It Is Time to Focus on Prevention: a Scoping Review of Practices Associated with Prevention of Child Sexual Abuse and Australian Policy Implications

Child sexual abuse (CSA) is a significant public health problem, impacting individuals, families and communities across the lifespan. This systematic scoping review aimed to identify practices associated with the prevention of CSA before it happens using the PRISMA method (Moher et al., 2009). Nine databases were searched for empirical literature, resulting in a sample of 47 articles addressing the prevention of child sexual abuse. A definition of CSA prevention and research questions were developed in consultation with subject matter experts to provide a conceptual guide for analysing available empirical and theoretical literature published between 2012 and 2022. Studies were excluded that reported on CSA education. Included articles were analysed to identify common elements of prevention approaches and the policy conditions enabling and constraining prevention. Three approaches were identified: (i) engaging and stopping those at risk of using sexually harmful behaviour; (ii) situational prevention in child- and youth-serving organisations; (iii) preventing the emergence of CSA by promoting healthy families and communities. The article also discusses policy settings that enable and constrain CSA prevention in Australia and identifies gaps in existing research.


Introduction
CSA is a pervasive and significant social problem with serious and ongoing impacts on individual children and young people across the lifespan, in addition to systemic social and economic costs (Kennedy & Prock, 2018;Lewis et al., 2016; 1 3 Lind et al., 2018). The World Health Organisation (WHO) has identified CSA as a significant and gendered public health issue affecting between 8 and 20% of children and young people globally (Stoltenborgh et al., 2011). WHO (1999WHO ( , 2017 defines CSA as The involvement of a child or an adolescent in sexual activity that he or she does not fully comprehend and is unable to give informed consent to, or for which the child or adolescent is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society (WHO, 2017, p. vii).
Yet this definition is not consistently applied internationally, with disagreement on the age range, the acts that constitute abuse, and the language used to differentiate normative sexual play of children from harmful sexual behaviour (Mathews & Collin-Vézina, 2019). The resulting methodological and conceptual confusion continues to limit the empirical study of CSA and its application to prevention efforts, including policy settings and program interventions.
Recognising the widespread nature of child sexual abuse and its costs to individuals, families, and communities across the lifespan, there has been an increasing focus on CSA education in recent years (Babatsikos & Miles, 2015;Fryda & Hulme, 2015;Morawska et al., 2015). Education programs may be effective for increasing knowledge about CSA for children, young people and adults, encouraging help-seeking and early reporting, and promoting effective responses to indicators of sexual abuse. In a systematic review of 31 unique school-based education program for children and their availability in Australia, Walsh et al., (2019) described nine program based on the protective behaviours (PB) model and seven programs combining PB with other programs: Good Touch Bad Touch, Keeping Ourselves Safe, Let's Prevent Abuse, Safe Child Program, and The Block Parent Program. Programs were available across all primary school grades, although some focused on younger or older primary school children. They reached more than 600,000 children in 1 year, or just over ¼ of primary-school-aged children in Australia.
Common features of these programs include • explanation of CSA, including prevalence and range of abusive behaviour; • evidence dispelling myths about perpetrators as strangers; • perpetrator tactics, including grooming of children and their carers; • indicators of sexual abuse in children and young people; • risk and protective factors; • effective responses to both indicators and disclosures of abuse; • impacts of CSA; and • mandatory reporting laws (Kaufman et al., 2019;Walsh et al., 2018).
School-based CSA education programs are the most common form of prevention delivered to minority ethnic communities (Sawrikar & Katz, 2018). A systematic review identified a need for recognition of ethnic minority children's 1 3 It Is Time to Focus on Prevention: a Scoping Review of Practices… diverse experiences and needs within CSA education in schools. One tension to be addressed in this process of recognition involves incorporating culturally tailored content into universal programs (so that all children can benefit) and ensuring students' access to quality interpreting, while also ensuring that such content is not used to fuel racism in the school or community context (Sawrikar & Katz, 2018). Contrary to Mathews' (2017) proposal that CSA education is best delivered by teachers in schools, Sawrikar and Katz (2018) recommended the codelivery of CSA education involving teachers and CALD CSA specialist service providers, to resolve these tensions within the Australian context. CSA education programs have been characterised as limited, after-the-fact interventions that fail to prevent the sexual abuse of children and young people (Assini-Meytin et al., 2020). CSA education places the burden of responsibility unfairly on children as the "primary preventer of their own victimisation" (Davis et al., 2013, p. 381). Few prevention programs target the use of harmful sexual behaviours by children and young people themselves (Tener et al., 2021). There is little alignment between theoretical models of CSA prevention and the programs delivered to prevent abuse from occurring in the first place (Zeuthen & Hagelskjaer, 2013). Despite increasing recognition of the importance of children and young people's participation in decisions that affect their lives, there are few examples of children and young people leading, designing, or contributing as educators in CSA education programs.
CSA education programs assume that increasing knowledge of CSA by children's parents/carers and other adults in the networks around children will translate into behaviour change that can effectively interrupt grooming and the subsequent sexual abuse of children. Yet 55% of CSA education programs did not record the number of sessions used, and the same percentage did not evaluate children's learning outcomes (Walsh et al., 2019). Whilst parent-led CSA education programs have been associated with lower rates of CSA amongst children, recent research found that it was the care and supervision associated with these practices that prevented CSA, not the education program itself (Rudolph et al., 2022).
It has been suggested that school-based CSA education programs can help children "recognise and avoid potentially sexually abusive situations and … to physically and verbally repel sexual approaches by offenders" (Walsh et al., 2018, p. 35). These programs may empower children with knowledge and skills, yet they also place a degree of burden on children and young people to prevent and report abuse (Hawkins & Teng Sze Wei, 2017). Continuing to focus resources on this aspect of CSA education as "prevention" thereby risks the responsiblisation of children and young people who have experienced or are at risk of experiencing CSA.
Research by Fix et al. (2021) emphasised the importance of seeing CSA as preventable and recognising the knowledge gap between research, public policy, and community attitudes. Their research showed that public awareness campaigns emphasise the prevalence and impacts of CSA and the criminal nature of such abuse. In so doing, campaigns may inadvertently reinforce the image of CSA perpetrators are "incorrigible predators for whom draconian criminal justice penalties were the only practical responses", creating an attitudinal barrier to programs that target potential offenders with evidence-informed prevention strategies (Fix et al., 2021, p. 3).
This paper reviews literature on the prevention of CSA before it happens. It aims to identify the practices associated with effective CSA prevention, the conditions enabling and constraining practice, and gaps in the literature that might be addressed with future research. This scoping review sample includes empirical and theoretical papers published between 2012 and 2022 that aim to prevent harmful and abusive sexual behaviour towards children and young people, with a focus on stopping abuse by adults and young people themselves, situational or organisational prevention, parent and community prevention programs, and multi-scalar prevention efforts.

Method
Drawing on Arksey and O'Malley (2005), a scoping review was selected to map literature in the field of CSA prevention, given the variation in research concepts and methods described above. The research team included two scholars experienced in child protection and childhood studies from Southern Cross University and four expert practitioners who were subject matter experts in the field of child sexual abuse from the Australian Childhood Foundation. The work of Smallbone, Marshall and Wortley (2011) was used to guide the inclusion and exclusion criteria for this review using two definitions: • CSA prevention is defined as approaches that stop the onset of sexually abusive behaviour towards children and young people or make it more difficult for sexual abuse of children and young people to occur in the first place. These studies were included. • CSA education is defined as approaches that improve knowledge and skills for early identification and intervention in the sexual abuse of young people. These studies were excluded from the scoping review.
The researchers used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher et al., 2009) to guide this systematic rapid review.

Research Questions
The review aimed to understand effective approaches to CSA prevention, identify research gaps, and inform future research priorities by systematically searching and analysing evidence that drew on a range of empirical approaches. These included randomised controlled trials, systematic and meta-reviews, and qualitative research into the prevention of child sexual abuse, in addition to a small number of grey literature articles recommended by subject matter experts.
Four research questions framed the scoping review: 1. What are the common elements of practices associated with effective prevention of the sexual abuse of children and young people before it happens? 2. What conditions enabled and constrained effective prevention practices? 3. What are the policy implications of these findings in the Australian context? 4. What are the gaps in existing evidence that could inform future CSA prevention research?
The research team of two researchers and four subject matter experts consulted to agree on the investigation rationale and framing of research questions, eligibility criteria, search terms for identification of the literature, and data collection and analysis processes.

Managing the Risk of Bias
An initial meeting of the research team to frame the investigation was critical in establishing the guiding definitions of CSA education and CSA prevention and agreeing on the literature search strategy, information sources, and inclusion and exclusion criteria. Following the review of abstracts and initial categorisation of records conducted by two researchers, the full research team met to discuss and analyse the findings, policy, and research implications. The manuscript was drafted by the two researchers and reviewed by two subject-matter experts prior to completion. Due to the large number of included studies, an entire list of the studies included in the sample for review is attached as Appendix 1, rather than included within the text.

Information Sources, Search, and Study Selection Method
Between December 2021 and May 2022, a rapid review of the literature was conducted to investigate the prevention of sexual abuse of children and young people, commissioned by the Australian National Centre for Action on Child Sexual Abuse (NCACSA). The NCACSA study included a large sample of 129 records and identified conceptual confusion and definitional slippage in CSA prevention literature. In response to this limitation, the current scoping review excluded 83 articles reporting on education programs targeting children and young people at risk of CSA, and reports on the resulting sample of 47 articles addressing CSA prevention before it occurs.
Nine EBSCO academic journal databases were searched for peer-reviewed and scholarly sources publishing research and theory relating to the prevention of child sexual abuse, including program evaluations and approaches to CSA prevention. Searches were conducted in Academic Search Premier, CINAHL Plus with Full Text, Education Research Complete, ERIC, Humanities International Complete, MasterFILE Premier, MEDLINE with Full Text, APA PsycArticles, and APA Psy-cInfo for the terms "child sexual abuse" OR "child sexual assault" OR "childhood sexual abuse" OR "child sexual trauma" AND "prevention" OR "preventive measures" OR "preventive interventions" OR "primary prevention" AND "child*" OR "young" OR "youth" OR "adolescent".

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The resulting 4552 records were screened to limit the sample to peer-reviewed records published between 2012 and 2022 that were available in English, and duplicate records were removed. Two researchers reviewed the abstracts of the remaining articles and excluded records that did not address CSA prevention, including 83 articles reporting on CSA education programs. These were supplemented with six articles recommended by subject matter experts, including three influential book chapters, one grey literature publication from the Australian Institute of Family Studies (AIFS), and two peer-reviewed articles. Four were excluded as they summarised findings already found in the sample; these were used to inform the introduction to the review and inform the analytic approach. One of the additional records recommended by subject matter experts did not address CSA prevention and was excluded. One of the recommended records was included in the final sample for analysis and was a peer-reviewed empirical source.
Following the search strategy and selection process, Fig. 1 represents the literature search, selection, screening, eligibility, and inclusion process.

Limitations
Limiting the scoping review search to peer-reviewed empirical studies may have excluded CSA prevention programs that are not evaluated or published in academic databases. Collaborating with subject matter experts may have offset this limitation in part, as several of the sources they suggested were already included in the review sample. Some sexual offender treatment using medication was not covered in this review, except where it was included as part of a multi-systemic approach to offender risk reduction. Finally, the review has excluded CSA education programs. It is clear that there is little evidence linking such programs with the prevention of CSA before it happens; however, this decision may have excluded studies that show promise for the early intervention and identification of children and young people at risk of abuse other than situational prevention studies.

Results
Full-text screening of the final sample of 47 articles was conducted by two researchers. These were assigned to either: • Group 1: evaluated randomised controlled trials, systematic and meta-reviews (n = 7) or • Group 2: empirical research with findings relevant to CSA prevention (n = 40).
The sample was then analysed to identify key themes responding to the research questions, including effective approaches to preventing the sexual abuse of children and young people before it happens; common elements or characteristics of effective CSA prevention, approaches addressing the needs of First Nations children and young people, specific cohorts including LGBTIQA+ children and young people and children and young people with disability; and gaps in available evidence. The sample of full-text articles in Groups 1 and 2 were then analysed to identify evidence responding to the research questions.
Three common elements of a effective prevention approaches emerged from the analysis: engaging those at risk of using sexually harmful behaviour to stop; reducing and preventing CSA in child-and youth-serving organisations; and preventing CSA by promoting healthy families and communities. These elements are described in the remainder of the article, followed by a discussion of the policy conditions enabling and constraining CSA prevention, gaps in evidence, and identification of future research to target effective CSA prevention. Fig. 1 Literature search, selection, screening, eligibility, and inclusion process (Moher et al., 2009)

Engaging Those at Risk of Using Sexually Harmful Behaviour and Enabling them to Manage and Stop Their Behaviour
Considering a primary health prevention approach, Levine and Dandamudi (2016) adapted a diabetes prevention protocol to outline six steps for good practice in CSA prevention. The steps involve using evidence to identify and respond to risk, including: 1. Define and monitor the extent of the problem; 2. Map a coherent risk profile to identify those at risk of offending; 3. Identify credible, reliable screening tests; 4. Evaluate the efficacy of prevention programs and treatment interventions; 5. Share outcome and process evaluation data; and 6. Continuously improve interventions.
Preventing CSA by intervening with potential offenders requires addressing barriers to the delivery of these programs. Barriers included beliefs that no intervention is effective with potential offenders, that schools are already over-burdened with nonacademic programs, and that the CSA potential offender programs themselves will be too confronting to young people, staff, and parents (Ruzicka et al., 2021). Given their focus on evaluating interventions to prevent, rather than reduce, the sexual abuse of children, the programs in the current review sample that target potential offenders are summarised in Table 1 and described below.

Dunkelfeld Prevention Project (Engel et al., 2018)
Description The program provides treatment to people who may be diagnosed with a paedophilic disorder but who have not yet been investigated or convicted of CSA. Dunkelfeld means those in the "dark field", whose potential or actual criminal behaviour is undetected. The program used a media campaign promoting the project and the use of a confidential helpline. Treatment aimed to reduce risk factors for CSA and the consumption of child-abusive content.
Inclusion To qualify, participants could not have other conditions preventing the effect of treatment, such as substance use, and had to be seeking help for a paedophilic disorder. When people approached the helpline, they were assessed for inclusion/exclusion, and those who were excluded were offered referrals to other services. Extensive individual assessment was conducted using a range of validated measures. Assessment was ongoing throughout treatment and repeated at the conclusion of the program. Of the 1453 people who contacted the helpline, only 100 were offered treatment in the program, and all identified as male. Most participants had committed offences with child abusive material that were not detected through investigation or conviction. There were no significant differences in risk factors between the treatment group, the dropout group, and those who refused treatment.

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It Is Time to Focus on Prevention: a Scoping Review of Practices… Table 1 Evaluated prevention programs The Program Five psychoeducation sessions were conducted before the therapeutic program. Then participants were treated in either a group addressing the use of child-abusive content or a group addressing CSA prevention. Treatment was a structured group therapy program, including the incorporation of individual needs, using weekly sessions over an average of 26 months. Treatment involved psychotherapy, sexological, psychological, and pharmacological approaches, which aimed to increase impulse control, including understanding and prevention of offending in risky situations.

Evaluation
The program achieved a reduction in offence-supportive attitudes, reduced coping self-efficacy deficits, and reduced child identification of participants. Treatment refusers lived further away from the treatment centre than those who completed the program. A randomised controlled trial was not possible due to ethical constraints.
In a parallel project in Berlin conducted over 12 years (Beier, 2018), the Dunkelfeld Prevention approach attracted and treated over 500 men from all societal strata with an average age of 37 years who showed a sexual preference for children. While the Dunkelfeld Prevention Project approach relies on the absence of mandatory reporting laws to ensure confidentiality to participants, other aspects of the approach have been adapted in countries with similar policy frameworks to Australia, including the UK and USA, such as Stop It Now! (Van Horn et al., 2015).

The Berlin Project (Beier et al., 2016)
Description The project aimed to prevent CSA in young people. A media campaign was used to build empathy for young people who had sexual desire for pre-and early pubescent bodies, reduce stigma, and encourage help-seeking through the promotion of a hotline via memes and video on the internet, television, and radio. Initial assessments were conducted via the hotline, including information about whether young people had already participated in sexually abusive behaviour, including CSA and consumption of child abuse material, and their current legal status.
Inclusion Treatment was provided to 27 young people aged 9-19 years who voluntarily sought treatment and were at risk of engaging in harmful sexual behaviours with children. Those currently involved in a formal sexual abuse investigation were excluded and referred to other treatment services.
The Program Involved both the young person and family members, to increase support for the young person to take responsibility for their actions. Therapy was aimed at the young person accepting their sexual desire and improving behavioural control, including identifying and managing risk factors to prevent the onset of abuse or prevent a recurrence.

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It Is Time to Focus on Prevention: a Scoping Review of Practices… Evaluation The project showed that preventative interventions could be effective with young people aged 12-18 years with a sexual preference for pre-and/or early pubescent children. A total of 84% had already enacted sexually harmful behaviours, primarily undetected by a criminal investigation. Most young people were referred by a parent or carer. The study presented exemplary cases but did not publish overall outcome data.

Stop It Now! (Van Horn et al., 2015)
Description Conceived initially by a CSA survivor in the USA, the program offers a free, universally accessible helpline that aims to raise awareness and promote the evidence-informed management of risk and protective factors for CSA. Operating in the UK and the Netherlands, program responders are qualified graduates with experience working with offenders or at a helpline.
Inclusion Anyone concerned about CSA, including actual and potential offenders, people concerned about another adult or young person's behaviour towards children, or professionals concerned about the risk of CSA to a particular child. Approximately half of the helpline users were people concerned about their own sexual feelings or behaviour towards children, and the remainder were people concerned about the sexual behaviour of others.

The Program
In the initial phase, operators described confidentiality policies and explored the caller's concerns, providing information and discussing the next steps the caller would take, including protective actions. The second phase provided support to actual or potential offenders and their family supporters to reduce risk and promote protective actions to prevent CSA.
Evaluation Examined 3555 call logs, surveyed 115 callers, and conducted qualitative interviews and focus groups with 85 people. Results included greater awareness of individual triggers and risk factors, use of strategies to manage risks, and use of the helpline as a gateway to accessing additional services. The results suggest that in the Netherlands, people concerned about their own behaviour contacted the helpline earlier than in the UK, before the offending commenced.
The availability of the Stop It Now! helpline to bystanders, family members, and potential offenders was critical to its success (Grant et al., 2019). Research into helpline usage, treatment efficacy, and outcomes was enabled by this program design, which produced an array of evidence from different participants. This evidence can inform more effective programming and services that come closer to CSA prevention than education. The program also mobilised the desire of offenders and those in their networks to interrupt the perpetration of abuse and its personal, familial, and social costs.

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The evaluated programs included in this scoping review sample highlight elements common to CSA interventions and programs that aim to intervene with young people and adults at risk of CSA offending: • accessible information and evidence-informed therapeutic support to young people and adults at risk of offending and their supporters; • clear understanding of the difference between developmentally normative and sexually harmful behaviour by young people; • use of evidence-informed measures to evaluate outcomes for individuals at risk of CSA offending and whole-of-community prevalence outcomes; • social marketing approaches that promote help-seeking by those at risk of offending; and • therapeutic treatment to reduce the risk of reoffending, both in the community and within justice settings.
In a systematic review of empirical evidence on reducing recidivism among CSA offenders, Langstrom et al., (2013) found mixed results across common treatment modalities. Interventions were delivered in various settings, including correctional centres, prisons, the community, and probation services. Only three studies met the quality criteria for inclusion in a systematic review. The authors raised concern at the small number of quality treatment programs and attributed this to public attitudes that view punishment as a sufficient response to CSA offenders. More research is needed involving potential offenders who have not yet committed an offence to understand their experience and treatment outcomes.
There is also a need for a developmental and trauma-informed approach to CSA prevention practice as it emerges in early adulthood (McKillop et al., 2020). In the 18-to 24-year-old age cohort, in particular, adverse childhood experiences and youth justice involvement were linked with various types of offending behaviour, including CSA. This suggests the need for earlier attention and treatment of young people who use harmful sexual behaviours at this specific life stage. Evidence related to the higher risk of CSA amongst those in young adulthood also supports a greater emphasis on situational prevention in places and organisations where young people in this risk profile may be found (Letourneau et al., 2017;McKillop et al., 2020;Swartout et al., 2015).

Reducing and Preventing CSA in Child-and Youth-Serving Organisations
Organisational prevention recognises certain places, organisations, and institutions where factors about the setting can increase the likelihood of CSA occurring. These situational factors can be controlled, altered, or even eliminated completely (Kaufman et al., 2019). While only 1% of CSA in the USA was reported to occur in the 1 3 It Is Time to Focus on Prevention: a Scoping Review of Practices… context of a youth-serving organisation, Assini-Meytin et al., (2020) noted that those who sexually abuse children may seek opportunities to engage in these organisations. These people may be adult staff or volunteer at any level of the organisation. Situational prevention of CSA is not the primary objective of the risk-management approach. Ultimately, they seek the well-being of children and young people to participate in child-friendly places, families, and communities (Smallbone, 2017). This section discusses the findings related to the prevention of abuse in organisational settings.

In Child-and Youth-Serving Organisations (CYSO)
In Australia, CYSO include schools, sports and recreational organisations, cultural and faith-based organisations, health and social care organisations, and statutory residential services like youth detention and out-of-home care. Recognising that many millions of children and young people globally are involved with CYSO, Australia's Royal Commission into Institutional Responses to Child Sexual Abuse funded a systematic review of approaches to risk and protective factors in these organisations (Kaufman et al., 2019).
Reviewing over 400 CSA research articles from the USA, UK, and Australia, Kaufman et al., (2019) identified critical actions for prevention. Understanding offenders' behaviour is critical to creating a child-safe culture (Kaufman et al., 2019). CYSO need to understand how people identify and groom children, young people, and their families, the techniques they use to maintain the abuse and the child's silence, and the tactics they use to avoid detection and maintain the victim's silence. Even where their behaviour is unmasked, perpetrators are likely to deny, defend, and personalise the issue to isolate the victim from support in CYSO. Offenders exploit CYSO where the culture is complacent, relaxed, or careless and are more likely to avoid organisations where a culture of safety is upheld. Interactions between children and adults should be monitored, supervised, and regulated, or restricted in cases of unsupervised facilities.
Situational prevention in CYSO relies on thorough risk assessment and management. This includes place-based risk assessment, developing effective management strategies to reduce or prevent each risk, prioritising solutions to the risks of greatest concern, and developing and actioning effective implementation plans (Kaufman et al., 2019). Situational CSA risk management strategies should be developed locally in response to actual conditions where organisations engage with children. For instance, situational prevention might recognise settings and circumstances where physical touch is considered appropriate and outline practices required to manage risk, for example, no frontal hugs and the presence of two adults (Assini-Meytin et al., 2020).
The current implementation of National Principles for Child Safe Organisations (Australian Human Rights Commission, 2018) across Australia's states and territories is a critical undertaking to shift the practices, policies, and cultures of all CYSOs, and a significant legacy of the Royal Commission. Situational prevention enables organisations to take responsibility for protecting children and young people on their watch, establishing practices and procedures that prevent access to children and young people by those adults motivated to abuse. Yet the development of child-safe cultures at the grassroots, where staff and volunteers interact daily with children and young people, is a substantial undertaking, and there is a risk of reliance on compliance-based approaches. Situational prevention must also seek to prevent the sexually harmful behaviours of young people themselves (Smallbone, 2017).

In Schools
The prevention of CSA in schools has primarily relied on CSA education programs delivered to children, young people, and adults that aim to increase children and young people's knowledge about CSA, risk, and protective factors, and how to disclose or report suspected abuse. In the USA, 10% of students experience some form of school-based sexual misconduct by adults (Shakeshaft et al., 2019), defined as Any conduct directed toward a student which creates a sexually hostile learning or school environment and includes sexual or romantic advances; sexual violence; sexual conduct that constitutes a crime; sexual touching; indecent exposure of a sexual nature; sexual remarks, comments, displayed materials, printed materials, electronic media, or jokes (Shakeshaft et al., 2019, p. 102) Recognising that a duty of care is owed to children and young people in schools, Shakeshaft et al., (2019) surveyed school-based CSA specialists, lawyers, and school leaders to determine the components of a standard of care to keep children safe in school. Seventy-five percent of respondents agreed or strongly agreed on • recruitment and screening practices, such as criminal record checks, specific interview questions, and contacting referees by telephone; • CSA education is provided to teachers, students, and parents; • reporting all instances of conduct that may constitute a red flag or incident; and • implementation of policies to bolster CSA prevention in schools.
The research was significant in its involvement of CSA specialists and lawyers alongside school administrators in identifying critical components necessary for preventing CSA in schools. It could inform a coherent, consistent educational standard of care for Australia's prevention approaches.

In Faith-Based Organisations
Situational prevention also emerged as a theme in articles addressing CSA in faith-based organisations, including Christian churches, Christian schools, and Orthodox Jewish communities, which sought to understand the implications of perpetrators' behaviour for prevention. One study examined the responses of 1121 clergy to mental health treatment, seeking to identify individual-, relationship-, and community-level factors in prevention (Calkins et al., 2015). Compared to a control group, perpetrators of CSA reported higher rates of CSA as children themselves, higher reports of family stress, and lower rates of parental divorce. Perpetrators had fewer dating experiences and less positive relationships with young people but more positive relationships with their adult peers than the control group. At the community level, perpetrators were more likely to seek opportunities for working with children and young people and were more likely to be involved in a youth-counselling role than the control group. Calkins et al., (2015) recommended the supervision of clergy working directly with children and young people, particularly one-to-one interactions, and the provision of CSA education to children and young people. Reportable conduct systems were recommended to ensure children and young people and other staff and volunteers have safe systems for reporting any conduct of concern by clergy (Calkins et al., 2015).
While it is important for CSA prevention to be locally adapted and implemented, a review of CSA prevention policies in the USA found that reliance on 32 individual Catholic archdioceses to implement their own policies was failing (Dallam et al., 2021). The study showed significant variation in the 102 practices, procedures, or directives that aimed to prevent CSA across the archdioceses and demonstrated the need for centralised support and guidance in developing and implementing CSA prevention policies. Areas for improvement in prevention policy across all archdioceses were: • Screening of potential new employees and volunteers: including state and national criminal history and sex offender registries and ensuring standard checks are completed, for example, references, interviews, employment history, credentials, and identity. • Codes of conduct: implementation of which can help to identify misconduct behaviour before abuse occurs, including common CSA grooming tactics such as "over-identification with children, keeping secrets with children, allowing children under supervision to break rules, and developing a special relationship with an individual child" (Dallam et al., 2021, pp. 904-905). These should also describe specific practices of concern regarding online communication and social media interaction with children and young people. • Training: monitoring the completion of high-quality, standardised training before people interact with children and repeating training regularly to emphasise the organisation's stance on CSA and also to incorporate new research, practices, and interventions. • Education: implementation of evidence-informed, evaluated CSA education programs with children, parents, and staff in church schools.
It should be noted that only the screening of potential new employees and volunteers and, to some extent, the codes of conduct are before-the-fact prevention policies. They rely on children and other staff to report behaviours of concern, and on systems and leadership to respond effectively. Dallam et al., (2021) recommended that child-safe policies must include penalties for those who do not report breaches and protections for people who report behaviours of concern, such as access to an independent hotline to protect those who need to report the conduct of senior staff.

In Out-of-Home Care Settings
Situational prevention strategies need to consider the setting in which activities involving children and young people occur, (a) the age and gender of children; (b) what activities are being delivered and the level of supervision that is typical; and (c) the extent to which staff and volunteers can control or influence children's lives and decisions, for example, what they wear or eat (Kaufman et al., 2019). One setting in which situational prevention may be more complex is residential out-of-home care. Young people in these settings may experience CSA from paid staff and/or managers and are likely to have experienced a range of adverse childhood experiences, including CSA from parents and/or carers. They may also be using harmful sexual behaviours that involve harming themselves or others (young people or staff). While there are over 45,000 children and young people in OOHC in Australia, only 5% are placed in residential out-of-home care, which provides 24-hr support and supervision through paid staff rather than in family-like environments with foster carers or extended family members (McKibbin et al., 2022).
For the residential out-of-home care setting, prevention practices should Construct educative interventions for children and workers about sexual health and safety; target grooming behaviours of perpetrators and problematic sexual behaviour of children, including peer-to-peer grooming; and provide children with a holistic treatment response for harmful sexual behaviour and long-term ways out of exploitation (McKibbin et al., 2022, p. 113).
Recognising the need for education of young people in residential care homes to identify and intervene early in problematic sexual behaviour, McKibbin et al., (2022) used action research to collaborate with residential care staff and expert advisors in developing a three-tiered situational prevention pilot called Respecting Sexual Safety. The program included: 1. Adapting respectful relationships education to the residential care setting, including training all staff, upskilling them to identify and respond effectively to harmful sexual behaviours, and a whole-of-house approach to gender equity, respectful relationships, and sexual health. 2. Responding to young people who are missing from home, to prevent their sexual exploitation and to build a strong relationship with one carer in the home as a protective factor.
3. Addressing harmful sexual behaviours and identifying potentially exploitative situations using an ecological approach in collaboration with local therapeutic services.
Some of the challenges experienced in implementing the program included: integrating with external services across a decentralised and diverse sector; difficulty accessing resources to do early intervention work with young people; and the low efficacy workers feel to intervene in young people going missing from the house (McKibbin et al., 2022). While further evaluation is needed, this program reflected research evidence and good practice in collaborating with young people, staff, and external services. Considering prevention in high-risk settings like residential outof-home care, McKibbin et al., (2022) noted that prevention practices move between secondary and tertiary prevention due to the high likelihood of sexual violence experienced by young people before entering residential care and the involvement of staff in their daily lives.

CSA Prevention in First Nations Communities
A review by Barsalou-Verge et al., (2015) identified very similar risk factors for CSA in First Nations communities as have been seen amongst non-Indigenous communities. However, they also recognised the interaction of CSA with the ongoing implications of colonisation, including poverty and other social problems amongst the hundreds of diverse First Nations communities in Canada and the USA. Barsalou-Verge et al., (2015) described these practices for CSA intervention with Indigenous communities: i. Ensuring practice is culturally informed, for instance, those that recognise the poor fit of interventions centred on a nuclear family model and are led by Indigenous communities; ii. Locally-adapting programs and interventions, recognising that each community's experiences, practices, and strengths may be different, and ensuring that interventions have benefits for local people; iii. Reconciling CSA prevention practices with other evidence-informed interventions, including evaluation of mainstream interventions using culturally informed protocols to understand their efficacy and making adaptations to those programs; iv. Addressing the real needs of First Nations people and communities, including recognising and alleviating the compounding impacts on First Nations practitioners, adequately funding interventions, building the capacity, and providing training to local practitioners; v. Identifying and implementing effective prevention strategies that are culturally evidence-informed.
First Nations children and young people face intersectional barriers to disclosure of CSA, including intergenerational abuse and trauma, lack of information about support services, fear of mainstream education, forensic and legal systems, and intimidation to prevent disclosure by perpetrators, friends, and family members of victims/survivors of CSA. These fears and systemic barriers have led to disclosures of CSA more commonly where severe violence has been experienced.

Preventing the Emergence of Sexually Abusive Behaviour Towards Children and Young People by Promoting Healthy Families and Communities
The high prevalence of CSA worldwide suggests the need for primary prevention and effective programs to reduce the risk of CSA (Van Horn et al., 2015). Targeted parenting programs may build the skills and capabilities of families where risk factors are evident. However, there is little evidence that they prevent CSA (Higgins, 2015). Three examples of CSA prevention programs promoting healthy parenting and family relationships to reduce the emergence of sexually harmful behaviours in children and young people were included in the sample and are described here.

Early Head Start (Green et al., 2014)
Description Early Head Start (EHS) was established in 1994 in the USA and aimed to promote child development, positive parenting, and family self-sufficiency through supporting children aged 0-3 years and their parents/carers. Inclusion A total of 3001 low-income families with a pregnant woman or an infant under 12 months were enrolled in the study in the late 1990s, and data was collected until the children reached 10 years.
The Program EHS supported over 1000 programs, primarily using two models: 90-min regular home visits and child development services delivered through EHS service centres.

Evaluation
The research used child welfare/protection system administrative records to examine the child welfare system involvement of 1247 children using EHS and a control group across seven sites in six states over 13 years. Outcomes included substantiated reports and types of child maltreatment, including outof-home care placements. However, physical and sexual abuse were reported together due to the low number of CSA reports. Children aged 5-9 years were less likely to have substantiated physical and sexual abuse reports and less likely to have a second substantiated abuse or neglect report than those children not receiving the EHS program.

Responsible Behaviour with Younger Children (Ruzicka et al., 2021)
Description Universal school-based CSA prevention for students, teachers, and family members to prevent harmful sexual behaviour by young people.

Inclusion
In total, 421 students in Grades 6 and 7 across four schools in the USA.
The Program Using a developmental and trauma-responsive approach, the program included 10 × 45-min sessions of classroom-based student discussions regarding developmental differences between young people and children; developing empathy with children; developing knowledge about CSA and its dynamics; intervening and preventing sexual abuse of younger children; information about sexual harassment sexual abuse perpetration; and bystander involvement.
Evaluation Research interviews and focus groups were used to test the feasibility of the program, rather than evaluate outcomes. While the program was found to be feasible, the barriers included government policy and funding guidelines, as well as parental attitudes. The outcomes are unknown, and further research is needed to understand the effect of this promising program.

Enough Abuse Campaign (Schober et al., 2012)
Few CSA prevention programs address the problem of CSA on a societal or whole-of-community level. The Enough Abuse Campaign in MA, USA, used a multi-level strategy of state-level infrastructure for CSA prevention (Schober et al., 2012). The campaign assessed community beliefs about CSA, implemented targeted training programs focused on preventing perpetration by reducing risk factors, and facilitated changes in local communities to improve CSA systems using group advocacy in Massachusetts. The training included components to identify and address risk factors for the perpetration of abuse by adults and a component responding to harmful sexual behaviour by children and young people, delivered in collaboration with child specialists in the prevention and treatment of abuse and neglect. The training targeted community leaders, situational abuse in youth-serving organisations, and individual community members.
Importantly, the campaign approach shifted the focus of responsibility from children's protection of themselves to community and organisational responsibility for the protection of children and young people, while still enhancing children's knowledge and skills for disclosure and early identification. The campaign also collaborated with similar projects in other jurisdictions to agree on and track community and societal outcome measures, reflecting a public health approach to both intervention and evaluation (Schober et al., 2012).
Three common elements of approaches to preventing sexual abuse of children and young people have been described here, embedded in a range of programs targeting reducing sexual offending, reducing situational risk to prevent opportunities for CSA, and preventing the emergence of sexually harmful behaviours within families through parenting and multi-scalar programs supporting healthy families and communities. We now consider the policy settings enabling and constraining practice, with a focus on the public health model and characterisation of programs as primary or secondary prevention. While this section refers to international policies, they are applied specifically in the Australian CSA prevention landscape.

Policy and Practice Conditions for Preventing CSA
The programs used in Australia fall mainly into the school-based CSA education approach, which aims to educate children about CSA and relies, to some extent, on their skills and knowledge to protect themselves and report abuse early. While there are cultural, ideological, and policy barriers to prevention programs with adult and adolescent potential offenders in Australia, there are also examples of these programs being delivered in countries with similar policy settings that may be more effective. Examples discussed in this review include Stop It Now (UK), Responsible Behaviour with Younger Children (USA), and Enough Abuse Campaign (USA). The practice of CSA prevention requires the availability and accessibility of services to those not yet convicted or currently being investigated for CSA-related behaviour.

The Public Health Model and Prevention of Child Sexual Abuse in Australia
Whilst mandatory reporting policy and a dearth of available treatment for people at risk of CSA offending prevent the implementation of Dunkelfeld-type elements in Australia, similar policy settings enabled Stop It Now! by providing free, accessible and evidence-informed helpline information and therapeutic interventions for young people and adults at risk of offending. Responsible Behaviour with Younger Children showed promise for the reduction of harmful sexual behaviour by young people, suggesting that early intervention can be effectively implemented in schools that promote ethical behaviour between young people and children without placing the onus for addressing abusive behaviour on children themselves. The Enough Abuse campaign also demonstrated that collaboration across jurisdictions can track societal prevalence linked to program effects.
In Australia, as in other countries, CSA has been conceptualised as a preventable public health issue (Higgins, 2015). Most of the authors included in this review sample position their work with the public health model promoted by the World Health Organisation (Quadara et al., 2015). A public health approach to CSA includes four elements: i. Gathering evidence: collection and analysis of data about CSA prevalence, abusive behaviours (including grooming behaviour), the characteristics of people who sexually abuse children and young people, and the effectiveness of interventions.

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It Is Time to Focus on Prevention: a Scoping Review of Practices… ii. Identifying risk and protective factors: involving research with adults and young people who have already committed CSA and those who have not, to inform prevention programs, strategies, and other interventions. iii. Developing and evaluating interventions: the trial and evaluation of interventions that prevent those adults and young people with sexual attraction to children. Includes evidence-informed pilots, feasibility studies and a range of evaluation measures, including RCT but also effective evaluation of the process. iv. Implementing effective interventions: using programs and strategies that are informed by evidence, including adherence to program fidelity (Assini-Meytin et al., 2020;Mathews, 2017).
Applying the public health model, Australia has stratified the service system into: • primary universal services that support all families to "provide warm, positive interactions and a secure base" for children; • secondary targeted, early intervention services to those families potentially at risk; and • tertiary services that include statutory and health system responses to the risk of harm reports (Higgins, 2015, p. 42).
It is not clear that this stratification of primary, secondary, and tertiary services translates smoothly into a public health approach to CSA prevention. Primary prevention involves universally accessible programs that aim to prevent from emerging in the first place. They provide free support to promote healthy children and families where there is no current risk of CSA and aim to prevent abuse from occurring (Green et al., 2014). Secondary prevention involves programs and policies that aim to reduce risk factors and promote protective factors for children and young people at risk of CSA, including targeting potential offenders. Tertiary prevention programs are the statutory and health system interventions that respond to CSA and its impacts on children, young people, and adult victims/survivors and offenders.
The terms primary and secondary are not consistently defined in the literature included in this review. Primary prevention is defined as "strategies [that] target whole populations … aimed at preventing children from being victimised or preventing people from committing abuse" (Van Horn et al., 2015, p. 355). While the Stop It Now! hotline is universally accessible, it provides information to reduce risk and improve the protection of children at risk of CSA (Van Horn et al., 2015). Analysing various prevention programs, Zeuthen and Hagelskjaer (2013, p. 743) define primary prevention as "efforts facilitated before any kind of CSA had occurred". Programs like the Dunkelfeld Prevention Project most closely align with this secondary prevention approach, as they provide free treatment for potential offenders to "reduce the risk of paedophilic sexual offending of both direct contact and indirect contact via consumption and production of child abusive content" (Engel et al., 2018(Engel et al., , p. 1630. Van Horn et al., (2015) as those efforts that reduce the risk of abuse amongst groups at higher risk of committing or experiencing CSA or in settings where there is a higher risk. Most of the programs and interventions included in the review sample fall into this category; programs that aim to reduce risk factors and promote protective factors in families, organisations, and places where children are more vulnerable and potential offenders have access to them, and programs that engage with potential offenders directly. School-based CSA education programs commonly claim to prevent abuse by improving children's knowledge and skills to protect themselves (and each other), supporting them and adults to identify risks and take protective action to stop the abuse. Where CSA education programs delivered to children and adults aim to identify risk and early signs of CSA in families, schools, and other settings, they also reflect most closely this definition of secondary prevention.

Secondary prevention is defined by
There is disagreement in the literature on the meaning of these terms so critical to the public health approach to prevention. Reviewing 31 unique schoolbased CSA education programs, Walsh et al. (2018, p. 34) noted that primary prevention programs "can be implemented universally at comparatively little cost without stigmatising those at greater risk". Here, the definition of primary prevention seems to reflect the universal, school-based setting in which the program is delivered rather than preventing CSA before it happens. Situational prevention also falls most closely into secondary prevention, as they aim to create safe cultures, spaces, and practices that reduce the risk of harm to children in the organisations, places, and spaces, where they spend time.
This lack of clarity suggests that the categorisation of primary, secondary, and tertiary prevention of CSA is not helpful in the current Australian policy context and may detract from the effective prevention of CSA. The findings of this review suggest that a public health approach could be better informed by available evidence, including the views of children and young people, with a view to a. building child, family, and community health and well-being, preventing the risk of abuse from emerging and informed by culturally appropriate understandings of family; b. developing child-safe organisations, places, and situations, preventing and identifying risks early; c. promoting early detection, disclosure, and support for those who have experienced abuse through education, service system accessibility, inclusion, and availability; d. promoting early helps seeking and treatment of young people and adults at risk of using harmful or abusive sexual behaviours; e. providing accessible treatment for those who are engaging in sexually abusive and harmful behaviour; and f. preventing CSA recurrence, including child protection and forensic responses.
Whilst the lack of clarity about primary and secondary prevention efforts continues, the evidence to support intervention with potential offenders and prevention campaigns that include individual, family, and whole-of-community strategies is growing. In a 2019 review, Knack et al. (2019) noted that the evidence supports increased demand for secondary prevention services by adults and young people at risk of sexually offending outside of the legal system and various benefits and outcomes that may reduce offending and improve the lives of children.
A reframing of CSA prevention interventions is needed to address this significant public health issue and its impacts on children, families, and communities throughout their lifespan. Lasher and Stinson (2017) identified critical strategies needed to reframe CSA prevention, including • identifying and addressing barriers to outreach and treatment programs, including physical, cultural, policy, and health system barriers; • reconsidering the policy settings enabling and constraining CSA prevention; and • trialling evidence-informed treatment for those who are at risk of sexually abusing children, including young people themselves.
Child sexual abuse is a growing concern in Australia. The Australian Institute of Health and Welfare data regarding victims of sexual assault at the age at the report of 0-14 years, by sex, from 2013 to 2020 showed a decrease from 77 to 74 boys per 100,000. However, the data showed a marked increase for girls from 163 to 176 per 100,000 in this period (AIHW, 2022). The Personal Safety Survey of adults also showed that of the 1.4 million people who experienced CSA in Australia, the majority experienced multiple incidents of abuse over time, and were abused predominantly by non-familial known persons (Australian Bureau of Statistics [ABS], 2016). The behavioural, emotional, and social costs of CSA include higher rates of internalising and externalising problems, higher rates of disability, poorer health, lower rates of educational completion, and greater financial stress (Lewis et al., 2016;ABS, 2016). Reflecting on this review's findings and the costs to those who experience CSA, effective policy and programs need to: (i) prevent the emergence of CSA in the first place universally accessible programs, (ii) target those at risk of perpetration of CSA, and (iii) reduce household overcrowding.
This review explored the literature relating to the prevention of child sexual abuse, excluding studies about child abuse and neglect (CAN) more broadly. A correlation has been found between household overcrowding and sexual abuse of children (Cant et al., 2019, cited in Bywaters et al., 2022, however, there is no further evidence that specific forms of CAN are more or less likely to be associated with poverty (Bywaters et al., 2022). To date, the challenge to prevent the emergence of CSA by people at risk of offending against children has been largely unmet at a systemic policy level in Australia. This would appear to be the critical challenge for Australia's National Centre for Action on Child Sexual Abuse.
Collaborating with children, young people, and adults who have lived experience of CSA is an opportunity for bringing their knowledge of CSA and its dynamics within families, organisations, and communities into the formulation of prevention policy, programs, and services. On the local and organisational level, co-production is indicated for the development of effective safeguarding practices and service redesign (Gupta & Blumhardt 2018;Oakley et al., 2022). Community-led initiatives 1 3 afford policymakers the opportunity to bring together a range of expertise, including lived experience expertise, and leadership, including cultural leadership, in ways that respect and build on communities' strengths, assets, and values.

Gaps in Evidence and Future Research
Three key gaps in evidence emerged in this review: the lack of knowledge about culturally informed approaches, the lack of interventions targeting potential offenders in Australia, and the lack of evidence about intrafamilial and sibling sexual abuse. Knowledge is lacking about how mainstream prevention strategies might be applied in situations or organisations where First Nations children may be overrepresented, such as residential OOHC. Reflecting on Barsalou-Verge et al., (2015), this gap in evidence has multiple perspectives, including i. culturally informed evidence about how CALD and First Nations children, young people, and adults experience mainstream, universally delivered programs; ii. interventions informed by Indigenous knowledge and culturally responsive research that are tailored to local conditions and protocols; iii. evidence about the experience and efficacy of prevention of sexual abuse of sexuality and gender-diverse children, and children and young people with a range of disabilities; iv. implementation and evaluation that enables culturally responsive strategies to be adapted to serve whole communities; v. First Nations-led responses to challenges such as the co-occurring social and economic concerns of First Nations communities and the challenges for First Nations staff and volunteers working in community-led, culturally informed and mainstream prevention programs.
An understanding of perpetrator tactics and the sexually abusive behaviour of young people themselves is critical for the effectiveness of CSA education to support young people's help-seeking and disclosure (McKibbin & Humphreys, 2019). Targeting prevention approaches to those most at risk of using harmful sexual behaviours with children is warranted within a public health approach, but additional research is needed to understand the circumstances in which it first occurs (Smallbone et al., 2011). Examining the discourse of adult sexual offenders against children, grooming processes can be deconstructed and used to interrupt the cyclic nature of CSA, particularly the orchestration of abuse and the establishment of transactional relationships with children and young people (Naidoo & Van Hout, 2021). Victim-focused CSA research has built a large source of evidence to support tertiary responses to victims but has not resulted in effective prevention measures. Whereas offender-and situational-focussed research has supported the development of theory, practice and evaluation of CSA prevention (Smallbone et al., 2011). There is far less evidence in the prevention program literature about the prevention of sibling CSA or other forms of intrafamilial CSA. Myths and stigma about It Is Time to Focus on Prevention: a Scoping Review of Practices… CSA perpetrators as unable to be helped, and adult strangers are far from the reality supported by evidence. To address the large proportion of incidents of CSA, qualitative and quantitative evidence is needed about the dynamics of sexual abuse in families, including young people using harmful sexual behaviour, the effective practices of intrafamilial CSA prevention, and the conditions that enable and constrain such practices. In this regard, evidence about the age cohorts of children and young people who engage in harmful sexual behaviour and the nature of their behaviour points to opportunities for intervening before more harm is done to children and other young people in their lives. The efforts of parents, communities, schools, and other youth-serving organisations may be mobilised for more effective interventions.

Funding
The initial scoping of this study was funded by the Australian Childhood Foundation to prepare a rapid review of CSA prevention literature. Following the submission of the rapid review, an additional scoping search and analysis were conducted, as described in the manuscript for submission to IJCM. The manuscripts are substantially different.
Data Availability Data is available in the supplemental material provided in Appendix 1.
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