A mixed methods approach to understanding factors contributing to the reduction of childhood sexual violence: A case study of Eswatini

Based on the Violence Against Children and Youth Surveys (VACS), the prevalence of childhood sexual violence in Eswatini decreased from 33.4% in 2007 to 5.4% in 2022 among girls aged 13-24. However, there is limited understanding of the policies, programs, and changes in social values that may have contributed to this reduction and if the decrease in CSV was also associated with improvement in the mental health and sexual risk outcomes associated with CSV. This mixed-methods case study triangulated the analysis of the 2007 and 2022 VACS, a content analysis of national policy and programmatic documents, and key informant interviews with national stakeholders within a multiple streams framework. The aims of this research were 1) to describe the changes in CSV prevalence and associated outcomes of sexual health and suicidality and 2) to investigate factors that contributed to the reduction of CSV in Eswatini. Within the problem stream, the convergence of HIV, gender-based violence, and CSV agendas opened policy windows, with civil society actors as problem brokers and expanding national awareness of CSV. The work of civil society coupled with the 2017 qualitative study by the DPMO may have contributed to increased identification of familial perpetrators (33.4% vs. 14.4% in 2007; p< .0001). Within the policy stream, the Sexual Offenses and Domestic Violence Act (2018) served as a legislative milestone strengthening justice responses and deterrence of sexual offenses. Complementary national reforms, including free primary education, life skills education, and One Stop Centers, provided the foundation of Eswatini’s child protection infrastructure. Following these policy and programming changes, shifts in higher educational attainment (≤primary education: 3.9% vs. 30.8% in 2007; p< .0001), reduced orphanhood (29.5% vs. 40.9% in 2007; p=0.0041), reduction of early sexual debut (19.0% vs. 26.6% in 2007; p=0.0323) and reduced poly-victimization (28.8% vs. 66.0% in 2007; p< .0001) were observed among CSV survivors. Within the politics stream, the country transitioned from fragmented service provision to a coordinated multi-sectoral national response led by the DPMO. Despite progress, female CSV survivors remained significantly more likely to report risky sexual behaviors (aOR: 2.9; p< .0001) with suicidality increasing over time (aOR 1.7 in 2007 vs. 6.0 in 2022; p< .0001; interaction p< .0001) compared to girls that do not report CSV. This case demonstrates how aligning problem recognition, policy reform, and political leadership produced measurable national reductions in CSV, while highlighting the need for investment in survivor-centered mental health systems.