informed of the situation they do nothing. We had a big problem in one of our (rural) communities…There was a child whose father was abusing her. The mother supported the situation. I mean we knew that the mother would tie her children up as punishment and since I knew the father did worse, I called the ISNA. They did an investigation and they couldn’t tell me anything, but all I know is that nothing was done. I feel better because later on I discovered that the mother separated from that man.
Two teachers questioned the appropriateness of the role of educators in sexual abuse prevention. They expressed concern that they would be disrespecting parents’ religious beliefs by talking about sexual abuse prevention. As one of them stated, ‘Some parents don’t want issues of sex being discussed with their children’. Another teacher offered a different perspective: But I [don’t] think that we are… talking about sexual education; …actually we are talking about protecting children. Sexual reproduction is different than …[sexual abuse]. I agree that sexual reproduction is something that needs to be addressed in the home. The church is right.
Other teachers expressed resentment towards having to fill in for parents ‘who do not want to educate their children’. One teacher explained, ‘Parents just don’t give their children any importance. That is why we as teachers need to be involved’. However, other participants reported being eager to help parent a child who has been neglected at home. One teacher identified migration as one of the factors contributing to the incidence of CSA. She stated: It is a reality for our country that so many parents leave their children behind… [to be] raised by grandparents, aunts and uncles who sometimes don’t look after these children in the same manner that a parent would.
Despite expressing concern over the added responsibility that screening for child abuse would entail, teachers were nonetheless willing to take on that extra role. One teacher
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stated, ‘Our students trust us and if parents are abusing their children then we are the next closest to these children. For some of these children, we are the only educated individuals, the only ones that are aware of what the laws are’. Another teacher expressed, ‘But we do have a role as teachers. This is part of the education we provide to our students. We have an obligation to our children’.
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Discussion From teachers’ questionnaires In response to the Teachers’ Questionnaire, an overwhelming majority of teachers agreed that it is their responsibility to teach children about child abuse prevention, that they have a role in protecting children and that learning about child abuse prevention is worth their time. Despite the taboo nature of this subject, an overwhelming number of teachers affirmed that they ‘would like to develop a class lesson after visiting the museum with my students about the prevention of sexual abuse’. The willingness to participate in child abuse prevention programme among these teachers was much higher than expected. This overwhelming response to participation may have been influenced by teachers’ eagerness to please the investigator distributing the Teachers’ Questionnaire. It is also possible that this reflects the extent to which teachers believe that child abuse is a problem that needs to be addressed, as shown by the 68% of teachers who reported that CSA is a problem not being adequately addressed in El Salvador. A majority of teachers reported that they had spoken to children both individually and as a group about physical and sexual abuse. However, we were surprised that these numbers were so high among Salvadoran teachers, as only 27% of the teachers reported having received training in CSA prevention. Again, it is possible that teachers overreported having spoken to children about abuse as they wanted to please the investigators or were too ashamed to say that they had not. It is also important to note that we do not know the content of these discussions, nor if they were educational and helpful in preventing CSA. This high number of teachers reporting that they had spoken to children about abuse prevention could also reflect the number of years of teaching experience. The mean number of years teaching was about 13 years, and from our data, teachers with more experience reported talking with children about sexual abuse at a higher rate than those with less experience. Surprisingly, teachers were much more knowledgeable about the subject of CSA prevention despite the low percentage of teachers reporting formal training. Among the teachers surveyed, 89% of teachers were able to identify at least two symptoms of physical or sexual abuse. We did not ask teachers to identify separate symptoms for sexual and physical abuse, but even so, these numbers are higher than expected. It is possible that even though formal training in abuse prevention had not taken place, teachers have learned about child abuse prevention through other mediums, such as college courses, the media or NGOs. Furthermore, while most of the teachers surveyed indicated that they believe that a child would be protected if they reported a case of abuse to authorities, a large percentage (35%) did not. This trend is similar to that expressed during focus groups, where teachers expressed concern that child protective agencies and other authorities are not able to provide safety for children, their families or informants. Based on our survey, an overwhelming majority of teachers reported that they would inform someone if they believed a child was being physically or sexually abused.
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However, it is important to note that we did not ask if cases had actually been reported, but rather whether they would inform someone if they suspected that a child was being physically or sexually abused.
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From teachers’ focus groups Focus groups provided further information regarding barriers to reporting and potential consequences of reporting. They touched on the dilemma that exists between the desire to take action and protect a child when a case of abuse is identified and the reality of the sociopolitical environment in which Salvadorans live. Although 90% of the teachers surveyed reported that they would inform someone, focus groups elicited the dangerous sociopolitical context in which reporting occurs. Consistent with what was reported in the Teachers’ Questionnaire, where teachers reported knowing whom to inform about physical and sexual abuse at the rates of 92% and 96%, respectively, teachers in the focus groups reported that they knew whom to inform about both physical and sexual abuse. From the focus groups and Teachers’ Questionnaires, it appears that the person to whom teachers would most likely report abuse is the school principal. In many states in the USA, it is mandatory for teachers to report cases of child abuse directly to authorities, even if they already informed their principal. This is particularly important as it is up to authorities to determine whether an incident is deemed child abuse or not, and the principal may have reasons for wanting to keep reported child abuse cases low. Mistrust by Salvadoran teachers of the government or the authorities is not surprising given the fact that during the civil war in El Salvador many lost faith in the Salvadoran government and relied more on NGOs for protection and services. Furthermore, during the civil war, many teachers suffered persecution or death by the Salvadoran government and authorities for joining the teacher’s union (Flaitz, 2006). It is perhaps for this reason that teachers most frequently identified the principal before the police or a child protective agency as the person they would inform if a child was being abused. However, this question merits further research in order to ensure that teachers are informed about the most appropriate protocol to protect children under the current Salvadoran political system. Past research has also noted that an obstacle identified by teachers in reporting is their lack of knowledge about the legal procedures in reporting (Hinkelman & Bruno, 2008; Kenny, 2001) and fear of legal ramifications of making false allegations (Abrahams, Casey, & Daro, 1992). This was not an identified barrier to reporting in our study group. This may reflect the sentiment expressed by teachers in focus groups that the legal system in El Salvador is ‘weak’, and as a result legal proceedings are not seen as a major obstacle. However, it does appear that there was an ongoing theme from statements provided in the focus groups that part of the dissatisfaction with the way that CSA is being addressed is the lack of legal protection for both teachers and children. From this data, it also appears that teachers living in rural parts of El Salvador are more afraid of retribution for reporting cases, such as retribution from family members affiliated with gangs. These fears are not unfounded given that authorities estimate that there are 800,000 firearms in the hands of civilians and gang members in El Salvador, many of which are left over from the civil war (FESPAD, 2010). El Salvador is one of the most violent countries in the world with a homicide rate of 51.9 per 100,000 population in 2008 and, more recently in 2011, a homicide rate of 69.2 per 100,000 (UNDOC, 2012). In the USA, the homicide rate was 4.6 per 100,000 population in 2008 (UNDOC,
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2012). However, from Teachers’ Questionnaires, it appears that more teachers in rural settings reported having spoken to children about both sexual and physical abuse in a classroom setting. This finding may reflect that even though there is more resistance to reporting in rural areas, more teachers feel compelled to teach their students how to protect themselves. Based on reports from the ISNA, in 2010, there were more reports of child abuse made to ISNA from outside the urban area of San Salvador (1613) than from San Salvador (1050), even though the population of San Salvador is greater (ISNA, 2010). This fear of retribution may also explain why 95% of Salvadoran teachers surveyed reported that they would support legislation that would encourage teachers to report child abuse cases anonymously.
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Limitations It is important to recognise the limitations of our study. Only 4 out of 105 individuals approached to complete the survey refused. However, 10 out of 29 approached to participate in the focus groups refused. Thus, this increases the chances of bias in the focus groups. Most teachers stated that their reason for refusing to participate was not wanting to give up their lunch hour in order to participate in the focus group. However, we suspect that a reason for refusing to participate in focus groups was fear of identification, retribution or, at worst, losing their jobs for making comments that may be perceived as critical of the current education system. It is important to note that during the time that this project took place, there was an ongoing national debate about sex education in the classroom; a strong conservative opposition was spearheaded by the Catholic Church. The majority of the population in El Salvador, like most Latin American countries, is Catholic (Central Intelligence Agency, 2013). We suspect that some teachers fearing identification and its repercussions were concerned that a discussion on sexual abuse prevention in public schools would be too controversial. Interestingly, teachers participating in the focus groups had no difficulty discussing topics, such as gang violence and fear of retribution. It may be that teachers felt more comfortable disclosing in focus groups with a Spanish-speaking Salvadoran researcher, while the surveys may have been more threatening. Another limitation is that we do not know how representative this sample of teachers and students is of the Salvadoran population, thus potentially limiting generalisability of the findings. Finally, El Salvador is a country stricken by high rates of poverty and violence resulting from years of war. It is integral that future studies examining child abuse prevalence and interventions explore these factors more systematically than we were able to do here. However, as identified by teachers interviewed, a programme educating children and teachers about prevention and identification is insufficient when victims and those brave enough to disclose are not sufficiently protected from further violence and retribution. In 2009, a new Salvadoran government was elected. According to UNFPA, this new government has demonstrated a commitment to social inclusion, reproductive health and gender equality. This commitment led to the passing of the Special Law for Integral Life Free of Violence Against Women, which took effect on 1 January 2012. This law provides harsher penalties for violence against women, including not only physical violence, but also pornography and psychological abuse (UNDP, 2011). Furthermore, in 2011, the Law for the Protection of Children and Adolescents (LEPINA) took effect. This law establishes a comprehensive framework for protecting children, directly addresses physical and sexual abuse, and commits the state to protecting children. Unfortunately, a
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lack of resources is preventing fulfilment of the provisions established by this law (Global Issues, Ayala, 2011). Currently the Salvadoran Ministry of Education is working with Oxfam on ‘La Ruta del Arte’, a project in which thousands of schoolchildren will watch a performance intended to empower them to say no to child abuse and encourage them to disclose their perpetrators (Oxfam, 2010). These changes are a step in the right direction towards removing some of the barriers to protecting Salvadoran children. However, these legislative changes do not directly address the need to protect those who report child physical or sexual abuse. In conclusion, a CSA prevention programme where teachers are trained to speak to their students about issues regarding body ownership, types of inappropriate touching, and escaping and reporting skills would be supported by Salvadoran teachers. Furthermore, it is imperative for future CSA prevention programmes to focus on not only identification and reporting, but also how to protect children without risking teachers’ safety given the current sociopolitical climate. Acknowledgements The authors would like to thank the staff of El Tin Marin Children’s Museum, namely Celeste de Trabanino and Ricardo Granada, for being so welcoming and accommodating. We also thank the Mount Sinai School of Medicine Centre for Multicultural and Community Affairs, including Dr Butts, Ray Cornbill and Ann-Gel Palermo for their encouragement and guidance. Finally, we thank Drs Sharma and Ozbay, and Kathryn Marrone for facilitating the writing of this paper; and Mary Rojas, Dr Adriana Feder and Bertille Gaigbe-Togbe for their contributions.
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