The Journal of School Nursing2024, Vol. 40(6) 696–702© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241277837journals.sagepub.com/home/jsn
Abstract
Adolescents with food allergies (FA) face unique challenges, including an increased risk of bullying, yet comprehensive national studies on this intersection are lacking. Our study examines the prevalence and association between FA and bullying among US high-school adolescents, utilizing Youth Risk Behavior Survey (2015–2019) data. Analyzing responses from 27,781 adolescents, we found that 19.1% reported on-campus bullying, and 14.9% reported electronic bullying, while 15.8% reported FA. Food allergy was significantly more common among those who reported bullying (23% vs. 13.9%, p < .001). Logistic regressions revealed that adolescents with FA were more likely to experience on-campus (adjusted odds ratio [AOR] 1.51, 95% CI 1.35–1.69) and electronic bullying (AOR 1.42, 95% CI 1.27–1.58) compared to their peers without FA. These findings underscore the vital role of school nurses in identifying and addressing bullying among FA adolescents, thereby ensuring supportive environments, promoting well-being, and fostering academic success.
Keywordsfood allergies, adolescents, bullying, school health
The National Academy of Sciences acknowledges bullying as a critical public health issue (National Academies of Sciences, Engineering, and Medicine, 2016), significantly impacting the short-term and long-term well-being of adolescents (Bhatia, 2023; Blakeslee et al., 2023; Martínez et al., 2024; National Academies of Sciences, Engineering, and Medicine, 2016). Research consistently indicates that adolescents with chronic health conditions, including food allergies (FA), are especially susceptible to bullying (including teasing and social exclusion) compared to their peers without such conditions (Awadallah et al., 2023; Reisert et al., 2023). This vulnerability is concerning because bullying can exacerbate emotional distress and affect their overall quality of life.
Despite this recognized vulnerability, there is a notable absence of nationally representative studies focusing on the relationship between FA and bullying among adolescents. Previous research on this topic has primarily involved sampling patients from allergy clinics or individuals, such as teens, adults, or parents, attending regional food allergy & anaphylaxis network conferences, and thus often failed to include comprehensive comparative analyses of bullying rates among adolescents with and without FA (Bingemann et al., 2024; Brown et al., 2021; Feng & Kim, 2019; Fong et al., 2017; Khamsi, 2020; Lieberman et al., 2010; Lin & Sharma, 2014; Muraro et al., 2014; Polloni et al., 2016; Rocheleau & Rocheleau, 2022; Shemesh et al., 2013). These studies often relied on parent-proxy reports and lacked adjustments for key demographic factors or sexual identity in their analyses. Furthermore, the absence of a nationally representative sample limits the generalizability of findings due to variations in stigma, state-laws, school policies, and screening or prevention strategies across regions.
For example, bullying experiences were explored among 120 FA participants attending an allergy clinic in Italy, matched with healthy controls (Muraro et al., 2014). Another study from US involving 93 children and their parents in allergy clinic settings revealed that 42% of the children reported experiencing some form of bullying (Shemesh et al., 2013). These studies are not populationbased and are thus susceptible to selection bias, where participants who have experienced bullying may be more willing to participate, skewing the results. Moreover, such studies may not fully capture the experiences of adolescents with limited healthcare access or those from diverse demographic backgrounds who are at higher risk of bullying (Lebrun-Harris et al., 2019).
Feelings of sadness or hopelessness, asthma diagnosis, sexual identity, and demographic variables are crucial factors associated with bullying victimization (Kosciw et al., 2022; McCabe & Strauss, 2022; Nguyen et al., 2023; Webb et al., 2021). Nguyen et al. (2023) conducted a study involving 13,605 U.S. high school adolescents, revealing that those who experienced bullying—whether at school or electronically—were 3.4 times more likely to report depressive symptoms of sadness or hopelessness (Nguyen et al., 2023). This also underscores the profound impact bullying can have on mental health outcomes among adolescents. Similarly, studies have shown that adolescents with chronic illnesses like asthma are at an increased risk of being bullied (Ancheta et al., 2023; McCabe & Strauss, 2022). Asthma has also been linked to FA (Emons & Gerth van Wijk, 2018; Ohayon et al., 2024); a study of about 600 children from Chicago, IL, found that children with asthma had 5.3 times higher odds of having FA as well (Schroeder et al., 2009). Prior smaller studies on FA and bullying failed to account for these significant risk factors.
Additionally, disparities in bullying experiences exist across different demographic groups (National Academies of Sciences, Engineering, and Medicine, 2016; Webb et al., 2021). A study of more than 35,000 LGBTQ+ adolescents, for instance, reported high rates of bullying in school (86%) and electronically (71%) (Kosciw et al., 2022). Ethnicity and gender also play significant roles, with variations observed in bullying prevalence among different racial and gender groups (National Academies of Sciences, Engineering, and Medicine, 2016; Webb et al., 2021). These findings underscore the need for making thorough adjustments in future studies to account for potential confounders.
To address these gaps, our study utilizes data from multiple administrations of the Youth Risk Behavior Survey (YRBS) to thoroughly investigate the association between FA and bullying. By examining both on-campus bullying and electronic harassment via texting or social media, our study aims to provide a more inclusive and nationally representative perspective on the challenges faced by adolescents with FA. We hypothesize that adolescents with FA experience higher rates of bullying compared to peers without FA, considering the unique vulnerabilities associated with living with FA, as indicated by prior studies. This study aims to advocate for targeted interventions and support strategies to improve the well-being of adolescents with FA.
The study analyzed data from the three (2015, 2017, and 2019) National High School YRBSs. The YRBS is conducted biannually by the Centers for Disease Control and Prevention (CDC) to assess health risk behaviors among adolescents in the United States. The YRBS uses a three-stage cluster sampling method to collect nationally representative samples from both public and private schools across all 50 US states and the District of Columbia. The YRBS survey is approved by the Institutional Review Board of the CDC. Additionally, YRBS adjusts for school and student nonresponse in each jurisdiction by applying appropriate weighting factors to each record (Underwood et al., 2020). We utilized publicly available data from 2015 (n = 15,624), 2017 (n = 14,765), and 2019 (n = 13,677) administrations of the YRBS. Response rates of the YRBS ranged from 59.3% to 60.3%.
Out of 44,066 respondents, 16,285 were excluded due to missing data on outcomes (bullying on school property, n = 565; electronic bullying, n = 159) or exposures (food allergy, n = 13,295), as well as demographic covariates (sex, n = 239; age, n = 28; race, n = 420), sexual identity (n = 1,266), feelings of sadness or hopelessness (n = 58), and asthma diagnosis (n = 255). This resulted in a final study sample of 27,781 participants. We assessed for selection bias by comparing the characteristics of the final analytic sample (n = 27,781) with the characteristics of all 44,066 survey respondents and found no significant differences.
Outcome variables: Bullying was assessed using two questions to gather information on both: (1) on-campus bullying and (2) electronic bullying (e.g., via texting, Instagram, Facebook). The questions asked were, “During the past 12 months, have you ever been bullied on school property?” and “During the past 12 months, have you ever been electronically bullied? This includes things like being bullied through texting, Instagram, Facebook, or other online platforms.” For both the questions, responses were recorded as either “Yes” or “No.” Before asking the questions in the survey, YRBS also defined, “Bullying” in their survey questionnaire as persistent harmful behaviors such as teasing, threatening, spreading rumors, hitting, shoving, or other repetitive actions toward another student.
Predictor variables: FA was assessed using the question, “Do you avoid certain foods due to potential allergic reactions (e.g., skin rashes, swelling, itching, vomiting, coughing, trouble breathing)?” Responses were recorded as either “yes” or “no.” Demographic factors such as sex assigned at birth, age, race/ethnicity, sexual identity (current gender identity), and indicators such as feelings of hopelessness or sadness within the past year, lifetime diagnosis of asthma confirmed by a doctor or nurse, and survey years were also adjusted. These variables were selected and controlled for due to theoretical and empirical relevance to the independent and dependent variables under investigation (Awadallah et al., 2023; Ohayon et al., 2024; Reisert et al., 2023).
All predictor variables showed significance in the chi-square test for independence with both food allergy and bullying variables. Controlling for these factors is crucial as they have the potential to confound the relationship between the variables of interest, thereby ensuring a more accurate assessment of their true impact. Additionally, demographic variables play a pivotal role in understanding how social and environmental factors intersect with health outcomes, thereby enhancing the study’s comprehensiveness and applicability across diverse populations and contexts.
Associations between bullying victimization and FA were evaluated using descriptive statistics and logistic regressions. Differences in descriptive statistics were assessed using the adjusted F statistic, a variant of the second-order Rao-Scott adjusted chi-square statistic. Model 1 examines the association between on-campus bullying victimization and FA, while Model 2 investigates the association between electronic bullying via texting or social media and FA. Both models were adjusted for the demographics and healthrelated factors mentioned earlier. Additionally, a sensitivity analysis was also conducted through unadjusted logistic regression analyses including observations initially excluded due to missing data in covariates (n = 30,047). We also assessed multicollinearity among variables in the logistic regression analysis, reporting variance inflation factors (VIFs). The VIF values for all variables were below 1.30 in bullying at school property and electronic bullying models, indicating that multicollinearity was not a concern (O’brien, 2007). The analyses were performed using STATA17.0 software (StataCorp).
Table 1 displays the descriptive statistics of the study sample. Of the 27,781 adolescents, 49.6% were girls and 50.4% were boys; 87.1% identified themselves as heterosexual, while 9.4% identified themselves as gay, lesbian, or bisexual, and 3.6% were unsure about their sexual identity. Over 25% of them were 15 or 16 years old, with over half being non-Hispanic white, and the majority (87%) identified as heterosexual. Feelings of hopelessness or sadness within the past year were reported by 32.7%. Bullying on school property (on-campus) was reported by 19.1% of the respondents, with electronic bullying reported by 14.9%.
Food allergy was reported by 15.8% of all respondents. Food allergy was significantly more common (p < .001) among respondents who reported being bullied (electronic [23%] or on-campus [22.7%]) compared to those who did not report bullying experiences (13.9%). Similarly, 22.3% of all respondents reported an asthma diagnosis, and it was more common among respondents who reported any form of bullying (p < .001). Feelings of sadness or hopelessness were also significantly more common among respondents who reported being bullied (on-campus or electronically) compared to those who did not report bullying experiences (p < .001).
Results from multivariate logistic regression analyses indicate a significant association between bullying victimization (on-campus or electronic) and FA (Table 2). In Model 1, adolescents with FA were significantly more likely to report experiences of being bullied on school premises compared to those without FA (adjusted odds ratio [AOR] 1.51, 95% CI 1.35–1.69). Model 1 also found that girls (AOR 1.24, 95% CI 1.13–1.37), non-Hispanic whites, sexual minorities (AOR 1.52, 95% CI 1.34–1.72), those experiencing feelings of sadness or hopelessness (AOR 3.20, 95% CI 2.90–3.53), and those diagnosed with asthma (AOR 1.27, 95% CI 1.15– 1.40) were more likely to experience bullying on school property. Model 2 revealed that adolescents with FA were significantly more likely to report electronic bullying (AOR 1.42, 95% CI 1.27–1.58). Similarly, in Model 2, girls, non-Hispanic whites, sexual minorities, individuals with asthma, and those experiencing feelings of hopelessness or sadness were more likely to be bullied electronically through texting or social media compared to their counterparts.
The sensitivity analysis, including all observations and conducting unadjusted logistic regression models, also remained significant. Adolescents with FA were more likely to report being bullied on school property (odds ratio [OR] 1.76, 95% CI 1.60–1.93) and electronic bullying (OR 1.74, 95% CI 1.57–1.94) (n = 30,047).
Using a nationally representative sample, our study underscores the critical role of addressing bullying among adolescents with FA in the context of school health. To the best of our knowledge, this is the first nationwide study to investigate the association between FA and bullying victimization among adolescents, highlighting an overlooked aspect of adolescent health. The observed effect sizes are comparable to well-established risk factors such as gender and race, reinforcing the significance of this issue (Awadallah et al., 2023; Bhatia, 2023; Blakeslee et al., 2023). These findings align with previous studies conducted in allergy clinic patient populations, further validating the association between FA and an increased risk of bullying.
We found that girls, non-Hispanic whites, sexual identity minorities, and younger adolescents are more likely to experience bullying both at school and electronically. Specifically, adolescents who are unsure of their sexual identity are also at increased risk of being bullied at school. These insights could guide interventions to overcome barriers and improve outcomes for all adolescents. Our findings affirm prior research on demographic characteristics associated with bullying victimization among adolescents (Awadallah et al., 2023; Bhatia, 2023; Blakeslee et al., 2023; Webb et al., 2021).
Additionally, our study reveals a significant association of asthma diagnosis and feelings of hopelessness or sadness, with an increased likelihood of bullying victimization both at school and electronically. This finding aligns with existing literature on the vulnerability of adolescents with chronic health conditions (including asthma) to bullying (Ancheta et al., 2023; McCabe & Strauss, 2022). Adolescents with FA often experience social rejection due to special accommodations, including dietary restrictions and the need for medications such as epinephrine, contributing to stigma, isolation, and increased susceptibility to bullying (Bingemann et al., 2024; Feng & Kim, 2019).
Our study findings highlight the vital role of school nurses in addressing bullying among adolescents with FA (Aktas et al., 2019; Heitmann et al., 2024; Jacobson et al., 2011; Weiss et al., 2004). First, given the prevalence of FA, school nurses can play a crucial role in early identification and intervention to prevent bullying and mitigate the other consequences related to FA (Schoessler & White, 2013). Implementing allergy screening protocols during student health assessments can be beneficial (Aktas et al., 2019). Second, assessing psychological distress and social exclusion among adolescents with FA can help identify at-risk individuals (Jacobson et al., 2011). Nurses can provide supportive counseling and collaborate with victims and teachers to establish support groups to mitigate the impact of bullying and promote a positive school environment (Heitmann et al., 2024). Third, promoting awareness and understanding of FA through educational initiatives can cultivate empathy and reduce peer stigma (Cooper et al., 2012; Feldman et al., 2022). While discussions are ongoing about whether school nurses should take part in comprehensive physical and mental health screening and follow-up practices, this vulnerable population merits additional consideration (McCabe et al., 2024).
Despite its contributions, our study has limitations. The cross-sectional design precludes establishing causality between FA, bullying experiences, and their long-term impacts. Future studies using longitudinal designs are necessary to explore the temporal dynamics and causal pathways between these variables. Additionally, self-reported survey data may introduce biases such as recall or social desirability biases, potentially affecting the accuracy of reported information. Future research should consider incorporating objective measures and clinical data to comprehensively assess the severity of FA symptoms and the nature of bullying experiences. Furthermore, the lack of information on other allergies, comorbidities, medications, socioeconomic status, and parental involvement could influence the relationship between FA and bullying (Polloni et al., 2016). Exploring innovative approaches to digital literacy and resilience training as part of comprehensive antibullying strategies could also benefit adolescents with FA.
Our study revealed significant associations between adolescents with FA and experiences of bullying, both at school and electronically. These findings are consistent with prior research conducted in allergy clinics and conferences, now validated through a nationally representative sample. They underscore the vital role of school nurses in identifying and addressing bullying among FA adolescents with an eventual goal to foster supportive environments, enhance well-being, and ensure academic success for vulnerable adolescents.
Saurabh Kalra: Conceptualization; Investigation; Methodology; Project administration; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.
Deepak Kalra: Investigation; Methodology; Project administration; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.
Saurabh Kalra is currently affiliated with Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.
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.
Saurabh Kalra https://orcid.org/0000-0002-0398-6384
Supplemental material for this article is available online.
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Saurabh Kalra, MS, MPH, is a PhD student in epidemiology at the Miller School of Medicine, University of Miami, in Miami, Florida.
Deepak Kalra, MD, MPH, PhD, is an assistant professor of neurology at the Penn State College of Medicine, Pennsylvania State University, in Hershey, Pennsylvania.
1 Rutgers School of Public Health, Rutgers University, Piscataway, NJ, USA
2 Department of Neurology, Penn State College of Medicine, Hershey, PA, USA
Corresponding Author:Saurabh Kalra, Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St #905, Miami, FL 33136, USA.Email: sxk2080@miami.edu
