Peer Victimization and Subjective Health- A comparison be-
tween students with and without disabilities in Sweden
Lijin Su
Two-year master thesis 15 credits Supervisor
Interventions in Childhood Lilly Augustine
Examinator
SCHOOL OF EDUCATION AND COMMUNICATION (HLK) Jönköping University
Master Thesis 15 credits Interventions in Childhood Spring Semester 2021
ABSTRACT
Author: Lijin Su Main title
Peer Victimization and Subjective Health- A comparison between students with and without disa- bilities in Sweden
Pages: 48
Bullying can have a negative impact on children’s development and mental health. Students with disabilities are more likely to be targeted for bullying than students without disabilities. In particu- lar, studies have shown that students with disabilities are at greater risk of bullying than students without disabilities. In addition, children with disabilities have higher risk of low subjective health. Results showed that there were significant differences in the dependent variables among four dif- ferent groups of bullying participants (disabled victims, victims without disabilities, non victims with disabilities and non-victims without disabilities). Non-disabled students who were not bullied had the highest level of subjective health, while the subjective health of disabled students who are not bullied is higher than that of disabled students who are bullied and non-disabled students who are bullied. This means that as the risk of exposure to bullying increases, the subjective health of children with disabilities will be further lower. Children with disabilities alone have higher life satisfaction than those with disabilities who and bullied and have higher life satisfaction than those bullied without disabilities. And children with disabilities are more likely to report somatic and psychological symptoms than children without disabilities. Children who were bullied reported more somatic symptoms than children who were not bullied. Therefore, schools should establish student violence prevention interventions to reduce peer victimization regardless of students’ disabilities.
Keywords: peer victimization, bullying, life satisfaction, self-rated health, health complaints, sub- jective health Postal address Högskolan för lärande och kommunikation (HLK) Box 1026 551 11 JÖNKÖPING Street address Gjuterigatan 5 Telephone 036– 101000 Fax 036162585
Table of Content
Introduction ... 1 Background ... 4 2.1 Disability ... 4 2.2 Subjective Health ... 5 2.2.1 Self-rated health ... 6 2.2.2 Life satisfaction ... 7 2.2.3 Health complaints ... 8 2.3 Bullying ... 92.3.1 The definition of bullying ... 9
2.3.2 Forms of bullying ... 10
2.3.3 Students with disability and peer victimization ... 11
2.3.4 Peer victimization and subjective health ... 12
2.4 Theoretical Framework ... 13
2.5 Research Aim and questions ... 14
Method ... 15 3.1 Study design ... 15 3.2 Participants ... 15 3.3 Instrument ... 16 3.31 Independent Variables ... 17 3.32 Dependent Variables ... 17 3.4 Procedure ... 18 3.4.1 Data collection ... 18 3.4.2 Data analysis ... 19 3.5 Ethical Consideration ... 19 Results ... 22
Table 2. The characteristics and related measurements of the study population from different groups ... 23
Table 3. Normality tests results ... 24
Fig 3. Box plot of life satisfaction in the four victim and disability groups ... 24
Fig 4. Bar chart of health/not so health status in the four victim and disability groups ... 25
Fig 5. Physical symptoms score in the four victim and disability groups... 26
Fig 8. Health complaints comparisons in have experienced peer victimization/never groups..27
Discussion ... 28
5.1 Reflection on findings ... 28
5.2 Methodological discussion and limitations ... 29
5.3 Future research and practical implications ... 30
6 Conclusion ... 32
7 References ... 33
Introduction
Preventing bullying will prevent future health problems and as such bullying is a serious public health issue. Bullying is defined as a form of aggression that is repetitive, deliberate, and involves an unequal power relationship (physical, social or emotional power) between the bully and the victim (Olweus, 2001, 2013). According to the Convention on the Rights of the Child,
children should be brought up in a spirit of peace, dignity, tolerance, freedom, equality and soli- darity (Unicef, 1989). Therefore, education should provide children with a peaceful and caring learning environment. However, bullying in school is commonly experienced by students in many countries around the world (Due & Bjørn, 2008). The proportion of adolescents who were bul- lied was on average 10 per cent, with prevalence of reported being bullied ranging from 0.5 per cent for girls aged 13 in Iceland to 32 per cent for boys aged 13 in Lithuania across the 45 coun- tries and regions involved in the Health Behavior in School-age Children 2017/2018 Survey
(WHO, 2020). Although in Sweden, according to the Education Act (2010:800), Swedish schools are obliged to take measures to prevent school bullying. Since 2014, however, there has been an increase in bullying victimization in Sweden from 4 per cent to 8 per cent for boys and 7 per cent to 10 per cent for girls (WHO, 2020).
Peer victimization increases the risk of mental health problems for children and adolescents (Bond, Carlin, Thomas, Rubin, & Patton, 2001; Takizawa, Maughan, & Arseneault, 2014; Wolke, Copeland, Angold, & Costello, 2013). Students who are bullied have a range of negative psycho- somatic issues (Gini & Pozzoli, 2009; Yen et al., 2014). Common psychological problems for vic- tims include anxiety and depression, while somatic include headaches, stomach aches, and sleep problems (Gini & Pozzoli, 2013; Zablotsky, Bradshaw, Anderson, & Law, 2013b). Also, in a lon- gitudinal study, the experience of bullying was found to be a risk factor for later self-harm among adolescents (Lereya et al., 2013). At the same time, physical and psychosocial problems caused by bullying may persist from adolescence to adulthood (Bond et al., 2001; Fekkes, Pijpers, Fredriks, Vogels, & Verloove-Vanhorick, 2006; Lund et al., 2008).
The risk for victimization is not random. Some students are more at risk for becoming a vic- tim of bullying, one of these risk factors is having a disability (Blake, Lund, Zhou, Kwok, & Benz, 2012). In a Swedish survey of sixth and ninth grade students, students with disabilities are four times more likely to be bullied than students without disabilities (disability includes: epilepsy, dia- betes, visual and/or hearing impairment, dyslexia and physical disability) (Fridh, 2018). As
reported in a review of the literature on bullying perpetration and victimization among students with disabilities(Rose, Monda-Amaya, & Espelage, 2011), students with disabilities are bullied at a higher prevalence rate than students without disabilities, but the rate of peer victimization varies with the type of disability. A cross sectional study in the United States examined the risk of bully- ing victimization among children with autism, intellectual disability, physical disability, speech im- pairment, emotional disturbance, learning disability, and ADHD, and found that children with ADHD were at the greatest risk of victimization, followed by children with emotional disturb- ance (Blake et al., 2014). In another study, Swear, Wang, Maag, Siebecker and Frerichs classified disabilities as visible (speech, hearing and mild intellectual disabilities) and invisible (learning disa- bilities) , and found that students with visible disabilities were more likely to be victims, the de- gree of victimization of students with invisible disabilities was similar to that of non-disabled stu- dents. This result may be due to the fact that the invisibility of the disability may protect them from bullying compared to the visibility of the disability (Swearer, Wang, Maag, Siebecker, & Fre- richs, 2012). However, this finding is not consistent with Mishna’s (2003) study. The latter indi- cates that learning disabilities are more vulnerable to be bullied(Mishna, 2003). More research is needed to explore the relationship between the degree of victimization and the type of disability. But disability victimization is still a severe problem in school settings. Therefore, the disability in this thesis does not focus specifically on the type of disability, but rather on students with disabil- ities in the school environment in Sweden. In the Swedish National Public Health Survey, disabil- ity includes long-term illness , hearing loss, impaired vision, impaired mobility, physical disability, mobility impairment and disability (Folkhälsomyndigheten, 2020). Therefore, in this thesis, long term illness will be included in disability.
Children with disabilities also face lower subjective health, and studies have shown that they report more complaints of psychosomatic illnesses (Beckman, Stenbeck, & Hagquist, 2016). Therefore, having both a disability and being bullied increases the risk of lower mental health even more than just having one risk factor (Sentenac et al., 2012). An Israeli study found relation between bullying and emotional distress and behavioral problems in adolescents with intellectual disabilities (Reiter & Lapidot-Lefler, 2007). Cappadocia, Weiss and Pepler (2012) found that 5-to 12-year-olds with autism who had been bullied once a week or several times in the past month had higher rates of anxiety and suicidal behavior than those who had been bullied once or three times in the past month and had never been bullied (Cappadocia, Weiss, & Pepler, 2012). In addi- tion, an American study investigated 1,221 autistic students from elementary school to high school, and found that those who had been bullied more than twice in the past month have more
internalized behavior problems than those who had been bullied less than once in the past month (Zablotsky, Bradshaw, Anderson, & Law, 2013a). As can be seen from the above studies, Stu- dents with disabilities who are bullied are more likely to affect their physical and mental health.
Based on previous research, this paper hypothesizes that students with disabilities are at risk of low subjective health, which is not related to disability, but rather exposure to bullying. Under- standing the relationship between peer victimization and the subjective health of students with and without disabilities is crucial if considering bullying prevention. Therefore, the purpose of this thesis to conduct a more comprehensive study to explore the link between peer victimization and subjective health among students with and without disabilities.
Using two cross-sectional data sets from the Swedish Center for HBSC, the study examined bullying experiences among 11,13 and 15-year-olds in Sweden, to look at peer victimization and the potential subjective health problems of students with disabilities.
Background
2.1 DisabilityDisability is a multidimensional concept. According to Article 1 of the Convention on the Rights of Persons with Disabilities(CRPD), disability is defined as “having long term physical, mental, intellectual or sensory impairments, interacting with various barriers hinder their full and effective participation in society on an equal basis with others”(UN, 2006). The definition of disa-
bility by CRPD focuses on the impairment of physical function and the barriers to participation in society. In addition to Article 1 of CRPD, the preamble to the CRPD rec that “ disability is a developing concept and that disability results from the interaction between persons with impair- ments and attitudinal and environmental barriers that hinders their participation in society on an equal basis with others” (UN, 2006). This definition implies that the disorder is not a personal
trait, and interactions between persons with impairments and environment are the main cause of the disability.
In the medical perspective, disability is considered to be associated with impairment of physical function at the personal level (Barnes & Mercer, 1997). The perspective views the disa- bility as an effect of impairment. Oliver (2009) believes that from a medical perspective, disability is simply regarded as impairment, therefore he proposes we consider the definition of disability from a social dimension. The social dimension focuses on the influence of the social environ- ment on the disability, considering the impairment to be an objective fact on the biological level (Oliver, 2009). Whereas the disability results from the society’s failure to provide appropriate ser- vices and ensure the needs of the disability. In addition, Oliver (2009) also emphasizes that disa- bility is a long-term social condition, which cannot be completely solved by treatment and inter- vention through medical treatment and rehabilitation, and that society should accept the appear- ance of people with disability, removing disadvantages for the disabled by changing the social environment.
The International Classification of Function, Disability and Health (ICF) developed by the World Health Organization (WHO) includes the medical model and social model (Mitra & Shakespeare, 2019). ICF adds personal factors and environment factors as the classification standards, and considers the limitation of the social environment, which changes the angle of view of disability from using only a medical model. ICF is a physiological-psychological-social model. That is, ICF is a bio-psycho-social model (Mitra & Shakespeare, 2019). ICF defines
disability as a dynamic interaction between person with health condition and environment, in- cluding personal factors and environmental factors (WHO, 2007). The model is shown in figure 1.
Figure 1. The model of ICF, Adapted from” International Classification of Functioning, Disability, and Health” by World Health Organization, 2007
ICF divides the health conditions into three interacting elements: (1) impairment: refers to functional and structural problems in the body, such as blind. (2) activity: refers to carry out an activity, such as walking. (3) participation: refers to involvement in a life situation. When an indi- vidual encounters any restrictions or limitations in the above-mentioned field, it can be called dis- ability. The above elements can be divided by personal or environmental factors such as gender, age, education, social background and so on. Environmental factors refer to the physical, social and attitudinal environment in which people lives and conduct their lives (WHO, 2007). There- fore, ICF categorizes the disability as a continuous state. The understanding of disability is similar between CRPD and ICF. CRPD also judges disability through elements such as “body function and structure” , “activity” and “participation”.
The classification of disability in this thesis adopts the classification of disability used by the Swedish National Institute of Public Health. The Swedish National Institute of Public Health in- cludes disability as long-term illness , hearing loss, impaired vision, impaired mobility, physical disability, mobility impairment and disability (Folkhälsomyndigheten, 2020).
Health is a complex concept(Bircher, 2005). The WHO defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO,
2006). According to this definition, health can be understood as enjoying a good quality of life
and experiencing a state of harmony and balance among the spiritual, natural, social and cultural environments (Kirsten, Van der Walt, & Viljoen, 2009). In this sense, individuals' descriptions of their health are strongly subjective. Therefore, health should be defined from a holistic perspec- tive including biological, psychological, social, and cultural perspectives (Pender, Murdaugh, & Parsons, 2002). It can be seen that health is a dynamic and positive concept that values social and individual resources and physical capabilities (WHO, 1986).
When considering the overall health status of an individual, a comprehensive measurement should be taken at the physical, mental and social levels. Therefore, the personal physical condi- tion defined by biomedicine cannot represent the overall health of the individual. In the modern psychosocial literature, subjective health has long been used as a legitimate indicator of the over- all health status of the individual (Brook et al., 1979; Ferraro, Farmer, & Wybraniec, 1997; Hunt & McEwen, 1980; Kaplan & Baron-Epel, 2003; Larue, Bank, Jarvik, & Hetland, 1979). Subjective health refers to one’s subjective evaluation of one’s current overall health condition (Frank- Stromborg, Pender, Noble Walker, & Sechrist, 1990). There is evidence that subjective health in- fluences individual health behaviors and has predictive power for future health outcomes (Benyamini & Idler, 1999; Ellen L Idler & Benyamini, 1997; Jensen, Counte, & Glandon, 1992). Therefore, subjective health can be used as a comprehensive index for individuals to understand their own physical and mental health. Based on WHO’s measurement of subjective health, this article will use three dimensions (self-rated health, life satisfaction and health complaints) as an index of subjective health (HBSC, 2014).
2.2.1 Self-rated health
Self-rated health is an individual’s self-evaluation of overall health (Cavallo et al., 2015). The perception of health status varies according to different life styles of individuals, so self-rated health measures health status through personal perception (Boardman, 2006; Halford, Ekselius, Anderzen, Arnetz, & Svärdsudd, 2010; Jerdén, Burell, Stenlund, Weinehall, & Bergström, 2011).
There are strong studies with evidence that this indicator is the best predictor of morbidity and mortality (Hubbard, Inoue, & Diehr, 2009; E. L. Idler & Angel, 1990; Ellen L. Idler & Kasl, 1991; Mossey & Shapiro, 1982). In addition, research has shown a significant correlation between self-rated health and changes in physical functioning (Hubbard et al., 2009). Health status varies with conditions of daily life, health care and socioeconomic status
(Commission on Social Determinants of Health, 2008). Research in Norway shows that
adolescents perceive self-rated health as a concept composed of many factors, including medical, psychologi- cal, social and lifestyle factors (Breidablik, Meland, & Lydersen, 2008). Factors such as chronic illness/disability, peer relationships, school, family and community levels all have a direct or indi- rect impact on self-rated health (Viner et al., 2012; Vingilis, Wade, & Seeley, 2002; Wade, Pevalin, & Vingilis, 2000). Therefore, bullying as a peer relationship-related factor may also influence self- rated health.
2.2.2 Life satisfaction
Life Satisfaction is one of the aspects of subjective health, which is defined as an individual’s cognitive evaluation of their whole life (Pavot, Diener, Colvin, & Sandvik, 1991; Ravens-Sieberer et al., 2009). Gilman and Huebner (2006) believes that life satisfaction is a key component of well-being (Gilman & Huebner, 2006). If the individual is more satisfied with the overall life, then the individual will experience more positive emotions (Diener, 2000). At the same time, positive emotions can enhance the functioning of the individual's immune system, reduce pain and other disease symptoms, contributing to physical and mental health (Cohen, Doyle, Turner, Alper, & Skoner, 2003; Pressman & Cohen, 2005).
For the subjects in this study, students’ life satisfaction was related to the interaction be- tween the individual and the external environment (Suldo, Huebner, Friedrich, & Gilman, 2009) . Based on the theory of Bronfenbrenner’s Bioecological perspectives, the microsystem focuses on the impact of adolescents’ direct exposure to the environment on life satisfaction
(Bronfenbrenner, 1994). According to Suldo et al. (2009), the relationship between external envi- ronment and life satisfaction mainly focuses on the influence of family, school and peer relation- ship on the individual (Suldo et al., 2009). Adolescents with high life satisfaction also received higher levels of social support from parents, teachers and peers than adolescents with low life sat- isfaction (Gilman & Huebner, 2006). In addition, the study found a significant positive correla- tion between positive peer relationships and life satisfaction , and that adolescents with higher life satisfaction also showed better peer relationships (Martin & Huebner, 2007). Bullying, as a factor related to peer relationships, could also consider its impact on life satisfaction.
Therefore, in addition to personal factors, life satisfaction of adolescents is the result of multiple environmental factors at different levels of influence and interaction (Bronfenbrenner & Evans, 2000a). For example, people, things, and symbols in the immediate environment (family, school) in which direct interaction with an individual may have an impact on the individual’s
subjective cognition, further enables the individual to compare and assess life satisfaction with their direct environment.
2.2.3 Health complaints
Health complaint is one of important indicators of subjective health (HBSC, 2014). It could be defined as an individual who has somatic and psychological symptoms due to subjective expe- rience even without a clearly defined diagnosis (Garralda, 1992). Symptoms can manifest as head- aches, backache,difficulty in falling asleep and other symptoms, and may not be linked to a spe- cific diagnosis but may also have a negative impact on a child’s somatic and mental health (Haugland, WOLD, Stevenson, Aaroe, & Woynarowska, 2001a). Past research has shown that complaints with physical symptoms are common among adolescents, and are often an important factor in school absenteeism (Mikkelsson, Salminen, & Kautiainen, 1997). Zwaigenbaum, Szatmari, Boyle, & Offord (1999) tracked 13-to 16-year-olds for four years in Canada and found that high somatic complaints were a risk factor for depression four years later (Zwaigenbaum, Szatmari, Boyle, & Offord, 1999). A cross sectional study from the United States also found that somatic symptoms were more likely to be associated with other mental illnesses, with over 50 percent of cases having symptoms of depression, anxiety, and somatization, with an additional negative effect on life functioning (Löwe et al., 2008). Therefore, somatic complaints not only cause subjective discomfort, but also anticipate high risk for depression and anxiety.
Health complaints begin to appear in childhood and are quite common (Garralda, 1996; Goodman & McGrath, 1991). The 1993-1994 cross-sectional study by Haugland et al. (2000) used the HBSC symptom checklists (HBSC-SCL) to examine subjective psychosomatic com- plaints from adolescents in Finland, Norway, Poland, and Scotland, where HBSC-SCL questions included headaches, abdominal pain, backache feeling low, irritability, nervousness, sleeping diffi- culties and dizziness. Comparing health complaints from 11,13 and 15 year olds by country, age and sex, respectively, and finding that adolescents in all countries report high levels of health complaints by age 11, and the proportion of somatic and psychological complaints increased with age, with the proportion of female students significantly higher than male students (Haugland et al., 2001a). This suggests that health complaints do not diminish with age, and that more com- plaints are common among girls.
Berntsson and Gustafsson (2000) developed the model of health complaints from the per- spectives of pediatrics, epidemiology, neurobiology, psychiatry, psychology and sociology. The model has six symptoms to measure health complaints, including stomachache, headache, sleep- lessness, dizziness, backache and loss of appetite, and assumes that the three dimensions that
affect health complaints include proximal factors, intermediate factors and distal factors (Berntsson & Gustafsson, 2000). The proximal factors include mental health stability (calm/rest- less, stable, depression/happiness, and anxiety/confidence), activity status (sports activities, and music activities), and long-term illness/disability, school satisfaction (academic achievement and school satisfaction), peer relationships (close friends, friendships, bullying), social competence (passive/active, lonely/not lonely), and these factors have a direct impact on the performance of health complaints. The intermediate factors refer to family factors, which can influence students’ health complaints, including family activities, parents’ sense of coherence, social support and par- ents’ health status. The distal factors are mainly about background variables which can be re- garded as the variables affecting the intermediate level. Based on this model, 1,163 pupils aged 7- 12 in Sweden and their parents were studied. The results showed that the best predictors of chil- dren’s health complaints were the health of their mothers and peer relationships, long-term ill- nesses/disabilities and mental stability (Berntsson & Gustafsson, 2000). Therefore, a predictive model can be constructed made up of supporting individual, family factors and social back- ground, whichcan be used to explore the subjective health of children.
2.3 Bullying
2.3.1 The definition of bullying
According to the World Health Organization’s survey of bullying of 11, 13, and 15-year-olds in 38 countries in Europe and America, an average of 24% of adolescents said they had suffered bullying at least twice in the past few months(WHO, 2009). Bullying has become an international social issue, but its definition varies by researcher and region(Huang, Hong, & Espelage, 2013). According to Olweus’ definition, bullying in school refers toa student being repeatedly exposed to aggressive behaviour by one or more students (Olweus, 2001). Bullying behaviour has three indicators: aggressive behaviour or intentional harm behaviour; continuous and repeated occur- rence; and interpersonal interaction with unequal power (Olweus & Limber, 2010). Furthermore, Boulton and Underwood (1992) believe that maintaining social status and dominance is the rea- son why children engage in bullying others in the school environment. Therefore, the purpose of bullying is not to cause physical or psychological harm to the victim, but to display dominance (Boulton & Underwood, 1993).
Farrington (1993) synthesizes multiple studies on the definition of bullying and suggests that the definition of bullying should have five elements: Physical, verbal or psychological attack or intimidation; intentional infliction of fear, pain and harm to the victim; Imbalance of power;
absence of provocation by the victim; the same child is subjected to repeated and pro-longed ag- gressive behaviour (Farrington, 1993). Hence, school bullying must take place in a situation of asymmetric power relationship. Bullies deliberately and continuously carry on aggressive behav- ior, causing victims to suffer physical and psychological harm in order to gain dominance within the group.
2.3.2 Forms of bullying
Olweus (2003) points out that when students participate in bullying or watching bullying, most students are involved in the "bullying circle" in various ways and play an important role (Olweus, 2003). Figure 2 outlines the bullying circle. In this study, peer victimization occurs in those who are exposed to peer bullying.
Figure 2. The Bullying Circle. Adapted from “A profile of bullying at school,” by Olweus, Dan.,
2003, Education leadership, 60(6), 12-17.
Olweus divides bullying into direct and indirect bullying/victimization, where verbal, physi- cal, racial and sexual bullying are often seen as direct bullying/victimization, while cyber and rela- tional bullying is seen as indirect bullying/victimization (Olweus, 1994, 1996; Olweus, Limber, & Breivik, 2019). Relational bullying refers to harming others by spread malicious rumors or social exclusion(Wolke, Woods, Bloomfield, & Karstadt, 2000). Based on the developmental period of adolescents, the importance of peer relationships for adolescents, coupled with the gradual devel- opment of social cognitive skills, makes adolescents more likely to be at high risk of relational bullying than direct physical bullying, peer relational bullying is more prevalent than physical bul- lying from childhood to adolescence (Loflin & Barry, 2016; Prinstein, Boergers, & Vernberg,
2001; Smith, Rose, & Schwartz-Mette, 2010). The ability of adolescents in the developmental stage to communicate and interact with others gradually develops(Smith et al., 2010). Therefore, physical bullying between peers is relatively reduced, while relational bullying gradually increases. In early childhood, because verbal and social skills are not yet fully developed, aggressive be- havior is usually physical pushing and beating (Smith et al., 2010). After the development of lan- guage skills, the aggressive behavior may be verbal attack, instead of physical bullying, and when social cognitive skills are developed to analyze social relationships, it is possible to use relational, social, and indirect aggression as a form of bullying (Coie, Dodge, & Coppotelli, 1982; Crick et al., 1999; Kaukiainen, 1992; Parker & Asher, 1993). The focus for this thesis will be on the peer victims with disabilities and their subjective health will be compared to those who are not bullied and do not have a disability.
2.3.3 Students with disability and peer victimization
Research indicates that students with disabilities are at increased risk of being bullied. Luukkonen (2010) found that children with chronic illness (e.g. receiving regular care or are over- weight) are more likely to be bullies or bullying-victims (Luukkonen, Räsänen, Hakko, & Riala, 2010).
A 2013 study of children with specific disorders found that children with learning disabilities had the highest proportion of bullying-victims, while children with attention deficit or hyperactiv- ity disorder(ADHD) and autism spectrum disorders(ASD) at higher risk of peer rejection (Twyman et al., 2010). Blake, Lund, Zhou, Kwok and Benz (2012) found that in the United States, the proportion of peer victimization of students with disabilities was 24.5 per cent in ele- mentary school, while 34.1 per cent of students with disabilities have suffered peer victimization in middle school. This is one and a half times the national average for non disabled students to be bullied (Blake et al., 2012). In addition, a survey of peer victimization between students with mild disabilities and general education students has shown that students with mild disabilities were more likely to be bullied by their peers than students without disabilities (Estell et al., 2009). Beaty and Alexeyev (2008) point out that about 25% of mainstream students are bullied by their peers in class, while 67% of disabled students suffered peer victimization in class (Beaty & Alexeyev, 2008). In a literature review study, more than 50% of students with disabilities have ex- perienced peer victimization in studies involving bullying by disabled students, which proves that they are more likely to be victims of peer relationships than their non- disabled peers (Rose et al., 2011).
2.3.4 Peer victimization and subjective health
In this study the focus will be on victims of peer bullying; however bullying can have effects on all students involved in bullying. School bullying can have different levels of physical, psycho- logical and social negative effects on victims and bullying-victims (Sherer & Nickerson, 2010).There are also numerous studies which find a relation between peer victimization and men- tal health. A study pointed out that victims of bullying are more likely than others to be anxious, depressed and lower life satisfaction (Estévez, Murgui, & Musitu, 2009). Reijntjes, Kamphuis, Prinzie and Telch (2010) conducted a meta-analysis of the relationship between peer victimiza- tion and internalizing problems, which has showed that peer victimization significantly predicted subsequent internalizing problems, including anxiety, depression, withdrawal, loneliness, and so- matic symptoms , and internalizing problems can also predict the degree of peer victimization (Reijntjes, Kamphuis, Prinzie, & Telch, 2010). Therefore, the relationship between child peer vic- timization and internalizing problems creates two-way feedback, and peer victimization in child- hood may be a precursor to subsequent psychological intrinsic symptoms, while the problem of psychological internalization is both a possible cause and a consequence of peer victimization.
Sansone et al. (2010) points to extrinsic behaviors (including self-harm, excessive spending, alcohol, substance misuse, and binge eating) as well as psychological treatment (e.g. seeing a psy- chiatrist, receiving psychiatric hospitalization, receiving counselling, receiving medication) that are associated with bullying at school (Sansone, Lam, & Wiederman, 2010). Rudolph et al. (2011) ex- amined how peer victimization predicted depressive symptoms and aggressive behavior in early (second grade) peer victimization up to fifth grade. A study of 433 children (238 girls and 195 boys) found that those who experienced peer victimization in the second grade of elementary school continued to increase to the fifth grade, followed by higher symptoms of depression and overt aggression, these results suggest that children exposed to peer victimization at an early age are at risk for subsequent mental health problems, such as long-term emotional and behavioral problems (Rudolph, Troop-Gordon, Hessel, & Schmidt, 2011). Children who are bullied may have headaches, stomachaches, low self-concept, depression, loneliness, anxiety and so on, result- ing in low learning achievement and self-esteem, or even somatic and psychological illness, trig- gering the risk of suicide (Estévez, Musitu, & Herrero, 2005; Guterman, Hahm, & Cameron, 2002; Hawker & Boulton, 2000; Kumpulainen, Räsänen, & Puura, 2001; Vanderbilt & Augustyn, 2010).
The above research shows that peer victims are prone to psychological issues, and it is easy for the victim to produce negative emotions and thoughts of suicide, triggering emotional distress
such as depression. In addition, interpersonal interaction and mental status can be related to sub- jective health (Berntsson & Gustafsson, 2000; Martin & Huebner, 2007; Viner et al., 2012; Vingilis et al., 2002; Wade et al., 2000). Therefore, this study considers that the higher the level of peer victimization, the lower the level of subjective health.
2.4 Theoretical Framework
According to the bio-ecological system theory (Bronfenbrenner, 1979), child development is carried out through a proximal process, which is the interaction process between family, school and society in its immediate environment (Bronfenbrenner & Evans, 2000b). The bio-ecological system theory, and Bronfenbrenner’s proximal process-person-context-time (PPCT) model could help to understand the negative consequences of peer victimization for the physical and mental health of students with disabilities(Rosa & Tudge, 2013).
The PPCT model focuses on proximal process rather than the environment
(Bronfenbrenner & Morris, 2007). The process refers to the interaction between individuals and their environment, including the interaction with family and peers ( Bronfenbrenner & Evans, 2000b).In the process, child development is positively influenced by the promotion of
knowledge, skills and abilities or the reduction of the likelihood of dysfunctional outcomes (Rosa & Tudge, 2013). But children's development outcomes are also affected by person characteristics. Person includes an individual’s external characteristics (gender and appearance), individual abili- ties and body function, and disposition (Bronfenbrenner & Morris, 1998; Bronfenbrenner & Morris, 2007; Rosa & Tudge, 2013). Context describes the immediate and indirect environment that could affect child development(Bronfenbrenner & Evans, 2000b). Time refers to specific events in proximal processes, with the frequency of events and changes in the indirect environ- ment over time affecting child development outcomes(Bronfenbrenner & Morris, 2007).
In the study based on PPCT model (reference please), proximal process involves the social interaction of the students with their peer. Bullying behavior is a negative social interaction that many students participate in (Nishina, 2004). The interaction (proximal process) is considered to be the driving force for children's development (Bronfenbrenner & Evans, 2000b;
Bronfenbrenner & Morris, 2007). Therefore, negative social interaction has a negative impact on the development of children, including disrupting the development of peer relationships. Person characteristics related to students’ disabilities and serious and persistent illness (Rosa & Tudge, 2013). Person characteristics involve the victim's physical disability or serious and persistent ill- ness. Children who are often physically weak are more likely to be targeted for bullying(Card &
Hodges, 2008). They also exhibit low levels of prosocial and social skill behaviors, and so suffer from many internalized problems such as anxiety and depression, along with some externalized problems such as hyperactivity(Baumeister, Storch, & Geffken, 2008; Card & Hodges, 2008).
Context refers to the school environment that is associated with the students, as it is an im- portant factor in bullying (Natvig, Albrektsen, & Qvarnstrøm, 2001). Unhealthy school climates are more likely to prompt bullying behavior, and so the school is an unsafe environment for vic- tims (Wang, Berry, & Swearer, 2013). At the same time, compared with students who did not par- ticipate in bullying, the victims had less connect with the school, and lower life satisfaction (O'Brennan, Bradshaw, & Sawyer, 2009; You et al., 2008). Time refers to specific events in proximal process, the frequency of events and changes in the indirect environment over time
that affect child development outcomes (Bronfenbrenner & Morris, 2007). Victims of repeated
bullying will suffer long-term negative impacts on their s psychosomatic health that can extend from childhood to adulthood (Hoffman, Phillips, Daigle, & Turner, 2016; Sigurdson, Undheim, Wallander, Lydersen, & Sund, 2015).
2.5 Research Aim and questions
Looking at person, process, context and time we can see that, in context bullying will over time affect health. Person factors such as disability increase the risk for exposure to bullying, something that will also affect development. Students with disabilities have a higher risk of hav- ing low subjective health measures as low self-rated health, low life satisfaction and high health complaints. However it is the hypothesis of this thesis that it is not the disability rather the expo- sure to bullying that creates risk factors. Therefore, it is possible to improve subjective health by preventing bullying rather than by changing disability. Students both bullied and with disabilities as well as those without disability but bullied will have lower life satisfaction that those with disa- bility but not bullied. However those not bullied and not having a disability will have the highest level of life satisfaction. I hypothesize that:
1. Children with disability alone will have higher life-satisfaction than those with disabilities who are bullied and have higher life satisfaction than those bullied without disabilities. 2. Children without disabilities not bullied will however have the highest subjective health as
they face less risk of negative processes in their proximal environment.
3. Children that are bullied will have higher levels of somatic complaints than non-bullied, and children with disabilities will have higher level of complaints that those without disa- bilities.
Method
3.1 Study designIn this study Swedish data from the Health Behaviour in School-aged Children (HBSC) will be used. This study will be using data from two waves from Sweden 2013/2014 and 2017 / 2018 data collections. HBSC is a repeated cross-sectional survey of health behaviour and health status of adolescents in 49 countries in Europe and North America in collaboration with the World Health Organization (Al Sabbah et al., 2009). The study is repeated every 4th year, consisting ofyoung people attending school aged 11-, 13-and 15-years of age (Al Sabbah et al., 2009). These three age groups were selected because they represented the onset of puberty, physical and psy- chological transition and changes, and the age at which important decisions about life are begin- ning to be made (Roberts et al., 2009).
The study covered a range of health indicators and health-related behaviours as well as the living conditions of young people, in the areas of demographic factors (gender), social back- ground (such as family and school) , health outcomes (such as self-rated health) , health behav- iours (such as eating habits) and risk behaviours (such as drinking and smoking) (Roberts et al., 2009). The participants were recruited using cluster sampling design based on the school to ob- tain a nationally representative sample (Sentenac et al., 2012). The required sample size should be at least 1,550 students per age group (Currie et al., 2011). Participating countries needed to obtain a sample group with an average age of 11.5 years, 13.5 years and 15.5 years (Sentenac et al., 2012). The data are collected in the classroom through self-administrated anonymous questionnaires (Al Sabbah et al., 2009; Roberts et al., 2009).In addition, research teams in participating countries must follow HBSC international protocols for data collection (Al Sabbah et al., 2009; Roberts et al., 2009). Participating countries were approved by the ethics committee.
3.2 Participants
The key demographic statistics of the two samples are presented in Table 1. Students aged 11-15 years old from Sweden filled out the HBSC survey. In the present study, analyses were based on data from 7867 students (3896 boys, 49.90%) in 2013/2014, 4294 (2101 boys, 49.8%) in 2017/2018. Participants spread almost equally from grade 5, grade 7 and grade 9 in 2013/2014 while different from the spread from 2017/2018 (p<0.001). Among all participants, 1612 sub- jects (21.2%) presented with a disability while others were typically developed in 2013/2014. In the 2017/2018 sample, 23.3% of students with disability 349 participants (4.5%) from 2013/2014
and 310 (7.6%) from 2017/2018 reported experiencing peer victimization, and the percentages from the two different survey years are different (p<0.001).
3.3 Instrument
In the HBSC questionnaire, the definition of bullying from the revised Olweus Bully/Victim Questionnaire was used to describe bullying. Subjective health problems were measured with Self-rated Health, Life satisfaction and Health complaints questionnaire. The independent varia- ble in this study was peer victimization and disabilities, and the dependent variable was three sub- jective health measures including self-rated health, life satisfaction and health complaints. In or- der to combine the two cohorts in the follow-up data analysis, this thesis used chi-square test and Mann-Whitney U-test test to test the difference of samples. Table 1 is also a cohort analysis of two groups.
The key demographic statics of the two samples are presented in Table 1. Little peer victimi- zation, grade and psychological symptoms differences were found between the samples. Differ- ences were all negligible in size and combining the cohorts was possible for analysis.
Table 1. The characteristics and related measurements of the study population from differ- ent years 2013/2014 2017/2018 P value Count N % Count N % Total 7867 4294 Gender 0.936a Boys 3896 49.9% 2101 49.8% Girls 3908 50.1% 2114 50.2% Missing 63 79 Grade <0.001a Grade 5 2691 34.5% 1181 27.5% Grade 7 2292 29.4% 1452 33.8% Grade 9 2810 36.1% 1661 38.7% Missing 74 0 Peer victimization <0.001a No 7383 95.5% 3795 92.4% Yes 349 4.5% 310 7.6% Missing 135 189 Disability 0.009a
No 6002 78.8% 3173 76.7% Yes 1612 21.2% 962 23.3% Missing 253 159 Self-rated health 0.404a Not so Healthy 4857 64.5% 2755 65.3% Healthy 2673 35.5% 1466 34.7% Missing 337 73 Life-satisfaction (Mean, SD) 7603 7.35 (1.93) 4093 7.45 (1.94) 0.002b
Health complaints (Mean, SD)
Somatic symptoms 7786 0.75 (1.04) 4209 0.80 (1.07) 0.007b
Psychological symptoms 7747 0.77 (1.16) 4174 0.95 (1.20) <0.001b
Note: a: Chi-square test, b: Mann-Whitney U-test test
3.31 Independent Variables
Disabilities are measured based on one question in HBSC. The question is Do you have a long-term illness, disability, or medical condition like diabetes, arthritis, allergy or cerebral palsy that has been diagnosed by a doctor? The answer is divided into two categories: non-disabled stu-
dents and disabled students.
Peer victimization is measured by two questions. The first question is How often have you taken part in bullying another student(s) at school in the past couple of months? The second
question is How often have you been bullied at school in the past couple of months? All of the
responses were based on a 5-point Likert scale: I haven’t been bullied/bullied other students at school in the past couple of months, only once or twice, 2 or 3 times a month, about once a week, and several times a week. These were adapted by Olweus Bully/Victim Questionnaire
(Gobina, Zaborskis, Pudule, Kalnins, & Villerusa, 2008). Thus, three categories of students were defined for the present analyses: bystander (uninvolved a cut off for bully), victims and bully- vic- tims. Students who had bullied others 2 or 3 times a month or more often were classified as vic-
tims, and students who had not been bullied by others or only once or twice were categorized as
bystander, in line with definition by Olweus (Solberg & Olweus, 2003). For students both bullied and bullying others, these students will be categorized as bully/victims.
3.32 Dependent Variables
Subjective health are measured using three dependent variables, measuring three aspects of health, namely the general health perception, the cognitive evaluation of one’s life, and psychoso-
Self-rated health measuring the perception of overall health is assessed by using a four-point
Likert scale for each item, ranging from excellent (1) to poor (4) (Ravens-Sieberer et al., 2009; Sentenac et al., 2012).. For example, Would you say your health is…? Each student answered
based on an individual’s perception and assessment of his or her own health. Responses were di- chotomized, such that healthy was coded 1, and not so healthy was coded 0.
Life satisfaction representing the cognitive-evaluative aspects of subjective health and well-
being is investigated by using a binary cut off from responses to the following question: Here is a picture of a ladder. The top of the ladder “10” is the best possible life for you and the bottom “0” is the worst possible life for you. In general, where on the ladder do you feel you stand at the moment? These were adapted by Cantril ladder (Levin & Currie, 2014).
Psychosomatic Health complaints measuing psychosomatic unhealth rather than health are
measured by asking students how often they experienced physical and psychological discomfort in the past 6 months. This scale consists of eight items (including headaches, stomachache, backache, feeling low, irritability, feeling nervous, difficulty falling asleep, and dizziness) using a five-point Likert scale (about every day, more than once a week, about every week, about every month and rarely or never) (Hagquist & Andrich, 2004; Ravens-Sieberer et al., 2009). And then eight items divided into two categories: somatic symptoms ( headaches, stomachache, backache and dizziness), and psychological symptoms( feeling low, irritability, feeling nervous and difficulty falling asleep). Ratings were made on a 1-5 scale, where “never” of a symptom was rated as 5 and “every day” of symptoms rated as 1 (Haugland, Wold, Stevenson, Aaroe, & Woynarowska, 2001b). Respondents with recurrent multiple health complaints (two or more complaints at least weekly) are considered as displaying noticeable subjective health complaints. Each symptom was dichotomized, depending on if there werecomplaints twice a week or more. The answers were dichotomized, such that having the health complaint less than twice per week was coded as 0, and having the health complaint twice a week or more was coded as 1. Higher values indicate more and severe health complaints. The Cronbach’s alpha was 0.853. This means that the internal consistency of the items are very high, and this scale has high reliability.
3.4 Procedure
3.4.1 Data collection
Data from the Swedish HBSC collected in 2013/2014 and 2017/2018 was used. School children aged 11,13 and 15 were randomly sampled using a stratified cluster sampling with school class as the sampling unit (Sentenac et al., 2012). The questionnaire was administered during
school hours in the classroom. Students who were in class on the day of the survey filled out the questionnaire anonymously.
3.4.2 Data analysis
In this thesis, the chi-square test was used to test the difference across samples to therefore justify combining the two cohorts in the follow-up data analysis. We combined peer victimization and disability into four groups based on research aims and hypotheses including status: non-vic- tims without disabilities, non-victims with disabilities, victims without disabilities and disabled victims. Participants characteristics were Self-rated health, Life-satisfaction and Health com- plaints and were summarized as mean (SD) or n (%) by different victim/disability groups. Differ- ences in these characteristics and measurements were compared using Mann-Whitney U test or Kruskal–Wallis test for continuous variables as they showed non-normality distribution and the Pearson chi-square test for categorical variables. Pairwise multiple tests were adjusted by the Bon- ferroni correction.Analyses were performed with SPSS 26.0.
3.5 Ethical Consideration
All data used in this report has been depersonalized so there are no variables that can iden- tify any specific individual. As the study is aimed at young people under the age of 18, research involving children usually requires the active consent of the parents, in accordance with the Con- vention on the rights of the Children (Unicef, 1989).
The researchers were unable to include the children in the study without parental consent. Even though parents may not reject their child's participation, in an active consent procedure, parents may not respond for multiple reasons, in which case the child is deprived of the right to decide whether to participate or not. Children get information and can opt out, i.e. choose not to fill in the questionnaire..
In the HBSC study, researchers used a passive consent procedure, requiring parents to re- spond only when they did not want their children to participate. Failure to respond was consid- ered passive consent. This has the advantage of a higher participation rate and therefore in- creased sample representativeness (Esbensen, Melde, Taylor, & Peterson, 2008). In line with Arti- cle 12 of the United Nations Convention, the passive consent procedure used in the study gave children's rights to speak priority over parental rights to privacy(Carroll-Lind, Chapman, Gregory, & Maxwell, 2006).
A three-stage consent procedure was used to gain access to participating children in the study on healthy behaviour among school-age children. At all stages, the three-stage consent
procedure provides schools, parents and children with the option to refuse to participate. Schools were randomly selected. All children in that given classroom were selected. The third stage of the consent process involved the informed consent of selected children in the class. The children must sign an informed consent form indicating that they understand the aim of the study and agree to participate, knowing that children could opt out by informing teachers, and their parents could also opt out by informing the school. They got information from teacher and they filled out the questionnaire in classroom. The teacher could not see individual responses and all ques- tionnaire were individually sealed in envelops upon completion. The students were verbally as- sured that their answers were anonymous and confidential and that they would not provide any information to anyone. To minimize their anxiety, it was made clear to children that it was not a test, that there are no right or wrong answers, and that those steps were taken to ensure anonym- ity and confidentiality, and allow freedom of expression.
In this study, 2013/2014 and 2017/2018 data used. In the 2013/2014 data, Statistics Swe- den reminded schools to answer questions, so the participation rate for most schools was 79.8% , and the response rate for students was 69.4% , based on 500 schools (Statistics Sweden, 2014). In the 2017 / 2018 dataset, the sample size was 450 school units, with an attrition rate of 52.6% and students’ response rate of 42.1% (Statistics Sweden, 2018). Low response rates are common in cross-sectional surveys (Schoeni, Stafford, McGonagle, & Andreski, 2012), but it is important to consider whether low response rates affect data representation. Research has shown that there is no direct relationship between response rate and validity, but there is a potential risk of low valid- ity(Morton, Bandara, Robinson, & Carr, 2012) Instead, the representativeness of the reaction is more important than the reaction rate (Cook, Heath, & Thompson, 2000). Low response rates do not necessarily lead to biased results (Rindfuss, Choe, Tsuya, Bumpass, & Tamaki, 2015) .
In addition to the lack of response and gender distribution, there are other factors to con- sider, including representativeness, reliability, and validity. The HBSC questionnaire is distributed within the school context, so there is a risk of selection bias, since only children attending school are the respondents. Absent students on the day of data collection are excluded. Victims typically have a higher rate of absenteeism than non-victims (Cross, Lester, & Barnes, 2015), meaning vic- tims are under-represented in the sample. Second, unserious responses usually occur in a small percentage of respondents and may be influenced by their reading level, mood, and attitude. Third, there may be a social desirability effect that Denies bullying (Cornell & Bandyopadhyay, 2009). Victims may be reluctant to admit to being bullied because they associate bullying with negative labels such as insecurity, low self-esteem and fewer friends (Smith et al., 1999). As a
result, victimized children bring shame to their parents(Smith et al., 1999). In such cases, children may hide the fact of their being bullied from their parents in an attempt to protect them from the stigma of bullying, which will have an impact on the child response rate of HBSC, where there is a risk of a wrong negative response.
Results
The characteristics and the other measurements of the study population across different vic- tim/disability groups are given in Table 2. As showed in Table 2, the comparisons of Self-rated health, Life-satisfaction and Health complaints from the four groups are all statistically significant with p<0.001. As all the variables did not follow Normality distribution as showed in Table 3 with normality test p values less than 0.001, all our analysis was carried out with non-parametric
methods including Mann-Whitney U-test test and Kruskal-Wallis test with Bonferroni correc- tion.
Table 2. The characteristics and related measurements of the study population from different groups Non-victims without
disabilities
Non-victims with disabili- ties
Victims without disabilities Disabled victims P value
Count N % Count N % Count N % Count N %
Total 8570 74.40% 2307 20.00% 433 3.80% 213 1.80% Gender 0.004a Boys 4252 50.1% 1086 47.5% 201 46.7% 84 40.2% Girls 4235 49.9% 1199 52.5% 229 53.3% 125 59.8% Missing 83 22 3 4 Grade 0.001a Grade 5 2713 31.8% 698 30.4% 164 38.1% 78 36.6% Grade 7 2630 30.8% 709 30.9% 142 33.0% 74 34.7% Grade 9 3183 37.3% 890 38.7% 124 28.8% 61 28.6% Missing 44 10 3 0 Self-rated health <0.001a Not so health 2591 31.1% 1003 44.7% 221 53.0% 128 62.4% health 5751 68.9% 1240 55.3% 196 47.0% 77 37.6% Missing 228 64 16 8 Life-satisfaction (m(SD)) 8340 7.55 (1.80) 2242 7.14 (2.00) 420 6.13 (2.00) 198 5.47 (2.79) <0.001b Missing 230 65 13 15 Health complaints (m(SD)) Somatic symptoms 8535 0.66 (0.97) 2296 0.93 (1.12) 431 1.34 (1.31) 211 1.77 (1.42) <0.001b Missing 35 11 2 2 Psychological symptoms 8489 0.70 (1.08) 2288 1.03 (1.27) 424 1.61 (1.41) 211 2.09 (1.48) <0.001b Missing 81 19 9 2
Note: a: Chi-square test, b: Kruskal-Wallis Test
Table 3. Normality tests results Variable Groups Kolmogorov- Smirnova P value Shapiro-Wilk P value Non victims without disabilities <0.001
Life satisfaction Non victims with disabilities <0.001 <0.001
Victims without disabilities <0.001 <0.001
disabled victims <0.001 <0.001
Non victims without disabilities <0.001
somatic symptoms Non victims with disabilities <0.001 <0.001
Victims without disabilities <0.001 <0.001
Disabled victims <0.001 <0.001
Non victims without disabilities <0.001 Psychological symp-
toms
Non victims with disabilities <0.001 <0.001
Victims without disabilities <0.001 <0.001
Disabled victims <0.001 <0.001
For the Life-satisfaction (See Table. 2), non victims without disabilities have highest scores (mean (SD): 7.55(1.80)). The participants with disability and have never experienced peer victimi- zation have higher scores (mean (SD): 7.14 (2.00)) than these have experienced peer victimization with disability (5.47(2.79) and without disability (6.13 (2.00)) with all Bonferroni adjusted p<0.001(See Fig. 3), yielding some support for hypotheses 1 and 2.
Fig 3. Box plot of life satisfaction in the four victim and disability groups
For the Self-rated health (Health/ Not so health) status (See Table. 2), non victims without disabilities have the highest health proportion which is 68.9%. the participants with disability and have never experienced peer victimization have the higher health proportion which is 55.3% than those who have experienced peer victimization with disability (37.6%) and without disability (47.0%) with all Bonferroni adjusted p<0.001(See Fig. 4),yielding some support for hypothesis 2.
Fig 4. Bar chart of health/not so health status in the four victim and disability groups
For the somatic symptoms in health complaints(See Table. 2), we also found that non vic- tims without disabilities have lowest complaints(mean (SD): 0.66 (0.97)), and the participants with disability and have never experienced peer victimization have lower complaints (mean (SD): 0.93 (1.12)) than these have experienced peer victimization with disability (1.77 (1.42)) and with- out disability (1.34 (1.31)) with all Bonferroni adjusted p<0.001(See Fig. 5), yielding some sup- port for hypothesis 2.
Fig 5. Physical symptoms score in the four victim and disability groups
For the psychological symptoms in health complaints(See Table. 2), we also found non vic- tims without disabilities have lowest complaints (mean (SD): 0.70 (1.08)) and the participants with disability and have never experienced peer victimization have lower complaints (mean (SD): 1.03 (1.27)) than these have experienced peer victimization (2.09 (1.48)) with disability and (1.61 (1.41)) without disability with all Bonferroni adjusted p<0.001(See Fig. 6), yielding some support for hypothesis 2.
Fig 6. Psychological symptoms in the four victim and disability groups
For the health complaints comparisons in disability/non-disability (See Table. 2), we found the participants with disability have higher somatic and psychological complaints than non-disa- bility participants with Mann-Whitney tests P<0.001(See Fig. 7). yielding some support for hy- pothesis 3.
Fig 7. Health complaints comparisons in disability/non-disability groups
For the Health complaints comparisons in have experienced peer victimization/never(See Table. 2), we found the participants who have experienced peer victimization have higher physi- cal and psychological complaints than non-disability participants with Mann-Whitney tests P<0.001(See Fig. 8). yielding some support for hypothesis 3.
Fig 8. Health complaints comparisons in have experienced peer victimization/never groups
Discussion
5.1 Reflection on findings
Bullying in schools has become a major issue of global concern (Hazler & Carney, 2000, 2002). The aim of this study is to explore the link between peer victimization and subjective health among groups of children who are most likely to be bullied because of their disability. We tried to explain that the higher risk of low subjective health indicators among students with disa- bilities was not due to disability, but rather to exposure to bullying. Overall, the findings support our hypothesis that children with disabilities alone have higher life satisfaction than both victims of with disabilities and without disabilities. Children with disabilities are more likely to report so- matic and psychological symptoms than children without disabilities. Children who were bullied reported more somatic symptoms than children who were not bullied. This finding is consistent with previous literature that suggests a link between victimization and psychological symptoms. Bullying is associated with negative mental health outcomes in children (Viljoen, O'Neill, & Sidhu, 2005). Studies have shown that victims of bullying are often depressed, anxious, lonely and lack adequate social skills, making them more likely to avoid social situations and have suicidal thoughts (Davidson & Demaray, 2007; Menesini, Modena, & Tani, 2009; Newman, Holden, & Delville, 2005; Storch & Masia-Warner, 2004). In general, children who are not bullied and have no disability will have the highest subjective health level, while the subjective health of disabled students who are not bullied is higher than that of disabled students who are bullied and non-dis- abled students who are bullied. This means that as the risk of exposure to bullying increases, the subjective health of children with disabilities will be further lower.
When considering the process-person-context- time (PPCT) model of bioecological theory (Bronfenbrenner & Morris, 2007). Bullying involvement is not due solely to the child’s personal attributes (e. g. , disability) , but rather to the child’s social interaction across multiple environ- ments (Bronfenbrenner, 1994). Since the study was a cross-sectional study, it only considered bullying that occurred at a micro-time level (Bronfenbrenner & Morris, 2007). Bullying is an ex- tremely negative process that occurs in the proximal environment (Bronfenbrenner & Morris, 2007). Good interpersonal relationships allow individuals to have confidence in their ability to build relationships with others, and have the ability to repair those relationships (Lynch & Cic- chetti, 1997; O'Connor & McCartney, 2006). However, relationships in bullying situations do not have this ability, it can also cause physical and psychological issues (Hazler & Denham, 2002). Victims of peer bullying often fail to maintain interpersonal relationships with their peers and to learn communication skills because of their decline in social skills (Champion, Vernberg, &
Shipman, 2003). As a result of the decline in social skills, individuals with poorer peer relation- ships and fewer friends are more likely to be victimized (Carlson, Flannery, & Kral, 2005). This creates a negative cycle where children are targeted for bullying because of their lack of social skills, the experience of being bullied can worsen a child’s proximal environment and make them lose confidence in their social abilities, thereby avoiding social interaction and isolating them- selves from the outside world (Coleman & Byrd, 2003; Fox & Boulton, 2005; Slee, 1994). With- out daily social interaction and healthy peer relationships, children will gradually lose their social skills.
When the bullying pattern begins, victims are unable to break out of the cycle because they are unable to deal with and face the social issues, and a lack of social skills leaves them with no sup- port group to help. Therefore, bullying behavior is a major obstacle to children’s social ability to obtain healthy social relationships (Rodkin & Hodges, 2003). Improved social skills can build confidence through constant stimulation of positive social interaction practices, as well as avoid- ing contact with negative social activities (Andreou, Vlachou, & Didaskalou, 2005). To be bullied is to immerse a teenager in a disorder, unhealthy peer interactions also isolate adolescents from positive social activities and intimate relationships and can cause most classmates to refuse to in- teract with victims (Newman et al., 2005).
In this study, there was evidence that non-victims without disabilities had the highest sub- jective health level, while children with only disabilities had higher subjective health level. When children’s personal characteristics are stable, such as interpersonal relationships, family structure, social adjustment, and self expression, it is assumed that their proximal environment is less likely to be a negative process(bullying) (Ttofi, Bowes, Farrington, & Lösel, 2014). A study pointed out that children who did not get involved in bullying are more likely to be active in school and have better peer relationships than children who are bullies and victims (Spriggs, Iannotti, Nansel, & Haynie, 2007). Therefore, interventions to prevent bullying should consider providing children with basic social skills while improving their interpersonal communication deficits, to help chil- dren to integrate into the school environment and to complete their studies in a good school at- mosphere (Saracho, 2017).
5.2 Methodological discussion and limitations
There are limitations in this study, because the cross-sectional study used in this study can only describe the relationship between variables, and cannot further explain the causal relation- ship between variables. Although the anonymous self-administered questionnaire proved to be
may have the possibility of subjectively hiding true information in their responses to the report (Lothen-Kline, Howard, Hamburger, Worrell, & Boekeloo, 2003). In research on bullying and subjective health, important confounding factors related to variables should be considered more comprehensively, as they may influence the established association. In addition, the sample size of students with disabilities was smaller than that of students without disabilities, and the sample size of students without disabilities was about three times larger than that of students with disa- bilities, and there was no information about the severity of the disability in the study, only the number of people with disabilities. Therefore, this study was unable to consider whether different levels of disability affect the relationship between victimization and subjective health. It is clear that we need large-scale studies, with a large enough sample of students with varying degrees of disability. There was no classification of bullying types in this study, and a studies have shown that students with disabilities who are bullied differ from other students in the form of bullying they receive (Pittet, Berchtold, Akré, Michaud, & Surís, 2010). Therefore, it would be useful to explore the relationship between bullying forms, subjective health and disability status.
5.3 Future research and practical implications
The participants of this study were 11, 13 and 15-year-old school children in Sweden. The variables included only sociodemographic characteristics, bullying involvement, disability and subjective health indicators. However, a variety of personal characteristics and external environ- mental factors, such as family structure, communication with parents, peer support, and school climate, all contribute to bullying and mental health, therefore, the relationship between victims of bullying and subjective health in the context of disability can be studied by controlling for in- ternal personal characteristics and external environmental factors. This study uses a HBSC ques- tionnaire to conduct a cross-sectional study. If we want to further explore the long-term effects of bullying on the physical and mental health of children and adolescents. In the future, we can do a longitudinal study on the bullying behavior of adolescents. In addition to victims, bullying involvement also include bullies and bystanders, so future studies could be included in studies to better understand the impact of bullying on the subjective health of adolescents with disabilities. In addition to students, future study could also be extended to their teachers or parents, so that they can have a better understanding of bullying and the mental health of students.
This study allows educators and researchers, and policy makers to have an understanding of the negative impact of bullying on the physical and mental health of children with disabilities, as children with disabilities are more likely to be targeted as victims. Therefore, educators and re- search should pay more attention to preventing the occurrence of bullying of children with
disabilities and trying to avoid bullying behavior. Pivik et al. (2002) suggests that educating non- disabled students and all teachers to make children with disabilities more inclusive, understanda- ble and accepted, thus protecting children with disabilities from bullying and developing social competence (Pivik, McComas, & Laflamme, 2002). As teachers, students with disabilities have an obligation to help them integrate into the group and not be bullied by other students and to pro- vide maximum physical and emotional support and understanding (Bourke & Burgman, 2010). Finally, this study contributes to a better understanding of the determinants of subjective health in the disabled population and to focus more specifically on specific populations in bullying stud- ies.
6 Conclusion
The purpose of this study was to explore the effects of peer victimization on the subjective health of students with disabilities, we can see that this study found that students with disabilities who were not bullied had higher levels of subjective health than students with disabilities and stu- dents without disabilities who experienced peer victimization. However, children who are not bullied and not disabled will have the highest level of subjective health, which means increased risk of exposure to bullying leads to a further lower subjective health of children with disabilities. Although the study has some limitations, the findings highlight the impact of bullying on chil- dren’s subjective health. Therefore, schools can assess children’s risk of peer victimization in or- der to be able to provide targeted prevention, while educating non-disabled students and all teachers to make children with disabilities more inclusive, understandable and acceptable, to pro- tect children with disabilities from bullying and develop social skills. Future research should con- sider more personal and environmental factors related to children with disabilities and their im- pact on bullying and mental health. Other types of bullying involvement including bystanders and bullies should also be included in the study of subjective health of children with disabilities.
