Miyairi Reel Prospero 2016

Exploring Associations between Teasing as a Form of Bullying, Body Esteem, and Self-esteem Maya Miyairi, PhD Justine J. Reel, PhD, LPC, CC-AASP Moisés Próspero, PhD Objectives: This study examined bullying trends associated with victimization of teasing, body esteem, and self-esteem among middle school students. Methods: A cross-sectional survey method was used to collect data from 143 students in seventh grade in health classes at a middle school. Results: Overall, 52.8 % of participants admitted that they were bullied within the past 4 weeks. Of those, verbal bullying (46.5%) was the most frequently reported form of bullying experience. Conclusions: The results revealed that verbal bullying (eg, teasing) was the most frequently reported form of bullying and competency teasing and its victimization were more concerning than weight-related teasing in this study. Additional research is needed to determine if competency teasing is more prevalent than weight-related teasing among middle school students. Key words: bullying; teasing; body image; self-esteem; obesity Health Behav Policy Rev.™ 2016;3(2):144-152 DOI: http://dx.doi.org/10.14485/HBPR.3.2.6 B ullying among adolescents has become an alarming public health concern in the United States (US).1,2 Research has shown poorer psychosocial functioning among both bullies and victims of bullying and higher levels of behavioral problems and dislike of school among bullies.1 Although bullying incidents influence bullies, victims, and bystanders, bullied youths tend to experience higher levels of insecurity, anxiety, depression, loneliness, unhappiness, and low self-esteem due to bullied experiences.1,3-10 Additionally, victims of bullying are likely to experience immediate physical health consequences including sleep difficulties, headaches, stomach pain, and general tension.11 Another important note is that victims of bullying may have some risks to become more aggressive as a result of being bullied12,13 or avoid school attendance,2 which can adversely influence academic achievement and the decision to drop out of school.1 Moreover, Houbre et al11 found a variety of health consequences among bullies, victims, bystanders, and bullies-victims (individuals who had experienced bullying others and also being bullied). First, bullies and victims showed the lowest selfconcept compared to other groups in their study. Secondly, a group of bullies-victims reported more psychosomatic problems than bullies, victims, or bystanders. Lastly, victims who had experienced aggressive acts tended to struggle with high levels of post-traumatic stress. Other studies14-16 have shown negative psychological effects of bullying experiences into adulthood. Olweus14 discovered that former bullies had a 4-fold increase in criminal behavior by age 24, with 60% of former bullies having at least one criminal conviction, and 35% to 40% having 3 or more convictions. Conversely, individuals who were bullied struggled with higher levels of depression and poorer self-esteem at the age of 23 even though as adults they were no longer being harassed or socially isolated,15 which demonstrates the lasting negative impacts of bullying. Bullying Prevalence in the US It is clear that there is a strong association be- Maya Miyairi, Utah State University, Department of Health, Physical Education, and Recreation, Brigham City, UT. Justine J. Reel, University of North Carolina Wilmington, College of Health & Human Services, Wilmington, NC. Moisés Próspero, Institute for Innovative Justice, Salt Lake City, UT. Correspondence Dr Miyairi; [email protected] 144 Miyairi et al tween bullying behaviors and wellbeing and quality of life. However, bullying prevention research is considered as a relatively new research topic. In fact, until 2008, there was a paucity of research evidence on bullying in the US.17 According to Michaurd’s18 data, there were only 8 articles on bullying through MEDLINE between 1991 and 1993, but about 80 articles were published in 2008 alone. Since 2008, studies on bullying have been increasingly undertaken in the US and other countries.17,18 Nansel et al1 were the first to collect national data on bullying prevalence in the US. In their study, 29.9% of the participants (N = 15,686) reported that they were moderately or frequently involved in bullying, as a bully (13%), one who was bullied (10.6%), or both (6.3%). Boys were more likely to be perpetrators and targets of bullying. Students between sixth and eighth grade showed a higher frequency of bullying compared to ninth and tenth grade students.1 As a second national prevalence data on bullying among US adolescents between sixth and tenth grade (N = 7182), Wang, Iannotti, and Nansel19 examined 4 forms of school bullying behaviors and their association with sociodemographic characteristics, parental support, and friends. The results showed higher prevalence rate on verbal bullying (53.6%) compared to other forms of bullying such as social (51.4%), physical (20.8%) and cyber (13.6%) bullying. According to the results, boys were more involved in physical or verbal bullying and more likely to use a form of cyber bullying. On the other hand, girls were more involved in relational bullying and more likely to be victims of cyber bullying. The data also revealed that more bullying incidents (physical, verbal, or cyber) were reported among African-American adolescents but less victimization (verbal or relational). Additionally, Wang et al19 noted that a high degree of parental support tended to be a protective factor against bullying. These 2 national studies indicated that bullying incidents had increased in the US between 2001 and 2008. More importantly, it seems that verbal bullying has been more prevalent compared to other types of bullying. However, Rigby and Smith17 insisted that none of the empirical studies in a wide range of countries, including the US, reported that bullying in general increased between 1990 and Health Behav Policy Rev.TM 2016;3(2):144-152 2009. Their findings showed that only cyber bullying, as opposed to other forms of bullying, had increased. Because of the short length of the bullying research history, further studies to qualify the depth and nature of bullying are needed. Trends in Bullying Behavior As obesity prevalence has steadily maintained a higher rate among K-12 students in the US,20 bullying behaviors based on body type, size, and appearance have become a conspicuous trend in the past decade.21-29 For example, data from Project Eating and Activity in Teens 2010 showed evidence of higher bullying incident rates among teens whose body mass index (BMI) scores were in the range of obese.22 Of those data, weight- and race-based harassment (35.3% and 35.2%, respectively) were most prevalent compared to other types of harassment such as sexual harassment (25.0%) and socioeconomic status-based harassment (16.1%).22 Moreover, teens whose BMI scores were in the obese range experienced more weight-based harassment (boys: 58.2%, girls: 59.7%) compared to the study participants in other BMI ranges.23 Sex comparison in the study also indicated that girls were more likely to experience weight-based harassment (38.2%), followed by race-based harassment (31.4%), sexual harassment (29.0%), and socioeconomic status-based harassment (14.0%).22 Boys’ incident rate on weight-based harassment (31.8%) was the second most prevalent type following racebased harassment (39.5%).22 Additionally, another study conducted at 20 US public middle and high schools found that 27% of the students experienced weight-related teasing.27 In the same study, results showed that weight-related teasing was associated with lower self-esteem and greater body fat dissatisfaction in girls and greater depressive symptoms in boys.27 One study also found that 17.3% of middle school students were teased about being overweight.25 Results from the same study illustrated associations between teasing experience and low levels of psychological well-being, physical self-concept, self-efficacy of physical activity, and some fitness abilities such as cardiorespiratory fitness and push-ups.25 Self-esteem as a Predicting Factor Previous bullying studies have pointed out the DOI: http://dx.doi.org/10.14485/HBPR.3.2.6 145 Exploring Associations between Teasing as a Form of Bullying, Body Esteem, and Self-esteem negative impact of bullying experiences on victims’ levels of self-esteem.8-10 Of various bullying types, teasing about weight has been associated with lower self-esteem in girls.29 Greenleaf et al25 also revealed that middle school students who were teased had significantly lower self-esteem and higher depression scores than students who had no experience of being teased about being overweight. More importantly, their findings found an association between lower self-esteem and higher levels of depression among the participants who were teased about being overweight compared to other participants who were not teased.25 Other studies also found negative associations between low self-esteem, depression, unhealthy or extreme weight control behaviors including purging, using laxatives and diet pills, and health-risk behaviors such as substance use and suicidal ideology.27,30-32 It is crucial for bullying research to assess participants’ self-esteem to examine potential associations and monitor how anti-bullying intervention programs change participants’ levels of self-esteem as an outcome variable. Focusing on early prevention efforts is a common aim for any bullying research. To address bullying issues effectively, it is important to identify which forms of bullying are more prevalent among children and adolescents in each school environment. Negative perceptions towards individuals who are overweight or obese may start as early as 3 years old;26 moreover, teachers and family members have been recognized in previous studies as perpetrators of weight-related teasing.21,26 To address newly identified weight-related teasing incidents, individuals including students, parents, and teachers need more education about the impact of weightrelated teasing. Furthermore, raising awareness and providing education about weight-related teasing requires immediate attention in our society beyond doubt or question. Thus, understanding students’ characteristics such as types of bullying behaviors occurring in our study population is the first step to consider for anti-bullying intervention program research.24 In this study, a needs assessment was conducted to examine particular bullying behaviors in our study population prior to an intervention program that we designed to reduce bullying behaviors in our selected study population. In particular, our study assessed whether our participants had experienced 146 weight-related or competency teasing and explored how body esteem and self-esteem were associated with teasing experiences and its victimizations among participants. Furthermore, we examined sex differences in associations among teasing experiences, body esteem, and self-esteem among participants. Based on findings of this needs assessment, we planned to develop and implement culturally tailored bullying prevention programs among the same population. METHODS Procedure and Participants We conducted the study in October 2012. Seventh graders at a middle school located in a suburban area of a Rocky Mountain state in the US were selected by the school district. The selected middle school was located in an above average socioeconomic status community. The median annual household income in the community was approximately $76,000. The community’s median income was above the eligibility threshold for reduced price lunch. One hundred forty-three students in health classes at the middle school were asked to participate in the study: accounting for half of the seventh grade students and approximately 17% of the entire student population at the middle school. Prior to data collection, school counselors sent a letter to students’ parents to explain the study purpose and request students and their parents to decide if they agree to fill out assent and consent forms. Students who returned signed assent and parental consent forms participated in the study. Those students who requested to opt out of the study were asked to do homework during data collection in the classroom. No incentive was given to participate in the study. The total number of seventh grade participants was 126, which represented an 89% return rate. More participants were girls (N = 73, 58%) than boys (N = 53, 42%). The majority of participants were Caucasian (78.7%), with the others being Latino/Hispanic (13.4%), Asian (3.1%), AfricanAmerican (2.4%), Native Hawaiian (1.6%) and American Indian (0.8%). Approximately 87% of the student population at the middle school usually identifies as Caucasian, so this study population was slightly more diverse compared to the school demographics. In addition, more Latino/ Miyairi et al Hispanic students participated in this study. The demographic breakdown in this study was similar to that of a typical school in the state of the study site which was made up of 74.3% Caucasian and 12.3% Latino/Hispanic Students on average. Instrumentation Participants were asked to complete 3 questionnaires that included general demographic information and descriptive questions on bullying experiences. First, we asked participants about sex, race/ethnicity and bullying frequency in the demographic information section. To measure the bullying frequency, participants were asked if they had ever been bullied in any of the following formats: (1) physical bullying (ie, trying to hurt you by hitting, kicking, or punching); (2) verbal bullying (ie, name-calling, making offensive comments, joking about religion, sex, ethnicity, socioeconomic status or appearance); (3) emotional bullying (ie, isolating you, being excluded from games, lunchroom, or other group activities, spreading lies and rumors in order to ostracize you); (4) cyber bullying (ie, sending mean messages, pictures, or information through emails, instant message, text messaging, Facebook™, Twitter™, and YouTube™); or (5) never. The questionnaires shown below were used to identify whether weight-related teasing was more prevalent and to examine the relationship between teasing (weight-related and competency), body esteem, and self-esteem. Perception of Teasing Scale (POTS). The POTS33 was originally designed for youth between 17 and 24 years old. However, it has been used among preadolescent children and was a valid measurement for the age group.34 The POTS has an 11-item scale using a 5-likert format ranging from 1 = never to 5 = very often. The POTS includes 2 subscales that have demonstrated internal consistency: (1) α = .90 for general weight teasing (ie, “People made fun of you because you were heavy”); and (2) α = .85 for competency teasing (ie, “People laughed at you because you didn’t understand something”). In addition, each subscale includes a category that scales the effect of each teasing form (ie, “How upset were you?”). Higher scores indicate higher bullying victimization frequency. Body Esteem Scale for Children. The BES-C35 is a 20-item questionnaire and was developed for Health Behav Policy Rev.TM 2016;3(2):144-152 children from 7 to 17 years old and has been recognized as a valid measure for the attitudinal component of body image (ie, body esteem) in children.36 The BES-C examines how a child values his or her appearance based on yes or no responses to 20 items such as “I like what I see when I look in the mirror.” Counting the number of responses indicating high esteem determined a final score. According to a recent study that tested the reliability of BES-C,37 correlation coefficients for 2-week test-retest reliability (r =.81) among 8-year-old participants were acceptable and internal consistency was supported (α = .89). Rosenberg Self-esteem Scale (RSS). The RSS38 measures one’s level of self-esteem and uses a 10item scale (ie, “I feel I do not have much to be proud of ”) with a 4-likert format ranging from strongly agree to strongly disagree. This scale has been widely used for a variety of population groups and shown internal consistency (α = .77 to .88) and test-retest reliability (r = .82 to 88).38 Data Analysis Statistical analyses were conducted using SPSS 20.0 for Windows (SPSS Inc., Chicago, IL). Descriptive statistics were calculated to determine the frequency of bullying incidence, perceptions of teasing and levels of body esteem and self-esteem among participants. A one-sample chi-square analysis evaluated the association between sex and the bullying types. Pearson correlation revealed the association between perceptions of teasing and body esteem among participants. A t-test assessed how sex differences influenced the perceptions of teasing and body esteem. RESULTS Bullying Frequency Participants could mark multiple items on forms of bullying if they experienced different types of bullying. Overall, 52.8% of participants admitted that they had experienced being bullied in the past. Specifically, verbal bullying (46.5%) was the most frequent form of bullying among participants. Twenty-eight percent of participants had experienced emotional bullying such as being isolated or excluded from games, lunch tables, or other group activities or/and being spread rumors in order to DOI: http://dx.doi.org/10.14485/HBPR.3.2.6 147 Exploring Associations between Teasing as a Form of Bullying, Body Esteem, and Self-esteem Table 1 Associations between Sex and Types of Bullying Experience Boys Types of Bullying Girls Yes No Chi-square p-value Yes No Chi-square p-value Physical 6 47 31.7 < .001 9 64 41.4 < .001 Emotional 9 44 23.1 < .001 26 47 6 < .014 Cyber 5 48 34.9 < .001 9 64 41.4 < .001 Verbal 20 33 3.2 .074 39 34 0.3 .558 Never 30 23 0.9 .336 29 44 3.1 .079 be ostracized whereas 12% of participants reported physical and 11% of participants reported cyber bullying. A one-sample chi-square analysis test was conducted to assess whether sex differences played a significant role to determine the bullying types experienced among the participants. Results showed that there were statistically significant associations between sex differences and the following bullying types; physical, emotional, and cyber bullying. Boys and girls were more likely to answer “Not experienced” to those 3 bullying types (Table 1). To note, more girls tended to answer yes to emotional bullying than boys did. Conversely, there were no statistically significant results for verbal bullying and “never” (bullied) between girls and boys. Relationships among Teasing, Body Esteem, and Self-esteem A Pearson product-moment correlation coefficient was computed to assess the POTS, BES and RSS relationships. There was a positive correlation between scores on BES and those on RSS (r = .679, p < .01). POTS had 4 subscales: weightrelated teasing, weight-related teasing effect, competency teasing, and competency teasing effect. Weight-related teasing was significantly associated with weight-related teasing effect (r = .816, p < .01), competency teasing (r = .440, p < .01) and competency teasing effect (r = .311, p < .01). On the other hand, both weight-related teasing and competency teasing showed a negative correlation with the body esteem measure and self-esteem scale (Table 2). Additionally, both weight-related teasing and competency teasing effect also were negatively associated with body esteem and self-esteem scales. Sex Differences between Teasing, Body Esteem, and Self-esteem An independent-samples t-test was conducted to examine if there were any sex differences with respect to teasing, body esteem, and self-esteem scores. Female mean scores on all subscales from POTS were higher than male mean scores on those variables. There were statistically significant differences in scores on weight-related teasing effect (95% CI [0.46, 0.56], t (101) = 2.34, p = .021), competency teasing (95% CI [0.39, 2.18], t (117) = 2.78, p = .006) and competency teasing effect (95% CI [0.37, 0.97], t (117) = 4.47, p < .001) between boys and girls, with girls scoring higher than boys. More importantly, girls’ scores on competency teasing and its victimization were much higher than their weight-related or weight-related Table 2 Relationships among Teasing, Body Esteem, and Self-esteem Weight-related Teasing Weight-related Teasing Effect Competency Teasing Competency Teasing Effect Body Esteem -.534** -.484** -.445** -.346** Self-esteem -.349** -.278** -.366** -.300** * = p < .05, ** = p < .01, *** = p < .001 148 Miyairi et al Table 3 Correlations of Teasing, Body Esteem, and Self-esteem by Sex Sex Weight-related Teasing Boys : M (SD) Girls : M (SD) t-test df 6.47 (1.03) 6.77 (2.04) 1.07 112 Weight-related Teasing Effect 1.09 (.41) 1.40 (.99) 2.34* 101 Competency Teasing 7.30 (1.84) 8.58 (3.26) 2.78** 118 1.40 (.61) 2.07 (1.05) 4.47*** 117 Body Esteem 17.16 (3.25) 15.79 (4.83) -1.87 121 Self-esteem 21.23 (3.68) 19.41 (4.95) -2.33* 121 Competency Teasing Effect * = p < .05, ** = p < .01, *** = p < .001 teasing effect scores (Table 3). In short, competency teasing was more concerning than weightrelated teasing among the participants, especially girls. Lastly, mean scores on BES and RSS among male participants were higher than female mean scores on those variables. There was statistically significant difference in RSS scores between boys and girls, with boys scoring higher than girls, (95% CI [-3.35, -.27], t(121) = -2.33, p = .022). Table 3 shows the summary of mean comparisons of teasing, victimizations of teasing, body esteem and selfesteem by sex. DISCUSSION This study was conducted to examine the frequency of bullying, what forms of bullying occurred most frequently, and how teasing influenced one’s body esteem and self-esteem among the participants. Similar to a study conducted by Wang, Iannotti, and Nansel,19 our results also revealed that verbal bullying registered as the most frequent type of bullying among middle school participants in this study. Because of increased media coverage and public awareness about cyber bullying, verbal bullying may be overlooked in our society. However, as our data indicated, teasing experiences may have given more impact on one’s body esteem and self-esteem. From this note, our study suggests that more research should emphasize teasing as equivalent to verbal bullying. Both weight-related and competency teasing were negatively associated with body esteem and self-esteem. As a key finding, there was a negative association between body esteem and all of the teasing variables. It was interesting to find competency Health Behav Policy Rev.TM 2016;3(2):144-152 teasing and its victimization also were statistically correlated with body esteem. Additionally, competency teasing and its victimization were more prevalent among the participants in this study. From this data, we noted that our intervention program should focus on adding more tools to address competency teasing among the participants. For data on bullying behaviors, sex comparison can give us rich insights for prevention approaches. The POTS results showed that girls experienced more competency teasing, victimization from weight-related teasing and competency teasing than did boys. Interestingly, weight-related teasing had no statistically significant difference between boys and girls. Additionally, boys had higher selfesteem than girls in this study. Although girls may have more verbal bullying/teasing experiences, the results did not reveal which sex played more significant role as an instigator in verbal bullying. Therefore, further research needs to examine whether girls are more likely to become victims of verbal bullying (teasing). Limitations There were several limitations to this study. First, the cross-sectional nature of the measurements limited the generalizability of the conclusions. Longitudinal studies are needed to confirm the predictive influences of teasing and body esteem and selfesteem. Second, all of the measures required selfreport responses from the students. It was reported by participants that some questions were hard for them to answer. For example, answering options for the BES were “Yes” or “No.” Some participants expressed difficulty to choose one answer because DOI: http://dx.doi.org/10.14485/HBPR.3.2.6 149 Exploring Associations between Teasing as a Form of Bullying, Body Esteem, and Self-esteem their confidence level for body might change depending on a day. In addition, questions in the weight-related teasing subscale on the POTS were designed on the assumption that individuals who are overweight or obese will be targeted for weightrelated teasing. To include individuals who are underweight, future studies may consider modifying the way to ask questions on the POTS. More importantly, testing information from multiple sources is recommended for future studies. Third, we did not examine the frequency of each type of bullying, the length of bullied experience(s) and detailed information of bullies. Last, 78.9% of participants were white. Future studies must examine a more diverse population on bullying to assess the relationship between race/ethnicity and bullying. Conclusions Our results revealed that verbal bullying including teasing was the most prevalent form of bullying and strongly associated with one’s negative body esteem and self-esteem among participants. Although the results demonstrated less impact of teasing on boys’ body esteem and self-esteem, this issue needs to be addressed among both girls and boys due to the fact that instigators of teasing could be both boys and girls. Additionally, it is necessary to educate students that teasing is a form of bullying. We must also recognize that whereas physical bullying tends to be more noticeable by others, teasing can leave invisible emotional scars. Again, as the second national data on bullying indicated,19 verbal and emotional bullying were more prevalent than physical or cyber bullying, as quantified by this study. This conclusion, along with the demonstrated effects of teasing on body esteem and self-esteem, should motivate school administrators, teachers and parents to make more effort to monitor bullying incidents and implement a bullying prevention program and educate adolescents about all types of bullying including teasing. IMPLICATIONS FOR HEALTH BEHAVIOR OR POLICY When a bullying incident occurs, there is always an assumption that teachers should know how to handle and solve bullying incidents. In reality, however, most peers and teachers may feel uncomfortable or clueless about how to intervene in bullying 150 incidents in an appropriate way. Even if they have a desire to stop bullying incidents, they may not know how to help. For peers, common responses to not intervene in bullying incidents are based on fear to be targeted as a victim of the bully by trying to help their bullied peers.39 Unfortunately, teachers are not the exception. A qualitative study conducted by O’Connor and Graber39 found that verbal bullying was often unaddressed by teachers observed in the study. In addition, students in the same study reported that their teachers did not care about bullying. This phenomenon is concerning if these findings are commonly observed in our school system. In the state where this study was conducted, both laws and policies are currently implemented to protect students from bullying.40 However, there are a few drawback points in those laws and policies. For example, the state does not monitor any implementation of policies or the number of reported bullying incidents. Although the state laws and policies indicate that school districts need to provide training and preventive education for all school staff, it is unknown that the training and preventive education are effective enough for school staff to feel competent to address the complex problem of bullying. In this study, the first author discussed with teachers and school counselors about their confidence for providing education to prevent bullying for students. All of them expressed no confidence on providing bullying prevention and intervention programs. The results in this study should help school districts understand importance of emphasizing the report of bullying incidents and implementation of intervention programs. In the current study, weight-related teasing scores were lower than competency teasing scores. The reason could be because overweight and obesity were not a major health concern among our participants. This finding helped us strengthen program contents to address competency teasing and the lower levels of self-esteem. On the other hand, weight-related teasing tends to occur more often among children and adolescents who are overweight in a school setting.26,41,42 Assessing and understanding similarities or differences in types of bullying among study population must be taken into consideration prior to designing an effective bullying intervention program. In conclusion, each school and school district must understand current Miyairi et al trends in bullying among students and provide appropriate prevention training and education for students, school staff, and parents. Human Subjects Approval Statement Data in this study was collected after approval received from the Institutional Review Board of the University of Utah and a school district that had a partnership with this study project team. Conflict of Interest Statement The authors have no conflict of interest to declare. 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