Assessment of awareness of ‘good touch’ and ‘bad touch’ in primary school children of a metropolis in North India

Introduction: ‘Good touch’ and ‘bad touch’ is a sensitive topic whose relevance is very high in the present-day scenario. Children in India are not aware about the topic and thus become more susceptible to child sexual abuse (CSA), a rising evil in society. Objectives: To assess the awareness of ‘good touch’ and ‘bad touch’ amongst school children. Method: An observational, questionnaire‐based cross-sectional study was conducted on 200 children studying in Class III to Class VI in two schools of a metropolis in North India. A structured pre-validated questionnaire was used to assess the awareness and knowledge of study participants on ‘good touch’ and ‘bad touch’. Statistical analysis was done using SPSS version 23.0. Results: Of the 200 children 61% said that they have some previous knowledge about ‘good touch’ and ‘bad touch’, while 39% were totally unaware about it. Excellent scores were obtained by 20% students, good scores by 63% students and average scores by 17% students. There was no significant association of awareness of ‘good touch’ and ‘bad touch’ with any of the socio-demographic variables. Conclusions: Excellent scores were obtained by 20% students, good scores by 63% students and average scores by 17% students regarding awareness of ‘good touch’ and ‘bad touch’. ______________


Introduction
'Good touch' is touch that makes a child feels secure, happy and cared for e.g., mother hugging child or grandparent kissing child. 'Bad touch' is touch that makes a child uncomfortable, afraid, nervous or unsafe e.g., if an adult touches child or kisses and he/she feels uncomfortable, shows something or touches the private parts and tells him or her not to tell anyone 1,2 . Young school children are not familiar with 'good touch' and 'bad touch'. Therefore, children are very easy targets of sexual abuse by their own close family members and relatives. Generally, these children remain silent and do not share such experiences with anyone 3,4 . A study conducted in 2007 by the Government of India, Ministry of Women and Child Development on 125,000 children in 13 Indian states reported the prevalence of child sexual abuse (CSA) as 53% 5 . The awareness of the difference between 'good touch' and 'bad touch' is crucial for the social and psychological development of all children 6,7 . Every child is 'special' and has the right to know everything to keep himself/herself safe and away from sexual abuse. Due to rising cases of CSA in society, it is necessary to assess the level of awareness in children. Research on the topic is scanty as of now and studies on awareness level among Indian children are especially limited.

Objectives
To assess the awareness of 'good touch' and 'bad touch' amongst school children.

Method
It was an observational cross-sectional study using a structured and pre-validated questionnaire conducted among children studying in two schools of a metropolis in North India. Study was conducted on 200 children studying in Class III to Class VI in two schools by systematic random sampling. All children included in the study belonged to upper middle class as per modified Kuppuswamy socioeconomic scale 8 . Children who had intellectual disability and were not able to answer the questionnaire appropriately were excluded.

Data collection:
A structured and pre-validated questionnaire was used to assess the awareness of the study participants on 'good touch' and 'bad touch'. Questionnaire contained 3 sections. Section 1 comprised questions on socio-demographic profile; section II comprised 12 questions based on knowledge about 'good touch' and 'bad touch' and section III contained 2 open-ended questions. The questionnaire was based on 'Children's Knowledge of Abuse Questionnaires (CKAQ)-Short: Two Brief Ten-Item Measures of Knowledge about Child Sexual Abuse Concepts' and the Children's Knowledge of Abuse Questionnaire-Revised (CKAQRIII) validated by the subject experts and Child Psychologist of the Department of Paediatrics was administered to the children 9,10 . Awareness (knowledge) levels were categorized as poor (<3), average (4-6), good (7-9) and excellent (10)(11)(12). At the end of 2 months, a reinforcement awareness programme was conducted in the school in which the children were shown educational videos, pamphlets, flash cards, banners and toys, related to CSA.

Results
The study was conducted on 200 school children studying from Class III to Class VI. The mean age group of study population was 10.30 ± 0.8131 years. All children belonged to upper middle class according to modified Kuppuswamy socioeconomic scale and except for one child, all were urban residents. There were no reports of marital disharmony in the family. The socio-demographic details of the study population are shown in Table 1. Out of the 200 children, 61% said that they have some previous knowledge about good touch and bad touch, while 39% were totally unaware about it ( Figure 1). Table 2 shows the percentage of students who answered each of the 12 questions of the knowledge questionnaire correctly. 'Being hit violently is also not bad touch' The awareness level of the sample population was categorized into average (4-6), good (7)(8)(9), and excellent (10-12) based on the correct scores obtained. Excellent scores were obtained by only by 20% students, good scores by 63% students and average scores by 17% students (Figure 2).  13 , only 150 girls were included. Excluding boys from the knowledge questionnaire further enhances the taboo around this sensitive topic. When a co-ed class is told that a topic will be taught only to the girls in that class, the boys stay unaware, ignorant, and often amused by the whole scene. This, in turn, leads to a huge gap in the prevention programme, as well as the research study on the same.
In our study, 71.5% of the children belonged to a nuclear family and the mean age was 10.30 ± 0.8131 years. This was in contrast to the Mehsana district study 13 where the sample population belonged to a joint family in 55.3% and most children were 12 years of age. Again, previous knowledge amongst the children was only 50.6% 9 . In a similar study carried out in Chennai, the sample size was only 10 and the population consisted of 13-to 19-year-old children. Even in this age group, 50% showed inadequate knowledge of 'good touch' and 'bad touch' 1 .
A study conducted in a school in Ludhiana among 100 children of 9-12 years of age found that 76% had excellent knowledge, 23% had good, and 1% had fair knowledge regarding 'good touch' and 'bad touch' 14  In the study by Abujamand Y, et al 12 , the association between level of knowledge regarding 'good touch' and 'bad touch' and selected socio-demographic variable of the children, it was found that a significant association was found in regard to age. In a similar study conducted in 2021 in Jodhpur, significant association of religion, total number of siblings and marital disharmony with the pre-test score was revealed 2 . This was different from our study where no association could be found with any of the socio-demographic variables. Tutty LM 9 study found that the grade level (age) of the child is a key variable in both children's knowledge of prevention concepts and their parent's ability to predict their responses. Parents of young children were also likely to seriously overestimate their child's understanding of prevention concepts of CSA.
In the sample population, 55% of the children's fathers and 58% of the mothers had studied up to Class 12 only; 53% of the sample population feel that if a grown up tells them to do something, they always have to do it. This may be traced to the fact that young children, during their upbringing, are repeatedly told to follow their elders and not question them. As a result, 42% children still believe that it is not OK to say "no" to a grownup. However, when asked if they must let grown-ups touch them whether they like it or not, 70.5% children said no.
These results indicate a lack of clarity amongst children on the subject of 'touch'. Children are generally not spoken to about this topic in detail, due to its sensitive nature and lack of initiative taken by parents and teachers. This further leads to doubts and questions in a growing child's mind, especially in the years leading to puberty.
The Jodhpur study showed the effectiveness of video assisted teaching programme amongst school children. Here, there was a spike in mean test score of the sample population after the programme 2 . Such studies highlight the importance of awareness campaigns amongst children. Similar results were seen in the study by Abujamand Y, et al 12 emphasizing that children being given structured awareness programme were better aware of 'good touch' and 'bad touch' and thus could protect themselves against such abuse. Parents and teachers need to play a big role in making children understand the concepts of 'good and a bad touch' and help improve the child's response in case of an occurrence of CSA. This training can also go a long way in the prevention of CSA anywhere.

Conclusions
Based on the current study, one may conclude that although a good majority of children understand the rights and wrongs of a touch, they are unable to perceive their family members as potential sources of 'bad touch'. There was no significant association of awareness of 'good touch' and 'bad touch' with any of the socio-demographic variables.