Tackling CSA with public health, USA

This is an abridged version of Exploring the need for a widely adopted and accessible public health framework to address child sexual abuse in the UK by Pat Branigan, an assistant director at the NSPCC and medical anthropologist with a background in public health. For his Churchill Fellowship Branigan travelled to North America in late 2022 to meet and speak with experts in the field of child sexual abuse (CSA) prevention and treatment. This included a week in residence with the Department of Human Development and Family Studies at the Pennsylvania State University.

The findings draw on experiences and ideas from the US and Canada to build on current prevention frameworks and activities in use in the UK. The report explores gaps in prevention initiatives and thinking and recommends a way forward to develop a shared framework informed by the latest thinking from North America.

UK context

In the UK, 7.5 per cent of adults are estimated to have experienced sexual abuse before the age of 16, according to 2021 Home Office research. This translates to an estimated 3.1 million people having experienced CSA in England and Wales – 700,000 men and 2.4 million women. The most recent data (February 2023) from the Centre of Expertise on Child Sexual Abuse states that in 2021/22, local authority children’s services in England recorded concerns about CSA in 33,990 assessments of children, a 15 per cent increase on 2020/21; and police forces in England and Wales recorded 103,055 CSA offences, the highest ever level. The centre suggests prevalence could be even higher, estimating that 15 per cent of girls and five per cent of boys experience some form of sexual abuse.

A political shift in focus from treating often entrenched problems to intervening early came in 2008 with a cross-party paper on early intervention which provided the groundwork for two independent government reviews of early intervention by Graham Allen MP, published in 2011. More than a decade on, more co-ordinated action is needed to create a common framework of policies and high-quality evidence-based preventative programmes to bring about social change and eradicate CSA in the UK.

US context

While the US is one of the few countries to have implemented a raft of primary prevention CSA programmes since the 1980s, there are still ongoing calls for a more formal inclusion of CSA in existing strategies to address maltreatment of children and young people.

CSA affects 10 to 17 per cent of girls and around five per cent of boys in the USA. However, between 1990 and 2017, rates of CSA declined 62 per cent according to a 2020 study by Finkelhor et al.

The reasons for this decline are unclear, but it is likely that primary prevention efforts, beginning in the 1980s, contributed to the reduction in prevalence by raising public awareness about the signs of abuse and how to respond. However, the decline has plateaued recently, and prevalence estimates from 2018 indicate that rates of CSA in the US may be on the rise again. So, while gains have been made, there appears to be a case for effective CSA primary prevention strategies to be further understood and rolled out.

A public health approach

Among North American experts, academics and researchers there was strong consensus that adopting a public health approach to child sexual abuse prevention has enormous potential as a framework to organise, structure and develop our thinking.

At its very simplest, a definition of a “public health approach” would be preventing disease, prolonging life and promoting health through the efforts of society, rather than through clinical health interventions such as medicine and surgery.

Experts pointed out that by conceptualising CSA as a public health problem the following objectives could be achieved:

• Situating CSA within the personal/familial context (as opposed to the stranger/predator stereotypes)

• Recognising CSA as a correlation or consequence of other social issues, such as inequality, neglect and education

• Shifting activity, research and policy attention to prevention rather than reaction.

If child sexual abuse is understood and approached as a public health problem – in that it affects all communities, its impacts can be multiple, long lasting, and costly, and it can be prevented from occurring in the first place – this can provide a helpful framework through which prevention activity can be planned and delivered. There is no reason why we cannot stop child sexual abuse before it occurs by employing a public health approach.

Prevention

Preventing the abuse in the first place is far more desirable than trying to reverse the insidious impacts of child abuse, and it is far more proactive to address and improve family interactions before they get locked into potentially negative and harmful behaviours.

Public health approaches start from the principle that prevention is better than cure. A three-tier approach and the language used in both the US and the UK recognise that there are opportunities for prevention even after a problem has emerged:

• Primary prevention is preventing the problem occurring in the first place. This work is at the core of public health initiatives and tends to address the entire population

• Secondary prevention is intervening early when the problem starts to emerge and resolving it, often using targeted interventions to prevent greater risk factors

• Tertiary prevention is making sure an ongoing problem is managed to avoid further incidents and reduce overall harmful consequences.

The very implications of a public health approach mean an effective preventative response will require effort from all areas of society – at individual, relational, family, community, societal and system levels. This is important and translates to mean that every child, parent/carer, teacher, social worker, healthcare professional who works with children, family member, and friend should understand what child sexual abuse is and know how they can play a part in preventing it.

Place-based prevention

We have a real opportunity to understand and explore what it looks like to prevent child sexual abuse in a community through the place-based initiatives that are currently running in several locations in the UK and US. Together for Childhood is an ambitious 10-year place-based partnership approach developed by the cities of Plymouth and Stoke-on-Trent. It aims to radically improve the way we prevent child sexual abuse. Through collaborative working the two sites are developing and testing preventative approaches, focusing action at a local scale, and drawing on examples of best practice from around the world. Together for Childhood uses a theory of change already employing a public health philosophy to identify gaps, commission activities and interventions as part of a pipeline of preventative development work.

The Together for Childhood partnerships place a growing emphasis on empowering and educating communities to tackle child sexual abuse through bystander interventions and campaigns to deter people from online child sexual abuse across Plymouth and Stoke-on-Trent. The main target audience for the latest mass media campaign was pre-arrest offenders, also with messaging for their families and friends, and the wider public.

Post fellowship

In late 2023 a development group started the creation of an evidenced-informed public health model incorporating prevention frameworks to address child sexual abuse in the UK. The approach is informed and updated by learning from primary prevention initiatives across the UK and internationally. Three sub-groups are taking the work forward.

Preparing the ground is outlining the evidence and need for a public health approach to tackling child sexual abuse in the UK, through the development of an “untranslated” story of child sexual abuse in the UK – the core content that experts wish to communicate to members of the public.

• Framing the issue is linking with Frameworks UK to develop “the frame” that child sexual abuse can be prevented, by:

• Identifying expert and public perspectives about CSA and the differences between these

• Developing and testing communication strategies to align public with expert perspectives

• Disseminating validated communication strategies.

Architecture is scoping out the principles and designing the preventative framework that:

• Is informed by child sexual abuse theory and composed of the four components of public health approach (identifying the problem, risk and protective factors, development and evaluation of interventions and implementation)

• Outlines the essential elements of developing and delivering an integrated and effective child sexual abuse response, which prioritises prevention across every area of society – using primary, secondary and tertiary preventative approaches.

Target audience for the framework will be local authorities, safeguarding partnerships and government departments in the UK and it would help inform local and national child sexual abuse policy and practice, ensuring a preventative focus on the future funding of activities and priorities.

Report from https://media.churchillfellowship.org/documents/Branigan_P_Report_2020_Final.pdf

About the Churchill Fellowship

The Churchill Fellowship is a national network of 3,800 inspiring individuals whose mission is to find the world’s best solutions for the UK’s current challenges.

Up to 150 Churchill Fellows are funded each year to visit the world’s leading practitioners and projects on a topic of their choice – from social policy to healthcare to education and more – and bring back new ideas for their communities and sectors across the UK.

Any UK adult citizen can apply, regardless of qualifications, background or age. Fellows are chosen for their potential as change-makers, not their past track record or status.

Find out about fellows and their ideas at www.churchillfellowship.org