Date of Award

Spring 2019

Document Type

Open Access Dissertation


College of Nursing

First Advisor

Laura C. Hein


Child sexual abuse (CSA) affects approximately one in four US children through adolescence. As an adverse childhood experience (ACE) implicated in long-term health and wellbeing, CSA is a pervasive safety concern. The influence of caregivers and healthcare providers is under-realized in CSA prevention. Examining the thinking processes preceding CSA vigilance response has been limited in research. Understanding the complexities in healthcare related to addressing CSA will facilitate caregiver-focused intervention in primary care. Guided by social ecology and protection motivation theories (PMT), the goals of this two-phase study were to explore caregiver cognitive processes towards vigilance for CSA and the challenges of CSA prevention and intervention in primary care. Phase I explored how the proposed cognitive process of situational risk perception related to caregiver prior experience and sociodemographic variables in a PMT model. Phase II explored challenges in primary care for providing guidance, appraisal, and treatment for CSA.

During Phase I, caregivers of children 4 – 10 years old were surveyed (n = 183). A multinomial logistic regression model identified prior childhood adversity and financial security as predictors of caregivers’ CSA situational risk perception across both microsystem and exosystem layers. The investigator-developed 10-option measure of CSA risk situations was reliable (Cronbach’s alpha = .80). A principle components analysis identified two factors, microsystem and exosystem-level CSA risks.

During Phase II, three focus group sessions were conducted with primary care providers and staff. Six themes were identified. Two themes were specific to the provider’s role: (1) Competing care demands for high-risk children and (2) Challenges with appraisal and treatment. Two proximal processes with families were identified: (1) Navigating stigma, denial, and avoidance and (2) Sporadic interaction for guidance and appraisal. Two proximal processes with community resources were identified: (1) Fragmentation of community resources and (2) Constrained information sharing with community agencies.

Identifying influences on caregiver risk perception is a needed precursor to studying caregiver vigilance. This study supports developing a tailored intervention for caregivers grounded in cognitive processes for CSA risk and vigilance. This study identified primary care challenges and resources for addressing CSA, important for planning feasible PMT-based caregiver interventions in primary care.


© 2019, Kate K. Chappell

Included in

Nursing Commons