A Cross-Sectional Study on Bullying and Psychological Disturbances among Malaysian School Children

Background: Bullying is a common violence in school and has become a major public health and global concern. Bullying influences mental health and is identified as a leading factor of depression. Therefore, this study aimed to identify bullying prevalence and its association toward psychological disturbances (stress, anxiety, and depression). Methods: This cross-sectional study was conducted in three secondary schools in Kuantan. After obtaining consent from parents/guardians, participants were asked to answer a self-administered questionnaire, including School Climate Bullying Survey, Depression Anxiety Stress Questionnaire-21, Patient Depression Questionnaire, and Generalized Anxiety Disorder. Demographic data were self-reported. Data were analyzed using SPSS version 20.0, and chi-square and correlation tests were conducted for variables. Results: A total of 207 students were included in this study. Of respondents, 50.7% were boys and 49.3% girls, and the majority (92.8%) were Malays. Of students, 63.2% were involved in bullying problems through the school years, with verbal bullying as the highest (55.1%). Bullying is significantly associated with stress (p = 0.045), anxiety (p = 0.018), and depression (p = 0.012). Conclusions: School children in Kuantan continue to be involved in bullying. The current study supported that involvement with any bullying activity was associated with psychological disturbances including anxiety, stress, and depression.


I N T R O D U C T I O N
Bullying can be defined as when a person uses his or her strength or power to harm or torture another person repeatedly. Bullying can take many forms including physical, verbal, social, and cyber. 1 Bullying can happen anywhere but is commonly reported in the school setting, and the most common types are verbal and physical. 2 Verbal bullying occurs when bullies repeatedly tease, put down, or insult someone purposely, whereas physical bullying involves repeatedly hitting, kicking, or shoving someone weaker on purpose. 3 It became a serious problem among school-age children as they result in negative impacts on students' academic performance, psychological well-being, social adjustment, and physical wellness. 4 Students who are bullied or victimized are more likely to develop anxiety, panic disorder, and sociality compared with bully-victims and perpetrators. 5,6 These conditions will trigger the students' psychological health status that causes stress, anxiety, and depression. The Ministry of Education Malaysia in 2016 reported that the prevalence of bullying was more than 14,000 cases between 2012 and 2015. 7 Many studies on bullying and health established the links between low self-esteem, anxiety, depression, and adjustment problems among bullied victims. 8,9 Students who are bullied had a higher prevalence of suicidal ideation than those who were not bullied. The predictors of suicidal ideation among the students were depression, anxiety, stress, bullying, and low-esteem. 10 Although the prevalence of bullying has been reported previously, the number in suburban areas is scarce. The impact on school children in one of the east-coast city of Peninsular Malaysia is also unknown. Therefore, this study aimed to identify the bullying prevalence and its association toward psychological disturbances (stress, anxiety, and depression).

M E T H O D S
This cross-sectional study was conducted from March to April 2019 with approval from the Kulliyyah of Nursing Postgraduate Research Committee (IIUM/313/C/20/4/10), IIUM Research Ethics Committee (IREC 2019-035), and Ministry of Education (KPM.600-3/2/3-eras(3386)). The parent/legal guardians were asked for the assent/consent for the participation of the selected children, whom their identity and participation would not be revealed to anyone. All information was kept confidential, and results from the collected data were reported anonymously, with no references to specific individuals.
We applied a simple random sampling method to select the schools in Kuantan, Pahang, and convenience sampling method for eligible participants. School children were included if they were Malaysians, aged 13-17 years, and physically and mentally intact. Those who were not willing to participate were excluded.
The sample size was calculated using the online sample size calculator Raosoft ® (Raosoft Inc., USA). 11 The minimum effective sample for this study was n = 207, with a confidence level of 95%, a response distribution of 50%, and total estimated schoolchildren of 1300. We managed to secure 207 participants from three schools whose parents/guardian assented/consented to participate in this study, completed the questionnaire, and considered them for analysis. During the data collection, all the respondents were gathered at the school's hall, and a hard copy of the questionnaire was distributed after the researcher explained the study. Respondents were given about 30 min to answer all questionnaires.
Participants who assented/consented to participate in the study were asked to complete a set of selfadministered questionnaires written bilingually. It consists of five parts, namely, sociodemographics data, School Climate Bullying Survey, 12 Depression Stress Anxiety Scale (DASS-21), 13 Generalized Anxiety Disorder Scale (GAD-7), 14 and Patient Depression Questionnaire-9 (PHQ-9). 15 For the DASS-21, only the stress scale part was used in this study because GAD-7 and PHQ-9 have more excellent validity. 16 The sociodemographic data consist of four questions, including age, gender, ethnicity, and family income. The School Climate Bullying Survey consists of ten questions with four options to classify the prevalence of bullying based on the four types of bullying. The stress scales of DASS-21 and GAD-7 consist of seven questions with four options to measure the stress and anxiety levels of the students. The last part was the PHQ-9 that consists of nine questions related to depression. The scores of all three parts of the psychological disturbance questionnaires were added to classify the level of the respondents.
Data were analyzed and transformed using IBM SPSS version 20. Data were descriptively analyzed, whereas associations between bullying and psychological disturbances were determined using the chi-square test. A p of 0.05 or less indicates statistical significance.

R E S U L T S
A total of 207 secondary school students with mean age of 14.5 ± 1.2 from three schools in Kuantan, Pahang, participated in this study. Table 1 shows the sociodemographic factors of the respondents. Based on the survey, there were 105 (50.7%) boys and 102 (49.3%) girls, and the mean age was 14.49 years. Besides, most students in this study were Malays 192 (92.8%), followed by Indians 9 (4.3%) and Chinese 6 (2.9%). Meanwhile, 105 (50.7%) students have a family income between Ringgit Malaysia (RM) 1000 and RM 3000 per month.  Table 1 also shows the Bullying School Climate Survey, which indicated that 132 (63.2%) students were involved in bullying problems through the school years, whereas 75 (36.2%) were never involved. Verbal bullying has the highest reported incidence among the school children (n = 114, 55.1%), followed by social (n = 64, 30.8%), physical (n = 44, 21.2%), and cyber (n = 23, 11.1%).

D I S C U S S I O N
Findings from this study indicated that most respondents were involved in bullying throughout school years as consistently reported by the Ministry of Education Malaysia. 7 Another review reported that bullying peaks among 12-15 years old and continues to decline by the end of high school. 2 Another study estimated that approximately 20-25% of young people were specifically involved in bullying as victims, perpetrators, or both. 6 Bullying not only negatively affects the health of both bullies and victims but also harms the audience. 17 The most common type of bullying was verbal, followed by social. This result was supported by a study among universities in Virginia, where the verbal form of bullying was the most common occurrence among students followed by the social form. 12 The impact of verbal and social forms has greater and long term damage to victims in terms of psychological status. In this study, cyberbullying has been shown as the least common among the respondents, although the statistics have increased globally. 18 This could be due to the number of school children having lesser technology update than adults within the population of study context.
Bullying is also associated with psychological disturbances among school children. It has the risk of poor sleep quality, 19 stress, anxiety, and depression. 20 This finding is also supported by other studies that indicated that bullying is associated with academic performance and mental health status. 7,21 Thus, bullying is added to the list influencing mental well-being among school children despite obesity, which was reported earlier. 22,23 Moreover, students who have disabilities, are suffering from obesity, or belong to ethnic or sexual minorities are at greater risk of being victimized than their peers. 9 Studies that also addressed the issues of causality found that bullying problems most likely lead to anxiety, depression, social withdrawal, delinquent behavior, and poor academic performance. 24,25 At first, they might experience stress and anxiety, but in the long term, this condition might lead to depression as stress and anxiety have been identified as predisposing factors of depression. 10 The victims of bullying frequently experience anxiety, low self-esteem, vulnerability, depression, introversion, oversensitivity, and withdrawal from social activities; thus, higher levels of physical fitness can favor higher well-being in children and adolescents. 26 In particular, the risk factors reported at the adolescent stage for the development of violent behavior toward peers are as follows: low life satisfaction, high psychological distress, lack of empathic capacity, a propensity to depressive symptomatology, and low self-esteem. 20 Another study also indicated that psychological distress completely mediated the relationship between school bullying victimization and breakfast skipping in girls, whereas that relationship was only partially mediated between boys. 27 The previous study discussed that the academic outcomes of bullied students were below the normative expectation as most of them earned a lower grade in achievement tests and were poorly engaged with the teacher for academic purposes. 28,29 These students also have difficulties making friends, have a poor relationship with classmate, and experience loneliness.
Similar to other studies, this study has a range of strengths and limitations. One strong point is the sample size of school children in the east-coast region of Peninsular Malaysia for whom data on bullying and psychological are not available. However, the limitation of the study is that other variables, such as academic performance and social status, may be considered important factors affecting depressive symptoms among school children. Socioeconomic factors have been stated to be linked to bullying prevalence as it has been proposed that adolescents of lower social groups are more vulnerable to victimization than adolescents from high socioeconomic status. 30 Further research strategies in bullying are suggested to enhance the understanding of bullying among school children. 31

C O N C L U S I O N S
This study shows that bullying continues to be frequently experienced by school children. The current study supported that involvement with any bullying activity was associated with psychological disturbances including anxiety, stress, and depression. Current evidence may be used to inform governmental or nongovernmental organizations to pay attention to this behavior among school children. Further strategies could be implemented before the number of mental health illness increases among our future generations.

A C K N O W L E D G E M E N T S
The authors would also like to thank all the participants that participated in this study.

C O N F L I C T O F I N T E R E S T
The authors declare conflict of interests.

F U N D I N G
There is no funding received.