Knowledge of child sexual abuse and attitudes towards reporting it among teachers and parents of children studying in selected primary schools of Udupi Taluk, India

Child sexual abuse is one of the major issues of concern globally. Teachers and parents being the child’s primary caregivers should be knowledgeable regarding child sexual abuse. This study aimed to assess knowledge about child sexual abuse, determine attitudes toward reporting child sexual abuse, and find the relationship between knowledge and the attitude among the teachers and parents of the children studying in selected primary schools of Udupi taluk. A descriptive survey design was adopted; the study participants were 90 teachers and 50 parents of the children studying in selected primary schools of Udupi Taluk. The instruments used were demographic proforma, a structured knowledge questionnaire about child sexual abuse, and an attitude scale toward reporting it. Results depicted that 50% of the teachers had average knowledge and 50% had good knowledge about child sexual abuse. All the teachers reported a favorable attitude towards reporting child sexual abuse. Similarly, 80% of the parents had average knowledge about child sexual abuse, and a majority of 76% had a favorable attitude towards reporting child sexual abuse. Unfavorable attitude towards reporting child sexual abuse was reported by 24% of the parents. No statistically significant correlation was found between knowledge and attitude toward reporting child sexual abuse among parents ((χ2 = 1.891, p = 0.388). A significant association was found between teachers’ knowledge scores, their previous knowledge about child sexual abuse (χ2 = 7.56, p = 0.006), and the existence of a school counselor (χ2 = 5.40, p = 0.020). Likewise, the association was found between parents’ knowledge score, educational level of parents (χ2 = 18.3, p = 0.019), and marital status (χ2 = 18.5, p = 0.005). Child sexual abuse is one of the major issues of concern globally. Teachers and parents being the child’s primary caregivers should be knowledgeable regarding child sexual abuse. As parents are not exposed to any training regarding identifying and reporting child sexual abuse, they may have unfavorable attitudes toward reporting it.


Background
India has the highest population in the world which stands in second place, the latest census reveals that it is home to 17.7% of the world's population (India Population, 2021).In addition, 2022 data from UNICEF says that a total of 432,881,342 children are currently living in India.To continue, in the year 2018, the National Crime Records Bureau (NCRB) reported that 109 children were abused sexually in India every single day, and under the Protection of Children from Sexual Offences (POCSO) Act, 39,827 cases were reported in the same year (India News, 2020).This is just an official number, whereas it can be safely assumed that the actual numbers are much higher keeping in mind the population density of the country, and the unreported cases of child sexual abuse (CSA) due to multiple reasons perceived by the victims.The World Health Organization has estimated that 7.6% of boys and 18% of girls under the age of 18 years had experienced various forms of sexual abuse in their lifetime (WHO, 2014).The prevalence is higher among female than male children.
CSA is a serious problem of considerable magnitude throughout the world.According to a systematic review of 55 research from 24 countries, rates of CSA for girls ranged from 8 to 31%, while those for boys ranged from 3 to 17% (Barth et al. 2013).Subsequently, a systematic review of quantitative and qualitative studies in India reported the prevalence of CSA ranged from 4 to 41% of girls and 10 to 55% of boys in school and college samples (Choudhry et al. 2018).A 1-year prevalence of child sexual abuse of 16.7% and a lifetime prevalence of 19.9% was reported in a cross-sectional study conducted in Kerala, India (Kumar et al. 2019).
Several studies globally documented the teacher's and parents' knowledge of CSA.In Spain, 65.3% of the teachers had received education and training on CSA, and 90.7% of them did not possess knowledge about identifying CSA cases (Marquez-Flores et al., 2016).In Jordan, preventive measures for CSA were practiced by 17% of the mothers and 74% opined that children should get an education about CSA (Alzoubi et al. 2018).A study conducted in Iraq found that 90.5% of teachers had a positive attitude toward reporting CSA (Mohammed and Khudair 2019).Nearly 65.7% of the parents who belong to El Salvador had an opinion that strangers are more likely to abuse children (Salloum et al., 2020).A negative attitude was reported by a majority (62%) of the teachers belonging to Minia City about child abuse (Abd EL-Aziz et al. 2018).In Fuxin City, China, about 80% of mothers agreed with education in the school regarding preventing CSA, 47.3% of parents had an opinion that this may encourage the young mind to explore more about sex, and 60% of parents had taught their children that others are not allowed to touch their private parts (Chen and Chen 2005).
There is a lack of knowledge and apparent underreporting of child sexual abuse in Indian communities.Cultural and language boundaries may also impact parents' decision to report.A study conducted in Tamil Nadu, India, found that only 12.9% of the mothers were aware of the POCSO Act and 32.8% were aware of the child helpline 1098.About 50.5% of the mothers believed that the major role in preventing child sexual abuse is played by the parents (Shirley & Kumar 2020).A lack of knowledge regarding child abuse in parents was found in the majority of the parents.About 25% of parents believe that child abuse is just sexual violence.Only 2% of parents were well informed about the POCSO Act, those were highly educated parents and 21% of parents did not have any clue about this Act (Shankar et al. 2020).A study by Rani demonstrated that 38% of teachers have scored an attitude score below the mean value regarding CSA.About 43% of them had a score of knowledge less than the mean (Rani, 2019).
CSA can be prevented if one is aware of this, especially teachers and parents who are the primary caregivers of the child.They need to have intense knowledge about CSA and a positive attitude toward reporting, their role is crucial in preventing CSA (Nurmala, 2017).Parents are thought to play a significant role in protecting their kids from all forms of violence, including sexual abuse.The prevention of CSA depends on parenting behaviors, attitudes, and knowledge (Mlekwa et al. 2016).Caregivers must be aware of the physiological and behavioral markers that signify early abuse because children frequently do not report experiences of abuse for months or years.In all routine examinations, the primary care provider should check for both physical and mental health issues because the long-term physical and psychological impacts of abuse can be fatal (Sapp & Vandeven 2005).
India is home to the largest child population in the world and has the largest number of child sexual abuse instances, despite widespread under-reporting of CSA, which has far-reaching consequences.The stigmatization, helplessness, painful sexualization, and betrayal that the child endures have serious detrimental effects that are frequently alarmingly long-lasting (Chandran et al. 2018).In India, the topic of CSA is still taboo, and the vast majority of people keep quiet about it.Due to social stigma, fear of indignity, community denial, mistrust of governmental institutions, and a communication gap between parents and children, there is silence in this situation (Study on Child Abuse: India 2007).Chronic lack of awareness of parents' own rights and resources and lack of understanding as to how to report sexual abuse leads to underreporting which has influenced the researchers to take up this study.

Research design
A descriptive survey design was adopted for this study.

Study setting
The study was conducted in selected primary schools of Udupi taluk.Udupi is a part of coastal Karnataka state in the southwest region of India.As per the Udupi Population 2023-India Census, Udupi taluk has an estimated population of 1,341,250 of which 640,380 are males and 700,870 are females.Out of the total population, 53.68% population live in urban areas, and 46.32% live in rural areas.The gender ratio of Udupi City is 1022 females per 1000 males.The child sex ratio of girls is 927 per 1000 boys.Udupi is renowned as an educational and medical hub with a large student population pursuing higher education from different parts of India and the globe; hence, the city is found to have an equal share of the stagnant and mobile population.The average literacy rate of Udupi city is 93.55% of which male and female literacy was 95.94 and 91.22% (Udupi population 2023-India Census, n.d.).

Sample and sample size
The sample consisted of 90 teachers and 50 parents of children studying in selected primary schools of Udupi taluk.Schools were selected using a simple random sampling technique and samples were selected using a convenient sampling technique (Fig. 1).The sample size was calculated by estimating proportion based on previous studies (Okiche et al. 2019;Gurung & Bhattarai 2015).
Z α/2 = 1.96, value at a specified confidence level (95%).P = proportion of the event in the population (Teachers-0.7 and for Parents-0.6)d = acceptable margin of error in estimating the true population proportion (0.1) Thus, the required sample size for teachers was 81 and for parents was 93.The study was conducted during the COVID pandemic, all the schools were closed and the researchers had to access the participants only through online mode.Moreover, the majority of parents were from rural villages and did not have an email account and neither a smartphone to access the questionnaires and provide the responses.So, the researcher could gather information from 50 parents only, the majority being urban residents.

Data collection tools Tool 1: demographic Proforma
The demographic Proforma was developed for teachers and parents to assess sample characteristics.Teachers' Proforma consists of age, gender, education, total years of experience, previous knowledge of CSA, the existence of policy on CSA in school, availability of counselors at   reliability of the tool was 0.7.The knowledge questionnaire has been provided in the tables section (Additional file 1).

Tool 3: Teachers' Reporting Attitude Scale for CSA (TRAS-CSA)
TRQ-CSA tool was developed by Kerryann Walsh and the team (Walsh et al. 2012).As it was a standardized tool, permission to use the tool was obtained, and the tool was used in both English and Kannada language.The tool consists of 21 questions.The scale has a minimum score of 21 and a maximum score of 105.The scores were graded as unfavorable attitude (21-54) and favorable attitude (55-105).The attitude scale for parents was prepared by modifying TRAS-CSA and validated by seven experts, and content validity was 1.0.Reliability scores were 0.84 and 0.80 for teachers as well as parents' tools.

Ethical consideration
Ethical permission was obtained from the Institutional Ethics Committee (IEC No; IEC:900/2020, IRC 273/2020).The study was registered under the Clinical Trials Registry of India (CTRI/2021/04/033071).The study participants were provided with a subject information sheet explaining the purpose, risks, and benefits of participation.The informed consent form was explained and given to the participants before the data collection, which indicates their willingness to take part in the study.

Procedure for data collection
After obtaining prior permission from school authorities and the ethical committee, schools were selected for the study through the lottery method.Informed consent before the procedure was obtained, and the subject information sheet was distributed among teachers.For parents, contact details were collected from the schools, and Google Forms were forwarded along with the subject information sheet and informed consent form.

Statistical analysis
Data were analyzed using descriptive and inferential statistical methods, with the statistical package for Sciences (SPSS) 16.0 version.

Results
Frequency and percentage were used to analyze the demographic variables, knowledge level, and attitude toward CSA.The chi-square test is used to find the relationship between knowledge and attitude toward reporting CSA among parents and teachers and to find the association between knowledge, attitude, and demographic variables.In the analysis, the p value was tested at a 0.05 level of significance.
The data in Table 1 depicts that most (37.8%) of the school teachers belong to the 36-45 years age group.The majority (73.3%) of the respondents were postgraduates, and 36.7% of them said that they have 6-10 years of working experience.Around 52.2% of them had previous knowledge of CSA.The majority (64.4%) were permanent employees, and 81.1% of respondents reported the existence of school policy on CSA at their school.Around 78.9% of them have reported that they have a counselor at their schools.
The findings presented in Table 2 show that (44%) of parents belong to the age group 31-40 years.The majority (52%) had an education up to graduation.In addition, the majority (66%) of parents live in urban areas.Most (44%) parents have two children under 12 years of age.Almost 34% of parents reported that their monthly income is between 5001 and 15,000 Indian rupees.Nearly 48% of them said that television is their source of information regarding CSA.
Furthermore, 50% of the teachers had average knowledge of CSA, and 50% had good knowledge (Fig. 2).All  of them (100%) had a favorable attitude toward reporting CSA, whereas 80% of the parents had average knowledge of CSA, 10% had good knowledge of CSA, 10% of them had poor knowledge of CSA (Fig. 3), 76% of the parents had a favorable attitude towards reporting CSA, and 24% of them had an unfavorable attitude towards reporting CSA (Fig. 4).
The relationship between knowledge and attitude toward reporting CSA among parents shows no statistically significant relationship (χ 2 = 1.891, p = 0.388) (Table 3).Since all the teachers had favorable attitudes towards reporting CSA, no relationship was found between knowledge and attitude.
Similarly, there is a significant association found between knowledge and previous knowledge of CSA among teachers (χ 2 = 7.56, p value = 0.006).A significant association was found between knowledge and the existence of school counselors at their schools (χ 2 = 5.40, p value = 0.020) at a 0.05 level of significance (Table 4).
A significant association was found between the knowledge and education level of parents (χ 2 = 18.3, p = 0.019), knowledge, and their marital status (χ 2 = 18.5, p = 0.005) at a 0.05 level of significance (Table 5), and there is no significant association was found between attitude score and demographic variables of parents, at 0.05 level of significance (Table 6).

Discussion
The researchers of this study found that, among the 90 teachers, 50% had average knowledge about CSA and all (100%) teachers had a favorable attitude toward reporting CSA.Teachers considered to be the primary caregivers during childhood need to have more than adequate knowledge of CSA.They serve to be the critical link between the child and his/her immediate environment.Several studies have shown that teachers had only average knowledge of CSA which is not enough to fight the menace of CSA in our society, especially in lowand middle-income countries (Hynniewta et al. 2017;Shah, 2018).Schools considered to be the accurate places of knowledge providers can also serve as ideal places for the implementation of CSA awareness programs with teachers being the primary resource persons.Teachers with thorough knowledge of CSA could also be the first link in the referral service for the survivors of sexual abuse.Hence, several pioneers in education and other stakeholders have demanded sex education and CSA prevention programs to be an integral part of the education system.
In this study, it was also found that 80% of the participants (parents) had average knowledge about CSA while 24% of them had an unfavorable attitude towards reporting CSA incidents to the higher authorities.Both these findings are issues of concern and striking findings of this study.Parents the primary caregivers of a child need to be the front-line soldiers in reducing the prevalence of CSA.However, many studies especially from low-and middleincome countries have revealed that parents have average knowledge about CSA and also are quite reluctant to report cases of sexual abuse to authorities (Thangavelu 2016;Mlekwa et al. 2016;Goswami et al. 2019).The reasons for having an unfavorable attitude toward reporting may be several like the stigma associated with CSA, victim blaming, and family honor to name a few.This striking finding of this study must be an area of concern to all those who are worried about CSA.The researchers of this study recommend further studies to understand the reasons for this reluctance to report CSA cases among the primary caregivers of a child.To have successful CSA prevention programs, we need to navigate these sociocultural issues which act as the major hindrances.

Conclusions
This study found that the teachers had average to good knowledge about CSA and a favorable attitude toward reporting it.In contrast, the parents (80%) who are the primary caregivers of a child had average knowledge about CSA, and around 10% of them had poor knowledge.It is shocking to note that around 24% of the parents, which is quite a significant finding of this study, had an unfavorable attitude towards reporting CSA to the higher authority.The researchers assume that socio-cultural norms like the patriarchal society, the stigma associated with CSA, victim blaming, and family honor could be the possible reasons why the parents are reluctant to report CSA incidents to the higher authority.Several reports on CSA incidents have found that 80% of the incidents were perpetuated by the survivor's close relatives or known people (Tyagi & Karande, 2021), this finding also highlights the reason why the parents are reluctant to unmask CSA incidents as it may destabilize the family equilibrium and disrupt the complex family dynamics.It is recommended a further mixed method approach could be carried out to determine the hesitancy to report CSA cases by the parents of the victim.
In addition, few parents had opined that CSA can happen only in urban areas, as well as they had suggested that it is unnecessary to educate parents regarding CSA.Though the incidents are reported more in urban areas, it is far unlikely that such incidents do not occur in rural areas (Ruback & Menard, 2001).These results indicate that knowledge deficiencies do exist about CSA among caregivers and highlight the need for training in this field.The findings in this study provide useful information for developing further CSA education packages for teachers and parents.This study also indirectly reflects on the influence of the sociocultural norms, patriarchal mindset, and survivor blaming on the attitude towards reporting incidents of CSA, which should be kept in mind while designing the workshops/education packages for CSA prevention in the future.The researchers strongly feel that CSA is a complex phenomenon, especially in South Asian countries where culture, socio-economic status, and literacy among its population all play an important part.Hence, while designing strategies to prevent this menace, it should be multi-interventional.

Fig. 1
Fig. 1 Schematic representation of the sampling technique

Fig. 2 Fig. 3
Fig. 2 Bar diagram showing knowledge of the teachers on child sexual abuse

Fig. 4
Fig. 4 Bar diagram depicts the attitude of parents on CSA Frequency and percentage distribution of demographic characteristics of teachers, N = 90 Tool 2: self-structured knowledge questionnaireThe researcher developed a knowledge questionnaire after a thorough review of the literature.It included 30 items of multiple-choice under the areas of CSA and the POCSO Act.The scores were categorized as 0-10 poor knowledge, 11-20 average knowledge, and 21-30 good knowledge.Content validity was found to be 0.87.A split-half test was used to calculate the reliability, the Table 1

Table 2
Frequency and percentage distribution of demographic characteristics of parents, N = 50

Table 3
Relationship between knowledge and attitude towards reporting CSA among parents, N = 50 df degree of freedom, χ 2 chi-square, * significant at p = < 0.05

Table 4
Chi-square between knowledge score and demographic variables among teachers df degree of freedom, χ 2 chi-square, * significant at p = < 0.05

Table 5
Chi-square between knowledge score and demographic variables of parents, N = 50 df degree of freedom, χ 2 chi-square, * significant at p = < 0.05

Table 6
Chi-square between attitude score and demographic variables of parents, N = df degree of freedom, χ 2 chi-square, * significant at p = < 0.053