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Contents lists available at ScienceDirect

EClinicalMedicine
journal homepage: https://www.journals.elsevier.com/eclinicalmedicine

Research Paper

Global variation in the prevalence of bullying victimisation amongst

adolescents: Role of peer and parental supports
Tuhin Biswasa,b,*, James G. Scottc,d,e,f, Kerim Munirg, Hannah J. Thomasc,d,f,h,
M. Mamun Hudaa,b, Md. Mehedi Hasana,b, Tim David de Vriesi, Janeen Baxtera,b,
Abdullah A. Mamuna,b
a
Institute for Social Science Research, The University of Queensland, Brisbane, Australia
b
ARC Centre of Excellence for Children and Families over the Life Course, The University of Queensland, Brisbane, Australia
c
QIMR Berghofer Medical Research Institute, Herston, Qld, 4006
d
Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
e
Metro North Mental Health, Royal Brisbane and Women’s Hospital, Herston, Brisbane, QLD, Australia
f
Queensland Centre for Mental Health Research, Wacol, Brisbane, QLD, Australia
g
Developmental Medicine Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
h
School of Public Health, Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
i
Utrecht University, Netherlands

A R T I C L E I N F O S U M M A R Y

Article History: Background: Bullying victimisation is a global public health problem that has been predominantly studied in
Received 10 August 2019 high income countries. This study aimed to estimate the population level prevalence of bullying victimisation
Revised 13 January 2020 and its association with peer and parental supports amongst adolescents across low and middle income to
Accepted 22 January 2020
high income countries (LMIC HICs).
Available online xxx
Methods: Data were drawn from the Global School-based Student Health Survey of school children aged
12 17 years, between 2003 and 2015, in 83 LMIC HICs in the six World Health Organization (WHO)
regions. We estimated the weighted prevalence of bullying victimisation at country, region and global level.
We used multiple binary logistic regression models to estimate the adjusted association of age, gender, socio-
economic status, and parental support and peer support, and country level variables (GDP and government
expenditure on education) with adolescent bullying victimisation.
Findings: Of the 317,869 adolescents studied, 151,036 (48%) were males, and 166,833 (52%) females. The
pooled prevalence of bullying victimisation on one or more days in the past 30 days amongst adolescents
aged 12 17 years was 30¢5% (95% CI: 30¢2 31¢0%). The highest prevalence was observed in the Eastern Med-
iterranean Region (45¢1%, 44¢3 46¢0%) and African region (43¢5%, 43¢0 44¢3%), and the lowest in Europe
(8¢4%, 8¢0 9¢0%). Bullying victimisation was associated with male gender (OR: 1¢21; 1¢11 1¢32), below aver-
age socio-economic status (OR: 1¢47, 1¢35 1¢61), and younger age (OR: 1¢11, 1¢0 1¢24). Higher levels of peer
support (0¢51, 0¢46 0¢57), higher levels of parental support (e.g., understanding children’s problems (OR:
0¢85, 0¢77 0¢95), and knowing the importance of free time spent with children (OR: 0¢77, 0¢70 0¢85)), were
significantly associated with a reduced risk of bullying victimisation.
Interpretations: Bullying victimisation is prevalent amongst adolescents globally, particularly in the Eastern
Mediterranean and African regions. Parental and peer supports are protective factors against bullying victim-
isation. A reduction in bullying victimisation may be facilitated by family and peer based interventions aimed
at increasing social connectedness of adolescents.
© 2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license.
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction

Adolescence is a critical phase of development during which the

foundations for future health and wellbeing are laid [1]. An environ-
* Corresponding author: Tuhin Biswas. Institute for Social Science Research, The Uni- ment characterised by supportive family and peer relationships plays
versity of Queensland, 80 Meiers Road, Indooroopilly, Queensland 4068, Australia. a key role in supporting healthy cognitive, emotional, sexual, and
E-mail address: [email protected] (T. Biswas).

https://doi.org/10.1016/j.eclinm.2020.100276
2589-5370/© 2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
parental supports, EClinicalMedicine (2020), https://doi.org/10.1016/j.eclinm.2020.100276
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Student Health Survey (GSHS) reported that greater parental under-

Research in context
standing and monitoring was associated with a reduced risk of bully-
ing victimisation [12]. In addition, Hong et al. (2012) suggest that
Evidence before this study
interventions to address school bullying behaviour need to incorporate
We systematically searched PubMed, EMBASE, PsycNIFO with a the support of peers [13], which can function as a protective factor to
combination of MeSH heading terms and keywords. The key promote psychological well-being of adolescent school students under
words used in the search (“bullying” OR “bullying victimisation”) adverse conditions [14,15]. However, the research underlying advo-
and (“adolescents” OR “child*” OR “teenager” OR “youth”) and cacy for peer support is largely derived from research into bullying vic-
(“developing country” OR “low socioeconomic status” OR “low timisation conducted in higher income countries (HICs).
income country” OR “middle income country” OR “low- and mid- There are a paucity of reports on adolescent bullying in low and
dle-income country” OR “ high income country” OR “developed middle income countries (LMICs). A study of countries in the South-
country” OR “high socioeconomic status” OR “low and middle East Asia region reported high rates of bullying victimisation with
income to high income countries” OR “LMIC HICs” OR “LMICs”). 20¢7% of students in Indonesia, and at least half of students in Myan-
The literature search was conducted up to June 25, 2019. We iden- mar and Nepal reporting experiencing one or more episodes of bully-
tified only three publications, the first study conducted in 2001/2 ing in the previous 30 days [16]. To date, there has not been a
used the Health Behaviour in School-aged Children survey (HBSC) comprehensive comparative study of the prevalence of bullying vic-
and the Global School-based Students Health Survey (GSHS) data timisation amongst adolescents across both high income countries
from 66 countries. The second study used the Global School-based (HIC) and low and middle income countries (LMIC). No study has eval-
Student Health Survey (GSHS) focusing on South East Asia, and uated the association between bullying victimisation and peer and
provided an overview of the prevalence of bullying victimisation parental supports across a wide distribution of countries with varying
experiences amongst the adolescents in South East Asia. income levels and cultures. This study aimed to address these gaps by
providing a comprehensive overview of the global prevalence of bully-
Added value of this study ing victimisation in schools and to examine the association of bullying
victimisation with parental and peer support in HIC and LMIC.
This is the first study to comprehensively estimate the popula-
tion prevalence of bullying victimisation and its relationship
Methods
with peer and parental support amongst adolescents across
LMIC HICs. We used data from the GSHS of adolescents, ages
Data sources
12 17 years (2003 2015), in 83 LMIC HICs in the six WHO
regions to show the geographic variation in prevalence of bully-
This study used data from the Global School-based Student Health
ing victimisation in 83 LMIC HICs. We demonstrated that
Survey (GSHS), which commenced in 2003. The GSHS was jointly
parental support and peer support were strongly associated
developed by the WHO and the United States Centre for Disease Con-
with reduced levels of bullying victimisation.
trol and Prevention (CDC) in collaboration with The United Nations
International Children's Fund (UNICEF), The United Nations Educa-
Implications of all the available evidence
tional, Scientific and Cultural Organisation (UNESCO), and The Joint
This study shows that although there is a high variation in the United Nations Programme on HIV and AIDS (UNAIDS). GSHS is
prevalence of bullying victimisation, a large proportion of ado- administered to adolescents aged 12 17 years to capture informa-
lescents in all countries irrespective of income status are tion on a wide range of health indicators using validated items from
exposed. In every country, those adolescents with lower levels ten core modules including: nutrition, physical activity, hygiene,
of peer support and parental support were more likely to report mental health, alcohol use, tobacco use, drug use, sexual behaviors,
experiencing bullying victimisation. There is an urgent need to violence/injury, and protective factors [17]. In collecting this informa-
develop culturally appropriate interventions that increase tion, GSHS employed a two-stage cluster sampling technique. In the
parental support and foster development of peer supports to first stage, the schools were selected randomly. Classes that provided
reduce the global prevalence of bullying. The findings of this a representative sample of the general population aged 12 17 years
study can help to inform such prevention programmes. were identified within the selected schools at the second stage of
sampling [18]. The study design and selection procedure of partici-
pants were similar across the GSHS countries. For this study we
psychological development for adolescents [2]. Bullying victimisation included data from 83 LMIC HICs from inception to 2015. For those
during school years is a serious global health problem with those countries with repeated time point data in this study, we used data
adolescents experiencing bullying having an increased risk of physi- from the most recent survey.
cal, cognitive, and mental health issues [3], specifically higher rates of
depression, anxiety, and suicidality [4]. Victimised adolescents are Ethics statement
also more likely to experience difficulties in their academic perfor-
mance [5,6] which leads to an increased risk of longstanding eco- In each of the participating countries, the GSHS received ethics
nomic consequences for both the individual and their family [7,8]. approval from the Ministry of Education or a relevant institutional
Bullying victimisation in schools has predominantly received ethics review committee, or both. Only those adolescents and their
attention in high income countries. For example, in Australia a meta- parents or guardians who provided written or verbal consent partici-
analysis of 46 studies reported that nearly one of every seven adoles- pated. As the current study used retrospective publicly available data,
cents were victimised by the 12-month bullying and approximately we did not require ethics approval.
one in four students reported life time bullying [9]. A recent study in
England reported that 36% of females and 24% of males experienced Measurements
regular bullying victimisation [10]. Another study from the United
Kingdom reported that 21% of students aged 9 16 years were bullied Bullying victimization
[11]. Risk factors associated with bullying victimisation are wide Respondents were asked to read a short definition of bullying
ranging and include family dynamics, school factors, and peer sup- which incorporated power imbalance and the intent to harm and dis-
ports. A study in Vietnam using data from the Global School-based tinguished the behaviour from teasing. They were then asked on how
Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
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many days were they bullied in the past 30 days. Possible responses prevalence or mean estimates (with corresponding 95% confidence
ranged from ‘0 days’, ‘1 2 days’, following in increments through to intervals, CIs). Weighted prevalence estimates were calculated for
‘all 30 days’ (Supplementary Table 1). Consistent with previous GSHS individual countries to allow cross-country comparisons, and by gen-
bullying victimization research [12], responses were dichotomized der across countries to understand gender disparities within coun-
with those who reported bullying experiences on ‘one or more days’ tries. Bivariate analysis was performed to calculate the prevalence of
included as being exposed to bullying victimisation. bullying victimization over background characteristics at the global
and regional level. We conducted binary logistic regression analysis
Parental support and peer support to examine the factors associated with bullying victimisation. In
Parental support was assessed using a proxy variable based on binary logistic regression models, we considered bulling victimiza-
two questions: i) parental understanding of student’s problems tion (a binary variable coded as 0 if not victimized and 1 if victimized)
(“During the past 30 days, how often did your parents or guardians as a dependant variable. We considered a set of independent varia-
understand your problems and worries?”) and parental knowledge bles in the regression model. These included survey year, age, gender,
of student’s activities during their free time (“During the past socioeconomic status, peer and parental support, GDP per capita and
30 days, how often did your parents or guardians really know what expenditure on education. First we conducted a simple logistic
you were doing with your free time?”). Possible response options to regression analysis (Model 1) by only adjusting for survey year in
each of these questions were ‘never’, ‘rarely’, ‘sometimes’, ‘most of order to select variables which had a bivariate association with bully-
the times’ and ‘always’. These variables were recoded and classified ing. We then fitted a two multiple regression models i) one by includ-
as never/rarely, sometimes, most of the time and always. ing all the population level variables (Model 2) and ii) another by
Peer support was also assessed using a proxy variable based on including population as well as country level variables (GDP and gov-
the question “During the past 30 days, how often were most of the ernment expenditure on education) in Model 3 to explore indepen-
students in your school kind and helpful?” to which students could dent factors associated with bullying victimisation. Variations in
respond “never, rarely, sometimes, most of the time or always”. errors due to complex sample design were controlled in all the analy-
Responses were recoded as never/rarely, sometimes, most of the sis by using “svy” command in STATA (version 14).
time and always.
Results
Socio-demographic factors
The gender and age of the participants were included in the sur- Of the 317,869 adolescents aged 12 17 years, the mean age was
vey. Participants were categorized into three age groups: 14.6 (SD 1¢18) years. 151,036 (48%) were males and 166,833 (52%)
12 13 years, 14 15 years, and 16 17 years. Socioeconomic status were females. Response rates ranged from 60% in Chile to 99.8% in
(SES) was measured by the variable, “During the past 30 days, how Jordan (see Supplementary Table 2). Of the 83 participating countries,
often did you go hungry because there was not enough food in your 20¢8% of the data came from low-income countries, 40¢4% from
home?” Responses of “never to rarely” were recoded as ‘average’, and lower-middle-income countries, 19¢1% from upper-middle-income
“sometimes to always” as ‘below average’ SES. We included country countries, i.e., 80¢3% LMICs and 19¢7% from high-income countries,
gross domestic product (GDP) and government expenditure on edu- according to World Bank classification.
cation, measured in total percentage of GDP in our adjusted model. The pooled prevalence of bullying victimisation was 30¢5% (95%
Countries’ GDP correspond to the survey year as reported by the CI: 30¢2 31¢0%) in LMICs-HICs. The highest pooled prevalence was
World Bank. For a few countries, Index Mundi data were used where observed in the Eastern Mediterranean Region (45¢1%, 44¢3 46¢0%)
GDP and Government expenditure on education were not listed in and the lowest was in the European region with 8¢4% (8¢0 9¢0%;
the World Bank list [19]. Fig. 1). The country-specific prevalence ranged from 7¢0% in Tajikistan
to 75¢0% in Samoa (Supplementary Table 3). According to the country
Statistical analysis income classification, pooled prevalence amongst the adolescents
was lower in HICs (20¢0%, 19¢0 20¢4%) and the highest in the upper-
The data were weighted to allow the samples to be nationally rep- middle-income group of LMICs (40¢4%, 40¢0 41¢1%; Fig. 1). Nearly
resentative. This included using strata and primary sampling units at one-third (33¢0%, 32¢2 33¢2%) of male adolescents were bullied at
the country level. We used sample weights to calculate weighted least once at school within the past 30 days prior to the survey,

Fig. 1. Overall burden of bullying by global, regions, gender and economic positions.

Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
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Fig. 2. Prevalence of bullying in the 30 days preceding survey completion amongst adolescents aged 12 17 years for 83 low-to-high income countries, 2003 15.

Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
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whereas the prevalence was lower (28¢2%; 28¢0 29¢0%) amongst support and parental support in a wide range of countries. There are
female adolescents. A large variation in prevalence amongst both three major findings: first, there was a high prevalence of bullying
male and female adolescents was observed (Fig. 2). The highest prev- observed in most of the 83 countries, irrespective of income classifi-
alence of bullying was observed in Samoa for both males (79¢0%) and cation. Second, there was a wide variation between countries in the
females (70¢0%). The lowest prevalence was observed in Tajikistan prevalence of bullying victimisation. This suggests that social and cul-
for males (7¢0%) and females (8¢0%) (see Supplementary Table 3). tural factors may influence the national prevalence of bullying. Third,
Table 1 shows the prevalence of bullying victimization by age group, in all countries, increased peer support and parental support was
socioeconomic status, peer support and parental support. In almost all associated with lower risk of bullying victimisation.
regions, the prevalence was higher amongst the younger ages and those A previous study published in 2008 using GSHS data reported that
who had a below average SES. Almost without exception, there was a the prevalence of bullying was 37.4% [20]. A similar study in low-
lower prevalence of bullying victimisation amongst adolescents who income and middle-income countries reported the prevalence of bul-
reported higher levels of peer support and parental support (Table 1). lying was 34.4% [21]. However, this study was conducted in 2008 and
The country-specific prevalence of bullying victimisation by peer sup- did not include Europe and the South-East Asia regions. In the current
port and parental support reported in supplementary Table 4 and 5. study, we captured data from LMIC HICs across the six WHO
Table 2 shows the mutually adjusted independent associations regions, including South-East Asia. Our reported prevalence of 31% is
(Models 1 to 3) of bullying victimization at global and regional levels. consistent with previous studies and a large study using HBSC data
At the global level, the odds of being bullied were comparatively which was also found that 30% of adolescents reported bullying vic-
higher amongst males (OR: 1¢27, 95% CI 1¢18 1¢37) (Model 1). These timisation in the past two months [22].
associations did not substantially change upon adjustments for sur- Consistent with a study using the HBSC and GSHS data [20], we
vey year, gender, age, socioeconomic status, peer support, parental found there is a wide variation in bullying victimisation prevalence
support, GDP and government expenditure on education (Model 3). between countries. The variation in prevalence amongst males and
Overall (see Model 3), being male (OR: 1.21, 1¢11 1¢32), younger in females by both region and country provides an important opportunity
age (OR: 1¢11, 1¢0 1¢24), and having a below average socioeconomic to examine the cultural and social determinants of bullying. For exam-
status (OR: 1¢47, 1¢35 1¢61) were associated with a greater risk of ple, in Africa, the bullying victimization prevalence was 45% amongst
bullying victimisation. However, there was a significant reduction in the females and 42% amongst males, compared to 19% amongst females
bullying victimisation reported by those students who responded vs. 28% amongst males in South-East Asia. Such variations may reflect
“always” to questions on experiencing peer support (OR: 0¢51, important regional differences in the implementation of national poli-
0¢46 0¢57) and parental support (understand their problem, OR: cies and preventive intervention programs to reduce bullying, beyond
0¢85, 0¢77 0¢95; and knew about the free time of their children, OR: sociocultural influences. This study found that most of the countries did
0¢77, 0¢70 0¢86) (Table 2 and Supplementary Figure 1). not have available prospective follow up data on bullying. Monitoring
the trends in the prevalence of bullying victimisation in adolescents,
Discussion through the implementation of surveys at regular intervals could inform
national policies. Recently, the Lancet commission on adolescent health
The present study based on the GSHS data provides the most com- and wellbeing reported that over 50% of adolescents grow up in multi-
prehensive summary to-date of the prevalence of bullying victimisa- burden countries, characterised by high levels of adolescent health
tion amongst adolescents across 83 LMIC HICs and is the first study problems, including violence [23], with a particular need for maintain-
to examine the relationship of bullying victimisation with peer ing data monitoring in those countries.

Table 1
Regional Prevalence of bullying victimization by age group, socioeconomic status, school environment and parental support.

Variables Southeast African Eastern Mediterranean Region of the Western Pacific European
Asia (%) Region (%) Region (%) Americas (%) Region (%) Region (%)

Gender
Male 28 42 47 28 33 8
Female 19 45 43 27 31 9
Age group
12 13 years 23 41 50 27 44 10
14 15 years 24 41 45 29 36 8
16 17 years 22 42 34 23 25 8
Socioeconomic status
Average 21 36 43 24 28 9
Below average 27 55 52 44 44 23
Peers were supportive
Never/rarely 33 33 44 37 43 13
Sometimes 24 43 46 37 35 9
Most of the times 21 27 34 29 27 8
Always 17 30 27 20 24 5
Parents or guardians understood problem
Never/rarely 28 34 41 36 36 14
Sometimes 22 43 46 37 35 10
Most of the times 22 27 36 30 29 12
Always 20 32 28 22 28 7
Parents or guardians know about free time
Never/rarely 28 33 42 38 38 13
Sometimes 24 41 41 38 36 10
Most of the times 21 28 35 31 27 12
Always 19 34 34 22 26 7

Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
parental supports, EClinicalMedicine (2020), https://doi.org/10.1016/j.eclinm.2020.100276
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Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
Factors associated with bullying amongst the adolescent, per WHO region.

Overall Asia region Africa region Eastern Mediterranean region Region of Americas Western Pacific Region European Region

Model-1 OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value

Boys 1¢27 (1¢18-1¢37) <0¢001 1¢65 (1¢47-1¢85) <0¢001 0¢87 (0¢79-0¢96) 0¢004 1¢28 (1¢04-1¢57) 0¢018 1¢05 (0¢98-1¢13) 0¢167 1¢08 (1-1¢17) 0¢063 0¢92 (0¢69-1¢24) 0¢598
14-15 years 1¢14 (1¢04-1¢26) 0¢007 1¢09 (0¢9-1¢33) 0¢375 1¢05 (0¢93-1¢18) 0¢472 1¢15 (1-1¢32) 0¢056 1¢14 (1¢03-1¢26) 0¢009 1¢45 (1¢23-1¢72) <0¢001 0¢99 (0¢74-1¢33) 0¢946
11-13 years 1¢09 (0¢95-1¢25) 0¢229 1¢08 (0¢86-1¢36) 0¢521 1¢1 (0¢94-1¢3) 0¢238 1¢19 (0¢97-1¢47) 0¢103 1¢18 (1¢04-1¢33) 0¢009 1¢62 (1¢4-1¢86) <0¢001 1¢2 (0¢82-1¢74) 0¢343
SES (Below average) 1¢56 (1¢45-1¢68) <0¢001 1¢48 (1¢27-1¢73) <0¢001 1¢89 (1¢73-2¢07) <0¢001 1¢67 (1¢41-1¢97) <0¢001 2¢23 (2¢03-2¢45) <0¢001 0¢82 (0¢71-0¢94) 0¢006 0¢66 (0¢5-0¢87) 0¢003
Peers supportive 0¢71 (0¢66-0¢76) <0¢001
Sometimes 0¢57 (0¢5-0¢64) <0¢001 0¢65 (0¢58-0¢72) <0¢001 1¢11 (0¢94-1¢3) 0¢222 1¢14 (0¢99-1¢31) 0¢072 0¢94 (0¢85-1¢03) 0¢182 0¢61 (0¢53-0¢72) <0¢001 0¢55 (0¢32-0¢97) 0¢037
Most of the times 0¢46 (0¢42-0¢51) <0¢001 0¢52 (0¢43-0¢65) <0¢001 0¢76 (0¢63-0¢91) 0¢003 0¢78 (0¢63-0¢97) 0¢025 0¢68 (0¢61-0¢76) <0¢001 0¢53 (0¢43-0¢65) <0¢001 0¢36 (0¢2-0¢64) <0¢001
Always 0¢81 (0¢74-0¢88) <0¢001 0¢41 (0¢35-0¢49) <0¢001 0¢64 (0¢55-0¢74) <0¢001 0¢61 (0¢53-0¢71) <0¢001 0¢45 (0¢39-0¢51) <0¢001 0¢9 (0¢81-1) 0¢055 0¢95 (0¢62-1¢48) 0¢835
Parents or guardians understood problem
Sometimes 0¢80 (0¢744-0¢87) <0¢001 0¢74 (0¢63-0¢86) <0¢001 1¢2 (1¢06-1¢36) 0¢005 1¢01 (0¢83-1¢22) 0¢925 0¢98 (0¢89-1¢07) 0¢636 0¢79 (0¢68-0¢9) <0¢001 0¢88 (0¢55-1¢41) 0¢587
Most of the times 0¢74 (0¢67-0¢81) <0¢001 0¢71 (0¢6-0¢85) <0¢001 0¢73 (0¢62-0¢86) <0¢001 0¢91 (0¢76-1¢09) 0¢317 0¢75 (0¢68-0¢82) <0¢001 0¢67 (0¢57-0¢79) <0¢001 0¢49 (0¢37-0¢66) <0¢001
Always 0¢63 (0¢58-0¢69) <0¢001 0¢65 (0¢54-0¢77) <0¢001 0¢69 (0¢6-0¢81) <0¢001 0¢66 (0¢59-0¢74) <0¢001 0¢53 (0¢48-0¢58) <0¢001 0¢91 (0¢81-1¢03) 0¢139 0¢73 (0¢52-1¢03) 0¢069
Parents or guardians knew about free time
Sometimes 0¢83 (074-0¢92) 0¢001 0¢82 (0¢68-0¢99) 0¢039 1¢16 (1¢03-1¢31) 0¢014 1¢03 (0¢87-1¢22) 0¢741 0¢98 (0¢88-1¢1) 0¢735 0¢7 (0¢6-0¢81) <0¢001 0¢87 (0¢54-1¢41) 0¢580
Most of the times 0¢69 (0¢63-0¢76) <0¢001 0¢68 (0¢58-0¢79) <0¢001 0¢83 (0¢73-0¢94) 0¢003 1¢01 (0¢8-1¢27) 0¢935 0¢78 (0¢7-0¢85) <0¢001 0¢61 (0¢52-0¢72) <0¢001 0¢51 (0¢34-0¢75) <0¢001
Always 0¢59 (0¢54-0¢64) <0¢001 0¢6 (0¢52-0¢69) <0¢001 0¢77 (0¢64-0¢92) 0¢004 0¢75 (0¢65-0¢85) <0¢001 0¢52 (0¢48-0¢56) <0¢001 1¢74 (1¢6-1¢89) <0¢001 2¢88 (1¢66-5) <0¢001

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Model-2
Boys 1¢24 (1¢14-1¢35) <0¢001 1¢51 (1¢34-1¢72) <0¢001 0¢99 (0¢86-1¢15) 0¢944 1¢24 (1¢02-1¢49) 0¢029 0¢91 (0¢85-0¢98) 0¢013 1¢05 (0¢96-1¢14) 0¢322 0¢93 (0¢63-1¢38) 0¢734
14-15 years 1¢15 (1¢04-1¢26) 0¢006 1¢05 (0¢88-1¢27) 0¢544 1¢18 (1¢01-1¢39) 0¢042 1¢17 (1-1¢37) 0¢047 1¢08 (0¢97-1¢19) 0¢163 1¢5 (1¢27-1¢77) <0¢001 0¢92 (0¢7-1¢23) 0¢586
11-13 years 1¢09 (0¢95-1¢26) 0¢216 1¢055 (0¢85-1¢3) 0¢620 1¢28 (1¢02-1¢61) 0¢034 1¢25 (1-1¢57) 0¢054 1¢15 (1-1¢32) 0¢055 1¢74 (1¢49-2¢02) <0¢001 0¢8 (0¢49-1¢31) 0¢376
SES (Below average) 1¢5 (1¢38-1¢63) <0¢001 1¢44 (1¢24-1¢7) <0¢001 1¢97 (1¢69-2¢29) <0¢001 1¢55 (1¢31-1¢84) <0¢001 1¢98 (1¢78-2¢19) <0¢001 1¢69 (1¢55-1¢84) <0¢001 2¢66 (1¢54-4¢58) <0¢001
Peers were supportive
Sometimes 0¢73 (0¢68-0¢78) <0¢001 0¢68 (0¢61-0¢77) <0¢001 1¢1 (0¢93-1¢3) 0¢256 1¢15 (1-1¢32) 0¢057 0¢93 (0¢85-1¢03) 0¢186 0¢83 (0¢73-0¢95) 0¢008 0¢45 (0¢25-0¢79) 0¢005
Most of the times 0¢62 (0¢54-0¢7) <0¢001 0¢58 (0¢47-0¢74) <0¢001 0¢81 (0¢67-0¢99) 0¢036 0¢79 (0¢62-1¢01) 0¢062 0¢74 (0¢66-0¢82) <0¢001 0¢67 (0¢58-0¢77) <0¢001 0¢72 (0¢54-0¢96) 0¢023
Always 0¢52 (0¢48-0¢58) <0¢001 0¢46 (0¢39-0¢56) <0¢001 0¢74 (0¢63-0¢87) <0¢001 0¢7 (0¢61-0¢8) <0¢001 0¢53 (0¢47-0¢6) <0¢001 0¢58 (0¢48-0¢7) <0¢001 0¢62 (0¢34-1¢14) 0¢124
Parents or guardians understood problem
Sometimes 0¢89 (0¢8-0¢99) 0¢028 0¢82 (0¢67-1¢02) 0¢077 1¢19 (1¢04-1¢36) 0¢010 0¢96 (0¢79-1¢16) 0¢637 1¢04 (0¢94-1¢14) 0¢426 1¢05 (0¢94-1¢18) 0¢361 0¢84 (0¢5-1¢4) 0¢500
Most of the times 0¢9 (0¢81-1¢01) 0¢069 0¢88 (0¢71-1¢1) 0¢277 0¢77 (0¢65-0¢92) 0¢003 0¢95 (0¢8-1¢13) 0¢545 0¢92 (0¢84-1¢01) 0¢095 0¢97 (0¢84-1¢12) 0¢701 0¢92 (0¢52-1¢63) 0¢773
Always 0¢84 (0¢75-0¢94) 0¢002 0¢87 (0¢69-1¢11) 0¢263 0¢82 (0¢68-0¢98) 0¢032 0¢76 (0¢68-0¢85) <0¢001 0¢76 (0¢68-0¢84) <0¢001 0¢9 (0¢77-1¢05) 0¢173 0¢77 (0¢54-1¢09) 0¢144
Parents or guardians knew about free time
Sometimes 0¢92 (0¢81-1¢04) 0¢179 0¢96 (0¢77-1¢22) 0¢786 1¢16 (1¢01-1¢33) 0¢033 1¢05 (0¢89-1¢25) 0¢535 1¢03 (0¢92-1¢16) 0¢632 0¢95 (0¢85-1¢07) 0¢416 0¢77 (0¢49-1¢2) 0¢245
Most of the times 0¢85 (0¢77-0¢93) 0¢001 0¢90 (0¢76-1¢07) 0¢245 0¢95 (0¢81-1¢1) 0¢494 1¢11 (0¢89-1¢38) 0¢362 0¢92 (0¢83-1¢03) 0¢132 0¢79 (0¢69-0¢91) <0¢001 1¢04 (0¢59-1¢83) 0¢895
Always 0¢77 (0¢7-0¢85) <0¢001 0¢84 (0¢7-1¢03) 0¢095 0¢92 (0¢76-1¢12) 0¢411 0¢94 (0¢83-1¢07) 0¢368 0¢68 (0¢62-0¢75) <0¢001 0¢73 (0¢62-0¢85) <0¢001 0¢66 (0¢41-1¢09) 0¢105

Model-3
Boys 1¢21 (1¢11-1¢32) <0¢001 1¢52 (1¢33-1¢75) <0¢001 0¢99 (0¢86-1¢15) 0¢944 1¢24 (1¢02-1¢49) 0¢029 0¢91 (0¢85-0¢98) 0¢011 1¢05 (0¢96-1¢15) 0¢283 0¢93 (0¢63-1¢38) 0¢734
14-15 years 1¢11 (1-1¢24) 0¢057 1¢00 (0¢81-1¢25) 0¢950 1¢18 (1-1¢39) 0¢044 1¢17 (1-1¢37) 0¢049 1¢07 (0¢96-1¢18) 0¢229 1¢46 (1¢24-1¢73) <0¢001 0¢92 (0¢7-1¢23) 0¢586
11-13 years 1¢03 (0¢89-1¢21) 0¢679 0¢98 (0¢78-1¢24) 0¢887 1¢28 (1¢02-1¢61) 0¢036 1¢25 (0¢99-1¢57) 0¢055 1¢12 (0¢98-1¢29) 0¢1 1¢61 (1¢39-1¢87) <0¢001 0¢8 (0¢49-1¢31) 0¢376
Socioeconomic status (Below 1¢47 (1¢35-1¢61) <0¢001 1¢43 (1¢2-1¢73) <0¢001 1¢97 (1¢69-2¢29) <0¢001 1¢54 (1¢3-1¢83) <0¢001 2 (1¢81-2¢21) <0¢001 1¢69 (1¢55-1¢85) <0¢001 2¢66 (1¢54-4¢58) <0¢001
average)
Peers were supportive
Sometimes 0¢74 (0¢69-0¢79) <0¢001 0¢73 (0¢64-0¢85) <0¢001 1¢1 (0¢93-1¢3) 0¢256 1¢14 (0¢99-1¢31) 0¢068 0¢94 (0¢85-1¢04) 0¢263 0¢85 (0¢74-0¢97) 0¢016 0¢72 (0¢54-0¢96) 0¢023
Most of the times 0¢61 (0¢53-0¢7) <0¢001 0¢59 (0¢46-0¢77) <0¢001 0¢81 (0¢67-0¢99) 0¢036 0¢78 (0¢61-1) 0¢048 0¢74 (0¢66-0¢82) <0¢001 0¢67 (0¢58-0¢78) <0¢001 0¢62 (0¢34-1¢14) 0¢124
<0¢001 0¢46 (0¢37-0¢58) <0¢001 0¢74 (0¢63-0¢88) <0¢001 0¢69 (0¢6-0¢79) <0¢001 0¢52 (0¢46-0¢6) <0¢001 0¢59 (0¢49-0¢71) <0¢001 0¢45 (0¢25-0¢79)

[m5G;February 13, 2020;20:21]

Always 0¢51 (0¢46-0¢57) 0¢005
Parents or guardians understood problem
Sometimes 0¢89 (0¢79-0¢99) 0¢040 0¢85 (0¢66-1¢1) 0¢215 1¢19 (1¢04-1¢35) 0¢010 0¢95 (0¢79-1¢15) 0¢604 1¢05 (0¢96-1¢16) 0¢304 1¢05 (0¢94-1¢17) 0¢382 0¢84 (0¢5-1¢4) 0¢500
Most of the times 0¢91 (0¢81-1¢02) 0¢107 0¢933 (0¢72-1¢2) 0¢590 0¢77 (0¢65-0¢92) 0¢003 0¢94 (0¢79-1¢12) 0¢489 0¢93 (0¢85-1¢02) 0¢116 0¢96 (0¢83-1¢11) 0¢597 0¢92 (0¢52-1¢63) 0¢773
Always 0¢85 (0¢77-0¢95) 0¢005 0¢95 (0¢74-1¢24) 0¢713 0¢82 (0¢68-0¢98) 0¢034 0¢75 (0¢67-0¢84) <0¢001 0¢77 (0¢69-0¢85) <0¢001 0¢89 (0¢76-1¢03) 0¢127 0¢77 (0¢54-1¢09) 0¢144
Parents or guardians knew about free time
Sometimes 0¢92 (0¢81-1¢04) 0¢163 0¢98 (0¢77-1¢27) 0¢899 1¢16 (1¢01-1¢33) 0¢034 1¢05 (0¢89-1¢24) 0¢557 1¢04 (0¢92-1¢17) 0¢556 0¢97 (0¢86-1¢08) 0¢531 0¢77 (0¢49-1¢2) 0¢245
Most of the times 0¢86 (0¢78-0¢95) 0¢002 0¢94 (0¢78-1¢13) 0¢515 0¢95 (0¢81-1¢1) 0¢485 1¢1 (0¢88-1¢37) 0¢407 0¢92 (0¢83-1¢03) 0¢152 0¢8 (0¢69-0¢92) 0¢002 1¢04 (0¢59-1¢83) 0¢895
Always 0¢77 (0¢7-0¢85) <0¢001 0¢86 (0¢71-1¢07) 0¢178 0¢92 (0¢76-1¢12) 0¢407 0¢94 (0¢83-1¢07) 0¢326 0¢68 (0¢62-0¢75) <0¢001 0¢73 (0¢62-0¢85) <0¢001 0¢66 (0¢41-1¢09) 0¢105
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T. Biswas et al. / EClinicalMedicine 00 (2020) 100276 7

We found both greater peer and parental support were associated Contributors
with a lower risk of bullying victimisation. This finding is consistent
with studies from HICs showing family and parental support are All authors critically reviewed earlier versions of the draft and
associated with lower levels of bullying [24,25]. In our study we approved the final manuscript. TB and AAM conceived the paper. TB,
found that higher prevalence of bullying victimisation amongst ado- JGS, MMH and MMH developed the analysis plan. TB did the analysis
lescents living in LMICs who reported lower levels of peer support and wrote the initial draft. TB, MMH, and MMH contributed to the
and parental support even though there is significant cultural and analysis. TDV, KM, HJT and JB contributed to the write up and editing.
demographic diversity between countries. Other studies have identi-
fied that parental monitoring can reduce engagement in high risk Declaration of Competing Interest
behaviours (including substance use) amongst adolescents [26,27].
Increased parental involvement and support for adolescents may All other authors declare no competing interests.
facilitate early detection of problematic peer relationships which
enables opportunities to for parents to assist adolescents with prob-
Acknowledgments
lem solving, appropriate assertive peer interactions and parental
intervention if required which may prevent bullying victimisation.
We thank the US Centers for Disease Control and WHO for making
Culturally appropriate skills training for parents of adolescents may
Global School-based Student Health Survey (GSHS) data publicly
assist in reducing bullying as well as reduce other mental health and
available for analysis. This research was partially supported by the
high-risk behaviours in adolescents in all countries, irrespective of
Australian Research Council Centre of Excellence for Children and
income level [28]. This may be an effective intervention to address
Families over the Life Course (project number CE140100027).
the relative increase in the global burden of mental disorders
amongst adolescents.
The present study has limitations. First, there is a risk of selection Supplementary materials
bias because school attendance is low in some counties and only chil-
dren that attend school participated. Further, some students were Supplementary material associated with this article can be found
absent from school on the day of data collection. Students who are in the online version at doi:10.1016/j.eclinm.2020.100276.
exposed to bullying victimisation have higher rates of absenteeism
from school and are more likely to exit education early [3]. Therefore, References
the prevalence of bullying victimisation may be underestimated due to
1 Azzopardi PS, Hearps SJ, Francis KL, et al. Progress in adolescent health and wellbe-
those students who are absent or out of education being more likely to
ing: tracking 12 headline indicators for 195 countries and territories, 1990 2016.
be victimised by their peers. This may also lead to differential bias in Lancet 2019;393(10176):1101–18.
prevalence in comparing LMIC HICs with variation in school atten- 2 Patton GC, Olsson CA, Skirbekk V, et al. Adolescence and the next generation.
dance by gender (females less likely to attend school in later ages in Nature 2018;554(7693):458.
3 Moore SE, Norman RE, Suetani S, Thomas HJ, Sly PD, Scott JG. Consequences of bul-
LMICs) and age (older adolescents less likely to attend). Second, the lying victimization in childhood and adolescence: a systematic review and meta-
GSHS measurement of bullying victimisation was self-reported. While analysis. World J Psychiatry 2017;7(1):60.
pez-Lo
4 Moore T., Kesten J., Lo  pez J., et al. The effects of changes to the built environ-
self-report is an accepted method of measuring bullying victimisation
ment on the mental health and well-being of adults: systematic review. 2018; 53:
in adolescents, there is a limitation of possible shared method variance 237 57.
[29]. The measure for peer support overlaps with the constuct of bully- 5 Brendgen M. Peer victimization and adjustment in young adulthood: introduction
ing. An item which assessed peer support in a manner which was more to the special section. J Abnorm Child Psychol 2018;46(1):5–9.
6 Espelage DL, Colbert CL. School-based bullying: definition, prevalence, etiology,
independent of bulllying would have been preferable. Another limita- outcomes, and preventive strategies. Critical issues in school-based mental health:
tion is the measure of socioeconomic status, which was based on a Evidence-Based Research, Practice, And Interventions 2016:132–44.
proxy derived from one variable and the study findings to the wider 7 Morrow V, Barnett I, Vujcich D. Understanding the causes and consequences of
injuries to adolescents growing up in poverty in Ethiopia, Andhra Pradesh (India),
population; given that some regions (European and African) were not
Vietnam and Peru: a mixed method study. Health Policy Plan 2013;29(1):67–75.
well represented in the study. The study design was cross-sectional, 8 Peyton RP, Ranasinghe S, Jacobsen KH. Injuries, violence, and bullying among mid-
therefore the establishment of causality was not possible. Finally, data dle school students in Oman. Oman Med J 2017;32(2):98.
9 Jadambaa A, Thomas HJ, Scott JG, Graves N, Brain D, Pacella R. Prevalence of tradi-
were collected between 2003 and 2015 presents differential significant
tional bullying and cyberbullying among children and adolescents in Australia: a
period effects on prevalence of bullying. However, our multivariable systematic review and meta-analysis. Aust NZ J Psychiat 2019 0004867419846393.
estimates were adjusted for period effects. 10 Przybylski AK, Bowes L. Cyberbullying and adolescent well-being in England: a
Nonetheless, the study has a number of strengths that help population-based cross-sectional study. Lancet Child Adolesc Health 2017;1
(1):19–26.
uniquely estimate the global prevalence of adolescents bullying vic- 11 Vazsonyi AT, Machackova H, Sevcikova A, Smahel D, Cerna A. Cyberbullying in con-
timisation. First, the GSHS methodology represents a collaborative text: direct and indirect effects by low self-control across 25 European countries.
standardized questionnaire. Data collection was standardized and Euro J Dev Psychol 2012;9(2):210–27.
12 Nguyen HTL, Nakamura K, Seino K, Al-Sobaihi S. Impact of parent adolescent
always occurred during a regular class period. The questionnaire did bonding on school bullying and mental health in Vietnamese cultural setting: evi-
not allow skip patterns in questions enabling consistency and unifor- dence from the global school-based health survey. BMC Psychol 2019;7(1):16.
mity of comparison across participant sites. Another strength is the 13 Hong JS, Espelage DL. A review of research on bullying and peer victimization in
school: an ecological system analysis. Aggress Violent Behav 2012;17(4):311–22.
use of survey data with large random sample sizes taken from a wide 14 Noltemeyer AL, Bush KR. Adversity and resilience: a synthesis of international
variety of international geographical and cultural settings. Finally, research. Sch Psychol Int 2013;34(5):474–87.
the analyses were inclusive of data from 83 countries. 15 Du C, DeGuisto K, Albright J, Alrehaili S. Peer support as a mediator between bully-
ing victimization and depression. 2018.
The findings of the study confirm that nearly one-third of the
16 WHO. Mental health status of adolescents in South-east Asia: evidence for action.
world’s adolescents had experienced bullying victimisation over the 2017.
previous 30 days. The variation between countries and regions and the 17 WHO. Global school-based student health survey (GSHS). http://www.who.int/
ncds/surveillance/gshs/en/ (Accessed 25 July 2019).
findings that peer and parental support reduces the risk of bullying can
18 WHO. Global school-based student health survey (GSHS) and global school health
inform interventions which may reduce the prevalence of bullying. policy and practices survey (SHPPS). 2012. http://www.searo.who.int/entity/non-
Given that bullying victimisation of adolescents in schools is a causal communicable_diseases/events/2013-gshs-survey-implementation-english-
risk factor of anxiety and depression [30], a meaningful reduction in the updated.pdf (Accessed 25 July 2019).
19 Xi B, Liang Y, Liu Y, et al. Tobacco use and second-hand smoke exposure in young
prevalence of bullying offers an opportunity to reduce the global burden adolescents aged 12 15 years: data from 68 low-income and middle-income
of disease associated with mental illness in adolescents. countries. 2016; 4(11): e795 805.

Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
parental supports, EClinicalMedicine (2020), https://doi.org/10.1016/j.eclinm.2020.100276
JID: ECLINM
ARTICLE IN PRESS [m5G;February 13, 2020;20:21]

8 T. Biswas et al. / EClinicalMedicine 00 (2020) 100276

20 Due P, Holstein BE. Bullying victimization among 13 to 15 year old school children: 26 Ewing BA, Osilla KC, Pedersen ER, Hunter SB, Miles JN, D'Amico EJ. Longitudinal
results from two comparative studies in 66 countries and regions. Int J Adolesc family effects on substance use among an at-risk adolescent sample. Addict Behav
Med Health 2008;20(2):209–22. 2015;41:185–91.
21 Han L, You D, Gao X, et al. Unintentional injuries and violence among adolescents 27 Tobler AL, Komro KA, Maldonado-Molina MM. Relationship between neighborhood
aged 12 15 years in 68 low-income and middle-income countries: a secondary context, family management practices and alcohol use among urban, multi-ethnic,
analysis of data from the global school-based student health survey. Lancet Child young adolescents. Prev Sci 2009;10(4):313–24.
Adolesc Health 2019. 28 Scott JG, Mihalopoulos C, Erskine HE, Roberts J, Rahman A. Childhood mental and
22 Craig W, Harel-Fisch Y, Fogel-Grinvald H, et al. A cross-national profile of bullying developmental disorders. 3rd Edition Mental, neurological, and substance use dis-
and victimization among adolescents in 40 countries. Int J Public Health 2009;54 orders: disease control priorities, 4. The International Bank for Reconstruction and
(2):216–24. Development/The World Bank; 2016.
23 Patton GC, Sawyer SM, Santelli JS, et al. Our future: A lancet commission on adoles- 29 Thomas HJ, Connor JP, Scott JG. Integrating traditional bullying and cyberbullying:
cent health and wellbeing. Lancet 2016;387(10036):2423–78. challenges of definition and measurement in adolescents a review. Educ Psychol
24 Burkhart KM, Knox M, Brockmyer J. Pilot evaluation of the act raising safe kids pro- Rev 2015;27(1):135–52.
gram on children’s bullying behavior. J Child Fam Stud 2013;22(7):942–51. 30 Gakidou E, Afshin A, Abajobir AA, et al. Global, regional, and national comparative
25 Graber JA, Nichols T, Lynne SD, Brooks-Gunn J, Botvin GJ. A longitudinal examina- risk assessment of 84 behavioural, environmental and occupational, and metabolic
tion of family, friend, and media influences on competent versus problem behav- risks or clusters of risks, 1990 2016: a systematic analysis for the global burden of
iors among urban minority youth. Appl Dev Sci 2006;10(2):75–85. disease study 2016. Lancet 2017;390(10100):1345–422.

Please cite this article as: T. Biswas et al., Global variation in the prevalence of bullying victimisation amongst adolescents: Role of peer and
parental supports, EClinicalMedicine (2020), https://doi.org/10.1016/j.eclinm.2020.100276