The Journal of School Nursing
© The Author(s) 2020
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DOI: 10.1177/1059840520951635
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2022, Vol. 38(4) 380–386
Although adolescent females with asthma are at increased risk for bullying, relationships between bullying at school and electronic bullying and demographics, mental health issues, and substance use have not specifically been studied in these young women. The purpose of this research was to examine such relationships among adolescent females with asthma. Complex sampling software was used to extrapolate frequencies and χ2 analyses to adolescent females with asthma. In this U.S. sample of adolescent females with asthma (n = 1,634), younger age, mental health issues, and substance use were significantly related to bullying at school and electronic bullying, while race/ethnicity and grade in school were significantly related only to bullying at school. In general, findings are consistent with previous research regarding relationships between bullying and risk factors among all U.S. adolescent females. Guidance by school nurses is needed to create effective supports for victimization reduction in this vulnerable group.
Keywords
asthma, bullying, high school, quantitative research
Bullying, the unwanted, aggressive behavior, repeated over time by another person which includes a perceived or observed power discrepancy (Gladden et al., 2014; Heirman, & Walrave, 2008; Olweus, 1997), is a widespread challenge faced by adolescents (Moreno et al., 2018). While much bullying occurs at school, electronic bullying, which may occur through email, texts, or social media (Gladden et al., 2014; Heirman, & Walrave, 2008), has intensified in adolescents due to their increasing use of technology (Nixon, 2014). Bullying is a significant public health concern, given its negative effects on adolescents’ self-confidence, sense of control, and awareness of fitting in (Jochman et al., 2017; Pontes, Ayres, Lewandowski, & Pontes, 2018).
According to the 2017 Youth Risk Behavior Survey (YRBS), 19.0% of youth in Grades 9–12 in the United States reported being bullied at school, and 14.9% reported electronic bullying (Kann et al., 2018). This same survey found that the prevalence of having been a victim of bullying at school was higher among females (22.3%) than males (15.6%) as was the prevalence of electronic bullying (19.7% among females and 9.9% among males; Kann et al., 2018). The higher prevalence of bullying at school and electronic bullying for females compared with males is consistent with prior research (Hertz et al., 2015; Kann et al., 2018; Merrill & Hanson, 2016; Sampasa-Kanyinga et al., 2014). Among adolescent females, those in lower high school grades are more likely to be victims of bullying at school (Kann et al., 2018; Merrill & Hanson, 2016; Pontes, Ayres, Lewandowski, & Pontes, 2018). In the 2017 YRBS, a greater proportion of girls in Grade 9 indicated that they experienced bullying at school compared with girls in Grades 10–12 (25.2%, 23.6%, 23.5%, and 16.3%, respectively; Kann et al., 2018). As for electronic bullying, research results with regard to grade in school are mixed. Some research suggests there are no differences across grade in school (Merrill & Hanson, 2016), while other research reports that adolescent females in higher grades are more likely to be victims of electronic bullying (Pontes, Ayres, Lewandowski, & Pontes, 2018; Sampasa-Kanyinga et al., 2014). The 2017 YRBS reports that girls in Grade 9 have a higher prevalence of experiencing electronic bullying compared with girls in Grades 10–12 (22.3%, 19.7%, 19.9%, and 16.4, respectively; Kann et al., 2018). Regarding the relationship between race/ethnicity and bullying in adolescent females, findings from the 2017 YRBS indicate that the prevalence of bullying at school is highest in White females (24.6%), followed by Hispanic females (21.0%), and then by Black females (14.5%). Similar trends were observed regarding electronic bullying: The highest reports are in White females (23.0%), followed by Hispanic females (17.2%), and then by Black females (13.3%).
In a U.S. sample of high school students, those who reported bullying at school or electronic bullying were more likely to also report sadness and suicidal ideation including suicide attempts (Messias et al., 2014). Bullying victimization is significantly more likely to be associated with depressive indicators, suicidal ideation, and suicide attempts among females than among males (Pontes, Ayres, & Pontes, 2018; Pontes et al., 2020; Sibold et al., 2015). In addition, for high school females, an association has been found between bullying victimization and marijuana use (Turner et al., 2018), prescription drug use (Turner et al., 2018), illicit drug use (Hertz et al., 2015), and current alcohol and cigarette use (Hertz et al., 2015). Vaping has been associated with strong peer influences (Perikleous et al., 2018) and harassment (Coulter et al., 2018), but its relationship with bullying among adolescent girls is unknown.
Although adolescents with and without chronic illness such as asthma, experience bullying, adolescents with asthma are particularly vulnerable (Gibson-Young et al., 2014; Merrill & Hanson, 2016; Muhammad et al., 2018). In their study of Florida adolescents, Gibson-Young and colleagues (2014) found that 19.7% of adolescents with asthma reported bullying at school as compared with 13.4% of those without asthma. They also found that 18.1% of adolescents with asthma reported electronic bullying as compared with 11.8% of those without asthma. Research has found that bullying among adolescent males and females with asthma who also report mental health symptoms indicates higher bullying and electronic bullying rates than those without mental health symptoms (Gibson-Young et al., 2014). We are not aware of any research that has specifically studied substance use and bullying in adolescents with asthma. However, the research that has found a relationship between various forms of substance use and bullying in school and electronic bullying among adolescents in the general population (Hertz et al., 2015; Turner et al., 2018) suggests that these relationships may exist for adolescents with asthma as well. Overall, to the best of our knowledge, relationships between bullying and demographics, mental health, and substance use have not been studied solely in adolescent females with asthma.
In view of the higher bullying prevalence in females than in males and the positive association between having a diagnosis of asthma and higher bullying prevalence, the purpose of this study is (1) to examine the prevalence of bullying at school and electronic bullying among high school females with asthma in the United States and (2) to examine relationships between demographic characteristics, mental health, and substance use and bullying at school and electronic bullying among this group of particularly vulnerable female adolescents. To do so, we use data from a sample of 1,634 female adolescents with asthma in the YRBS 2017 and extrapolate our results to the population of female adolescents with asthma in the United States. We hypothesized that the prevalence of bullying at school and electronic bullying among high school females with asthma in the United States would be greater than those of all adolescent girls in the United States as has been determined by earlier research. This earlier research reported this prevalence for a representative sample of all U.S. adolescent girls including those with and without asthma (Kann et al., 2018). We also hypothesized that female adolescents with asthma who reported bullying would have more mental health and substance use issues than female adolescents with asthma who did not report bullying. Additionally, we anticipated that demographic differences of adolescent girls with asthma who were and were not bullied would be consistent with national findings for the population of all adolescent girls in the United States who were and were not bullied. An understanding of these prevalences and relationships may influence anticipatory guidance during primary care visits and educational interventions within schools and elsewhere for adolescent girls with asthma to guide and create effective supports for victimization reduction in this especially vulnerable group of females.
Data from the YRBS 2017 were used in the analyses. The national YRBS 2017, conducted by the Centers for Disease Control and Prevention (CDC), examined adolescent health risk and health-protective behaviors. These behaviors included diet, physical activity, unintentional injuries and violence, tobacco, alcohol, and other drug use. Additionally, YRBS 2017 examined the prevalence of asthma and obesity.
Data collection for YRBS included a three-stage cluster sampling procedure in obtaining a sample of U.S. students in Grades 9–12. Stage 1 included primary sampling units (PSUs) comprised of large-sized counties or groups of smaller, neighboring counties in the United States. Stage 2 involved school selection from private and public schools in the PSUs. The final step involved the random selection of one or two classes in each of the selected schools in each of the four high school grades. A comprehensive explanation of the sampling can be found elsewhere (Kann et al., 2018).
Ours was a secondary data analysis of data collected for YRBS 2017. Primary data collection had been performed by International Classification of Functioning, Disability, and Health (ICF) Macro, Inc., an ICF global company. They worked with the CDC and were responsible for sample design and school selection. ICF Macro also worked with the chosen schools to select classes and obtain parental permission for their child’s participation. Students completed a computer-scannable 99-item questionnaire administered in a 45-min class period. Participation was voluntary and anonymous, and the publicly available data were considered exempt from review by the Institutional Review Board at Hunter College. The 2017 YRBS data consist of questionnaire responses from 14,765 students in 21 large urban school districts and 39 states (Kann et al., 2018). A total of 144 schools completed the survey, with a student response rate of 81% and a school response rate of 75% (Kann et al., 2018).
We limited our analyses to adolescent females with asthma and determined the presence of asthma according to response to the query: Has a doctor or nurse ever told you that you had asthma? Those who responded “yes” were considered to have asthma.
We examined the self-reported prevalence of school bullying and electronic bullying in females in Grades 9–12 with asthma. Bullying was quantified by a reply to the question: During the past 12 months, have you ever been bullied on school property? (yes or no). Electronic bullying was measured by a response to the question: During the past 12 months, have you ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media; yes or no).
The data were analyzed to establish the relationships of each of the bullying variables with demographic variables including age (16 years or older vs. 15 years or younger), race/ethnicity (Black/African American, Hispanic, White, or other racial/ethnic groups), and grade (11 or 12, vs. 9 or 10). Additionally, we examined relationships of each of the bullying variables with mental health and substance use variables.
The mental health questions included the following: During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities? (yes or no); during the past 12 months, did you ever seriously consider attempting suicide? (yes or no); and during the past 12 months, did you make a plan about how you would attempt suicide? (yes or no).
The substance use questions included the following: Have you ever tried cigarette smoking, even one or two puffs? (yes or no); have you ever used an electronic vapor product? (yes or no), and during the past 12 months, has anyone offered, sold, or given you an illegal drug on school property? (yes or no). Regarding alcohol use, respondents were asked, during your life, on how many days have you had at least one drink of alcohol? (0 days, 1 or 2 days, 3–9 days, 10–19 days, 20–39 days, 40–99 days, or 100 or more days). To be consistent with the questions and responses involving cigarette smoking, electronic vaping, and illegal drug use, we recoded the response to alcohol use to reflect whether the adolescent ever used alcohol, that is, 0 days (never used alcohol) versus all other responses (ever used alcohol). Similarly, regarding marijuana use, respondents were asked: During your life, how many times have you used marijuana? (0 times, 1 or 2 times, 3–9 times, 10–19 times, 20–39 times, 40–99 times, or 100 or more times). Again, as with the questions and responses involving cigarette smoking, electronic vaping, and illegal drug use, we recoded this response to reflect whether the adolescent ever used marijuana, that is, 0 times (never used marijuana) versus all other responses (ever used marijuana).
As described earlier, the YRBS employs a three-stage cluster sampling procedure in obtaining a sample of U.S. high school students. Therefore, the data were analyzed using complex samples software (the complex samples module in statistical package for social sciences (SPSS) Version 25) to analyze the data appropriately. In particular, the use of complex samples software that uses the sample weights and design variables that YRBS 2017 provided enabled the achievement of valid point estimates, standard errors, confidence intervals, and tests of hypotheses, given the stratification, clustering, and unequal selection probabilities in the sampling plan (West et al., 2018). It also enabled the extrapolation of findings to the U.S. population of adolescent females with asthma. Descriptive statistics were calculated for each of the included variables, and prevalences of bullying at school and electronic bullying were determined for the U.S. population of adolescent girls with asthma. χ2 statistics were then utilized to determine statistically significant associations between each of the bullying variables and the demographic, mental health, and substance use variables. Statistical significance was set at p < .05.
A total of 1,634 adolescent females with asthma responded to whether or not they were bullied at school, whether or not they were electronically bullied, and questions about their demographic characteristics, mental health, and substance use. These 1,634 females constitute the study sample. When extrapolated to the population of adolescent females with asthma in the United States, 27.5% of adolescent females with asthma were bullied at school compared with 72.5% who were not, and 24.7% of adolescent females with asthma were electronically bullied as compared with 75.3% who were not. Almost two thirds (62.7%) were 16 years or older, 52.2% were White, and almost half (47.3%) were in high school Grades 11 or 12 (left column, Table 1).
Bullying at school. As shown in Table 1, the relationship between race/ethnicity and bullying at school was statistically significant (p = .021). Compared with females with asthma who were not bullied at school, a smaller proportion of those who were bullied at school was Black/African American and a greater proportion was White. Compared with females with asthma who were not bullied at school, females with asthma who were bullied at school were significantly less likely to be 16 years or older (p < .001) and in Grades 11 or 12 rather than in Grades 9 or 10 (p = .001).
In addition, compared to females with asthma who were not bullied at school, females with asthma who were bullied at school were significantly more likely to report (a) feeling sad or hopeless (p < .001), (b) considering suicide (p < .001), (c) making a suicide plan (p < .001), (d) ever using cigarettes (p = .025), (e) using electronic vapor products (p = .007), (f) ever using alcohol (p = .002), (g) ever using marijuana (p = .046), and (h) having contact with illegal drugs at school (p < .001).
Electronic bullying. As presented in Table 2, there were no statistically significant relationships between electronic bullying and either race/ethnicity or grade in school. However, compared with females with asthma who were not electronically bullied, females with asthma who were bullied electronically were significantly less likely to be 16 years or older (p = .041).
In addition, females with asthma who were electronically bullied were significantly more likely than females with asthma who were not electronically bullied to report (a) feeling sad or hopeless (p < .001), (b) considering suicide (p < .001), (c) making a suicide plan (p < .001), (d) ever using cigarettes (p = .001), (e) using electronic vapor products (p = .001), (f) ever using alcohol (p < .001), (g) ever using marijuana (p = .002), and (h) having contact with illegal drugs at school (p < .001).
Bullying in adolescents, whether experienced at school or electronically, is a threat to adolescent well-being and health. Prior research has focused on adolescent girls in the general population and the associations between bullying and identified risk factors. Yet, relatively little is known about the associations with risk factors and bullying in girls with asthma. The relationship between bullying and its risk factors and asthma, the most common chronic lung disease affecting almost 6 million children (CDC, 2017), warranted further investigation in this adolescent group. We found that 27.5% of adolescent females with asthma were bullied at school as compared with 72.5% who were not. We also found that 24.7% of adolescent females with asthma were electronically bullied as compared with 75.3% who were not. Compared with a representative sample of adolescent girls in the general population (including girls with and without asthma) and consistent with our first hypothesis, there was a greater prevalence of bullying among adolescent girls with asthma. In particular, 22.3% of all adolescent girls with and without asthma were bullied at school versus 27.5% of adolescent girls with asthma. In addition, 19.7% of all adolescent girls with and without asthma were electronically bullied versus 24.7% of adolescent girls with asthma (Kann et al., 2018). Notably, differences between the prevalences of each type of bullying between girls with and without asthma will be even greater than those between adolescent girls with asthma and all adolescent girls.
To our knowledge, this is the first study to examine relationships between demographic, mental health, and substance use and bullying at school and electronic bullying in U.S. adolescent females with asthma. In the general adolescent population, there is growing attention to bullying, especially its relationship with sadness, depression, and suicide (Pontes, Ayres, & Pontes, 2018; Pontes et al., 2020; Sibold et al., 2015). Prior research has examined factors associated with bullying, both in-person and electronic, but little of it has focused on adolescents with asthma (Gibson-Young et al., 2014; Muhammad et al., 2018).
Analyses from this study indicate age to be significant, as adolescent females with asthma who experienced bullying at school and electronic bullying were more likely to be younger than 16 years of age. The finding of bullying at school and its association with younger females is consistent with prior research in the general adolescent female population (Merrill & Hanson, 2016; Pontes, Ayres, Lewandowski, & Pontes, 2018). However, our findings regarding the association between younger age and electronic bullying differ from prior research, with one study showing no differences regarding age and electronic bullying (Merrill & Hanson, 2016) and others supporting an association with electronic bullying and older age (Pontes, Ayres, Lewandowski, & Pontes, 2018; Sampasa-Kanyinga et al., 2014). Consistent with prior research in the general high school population (Merrill & Hanson, 2016; U. S. Department of Education, 2014), we found that girls with asthma who were bullied at school were less likely to be Black/African American or Hispanic as compared with White or of other races/ethnicities. Merrill and Hanson (2016) suggest that Black and Hispanic adolescents may appear less vulnerable or less willing to be victims of bullying. We also found no statistically significant differences in the relationship between race/ethnicity and electronic bullying. This is inconsistent with prior research demonstrating that electronic bullying is higher in Whites and Hispanic students compared with Black students (Hertz et al., 2015). Nevertheless, because the reporting of electronic bullying continues to increase among adolescent females (Jones et al., 2012; Kessel Schneider et al., 2015), this relationship in all races/ethnicities warrants continued examination. Thus, our hypothesis that demographic differences of adolescent girls with asthma who were and were not bullied would be consistent with national findings for the population of all adolescent girls in the United States who were and were not bullied was partially supported.
This study found several commonalities across the bullying at school and electronic bullying variables. The selected mental health issues (feeling sad or hopeless, considered suicide, and made a suicide plan) were significantly related to both bullying variables among adolescent girls with asthma. These results are consistent with previous work that examined bullying of all adolescent females, which demonstrated significant relationships between attempted suicide across both bullying variables (Hertz et al., 2015; Merrill & Hanson, 2016), and feeling sad and creation of a suicide plan with both bullying at school and electronic bullying (Merrill & Hanson, 2016). Thus, our hypothesis that adolescent females with asthma who were bullied would experience higher rates of mental health issues than those who were not bullied was borne out.
In addition, cigarette use, marijuana use, electronic vapor use, alcohol use, and exposure to illegal drugs at school were significantly related to both bullying variables in this study, supporting our hypothesis that adolescent females with asthma who were bullied would experience more substance use than those who were not bullied. Previous research involving all adolescent females found that the relationship between exposure to illegal drugs and both bullying variables reached statistical significance (Hertz et al., 2015). In that study, there were statistically significant relationships between cigarette and alcohol use and electronic bullying but not in-person bullying (Hertz et al., 2015). It is possible that females with asthma may feel more vulnerable due to their chronic condition. Therefore, in order to fit in with peers, they may be more inclined to engage in risky behaviors such as cigarette use, marijuana use, electronic vapor use, and illegal drugs.
This study has several limitations. First, the use of cross-sectional data prevented analysis of causal relationships between demographics, mental health issues, and substance use and types of bullying. Because this is a developing area of research in adolescent females with asthma, the cross-sectional design gave us a preliminary understanding of these relationships. A second limitation is the amount of missing data. The question related to cigarette use had about 20% missing data. Nonetheless, we felt it best to include this risk behavior in our analyses. It is possible that students did not answer the cigarette question due to social desirability, as these were females with a diagnosis of asthma. A third limitation of the study was that the data collected were self-reported, suggesting the potential for social desirability in responses to other questions, as well. A final limitation of the study was related to the questions and response options, themselves, including dichotomous answer options, no clear guidelines or consistency in the literature regarding recoding of answer choices, and socially desirable responses. Even with these limitations, the study results help shape the basis for future research that would analyze the relationships we examined longitudinally, which would allow for an appraisal of cause and effect. Future research should explore substance use as a coping means to avoid the sorrow or heartache involved with being a female adolescent with asthma who is also a victim of bullying. Additionally, an investigation of protective factors is needed as they may show an influence regarding bully victimization, chronic illness (asthma), and gender.
This study found that certain demographic, mental health, and substance use characteristics and behaviors were significantly associated with bullying at school and electronic bullying in adolescent females with asthma. There were strong relationships with both types of bullying and the mental health variables of sadness and creating and making a suicide plan. These findings affirm previous research that linked mental health issues in females (but not specifically females with asthma) and bullying and electronic bullying (Hertz et al., 2015). This study also found relationships between substance use and bullying. Future work is necessary regarding the specific association of vaping and bullying on adolescent girls with asthma, as this appears to be underexplored in the literature.
Our findings, generalized to adolescent females with asthma in the United States, reveal that bullying and electronic bullying present significant issues to these young women’s lives. The findings should inform school nurses, other health providers, faculty, staff, and parents regarding awareness about bullying related to gender and chronic illness. School nurses should intervene with this group of young women with asthma who experience bullying and its associated risk factors. Although school nurses already have substantial expertise to intervene effectively, they should advocate for the receipt and allotted time to increase this expertise by participating in continuing education and training in the area of bullying prevention, chronic illness, and mental health. These trainings might occur periodically and include guidelines in care management and advice on how best to interview the adolescent and ask questions about mental health and substance use. Continued investigation is warranted into the role of certain behaviors that may be related to bullying vulnerability, and greater inquiry is warranted regarding the unique experiences of adolescent females with asthma. Research on schools’ and school nurses’ involvement in asthma management should further investigate the inclusion of antibullying recommendations and the effect of asthma on student outcomes. This research should also examine the role of potential risk and protective factors related to bullying and include these in individual health plans for the vulnerable group of adolescent females with asthma.
Ellen M. McCabe contributed to conception or design, data acquisition, data analysis, or data interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Shiela M. Strauss contributed to conception or design, data acquisition, data analysis, or data interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ellen M. McCabe, PhD, RN, PNP-BC https://orcid.org/0000-0003-2901-1670
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Ellen M. McCabe, PhD, RN, PNP-BC, is an assistant professor at Hunter-Bellevue School of Nursing, Hunter College, NY, USA.
Shiela M. Strauss, PhD, is a consultant at Hunter-Bellevue School of Nursing, NY, and adjunct professor at New York University Rory Meyers College of Nursing, NY, USA.
1 Hunter-Bellevue School of Nursing, Hunter College, New York, NY, USA
2 New York University Rory Meyers College of Nursing, New York, NY, USA
Corresponding Author:
Ellen M. McCabe, PhD, RN, PNP-BC, Hunter-Bellevue School of Nursing, Hunter College, 425 East 25th Street, New York, NY 10010, USA.Email: em3766@hunter.cuny.edu
