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RESEARCH ARTICLE Verbal Bullying Changes Among Students Following an Educational Intervention Using the Integrated Model for Behavior Change SALOSHNI NAIDOO, PhDa BENN K. SATORIUS, PhDb HEIN de VRIES, PhDc MYRA TAYLOR, PhDd ABSTRACT BACKGROUND: Bullying behavior in schools can lead to psychosocial problems. School-based interventions are important in raising student awareness, developing their skills and in planning to reduce bullying behavior. METHODS: A randomized controlled trial, using a school-based educational intervention to reduce verbal bullying, was conducted among grade 10 students in 16 urban and rural schools in KwaZulu-Natal, South Africa in 2013. Baseline and postintervention questionnaires, developed using the Integrated Model for Behavior Change theoretical model, were used to assess changes in verbal bullying. RESULTS: Postintervention there were reduced verbal bullying experiences. Improved social norms and awareness of verbal bullying were associated with reduced verbal bullying experiences and behavior. Although less likely to bully others verbally, girls were more likely to experience verbal bullying. Students with no living father were more likely to bully others verbally. CONCLUSIONS: The study findings indicate that a school-based intervention can positively impact on verbal bullying experiences and behavior. Keywords: bullying; Integrated Model for Behavior Change; school health instruction; verbal bullying. Citation: Naidoo S, Satorius BK, de Vries H, Taylor M. Verbal bullying changes among students following an educational intervention using the integrated model for behavior change. J Sch Health. 2016; 86: 813-822. Received on November 20, 2015 Accepted on June 5, 2016 Bullying is the repeated exposure of individuals to States when compared with physical (20.8%), social negative behavior perpetrated by another person (51.4%), and electronic (13.6%) bullying. or groups of people. These actions are distressing to Bullying in adolescents reported in several stud- ies globally highlights the individual and public the individual in the presence of a power imbalance health problem it poses among the youth. The reported prevalence of bullying in studies ranges between the perpetrator and the victim. Com- from a low of 4.8% to a high of 96.7%.1,2,4-9 There does not appear to be much difference in mon forms include verbal, physical, and relational bullying prevalence between Western and other bullying.1,2 Verbal bullying is characterized by name societies.1,2,8,9 calling, mocking, insulting, and being humiliated.3 Wang et al1 reported verbal bullying (53.6%) to be most prevalent among adolescents in the United aSenior Lecturer, ([email protected]), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, 2nd Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa. bAssistant Professor, ([email protected]), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, 2nd Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa. cProfessor, ([email protected]), Department of Health Promotion, School for Public Health and Primary Care (CAPHRI), Maastricht University, POB 616, 6200 MD, Maastricht, the Netherlands. dAssistant Professor, ([email protected]), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, 2nd Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa. Address correspondence to: Saloshni Naidoo, Senior Lecturer, ([email protected]), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, South Africa, 2nd Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa. The authors acknowledge the South African Medical Research Council for funding this project; the KwaZulu-Natal Department of Education for permitting the study; the principals, teachers, and students for supporting and participating in the study. We also acknowledge N. Dlamini, Z. Khanyile, S. Mpanza, M. Ngcongo for facilitating the field work on this study. Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association • 813

Risk factors for bullying include being a victim behavior including substance abuse when compared with victims of bullying. Importantly children who of domestic abuse, and living in the presence of experienced acquired immunodeficiency syndrome community violence.10-12 Adolescents from homes (AIDS)-related stigma are more likely to be bullied than their counterparts.11 in which there were authoritarian rearing patterns are more likely to be bullies.10 Adolescent boys are Hall and De Lannoy29 report that 97% of South more likely to bully or be victims of bullying.4,9,10 Africa’s children aged 7 to 17 years attend educational facilities. While 99% of 7- to 13-year-olds attend Boys are also more likely to be bullied by boys rather school, there is a rapid drop with 89% of 17-year- than girls.10 Younger adolescents, who feel alone, are olds attending school. Whereas reasons for dropping out of school are multifactorial, attention needs to be anxious and do not have friends are more likely to be paid to the school environment to identify factors, bullied.5 Adolescents who are close to their parents including bullying, which are contributing to students are more likely to be bullied.10 Bullies are more leaving school. Furthermore in the present context of the stigma related to the human immunodeficiency likely to come from a high socioeconomic environment (HIV)/AIDS epidemic in South Africa, the potential for bullying and victimization in schools does exist. As part whereas victims of bullying are more likely to come of a larger study of gender violence this paper reports from a low-socioeconomic environment.9,10,13 on changes in verbal bullying among adolescents following the use of an education intervention using The long-term impact of bullying on individuals has the Integrated Change Model.30-32 Verbal bullying in this study context, refers to the passing of negative implications for individual performance in adulthood comments about and demeaning of others. and for communities at large. Adolescent victims of The main goal of this article is to assess the effects of a school-based program preventing belittling on bullying tend to display psychological problems which cognitions, such as attitudes, social norms, and self- include depression,14,15 reduced self-esteem,15,16 and efficacy as well as on belittling behavior. anxiety.17 In the United Kingdom, Stapinski et al17 METHODS found that adolescent victims of bullying displayed Participants both immediate and delayed anxiety and depression, This randomized control trial (RCT) was conducted whereas among Peruvian adolescents, Lister et al18 among adolescents in a rural (Ugu) and urban reported increasing emotional and mental stress (eThekwini) district of KwaZulu-Natal, South Africa using an educational intervention between February among bullied adolescents. Bullying also can lead and October 2013. The proposed sample size of 240 in the intervention and 240 in the control to increased substance abuse with perpetrators more groups, respectively, when sampling 8 clusters with 30 participants each in the intervention and control likely to be involved in substance abuse as they grow groups (16 clusters in total), would achieve 80% older.19-21 Displays of violence have been reported in power to detect an absolute difference between the bullies and bullied victims. Camodeca and Goosens22 group proportions of 0.15% or 15%, assuming a baseline prevalence of bullying of 0.3% or 30% in the reported proactive violence in bullies and reactive control group and an intraclass correlation coefficient (ICC) of 0.03.33 The test statistic used is the 2-sided violence among both bullies and victims of bullying. Z-test (unpooled) and/or 2-sided score test.34 The significance level of the test was assumed at .05. Suicidal ideation and attempts at suicide are likely to A total of 16 schools (8 urban and rural, respec- occur in the presence of bullying and increase in risk tively) were randomly selected from a list of schools obtained from the KwaZulu-Natal Provincial Depart- relative to an increase in the types of victimization ment of Education. Eight schools were randomly being experienced.14,23 allocated to receive the intervention. In each school a single grade 10 class was randomly chosen for partici- A variety of intervention studies have been pation in the study. All students in the grade 10 class were invited to participate in the study. Two schools conducted to reduce bullying among adolescents in did not participate in the postintervention survey. At schools.24,25 These studies have included curriculum- baseline survey 685 students participated with a total based interventions such as lectures and video recordings delivered in the school focusing on a specific age group, multidisciplinary interventions which included training teachers, students, and parents focusing on the entire school, and, interventions which have focused on developing social and behavioral skills using peer mentoring and social workers.24-27 In South Africa several studies have described the extent of bullying with the prevalence of bullying among adolescents in South Africa ranging between 11% and 52%, with boys reporting higher levels of bullying than girls.4,11,18,28 Bullying among South African youth has been associated with several negative outcomes. Townsend et al28 reported that girls who had participated in bullying and were victims of bullying were more likely to drop out of school when compared with other youth. Liang et al4 reported that perpetrators of bullying were more likely to indulge in risk taking, and antisocial 814 • Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association

of 434 students having participated in the baseline and questions (α = .79), and a single question each assessed follow-up questionnaire survey of the study. Informed action plans and goals. written consent was obtained from their parents or guardian and the students assented to participate in Questions were also asked about their personal the study. experience of being verbally bullied by family, friends, and teachers in the past month and themselves having Instrumentation verbally bullied family, friends, and teachers in the The Integrated Model for Behavior Change Theo- past month. retical model was used as the conceptual framework Data Collection Procedure on which the questionnaire was developed. We have Data collection took place at baseline and then used the model previously and validated this in our population.35,36 A qualitative pilot study conducted in 4 months after implementation of the intervention. a sample of 2 schools from the study areas prior to Appointments were scheduled with each school and the onset of the RCT informed the development of a fixed time was allocated in the school day for the questionnaire used in this study. This quantitative students to complete the questionnaire. The students questionnaire was piloted in 2 grade 10 classes in an were informed about the study by trained researchers urban and a rural school and relevant changes were familiar with the project. After assenting, students made for use in this study. The questions assessed were provided with a questionnaire which took students’ responses on a 5-point Likert-type scale. The approximately 30 minutes to complete. Cronbach α for reliability of questions relating to each construct was calculated and ranged from .63 to .88. Intervention The intervention program was developed to address Predisposing factors. Information on demographics (biological factors), household income and composi- the topics raised in the focus group discussions which tion (social factors) was collected. These included sex, had been held as part of the exploratory research and age, home location, with whom they lived at home, if the generalizability of the data was confirmed by a their parents were alive and household assets. questionnaire. The intervention program comprised weekly modules to address gender-based violence and Awareness. Knowledge was assessed with 2 items bullying and was piloted in 2 schools prior to the RCT. testing participants’ understanding of verbal bullying For the RCT, the selected schools (intervention and (α = .81). There were 9 items measuring cues control) were invited to participate and the purpose of supporting verbal bullying which included observing the program was explained. There was good support verbal bullying in the family or community or on from the school principals and in the first half of television (α = .63). the year the trained facilitators (2 teams of male and female facilitators) visited each of the interventional Motivation factors. Attitudes were measured by schools once a week and were given one lesson attitudes promoting (α = .87) and attitudes preventing period in which to undertake the program. Each (α = .88) verbal bullying using 3 and 5 items, module had specific objectives and the class room respectively. Promoting attitudes included considering activities varied. These comprised small and large verbal bullying fun, making one feel good, and group discussions, role plays, videos (professionally being more popular. Preventive attitudes included made with local content), an innovative cartoon story considering verbal bullying as unkind, negative, (used to promote discussion) and creative drawing. disrespectful, unfair, and a threat to good relationships. The content of the 20 weekly modules focused on the following: Introduction and Getting to Know Social Influences preventing verbal bullying were Yourself, Gender Roles and Gender Issues, Peer assessed through norms, support, and modeling. Six Pressure, Decision Making, Characteristics of a Good questions each on social norms (α = .89), support Relationship, Gender Inequality and Power (including (α = .88), and modeling (α = .77) covered normative, Verbal bullying, Hitting, and Forced Sex), and supportive, and modeling behavior among family, Culture and Human Rights. The students completed a teachers, and friends in the participant’s social circle. questionnaire prior to the initiation of the program and again 5 months after the completion of the program. Self-efficacy behavior which prevented verbal Students at the control schools participated in the bullying was assessed through 9 questions that covered Department of Basic Education’s Life Skills’ Program regular (4 questions; α = .73) and situational behavior which forms part of the school curriculum but does (5 questions; α = .88). not focus on gender-based violence. The program used in the intervention was therefore provided to schools Intentions. Students’ intentions to not indulge in at the end of the study. verbal bullying toward others and in the subsequent 6 months were assessed by 6 questions (α = .84). Ability factors. The ability factors influencing students’ behavior were assessed through action skill plans and goals. Action skills were assessed by 3 Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association • 815

Figure 1. School and Student Participation by Intervention and Location. Total Number of Schools (N =1 6) Students Recruited (N = 685) Intervention Control School (N=8) School (N=8) Urban Rural T1 Urban Rural School (N = 4) School (N = 4) School (N = 4) School (N = 4) Students (N = 182) Students (N = 137) Students (N = 181) Students (N = 185) School (N = 3) School (N = 4) T2 School (N = 4) School (N = 3) Students (N = 86) Students (N = 105) Students (N = 138) Students (N = 105) Data Analysis. Data were processed and analyzed An adjusted p-value of less than .05 was deemed using Stata 13.0 (StataCorp. 2013, StataCorp LP: Stata statistically significant. Statistical Software: Release 13. College Station, TX). A socioeconomic status index (SES) was created using RESULTS multiple correspondence analysis (MCA) to weight the following categorical variables (employment, asset Participation of Students ownership, and hunger).37 The weighted scores for At baseline (T1) a total of 685 students participated each were summed to give an overall SES score. This score was categorized into tertiles (low, medium, and from 16 schools with an equal distribution of rural high). A single composite independent variable was and urban schools. Postintervention (T2) 1 urban created for each construct based on a summation intervention school and 1 rural control school did not of the students’ responses to the questions relating participate. The mean age of the 251 (36.6%) students to the specific construct. Two composite dependent who were lost to follow-up (mean: 16.6 years; 95% variables (having experienced verbal bullying in the CI: 16.7-17.2) was similar to that of the students who past month and having verbally bullied people in the continued in the study. A total of 122 boys (48.6%) past month) were created based on students’ responses and 129 girls (51.4%) were lost to follow-up with to having been verbally bullied by and having verbally 123 (49.2%) and 128 (50.8%) being from control bullied family, friends and teachers in the past month. and intervention schools, respectively. There were 112 Survey weights were incorporated using the svyset (44.6%) rural and 139 (55.4%) urban students lost to command given the complex multistage random follow-up. Overall, 434 (63.4%) students participated sampling strategy and utilized in the regression analysis at T1 and T2 (Figure 1) and our results refer to these to correctly weight point estimates and calculate students. 95% confidence intervals (CIs). Frequencies and means with 95% CIs were calculated for categorical Demographic Profile of Students and continuous variables respectively. Design based Randomization of the students participating in the (ie, survey weighted) multivariable linear regression was performed to assess the primary effect of the study was taken to be successful because for the most intervention as well as other factors associated with part there was no demographic difference between the exposure to and experience of verbal bullying. Age students from the intervention and control schools. was included as a confounder in the analyses as Only the mean age of students in the intervention it was significantly different across the trial arms. schools was slightly higher than that of students from the control schools (p = .043) (Table 1). 816 • Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association

Table 1. Baseline Demographic Profile of Students by of the intervention was found. Experiences of verbal Intervention (N = 434) bullying at post-test were significantly predicted by being younger (p = .024), female (p = .025), and Intervention Control experiencing more social norms against bullying (N = 191) (N = 243) p-Value (p = .008). Reports of increased cues about verbal bullying significantly reduced students experiencing Age (mean; 95% CI; years) 16.9 (16.7-17.2) 16.54 (16.4-16.7) .043 verbal bullying in the past month (p = .004) (Table 3). Sex (N, %) .351 100 (51.9) 136 (59.8) Verbal Bullying of Other People Boys 91 (48.1) 107 (40.2) .727 Comparing the verbal bullying of other people in Girls Location (N, %) 86 (13.4) 138 (19.4) .275 the intervention group versus control, from baseline to Urban 105 (86.6) 105 (80.6) postintervention (p = .042) was significantly reduced. Rural .157 Furthermore, being female (p < .001) and students Person living with (N, %) 133 (67.3) 181 (74.3) .770 living in an urban (p = .047) area were less likely to At least one parent 54 (30.4) 53 (24.5) .454 verbally bully people in the past month even when Family member other than parent 3 (2.3) 4 (1.2) covariates were included in the model. Students whose Unrelated to person 88 (27.9) 106 (22.4) father was not alive were more likely to report having Mother not alive 156 (44.5) 218 (46.4) verbally bullied people in the past month (p = .036). Father not alive Furthermore, high levels of awareness reduced verbal Socioeconomic status∗ 35 (17.8) 94 (11.4) bullying of others in the past month (p = .016) Low 59 (21.4) 96 (22.6) (Table 4). Medium 142 (60.8) 235 (66.0) High DISCUSSION ∗Survey weighted. In the current context of bullying4,38 in South African schools, a school-based intervention aimed at Comparison of Verbal Bullying Specific Variables Pre- reducing bullying will be beneficial. The findings of this study highlight that positive changes can be achieved and Postintervention with school-based interventions seeking to reduce bullying among students. This study found significant On the basis of bivariate analysis significant changes changes in awareness, motivation, intentions, and were noted within the intervention and control stu- ability among students who participated in an dent groups and between the intervention and control educational intervention on gender-based violence student groups from baseline to postintervention. and bullying on bivariate analysis and reduction in However the intervention group did not fare better verbal bullying behavior on multivariate analysis. than the control arm in experiencing verbal bullying. If anything postintervention social norms preventing Knowledge and awareness are known to have verbal bullying (p = .005) were significantly higher a positive impact on personal behavior. Studies in the control group compared with the intervention among patients with chronic diseases of lifestyle group postintervention (Table 2). have shown that raised awareness improves per- sonal health behavior.39 This study has shown rais- In the intervention group there was a significant ing awareness among students about verbal bullying improvement postintervention in the mean knowl- through a school-based intervention has the poten- edge of verbal bullying (p < .001), attitudes preventing tial to empower students, ensuring that they do not verbal bullying behavior (p = .001), intentions to not indulge in verbal bullying and avoid being verbally verbally bully (p = .010) and having an action plan bullied themselves. Several studies in a systematic against verbal bullying in the future (p = .004). The review of school-based interventions to prevent bully- mean of having verbally bullied people (p = .030) or ing reported reductions in bullying and victimization having experienced verbal bullying (p = .043) in the following implementation of the intervention.22 past month also significantly decreased from baseline to postintervention (Table 2). There was an improvement in motivational factors with students receiving the intervention in this study Among the control group of students there showing improvements in their attitudes against verbal were significant improvements in knowledge of bullying and toward factors which prevented verbal verbal bullying (p = .022), attitudes against (p = .016) bullying (bivariate analysis). A study conducted among and preventing (p = .002) verbal bullying, regular Greek primary school children using an education self-efficacy preventing verbal bullying (p = .013), intervention embedded in the school curriculum situational self-efficacy preventing verbal bullying found that there was a significant improvement in (p = .043), having an action skill against verbal bullying (p = .015) (Table 2). Having Experienced Verbal Bullying To assess the effect of the intervention and other factors on experiencing verbal bullying a multivariate linear regression was conducted. No significant effect Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association • 817

Table 2. Mean Scores (95% CI) for Responses on Verbal Bullying Experienced and Perpetrated and Determinants Among Students at T1 and T2 by Intervention and Control Using a Regression Approach Corrected for Age (N = 434) Intervention Control p-Value p-Value p-value p-Value (Intervention (Intervention T2 (Intervention T1 T2 T1 Versus T2)∗,† T1 (Control T1 T1 Versus Versus T2 Versus T2)∗,† Control T1)∗,† Control T2)∗,† Knowledge of verbal 7.2 (6.8-7. 6) 8.1 (7.5-8.6) <.001 7.5 (6.52-8.4) 8.3 (7.8-8.7) .022 .717 .763 .135 22.3 (18.1-25.6) 21.6 (18.5-24.7) .329 .919 .221 bullying .225 20.2 (17.8-22.6) 22.3 (21.0-23.7) .016 .922 .065 .001 14.6 (12.1-17.1) 16.5 (12.2-18.7) .002 .593 .452 Cues about verbal bullying 20.7 (20.9-22.4) 23.1 (21.4-24.8) .464 16.9 (3.7-30.1) 24.6 (23.6-25.6) .199 .253 .005 .105 26.0 (24.3-27.7) 26.8 (25.7-27.9) .269 .224 .220 Attitudes against verbal 19.8 (17.3-22.4) 20.9 (20.4-21.5) .956 20.9 (19.7-21.9) 21.8 (20.2-23.4) .308 .920 .491 bullying .166 .013 .203 .690 Attitudes preventing 13.9 (13.5-14.5) 15.5 (14.4-16.6) .191 .043 .527 .705 verbal bullying .010 .052 .936 .607 .004 .079 .728 .992 Social norms preventing 22.4 (22.8-22.7) 22.8 (21-9-23.7) .066 .015 .242 .584 .157 .733 .786 .527 verbal bullying .043 .629 .935 .940 Social support preventing 25.0 (22.8-26.3) 25.9 (24.9-26.9) .030 .936 .627 .136 verbal bullying behavior Modeling behavior 21.1 (20.0-22.8) 21.1 (20.2-21.9) preventing verbal bullying Regular self-efficacy 13.9 (13.1-14.8) 14.3 (13.5-15.1) 13.0 (11.5-14.6) 14.6 (13.9-15.3) preventing verbal bullying Situational self- efficacy 17.7 (16.3-19.0) 18.5 (15.8-21.1) 17.2 (14.8-19.7) 18.9 (17.5-20.8) preventing verbal bullying Intentions to not verbally 20.8 (20.6-21.1) 22.7 (21.3-24.0) 21.34 (17.9-24.69) 23.64 (20.6-26.7) bully Having an action plan 10.6 (9.9-11.1) 11.5 (10.8-12.2) 10.8 (9.8-11.8) 11.6 (10.7-12.4) against verbal bullying Having an action skill 3.8 (3.4-4.1) 4.1 (3.7-4.4) 3.5 (3.1-3.9) 3.9 (3.6-4.3) against verbal bullying Having an action goal 3.9 (3.7-4.1) 4.8 (3.9-4.4) 3.9 (3.7-4.2) 4.1 (3.7-4.4) against verbal bullying Experienced verbal 17.8 (16.6-19.0) 17.0 (16.0-18.0) 18.6 (10.8-26.4) 18.1 (16.5-19.6) bullying in the past month Verbally bullied people in 31.5 (29.8-33.4) 29.6 (29.3-29.9) 30.2 (26.8-33.6) 31.1 (29.9-32.2) the past month ∗Survey weighted linear regression. †Adjusted for age difference between trial arms. positive attitudes toward victims, negative attitudes within social groups influence adolescent risk behavior toward bullies, and less bullying behavior following such as substance abuse.42 Family, school, and peer the intervention.40 Whereas one would have expected influences play an important role in the development significant improvements in the intervention group as of prosocial norms in individuals. In childhood compared with the control group, the improvements parental influences are far greater but in adolescence in the attitudes against verbal bullying seen among the school environment has an important effect.43 controls may be as a result of increased awareness Thus, school-based interventions that can positively following involvement in the baseline study. influence prosocial norms are important in reducing antisocial behavior. The multivariable analysis suggests that improve- ments in social norms preventing verbal bullying were Increasing age was significantly associated with a associated with a decrease in the experiences of having decrease in verbal bullying experiences in our study been verbally bullied. Social environments and norms population postintervention. Bullies are more likely are important in shaping behavior among adolescents. to be older and victims of bullying are younger.44,45 Spending time with parents and parental support is With increasing age a student may be better equipped known to be protective against bullying behavior and to resist bullying, and thus, less likely to be a victim victimization in youth.41 Studies have found that being as opposed to younger counterparts who may find it exposed to negative experiences including community difficult to stand up to older students in the school and domestic violence are significant predictors of setting. This points to the need for targeted programs bullying behavior.8,12 Furthermore peer influences 818 • Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association

Table 3. Multivariable Models of Having Experienced Verbal Bullying in the Past Month—Intervention Versus Control Experienced Verbal Bullying in the Past Month Model 1 Model 2 Model 3 p-Value Coeff. (95% CI) p-Value Coeff. (95% CI) p-Value Coeff. (95% CI) .930 Intervention (T2 versus T1) 0.2 (−4.9 to 5.3) .934 0.5 (−5.1 to 6.1) .842 0.2 (−4.5 to 4.9) Sociodemographic (baseline predictors) .024 Age −0.7 (−1.1 to −0.2) .009 −0.7 (−1.2 to −0.1) .023 Sex (Female) 1.7 (0.2 to 3.3) .031 1.7 (0.3 to 3.2) .453 Location (Urban) 0.7 (−1.7 to 3.1) .537 0.9 (−1.7 to 3.7) Person live with .945 1 1 .241 At least one parent −0.3 (−2.3 to 1.8) .766 −0.21 (−2.2 to 2.1) Other family member −1.6 (−5.2 to 2.1) .371 −2.2 (−6.1 to 1.7) .742 Outsider .287 Socioeconomic status∗ 11 .870 Low .939 Medium −0.3 (−2.0 to 1.4) .723 −0.3 (−2.1 to 1.6) High .462 Mother not alive 1.0 (−0.8 to 2.8) .260 1.0 (−0.9 to 3.0) .004 Father not alive .454 Change in verbal bullying specific covariates −0.2 (−2.5 to 2.2) .891 −0.2 (−2.7 to 2.3) .791 Knowledge of verbal bullying .008 Cues about verbal bullying behavior 0.23 (−1.3 to 1.7) .746 −0.1 (−1.6 to 1.5) .679 Attitudes against verbal bullying .274 Attitudes preventing verbal bullying −0.1 (−0.4 to 0.2) .235 Social norms preventing verbal bullying −0.1 (−0.2 to 0.1) .103 Social support preventing verbal bullying 0.04 (−0.1 to 0.2) .688 Modeling behavior preventing verbal bullying 0.02 (−0.1 to 0.1) .753 Regular self-efficacy preventing verbal bullying −0.1 (−0.2 to 0.03) .691 Situational self-efficacy preventing verbal bullying −0.01 (−0.1 to 0.04) .439 Intentions to not verbally bully Having an action plan against verbal bullying 0.1 (−0.1 to 0.2) Having an action skill against verbal bullying −0.1 (−0.2 to 0.04) Having an action goal against verbal bullying 0.1 (−0.03 to 0.3) 0.02 (−0.1 to 0.1) −0.04 (−0.3 to 0.2) −0.1 (−0.6 to 0.4) 0.3 (−0.6 to 1.2) ∗Using multiple correspondence (MCA) to weight the following variables (employment, asset ownership, and hunger). aimed at younger students so as to better equip them leads to increased anxiety, depression, and potential with the skills to negotiate relationships at school. suicidal tendencies among victims.14,38 Bullying of any kind can lead to gender-based violence among adoles- In the intervention group of students in this study cents which may persist into adulthood. In South there were improvements with intentions and action Africa, the prevalence of gender-based violence is planning against verbal bullying postintervention. estimated to be 20% and 30%.48 A consequence of Action planning and intentions in other settings have violence may be forced sex that increases the risk for been shown to be important contributors to developing HIV transmission in endemic environments,49 which and sustaining health protective behaviors among has long-term implications for adolescents. participants.46,47 Having positive intentions against verbal bullying lends itself to positive action planning Postintervention there was a reduction in verbal which is likely to reduce verbal bullying behavior and bullying of people in the past month (p = .042). protect against being victims of verbal bullying. Students from urban schools were less likely to have verbally bullied people following the intervention. We found that girls were less likely to verbally bully Rural youth in other populations have reported higher but they were more likely to be verbally bullied. A levels of bullying as compared with urban youth.50 study from Brazil found that adolescent girls were sig- Our finding would suggest that future interventions nificantly less likely to participate in verbal bullying as for verbal bullying among South African youth must compared with boys,9 while work among Indian youth have a targeted intervention for rural schools. reported boys were more likely to be bullies and victims (27.9%) when compared with girls (12.0%).7 In South The association between a father who had died African schools Liang et al4 found that boys were sig- and increased verbal bullying was seen in this nificantly more likely than girls to be bullies, victims study. Involvement of a father in a child’s life has or bully-victims (p < .01 to .03). Boyes et al38 reported been associated with decreased bullying.10 This is an more relational bullying victimization among South important issue to consider among students in South African adolescent girls as compared to boys. Bullying Africa in the presence of the HIV epidemic which is Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association • 819

Table 4. Multivariable Models of Having Verbally Bullied People in the Past Month—Intervention Versus Control Verbally Bullied People in the Past Month Model 1 Model 2 Model 3 Coeff. (95% CI) p-Value Coeff. (95% CI) p-Value Coeff. (95% CI) p-Value Intervention (T2 versus T1) −1.0 (−1.9 to 0.01) .052 −0.9 (−1.7 to −0.1) .030 −0.9 (−1.7 to −0.04) .042 Sociodemographic (baseline predictors) Age −0.01 (−0.2 to 0.1) .823 −0.01 (−0.15 to 0.16) .942 Sex (Female) z−1.0 (−1.4 to −0.7) <.001 −1.1 (−1.4 to −0.7) <.001 Location (Urban) −0.54 (−1.1 to 0.02) .058 −0.6 (−1.1 to 0.01) .047 Student lives with at least one parent 11 Student lives with family member other than parent 0.04 (−0.7 to 0.7) .788 0.02 (−0.7 to 0.7) .950 Student lives with an outsider 0.2 (−0.4 to 8) .487 −0.2 (−0.4. to 0.8) .852 Socioeconomic status∗ Low 1 1 Medium 0.4 (−0.6 to 0.7) .888 0.02 (−0.67 to 0.71) .950 High 0.2(−0.4 to 0.78) .487 0.2 (−0.4 to 0.8) .520 Mother not alive −0.02 (−0.7 to 0.67) .958 −0.03 (−0.7 to 0.62) .932 Father not alive 0.2 (−0.02 to 0.5) .069 0.3 (0.02 to 0.5) .036 Change in verbal bullying specific covariates Knowledge of verbal bullying −0.06 (−0.1 to −0.01) .016 Cues about verbal bullying behavior −0.02 (−0.1 to −0.03) .294 Attitudes against verbal bullying behavior −0.01 (−0.1 to 0.03) .640 Attitudes preventing verbal bullying behavior −0.01 (−0.1 to 0.02) .425 Social norms preventing verbal bullying behavior −0.01 (−0.04 to 0.02) .662 Social support preventing verbal bullying behavior 0 (−0.04 to 0.1) .904 Modeling behavior preventing verbal bullying 0.02 (−0.04 to 0.08) .477 Regular self-efficacy preventing verbal bullying −0.01 (−0.04 to 0.03) .706 Situational self-efficacy preventing verbal bullying 0.02 (−0.02 to 0.1) .241 Intentions to not verbally bully −0.02 (−0.1 to 0.02) .360 Having an action plan against verbal bullying −0.03 (−0.1 to 0.03) .245 Having an action skill against verbal bullying 0.04 (−0.23 to 0.32) .742 Having an action goal against verbal bullying 0.2 (−0.1 to 0.13) .725 ∗Using multiple correspondence (MCA) to weight the following variables (employment, asset ownership, and hunger). leaving many children orphaned. There is a need for Department of Basic Education passed the Integrated positive male role models in such circumstances. School Health Policy in 201252 which provides for the appointment of school health teams comprising nurses Although this study reported positive reductions who support the school community creating safe in verbal bullying among participants there were and secure environments for children. Gender-based several limitations which need to be addressed when violence and bullying are among the core areas of focus implementing a school-based intervention in the for the school health teams.52 Thus, using a school- South African context. More than one third of the based educational program with teachers and peers study population was lost to follow-up due to schools trained to deliver the intervention and school health leaving the study citing the pressure of examinations teams providing support for bully victims and trainers as the reason for withdrawing. Our study did not is likely to be successful. This would also ensure evaluate implementation of the program which may the sustainability of the program. This study was have impacted on the loss to follow-up which was designed to be completed within a year, and has shown witnessed in this study. The intervention was delivered potential but it has not been able to demonstrate to a single class by facilitators who visited the school long-term improvements nor whether the reduction in as opposed to being delivered to the whole school, and bullying and attitudes to bullying will be sustained. In by staff based at the schools. There was no continuous conclusion, whereas a school-based training program reinforcement and support for students in the school. was shown to achieve a degree of success in this Schools do not provide counseling for students. The study, teacher and school health team involvement is class and school environment at large can contribute to necessary to ensure sustainability of the program. bullying behavior. Interventions which focused on the whole school and made use of teachers and peers in IMPLICATIONS FOR SCHOOL HEALTH school antibullying programs have been successful.24 Bullying in schools can be addressed by educational Low et al51 in the Steps to Respect project showed that programs such as this program. The implementation student engagement and support were very important in achieving program outcomes. The South African 820 • Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association

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