Assessing Mothers’ Awareness Regarding their Preschool Children Sexual Harassment Protection in Alexandria, Egypt

Background : Child sexual harassment is a significant societal concern that affects children across various socioeconomic backgrounds. Despite Egypt's efforts to combat this issue, this harmful phenomenon continues to persist within Egyptian society. Objective: To assess mothers’ awareness regarding their preschool children's sexual harassment protection in Alexandria Governorate. S ettings: The study was conducted at sixteen family health facilities affiliated with the Ministry of Health and Population (MOHP) in Alexandria Governorate. Subjects: A convenient sample of 400 mothers who have at least one child under the age of 6 years. Tools: Three tools were used : I) A semi-structured interview to assess mothers’ demographic and socio - economic characteristics. II) Mothers’ knowledge regarding the child sexual harassment protection scale III) Mothers’ attitude regarding the child sexual harassment protection scale Results: The findings indicated that 51.50% of the participant mothers have an average level of knowledge, while 69.75% hold positive attitudes toward child sexual harassment protection. Furthermore, the results revealed that higher education levels were associated with better knowledge and more positive attitudes among mothers. Conclusion : The study concluded that mothers have average knowledge and a positive attitude towards child sexual harassment protection. A positive correlation was found between mothers' knowledge and their attitudes regarding child sexual harassment protection. Recommendations : Further efforts are needed to protect children and empower mothers with the necessary tools and knowledge to effectively address child sexual harassment. Policymakers, educators, and relevant stakeholders can develop targeted interventions and educational programs to enhance awareness and promote positive child protection strategies.


Introduction
Children are undoubtedly the backbone of society's future, making the safeguarding of their well-being a matter of utmost importance.As vulnerable members of society, it is not only ethically imperative but also crucial for the overall health and sustainability of our communities to protect and nurture them (Scourfield, 2018).Currently, there are approximately 2.2 billion children in the world.
necessitating the recognition and respect for their inherent rights (UNICEF, 2022).
Children are vulnerable to several forms of violence, including physical, sexual, psychological, and emotional violence, as well as neglect (WHO, 2016).Among these, child sexual harassment (CSH) stands out as one of the most hazardous forms of violence that involves a power imbalance which encompasses different types of harm inflicted upon children (Finkelhor et al., 2020).CSH term appears to have a generally agreed-upon meaning and/or can be used without stigmatizing or otherwise harming both the child and their family (Cochrane et al., 2019;Greijer & Doek, 2016).
Furthermore, CSH has profound effects that extend through families, communities, and society as a whole (Finkelhor et al., 2020).The Centers for Disease Control and Prevention (CDC) published a prevalence fact sheet in 2021, which states that nearly one in eight girls and one in four boys are affected by child sexual abuse before the age of 10 (CDC, 2022).
In Egypt, the situation is particularly concerning, as it has been a longstanding issue, yet there is a lack of accurate Egyptian epidemiological studies to assess the full extent of the problem.According to research conducted by Egypt's National Council for Childhood and Motherhood (NCCM) in 2018, 60% of Egyptian children have experienced some form of violence, including sexual harassment or abuse (NCCM, 2018).Furthermore, it is found that over 20% of children in Egypt have been subjected to sexual abuse before reaching the age of 8, and 62.6% of these victims were girls (Abd El Aziz et al., 2017;Abo-Seria et al., 2019).
Mothers, in particular, are vital in preventing CSH because they have a big influence on their children, as they are frequently the primary caregivers.They can effectively contribute to prevention by engaging in key strategies such as educating their children about sexual assault, encouraging open communication, encouraging them to speak up, and creating a safe environment where their children feel comfortable discussing and reporting any sensitive issues.(Jin et al., 2019;Xie et al., 2016).
Community health nurses (CHNs) also play a crucial role in reducing sexual harassment through the delivery of health education that raises mothers' awareness and fosters a proactive approach to protecting their children from this issue.They assist parents in safeguarding their children's health and safety (Bastable, 2021;Hanaa A. A., 2016).

Aims of the Study
This study aims to assess mothers' awareness regarding their preschool children's sexual harassment protection in Alexandria, Egypt.

Research Questions
-What is the mothers' level of knowledge regarding their preschool children's sexual harassment protection?
-What is the mothers' attitude toward their preschool children's sexual harassment protection?

Materials
Design: A cross-sectional descriptive research design was used to conduct this study.

Settings:
The present study was conducted in sixteen family health facilities (FHCs) affiliated with the MOHP in the Alexandria Governorate.
Subjects: Using the equal allocation method, a sample of 25 mothers who have at least one preschool child younger than 6 years was conveniently selected.giving a total of 400 mothers were included in the study.The sample size was calculated using CDC, EPI Info 7.0 statistical program based on the following parameters: population size ≈ 38900 mothers/months, expected frequency =50%, acceptance error=5%, confidence coefficient =95%.Tools: In order to collect the necessary data for the study three tools were used: Tool I: Demographic and socio-economic characteristics of the mothers and their preschool children.This tool was developed by the researchers after reviewing related literature (Fahmy et al., 2015;Smock & Schwartz, 2020;Borelli et al., 2019).It consisted of: • Demographic data included the age of mothers, residency area, marital status, as well as the age, gender, and number of their preschool children.• Socio-economic characteristics of mothers, which was adopted from Fahmy et al. (2015).This scale includes questions about educational level, occupation, family size, and crowding index.
Tool II: Mothers' knowledge regarding child sexual harassment scale.This tool was developed by the researchers after reviewing the related literature (AboElmagd et al., 2019;Berkmen & Seçim, 2019;Fatouh et al., 2020;Panigrahi et al., 2021).It consisted of 21 questions.It was used to identify the mothers' knowledge level about child sexual harassment.
• The knowledge items were scored 1 for the correct answers and 0 for the wrong and "I do not know" answers.• The total knowledge score was calculated, converted to a percentage, and classified into the following categories by using the scoring system: -Good knowledge > 75%, -Average knowledge ≥ 50% -75% -Poor knowledge < 50%.
Tool III: Mothers' Attitude Regarding Child Sexual Harassment Protection Scale.This tool was developed by the researchers after reviewing the related literature (Kelly & Karsna, 2017;Rudolph et al., 2022;Umar et al., 2019).It had a three-point Likert scale consisting of 24 statements and containing both negative and positive statements.
• Mothers were asked to indicate the extent of their agreement or disagreement with each statement.Their responses were rated on a scale of 1 = disagree, 2 = neutral, and 3 = agree.
• Negative statements were reverse-coded before summing up, converted into a percent score, and classified into three attitude levels.-< 50% = Negative level of attitude.

Method
Approval from the ethics committee of faculty of nursing, Alexandria University was obtained.An official approval to conduct this study was obtained after explaining the aim of the study.The study tools were tested for content validity by 5 experts in the fields of CHNg, pediatric, and psychiatric nursing.The necessary modifications were made accordingly.A pilot study was carried out on 10% of the study subjects to test the clarity and applicability of the research tools.The reliability of the tools was tested using Cronbach's Alpha test.The reliability coefficient was 0.694 for tool II and 0.905 for tool III, which is acceptable.Data was collected during the period from June to October 2022.In each FHC, twenty-five mothers were conveniently selected.Each mother was interviewed individually.

Ethical considerations:
Written informed consent was obtained from each mother after explaining the aim of the study and the right to refuse to participate in the study and/ or withdraw at any time.Data confidentiality was maintained during the implementation of the study.

Statistical Analysis
The collected data were organized, tabulated, and statically analyzed using the Statistical Package for social studies (SPSS) Version 25.0.Quantitative data were described as mean ± standard deviation.Finally, analysis and interpretation of data were conducted.P-values ≤ 0.05 were considered statistically significant.

Results
Table 1 shows participant mothers' demographic characteristics.The table revealed that the age of the participant mothers ranged from 21 to 50 years, with a mean of 30.04 + 5.035.Slightly more than three-quarters (77.75%) lived in urban areas.The vast majority of them (92.25%) were 150 married.Slightly less than two-thirds of mothers (62.25%) had only one child less than six years, with a mean of 1.423+ 0.5787.Almost two-fifths (41.75%) have boys.
Table 2 shows the socio-economic status of the participant mothers.The table shows that about one-third of mothers (33.50%) completed basic education, while approximately one-fifth (22.25%) completed university education.Approximately twofifths (40.75%) of them were employed.Slightly less than two-thirds (60%) of households had computers or access to the internet.Slightly more than three-quarters (78.25%) of the families are composed of less than five members.Slightly more than half (53.75%) were among the households with two to three members per room.Overall, it was found that slightly more than three-quarters (76.50%) of households had a medium socio-economic status, 14% had a high socio-economic status, and only 9.50% had a low socio-economic status, with a mean of 27.740+5.772.
Table 3 describes the correlation between mothers' knowledge and attitudes' mean percent score regarding CSH protection.The table revealed a moderately positive correlation between them, with a correlation coefficient (r) of 0.459.This correlation was found to be statistically significant (p = 0.000).
Figure 1 shows that approximately half (51.50%) of the participant mothers had average knowledge.About two-fifths (41.75%) had poor knowledge, while only 6.75% had good knowledge regarding child sexual harassment protection, with a mean percent score of 52.092% + 17.499.
Figure 2 shows that slightly more than two-thirds (69.75%) of the participant mothers had a positive attitude, 22% had a neutral attitude, and only 8.25% had a negative attitude towards child sexual harassment protection, with a mean percent score of 75.746%+13.476%.
Table 4 describes the association between mothers' knowledge and attitude towards child sexual harassment protection and their socio-demographic characteristics.The table showed that there was no statistically significant association between mothers' knowledge levels and their age, marital status, work status, or family size.While it was found that there was a statistically significant association between mothers' knowledge and place of residence, level of education, per capita income, and total socio-economic level.The table also revealed that there was a statistically significant association between the mother's attitude and the mother's age, place of residence, marital status, level of education, per-capita income, and total socio-economic level.While it found that there was no statistically significant association between mother attitude and their work status.

Discussion
The issue of child sexual harassment is a grave violation of children's rights, and while it is not a new problem, it has become an increasingly concerning issue (Radford et al., 2020).Consequently, the global communities has recognized the urgency of addressing and preventing this dangerous phenomenon to protect children from its harmful effects (Abbabsa, 2022).So, the current study was conducted to provide insight into the mothers' awareness regarding child sexual harassment protection in Alexandria Governorate by assessing their knowledge and attitudes towards this issue.
The significance of knowledge cannot be overstated in preventing CSH.On the other hand, the findings of the current study are inconsistent with the results of AlRammah et al. (2018) in Saudi Arabia, who found that 69% of respondents had good knowledge about sexual abuse in children.The disparities in knowledge levels between the two studies may be due to several variables.First, there were variances in the research participants' demographics and cultural backgrounds.Additionally, regional, or national-specific educational initiatives and efforts to raise public awareness might affect knowledge gaps.Resources and support systems, as well as their accessibility, can differ between regions and countries (Bright et al., 2022;Haruna et al., 2018).
Several studies, including those by El Said (2019), Bright et al. (2022) and Schneider and Hirsch (2020), have demonstrated the significant impact of sexual education programs in preventing CSA.The present study's findings align with these previous research findings, as slightly over half of the participating mothers acknowledged the importance of sexual education for children in our society.Similar results were also reported by Alzoubi et al. (2018) found similar findings.
Moreover, the results of the present study demonstrated that more than half of the participants recognize the importance of developing specialized programs to prevent child sexual harassment to be conducted in family health centers (FHCs).This finding is consistent with the results of a study conducted in Tanzania by Mlekwa et al. (2016), which also found that, more than half of the participants believed in the necessity of creating a specialized program for preventing sexual harassment in local health centers.Furthermore, the study found that slightly less than two-thirds (63.25%) of the participant mothers agreed that it is important to raise awareness through various media channels.This finding is consistent with the results of a study conducted in Pakistan by Umar et al. (2019), where threequarters (75.2%) of the participants approved of raising awareness about child sexual harassment through public programs such as television shows, school-based programs, and activities at public places.
The World Health Organization report (WHO, 2020) stated that all nations have laws and rules prohibiting sexual assault.A significant move was also taken by Egyptian courts in 2017 to protect children's rights and lessen their susceptibility to abuse and exploitation in Article 306 bis a&b (ECPAT, 2020;ICMEC, 2018).Which was consistent with Article 80 of the Rights of the Child, which mandates that the state shall protect children from all types of violence, abuse, mistreatment, and other forms of exploitation (Arts, 2019; UNICEF, 2022).However, despite these legal provisions, the current study revealed a concerning fact as only one-third of participating mothers were aware of the legal penalties for harassers.Such findings are consistent with what was revealed by Alzoubi et al. (2018) in Jordan.Which revealed that only 37.7% of mothers knew that there are laws to protect children from sexual abuse.This potentially represent a serious informational gap in laws prohibiting sexual harassment and abuse due to the complexity of the legal systems and the inadequate informational outreach by governments and agencies.
Human behaviour, thoughts, and emotions are greatly influenced by attitude.It describes how someone assesses, perceives, and behaves towards others, things, events, or ideas (Albarracin & Shavitt, 2018).In this aspect, the current results illustrated that slightly more than two-thirds of the participant mothers had a positive attitude towards CSH protection education.This finding is consistent with what Mohamed et al. ( 2022) found in Benha City, which found that 66.9% of participant mothers had a positive total attitude.Also, Jin et al. (2019) in China showed that parents had a reasonably positive attitude toward CSA prevention education, which features the possibility of providing a nurturing and safe environment for children.
On the other hand, regrettably, onequarter of mothers still hold the belief that discussing "sexual harassment" is considered a sensitive topic that should not be broached.This finding aligns with the research conducted by Alzoubi et al. (2018) which reported that 21.9% of participating mothers agreed that discussing sexual abuse with children could have negative consequences for them.This reflects a lack of understanding about the age-appropriate discussions on such matters.Also, it is essential to address the concerns and fears that may underline the reluctance to discuss sexual harassment protection.
Myths and disbeliefs about child sexual harassment include untrue assumptions about the perpetrators, victims, and appropriate responses to the incident.These erroneous beliefs can reinforce negative attitudes and aid in underreporting and improper dealing with these incidents.This is supported by the findings of the present study, as 34.5% of the participants' mothers' think that awareness may increase their children's knowledge about sexual content.Another common myth is that children who are sexually harassed will always exhibit obvious signs of abuse.In line with that, the present study found that slightly more than two-fifths (41.75%) of the mothers were unaware that a child who has been harassed may not exhibit any physical signs of abuse or harassment.This creates another potential knowledge gap that can hinder the disclosure of such incidents.The lack of visible physical signs can make it challenging for both children and adults to recognize and acknowledge the occurrence of sexual harassment.This disbelief has a significant negative effect on sexual harassment survivors, aggravating their suffering and diminishing their sense of support and validity.This disbelief might make it difficult for survivors to seek justice and reduce their willingness to come forward and disclose the crimes.(Bright et al., 2022).
The association between mothers' knowledge, and attitude levels towards child sexual harassment protection and their socio-demographic characteristics is an important and intricate area of study.which together create a complex web of influences on mothers' behaviour.First and foremost, mothers' education levels are crucial, as research consistently demonstrates that mothers with higher educational levels tend to know more, and have a more positive attitude (AlRammah et al., 2018;Alzoubi et al., 2018;Khoori et al., 2020).
In this regard, the current study found that there was a statistically significant association between mother's educational level and their knowledge and attitude.Specifically, it was observed that mothers with lower levels of education exhibited poorer knowledge.Moreover, they tended to display a more negative attitude towards child sexual harassment protection.
Knowledge about CSH protection was also found to be lower among mothers living in rural areas.This might be explained by the differences between cultures.Societal norms and beliefs prevalent in rural communities (Rudolph & Zimmer-Gembeck, 2018).
The study also revealed a significant positive correlation between mothers' knowledge and their attitude towards child sexual harassment.These findings align with the research conducted by Jin et al. (2019) in China, Hanaa A. A. (2016) in Banha, and Panigrahi et al. (2021) in India, who similarly concluded that parents' knowledge of CSA directly influenced their attitude towards preventing CSA.The findings imply that when mothers learn about CSA prevention, it changes their perspective.

Conclusion
Half of participant mothers had average knowledge, while two fifths still had poor knowledge, more than two-thirds had a positive attitude, and only one tenth had a negative attitude regarding CSH protection.A positive correlation was found between mothers' knowledge and their attitudes regarding CSH protection.Mothers play a crucial role as a primary source of information; empowering them becomes paramount in addressing this issue effectively.To achieve this, a multifaceted strategy involving collaboration among various stakeholders (nurseries, schools, community organizations, and governmental agencies) is needed.

Recommendations
In line with the findings of the study, the following recommendations are made: This finding is consistent with what Mlekwa et al. (2016) found, in which 43.2% of respondents agreed that child sexual abuse prevention education may induce the child to know too much about sex.Moreover, Umar et al. (2019), a research conducted in Pakistan, found that 36.2% of participants thought the same.Also, Hanaa A. A. (2016) and Zhang et al. (2020) reported similar results.

Figure ( 1 )
Figure (1) Total knowledge level of participant mothers regarding child sexual harassment protection.

Table ( 3): Correlation between Mother's Knowledge, and Attitude Percent Score regarding Child Sexual Harassment Protection.
Strong degree: If the coefficient value lies between ± 0.50 and ± 1. Moderate degree: If the value lies between ± 0.30 and ± 0.49.Weak degree: If the coefficient value lies below + 0.29.No correlation: If the coefficient value is zero.

Table ( 4): Association between Mothers' awareness (Knowledge and Attitude Levels) towards Child Sexual Harassment Protection and their Socio-demographic Characteristics
MC P: Mont Carlo exact probability X² Chi Square Test * Significance at p ≥ 0.05