The Journal of School Nursing2023, Vol. 39(4) 313–320© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211013522journals.sagepub.com/home/jsn
Girls between the ages of 9 and 10 begin to experience physical, physiological, and hormonal changes that may lead to internal stress. At this age, children are struggling for autonomy; on the other hand, they may experience emotional instability, and for these reasons, they may be vulnerable in many ways. This experimental study aimed to investigate the effect of resilience training on assertiveness in student girls aged 9–10. Data were collected before, immediately after, and 1 month after the intervention in the control (n = 40) and intervention (n = 37) groups. There was a significant difference between the assertiveness of the intervention immediately (26.80 ± 3.73) and 1 month after the intervention (27.05 ± 3.73), and assertiveness significantly increased in the intervention group (p = .0001). Resilience training leads to improvements in assertiveness in student girls aged 9–10.
Keywordsresilience training, assertiveness, students, girls, school nurses
The developmental readiness hypothesis posits that specific developmental tasks must be completed before the transition into puberty. Children’s vulnerability increases as they adapt to changes at puberty, and girls between the ages of 9 and 10 begin to experience physical, physiological, and hormonal changes (Galamandjuk et al., 2017; Gunnar et al., 2010; Slemming et al., 2010). Early-maturing girls will be at high risk for mood and behavior problems because of the inconsistency between physical, cognitive, social, and emotional maturity, and early puberty is becoming increasingly common in girls (Beltz, 2018).
The environmental stressors, the changing social expectations and behavioral norms, and the developmental asynchrony among physical, social, emotional, and cognitive maturity are likely to increase early-maturing children’s vulnerability to adjustment problems (Galamandjuk et al., 2017; Naghshineh et al., 2017). Early maturation for girls is associated with more adjustment problems compared with boys. Early-maturing girls have not had the time to acquire, assimilate, and strengthen the adaptive and coping skills to adequately deal with the convergent demands of pubertal transition (Negriff & Susman, 2011). During puberty, girls experience twice as much depression and mental distress as boys (Beltz, 2018).
It is essential to consider children’s mental health when they face fundamental physiological, social, and psychological changes and extreme stressors (Masten & Barnes, 2018). A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents showed that the worldwide-pooled prevalence of mental disorders was 13.4% (Polanczyk et al., 2015). Pediatric psychiatry is in its early stages in some developing countries. Therefore, these countries face many concerns regarding children’s mental health and its epidemiology (Mohammadi et al., 2019; Sarraf et al., 2019).
In Iran, about 16.34% of the country’s population is between 10 and 19 years old (Alimordi & Simbar, 2014). For cultural reasons, most youth in Iran, especially girls, do not have adequate information regarding reproductive health, and they may endanger their health because of acquiring information from uninformed and unreliable sources. Based on studies, adolescent girls’ challenges in health can be classified into social and cultural challenges such as taboos and structural and administrative challenges when seeking health care (Mirzaii Najmabadi et al., 2018). Exact statistics of the prevalence of psychiatric disorders are not available in Iran (Mohammadzadeh et al., 2018). According to reports, roughly 17.9% of children aged between 6 and 11 years suffer from psychiatric disorders (Mohammadi et al., 2019).
Several factors, such as parenting practices, disciplinary strategies, and parental psychological pathology, have been associated with various psychological outcomes in children (McKinney et al., 2016). These factors may predispose some children to psychological and social disorders and the inability to adapt to growth changes, stress, and other challenges (Cicchetti, 2013). Life skills are a set of abilities that enable individuals to adapt to their environment, society, and culture and also ensure their mental health (Ghani Far & Kharaei, 2019). One of these skills is assertiveness, which is regarded as one of the most important factors in children’s mental health (Hadyian & Dehghani, 2019).
The skill of assertiveness means standing up for one’s rights calmly and positively without being aggressive or passively accepting what others consider wrong (Neijmeijer et al., 2020). Assertiveness prepares children to play different roles in their future. Unassertiveness has a restrictive effect on children and prevents them from forming a healthy identity, realizing their talents, and achieving creativity and acquiring other mental and emotional skills (Avşar & Alkaya, 2017). Researchers stress the importance of assertiveness for all people. In the midst of the significant culture and lifestyle changes today’s societies are experiencing, many individuals lack the necessary ability to cope with life’s problems, which has made them unable to successfully face and address problems of everyday life (Ghani Far & Kharaei, 2019). An early adolescent with low resilience may not be able to cope with life struggles (Agbakwuru & Stella, 2012; Salari Koohfini & Ghasemali Kheirabadi, 2020). One strategy for developing assertiveness is resilience training.
Resilience training has been used to improve skills and treat behavioral and mental disorders (Joyce et al., 2018; Masten & Barnes, 2018). Resilience is one of the constructs of positivist psychology, defined as the process of coping with a stressful and challenging life (Pakdaman & Balideh, 2020). People can overcome problems with supportive and adaptive skills and recover from unpleasant experiences (Masten & Barnes, 2018; Sharma et al., 2020). Researchers claim that people can learn how to overcome stress, fears, and challenges with proper resilience training (Tabibnia & Radecki, 2018). One of the pioneers in studying children’s resilience states that resilient children are socially capable and possess skills such as self-awareness, self-efficacy, selfcontrol, problem-solving, assertiveness, critical thinking, and the ability to take action (Benard & Slade, 2009).
Furthermore, children who have a sense of purposefulness can envision a positive future for themselves and are motivated to reach their goals in life and at school (Benard & Slade, 2009). Since the consequences of undesirable experiences in childhood crises have adverse effects on people’s lives, resilience training aims to improve assertiveness. Individuals with high levels of assertiveness tend to be resilient and do not allow others to abuse them. As a result, these individuals achieve a higher level of adaptation in social interaction (Sattari Sefidan Jadid et al., 2019). Resilience training in childhood may prepare people for later challenges (Masten & Barnes, 2018). Researchers have reported that the best time for psychological interventions is in primary school when children experience personality formation and accelerated growth (Proctor & Linley, 2013).
School nurses provide care for children as direct care providers, supervisors, health educators, and school counselors (Bohnenkamp et al., 2015). The school nurse role also includes the primary, secondary, and tertiary prevention. School nurses are well positioned to identify and help students with resilience and assertiveness issues.
One study showed that resiliency training increased selfassertion in male sixth graders studying at all-boys elementary schools (Salari Koohfini & Ghasemali Kheirabadi, 2020). Due to the lack of studies on the effect of interventions on assertiveness in girls, this study was conducted to assess the effect of resilience training on assertiveness in Iranian student girls aged 9–10 years.
The present study had a pretest–posttest experimental design with an intervention and a control group. Follow-up was conducted after 1 month in two all-girls schools in southeast Iran.
The research setting was two schools from two districts. The schools are the main center of the provision of educational services for fourth-grade female students. Power analysis calculations with G*Power software 3.1 indicate that 35 participants would be needed per group to detect an effect size of .5 (power = 80%, p = .05). Of the total 100 female students aged 9–10 who were deemed eligible, 90 participated in this study and were allocated to the two groups of intervention (n = 45) and control (n = 45) using a random number table. Five participants of the intervention group were excluded due to their lack of participation in more than two training sessions. Moreover, seven control group participants were excluded because they did not complete the questionnaires after the intervention. Finally, the experiment and control groups consisted of 40 and 37 participants, respectively. The sampling list was collected from schools by the first researcher, and the samples were assigned to the experiment and control groups by a researcher outside the research team. The researcher was blind to the placement of the samples. Factors affecting education, such as demographic and background variables, were equal between the groups, and no significant difference was observed between the groups in terms of the variables associated with training (Table 1). The inclusion criteria consisted of the ability to use a smartphone or computer to attend class and the ability to communicate in virtual space. The exclusion criterion was the nonparticipation of a student in more than one training session.
Demographic and background information along with the assertion inventory was employed to collect data. The demographic and background form included parents’ education level, parents’ occupation, family income, number of children, birth order, history of visiting consultants or psychiatrists, parents’ diseases, and parents’ marital status (if they were divorced and whom the child lived with).
The assertion inventory was designed by Gambrill and Richey (1975). Each item demonstrates a situation that needs assertive behavior. This questionnaire has several categories, including rejecting a request, initiating a social interaction, expressing positive feelings, coping with and accepting criticism, expressing personal boundaries, representing oneself when there is a need for help, accepting differences, and negative feedback. Scoring was done using a 5-point Likert-type scale asking the degree of discomfort in each situation including 5 = very much, 4 = much, 3 = a fair amount, 2 = a little, and 1 = none. The score range was 22–110 for this questionnaire, and a higher score shows lower assertiveness (i.e., the scoring of this questionnaire is inverse). Analysis of the factors by Gambrill and Richey showed that the inventory has high validity and can differentiate between high and low assertiveness. According to Gambrill and Richey (1975), the factor validity of items was between. 39 and.70, and the reliability coefficient was .81. After Khameneh et al. (1995) eliminated 18 items and adapted the questionnaire to Iranian culture, the calculated test score correlation and the reliability coefficient were .46 and .82, respectively.
Due to the COVID-19 pandemic, the intervention was implemented in a synchronous virtual environment. Two separate links were made for intervention and control groups in WhatsApp and sent to virtual classes. The procedure was explained to parents and students. In the first session, the procedure, participation rules, and method of holding sessions were thoroughly introduced; afterward, the questionnaires were sent to the groups. Moreover, some explanations on the questionnaires were sent to the groups as video and audio files. When the two groups completed the questionnaires, 12 resilience sessions, based on the literature review (Milstein & Henderson, 1996; Peng et al., 2014), were held twice a week for 6 weeks by a trained researcher under the supervision of a professor of community medicine (Supplemental Table S1).
The first two sessions lasted for 30 min, and the others lasted for 15–20 min. There was an opportunity for students to actively participate in the discussion and with each other and breakout rooms for students to problem-solve together. Feedback was “live” during the sessions with the presence of the trained researcher and a counselor from each school. The starting time of each session was announced the day before so that everyone could take part in the workshop. The training was conducted using video and audio clips, films, animation, child-based scenarios, text messages, storytelling, and questions and answers. FastStone software 7.5 was used to create the clips (podcasts). A PowerPoint presentation of the related topic was used, the sound was added to it using the FastStone software, and the resulting material was sent to the intervention group. The educational content and the structure of each session were confirmed by a professor of community medicine. Animations related to the topic of some sessions were downloaded from authoritative websites and were used in the sessions after confirmation by the supervising professor of community medicine. The animation was sometimes sent before the educational clip to help students identify their weaknesses and strengths and to encourage brainstorming. Students were then asked to express their opinions during the following session. Some practice sessions were held in the form of storytelling to increase the effectiveness and understanding of the material. In some sessions, the students were asked to do some homework and send it to the researcher, who then reviewed the answers to correct them and address any problems students had experienced. Forty students participated in each session, and each student who was absent for more than one session was excluded from the study. Both schools participated simultaneously on the same platform. The intervention group students were asked not to provide educational content to the control group, and entertainment games unrelated to the main content of the training were used for the control group. After the end of the training sessions, data were collected immediately, and a 1-month follow-up was conducted in both groups. After data collection, the educational content was provided to the control group in the same manner.
The ethics committee of Kerman University of Medical Sciences approved the study (Ethics code No. IR.K-MU.REC.1398.415). Written consent electronically was obtained from all participants and their parents in both intervention and control groups, and they were assured that their personal information would remain confidential. Also, a training program was conducted for the control group after the study.
Data were analyzed using SPSS Version 18 (officially dubbed IBM SPSS statistics). Descriptive statistics were used to describe the demographic and clinical characteristics of the participants and other variables of the study. χ2 was used to compare the demographic and clinical characteristics of the samples between the two intervention and control groups. Since the parametric conditions were confirmed, the repeated measures analysis of variance (ANOVA) and Bonferroni test were used to compare the assertiveness scores within each group and between the groups at different times. A p value below .05 was considered significant.
According to the results, there was no significant difference between the two groups in terms of demographic and background variables including parents’ education, parents’ job, number of children, birth order, visiting a psychiatrist or counselor, parental illness, and monthly family income (Table 1).
According to Table 2, the ANOVA results in repeated measures showed that the association between group and time was significant in this study. The group and time variables were significantly related to changes in assertiveness. In the intervention group, the mean scores of assertiveness were 69.97 ± 17.28, 26.80 ± 3.73, and 27.05 ± 3.73 before, immediately after, and 1 month after the study, respectively. Due to the inverse scoring of the questionnaire, assertiveness increased significantly after the intervention. However, in the control group, the mean scores of assertiveness were 65.48 ± 16.556, 65.81 ± 16.09, and 65.56 ± 16.00 before, immediately after, and 1 month after the study, respectively, which indicated poor assertiveness. The results showed a significant difference between the two groups in terms of assertiveness.
The results of Bonferroni post hoc test showed that there was no significant difference between the assertiveness of the two groups before the intervention. However, immediately and 1 month after the intervention, assertiveness had increased in the intervention group, showing improvement in assertiveness in the intervention group compared with the control group (Table 3). Furthermore, Bonferroni post hoc test results indicated that the mean score of assertiveness in the intervention group had increased significantly 1 month after the intervention compared with before the intervention. However, the score 1 month after the intervention was not significantly different from the assertiveness score immediately after the intervention. Moreover, the level of assertiveness immediately after the intervention had significantly increased compared to the assertiveness level before the intervention. In other words, although the intervention had ended, its impact remained for 1 month. In the control group, the level of assertiveness 1 month after the intervention was not significantly different from its level before and immediately after the intervention. Also, the level of assertiveness immediately after the intervention was not significantly different from its level before the intervention (Table 4).
The findings of the present study showed that assertiveness had increased significantly immediately and 1 month after the intervention in the intervention group. On the other hand, assertiveness had not changed significantly in the control group. Moreover, there was a significant difference between the two groups in terms of assertiveness immediately and 1 month after the intervention. These results indicated that resilience-based training had positively affected the students in the intervention group, and the effect of the training lasted 1 month after the implementation of the intervention.
The present study’s findings were in line with those of the study conducted by other researchers who reported that resilience training improved assertiveness in sixth-grade male students (Koohfini & Kheirabadi, 2020). No other study was found investigating the effects of resilience training on assertiveness in the manner of the present study. However, other studies have investigated the effectiveness of other psychological interventions, such as positive psychology, on assertiveness. A study reported that positive thinking training impacted self-assertiveness in female students, which is in line with the findings of the present study (Hamidi et al., 2020). The researchers investigated and reported the effectiveness of cognitive reconstructing in group counseling therapy on the improvement of assertiveness and found that group counseling improved assertiveness skills (Aliem et al., 2019). Another study indicated that social skill training was effective on the improvement of assertiveness in students aged 9–11 and continued to be effective in a 25-day follow-up (Kashani & Bayat, 2010). One study reported that there was a positive correlation between assertiveness and resilience (Anastácio, 2016). Conversely, another study reported that resilience training did not affect assertiveness in university students (Kordmirza & Fallahi, 2015). They justified the ineffectiveness of the intervention by stating that the study did not have any precedent and that a limited sample and human error might have led to the outcome of the intervention. They also stated that there might be methods more effective than resilience training in improving assertiveness and that there is a need for further research in the field. Perhaps some of the reasons this study was not in line with the present study include differences in intervention implementation, training content, and study population.
The present study had limitations. First, data were collected using self-report questionnaires. Since many variables increase the chance of a student being resilient, using only assertiveness as a measure could be considered a limitation. Finally, the sample size of students in the control and intervention groups was small from only two schools from one region in one country. Therefore, it is suggested that a larger sample be used in future studies to improve generalizability.
The results of the present study indicated that resilience training is effective in improving the level and durability of assertiveness in student girls aged 9–10 years. Because early-maturing girls are at high risk for mood and behavior problems and environmental stressors, the changing social expectations and behavioral norms along with developmental asynchrony among physical, social, emotional, and cognitive maturity are likely to increase the vulnerability of them, and resilience training may improve skills such as assertiveness to cope with life struggles. School nurses based on their assessment skills and knowledge of the health needs of adolescents can identify students who lack assertiveness skills and collaborate with health educators to provide resilience training. School nurses can advocate for the whole school, whole child, and community approach that foster resilience and behavioral indicators of resilience.
Shima Gadari contributed to conception or design; contributed to acquisition, analysis, or 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. Jamile Farokhzadian contributed to conception or design, drafted the manuscript, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Parvin Mangolian Shahrbabaki contributed to conception or design; contributed to acquisition, analysis, or 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.
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.
Parvin Mangolian Shahrbabaki https://orcid.org/0000-0003-0539-5390
Supplemental material for this article is available online.
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Shima Gadari, is an MSc at Community Health Nursing, Kerman University of Medical Sciences, Kerman, Iran.
Jamile Farokhzadian, PhD, is an assistant professor at Community Health Nursing, Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran.
Parvin Mangolian Shahrbabaki, PhD, is an assistant professor at Critical Care Nursing, Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran.
1 Department of Community Health Nursing, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
2 Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran
3 Department of Critical Care Nursing, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
Corresponding Author:Parvin Mangolian Shahrbabaki, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Haft-Bagh Highway, Kerman 7616913555, Iran.Email: mangolian167@yahoo.com
