Skip to main content
NCBI home page
Elsevier - PMC COVID-19 Collection logoLink to Elsevier - PMC COVID-19 Collection
. 2022 Dec 15;135:105997. doi: 10.1016/j.chiabu.2022.105997

Prevalence and determinants of sexual abuse among adolescent girls during the COVID-19 lockdown and school closures in Ghana: A mixed method study

E Owusu-Addo a,⁎, SB Owusu-Addo b, DM Bennor a, N Mensah-Odum a, A Deliege c, A Bansal c, M Yoshikawa c, J Odame c
PMCID: PMC9750886  PMID: 36528934

Abstract

Background

In the wake of the COVID-19 pandemic, concerns have been raised that the pandemic may derail global efforts against child sexual abuse (CSA).

Objectives

This study examines the prevalence and associated factors of sexual abuse among adolescent girls in the context of the COVID-19 pandemic in Ghana.

Participants and setting

The sample comprised 853 adolescent girls aged 13–19 (16.03 ± 2.04 years) in Ghana.

Methods

The study employed a concurrent mixed-method design.

Results

Overall, the prevalence of CSA during the COVID-19 lockdown and school closures was 32.5 %. Protective factors for CSA were feeling safe in neighbourhood (AOR = 0.526, 95 % CI = [0.325, 0.850]) and parents often listen to opinions (AOR = 0.446, 95 % CI = [0.241, 0.826]). Risk factors for CSA were physical activity (AOR = 1.649, OR = 1.783, 95 % CIAOR = [1.093, 2.487, 95 % CIOR = [1.241, 2.561]), parents sometimes listen to opinions (AOR = 1.199, OR = 1.924, 95 % CIAOR = [0.504, 2.853], 95 % CIOR = [1.034, 3.582]), living with another relative (AOR = 2.352, OR = 2.484, 95 % CIAOR = [0.270, 20.523], 95 % CIOR = [0.317, 19.475]), Akan ethnicity (AOR = 1.576, OR = 1.437, 95 % CIAOR = [0.307, 8.091], 95 % CIOR = [0.316, 6.534]), having no disability (AOR = 1.099, OR = 1.138, 95 % CIAOR = [0.679, 1.581], 95 % CIOR = [0.786, 1.649]) and having a close relationship with parents (AOR = 1.334, OR = 1.752, 95 % CIAOR = [0.746, 2.385], 95 % CIOR = [1.096, 2.802]).

Conclusion

Knowledge of the risk and protective factors identified in this study can guide and inform the development of CSA prevention programmes during disruptive occurrences like school closures and lockdown.

Keywords: Child sexual abuse, Concurrent mixed-method design, Ghana, COVID-19, Lockdown, School closures

1. Introduction

Child sexual abuse (CSA) is defined by the World Health Organization (1999) 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 and cannot give consent, or that violates the laws or social taboos of society” (p.15). CSA is a violation of human rights and a public health problem with significant consequences for global health and development. While providing an exact figure for the scale of the problem is difficult, the findings from a recent global review shows that CSA is prevalent in all countries of the world and has a significant impact on the health and wellbeing of children (Radford et al., 2020; Singh et al., 2014).

A review of 217 studies conducted in 2011, found 1 in 8 of the world's children (12.7 %) had been sexually abused before reaching the age of 18 (Stoltenborgh et al., 2011). Another systematic review and meta-analysis by Barth et al. (2013) which included 55 studies from 24 countries estimated the prevalence of child sexual abuse between 8 and 31 % for girls and 3 to 17 % for boys. A recent review of evidence from UNICEF (2020) estimates that 1 in every 20 girls aged 15 to 19 (around 13 million) will have experienced forced sex at some point in their lifetime. Evidence from the WePROTECT Global Alliance (2019) further shows that the scale, complexity and danger of technology-facilitated child sexual abuse and exploitation is escalating. In terms of absolute numbers, it is estimated that 275 million children worldwide are exposed to domestic violence, including physical, sexual, and emotional abuse (Roca et al., 2020). CSA is gendered with girls more likely to be affected than boys. For instance, it has been estimated that, globally, 30 to 40 % of adolescent girls, experience sexual violence before turning 15 years-old, while approximately 20 % of adolescent boys experience the same before turning 19 years-old (Singh et al., 2014).

In Ghana, while official reporting of child sexual abuse cases remains low, the Ghana Demographic Health Survey (DHS) found that 16.5 % of adolescent girls aged 15–19 years old reported having experienced sexual violence (DHS, 2008). Further, one in four women (25 %) reported that their first sexual intercourse was forced and happened when they were <15 years old (DHS, 2008, p. 305). A 2015 study showed that the prevalence of children who had been sexually abused was around 27 % for girls and 11 % for boys (Böhm, 2016). A study by Quarshie (2021) focusing on sexual violence victimization and associated factors among school-going adolescents in urban Ghana found an overall, 17.6 % adolescents (males = 10.4 %; females = 24.3 %) reported sexual violence victimization during the previous 12 months.

CSA is associated with a range of psychological and behavioural consequences, including post-traumatic stress disorder, depression, anxiety, self-harm and attempted suicide (Berelowitz et al., 2013; Edinburgh et al., 2015). CSA can occur in all settings in which children spend their time including schools, homes and playgrounds (Bjørnseth and Szabo, 2018; Devries et al., 2015). Ending CSA is a global priority and critical for achieving all the Sustainable Development Goals for children. In September 2015, targets adopted by all United Nations member states in the Sustainable Development Goals (5.2, 16.1 and 16.2) ending all forms of violence against children, including sexual violence, by 2030.

In the wake of the COVID-19 pandemic, concerns have been raised that the pandemic may derail global efforts against CSA (Evelyn Aboagye Addae, 2021). According to Sserwanja et al. (2021) COVID-19 lockdown measures have exposed children to more sexual, physical and emotional abuse and neglect. Children, particularly girls, have heightened vulnerability to sexual violence committed by non-stranger perpetrators (e.g., neighbours) at private residences during the daytime, owing to school closures and a lack of alternative safe venues (Heather Flowe et al., 2020). Indeed, a recent paper published in the Lancet Child and Adolescent Health noted that not much is known about the effects of school closures during COVID-19 on sexual violence experienced by adolescents and called for further research in this area to understand the scale of the problem (Burzynska & Contreras, 2020). In Ghana, all schools were closed due to the outbreak of COVID-19 between March 2020 and January 2021 affecting approximately 9.2 million learners from Kindergarten to Senior High School (SHS) (Ministry of Education, 2020). This study aims to examine the prevalence and associated factors of sexual abuse among adolescent girls in the context of the COVID-19 pandemic. We explain the factors accounting for CSA with binary logistic regression and qualitative interviews in a concurrent mixed-method design. The study's findings could help ascertain the magnitude of the burden, which in turn could inform better policy formulation and implementation of intervention strategies.

1.1. Conceptual framework

The socio-ecological model (SEM) was used to inform the study. The SEM illustrates multiple dimensions and complex human interactions that influence health behaviours (Lee et al., 2017). The core principles of the model are: (1) there are multiple influences on an individual's behaviours (i.e., adolescent girls' sexual abuse), including factors at the intrapersonal level, interpersonal level, with increasing influence at levels of community, and public policy; (2) influences interaction across these different levels or spheres of influence; and (3) multilevel approaches can be the most effective interventions for preventing adolescent girls' sexual abuse.

2. Methods

2.1. Study design

This study employed a concurrent mixed-method design (Schoonenboom and Johnson, 2017). Levitt et al.'s (2018) guidelines on reporting a mixed-method study was used to guide the study. The quantitative component used a cross-sectional survey to ascertain adolescent girls' exposure to sexual violence during the COVID-19 outbreak. As adolescent girls live within a complex environment, specific survey questions were designed along the lines of the SEM to identify factors placing adolescent girls at risk of sexual abuse during the COVID-19 pandemic.

The qualitative component was an in-depth exploration of the lived experiences of participants. Qualitative in-depth interviews (IDs) and focus groups discussions (FGDs) explored the lived experiences of adolescent girls during school closures and their effect on sexual violence. Conceptually, the qualitative component draws on psychological and behavioural frameworks, in this case the socio-ecological model (Abbas & Jabeen, 2023) to gain a richer understanding of how adolescent girls were affected by COVID-19 lockdown and school closures. Key Informant Interviews were also held with community leaders, school teachers and service providers including Community Health Nurses, Midwives, and Nurses who provide sexual and reproductive health (SRH) services to adolescent girls.

2.2. Setting

To gain a balanced view of the impact of COVID-19 induced school closures on sexual violence among adolescent girls in Ghana, a maximum variation purposeful sampling strategy (Patton, 2014) was used to select two districts: Asokore Mampong Municipal (urban district) and Afigya Kwabre South District (rural district) in Ashanti region. The Ashanti region was chosen for this study as it recorded the highest number of adolescent pregnancies in 2020 in Ghana (Mensah, 2021). Further, the selected districts were part of the COVID-19 lockdown imposed by the Government on the Greater Kumasi Metropolitan Area in the Ashanti region between March 30 and April 20, 2020 as well as the prolonged school closures between March 2020 and January 2021. To maximise variation, in each of the districts, communities exhibiting rural and urban characteristics were selected for the fieldwork. School closures and CSA dynamics may differ between rural and urban settings. It was thus important to ensure that geographical variation among sites was represented in the study to capture any differential effects of the school closures.

2.3. Participants and sampling

For the quantitative survey, within the study districts and sites, stratified purposeful sampling (Patton, 2014) was used to include both in and out of school adolescent girls aged 13–19. The survey was conducted on a random sample of 853 adolescent girls (16.03 ± 2.04 years of age). The specific individuals were sampled from adolescent girls who were available on the dates of data collection in each study site. The girls were recruited from both the community and school settings. For girls recruited from school settings, permission was sought from the headmaster of the school to interview the girls during break periods. Assuming a population of approximately 100,000 adolescent girls in both districts, a sample size of 384 is sufficient to obtain a margin of error of 5 % and a 95 % confidence level (Cohen, 1998). For the qualitative component, to capture broader perspectives on the factors accounting for CSA, a maximum variation purposive sampling (Palinkas et al., 2015) was used to select adolescent girls, health care providers, parents and community leaders.

2.4. Data collection procedures

The research instruments (questionnaire and interview guides) were developed based on previous studies on the subject matter (Halperin et al., 1996; Mohler-Kuo et al., 2014). The research instruments were peer reviewed by UNICEF experts working in adolescent sexual and reproductive health and rights and child protection.

Research assistants and enumerators underwent training on the research background, methodology and ethical considerations including confidentiality, informed consent and data protection. Research instruments were further adjusted after a pilot with 50 adolescent girls. The enumerators were all females, which helped to create a conducive environment for the adolescent girls to talk.

The cross-sectional survey was administered between May and August 2021. Each survey lasted approximately 45 to 60 min, and was conducted using a Computer-Assisted Personal Interviewing technique. Before the survey started, the Research Assistants provided a short introduction to the study and informed participants about their rights to choose not to participate in the study and not to answer any question with which they felt uncomfortable. After the survey was completed, participants were referred to institutions that provide protection and counselling services.

All in-depth interviews and focus groups took place at designated places and times most convenient for the participants and were audio recorded with consent from the study participants. Focus groups were restricted to a maximum of 5–6 participants to accommodate social distancing protocol. Throughout the fieldwork, field notes were taken to record daily events and experiences. All data were collected face-to-face with strict adherence to COVID-19 safety protocols.

2.5. Measures (quantitative study)

The dependent variable was prevalence of CSA (i.e., during the COVID-19 lockdown and school closures). CSA was categorized as follows: “CSA without physical contact”; “CSA with physical contact” (Mohler-Kuo et al., 2014). The questionnaire contained 18 questions to assess various forms of CSA. The “CSA without physical contact,” had yes/no options; the “CSA with physical contact,” had four response options (“Yes”, No”, “Don't know” “Yes”, “Declined”. The SCA with physical contact questions were further categorized into “physical contact with penetration” and “physical contact without penetration.”

2.6. Data analyses

The “concurrent” technique was used to analyse the data. This technique allows for quantitative and qualitative findings to be jointly presented and discussed together through comparative analyses, which focus on differences and consistencies in the findings (Creswell, 2014).

Statistical analyses were done using SPSS version 26. Chi-square tests were used to assess the differences between CSA prevalence between urban and rural districts. Odds ratios were used to assess the association between sociodemographic characteristics and three categories of CSA (CSA without physical contact, CSA with physical contact without penetration, and CSA with penetration). Sociodemographic characteristics included: age; supervision of parents; relationship with parents; religion; disability; educational level; parents alive; ethnicity; parents, level of education; living arrangements; sense of safety in the neighbourhood; participation in a girl's club; participation in regular physical activity; previous experience of sexual intercourse. Both adjusted and unadjusted odds ratios and 95 % confidence intervals were reported using binary logistic regression models for each CSA type. Significance levels for all associations were set at p < 0.05.

The qualitative interviews and focus groups confirmed and extended the information provided by the cross-sectional survey. The qualitative data were analyzed using thematic analysis approach (Braun and Clarke, 2006). The interviews, focus groups, and field note data were transcribed verbatim to aid data analysis. Codes were developed from the combined transcripts and we pulled together core themes running through the entire data set. The analysis did not seek to draw attention to individuals' accounts and their individualised personal experiences, but to map out some of the prevalent issues as reported by the participants. The process was primarily inductive as the findings were dictated by the data. This approach ensured that the findings are dependent on the experiences and views of participants. Nonetheless, the identified themes were connected to the conceptual framework in the presentation and interpretation of the findings.

2.7. Rigour

The use of methodological triangulation (questionnaires, interviews and focus groups) and data triangulation (multiple sites for data collection) in this study strengthened the credibility and generalisability of the findings. Similarly, to ensure credibility and transparency in the research process, a memo was kept throughout the research process recording thoughts, feelings, insights, and ideas in relation to the study aims. The memo served as a reflective journal to aid research reflexivity. Additional strategies used to ensure trustworthiness and authenticity include data cleaning, verification of qualitative data through peer and member checking (e.g., seeking clarifications from participants during interviews, and discussion of codes and themes emanating from qualitative data during team meetings). Further, to achieve rigour of the qualitative data, the first and second authors conducted all the interviews and focus groups and thus became familiar with the data through the interview process. Next, after research assistants had transcribed the interviews, we thoroughly read through these and listened to audio recordings on several occasions to check the accuracy of the transcription. The themes were cross-checked with the transcript to ensure that they were coherent and consistent with the data to maximise their reliability.

2.8. Ethical considerations

In view of the sensitive nature of this research, we aimed at the highest ethical standards. Ethical review board approval for the study was provided by the Humanities and Social Sciences Research Ethics Committee (HuSSRECC) at the Kwame Nkrumah University of Science and Technology, Ghana. Participants were informed that they had the right to withdraw from the study at any time during the interviews. Introductory scripts were included in the beginning of the survey and at the beginning of each module to inform participants about the personal and sensitive nature of data being collected, and their choice to refuse to answer any question. Confidentiality and anonymity were assured, and factored into selection of the interview site. Participation was voluntary and based on oral informed consent. UNICEF's guideline on ethical research involving children and young people (Graham et al., 2013) guided the conduct of the interviews with children and young people.

A response plan was put in place to address any child safety issues that emerged during data collection. All enumerators were required to provide respondents with a Service Information Card containing contact information of social service providers available in the district. Respondents advised on how to store the card safely. All participants were informed that they could opt for referrals to institutions that provide protection, sexual and reproductive health and counselling services in their district.

3. Results

A total of 853 adolescent girls aged 13–19 (16.03 ± 2.04 years of age) were surveyed. The predominant ethnic groups of the adolescent girls were Akan (55.8 %) and Northern tribes (39.6 %). In terms of religion practised by the adolescents, 62.3 % were Christians while 37.4 % were Muslims. Regarding disability, a majority of the adolescent girls (70.9 %) did not have any form of disability. However, for those who had, the top four forms of disability were visual (13.2 %), emotional (5.5 %), learning (4.6 %) and hearing (3.6 %). Regarding employment, 52.5 % of the adolescent girls reported working and the nature of work were: learning a trade (29.9 %), domestic work (27.7 %), family business (22.2 %), street hawking (7.3 %) and kayayei1 (0.4 %).

Regarding the educational level, 52.4 % had completed Junior High School (JHS), followed by Senior High School (SHS)/Vocational Education (VOC) (29.1 %), primary (12.1 %) and tertiary (0.4 %). About 6.1 % of the adolescent girls had never been to school. Currently, more than half of the adolescent girls (63.3 %) reported being in school.

3.1. Prevalence and forms of CSA

The prevalence of sexual abuse was significantly higher in Afigya Kwabre South, the rural district than Asokore Mampong, the urban district (35.8 % vs 28.9 %; χ2 = 4.666, df = 1, p = 0.031). Overall, prevalence of sexual abuse was 32.5 %. That is, 3 in 10 adolescent girls had ever experienced at least one type of child sexual abuse during the COVID-19 lockdown and school closures.

As shown in Table 1 , the prevalence of the various forms of CSA during the COVID-19 lockdown and school closures were unwanted sexual touching (20.3 %), pressurised sex (3.5 %), attempted rape (14.5 %), forced sex (1.9 %), and forced exposure to pornography (14.8 %). In all, a total of 19 rape2 cases were reported by the adolescent girls during the COVID-19 lockdown and school closures.

Table 1.

Prevalence of CSA by type of abuse during the lockdown.

CSA domain Asokore Mampong (Urban) Afigya Kwabre (Rural) Overall sample Chi-Square Test
Child sexual abuse with physical contact without penetration
Touched in a sexual way 20.0 20.5 20.3 χ2 = 0.040, p < 0.842
Physically forced to have sex against will but did not succeed 12.8 16.0 14.5 χ2 = 1.705, p < 0.192



Child sexual abuse with penetration
physically forced to have sex and did succeed 1.9 1.8 1.9 χ2 = 0.011, p < 0.917
Pressurised to have sex and did succeed 3.6 3.4 3.5 χ2 = 0.023, p < 0.880



Child sexual abuse without physical Contact
Forced to watch pornographic material 14 15.6 14.8 χ2 = 0.424, p < 0.515
Forced to witness sexual exposure 3.4 3.2 3.3 χ2 = 0.021, p < 0.885
Forced to show naked body 1.9 2.1 2.0 χ2 = 0.016, p < 0.896
Taking pictures against your will 1 0.5 0.7 χ2 = 0.770, p < 0.380
Published nude pictures on the internet or social media platforms 0.5 0.5 0.5 χ2 = 0.003, p < 0.995
Open in a new tab

Quantitative findings suggest that adolescent girls' perceived vulnerability to CSA increased from 14.2 % before the COVID-19 pandemic to 25.9 % during the pandemic. The qualitative interviews and FGDs support the quantitative findings that adolescent girls were at increased risk of CSA during the school closures and the lockdown.

In this area, men treat ladies as something of no value. Sexual abuse was dormant even before the COVID, but the cases became serious when the COVID came. We were on lockdown, and no one was going to school, sometimes parents do not have money, peer influence, you can follow your friend somewhere that your parents will not even know your whereabouts. The school closures contributed a lot to this (IDI, Adolescent girl).

Yes, it is increased during the COVID-19. Because of the school closures, you see the boys sitting under a tree and will be calling us. A girl even died from having sex with a guy... I think he added something to a drink and gave it to her to drink. Some guys deceived the girls with materials like phone, laptop and the rest to have sex with them (FGD, Adolescent girls aged 13-19).

Watching of pornography too. This increased during the lockdown and school closures. A friend of mine has a lot of them on her phone and she got pregnant because she always wants to practice it with her boy. Some guys will deceive you that they have this and that, but ones you get pregnant, or they sleep with you, they will dump you (FGD, Adolescent girls aged 13-19).

Among the victims of CSA with physical contact with or without penetration, the most frequently reported places where incidents took place were another person's house (58.8 %) and the victim's house (17.6 %).

The evidence from the in-depth interviews with the adolescent girls revealed that the perpetrators of CSA were mostly adults over 18 years.

The older ones because some of them have done it for a long time so they have the experience. Because they are older than you, you don't think bad about them. We were in a room watching TV with a friend. My parents had left after watching the TV so I asked him to also go for me to go and bath. When I came from the bathroom to the room, thinking he had left, I undressed to apply my pomade then he came out from nowhere and saw my nakedness. He used my towel to cover my mouth to have sex with me, but I resisted. (IDI, Adolescent girl)

It is the grown-up men, men in their 50's, 60's, 40's who harass us. If the person is a teenager like yourself, you can defend yourself, but the grown-up men are very strong (FGD, Adolescent girls aged 13-19).

I attend the same church with a certain man, he was an elder in church, I took him as a brother. He teaches us the word and we used to go for evening service, so one day we were going to do decorations somewhere and we were only two girls and when I got somewhere I felt sleepy, so I went out and he didn't know I was out. We went with a sister, so she was lying in front and the man was in the middle between me and the sister. So, I noticed that whilst we laid down, he was touching the other sister in a sexual way which she did not like. (IDI, Adolescent girl).

The narratives above reveal the different circumstances in which adolescent girls were abused sexually in this study. The victims were mostly deceived, lured or pressurised by the perpetrators into the sexual abuse while others could not withstand the power dynamics or physical force exerted by male adults. The quantitative findings showed that the main relationship of the perpetrators of CSA to their victims were acquaintance (31.30 %), romantic partner (25.00 %), neighbour (18.8 %), peers (12.5 %), family member (6.3 %) and other (6.1 %).

Maybe he plays with you already so one day he may just take advantage of that to make those advances towards you. Some can send you to bring something to his room and once you enter there, he will just close the door. I have had that experience. He asked me to go to his kitchen to do something for him. (IDI, Adolescent girl).

I know of a 15year old girl who was lured, and she has even given birth. I also know of two siblings the older one got pregnant, but the man did not accept the baby and the younger one went somewhere else to give birth. Sometimes bring out the monies they have to lure us, which makes us follow them (IDI, Adolescent girl).

I met him during the COVID era. I remember he was visiting our tailoring shop and he expressed his feelings for me and was pestering me for my call contact number. Initially I was hesitant, but he continued putting pressure on me and eventually gave it up and that's where we took it off and had sex (IDI, Adolescent girl).

The qualitative findings revealed that the drivers of increased CSA cases were inactivity among adolescent girls due to school closures, poverty, and parental neglect. Most of the adolescent girls noted that their parents' works were negatively affected by the COVID-19 outbreak and preventive measures, especially the lockdown. Others also expressed the view that they were not engaged in learning activities during the school closures, which made them more vulnerable to the advances of the boys/men.

Most girls were influenced negatively during the lockdown and school closure because we were not engaged in learning activities. Many girls were taken advantage of by guys especially due to poor economic background, which makes it difficult for them to say no to sex. (IDI, Adolescent girl aged).

It was during the school closures that most of the girls became pregnant in this community. When the president lifted the lockdown most of the girls who were in school were not able to go back to school because they were pregnant… Other factors include poor parental care or child neglect, which is common in this community…because some parents in this community are illiterate, they let their children roam, which promotes teenage pregnancies (KII, Parent and community leader).

Also, sex education is now more focused on safe sex and prevention of pregnancy rather than abstinence…this makes girls experiment sex and men can take advantage of them (KII, Parent).

A few of the parents interviewed expressed a concern that sexuality education seems to have shifted from abstinence to pregnancy prevention and safe sex, which according to them could predispose girls who are adventurous to CSA.

The results of the adjusted model as presented in Table 2 indicate that the significant protective factors for CSA are feeling safe in neighbourhood (AOR = 0.526, 95 % CI = [0.325, 0.850]) and parents often listen to opinions (AOR = 0.446, 95 % CI = [0.241, 0.826]). Significant protective factors in the unadjusted model are early adolescence (13–15 years) (OR = 0.592, 95 % CI = [0.398, 0.882]), living with foster parent (OR = 0.399, 95 % CI = [0.198, 0.807]), and feeling safe in neighbourhood (OR = 0.558, 95 % CI = [0.368, 0.847]).

Table 2.

Determinants of CSA.

Determinants AOR (CI) OR(CI)
Age (Early adolescence 13–15 years) 0.766 (0.455, 1.289) 0.592 (0.398, 0.882) ⁎⁎
Supervision of parents (High) 0.934 (0.631, 1.382) 0.769 (0.546, 1.084)
Relationship with parents (Close) 1.334 (0.746, 2.385) 1.752 (1.096, 2.802)
Disability /None (Yes) 1.036 (0.679, 1.581) 1.138 (0.786, 1.649)



Highest level of schooling
No formal education 0.478 (0.151, 1.515) 0.532 (0.200, 1.471)
Primary 0.498 (0.168, 1.482) 0.549 (0.227, 1.328)
JHS 0.615 (0.194, 1.953) 0.457 (0.185, 1.127)
SHS/VOC 000 (0.000) 000 (0.000)
Currently in school? (Yes) 1.064 (0.654, 1.732) 0.818 (0.581, 1.152)



Ethnicity
Ethnicity (Akan) 1.576 (0.307, 8.091) 1.437 (0.316, 6.534)
Ethnicity (Ewe) 0.970 (0.555, 1.694) 0.875 (0.619, 1.237)
Ethnicity (Northern tribes) 0.687 (0.227, 2.082) 0.759 (0.295, 1.953)



Are your parents alive?
Are your parents alive? (Yes both) 2.034 (0.085, 48.712) 1.183 (0.481, 2.910)
Are your parents alive? (Only Father) 0.000 (0.000) 0.840 (0.529, 1.333)
Are your parents alive? (Only Mother) 0.000 (0.000) 0.582 (0.249, 1.358)



Father's level of education
Primary 2.156 (0.895, 5.191) 1.804 (0.816, 3.986)
JHS 2.083 (0.800, 5.419) 2.114 (0.895, 4.996)
(SHS /VOC 1.898 (0.550, 6.551) 2.460 (0.841, 7.196)
Tertiary 3.086 (1.278, 7.454) 2.699 (1.255, 5.807)



Mother's level of education
Primary 0.676 (0.347, 1.318) 0.802 (0.439, 1.465)
JHS 1.367 (0.562, 3.321) 1.630 (0.732, 3.630)
SHS/VOC 1.394 (0.232, 8.378) 1.565 (0.321, 7.632)
Tertiary 0.796 (0.377, 1.680) 1.195 (0.639, 2.235)



What is your living arrangement?
With both biological parents 2.267 (0.602, 8.538) 1.587 (0.461, 5.459)
With father only 0.775 (0.461, 1.302) 0.762 (0.497, 1.168)
With mother only 0.726 (0.430, 1.226) 0.676 (0.442, 1.034)
With another relative 2.352 (0.270, 20.523) 2.484 (0.317, 19.475)
With foster parent 0.462 (0.196, 1.090) 0.399 (0.198, 0.807) ⁎⁎



My parents or guardians listen when I share my opinion
Sometimes 1.199 (0.504, 2.853) 1.924 (1.034, 3.582)
Often 0.446 (0.241, 0.826) ⁎⁎ 0.682 (0.449, 1.036)
Rarely 0.575 (0.223, 1.481) 0.687 (0.422, 1.120)
Neighbourhood environment (Feels safe) 0.526 (0.325, 0.850) ⁎⁎ 0.558 (0.368, 0.847) ⁎⁎
Belong to any girls club (Yes) 0.919 (0.562, 1.504) 0.691 (0.451, 1.059)
Practice regular Physical Activity (Yes) 1.649 (1.093, 2.487) 1.783 (1.241, 2.561)
Ever talked with anybody about sexual and reproductive health matters(Yes) 0.677 (0.425, 1.080) 0.747 (0.495, 1.127)
Have you ever had sexual intercourse? (Yes) 2.207 (1.394, 3.495) 0.747 (0.495, 1.127)
Open in a new tab
⁎⁎

Significant at p < 0.05.

The adjusted model indicates that girls in their early adolescence (13–15 years) had 23.4 % lower risk of CSA during the COVID-19 lockdown and school closures compared to late adolescent girls (16–19 years). The odds of experiencing CSA is 6.6 % lower for respondents with high supervision from parents compared to those with low supervision. Girls with close relationships with parents were 33.4 % more likely to experience CSA compared to those who were not close with their parents. The odds of experiencing CSA for a child living with only father or only mother is 16 % and 41.8 % lower compared to a child living with both parents (which increased the risk by 18.3 %). In relation to educational level, having no formal education had the lowest odds of CSA in the last 12 months (AOR = 0.478). Girls with primary, JHS, SHS/VOC, or tertiary education have higher odds of experiencing CSA compared to respondents with no formal education.

Risk factors for CSA in both models include practicing regular physical activity (AOR = 1.649, OR = 1.783, 95 % CIAOR = [1.093, 2.487, 95 % CIOR = [1.241, 2.561]), parents sometimes listen to opinions (AOR = 1.199, OR = 1.924, 95 % CIAOR = [0.504, 2.853], 95 % CIOR = [1.034, 3.582]), living with another relative (AOR = 2.352, OR = 2.484, 95 % CIAOR = [0.270, 20.523], 95 % CIOR = [0.317, 19.475]), living with both parents (AOR = 2.267, OR = 1.587, 95 % CIAOR = [0.602, 8.538], 95 % CIOR = [0.461, 5.459]), Akan ethnicity (AOR = 1.576, OR = 1.437, 95 % CIAOR = [0.307, 8.091], 95 % CIOR = [0.316, 6.534]), having no disability (AOR = 1.099, OR = 1.138, 95 % CIAOR = [0.679, 1.581], 95 % CIOR = [0.786, 1.649]) and having a close relationship with parents (AOR = 1.334, OR = 1.752, 95 % CIAOR = [0.746, 2.385], 95 % CIOR = [1.096, 2.802]). Girls who were currently in school were 6.4 % more likely to have experienced CSA. In relation to living arrangements, living with another relative had the highest odds (AOR = 2.352) of exposure to CSA. In the unadjusted model, girls who were exposed to sexual and reproductive health talk were 25.3 % more likely to experience CSA compared to those who were not exposed. The odds of a girl with both parents alive experiencing CSA is 18.3 % higher compared to a girl whose parents are not alive. All levels of father's education were predictors of CSA while only higher levels of mother's education were predictors of CSA. In the adjusted model, girls with fathers who had obtained tertiary education were 3 times more likely to be sexually abused.

4. Discussion

Findings from both the quantitative and qualitative evidence indicate that CSA increased during the COVID-19 lockdown and school closures. The overall CSA prevalence of 32.5 % among adolescent girls during the COVID-19 lockdown and school closures is higher than previous estimates of 27 % (Böhm, 2016), and 16.5 % (DHS, 2008). This is consistent with UNFPA-Ghana's warning that Ghana should expect a spike in gender-based violence, sexual exploitation, rape, incest and other forms of violence during the pandemic (Addae, 2021). In this study, adolescent girls' vulnerability to CSA increased by 11.7 % during the COVID-19. This is lower compared to the South African situation which saw a 61.6 % increase in CSA (Gauteng, 2020), and a 20.1 % increase in CSA in Uganda (Sserwanja et al., 2021), during the COVID-19 lockdown and school closures. Adolescent pregnancy and CSA also increased significantly in Kenya during the COVID-19 pandemic (Stevens et al., 2021). This finding further suggests that CSA generally increases during disruptive occurrences. For instance, school closures during the Ebola epidemic in Sierra Leone in 2014–15 put children at greater risk of rape, and led to 65 % increase in teenage pregnancies (Bandiera et al., 2020; Goulds and Gallinetti, 2020; Onyango et al., 2019). Further, the odds of an adolescent girl in Haiti being sexually abused increased by 41 % during the 2010 earthquake in Haiti (Sloand et al., 2017).

The perpetrators of CSA identified in this study were acquaintances (31.30 %), romantic partners (25.00 %) and neighbours (18.8 %). This is in line with other studies, which have shown that children, particularly girls, have heightened vulnerability to sexual violence committed by non-stranger perpetrators (e.g., neighbours) (Flowe et al., 2020; Rockowitz et al., 2021). Among the victims of CSA in this study, the most frequently reported places where incidents happened were another person's house (58.8 %) and the victim's house (17.6 %). This finding corroborates other studies which have shown that CSA largely occurs in another person's house (Bandiera et al., 2020; Flowe et al., 2020; Rockowitz et al., 2021).

Results from this study indicate lower odds of prevalence of CSA for early adolescents compared to late adolescents. This is consistent with a self-report survey among adolescents, which revealed high rates of CSA among late adolescents (Finkelhor et al., 2014). Other key determinants of CSA identified in this study were engagement in physical activity, lack of parental supervision, parents not listening to adolescent girls' views, previous experience of sexual abuse and being an orphan.

Surprisingly, our findings indicate that having a close relationship with parents is a risk factor for CSA. This contradicts the evidence suggests that having a closer relationship with their children allows parents to have open and honest exchanges about sexual health matters and protect children from CSA (Widman et al., 2016). However, there could be several possible explanations for this finding in our study. For instance, being close to a parent may make a child more trusting of a family acquaintance, who may take advantage of the situation. Further, as shown in this study, lack of parental supervision even when parents are close to their children was a risk factor for CSA. Analysis of CSA perpetrators' modus operandi indicates that they benefit from, and exploit to their advantage, a lack of parental supervision (Leclerc et al., 2011; Leclerc et al., 2015). In examining the preconditions that must be present for CSA to occur, Finkelhor (1984) noted that parental supervision is one of the key external barriers that the perpetrator must be able to overcome in order to commit CSA. This suggests that with strong parental supervision, parents and caregivers are in the best position to maintain strong external barriers that can prevent a perpetrator gaining access to children to commit CSA. Lack of parental supervision has been found to be a risk factor for CSA in other studies (Finkelhor and Baron, 1986; Rudolph and Zimmer-Gembeck, 2018). Evidence from the US context suggests that children of parents who adopt strict supervision, an authoritative and more hands-on parenting style are less likely to engage in risk sexual behaviours (Askelson et al., 2012).

A key finding from this study is that children who had experienced sexual abuse were at a higher risk of being abused again. This is known as revictimization (Papalia et al., 2021; Pittenger et al., 2018). This suggests that a child survivor who lacks the support network and tools to cope with the trauma associated with CSA may become more vulnerable to a recurrence of sexual abuse. Also, a child who has been subjected to sexual abuse that has not been dealt with is likely still in an at-risk environment that allows the abuse to continue. This supports the existing evidence on the impact of CSA on sexual relationships in subsequent developmental stages and underline the need to consider CSA as a risk factor of adolescent sexual victimization (Krahé et al., 1999; Miron and Orcutt, 2014).

In the present study, some parents noted during the key informant interviews that exposure to sexual and reproductive health talk could put girls at risk of CSA, if the focus of adolescent sexual education moves away from the abstinence message. While this aligns with other studies which found that teaching young children about CSA protective behaviours might not be sufficient for prevention (Rudolph et al., 2018), it also evidences prevailing community perceptions about sexuality education as contributing to early sexual debut or increasing risk-taking sexual behaviours among adolescents. Considered a particularly sensitive topic on cultural and religious grounds in several sub-Saharan African contexts, this perception runs contrary to global evidence which has found that abstinence-only approaches have limited or no positive effect on adolescent sexual behaviours and mitigating risks of CSA (Heels, 2019; Kirby, 2008; UNESCO et al., 2016).

The qualitative findings further showed that power dynamics exerted by adult perpetrators and the use of gift items to lure girls contributed to adolescent girls being sexually abused as they could not resist the perpetrators. This aligns with Finkelhor (1984) proposition that for CSA to occur, the perpetrator must be able to overcome the child's resistance. That is, victim resistance is an important CSA preventive measure, and this goes far beyond the child being able to say ‘no’ to a potential abuser, with one major risk factor [being] anything that makes a child feel emotionally insecure, needy or unsupported, and thus being vulnerable and easy to be lured with a gift.

Participation in physical activity was also a risk factor for CSA. This may be explained by a variety of reasons. For example, adolescents who practice regular physical activity spend more time outside the family and/or home environment and could be exposed to a wider range of perpetrators in the spaces where they practice physical activity (United Nations Children’s Fund, 2020). Further, adolescents who practice regular PA could be abused by their trainers. During the focus groups, participants reported that adolescent girls who wear revealing dresses often fall prey to sexual violence in the hands of male trainers and peers, reflecting the prevalence of negative social norms that can contribute to gender-based coercion, violence and victim-blaming. Tschan (2013, p. 81) notes that sport is an ideal environment for CSA since it is seen as a ‘sacred’ part of the culture and thus suspends social norms and, therefore, accepts behavior that is normally unacceptable (East, 2012), where the coach is able to touch children as part of their work while enjoying the trust of the parents. In a recent systematic review on sexual violence against children in sports and exercise, both coaches and peer-athletes were identified as perpetrators of CSA (Bjørnseth and Szabo, 2018).

Fathers' level of education was found to be a determinant of CSA. A recent study in Nigeria found that fathers who had obtained at least a secondary education were 5 times more likely to have sexually abused children (Chime et al., 2021).

4.1. Limitations

The findings of this study need to be interpreted in light of some possible limitations. First, we do not seek to argue for causality as the study is based on cross-sectional data. Further, the sample was drawn from two districts in the Ashanti Region and is not representative of the adolescent girls' population in Ghana. The instruments used in measuring the dependent and independent variables and the qualitative interviews were largely subjective. Therefore, there is a likelihood of social desirability bias, which may have influenced the views of participants instead of sharing their actual experiences. Despite these limitations, the findings align with the extant literature on CSA prevalence and determinants.

4.2. Conclusion and implications

This study sought to examine the prevalence and associated determinants of CSA in the context of COVID-19 pandemic among adolescent girls. The findings suggest that CSA increased during the COVID-19 lockdown and school closures. It also indicates that having high supervision from parents, feeling safe in the neighbourhood, and parents/guardians often listening to opinions were protective factors of CSA. The findings indicate that one of the key lessons learned from the COVID-19 induced school closures has been the vital role of schools in safeguarding children – at least for those who attend school. These findings set the foundation for policy, practice and research recommendations relating to public health, child protection and social protection interventions aimed at CSA prevention, mitigation and response. Knowledge of the risk factors identified in this study can guide and inform the development of policies and programs to address CSA. The findings indicate that to protect children from sexual abuse during disruptive occurrences like the COVID-19 induced school closures and lockdown, there is the need for a multi stakeholder approach to CSA prevention and response.

While schools are deemed to be one of the most promising institution for the delivery of CSA prevention and response efforts due to their consistent and longitudinal contact with children and their families (Lu et al., 2022), school closures in disruptive occurrences like the COVID-19 pandemic make it necessary to look for alternatives.

The findings show that lack of parental supervision and monitoring of adolescent girls were a major risk factor for CSA. This suggests that parents and caregivers play a crucial role in keeping children safe from CSA. There is strong evidence to suggest that parental involvement in CSA prevention is an effective strategy (Walsh et al., 2012). For instance, parents and/or caregivers can play a crucial role as protectors of their children via two pathways: (a) by strengthening external barriers through parent supervision and monitoring; (b) by promoting their child's well-being, and self-esteem, which may make them less likely targets for abuse and better able to protect themselves from abusers who may use gifts to lure them. This means that there is the need to design and implement contextualised and targeted parenting programmes that promote positive parenting practices to reduce CSA risks for vulnerable children. Proactive and involved parenting with appropriate levels of monitoring can create safer environments in which there are fewer opportunities for children to be approached sexually or victimized.

One key area, which needs further investigation, but not covered in this paper, is in-depth analysis of adolescent girls' reporting of CSA and help-seeking behaviours during the COVID-19 pandemic and school closures as these have implications for the design of appropriate mitigation and response strategies.

Declaration of competing interest

This paper is independent research arising from commissioned research funded by UNFPA-UNICEF Global Programme to Accelerate Action to End Child Marriage. The views expressed in this publication are those of the authors and not necessarily those of the funders. The role of the funding body was limited to participating in framing the study aim and questions. They were however, not involved in the design of the study, nor the collection, analysis, and interpretation of data, or in writing the manuscript.

Footnotes

1

Kayayei - a term commonly used in Ghana to refer to a girl / woman who works as a head porter carrying heavy loads on her head for a fee. Kayayei are typically seen in market places in large cities or at busy roads and junctions. Street hawking is the act of selling retail goods directly on busy city/town streets.

2

In Ghana, rape is defined here as the carnal knowledge of a female of sixteen years or above without her consent.

Data availability

Data will be made available on request.

References

  1. Abbas S.S., Jabeen T. Child sexual abuse in Pakistan: Using evidence based social ecological model for explanation and policy formulation. Community Health Equity Research & Policy. 2023;43(2):219–228. doi: 10.1177/0272684X211013151. [DOI] [PubMed] [Google Scholar]
  2. Addae E.A. COVID-19 pandemic and adolescent health and well-being in sub-Saharan Africa: Who cares? The International Journal of Health Planning and Management. 2021;36(1):219–222. doi: 10.1002/hpm.3059. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Askelson N.M., Campo S., Smith S. Mother–daughter communication about sex: The influence of authoritative parenting style. Health Communication. 2012;27(5):439–448. doi: 10.1080/10410236.2011.606526. [DOI] [PubMed] [Google Scholar]
  4. Bandiera O., Buehren N., Goldstein M., Rasul I., Smurra A. 2020. Do school closures during an epidemic have persistent effects? Evidence from Sierra Leone in the time of Ebola. J-PAL working paper. [Google Scholar]
  5. Barth J., Bermetz L., Heim E., Trelle S., Tonia T. The current prevalence of child sexual abuse worldwide: A systematic review and meta-analysis. International Journal of Public Health. 2013;58(3):469–483. doi: 10.1007/s00038-012-0426-1. [DOI] [PubMed] [Google Scholar]
  6. Bjørnseth I., Szabo A. Sexual violence against children in sports and exercise: A systematic literature review. Journal of Child Sexual Abuse. 2018;27(4):365–385. doi: 10.1080/10538712.2018.1477222. [DOI] [PubMed] [Google Scholar]
  7. Böhm B. Ludwig-Maximilians-University; Munich: 2016. Perceptions of child sexual abuse in Ghana: Causes, consequences and implications for intervention. [Google Scholar]
  8. Braun V., Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77–101. [Google Scholar]
  9. Burzynska K., Contreras G. Gendered effects of school closures during the COVID-19 pandemic. The Lancet. 2020;395(10242):1968. doi: 10.1016/S0140-6736(20)31377-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Chime O.H., Orji C.J., Aneke T.J., Nwoke I.N. Prevalence, pattern and predictors of child sexual abuse among senior secondary school students in Enugu Metropolis. The Malaysian Journal of Medical Sciences. 2021;28(4):123. doi: 10.21315/mjms2021.28.4.13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cohen M.P. Determining sample sizes for surveys with data analyzed by hierarchical linear models. Journal of Official Statistics. 1998;14(3):267. [Google Scholar]
  12. Creswell J.W. 4th ed. Sage; London: 2014. Research design: Qualitative, quantitative and mixed methods approaches. [Google Scholar]
  13. Devries K.M., Knight L., Child J.C., Mirembe A., Nakuti J., Jones R., Parkes J. The Good School Toolkit for reducing physical violence from school staff to primary school students: A cluster-randomised controlled trial in Uganda. The Lancet Global Health. 2015;3(7):e378–e386. doi: 10.1016/S2214-109X(15)00060-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. East J. In: Sport, children's rights and violence prevention: A sourcebook on global issues and local programs. Brackenridge C., Kay T., Rhind D., editors. Brunel University Press; London, UK: 2012. The causes of violence in sport: Who is to blame? pp. 18–24. Chapter 1. [Google Scholar]
  15. Finkelhor D. Free Press; NY: 1984. Child sexual abuse. [Google Scholar]
  16. Finkelhor D., Baron L. Risk factors for child sexual abuse. Journal of Interpersonal Violence. 1986;1(1):43–71. [Google Scholar]
  17. Finkelhor D., Shattuck A., Turner H.A., Hamby S.L. The lifetime prevalence of child sexual abuse and sexual assault assessed in late adolescence. Journal of Adolescent Health. 2014;55(3):329–333. doi: 10.1016/j.jadohealth.2013.12.026. [DOI] [PubMed] [Google Scholar]
  18. Flowe H.D., Rockowitz S., Rockey J., Kanja W., Kamau C., Colloff M., Davies K. 2020. Sexual and other forms of violence during the COVID-19 pandemic emergency in Kenya. [Google Scholar]
  19. Gauteng C. COVID-19 - Report on help line data lockdown period 27th March 2020–30th April 2020. 2020. https://childlinegauteng.co.za/wp-content/uploads/2020/05/2.-Lockdown-Level-5_CLGP_-Stats-Report_Final.pdf (2020). Available online at. Retrieved from.
  20. Goulds S.F.I., Gallinetti J. Plan International; United Kingdom: 2020. Living under lockdown: Girls and COVID-19. Retrieved from. [Google Scholar]
  21. Graham A., Powell M.A., Anderson D., Fitzgerald R., Taylor N.J. UNICEF Office of Research-Innocenti Florence; 2013. Ethical research involving children. [Google Scholar]
  22. Halperin D.S., Bouvier P., Jaffe P.D., Mounoud R.-L., Pawlak C.H., Laederach J., Astie F. Prevalence of child sexual abuse among adolescents in Geneva: Results of a cross sectional survey. BMJ. 1996;312(7042):1326–1329. doi: 10.1136/bmj.312.7042.1326. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Heels S.W. The impact of abstinence-only sex education programs in the United States on adolescent sexual outcomes. Perspectives-Studies in Translatology. 2019;11:3. [Google Scholar]
  24. Kirby D.B. The impact of abstinence and comprehensive sex and STD/HIV education programs on adolescent sexual behavior. Sexuality Research & Social Policy. 2008;5:18–27. [Google Scholar]
  25. Krahé B., Scheinberger-Olwig R., Waizenḧofer E., Kolpin S. Childhood sexual abuse and revictimization in adolescence. Child Abuse & Neglect. 1999;23(4):383–394. doi: 10.1016/s0145-2134(99)00002-2. [DOI] [PubMed] [Google Scholar]
  26. Leclerc B., Wortley R., Smallbone S. Getting into the script of adult child sex offenders and mapping out situational prevention measures. Journal of Research in Crime and Delinquency. 2011;48(2):209–237. [Google Scholar]
  27. Leclerc B., Smallbone S., Wortley R. Prevention nearby: The influence of the presence of a potential guardian on the severity of child sexual abuse. Sexual Abuse. 2015;27(2):189–204. doi: 10.1177/1079063213504594. [DOI] [PubMed] [Google Scholar]
  28. Lee B.C., Bendixsen C., Liebman A.K., Gallagher S.S. Using the socio-ecological model to frame agricultural safety and health interventions. Journal of Agromedicine. 2017;22(4):298–303. doi: 10.1080/1059924X.2017.1356780. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Levitt H.M., Bamberg M., Creswell J.W., Frost D.M., Josselson R., Suárez-Orozco C. Journal article reporting standards for qualitative primary, qualitative meta-analytic, and mixed methods research in psychology: The APA publications and communications board task force report. American Psychologist. 2018;73(1):26. doi: 10.1037/amp0000151. [DOI] [PubMed] [Google Scholar]
  30. Lu M., Barlow J., Meinck F., Wu Y. Prevention alone is not enough:” Stakeholders’ perspectives about school-based child sexual abuse (CSA) prevention programs and CSA research in China. Journal of Interpersonal Violence. 2022;37(7–8):NP5116–NP5142. doi: 10.1177/0886260520959630. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Mensah A. A/R highest with over 1,000 teenage pregnancies – GES. 2021, Feb 1. https://3news.com/a-r-highest-with-over-1000-teenage-pregnancies-ges/?fbclid=IwAR3PJ9t8108KplWKL4PD0Xml-mbH1AJkRgR9IgOxzS_WldKBh42Kj3fS0Xc Retrieved from.
  32. Ministry of Education COVID-19 coordinated education response plan for Ghana. 2020. https://ges.gov.gh/wp-content/uploads/2020/04/EDUCATION-RESPONSE-PLAN-TO-COVID-19-IN-GHANA-APRIL-2020-1.pdf Retrieved from.
  33. Miron L.R., Orcutt H.K. Pathways from childhood abuse to prospective revictimization: Depression, sex to reduce negative affect, and forecasted sexual behavior. Child Abuse & Neglect. 2014;38(11):1848–1859. doi: 10.1016/j.chiabu.2014.10.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Mohler-Kuo M., Landolt M.A., Maier T., Meidert U., Schönbucher V., Schnyder U. Child sexual abuse revisited: A population-based cross-sectional study among swiss adolescents. Journal of Adolescent Health. 2014;54(3):304–311.e301. doi: 10.1016/j.jadohealth.2013.08.020. [DOI] [PubMed] [Google Scholar]
  35. Onyango M.A., Resnick K., Davis A., Shah R.R. Pregnant in the time of Ebola. Springer; 2019. Gender-based violence among adolescent girls and young women: A neglected consequence of the West African Ebola outbreak; pp. 121–132. [Google Scholar]
  36. Palinkas L.A., Horwitz S.M., Green C.A., Wisdom J.P., Duan N., Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research. 2015;42(5):533–544. doi: 10.1007/s10488-013-0528-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Papalia N., Mann E., Ogloff J.R. Child sexual abuse and risk of revictimization: Impact of child demographics, sexual abuse characteristics, and psychiatric disorders. Child Maltreatment. 2021;26(1):74–86. doi: 10.1177/1077559520932665. [DOI] [PubMed] [Google Scholar]
  38. Pittenger S.L., Pogue J.K., Hansen D.J. Predicting sexual revictimization in childhood and adolescence: A longitudinal examination using ecological systems theory. Child Maltreatment. 2018;23(2):137–146. doi: 10.1177/1077559517733813. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Radford L., Allnock D., Hynes P., Shorrock S. 2020. Action to end child sexual abuse and exploitation: A review of the evidence. [Google Scholar]
  40. Roca E., Melgar P., Gairal-Casadó R., Pulido-Rodríguez M.A. Schools that ‘open doors’ to prevent child abuse in confinement by COVID-19. Sustainability. 2020;12(11):4685. [Google Scholar]
  41. Rockowitz S., Stevens L.M., Rockey J.C., Smith L.L., Ritchie J., Colloff M.F., Kamau C. Patterns of sexual violence against adults and children during the COVID-19 pandemic in Kenya: A prospective cross-sectional study. BMJ Open. 2021;11(9) doi: 10.1136/bmjopen-2021-048636. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Rudolph J., Zimmer-Gembeck M.J. Parents as protectors: A qualitative study of parents' views on child sexual abuse prevention. Child Abuse & Neglect. 2018;85:28–38. doi: 10.1016/j.chiabu.2018.08.016. [DOI] [PubMed] [Google Scholar]
  43. Rudolph J., Zimmer-Gembeck M.J., Shanley D.C., Hawkins R. Child sexual abuse prevention opportunities: Parenting, programs, and the reduction of risk. Child Maltreatment. 2018;23(1):96–106. doi: 10.1177/1077559517729479. [DOI] [PubMed] [Google Scholar]
  44. Schoonenboom J., Johnson R.B. How to construct a mixed methods research design. KZfSS Kölner Zeitschrift für Soziologie und Sozialpsychologie. 2017;69(2):107–131. doi: 10.1007/s11577-017-0454-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Singh M.M., Parsekar S.S., Nair S.N. An epidemiological overview of child sexual abuse. Journal of Family Medicine and Primary Care. 2014;3(4):430. doi: 10.4103/2249-4863.148139. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Sloand E., Killion C., Yarandi H., Sharps P., Lewis-O'Connor A., Hassan M., Campbell D. Experiences of violence and abuse among internally displaced adolescent girls following a natural disaster. Journal of Advanced Nursing. 2017;73(12):3200–3208. doi: 10.1111/jan.13316. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Sserwanja Q., Kawuki J., Kim J.H. Increased child abuse in Uganda amidst COVID-19 pandemic. Journal of Paediatrics and Child Health. 2021;57(2):188–191. doi: 10.1111/jpc.15289. [DOI] [PubMed] [Google Scholar]
  48. Stevens L.M., Rockey J.C., Rockowitz S.R., Kanja W., Colloff M.F., Flowe H.D. Children's vulnerability to sexual violence during COVID-19 in Kenya: Recommendations for the future. Frontiers in Global Women's Health. 2021;2:7. doi: 10.3389/fgwh.2021.630901. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Stoltenborgh M., Van Ijzendoorn M.H., Euser E.M., Bakermans-Kranenburg M.J. A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreatment. 2011;16(2):79–101. doi: 10.1177/1077559511403920. [DOI] [PubMed] [Google Scholar]
  50. Tschan W. Hogrefe Publishing; Boston, MA: 2013. Professional sexual misconduct in institutions: Causes and consequences, prevention and intervention. [Google Scholar]
  51. UNESCO, UNFPA, UNAIDS . 2016. Fulfilling our promise to young people today: 2013-2015 progress review. ESA commitment review report. [Google Scholar]
  52. United Nations Children’s Fund . UNICEF; New York: 2020. Action to end child sexual abuse and exploitation: A review of the evidence. [Google Scholar]
  53. Walsh K., Brandon L., Chirio L. Mother–child communication about sexual abuse prevention. Journal of Child Sexual Abuse. 2012;21(4):399–421. doi: 10.1080/10538712.2012.675424. [DOI] [PubMed] [Google Scholar]
  54. WePROTECT Global Alliance . 2019. Global Threat Assessment 2019: Working together to end the sexual exploitation of children online. [Google Scholar]
  55. Widman L., Choukas-Bradley S., Noar S.M., Nesi J., Garrett K. Parent-adolescent sexual communication and adolescent safer sex behavior: A meta-analysis. JAMA Pediatrics. 2016;170(1):52–61. doi: 10.1001/jamapediatrics.2015.2731. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. World Health Organization . WHO; Geneva: 1999. Report of the consultation on child abuse prevention, 29-31 March 1999. Retrieved from. [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data will be made available on request.

Articles from Child Abuse & Neglect are provided here courtesy of Elsevier

RESOURCES