BULLYING ROLES AND ASSOCIATIONS WITH MENTAL HEALTH OF ADOLESCENTS IN VIETNAM: A SHORT-TERM LONGITUDINAL STUDY HA HAI THI LE, BA, MA Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy of Public Health School of Public Health and Social Work Faculty of Health Queensland University of Technology 2017 ii Abstract Bullying is a public health concern because this type of interpersonal aggression among adolescents is common and has substantial impact on mental health and wellbeing Although numerous studies on bullying have been conducted in Western countries, there has been relatively limited research in bullying with standardised measurement in the SouthEast Asian region Moreover, few longitudinal studies have measured both traditional bullying and cyberbullying to examine the change in bullying roles and the prospective influence of this change on health Research objectives: This thesis was conducted to address four research objectives: Examine the prevalence of various forms of traditional and cyberbullying victimisation and perpetration among school adolescents in Vietnam Examine temporal patterns of bullying roles (as a victim, bully, or bully-victim) among school adolescents over two time points Examine potential determinants (individual characteristics and family, school, and peer relationships) of temporal patterns of bullying roles over time Examine longitudinal associations between temporal patterns of bullying roles across two time points and mental health problems among adolescents (including depressive symptoms, psychological distress, and suicidal ideation) Research designs: This study employed a mixed methods approach and a shortterm longitudinal survey design The study was conducted in Hanoi and Hai Duong province in northern Vietnam across an academic year 2014–15 The research included four phases: Qualitative research In-depth interviews (IDIs) with 16 students in four schools (including two middle schools and two high schools) were conducted to explore the perceptions and experiences of students about traditional bullying and cyberbullying iii Pilot survey This was conducted with 226 students (56.7% female, age range 12–17 years, mean [SD]: 14.5 [1.6]) in two schools The qualitative interviews plus the pilot survey guided development of a standardised quantitative survey instrument to measure bullying victimisation and perpetration Baseline survey (Time 1) The baseline survey was conducted with 1424 middle and high school adolescents (54.9% females, age range 12–17 years, mean [SD]: 14.7 [1.9]) Follow-up survey (Time 2) Students who participated in the baseline survey were invited to the follow-up survey, six months later The longitudinal design enabled estimation of temporal stability or change in bullying roles as a victim, bully, or bullyvictim It also enabled analyses of determinants of the stability in bullying roles over time, and the effects of stability or change on mental health among adolescents Results The findings from baseline and follow-up surveys indicated that traditional bullying (including victimisation and perpetration) is more common than cyberbullying among Vietnamese school adolescents at both Time and Time The correlations between traditional victimisation and cyberbullying victimisation and between traditional bullying perpetration and cyberbullying perpetration are very high The large majority of students who experienced cyberbullying (about 81% for victims, 75% for bullies, and 100% for bullyvictim) did so in conjunction with traditional bullying There were only 17 students who were involved in cyberbullying victimisation or perpetration Analyses of bullying victimisation and perpetration over Time and Time show six in ten students (61%) were engaged in bullying roles as victim, bully, or bully-victim during one academic year Of these students, nearly three in four (74%) indicated unstable bullying roles The temporal patterns of bullying roles over time were captured as follows: (i) 554 students (38.9%) were not involved in any form of bullying at both times; (ii) 342 students (24%) were victims only (of them, 52% were stable-low, 17.0% declining, 14.3% increasing, and 10.5% stable-high); (iii) 94 students (6.6%) were bullies only (of them, 23.4% were stablelow, 36.2% declining, and 40.4% increasing or stable-high); (iv) 434 students were bullyiv victims (of those, 52.8% were stable-low, 19.3% declining, 14.5% increasing, and 13.4% stable-high) Analyses of determinants of temporal patterns of bullying roles found that gender, age, and mental health were significantly associated with victimisation and bully-victim status over time, indicating that younger male students with poorer mental health (depressive symptoms, psychological distress) had higher odds of being in victim only or bully-victim roles In contrast, there were no significant correlations between gender, age, and mental health status among those students who only bully others The effects of family environment were observed among all bullying roles Those who were not living with both biological parents, frequently witnessed parental violence, or experienced conflict with their siblings had significantly higher odds of frequent involvement in perpetration and bully-victim status at Time or Time Low parental supervision of online activities increased the odds of being victimised, and a high degree in parental control of the respondents’ mobile phone/Internet access decreased the odds of frequent involvement in bully-victim activity at Time 1, compared with the not-involved group Peers’ reaction towards bullying was significantly associated with bullying roles Specifically, those who perceived that students not try to stop bullying at school had significantly higher odds of being victimised at a low level over time or a high level at Time Meanwhile, those who supported the bullies and thought bullying is acceptable increased the odds of being frequently involved in bully-victim behaviours Adolescents who witnessed bullying events at school regardless of their roles as bystanders (such as passively witnessed bullying event, did nothing but thought they ought to help the victims, or tried to stop bullying) had higher odds of having bully-victim status at one-time point or both times The analyses of longitudinal associations between temporal patterns of bullying roles and mental health problems show those students, who were victimised often and classified as highly involved as both victims and bullies at one or both survey times (i.e., declining, increasing, and stable-high), had significantly higher levels of depressive symptoms, psychological distress, and suicidal ideation than those who were not involved or had stablelow involvement The mental health of adolescents, who were involved in bullying as a victim v or bully at stable-low, was generally similar to those not involved in any bullying However, females who experienced stable but low-level victimisation or the bully-victim role had worse mental health than males with stable-low level exposure Implications: This study has implications for preventive interventions for bullying in Vietnamese schools and internationally The dominance of traditional bullying and high correlations between traditional bullying and cyberbullying indicated that cyberbullying rarely occurs in isolation from traditional forms Preventive intervention should address all forms of bullying rather than focus heavily on the online environment Anti-bullying programs should include components on cyberbullying within the context of broader efforts to prevent interpersonal conflict and violence Although popular perception suggests that children tend to be either a bully or a victim and the behaviours are stable over time, research shows a more complex picture The findings of this study show a high degree of fluidity in bullying roles as victim, bully, or bullyvictim over an academic year The main implication of this key finding is that bullying prevention should seek to change whole-of-school culture that tolerates interpersonal aggression by promoting mutual respect Parents and family members need to be engaged as a part of anti-bullying efforts and be educated to recognise the impact of their own behaviours and home environment A minority of youth appear to be stable, high intensity bullies or victims, and these students may require special intervention and support This study’s findings indicate that mental health problems (depressive symptoms and psychological distress) can be both determinants and consequences of victimisation and bully-victim roles Anti-bullying programs should be a core element of mental health promotion in schools rather than addressed in standalone programs vi Keywords Adolescents, Cyberbullying, Depression, Longitudinal study, Mental health, Psychological distress, School-based survey, School adolescents, Suicidal ideation, Traditional bullying, Victimisation, Vietnam vii viii Table of contents ABSTRACT III KEYWORDS VII TABLE OF CONTENTS IX LIST OF TABLES XI LIST OF FIGURES XIII LIST OF ABBREVIATIONS XIV STATEMENT OF ORIGINAL AUTHORSHIP XV RELATED PUBLICATIONS AND PRESENTATIONS XVII ACKNOWLEDGEMENTS XIX CHAPTER 1: INTRODUCTION 1.1 RATIONALE 1.2 RESEARCH OBJECTIVES 1.3 SIGNIFICANCE OF THE STUDY 1.4 THESIS OUTLINE CHAPTER 2: LITERATURE REVIEW 2.1 WHAT IS BULLYING? 2.2 WHAT IS ALREADY KNOWN ABOUT BULLYING? 10 2.3 FACTORS ASSOCIATED WITH BULLYING ROLES 24 2.4 THE ASSOCIATIONS BETWEEN BULLYING AND MENTAL HEALTH 32 2.5 STUDIES ON BULLYING IN VIETNAM 35 2.6 THE NEED FOR LONGITUDINAL STUDY: WHAT IS STILL UNKNOWN? 36 CHAPTER 3: RESEARCH DESIGN 39 3.1 INTRODUCTION 39 3.2 CONCEPTUAL FRAMEWORK OF THIS STUDY 39 3.3 RESEARCH DESIGN 41 3.4 STUDY SITES 44 3.5 ETHIC APPROVALS 45 3.6 STUDY PARTICIPANTS 45 3.7 TIMELINES 47 3.8 INSTRUMENT DEVELOPMENT 47 3.9 DATA COLLECTION PROCEDURES 54 3.10 DATA MANAGEMENT AND ANALYSES 55 3.11 FINDINGS FROM EXPLORATORY QUALITATIVE RESEARCH 57 3.12 FINDINGS FROM THE PILOT SURVEY 65 3.13 RELIABILITY AND VALIDITY OF BULLYING VICTIMISATION AND PERPETRATION SCALES ix 75 CHAPTER 4: PREVALENCE AND TEMPORAL PATTERNS OF BULLYING ROLES OVER TIME AND 89 4.1 INTRODUCTION 89 4.2 DATA ANALYSES 89 4.3 CHARACTERISTICS OF RESPONDENTS 90 4.4 PREVALENCE OF BULLYING ROLES 94 4.5 THE OVERLAP BETWEEN BULLYING ROLES 102 4.6 TEMPORAL PATTERNS OF BULLYING ROLES OVER TIME AND TIME 4.7 SUMMARY 106 CHAPTER 5: 103 DETERMINANTS OF TEMPORAL PATTERNS OF BULLYING ROLES 109 5.1 INTRODUCTION 109 5.2 ANALYTICAL FRAMEWORK 110 5.3 DATA ANALYSES 110 5.4 DETERMINANTS OF TEMPORAL PATTERNS OF VICTIMISATION 112 5.5 DETERMINANTS OF TEMPORAL PATTERNS OF PERPETRATION 5.6 DETERMINANTS OF TEMPORAL PATTERNS OF BULLY-VICTIM STATUS 120 CHAPTER 6: 116 LONGITUDINAL ASSOCIATIONS BETWEEN TEMPORAL PATTERNS OF BULLYING ROLES AND MENTAL HEALTH AMONG ADOLESCENTS 129 6.1 INTRODUCTION 129 6.2 FRAMEWORK ANALYSIS AND METHODS 132 6.3 BIVARIATE ASSOCIATIONS 138 6.4 MULTIVARIATE ASSOCIATIONS 139 6.5 SUMMARY 142 CHAPTER 7: 7.1 DISCUSSION AND CONCLUSIONS 143 BULLYING FORMS AND CORRELATIONS BETWEEN TRADITIONAL BULLYING AND CYBERBULLYING 143 7.2 THE PREVALENCE OF BULLYING ROLES 146 7.3 THE TEMPORAL PATTERNS OF BULLYING ROLES 148 7.4 DETERMINANTS OF BULLYING ROLES OVER TWO TIME POINTS 149 7.5 THE LONGITUDINAL ASSOCIATIONS BETWEEN BULLYING ROLES AND MENTAL EHALTH 152 7.6 STRENGTHS AND WEAKNESS OF THIS STUDY 7.7 IMPLICATIONS FOR FURTHER RESEARCH AND INTERVENTION PROGRAMS 155 154 REFERENCES 161 APPENDICES 179 x Temporal patterns of victimisation Factors measured at Time N Not Stable low Declining Ref % OR (95% CI) % Increasing Stable high OR (95% CI) % OR (95% CI) % OR (95% CI) involved Perception of teachers trying to stop bullying Frequent 484 61.0 21.7 1.0 7.4 1.0 5.8 1.0 4.1 1.0 Infrequent 412 62.9 22.8 1.0 (0.7-1.4) 5.3 0.7 (0.4-1.2) 5.1 0.9 (0.5-1.5) 3.9 0.9 (0.5-1.8) High 527 64.7 21.1 1.0 5.9 1.0 5.7 1.0 2.7 1.0 Low 369 57.7 23.8 1.3 (0.9-1.8) 7.3 1.4 (0.8-2.4) 5.2 1.0 (0.6-1.8) 6.0 2.5 (1.3-5.0)*** High 547 63.8 22.3 1.0 6.6 1.0 4.6 1.0 2.7 1.0 Low 349 58.7 22.1 1.1 (0.8-1.5) 6.3 1.0 (0.6-1.8) 6.9 1.6 (0.9-2.9) 6.0 2.4 (1.2-4.7)** School social support Friends social support Perception of students trying to stop bullying 239 Temporal patterns of victimisation Factors measured at Time N Not Stable low Declining Ref % OR (95% CI) % Increasing Stable high OR (95% CI) % OR (95% CI) % OR (95% CI) involved Frequent 659 65.3 19.9 1.0 6.1 1.0 5.3 1.0 3.5 1.0 Infrequent 237 52.3 28.7 1.8 (1.3-2.6)*** 7.6 1.6 (0.9-2.8) 5.9 1.4 (0.7-2.7) 5.5 2.0 (0.90-4.0) Table K5- Multivariate multinomial logistic regression of predictors of temporal patterns of victimisation across Times 1&2 Predictors measured at Time Temporal patterns of Victimisation (the ref group: “Not-involved”) Stable low OR (95% CI) Declining OR (95% CI) Increasing OR (95% CI) Stable high OR (95% CI) Female 1.0 1.0 1.0 1.0 Male 1.3 (0.9-1.9) 1.8 (0.9-3.7) 0.6 (0.3-1.4) 3.5 (1.4-8.4)** Age (yrs.) 0.8 (0.7-0.9)*** 0.7 (0.6-0.9)** 0.8 (0.6-0.9)** 0.8 (0.6-1.0)Ϯ Depressive symptoms 1.0 (0.9-1.0) 1.04 (1.0-1.1) Ϯ 1.0 (0.9-1.0) 1.05 (1.0-1.1) Ϯ Psychological distress 1.1 (1.0-1.1)** 1.1 (1.0-1.1)* 1.0 (0.9-1.1) 1.08 (1.0-1.1)* Gender Reaction when seeing bullying events 240 Predictors measured at Time Temporal patterns of Victimisation (the ref group: “Not-involved”) Stable low OR (95% CI) Declining OR (95% CI) Increasing OR (95% CI) Stable high OR (95% CI) Never noticed 1.0 1.0 1.0 1.0 Take part in/think bullying is OK 0.8 (0.4-1.7) 1.0 (0.2-3.9) 1.6 (0.4-5.9) 0.8 (0.1-4.9) Think they ought to help 1.1 (0.6-1.9) 0.8 (0.2-2.8) 1.3 (0.4-3.9) 1.1 (0.3-4.5) Try to help stop bullying 0.9 (0.6-1.5) 2.2 (0.9-5.5) 1.7 (0.7-4.4) 2.4 (0.8-7.3) Time spent online 1.0 (0.9-1.1) 1.1 (0.9-1.2) 1.1 (0.9-1.2) 0.9 (0.8-1.1) Frequent 1.0 1.0 1.0 1.0 Infrequent 1.6 (1.0-2.4)** 1.0 (0.5-2.2) 0.7 (0.3-1.4) 1.7 (0.7-4.4) Infrequent 1.0 1.0 1.0 1.0 Frequent 1.4 (0.9-2.0) 1.1 (0.5-2.3) 0.8 (0.4-1.7) 1.8 (0.8-4.3) High 1.0 1.0 1.0 1.0 Low 1.5 (0.9-2.3)Ϯ 0.8 (0.4-1.7) 1.0 (0.4-2.2) 1.4 (0.5-3.7) No/rarely 1.0 1.0 1.0 1.0 Often 1.2 (0.8-1.8) 1.6 (0.8-3.3) 1.3 (0.6-2.7) 1.0 (0.4-2.4) Parents’ supervise online Parents’ control Internet access and mobile phone Family social support Witness parental violence 241 Predictors measured at Time Temporal patterns of Victimisation (the ref group: “Not-involved”) Stable low OR (95% CI) Declining OR (95% CI) Increasing OR (95% CI) Stable high OR (95% CI) No/rarely 1.0 1.0 1.0 1.0 Often 1.3 (0.9-1.9) 1.3 (0.6-2.6) 1.2 (0.5-2.4) 1.2 (0.5-2.9) Frequent 1.0 1.0 1.0 1.0 Infrequent 0.8 (0.5-1.2) 0.6 (0.3-1.3) 0.7 (0.3-1.5) 0.6 (0.3-1.5) High 1.0 1.0 1.0 1.0 Low 1.0 (0.6-1.5) 1.7 (0.7-3.8) 0.9 (0.4-2.1) 1.3 (0.5-3.5) High 1.0 1.0 1.0 1.0 Low 0.9 (0.6-1.5) 1.3 (0.6-2.8) 1.5 (0.7-3.2) 1.3 (0.5-3.1) High 1.0 1.0 1.0 1.0 Low 1.8 (1.2-2.9)** 3.0 (1.3-6.7)** 2.0 (0.9-4.6) Ϯ 1.5 (0.6-4.1) Conflict with siblings Perception of teachers trying to stop bullying School social support Friend social support Perception of students trying to stop bullying Note: Ϯp