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Bullying victimization and externalizing and internalizing symptoms among in-school adolescents from five ASEAN countries
Children and Youth Services Review 106 (2019) 104473
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Bullying victimization and externalizing and internalizing symptoms among in-school adolescents from five ASEAN countries Supa Pengpida,c, Karl Peltzerb,d,
T
⁎
a
ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Viet Nam c Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa d Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, Viet Nam b
A R T I C LE I N FO
A B S T R A C T
Keywords: Bullying victimization Substance use Interpersonal violence Hygiene Psychological distress Adolescents Southeast Asia
The study aimed to assess the relationship between bullying victimization and adverse health or psychosocial problems among in-school adolescents from five Southeast Asian countries. The sample consisted of 33,184 school-going children, mean age 14.6 years (SD = 1.7), from Indonesia, Laos, Philippines, Thailand and TimorLeste that took part in the cross-sectional “Global School-based Student Health Survey” (GSHS) in 2015. Results indicate 18.6% of the students reported infrequent (1–2 days/month) and 12.0% frequent (3–30 days/month) past-month bullying victimization. Among different types of bullying victimization, the most prevalent was psychological (13.5%), followed by other (5.6%), physical (3.6%) and social (1.3%). In adjusted Poisson regression analysis, bullying victimization is associated with tobacco, alcohol and drug use, physically attacked, in physical fight, injury, truancy and poor hand hygiene behaviour, anxiety, loneliness, suicidal ideation, suicide attempt, no close friends, sedentary behaviour, underweight and overweight or obesity. This study extends previous findings from mainly high-income countries on the relationship between bullying victimization and a large number of adverse outcomes in adolescents in Southeast Asia.
1. Introduction “Bullying refers to aggressive behavior that is repetitive and intentional in which a power differential exists between the victim and bully. The negative effects of bullying on an individual's mental and physical health are substantial and in line with other major forms of child maltreatment.” (Rette & Pawlowski, 2016, p.235) Bullying victimization has been associated various externalizing symptoms, such as tobacco use (Brown, Riley, Butchart, & Kann, 2008; Moore et al., 2017; Romo & Kelvin, 2016), alcohol use (Brown et al., 2008; Fleming & Jacobsen, 2010; Wiguna et al., 2018), drug use (Brown et al., 2008; Fleming & Jacobsen, 2010; Hong et al., 2014; Hong, Voisin, Cho, Smith, & Resko, 2018). Moore et al., 2017), physical fight (Brown et al., 2008; Hertz, Everett Jones, Barrios, David-Ferdon, & Holt, 2015; Moore et al., 2017; Romo & Kelvin, 2016; Rudatsikira, Mataya, Siziya, & Muula, 2008), injury (Hertz et al., 2015), truancy (Romo & Kelvin, 2016), and poor hygiene behaviour (Murshid, 2018). In addition, bullying victimization has been correlated with psychological distress or mental health problems (Nguyen, Bradshaw, Townsend, Gross, & Bass, 2019; Le et al., 2017; Owusu, Hart, Oliver, &
⁎
Kang, 2011; Moore et al., 2017; Thomas et al., 2016), loneliness (Fleming & Jacobsen, 2010; Moore et al., 2017), anxiety (Fleming & Jacobsen, 2010; Moore et al., 2017), depression (Abd Razak et al., 2019; Moore et al., 2017; Murshid, 2017), suicidal behaviour (Hertz et al., 2015; Hong, Kral, & Sterzing, 2015; Moore et al., 2017; Romo & Kelvin, 2016), sedentary behaviour (Hertz et al., 2015), physical inactivity (Hertz et al., 2015), underweight (Lian et al., 2018) and overweight or obesity (Lian et al., 2018; Moore et al., 2017). “Children who suffered more frequent bullying by peers tend to display worse outcomes” (Lian et al., 2018). “Compared to occasional victims and nonbullied children, victims of chronic bullying are at elevated risk for maladjustment, which may lead them to bully others or to self-harm” (Bowes et al., 2013). Protective factors from bullying victimization may include peer and parental support (Abdirahman, Fleming, & Jacobsen, 2013; Boel-Studt & Renner, 2013; Hong, Ryou, & Piquero, 2017); Zych, Farrington, & Ttofi, 2019). Globally, about 30% of adolescents reported past-month bullying victimization (Elgar et al., 2015). Among adolescents in Southeast Asian countries, the prevalence of past-month bullying victimization was, for example, 35.0% in 2017 in Malaysia (Abd Razak et al., 2019),
Corresponding author at: Ton Duc Thang University, Ho Chi Minh City, Viet Nam. E-mail address: [email protected] (K. Peltzer).
https://doi.org/10.1016/j.childyouth.2019.104473 Received 23 May 2019; Received in revised form 19 August 2019; Accepted 19 August 2019 Available online 20 August 2019 0190-7409/ © 2019 Elsevier Ltd. All rights reserved.
Children and Youth Services Review 106 (2019) 104473
S. Pengpid and K. Peltzer
2.3. Data analysis
45.0% in 2011 in the Philippines (Peltzer & Pengpid, 2015), and 27.8% in 2008 in Thailand (Pengpid & Peltzer, 2013).” Southeast Asia is composed of eleven countries of impressive diversity in religion, culture and history: Brunei, and Singapore (high-income countries), Malaysia and Thailand (upper middle-income countries), Burma (Myanmar), Cambodia, Indonesia, Laos, the Philippines, Timor-Leste, and Vietnam (lower middle-income countries). It is also one of the most dynamic areas of the world economically, a factor which largely accounts for its growing international significance.” (Northern Illinois University (2019, p.1). Although awareness of bullying victimization and correlated health risk behaviours and poor mental health (Brown et al., 2008; Hong et al., 2019; Hong, Voisin, Kim, Allen-Meares, & Espelage, 2019) may have increased globally, national recent studies describing the frequency and type of bullying victimization and correlations with adverse health behaviours and poor mental health are limited in Southeast Asia (Le et al., 2017; Nguyen et al., 2019; Rudatsikira et al., 2008; Sittichai & Smith, 2015; Wiguna et al., 2018). Considering this, the study aimed to assess the relationship between bullying victimization and adverse health or psychosocial problems among in-school adolescents from five Southeast Asian countries, using data from the “Global School-based Student Health Survey (GSHS)” in 2015. It was hypophesized that bullying victimization is associated with various adverse health or psychosocial problems in school adolescents in Southeast Asia.
Data analysis was done with STATA software version 15.0 (Stata Corporation, College Station, Texas, USA), taking the complex sampling design of the study into account. Taylor linearization methods were utilized in the statistical analyses to account for the sampling weighting and complex study design. Data results were described with descriptive statistics. In order to analyze the relationship between frequency and type of bullying victimization with adverse health or psychosocial problems, correlation analyses were performed. We used prevalence rate ratios (PR) to assess the magnitude of the statistical associations between frequency and type of bullying victimization, adjusted by country, sex, age, hunger (or socioeconomic status), peer support, and parental support, and each adverse health or psychosocial outcome. Prevalence ratios were obtained by Poisson regression, with a 95% confidence interval. Missing cases were excluded from the analysis. P < .01 was considered significant. 3. Results 3.1. Sample characteristics The overall study sample included 33,184 school children, mean age 14.6 years (SD = 1.7), males 48.9% and females 51.1% from Indonesia, Laos, Philippines, Thailand and Timor-Leste; response rates ranged from 72% in Laos to 94% in Indonesia (WHO, 2019). The sample size ranged from 3683 in Laos to 11,142 in Indonesia, 51.1% were female, and 39.6% had sometimes or mostly or always experienced hunger in the past 30 days. More than one-third of participants (36.8%) had received mostly or always peer support in the past 30 days, and 58.4% had two or more forms of parental support. Overall, 18.6% of the students reported infrequent (1–2 days/month) and 12.0% frequent (3–30 days/month) past-month bullying victimization. Among different types of bullying victimization, the most prevalent was psychological (13.5%), followed by other (5.6%), physical (3.6%) and social (1.3%) (see Table 2).
2. Methods 2.1. Study design and participants This analysis utilizes 2015 Southeast Asian “Global School-based Student Health Survey (GSHS)” cross-sectional data; detailed methodology and the dataset can be publicly accessed (World Health Organization (WHO), 2019). The conduct of the most recent GSHS in Southeast Asian countries, namely in 2015, was used as country inclusion criteria to select Indonesia, Laos, Philippines, Thailand, and Timor-Leste in this paper. Using a two-stage cluster sampling strategy (schools were selected by probability to size sampling and random selection of class rooms with students 13 to 15 years old), nationally representative samples of middle school students were produced in each country (WHO, 2019). “All students attending a selected class were eligible to participate, regardless of their age, and completed a selfadministered questionnaire in their language under the supervision of trained external survey administrators “(WHO, 2019). The study proposal was approved by the Ministry of Education or Health and a national ethics committee, and verbal or written consent was “obtained from the participating schools, parents and students before the survey was administered.” (WHO, 2019).
3.2. Correlations between frequency and type of bullying victimization with adverse health or psychosocial problems Table 3 describe the correlation coefficients between frequency and type of bullying victimization with each specific adverse health or psychosocial problem. Frequency of bullying victimization was positively and significantly correlated with all adverse health or psychosocial problems. Similarly, physical bullying victimization was positively and significantly correlated with all adverse health or psychosocial problems except for overweight or obesity, and physical bullying victimization was positively and significantly correlated with all adverse health or psychosocial problems except for physical inactivity and underweight. Social and other bullying victimization was positively and significantly correlated with 12 or 11 adverse health or psychosocial problems, while the remaining eight or nine adverse health or psychosocial problems were not significantly or negatively correlated, including physical inactivity, underweight and overweight or obesity, hand washing behaviours, school truancy, and for other bullying victimization substance use variables (see Table 3).
2.2. Measures The study questionnaire utilized in this investigation was from the GSHS (WHO, 2019) (see Table 1). An Olweus-type definition of bullying victimization was used (Olweus, 1999). Underweight was defined as “less than 2 standard deviation (SD) from median for BMI by age and sex”, and overweight or obesity was defined as “more than 1 standard deviation (SD) from the median body mass index by age and sex” (Cole, Bellizzi, Flegal, & Dietz, 2000). “Sedentary behaviour was defined as spending 3 or more hours per day sitting” (Guthold, Cowan, Autenrieth, Kann, & Riley, 2010). Inadequate physical activity was defined as not daily “at least 60 minutes of moderate to vigorous-intensity physical activity.”(WHO, 2017) The four items on parental or guardian support were summed, and classified into three groups, 0–1 low, 2 medium and 3–4 high support.
3.3. Associations with substance use variables In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization were associated with current tobacco use, current alcohol use, ever cannabis use and ever amphetamine use. Physical and psychological bullying victimization were associated with all four substance use indicators. In addition, social bullying victimization was associated with current tobacco and alcohol use, and other bullying victimization was associated with current alcohol use. 2
Children and Youth Services Review 106 (2019) 104473
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Table 1 Variable description. Variables
Question
Response options (coding scheme)
Age Sex Hunger
“How old are you?” “What is your sex?” “During the past 30 days, how often did you go hungry because there was not enough food in your home?” “[Bullying occurs when a student or a group of students say or do bad and unpleasant things to another student. It is also bullying when a student is teased a lot in an unpleasant way or a student is forced to withdraw from certain activities on purpose. It is not bullying when two students of about the same strength or power argue or fight or when teasing is done in a friendly and hilarious way.]” “During the past 30 days, on how many days were you bullied?” During the past 30 days, how were you bullied most often?
“11 years old or younger to 18 years old or older” “Male, Female” “1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)”
Bullied
Type of bullied
Current tobacco use
Current alcohol use Cannabis use Amphetamine use School truancy Physical attacks Physical fights Injury Leisure-time sedentary behaviour Physical inactivity
Height Weight Anxiety Loneliness Suicide ideation Suicide attempt No close friends Hand washing before eating Hand washing after toilet Hand washing with soap
Peer support Parental supervision Parental connectedness Parental bonding Parental respect for privacy
“During the past 30 days, on how many days did you smoke cigarettes/ use any tobacco products other than cigarettes, such as …country specific names?” “During the past 30 days, on how many days did you have at least one drink containing alcohol?” “During your life, how many times have you used marijuana (also called ….country specific names)?” “During your life, how many times have you used amphetamines or methamphetamines (also called ….country specific names)?” “During the past 30 days, on how many days did you miss classes or school without permission?” “During the past 12 months, how many times were you physically attacked?” “During the past 12 months, how many times were you in a physical fight?” “During the past 12 months, how many times were you seriously injured?” “How much time do you spend during a typical or usual day sitting and watching television, playing computer games, talking with friends, or doing other sitting activities, such as country examples?” “During the past 7 days, on how many days were you physically active for a total of at least 60 min per day? ADD UP ALL THE TIME YOU SPENT IN ANY KIND OF PHYSICAL ACTIVITY EACH DAY” “How tall are you without your shoes on?” “How much do you weigh without your shoes on?” “During the past 12 months, how often have you been so worried about something that you could not sleep at night?” “During the past 12 months, how often have you felt lonely?” “During the past 12 months, did you ever seriously consider attempting suicide?” “During the past 12 months, how many times did you actually attempt suicide?” “How many close friends do you have?” “During the past 30 days, how often did you wash your hands before eating?” “During the past 30 days, how often did you wash your hands after using the toilet or latrine?” “During the past 30 days, how often did you use soap when washing your hands?” Social-familial protective factors “During the past 30 days, how often were most of the students in your school kind and helpful?” “During the past 30 days, how often did your parents or guardians check to see if your homework was done?” “During the past 30 days, how often did your parents or guardians understand your problems and worries?” “During the past 30 days, how often did your parents or guardians really know what you were doing with your free time? “During the past 30 days, how often did your parents or guardians go through your things without your approval?”
1 = 0 days to 7 = All 30 days (coded 1 = 0 and 2–7 = 1)
Physical=” I was hit, kicked, pushed, shoved around, or locked indoors.” Psychological=” I was made fun of because of my race, nationality, or color.” OR “I was made fun of because of my religion.” OR” I was made fun of with sexual jokes, comments, or gestures.” OR “I was made fun of because of how my body or face looks.” Social = “I was left out of activities on purpose or completely ignored.” Other = “I was bullied in some other way” 1 = 0 days to 7 = All 30 days (coded 1 = 0 and 2–7 = 1)
1 = 0 days to 7 = All 30 days 1 = 0 times to 5 = 20 or more times (coded 1 = 0 and 2–5 = 1) 1 = 0 times to 5 = 20 or more times (coded 1 = 0 and 2–5 = 1) “1 = 0 days to 5 = 10 or more days (coded 1 = 0 and 2–5 = 1)” 1 = 0 times to 8 = 12 or more times 1 = 0 times to 8 = 12 or more times 1 = 0 times to 8 = 12 or more times (coded 1 = 0 and 2–8 = 1) “1 = < 1 h per day; 2 = 1–2 h/day; 3 = 3–4 h/day; 4 = 5–6 h/day; 5 = 7–8 h/day and 6 = 8 or more hours per day” “1 = 0 days to 8 = 7 days) (coded 1–7 = 1 and 8 = 0”
“1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)” “1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)” “Yes, No” “1 = 0 times to 5 = 6 or more times (coded 1 = 0 and 2–5 = 1)” “1 = 0 to 4 = 3 or more (coded 1 + =0, 0 = 1)” “1 = never to 5 = always (coded 1–4 = 1 and 5 = 0)” “1 = never to 5 = always (coded 1–4 = 1 and 5 = 0)” “1 = never to 5 = always (coded 1–4 = 1 and 5 = 0)”
1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)
(physical, psychological and other) were associated with past month school truancy, past 12-month physically attacked, in physical fight and had a serious injury, while social bullying victimization was associated with attacked, fight and injury.
3.4. Associations with violence related variables and truancy In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization and three types of bullying victimization 3
Children and Youth Services Review 106 (2019) 104473
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Table 2 Sample characteristics by bullying victimization frequency and type. Variable
Socio-demographics All Country Indonesia Laos Philippines Thailand Timor-Leste Age (years) ≤13 14 15 ≥16 Gender Female Male Hunger Never Rarely Sometimes/mostly/always Peer support (mostly/always) Parental/guardian support 0–1 2 3–4
Sample
Bullying victimization frequency
Type of bullying victimization
1–2 days/month
3–30 days/month
Physical
Psychological
Social
Other
N (%)
N (%)
N (%)
%
%
%
%
33,184
5812 (18.6)
3470 (12.0)
3.6
13.5
1.3
5.5
11,142 (33.6) 3683 (11.1) 8761 (26.4) 5894 (17.8) 3704 (11.2)
1465 (13.9) 326 (9.3) 2418 (28.2) 883 (15.6) 720 (21.5)
669 (6.7) 79 (2.5) 1740 (20.5) 738 (13.7) 244 (7.1)
2.0 2.6 5.6 5.4 4.8
9.0 3.2 21.7 13.1 9.9
1.1 0.1 1.9 1.1 0.9
5.6 2.6 5.6 5.0 3.0
9611 (29.1) 6826 (20.7) 6396 (19.4) 10,217 (30.9)
1785 1330 1085 1590
(18.3) (19.7) (20.6) (16.7)
1175 (12.2) 763 (12.5) 669 (12.8) 846 (10.5)
3.8 4.2 3.8 2.7
12.9 13.5 15.4 12.9
1.1 1.5 1.3 1.5
6.2 5.8 5.0 4.5
17,991 (51.1) 14,902 (48.9)
3006 (17.6) 2757 (19.8)
1576 (9.9) 1853 (14.1)
2.6 4.7
12.1 15.0
1.5 1.2
5.6 5.3
13,808 (40.4) 6346 (20.0) 12,885 (39.6) 1112 (36.8)
1791 1216 2779 1720
(13.8) (20.8) (22.6) (15.2)
1046 (8.7) 757 (14.0) 1653 (14.3) 1050 (9.8)
2.5 4.8 4.2 2.3
9.6 14.8 16.8 10.9
0.8 1.5 1.8 1.1
4.5 5.7 6.4 5.4
17,139 (51.6) 8479 (27.0) 6326 (21.4)
3314 (21.0) 1370 (17.7) 931 (14.8)
1954 (13.8) 747 (10.0) 562 (9.1)
4.9 2.5 2.0
15.0 12.3 11.0
1.5 1.3 1.1
5.4 5.9 5.3
3.5. Associations with physical activity level and weight related variables
3.6. Associations with psychological distress variables
Frequent bullying victimization and psychological and other bullying victimization were associated with sedentary behaviour, while frequent bullying victimization and psychological bullying victimization were inversely associated with physical inactivity. In addition, psychological victimization was associated with overweight or obesity.
In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization and all four types of bullying victimization were associated with anxiety, loneliness, suicidal ideation and suicide attempt. In addition, any bullying victimization frequency and physical and psychological bullying victimization was associated with no close friends.
Table 3 Correlations between frequency and type of bullying victimization with adverse health or psychosocial problems. Variable
Current tobacco use Current alcohol use Ever cannabis use Ever amphematime use School truancy Physically attacked In physical fight Injury Sitting 3 or more hours Physically inactive Underweight Overweight or obesity Anxiety Lonely Suicide ideation Suicide attempt No close friends Hand washing before eating Hand washing after toilet Hand washing with soap
Frequency of bullying victimization
Type of bullying victimization Physical
Psychological
Social
Other
rho(p)
r(p)
r(p)
r(p)
r(p)
0.17(0.000) 0.14(0.000) 0.16(0.000) 0.16(0.000) 0.14(0.000) 0.30(0.000) 0.33(0.000) 0.33(0.000) 0.05(0.000) 0.02(0.002) 0.03(0.000) 0.10(0.000) 0.15(0.000) 0.18(0.000) 0.16(0.000) 0.22(0.000) 0.05(0.000) 0.06(0.000) 0.07(0.000) 0.02(0.004)
0.12(0.000) 0.09(0.00) 0.13(0.000) 0.13(0.000) 0.07(0.000) 0.14(0.000) 0.17(0.000) 0.14(0.000) 0.02(0.007) 0.01(0.47) 0.02(0.000) 0.003(0.648) 0.04(0.000) 0.04(0.000) 0.06(0.000) 0.12(0.000) 0.03(0.000) 0.05(0.000) 0.06(0.000) 0.03(0.000)
0.10(0.000) 0.09(0.000) 0.09(0.000) 0.09(0.000) 0.08(0.000) 0.18(0.000) 0.19(0.000) 0.20(0.000) 0.05(0.000) 0.001(0.869) 0.01(0.091) 0.02(0.015) 0.11(0.000) 0.14(0.000) 0.12(0.000) 0.15(0.000) 0.02(0.000) 0.04(0.000) 0.04(0.000) 0.02(0.025)
0.03(0.000) 0.02(0.000) 0.03(0.000) 0.03(0.000) 0.008(0.140) 0.05(0.000) 0.05(0.000) 0.06(0.000) 0.01(0.021) −0.007(0.234) 0.004(544) −0.01(0.062) 0.03(0.000) 0.05(0.000) 0.02(0.000) 0.03(0.000) 0.01(0.061) 0.006(0.295) 0.004(0.479) 0.000(0.994)
−0.002(0.751) 0.01(0.014) −0.006(0.291) −0.006(0.317) 0.009(0.110) 0.08(0.000) 0.06(0.000) 0.09(0.000) 0.03(0.000) −0.01(0.051) 0.002(0.734) −0.01(0.041) 0.04(0.000) 0.05(0.000) 0.04(0.000) 0.02(0.007)
4
0.02(0.006) −0.003(598) 0.005(0.418)
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Table 4 Associations between frequency and type of bullying victimization with each adverse health or psychosocial problem. Variable
Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other
APR (95% CI)a
APR (95% CI)a
APR (95% CI)a
APR (95% CI)a
Current tobacco use
Current alcohol use
Ever cannabis
Ever amphetamine
1 (Reference) 1.73 (1.48, 2.01)⁎⁎ 2.00 (1.70, 2.34)⁎⁎
1 (Reference) 1.56 (1.40, 1.74)⁎⁎ 1.74 (1.50, 2.01)⁎⁎
1 (Reference) 2.31 (1.71, 3.10)⁎⁎ 3.45 (2.56, 4.65)⁎⁎
1 (Reference) 3.79 (2.83, 5.09)⁎⁎ 5.44 (4.14, 7.13)⁎⁎
1 (Reference) 2.63 (2.13, 3.26)⁎⁎ 1.63 (1.45, 1.84)⁎⁎ 1.57 (1.12, 2.20)⁎ 1.09 (0.90, 1.32)
1 (Reference) 2.18 (1.76, 2.71)⁎⁎ 1.57 (1.40, 1.76)⁎⁎ 1.76 (1.36, 2.28)⁎⁎ 1.39 (1.20, 1.62)⁎⁎
1 (Reference) 5.11 (3.76, 6.96)⁎⁎ 2.46 (2.01, 3.00)⁎⁎ 1.59 (0.77, 3.26) 0.79 (0.49, 1.29)
1 (Reference) 7.61 (5.45, 10.61)⁎⁎ 2.99 (2.40, 3.74)⁎⁎ 1.87 (0.80, 4.39) 0.80 (0.41, 1.51)
School truancy
Physically attacked
In physical fight
Sustained injury
1 (Reference) 1.47 (1.36, 1.58)⁎⁎ 1.61 (1.47, 1.75)⁎⁎
1 (Reference) 1.97 (1.85, 2.10)⁎⁎ 2.30 (2.15, 2.46)⁎⁎
1 (Reference) 2.14 (2.00, 2.30)⁎⁎ 2.38 (2.19, 2.57)⁎⁎
1 (Reference) 1.89 (1.79, 2.00)⁎⁎ 2.12 (1.97, 2.27)⁎⁎
1 (Reference) 1.76 (1.55, 1.99)⁎⁎ 1.41 (1.30, 1.53)⁎⁎ 1.32 (1.06, 1.66) 1.25 (1.12, 1.35)⁎⁎
1 (Reference) 2.37 (2.20, 2.56)⁎⁎ 1.92 (1.81, 2.02)⁎⁎ 1.95 (1.68, 2.26)⁎⁎ 1.82 (1.68, 1.97)⁎⁎
1 (Reference) 2.46 (2.26, 2.67)⁎⁎ 1.93 (1.81, 2.05)⁎⁎ 1.99 (1.70, 2.32)⁎⁎ 1.75 (1.56, 1.97)⁎⁎
1 (Reference) 2.08 (1.93, 2.23)⁎⁎ 1.82 (1.74, 1.90)⁎⁎ 1.97 (1.75, 2.21)⁎⁎ 1.82 (1.67, 1.98)⁎⁎
Sitting 3 or more hours
Physically inactive
Underweight
Overweight or obesity
1 (Reference) 0.98 (0.91, 1.04) 1.29 (1.20, 1.38)⁎⁎
1 (Reference) 1.00 (0.99, 1.02) 0.97 (0.95, 0.99)⁎⁎
1 (Reference) 1.14 (0.98, 1.32) 1.18 (1.00, 1.38)
1 (Reference) 0.96 (0.84, 1.00) 1.24 (1.04, 1.48)
1 (Reference) 1.07 (0.96, 1.20) 1.21 (1.13, 1.29)⁎⁎ 1.11 (0.92, 1.34) 1.20 (1.09, 1.32)⁎⁎
1 (Reference) 1.02 (0.99, 1.04) 0.97 (0.95, 0.99)⁎⁎ 0.94 (0.90, 0.99) 0.98 (0.95, 1.01)
1 (Reference) 1.31 (1.00, 1.73) 1.06 (0.89, 1.26) 1.13 (0.65, 1.94) 1.12 (0.89, 1.41)
1 (Reference) 1.11 (0.84, 1.48) 1.23 (1.06, 1.42)⁎ 0.65 (0.39, 1.07) 0.80 (0.60, 0.98)
Anxiety
Lonely
Sucide ideation
Suicide attempt
1 (Reference) 1.82 (1.57, 2.10)⁎⁎ 2.81 (2.44, 3.24)⁎⁎
1 (Reference) 1.78 (1.55, 2.03)⁎⁎ 3.19 (2.83, 3.59)⁎⁎
1 (Reference) 2.02 (1.79, 2.29)⁎⁎ 3.03 (2.60, 3.52)⁎⁎
1 (Reference) 2.40 (2.06, 2.81)⁎⁎ 3.57 (3.15, 4.05)⁎⁎
1 (Reference) 1.67 (1.22, 2.28)⁎⁎ 2.30 (1.97, 2.69)⁎⁎ 2.08 (1.39, 3.13)⁎⁎ 2.07 (1.69, 2.54)⁎⁎
1 (Reference) 1.70 (1.26, 2.28)⁎⁎ 2.48 (2.23, 2.76)⁎⁎ 1.94 (1.47, 2.56)⁎⁎ 2.36 (1.97, 2.82)⁎⁎
1 (Reference) 2.27 (1.70, 3.02)⁎⁎ 2.55 (2.28, 2.85)⁎⁎ 1.97 (1.37, 2.84)⁎⁎ 2.22 (1.86, 2.65)⁎⁎
1 (Reference) 3.62 (2.90, 4.52)⁎⁎ 2.68 (2.38, 3.01)⁎⁎ 1.97 (1.34, 2.89)⁎⁎ 1.70 (1.38, 2.10)⁎⁎
No close friends
Hand washing before eating
Hand washing after toilet
Hand washing with soap
1 (Reference) 1.53 (1.31, 1.78)⁎⁎ 1.86 (1.52, 2.27)⁎⁎
1 (Reference) 1.66 (1.28, 2.16)⁎⁎ 1.97 (1.53, 2.54)⁎⁎
1 (Reference) 2.09 (1.55, 2.82)⁎⁎ 2.33 (1.83, 2.96)⁎⁎
1 (Reference) 1.44 (1.19, 1.74)⁎⁎ 1.71 (1.44, 2.02)⁎⁎
1 (Reference) 2.13 (1.47, 3.07)⁎⁎ 1.45 (1.25, 1.69)⁎⁎ 1.35 (0.63, 2.87) 1.29 (0.98, 1.70)
1 (Reference) 2.85 (1.99, 4.07)⁎⁎ 1.57 (1.33, 1.86)⁎⁎ 0.82 (0.46, 1.45) 0.81 (0.58, 1.13)
1 (Reference) 2.95 (2.10, 4.15)⁎⁎ 1.61 (1.36, 1.91)⁎⁎ 1.21 (0.66, 2.21) 0.85 (0.55, 1.30)
1 (Reference) 2.38 (1.75, 3.22)⁎⁎ 1.39 (1.17, 1.65)⁎⁎ 0.76 (0.45, 1.28) 0.92 (0.70, 1.19)
APR = Adjusted Prevalence Ratio; CI=Confidence Interval. ⁎⁎ P < .001. ⁎ P < .01. a Adjusted for each item of each variable and for country, age, sex, socioeconomic status (hunger), peer support, and parental support.
3.7. Associations with hand hygiene variables
4. Discussion
In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization and physical and psychological bullying victimization were associated with all three poor hand washing hygiene behaviours (before eating, after toilet, and with soap). Social and other bullying victimization were not significantly associated with any of the poor hand hygiene variables (see Table 4).
The study aimed to assess the relationship between bullying victimization and adverse health or psychosocial problems among in-school adolescents from five Southeast Asian countries. Consistent with previous studies (Brown et al., 2008; Fleming & Jacobsen, 2010; Hertz et al., 2015; Hong et al., 2014; Hong et al., 2018); Moore et al., 2017; Murshid, 2018; Romo & Kelvin, 2016; Wiguna et al., 2018), this study found an association between bullying victimization and tobacco, 5
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alcohol and drug use, physically attacked, in physical fight, injury, truancy and poor hand hygiene behaviour. Moreover, in agreement with previous studies (Fleming & Jacobsen, 2010; Hertz et al., 2015; Lian et al., 2018; Moore et al., 2017; Murshid, 2017; Owusu et al., 2011; Romo & Kelvin, 2016; Thomas et al., 2016), this investigation established that bullying victimization was associated with anxiety, loneliness, suicidal ideation, suicide attempt, no close friends, sedentary behaviour, and overweight or obesity. Unlike in a previous study (Hertz et al., 2015), bullying victimization was negatively associated with physical inactivity in this study. It is possible that students are more likely bullied during physical education classes and/or in a physical sporting context (Méndez, Ruiz-Esteban, & Ortega, 2019). One possible mechanism explaining the effects of bullying victimization on health outcomes is the “diathesis-stress model in which individual biological and cognitive vulnerabilities interact with stressful life experiences (e.g., bullying victimization) to cause psychopathology that externalizes as negative health behaviours.” (Romo & Kelvin, 2016; Swearer & Hymel, 2015). Similar to a previous study (Lian et al., 2018), the strength of association between frequent bullying victimization and underweight was relative to overweight or obesity weaker. Previous research showed that “weight stigmatization translates into pervasive victimization, teasing, and bullying.” (Puhl & King, 2013). Regarding poor hand hygiene behaviours, Murshid (2018) proposes that “poor hygiene elicits disgust and disrespect manifesting as bullying among adolescents.” Consistent with previous studies (Bowes et al., 2013; Lian et al., 2018), this study found that compared to no or infrequent bullying victimization, frequent bullying victimization was associated with substance use, violence related variables, truancy, poor hand hygiene behaviour and psychological distress, sedentary behaviour, and overweight or obesity. This finding seems to confirm a dose-response relationship between bullying victimization frequency and a number of adverse outcomes (Moore et al., 2017). Among the different types of bullying victimization, physical bullying victimization was associated with substance use variables, truancy, violence-related variables, poor hygiene behaviours, no close friend and suicide attempt, and psychological bullying victimization was associated with sedentary behaviour, overweight or obesity, anxiety, loneliness and suicidal ideation than other types of bullying victimization. Similar to a study among adolescents in Latin America (Romo & Kelvin, 2016), this study found that both physical and psychological bullying victimization had significant effects on substance use, violence-related and psychological distress variables. Although the direction of the identified relationships between bullying victimization and various adverse health or psychosocial problems are unclear and probably complex, the possible harmful impacts of bullying victimization calls for effective anti-bullying programmes among school adolescents in Southeast Asia (Sittichai & Smith, 2015; Sivaraman, Nye, & Bowes, 2019).
even at greater risk of adverse health outcomes (Moore et al., 2017). 5. Conclusion This study extends previous findings from mainly high-income countries to adolescents in Southeast Asia, demonstrating that bullying victimization is associated with tobacco, alcohol and drug use, physically attacked, in physical fight, injury, truancy and poor hand hygiene behaviour and anxiety, loneliness, suicidal ideation, suicide attempt, no close friends, sedentary behaviour, and overweight or obesity. Further studies may investigate reasons for some of the current findings, try to elucidate the cultural context of bullying behaviour and guide to develop prevention and intervention programmes. The findings emphasise the need for implementing effective anti-bullying programmes among school adolescents in Southeast Asia. Declaration of Competing Interest None declared. Acknowledgements The World Health Organization is acknowledged for making the datasets publicly available. References Abd Razak, M. A., Ahmad, N. A., Abd Aziz, F. A., Jamaluddin, R., Sidik, S. M., Awaluddin, S. M., ... Sooryanarayana, R. (2019). Being bullied is associated with depression among Malaysian adolescents: Findings from a cross-sectional study in Malaysia. Asia-Pacific Journal of Public Health. https://doi.org/10.1177/1010539519867796 1010539519867796. Abdirahman, H., Fleming, L. C., & Jacobsen, K. H. (2013). Parental involvement and bullying among middle-school students in North Africa. Eastern Mediterranean Health Journal, 19(3), 227–233. Boel-Studt, S., & Renner, L. M. (2013). Individual and familial risk and protective correlates of physical and psychological peer victimization. Child Abuse and Neglect, 37(12), 1163–1174. https://doi.org/10.1016/j.chiabu.2013.07.010. Bowes, L., Maughan, B., Ball, H., Shakoor, S., Ouellet-Morin, I., Caspi, A., ... Arseneault, L. (2013). Chronic bullying victimization across school transitions: The role of genetic and environmental influences. Development and Psychopathology, 25(2), 333–346. https://doi.org/10.1017/S0954579412001095. Brown, D. W., Riley, L., Butchart, A., & Kann, L. (2008). Bullying among youth from eight African countries and associations with adverse health behaviours. Pediatric Health, 2(3), 289–299. Cole, T. J., Bellizzi, M. C., Flegal, K. M., & Dietz, W. H. (2000). Establishing a standard definition for child overweight and obesity worldwide: International survey. British Medical Journal, 320, 1240–1243. Elgar, F. J., McKinnon, B., Walsh, S. D., Freeman, J. D., Donnelly, P., de Matos, M. G., ... Currie, C. (2015). Structural determinants of youth bullying and fighting in 79 countries. Journal of Adolescent Health, 57(6), 643–650. https://doi.org/10.1016/j. jadohealth.2015.08.007. Fleming, L. C., & Jacobsen, K. H. (2010). Bullying among middle-school students in low and middle income countries. Health Promotion International, 25(1), 73–84. https:// doi.org/10.1093/heapro/dap046. Guthold, R., Cowan, M. J., Autenrieth, C. S., Kann, L., & Riley, L. M. (2010). Physical activity and sedentary behavior among schoolchildren: A 34-country comparison. Journal of Pediatrics, 157, 43–49. Hertz, M. F., Everett Jones, S., Barrios, L., David-Ferdon, C., & Holt, M. (2015). Association between bullying victimization and health risk behaviors among high school students in the United States. Journal of School Health, 85(12), 833–842. https://doi.org/10.1111/josh.12339. Hong, J. S., Davis, J. P., Sterzing, P. R., Yoon, J., Choi, S., & Smith, D. C. (2014). A conceptual framework for understanding the association between school bullying victimization and substance misuse. American Journal of Orthopsychiatry, 84(6), 696–710. Hong, J. S., Kim, J., Lee, J. J., Shamoun, C. L., Lee, J. M., & Voisin, D. R. (2019). Pathways from peer victimization to sexually transmitted infections among African American adolescents. Western Journal of Nursing Research, 41(6), 798–815. Hong, J. S., Kral, M. J., & Sterzing, P. (2015). Pathways from bullying perpetration, victimization, and bully-victimization to suicidality among school-aged youth: A review of the potential mediators and a call for further investigation. Trauma, Violence & Abuse, 16(4), 379–390. Hong, J. S., Ryou, B., & Piquero, A. R. (2017). Do family-level factors associated with bullying perpetration and peer victimization differ by race? Comparing European American and African American Youth. Journal of Interpersonal Violence, 1. https:// doi.org/10.1177/0886260517714441 886260517714441.
4.1. Study limitations The study was cross-sectional and restricted to adolescents attending school, which limits the interpretation of the findings. Due to the self-report of the data, results may have been biased. A further limitation may be that the reference period differed from 30 days to 12 months for the variables assessed. A further limitation is the possible role of unmeasured confounding. For example, adolescents with conduct disorders are not only more likely to report being bullied, but are also more likely to exhibit adolescent externalizing behaviours like substance use, aggression or truancy. The exposure to multiple types of bullying victimization was not assessed in this study, and should be assessed in future studies. Moreover, one of the increasing type of bullying, cyberbullying, was not assessed and should be included in future investigations. This study did also not assess if students were both victims and perpetrators of bullying, as those individuals may be 6
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Pengpid, S., & Peltzer, K. (2013). Bullying and its associated factors among school-aged adolescents in Thailand. ScientificWorldJournal, 2013, 254083. https://doi.org/10. 1155/2013/254083. Puhl, R. M., & King, K. M. (2013). Weight discrimination and bullying. Best Practice & Research Clinical Endocrinology & Metabolism, 27(2), 117–127. https://doi.org/10. 1016/j.beem.2012.12.002. Rette, D. C., & Pawlowski, S. (2016). Bullying. Child and Adolescent Psychiatric Clinics of North America, 25(2), 235–242. https://doi.org/10.1016/j.chc.2015.12.002. Romo, M. L., & Kelvin, E. A. (2016). Impact of bullying victimization on suicide and negative health behaviors among adolescents in Latin America. Pan American Journal of Public Health, 40(5), 347–355. Rudatsikira, E., Mataya, R. H., Siziya, S., & Muula, A. S. (2008). Association between bullying victimization and physical fighting among Filipino adolescents: Results from the Global School-Based Health Survey. Indian Journal of Pediatrics, 75(12), 1243–1247. https://doi.org/10.1007/s12098-008-0244-x. Sittichai, R., & Smith, P. K. (2015). Bullying in south-east Asian countries: A review. Aggression and Violent Behavior, 23, 22–35. Sivaraman, B., Nye, E., & Bowes, L. (2019). School-based anti-bullying interventions for adolescents in low- and middle income countries: A systematic review. Aggression and Violent Behavior, 45, 154–162. Swearer, S. M., & Hymel, S. (2015). Understanding the psychology of bullying: Moving toward a social-ecological diathesis-stress model. American Psychologist, 70(4), 344–353. Thomas, H. J., Chan, G. C., Scott, J. G., Connor, J. P., Kelly, A. B., & Williams, J. (2016). Association of different forms of bullying victimisation with adolescents' psychological distress and reduced emotional wellbeing. Australian and New Zealand Journal of Psychiatry, 50(4), 371–379. https://doi.org/10.1177/0004867415600076. Wiguna, T., Irawati Ismail, R., Sekartini, R., Setyawati Winarsih Rahardjo, N., Kaligis, F., Prabowo, A. L., & Hendarmo, R. (2018). The gender discrepancy in high-risk behaviour outcomes in adolescents who have experienced cyberbullying in Indonesia. Asian Journal of Psychiatry, 130–135. https://doi.org/10.1016/j.ajp.2018.08.021 2018 Oct;37. World Health Organization (WHO) (2017). Physical activity fact sheet. http://www.who. int/mediacentre/factsheets/fs385/en/, Accessed date: 10 January 2019. World Health Organization (WHO) (2019). Global school-based student health survey (GSHS). https://www.who.int/ncds/surveillance/gshs/en/, Accessed date: 20 March 2019. Zych, I., Farrington, D. P., & Ttofi, M. M. (2019). Protective factors against bullying and cyberbullying: A systematic review og meta-analyses. Aggression and Violent Behavior, 45, 4–19.
Hong, J. S., Voisin, D. R., Cho, S., Smith, D. C., & Resko, S. M. (2018). Peer victimization and substance use among African American adolescents and emerging adults on Chicago's Southside. American Journal of Orthopsychiatry, 88(4), 431–440. Hong, J. S., Voisin, D. R., Kim, J. W., Allen-Meares, P., & Espelage, D. L. (2019). Pathways from peer victimization to sexual risk-taking behavior among African American adolescents in Chicago's Southside. Psychology of Violence, 9(1), 88–97. Le, H. T., Nguyen, H. T., Campbell, M. A., Gatton, M. L., Tran, N. T., & Dunne, M. P. (2017). Longitudinal associations between bullying and mental health among adolescents in Vietnam. International Journal of Public Health, 62(Suppl. 1), 51–61. https://doi.org/10.1007/s00038-016-0915-8. Lian, Q., Su, Q., Li, R., Elgar, F. J., Liu, Z., & Zheng, D. (2018). The association between chronic bullying victimization with weight status and body self-image: A cross-national study in 39 countries. PeerJournal, 6, e4330. https://doi.org/10.7717/peerj. 4330 (eCollection 2018). Méndez, I., Ruiz-Esteban, C., & Ortega, E. (2019). Impact of the physical activity on bullying. Frontiers in Psychology, 10, 1520. https://doi.org/10.3389/fpsyg.2019. 01520 (eCollection 2019). Moore, S. E., Norman, R. E., Suetani, S., Thomas, H. J., Sly, P. D., & Scott, J. G. (2017). Consequences of bullying victimization in childhood and adolescence: A systematic review and meta-analysis. World Journal of Psychiatry, 7(1), 60–76. https://doi.org/ 10.5498/wjp.v7.i1.60. eCollection 2017 Mar 22. Murshid, N. S. (2017). Bullying victimization and mental health outcomes of adolescents in Myanmar, Pakistan, and Sri Lanka. Children and Youth Services Review, 76, 163–169. Murshid, N. S. (2018). Poor hygiene and bullying victimization in Pakistan. Children and Youth Services Review, 88, 197–204. Nguyen, A. J., Bradshaw, C. P., Townsend, L., Gross, A., & Bass, J. (2019). It gets better: Attenuated associations between latent classes of peer victimization and longitudinal psychosocial outcomes in four low-resource countries. Journal of Youth and Adolescents, 48(2), 372–385. https://doi.org/10.1007/s10964-018-0935-1. Olweus, D. (1999). Sweden. In P. K. Smith, Y. Morita, J. Junger-Tas, D. Olweus, R. Catalano, & P. Slee (Eds.). The Nature of School Bullying: A Cross-National Perspective (pp. 7–27). London & New York: Routledge. Owusu, A., Hart, P., Oliver, B., & Kang, M. (2011). The association between bullying and psychological health among senior high school students in Ghana, West Africa. Journal of School Health, 81(5), 231–238. https://doi.org/10.1111/j.1746-1561. 2011.00590.x. Peltzer, K., & Pengpid, S. (2015). Health risk behaviour among in-school adolescents in the Philippines: Trends between 2003, 2007 and 2011, a cross-sectional study. International Journal of Environmental Research and Public Health, 13(1), 73. https:// doi.org/10.3390/ijerph13010073.
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Bullying victimization and externalizing and internalizing symptoms among in-school adolescents from five ASEAN countries Supa Pengpida,c, Karl Peltzerb,d,
T
⁎
a
ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Viet Nam c Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa d Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, Viet Nam b
A R T I C LE I N FO
A B S T R A C T
Keywords: Bullying victimization Substance use Interpersonal violence Hygiene Psychological distress Adolescents Southeast Asia
The study aimed to assess the relationship between bullying victimization and adverse health or psychosocial problems among in-school adolescents from five Southeast Asian countries. The sample consisted of 33,184 school-going children, mean age 14.6 years (SD = 1.7), from Indonesia, Laos, Philippines, Thailand and TimorLeste that took part in the cross-sectional “Global School-based Student Health Survey” (GSHS) in 2015. Results indicate 18.6% of the students reported infrequent (1–2 days/month) and 12.0% frequent (3–30 days/month) past-month bullying victimization. Among different types of bullying victimization, the most prevalent was psychological (13.5%), followed by other (5.6%), physical (3.6%) and social (1.3%). In adjusted Poisson regression analysis, bullying victimization is associated with tobacco, alcohol and drug use, physically attacked, in physical fight, injury, truancy and poor hand hygiene behaviour, anxiety, loneliness, suicidal ideation, suicide attempt, no close friends, sedentary behaviour, underweight and overweight or obesity. This study extends previous findings from mainly high-income countries on the relationship between bullying victimization and a large number of adverse outcomes in adolescents in Southeast Asia.
1. Introduction “Bullying refers to aggressive behavior that is repetitive and intentional in which a power differential exists between the victim and bully. The negative effects of bullying on an individual's mental and physical health are substantial and in line with other major forms of child maltreatment.” (Rette & Pawlowski, 2016, p.235) Bullying victimization has been associated various externalizing symptoms, such as tobacco use (Brown, Riley, Butchart, & Kann, 2008; Moore et al., 2017; Romo & Kelvin, 2016), alcohol use (Brown et al., 2008; Fleming & Jacobsen, 2010; Wiguna et al., 2018), drug use (Brown et al., 2008; Fleming & Jacobsen, 2010; Hong et al., 2014; Hong, Voisin, Cho, Smith, & Resko, 2018). Moore et al., 2017), physical fight (Brown et al., 2008; Hertz, Everett Jones, Barrios, David-Ferdon, & Holt, 2015; Moore et al., 2017; Romo & Kelvin, 2016; Rudatsikira, Mataya, Siziya, & Muula, 2008), injury (Hertz et al., 2015), truancy (Romo & Kelvin, 2016), and poor hygiene behaviour (Murshid, 2018). In addition, bullying victimization has been correlated with psychological distress or mental health problems (Nguyen, Bradshaw, Townsend, Gross, & Bass, 2019; Le et al., 2017; Owusu, Hart, Oliver, &
⁎
Kang, 2011; Moore et al., 2017; Thomas et al., 2016), loneliness (Fleming & Jacobsen, 2010; Moore et al., 2017), anxiety (Fleming & Jacobsen, 2010; Moore et al., 2017), depression (Abd Razak et al., 2019; Moore et al., 2017; Murshid, 2017), suicidal behaviour (Hertz et al., 2015; Hong, Kral, & Sterzing, 2015; Moore et al., 2017; Romo & Kelvin, 2016), sedentary behaviour (Hertz et al., 2015), physical inactivity (Hertz et al., 2015), underweight (Lian et al., 2018) and overweight or obesity (Lian et al., 2018; Moore et al., 2017). “Children who suffered more frequent bullying by peers tend to display worse outcomes” (Lian et al., 2018). “Compared to occasional victims and nonbullied children, victims of chronic bullying are at elevated risk for maladjustment, which may lead them to bully others or to self-harm” (Bowes et al., 2013). Protective factors from bullying victimization may include peer and parental support (Abdirahman, Fleming, & Jacobsen, 2013; Boel-Studt & Renner, 2013; Hong, Ryou, & Piquero, 2017); Zych, Farrington, & Ttofi, 2019). Globally, about 30% of adolescents reported past-month bullying victimization (Elgar et al., 2015). Among adolescents in Southeast Asian countries, the prevalence of past-month bullying victimization was, for example, 35.0% in 2017 in Malaysia (Abd Razak et al., 2019),
Corresponding author at: Ton Duc Thang University, Ho Chi Minh City, Viet Nam. E-mail address: [email protected] (K. Peltzer).
https://doi.org/10.1016/j.childyouth.2019.104473 Received 23 May 2019; Received in revised form 19 August 2019; Accepted 19 August 2019 Available online 20 August 2019 0190-7409/ © 2019 Elsevier Ltd. All rights reserved.
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2.3. Data analysis
45.0% in 2011 in the Philippines (Peltzer & Pengpid, 2015), and 27.8% in 2008 in Thailand (Pengpid & Peltzer, 2013).” Southeast Asia is composed of eleven countries of impressive diversity in religion, culture and history: Brunei, and Singapore (high-income countries), Malaysia and Thailand (upper middle-income countries), Burma (Myanmar), Cambodia, Indonesia, Laos, the Philippines, Timor-Leste, and Vietnam (lower middle-income countries). It is also one of the most dynamic areas of the world economically, a factor which largely accounts for its growing international significance.” (Northern Illinois University (2019, p.1). Although awareness of bullying victimization and correlated health risk behaviours and poor mental health (Brown et al., 2008; Hong et al., 2019; Hong, Voisin, Kim, Allen-Meares, & Espelage, 2019) may have increased globally, national recent studies describing the frequency and type of bullying victimization and correlations with adverse health behaviours and poor mental health are limited in Southeast Asia (Le et al., 2017; Nguyen et al., 2019; Rudatsikira et al., 2008; Sittichai & Smith, 2015; Wiguna et al., 2018). Considering this, the study aimed to assess the relationship between bullying victimization and adverse health or psychosocial problems among in-school adolescents from five Southeast Asian countries, using data from the “Global School-based Student Health Survey (GSHS)” in 2015. It was hypophesized that bullying victimization is associated with various adverse health or psychosocial problems in school adolescents in Southeast Asia.
Data analysis was done with STATA software version 15.0 (Stata Corporation, College Station, Texas, USA), taking the complex sampling design of the study into account. Taylor linearization methods were utilized in the statistical analyses to account for the sampling weighting and complex study design. Data results were described with descriptive statistics. In order to analyze the relationship between frequency and type of bullying victimization with adverse health or psychosocial problems, correlation analyses were performed. We used prevalence rate ratios (PR) to assess the magnitude of the statistical associations between frequency and type of bullying victimization, adjusted by country, sex, age, hunger (or socioeconomic status), peer support, and parental support, and each adverse health or psychosocial outcome. Prevalence ratios were obtained by Poisson regression, with a 95% confidence interval. Missing cases were excluded from the analysis. P < .01 was considered significant. 3. Results 3.1. Sample characteristics The overall study sample included 33,184 school children, mean age 14.6 years (SD = 1.7), males 48.9% and females 51.1% from Indonesia, Laos, Philippines, Thailand and Timor-Leste; response rates ranged from 72% in Laos to 94% in Indonesia (WHO, 2019). The sample size ranged from 3683 in Laos to 11,142 in Indonesia, 51.1% were female, and 39.6% had sometimes or mostly or always experienced hunger in the past 30 days. More than one-third of participants (36.8%) had received mostly or always peer support in the past 30 days, and 58.4% had two or more forms of parental support. Overall, 18.6% of the students reported infrequent (1–2 days/month) and 12.0% frequent (3–30 days/month) past-month bullying victimization. Among different types of bullying victimization, the most prevalent was psychological (13.5%), followed by other (5.6%), physical (3.6%) and social (1.3%) (see Table 2).
2. Methods 2.1. Study design and participants This analysis utilizes 2015 Southeast Asian “Global School-based Student Health Survey (GSHS)” cross-sectional data; detailed methodology and the dataset can be publicly accessed (World Health Organization (WHO), 2019). The conduct of the most recent GSHS in Southeast Asian countries, namely in 2015, was used as country inclusion criteria to select Indonesia, Laos, Philippines, Thailand, and Timor-Leste in this paper. Using a two-stage cluster sampling strategy (schools were selected by probability to size sampling and random selection of class rooms with students 13 to 15 years old), nationally representative samples of middle school students were produced in each country (WHO, 2019). “All students attending a selected class were eligible to participate, regardless of their age, and completed a selfadministered questionnaire in their language under the supervision of trained external survey administrators “(WHO, 2019). The study proposal was approved by the Ministry of Education or Health and a national ethics committee, and verbal or written consent was “obtained from the participating schools, parents and students before the survey was administered.” (WHO, 2019).
3.2. Correlations between frequency and type of bullying victimization with adverse health or psychosocial problems Table 3 describe the correlation coefficients between frequency and type of bullying victimization with each specific adverse health or psychosocial problem. Frequency of bullying victimization was positively and significantly correlated with all adverse health or psychosocial problems. Similarly, physical bullying victimization was positively and significantly correlated with all adverse health or psychosocial problems except for overweight or obesity, and physical bullying victimization was positively and significantly correlated with all adverse health or psychosocial problems except for physical inactivity and underweight. Social and other bullying victimization was positively and significantly correlated with 12 or 11 adverse health or psychosocial problems, while the remaining eight or nine adverse health or psychosocial problems were not significantly or negatively correlated, including physical inactivity, underweight and overweight or obesity, hand washing behaviours, school truancy, and for other bullying victimization substance use variables (see Table 3).
2.2. Measures The study questionnaire utilized in this investigation was from the GSHS (WHO, 2019) (see Table 1). An Olweus-type definition of bullying victimization was used (Olweus, 1999). Underweight was defined as “less than 2 standard deviation (SD) from median for BMI by age and sex”, and overweight or obesity was defined as “more than 1 standard deviation (SD) from the median body mass index by age and sex” (Cole, Bellizzi, Flegal, & Dietz, 2000). “Sedentary behaviour was defined as spending 3 or more hours per day sitting” (Guthold, Cowan, Autenrieth, Kann, & Riley, 2010). Inadequate physical activity was defined as not daily “at least 60 minutes of moderate to vigorous-intensity physical activity.”(WHO, 2017) The four items on parental or guardian support were summed, and classified into three groups, 0–1 low, 2 medium and 3–4 high support.
3.3. Associations with substance use variables In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization were associated with current tobacco use, current alcohol use, ever cannabis use and ever amphetamine use. Physical and psychological bullying victimization were associated with all four substance use indicators. In addition, social bullying victimization was associated with current tobacco and alcohol use, and other bullying victimization was associated with current alcohol use. 2
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Table 1 Variable description. Variables
Question
Response options (coding scheme)
Age Sex Hunger
“How old are you?” “What is your sex?” “During the past 30 days, how often did you go hungry because there was not enough food in your home?” “[Bullying occurs when a student or a group of students say or do bad and unpleasant things to another student. It is also bullying when a student is teased a lot in an unpleasant way or a student is forced to withdraw from certain activities on purpose. It is not bullying when two students of about the same strength or power argue or fight or when teasing is done in a friendly and hilarious way.]” “During the past 30 days, on how many days were you bullied?” During the past 30 days, how were you bullied most often?
“11 years old or younger to 18 years old or older” “Male, Female” “1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)”
Bullied
Type of bullied
Current tobacco use
Current alcohol use Cannabis use Amphetamine use School truancy Physical attacks Physical fights Injury Leisure-time sedentary behaviour Physical inactivity
Height Weight Anxiety Loneliness Suicide ideation Suicide attempt No close friends Hand washing before eating Hand washing after toilet Hand washing with soap
Peer support Parental supervision Parental connectedness Parental bonding Parental respect for privacy
“During the past 30 days, on how many days did you smoke cigarettes/ use any tobacco products other than cigarettes, such as …country specific names?” “During the past 30 days, on how many days did you have at least one drink containing alcohol?” “During your life, how many times have you used marijuana (also called ….country specific names)?” “During your life, how many times have you used amphetamines or methamphetamines (also called ….country specific names)?” “During the past 30 days, on how many days did you miss classes or school without permission?” “During the past 12 months, how many times were you physically attacked?” “During the past 12 months, how many times were you in a physical fight?” “During the past 12 months, how many times were you seriously injured?” “How much time do you spend during a typical or usual day sitting and watching television, playing computer games, talking with friends, or doing other sitting activities, such as country examples?” “During the past 7 days, on how many days were you physically active for a total of at least 60 min per day? ADD UP ALL THE TIME YOU SPENT IN ANY KIND OF PHYSICAL ACTIVITY EACH DAY” “How tall are you without your shoes on?” “How much do you weigh without your shoes on?” “During the past 12 months, how often have you been so worried about something that you could not sleep at night?” “During the past 12 months, how often have you felt lonely?” “During the past 12 months, did you ever seriously consider attempting suicide?” “During the past 12 months, how many times did you actually attempt suicide?” “How many close friends do you have?” “During the past 30 days, how often did you wash your hands before eating?” “During the past 30 days, how often did you wash your hands after using the toilet or latrine?” “During the past 30 days, how often did you use soap when washing your hands?” Social-familial protective factors “During the past 30 days, how often were most of the students in your school kind and helpful?” “During the past 30 days, how often did your parents or guardians check to see if your homework was done?” “During the past 30 days, how often did your parents or guardians understand your problems and worries?” “During the past 30 days, how often did your parents or guardians really know what you were doing with your free time? “During the past 30 days, how often did your parents or guardians go through your things without your approval?”
1 = 0 days to 7 = All 30 days (coded 1 = 0 and 2–7 = 1)
Physical=” I was hit, kicked, pushed, shoved around, or locked indoors.” Psychological=” I was made fun of because of my race, nationality, or color.” OR “I was made fun of because of my religion.” OR” I was made fun of with sexual jokes, comments, or gestures.” OR “I was made fun of because of how my body or face looks.” Social = “I was left out of activities on purpose or completely ignored.” Other = “I was bullied in some other way” 1 = 0 days to 7 = All 30 days (coded 1 = 0 and 2–7 = 1)
1 = 0 days to 7 = All 30 days 1 = 0 times to 5 = 20 or more times (coded 1 = 0 and 2–5 = 1) 1 = 0 times to 5 = 20 or more times (coded 1 = 0 and 2–5 = 1) “1 = 0 days to 5 = 10 or more days (coded 1 = 0 and 2–5 = 1)” 1 = 0 times to 8 = 12 or more times 1 = 0 times to 8 = 12 or more times 1 = 0 times to 8 = 12 or more times (coded 1 = 0 and 2–8 = 1) “1 = < 1 h per day; 2 = 1–2 h/day; 3 = 3–4 h/day; 4 = 5–6 h/day; 5 = 7–8 h/day and 6 = 8 or more hours per day” “1 = 0 days to 8 = 7 days) (coded 1–7 = 1 and 8 = 0”
“1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)” “1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)” “Yes, No” “1 = 0 times to 5 = 6 or more times (coded 1 = 0 and 2–5 = 1)” “1 = 0 to 4 = 3 or more (coded 1 + =0, 0 = 1)” “1 = never to 5 = always (coded 1–4 = 1 and 5 = 0)” “1 = never to 5 = always (coded 1–4 = 1 and 5 = 0)” “1 = never to 5 = always (coded 1–4 = 1 and 5 = 0)”
1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1) 1 = never to 5 = always (coded 1–3 = 0 and 4–5 = 1)
(physical, psychological and other) were associated with past month school truancy, past 12-month physically attacked, in physical fight and had a serious injury, while social bullying victimization was associated with attacked, fight and injury.
3.4. Associations with violence related variables and truancy In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization and three types of bullying victimization 3
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Table 2 Sample characteristics by bullying victimization frequency and type. Variable
Socio-demographics All Country Indonesia Laos Philippines Thailand Timor-Leste Age (years) ≤13 14 15 ≥16 Gender Female Male Hunger Never Rarely Sometimes/mostly/always Peer support (mostly/always) Parental/guardian support 0–1 2 3–4
Sample
Bullying victimization frequency
Type of bullying victimization
1–2 days/month
3–30 days/month
Physical
Psychological
Social
Other
N (%)
N (%)
N (%)
%
%
%
%
33,184
5812 (18.6)
3470 (12.0)
3.6
13.5
1.3
5.5
11,142 (33.6) 3683 (11.1) 8761 (26.4) 5894 (17.8) 3704 (11.2)
1465 (13.9) 326 (9.3) 2418 (28.2) 883 (15.6) 720 (21.5)
669 (6.7) 79 (2.5) 1740 (20.5) 738 (13.7) 244 (7.1)
2.0 2.6 5.6 5.4 4.8
9.0 3.2 21.7 13.1 9.9
1.1 0.1 1.9 1.1 0.9
5.6 2.6 5.6 5.0 3.0
9611 (29.1) 6826 (20.7) 6396 (19.4) 10,217 (30.9)
1785 1330 1085 1590
(18.3) (19.7) (20.6) (16.7)
1175 (12.2) 763 (12.5) 669 (12.8) 846 (10.5)
3.8 4.2 3.8 2.7
12.9 13.5 15.4 12.9
1.1 1.5 1.3 1.5
6.2 5.8 5.0 4.5
17,991 (51.1) 14,902 (48.9)
3006 (17.6) 2757 (19.8)
1576 (9.9) 1853 (14.1)
2.6 4.7
12.1 15.0
1.5 1.2
5.6 5.3
13,808 (40.4) 6346 (20.0) 12,885 (39.6) 1112 (36.8)
1791 1216 2779 1720
(13.8) (20.8) (22.6) (15.2)
1046 (8.7) 757 (14.0) 1653 (14.3) 1050 (9.8)
2.5 4.8 4.2 2.3
9.6 14.8 16.8 10.9
0.8 1.5 1.8 1.1
4.5 5.7 6.4 5.4
17,139 (51.6) 8479 (27.0) 6326 (21.4)
3314 (21.0) 1370 (17.7) 931 (14.8)
1954 (13.8) 747 (10.0) 562 (9.1)
4.9 2.5 2.0
15.0 12.3 11.0
1.5 1.3 1.1
5.4 5.9 5.3
3.5. Associations with physical activity level and weight related variables
3.6. Associations with psychological distress variables
Frequent bullying victimization and psychological and other bullying victimization were associated with sedentary behaviour, while frequent bullying victimization and psychological bullying victimization were inversely associated with physical inactivity. In addition, psychological victimization was associated with overweight or obesity.
In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization and all four types of bullying victimization were associated with anxiety, loneliness, suicidal ideation and suicide attempt. In addition, any bullying victimization frequency and physical and psychological bullying victimization was associated with no close friends.
Table 3 Correlations between frequency and type of bullying victimization with adverse health or psychosocial problems. Variable
Current tobacco use Current alcohol use Ever cannabis use Ever amphematime use School truancy Physically attacked In physical fight Injury Sitting 3 or more hours Physically inactive Underweight Overweight or obesity Anxiety Lonely Suicide ideation Suicide attempt No close friends Hand washing before eating Hand washing after toilet Hand washing with soap
Frequency of bullying victimization
Type of bullying victimization Physical
Psychological
Social
Other
rho(p)
r(p)
r(p)
r(p)
r(p)
0.17(0.000) 0.14(0.000) 0.16(0.000) 0.16(0.000) 0.14(0.000) 0.30(0.000) 0.33(0.000) 0.33(0.000) 0.05(0.000) 0.02(0.002) 0.03(0.000) 0.10(0.000) 0.15(0.000) 0.18(0.000) 0.16(0.000) 0.22(0.000) 0.05(0.000) 0.06(0.000) 0.07(0.000) 0.02(0.004)
0.12(0.000) 0.09(0.00) 0.13(0.000) 0.13(0.000) 0.07(0.000) 0.14(0.000) 0.17(0.000) 0.14(0.000) 0.02(0.007) 0.01(0.47) 0.02(0.000) 0.003(0.648) 0.04(0.000) 0.04(0.000) 0.06(0.000) 0.12(0.000) 0.03(0.000) 0.05(0.000) 0.06(0.000) 0.03(0.000)
0.10(0.000) 0.09(0.000) 0.09(0.000) 0.09(0.000) 0.08(0.000) 0.18(0.000) 0.19(0.000) 0.20(0.000) 0.05(0.000) 0.001(0.869) 0.01(0.091) 0.02(0.015) 0.11(0.000) 0.14(0.000) 0.12(0.000) 0.15(0.000) 0.02(0.000) 0.04(0.000) 0.04(0.000) 0.02(0.025)
0.03(0.000) 0.02(0.000) 0.03(0.000) 0.03(0.000) 0.008(0.140) 0.05(0.000) 0.05(0.000) 0.06(0.000) 0.01(0.021) −0.007(0.234) 0.004(544) −0.01(0.062) 0.03(0.000) 0.05(0.000) 0.02(0.000) 0.03(0.000) 0.01(0.061) 0.006(0.295) 0.004(0.479) 0.000(0.994)
−0.002(0.751) 0.01(0.014) −0.006(0.291) −0.006(0.317) 0.009(0.110) 0.08(0.000) 0.06(0.000) 0.09(0.000) 0.03(0.000) −0.01(0.051) 0.002(0.734) −0.01(0.041) 0.04(0.000) 0.05(0.000) 0.04(0.000) 0.02(0.007)
4
0.02(0.006) −0.003(598) 0.005(0.418)
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Table 4 Associations between frequency and type of bullying victimization with each adverse health or psychosocial problem. Variable
Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other Bullying victimization frequency 0 1–2 3–30 Type of bullying victimization None Physical Psychological Social Other
APR (95% CI)a
APR (95% CI)a
APR (95% CI)a
APR (95% CI)a
Current tobacco use
Current alcohol use
Ever cannabis
Ever amphetamine
1 (Reference) 1.73 (1.48, 2.01)⁎⁎ 2.00 (1.70, 2.34)⁎⁎
1 (Reference) 1.56 (1.40, 1.74)⁎⁎ 1.74 (1.50, 2.01)⁎⁎
1 (Reference) 2.31 (1.71, 3.10)⁎⁎ 3.45 (2.56, 4.65)⁎⁎
1 (Reference) 3.79 (2.83, 5.09)⁎⁎ 5.44 (4.14, 7.13)⁎⁎
1 (Reference) 2.63 (2.13, 3.26)⁎⁎ 1.63 (1.45, 1.84)⁎⁎ 1.57 (1.12, 2.20)⁎ 1.09 (0.90, 1.32)
1 (Reference) 2.18 (1.76, 2.71)⁎⁎ 1.57 (1.40, 1.76)⁎⁎ 1.76 (1.36, 2.28)⁎⁎ 1.39 (1.20, 1.62)⁎⁎
1 (Reference) 5.11 (3.76, 6.96)⁎⁎ 2.46 (2.01, 3.00)⁎⁎ 1.59 (0.77, 3.26) 0.79 (0.49, 1.29)
1 (Reference) 7.61 (5.45, 10.61)⁎⁎ 2.99 (2.40, 3.74)⁎⁎ 1.87 (0.80, 4.39) 0.80 (0.41, 1.51)
School truancy
Physically attacked
In physical fight
Sustained injury
1 (Reference) 1.47 (1.36, 1.58)⁎⁎ 1.61 (1.47, 1.75)⁎⁎
1 (Reference) 1.97 (1.85, 2.10)⁎⁎ 2.30 (2.15, 2.46)⁎⁎
1 (Reference) 2.14 (2.00, 2.30)⁎⁎ 2.38 (2.19, 2.57)⁎⁎
1 (Reference) 1.89 (1.79, 2.00)⁎⁎ 2.12 (1.97, 2.27)⁎⁎
1 (Reference) 1.76 (1.55, 1.99)⁎⁎ 1.41 (1.30, 1.53)⁎⁎ 1.32 (1.06, 1.66) 1.25 (1.12, 1.35)⁎⁎
1 (Reference) 2.37 (2.20, 2.56)⁎⁎ 1.92 (1.81, 2.02)⁎⁎ 1.95 (1.68, 2.26)⁎⁎ 1.82 (1.68, 1.97)⁎⁎
1 (Reference) 2.46 (2.26, 2.67)⁎⁎ 1.93 (1.81, 2.05)⁎⁎ 1.99 (1.70, 2.32)⁎⁎ 1.75 (1.56, 1.97)⁎⁎
1 (Reference) 2.08 (1.93, 2.23)⁎⁎ 1.82 (1.74, 1.90)⁎⁎ 1.97 (1.75, 2.21)⁎⁎ 1.82 (1.67, 1.98)⁎⁎
Sitting 3 or more hours
Physically inactive
Underweight
Overweight or obesity
1 (Reference) 0.98 (0.91, 1.04) 1.29 (1.20, 1.38)⁎⁎
1 (Reference) 1.00 (0.99, 1.02) 0.97 (0.95, 0.99)⁎⁎
1 (Reference) 1.14 (0.98, 1.32) 1.18 (1.00, 1.38)
1 (Reference) 0.96 (0.84, 1.00) 1.24 (1.04, 1.48)
1 (Reference) 1.07 (0.96, 1.20) 1.21 (1.13, 1.29)⁎⁎ 1.11 (0.92, 1.34) 1.20 (1.09, 1.32)⁎⁎
1 (Reference) 1.02 (0.99, 1.04) 0.97 (0.95, 0.99)⁎⁎ 0.94 (0.90, 0.99) 0.98 (0.95, 1.01)
1 (Reference) 1.31 (1.00, 1.73) 1.06 (0.89, 1.26) 1.13 (0.65, 1.94) 1.12 (0.89, 1.41)
1 (Reference) 1.11 (0.84, 1.48) 1.23 (1.06, 1.42)⁎ 0.65 (0.39, 1.07) 0.80 (0.60, 0.98)
Anxiety
Lonely
Sucide ideation
Suicide attempt
1 (Reference) 1.82 (1.57, 2.10)⁎⁎ 2.81 (2.44, 3.24)⁎⁎
1 (Reference) 1.78 (1.55, 2.03)⁎⁎ 3.19 (2.83, 3.59)⁎⁎
1 (Reference) 2.02 (1.79, 2.29)⁎⁎ 3.03 (2.60, 3.52)⁎⁎
1 (Reference) 2.40 (2.06, 2.81)⁎⁎ 3.57 (3.15, 4.05)⁎⁎
1 (Reference) 1.67 (1.22, 2.28)⁎⁎ 2.30 (1.97, 2.69)⁎⁎ 2.08 (1.39, 3.13)⁎⁎ 2.07 (1.69, 2.54)⁎⁎
1 (Reference) 1.70 (1.26, 2.28)⁎⁎ 2.48 (2.23, 2.76)⁎⁎ 1.94 (1.47, 2.56)⁎⁎ 2.36 (1.97, 2.82)⁎⁎
1 (Reference) 2.27 (1.70, 3.02)⁎⁎ 2.55 (2.28, 2.85)⁎⁎ 1.97 (1.37, 2.84)⁎⁎ 2.22 (1.86, 2.65)⁎⁎
1 (Reference) 3.62 (2.90, 4.52)⁎⁎ 2.68 (2.38, 3.01)⁎⁎ 1.97 (1.34, 2.89)⁎⁎ 1.70 (1.38, 2.10)⁎⁎
No close friends
Hand washing before eating
Hand washing after toilet
Hand washing with soap
1 (Reference) 1.53 (1.31, 1.78)⁎⁎ 1.86 (1.52, 2.27)⁎⁎
1 (Reference) 1.66 (1.28, 2.16)⁎⁎ 1.97 (1.53, 2.54)⁎⁎
1 (Reference) 2.09 (1.55, 2.82)⁎⁎ 2.33 (1.83, 2.96)⁎⁎
1 (Reference) 1.44 (1.19, 1.74)⁎⁎ 1.71 (1.44, 2.02)⁎⁎
1 (Reference) 2.13 (1.47, 3.07)⁎⁎ 1.45 (1.25, 1.69)⁎⁎ 1.35 (0.63, 2.87) 1.29 (0.98, 1.70)
1 (Reference) 2.85 (1.99, 4.07)⁎⁎ 1.57 (1.33, 1.86)⁎⁎ 0.82 (0.46, 1.45) 0.81 (0.58, 1.13)
1 (Reference) 2.95 (2.10, 4.15)⁎⁎ 1.61 (1.36, 1.91)⁎⁎ 1.21 (0.66, 2.21) 0.85 (0.55, 1.30)
1 (Reference) 2.38 (1.75, 3.22)⁎⁎ 1.39 (1.17, 1.65)⁎⁎ 0.76 (0.45, 1.28) 0.92 (0.70, 1.19)
APR = Adjusted Prevalence Ratio; CI=Confidence Interval. ⁎⁎ P < .001. ⁎ P < .01. a Adjusted for each item of each variable and for country, age, sex, socioeconomic status (hunger), peer support, and parental support.
3.7. Associations with hand hygiene variables
4. Discussion
In adjusted Poisson regression analysis, both infrequent and frequent bullying victimization and physical and psychological bullying victimization were associated with all three poor hand washing hygiene behaviours (before eating, after toilet, and with soap). Social and other bullying victimization were not significantly associated with any of the poor hand hygiene variables (see Table 4).
The study aimed to assess the relationship between bullying victimization and adverse health or psychosocial problems among in-school adolescents from five Southeast Asian countries. Consistent with previous studies (Brown et al., 2008; Fleming & Jacobsen, 2010; Hertz et al., 2015; Hong et al., 2014; Hong et al., 2018); Moore et al., 2017; Murshid, 2018; Romo & Kelvin, 2016; Wiguna et al., 2018), this study found an association between bullying victimization and tobacco, 5
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alcohol and drug use, physically attacked, in physical fight, injury, truancy and poor hand hygiene behaviour. Moreover, in agreement with previous studies (Fleming & Jacobsen, 2010; Hertz et al., 2015; Lian et al., 2018; Moore et al., 2017; Murshid, 2017; Owusu et al., 2011; Romo & Kelvin, 2016; Thomas et al., 2016), this investigation established that bullying victimization was associated with anxiety, loneliness, suicidal ideation, suicide attempt, no close friends, sedentary behaviour, and overweight or obesity. Unlike in a previous study (Hertz et al., 2015), bullying victimization was negatively associated with physical inactivity in this study. It is possible that students are more likely bullied during physical education classes and/or in a physical sporting context (Méndez, Ruiz-Esteban, & Ortega, 2019). One possible mechanism explaining the effects of bullying victimization on health outcomes is the “diathesis-stress model in which individual biological and cognitive vulnerabilities interact with stressful life experiences (e.g., bullying victimization) to cause psychopathology that externalizes as negative health behaviours.” (Romo & Kelvin, 2016; Swearer & Hymel, 2015). Similar to a previous study (Lian et al., 2018), the strength of association between frequent bullying victimization and underweight was relative to overweight or obesity weaker. Previous research showed that “weight stigmatization translates into pervasive victimization, teasing, and bullying.” (Puhl & King, 2013). Regarding poor hand hygiene behaviours, Murshid (2018) proposes that “poor hygiene elicits disgust and disrespect manifesting as bullying among adolescents.” Consistent with previous studies (Bowes et al., 2013; Lian et al., 2018), this study found that compared to no or infrequent bullying victimization, frequent bullying victimization was associated with substance use, violence related variables, truancy, poor hand hygiene behaviour and psychological distress, sedentary behaviour, and overweight or obesity. This finding seems to confirm a dose-response relationship between bullying victimization frequency and a number of adverse outcomes (Moore et al., 2017). Among the different types of bullying victimization, physical bullying victimization was associated with substance use variables, truancy, violence-related variables, poor hygiene behaviours, no close friend and suicide attempt, and psychological bullying victimization was associated with sedentary behaviour, overweight or obesity, anxiety, loneliness and suicidal ideation than other types of bullying victimization. Similar to a study among adolescents in Latin America (Romo & Kelvin, 2016), this study found that both physical and psychological bullying victimization had significant effects on substance use, violence-related and psychological distress variables. Although the direction of the identified relationships between bullying victimization and various adverse health or psychosocial problems are unclear and probably complex, the possible harmful impacts of bullying victimization calls for effective anti-bullying programmes among school adolescents in Southeast Asia (Sittichai & Smith, 2015; Sivaraman, Nye, & Bowes, 2019).
even at greater risk of adverse health outcomes (Moore et al., 2017). 5. Conclusion This study extends previous findings from mainly high-income countries to adolescents in Southeast Asia, demonstrating that bullying victimization is associated with tobacco, alcohol and drug use, physically attacked, in physical fight, injury, truancy and poor hand hygiene behaviour and anxiety, loneliness, suicidal ideation, suicide attempt, no close friends, sedentary behaviour, and overweight or obesity. Further studies may investigate reasons for some of the current findings, try to elucidate the cultural context of bullying behaviour and guide to develop prevention and intervention programmes. The findings emphasise the need for implementing effective anti-bullying programmes among school adolescents in Southeast Asia. Declaration of Competing Interest None declared. Acknowledgements The World Health Organization is acknowledged for making the datasets publicly available. References Abd Razak, M. A., Ahmad, N. A., Abd Aziz, F. A., Jamaluddin, R., Sidik, S. M., Awaluddin, S. M., ... Sooryanarayana, R. (2019). Being bullied is associated with depression among Malaysian adolescents: Findings from a cross-sectional study in Malaysia. Asia-Pacific Journal of Public Health. https://doi.org/10.1177/1010539519867796 1010539519867796. Abdirahman, H., Fleming, L. C., & Jacobsen, K. H. (2013). Parental involvement and bullying among middle-school students in North Africa. Eastern Mediterranean Health Journal, 19(3), 227–233. Boel-Studt, S., & Renner, L. M. (2013). Individual and familial risk and protective correlates of physical and psychological peer victimization. Child Abuse and Neglect, 37(12), 1163–1174. https://doi.org/10.1016/j.chiabu.2013.07.010. Bowes, L., Maughan, B., Ball, H., Shakoor, S., Ouellet-Morin, I., Caspi, A., ... Arseneault, L. (2013). Chronic bullying victimization across school transitions: The role of genetic and environmental influences. Development and Psychopathology, 25(2), 333–346. https://doi.org/10.1017/S0954579412001095. Brown, D. W., Riley, L., Butchart, A., & Kann, L. (2008). Bullying among youth from eight African countries and associations with adverse health behaviours. Pediatric Health, 2(3), 289–299. Cole, T. J., Bellizzi, M. C., Flegal, K. M., & Dietz, W. H. (2000). Establishing a standard definition for child overweight and obesity worldwide: International survey. British Medical Journal, 320, 1240–1243. Elgar, F. J., McKinnon, B., Walsh, S. D., Freeman, J. D., Donnelly, P., de Matos, M. G., ... Currie, C. (2015). Structural determinants of youth bullying and fighting in 79 countries. Journal of Adolescent Health, 57(6), 643–650. https://doi.org/10.1016/j. jadohealth.2015.08.007. Fleming, L. C., & Jacobsen, K. H. (2010). Bullying among middle-school students in low and middle income countries. Health Promotion International, 25(1), 73–84. https:// doi.org/10.1093/heapro/dap046. Guthold, R., Cowan, M. J., Autenrieth, C. S., Kann, L., & Riley, L. M. (2010). Physical activity and sedentary behavior among schoolchildren: A 34-country comparison. Journal of Pediatrics, 157, 43–49. Hertz, M. F., Everett Jones, S., Barrios, L., David-Ferdon, C., & Holt, M. (2015). Association between bullying victimization and health risk behaviors among high school students in the United States. Journal of School Health, 85(12), 833–842. https://doi.org/10.1111/josh.12339. Hong, J. S., Davis, J. P., Sterzing, P. R., Yoon, J., Choi, S., & Smith, D. C. (2014). A conceptual framework for understanding the association between school bullying victimization and substance misuse. American Journal of Orthopsychiatry, 84(6), 696–710. Hong, J. S., Kim, J., Lee, J. J., Shamoun, C. L., Lee, J. M., & Voisin, D. R. (2019). Pathways from peer victimization to sexually transmitted infections among African American adolescents. Western Journal of Nursing Research, 41(6), 798–815. Hong, J. S., Kral, M. J., & Sterzing, P. (2015). Pathways from bullying perpetration, victimization, and bully-victimization to suicidality among school-aged youth: A review of the potential mediators and a call for further investigation. Trauma, Violence & Abuse, 16(4), 379–390. Hong, J. S., Ryou, B., & Piquero, A. R. (2017). Do family-level factors associated with bullying perpetration and peer victimization differ by race? Comparing European American and African American Youth. Journal of Interpersonal Violence, 1. https:// doi.org/10.1177/0886260517714441 886260517714441.
4.1. Study limitations The study was cross-sectional and restricted to adolescents attending school, which limits the interpretation of the findings. Due to the self-report of the data, results may have been biased. A further limitation may be that the reference period differed from 30 days to 12 months for the variables assessed. A further limitation is the possible role of unmeasured confounding. For example, adolescents with conduct disorders are not only more likely to report being bullied, but are also more likely to exhibit adolescent externalizing behaviours like substance use, aggression or truancy. The exposure to multiple types of bullying victimization was not assessed in this study, and should be assessed in future studies. Moreover, one of the increasing type of bullying, cyberbullying, was not assessed and should be included in future investigations. This study did also not assess if students were both victims and perpetrators of bullying, as those individuals may be 6
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