RESEARCH ARTICLE

Verbal Bullying Changes Among Students

Following an Educational Intervention Using
the Integrated Model for Behavior Change
SALOSHNI NAIDOO, PhDa BENN K. SATORIUS, PhDb HEIN de VRIES, PhDc MYRA TAYLOR, PhDd

ABSTRACT
BACKGROUND: Bullying behavior in schools can lead to psychosocial problems. School-based interventions are important in
raising student awareness, developing their skills and in planning to reduce bullying behavior.
METHODS: A randomized controlled trial, using a school-based educational intervention to reduce verbal bullying, was
conducted among grade 10 students in 16 urban and rural schools in KwaZulu-Natal, South Africa in 2013. Baseline and
postintervention questionnaires, developed using the Integrated Model for Behavior Change theoretical model, were used to
assess changes in verbal bullying.
RESULTS: Postintervention there were reduced verbal bullying experiences. Improved social norms and awareness of verbal
bullying were associated with reduced verbal bullying experiences and behavior. Although less likely to bully others verbally, girls
were more likely to experience verbal bullying. Students with no living father were more likely to bully others verbally.
CONCLUSIONS: The study findings indicate that a school-based intervention can positively impact on verbal bullying
experiences and behavior.

Keywords: bullying; Integrated Model for Behavior Change; school health instruction; verbal bullying.
Citation: Naidoo S, Satorius BK, de Vries H, Taylor M. Verbal bullying changes among students following an educational
intervention using the integrated model for behavior change. J Sch Health. 2016; 86: 813-822.

Received on November 20, 2015

Accepted on June 5, 2016

B ullying is the repeated exposure of individuals to

negative behavior perpetrated by another person
or groups of people. These actions are distressing to
States when compared with physical (20.8%), social
(51.4%), and electronic (13.6%) bullying.
Bullying in adolescents reported in several stud-
the individual in the presence of a power imbalance ies globally highlights the individual and public
between the perpetrator and the victim. Com- health problem it poses among the youth. The
mon forms include verbal, physical, and relational reported prevalence of bullying in studies ranges
bullying.1,2 Verbal bullying is characterized by name from a low of 4.8% to a high of 96.7%.1,2,4-9
calling, mocking, insulting, and being humiliated.3 There does not appear to be much difference in
Wang et al1 reported verbal bullying (53.6%) to be bullying prevalence between Western and other
most prevalent among adolescents in the United societies.1,2,8,9

a Senior Lecturer, (naidoos71@ukzn.ac.za), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, 2nd

Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa.
b
Assistant Professor, (sartorius@ukzn.ac.za), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, 2nd
Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa.
c
Professor, (hein.devries@maastrichtuniversity.nl), Department of Health Promotion, School for Public Health and Primary Care (CAPHRI), Maastricht University, POB 616, 6200 MD,
Maastricht, the Netherlands.
dAssistant Professor, (taylor@ukzn.ac.za), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, 2nd

Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa.
Address correspondence to: Saloshni Naidoo, Senior Lecturer, (naidoos71@ukzn.ac.za), Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health
Sciences, University of KwaZulu-Natal, South Africa, 2nd Floor, Room 236, George Campbell Building, Howard College, Durban 4041, South Africa.
The authors acknowledge the South African Medical Research Council for funding this project; the KwaZulu-Natal Department of Education for permitting the study; the principals,
teachers, and students for supporting and participating in the study. We also acknowledge N. Dlamini, Z. Khanyile, S. Mpanza, M. Ngcongo for facilitating the field work on this study.

Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association • 813
 Risk factors for bullying include being a victim
of domestic abuse, and living in the presence of
community violence.10-12 Adolescents from homes
in which there were authoritarian rearing patterns
are more likely to be bullies.10 Adolescent boys are
more likely to bully or be victims of bullying.4,9,10
Boys are also more likely to be bullied by boys rather
than girls.10 Younger adolescents, who feel alone, are
anxious and do not have friends are more likely to be
bullied.5 Adolescents who are close to their parents
are more likely to be bullied.10 Bullies are more
likely to come from a high socioeconomic environment
whereas victims of bullying are more likely to come
from a low-socioeconomic environment.9,10,13
The long-term impact of bullying on individuals has
implications for individual performance in adulthood
and for communities at large. Adolescent victims of
bullying tend to display psychological problems which
include depression,14,15 reduced self-esteem,15,16 and
anxiety.17 In the United Kingdom, Stapinski et al17
found that adolescent victims of bullying displayed
both immediate and delayed anxiety and depression,
whereas among Peruvian adolescents, Lister et al18
reported increasing emotional and mental stress
among bullied adolescents. Bullying also can lead
to increased substance abuse with perpetrators more
likely to be involved in substance abuse as they grow
older.19-21 Displays of violence have been reported in
bullies and bullied victims. Camodeca and Goosens22
reported proactive violence in bullies and reactive
violence among both bullies and victims of bullying.
Suicidal ideation and attempts at suicide are likely to
occur in the presence of bullying and increase in risk
relative to an increase in the types of victimization
being experienced.14,23
A variety of intervention studies have been
conducted to reduce bullying among adolescents in
schools.24,25 These studies have included curriculum-
based interventions such as lectures and video
recordings delivered in the school focusing on a specific
age group, multidisciplinary interventions which
included training teachers, students, and parents
focusing on the entire school, and, interventions which
have focused on developing social and behavioral skills
using peer mentoring and social workers.24-27
In South Africa several studies have described the
extent of bullying with the prevalence of bullying
among adolescents in South Africa ranging between
11% and 52%, with boys reporting higher levels of
bullying than girls.4,11,18,28 Bullying among South
African youth has been associated with several
negative outcomes. Townsend et al28 reported that
girls who had participated in bullying and were
victims of bullying were more likely to drop out
of school when compared with other youth. Liang
et al4 reported that perpetrators of bullying were
more likely to indulge in risk taking, and antisocial
814 • Journal of School Health • November 2016, Vol. 86, No. 11
behavior including substance abuse when compared
with victims of bullying. Importantly children who
experienced acquired immunodeficiency syndrome
(AIDS)-related stigma are more likely to be bullied
than their counterparts.11
Hall and De Lannoy29 report that 97% of South
Africa’s children aged 7 to 17 years attend educational
facilities. While 99% of 7- to 13-year-olds attend
school, there is a rapid drop with 89% of 17-year-
olds attending school. Whereas reasons for dropping
out of school are multifactorial, attention needs to be
paid to the school environment to identify factors,
including bullying, which are contributing to students
leaving school. Furthermore in the present context of
the stigma related to the human immunodeficiency
(HIV)/AIDS epidemic in South Africa, the potential for
bullying and victimization in schools does exist. As part
of a larger study of gender violence this paper reports
on changes in verbal bullying among adolescents
following the use of an education intervention using
the Integrated Change Model.30-32 Verbal bullying in
this study context, refers to the passing of negative
comments about and demeaning of others.
The main goal of this article is to assess the effects
of a school-based program preventing belittling on
cognitions, such as attitudes, social norms, and self-
efficacy as well as on belittling behavior.
METHODS
Participants
This randomized control trial (RCT) was conducted
among adolescents in a rural (Ugu) and urban
(eThekwini) district of KwaZulu-Natal, South Africa
using an educational intervention between February
and October 2013. The proposed sample size of
240 in the intervention and 240 in the control
groups, respectively, when sampling 8 clusters with
30 participants each in the intervention and control
groups (16 clusters in total), would achieve 80%
power to detect an absolute difference between the
group proportions of 0.15% or 15%, assuming a
baseline prevalence of bullying of 0.3% or 30% in the
control group and an intraclass correlation coefficient
(ICC) of 0.03.33 The test statistic used is the 2-sided
Z-test (unpooled) and/or 2-sided score test.34 The
significance level of the test was assumed at .05.
A total of 16 schools (8 urban and rural, respec-
tively) were randomly selected from a list of schools
obtained from the KwaZulu-Natal Provincial Depart-
ment of Education. Eight schools were randomly
allocated to receive the intervention. In each school a
single grade 10 class was randomly chosen for partici-
pation in the study. All students in the grade 10 class
were invited to participate in the study. Two schools
did not participate in the postintervention survey. At
baseline survey 685 students participated with a total
• © 2016, American School Health Association
of 434 students having participated in the baseline and
follow-up questionnaire survey of the study. Informed
written consent was obtained from their parents or
guardian and the students assented to participate in
the study.
Instrumentation
The Integrated Model for Behavior Change Theo-
retical model was used as the conceptual framework
on which the questionnaire was developed. We have
used the model previously and validated this in our
population.35,36 A qualitative pilot study conducted in
a sample of 2 schools from the study areas prior to
the onset of the RCT informed the development of
the questionnaire used in this study. This quantitative
questionnaire was piloted in 2 grade 10 classes in an
urban and a rural school and relevant changes were
made for use in this study. The questions assessed
students’ responses on a 5-point Likert-type scale. The
Cronbach α for reliability of questions relating to each
construct was calculated and ranged from .63 to .88.
Predisposing factors. Information on demographics
(biological factors), household income and composi-
tion (social factors) was collected. These included sex,
age, home location, with whom they lived at home, if
their parents were alive and household assets.
Awareness. Knowledge was assessed with 2 items
testing participants’ understanding of verbal bullying
(α = .81). There were 9 items measuring cues
supporting verbal bullying which included observing
verbal bullying in the family or community or on
television (α = .63).
Motivation factors. Attitudes were measured by
attitudes promoting (α = .87) and attitudes preventing
(α = .88) verbal bullying using 3 and 5 items,
respectively. Promoting attitudes included considering
verbal bullying fun, making one feel good, and
being more popular. Preventive attitudes included
considering verbal bullying as unkind, negative,
disrespectful, unfair, and a threat to good relationships.
Social Influences preventing verbal bullying were
assessed through norms, support, and modeling. Six
questions each on social norms (α = .89), support
(α = .88), and modeling (α = .77) covered normative,
supportive, and modeling behavior among family,
teachers, and friends in the participant’s social circle.
Self-efficacy behavior which prevented verbal
bullying was assessed through 9 questions that covered
regular (4 questions; α = .73) and situational behavior
(5 questions; α = .88).
Intentions. Students’ intentions to not indulge in
verbal bullying toward others and in the subsequent 6
months were assessed by 6 questions (α = .84).
Ability factors. The ability factors influencing
students’ behavior were assessed through action skill
plans and goals. Action skills were assessed by 3
Journal of School Health • November 2016, Vol. 86, No. 11
questions (α = .79), and a single question each assessed
action plans and goals.
Questions were also asked about their personal
experience of being verbally bullied by family, friends,
and teachers in the past month and themselves having
verbally bullied family, friends, and teachers in the
past month.
Data Collection Procedure
Data collection took place at baseline and then
4 months after implementation of the intervention.
Appointments were scheduled with each school and
a fixed time was allocated in the school day for
students to complete the questionnaire. The students
were informed about the study by trained researchers
familiar with the project. After assenting, students
were provided with a questionnaire which took
approximately 30 minutes to complete.
Intervention
The intervention program was developed to address
the topics raised in the focus group discussions which
had been held as part of the exploratory research and
the generalizability of the data was confirmed by a
questionnaire. The intervention program comprised
weekly modules to address gender-based violence and
bullying and was piloted in 2 schools prior to the RCT.
For the RCT, the selected schools (intervention and
control) were invited to participate and the purpose of
the program was explained. There was good support
from the school principals and in the first half of
the year the trained facilitators (2 teams of male and
female facilitators) visited each of the interventional
schools once a week and were given one lesson
period in which to undertake the program. Each
module had specific objectives and the class room
activities varied. These comprised small and large
group discussions, role plays, videos (professionally
made with local content), an innovative cartoon story
(used to promote discussion) and creative drawing.
The content of the 20 weekly modules focused on
the following: Introduction and Getting to Know
Yourself, Gender Roles and Gender Issues, Peer
Pressure, Decision Making, Characteristics of a Good
Relationship, Gender Inequality and Power (including
Verbal bullying, Hitting, and Forced Sex), and
Culture and Human Rights. The students completed a
questionnaire prior to the initiation of the program and
again 5 months after the completion of the program.
Students at the control schools participated in the
Department of Basic Education’s Life Skills’ Program
which forms part of the school curriculum but does
not focus on gender-based violence. The program used
in the intervention was therefore provided to schools
at the end of the study.
• © 2016, American School Health Association • 815
Figure 1. School and Student Participation by Intervention and Location.
Total Number of Schools (N =1 6)
Students Recruited (N = 685)
Intervention
School (N=8)
Urban Rural T1
School (N = 4) School (N = 4)
Students (N = 182) Students (N = 137)
School (N = 3) School (N = 4) T2
Students (N = 86) Students (N = 105)
Data Analysis. Data were processed and analyzed
using Stata 13.0 (StataCorp. 2013, StataCorp LP: Stata
Statistical Software: Release 13. College Station, TX).
A socioeconomic status index (SES) was created using
multiple correspondence analysis (MCA) to weight
the following categorical variables (employment, asset
ownership, and hunger).37 The weighted scores for
each were summed to give an overall SES score. This
score was categorized into tertiles (low, medium, and
high). A single composite independent variable was
created for each construct based on a summation
of the students’ responses to the questions relating
to the specific construct. Two composite dependent
variables (having experienced verbal bullying in the
past month and having verbally bullied people in the
past month) were created based on students’ responses
to having been verbally bullied by and having verbally
bullied family, friends and teachers in the past month.
Survey weights were incorporated using the svyset
command given the complex multistage random
sampling strategy and utilized in the regression analysis
to correctly weight point estimates and calculate
95% confidence intervals (CIs). Frequencies and
means with 95% CIs were calculated for categorical
and continuous variables respectively. Design based
(ie, survey weighted) multivariable linear regression
was performed to assess the primary effect of the
intervention as well as other factors associated with
exposure to and experience of verbal bullying. Age
was included as a confounder in the analyses as
it was significantly different across the trial arms.
816 • Journal of School Health • November 2016, Vol. 86, No. 11
Control
School (N=8)
Urban Rural
School (N = 4) School (N = 4)
Students (N = 181) Students (N = 185)
School (N = 4) School (N = 3)
Students (N = 138) Students (N = 105)
An adjusted p-value of less than .05 was deemed
statistically significant.
RESULTS
Participation of Students
At baseline (T1 ) a total of 685 students participated
from 16 schools with an equal distribution of rural
and urban schools. Postintervention (T2 ) 1 urban
intervention school and 1 rural control school did not
participate. The mean age of the 251 (36.6%) students
who were lost to follow-up (mean: 16.6 years; 95%
CI: 16.7-17.2) was similar to that of the students who
continued in the study. A total of 122 boys (48.6%)
and 129 girls (51.4%) were lost to follow-up with
123 (49.2%) and 128 (50.8%) being from control
and intervention schools, respectively. There were 112
(44.6%) rural and 139 (55.4%) urban students lost to
follow-up. Overall, 434 (63.4%) students participated
at T1 and T2 (Figure 1) and our results refer to these
students.
Demographic Profile of Students
Randomization of the students participating in the
study was taken to be successful because for the most
part there was no demographic difference between the
students from the intervention and control schools.
Only the mean age of students in the intervention
schools was slightly higher than that of students from
the control schools (p = .043) (Table 1).
• © 2016, American School Health Association
Table 1. Baseline Demographic Profile of Students by
Intervention (N = 434)
Intervention
(N = 191) (N = 243)
Age (mean; 95% CI; years) 16.9 (16.7-17.2) 16.54 (16.4-16.7)
Sex (N, %)
Boys 100 (51.9)
Girls 91 (48.1)
Location (N, %)
Urban 86 (13.4)
Rural 105 (86.6)
Person living with (N, %)
At least one parent 133 (67.3)
Family member other than parent 54 (30.4)
Unrelated to person 3 (2.3)
Mother not alive 88 (27.9)
Father not alive 156 (44.5)
Socioeconomic status∗
Low 35 (17.8)
Medium 59 (21.4)
High 142 (60.8)
∗ Survey weighted.
Comparison of Verbal Bullying Specific Variables Pre-
and Postintervention
On the basis of bivariate analysis significant changes
were noted within the intervention and control stu-
dent groups and between the intervention and control
student groups from baseline to postintervention.
However the intervention group did not fare better
than the control arm in experiencing verbal bullying.
If anything postintervention social norms preventing
verbal bullying (p = .005) were significantly higher
in the control group compared with the intervention
group postintervention (Table 2).
In the intervention group there was a significant
improvement postintervention in the mean knowl-
edge of verbal bullying (p < .001), attitudes preventing
verbal bullying behavior (p = .001), intentions to not
verbally bully (p = .010) and having an action plan
against verbal bullying in the future (p = .004). The
mean of having verbally bullied people (p = .030) or
having experienced verbal bullying (p = .043) in the
past month also significantly decreased from baseline
to postintervention (Table 2).
Among the control group of students there
were significant improvements in knowledge of
verbal bullying (p = .022), attitudes against (p = .016)
and preventing (p = .002) verbal bullying, regular
self-efficacy preventing verbal bullying (p = .013),
situational self-efficacy preventing verbal bullying
(p = .043), having an action skill against verbal
bullying (p = .015) (Table 2).
Having Experienced Verbal Bullying
To assess the effect of the intervention and other
factors on experiencing verbal bullying a multivariate
linear regression was conducted. No significant effect
of the intervention was found. Experiences of verbal
bullying at post-test were significantly predicted by
being younger (p = .024), female (p = .025), and
Control
p-Value experiencing more social norms against bullying
(p = .008). Reports of increased cues about verbal
.043 bullying significantly reduced students experiencing
verbal bullying in the past month (p = .004) (Table 3).
136 (59.8) .351
107 (40.2)
138 (19.4) .727
Verbal Bullying of Other People
105 (80.6) Comparing the verbal bullying of other people in
the intervention group versus control, from baseline to
181 (74.3) .275 postintervention (p = .042) was significantly reduced.
53 (24.5) Furthermore, being female (p < .001) and students
4 (1.2)
living in an urban (p = .047) area were less likely to
106 (22.4) .157
218 (46.4) .770 verbally bully people in the past month even when
covariates were included in the model. Students whose
94 (11.4) .454 father was not alive were more likely to report having
96 (22.6) verbally bullied people in the past month (p = .036).
235 (66.0) Furthermore, high levels of awareness reduced verbal
bullying of others in the past month (p = .016)
(Table 4).
DISCUSSION
In the current context of bullying4,38 in South
African schools, a school-based intervention aimed at
reducing bullying will be beneficial. The findings of this
study highlight that positive changes can be achieved
with school-based interventions seeking to reduce
bullying among students. This study found significant
changes in awareness, motivation, intentions, and
ability among students who participated in an
educational intervention on gender-based violence
and bullying on bivariate analysis and reduction in
verbal bullying behavior on multivariate analysis.
Knowledge and awareness are known to have
a positive impact on personal behavior. Studies
among patients with chronic diseases of lifestyle
have shown that raised awareness improves per-
sonal health behavior.39 This study has shown rais-
ing awareness among students about verbal bullying
through a school-based intervention has the poten-
tial to empower students, ensuring that they do not
indulge in verbal bullying and avoid being verbally
bullied themselves. Several studies in a systematic
review of school-based interventions to prevent bully-
ing reported reductions in bullying and victimization
following implementation of the intervention.22
There was an improvement in motivational factors
with students receiving the intervention in this study
showing improvements in their attitudes against verbal
bullying and toward factors which prevented verbal
bullying (bivariate analysis). A study conducted among
Greek primary school children using an education
intervention embedded in the school curriculum
found that there was a significant improvement in

Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association • 817
Table 2. Mean Scores (95% CI) for Responses on Verbal Bullying Experienced and Perpetrated and Determinants Among Students
at T1 and T2 by Intervention and Control Using a Regression Approach Corrected for Age (N = 434)

Intervention Control
p-Value p-Value
p-value p-Value (Intervention (Intervention T2
(Intervention (Control T1 T1 Versus Versus
T1 T2 T1 Versus T2 )∗,† T1 T2 Versus T2 )∗,† Control T1 )∗,† Control T2 )∗,†
Knowledge of verbal 7.2 (6.8-7. 6) 8.1 (7.5-8.6) <.001 7.5 (6.52-8.4) 8.3 (7.8-8.7) .022 .717 .763
bullying
Cues about verbal bullying 20.7 (20.9-22.4) 23.1 (21.4-24.8) .135 22.3 (18.1-25.6) 21.6 (18.5-24.7) .329 .919 .221
Attitudes against verbal 19.8 (17.3-22.4) 20.9 (20.4-21.5) .225 20.2 (17.8-22.6) 22.3 (21.0-23.7) .016 .922 .065
bullying
Attitudes preventing 13.9 (13.5-14.5) 15.5 (14.4-16.6) .001 14.6 (12.1-17.1) 16.5 (12.2-18.7) .002 .593 .452
verbal bullying
Social norms preventing 22.4 (22.8-22.7) 22.8 (21-9-23.7) .464 16.9 (3.7-30.1) 24.6 (23.6-25.6) .199 .253 .005
verbal bullying
Social support preventing 25.0 (22.8-26.3) 25.9 (24.9-26.9) .105 26.0 (24.3-27.7) 26.8 (25.7-27.9) .269 .224 .220
verbal bullying behavior
Modeling behavior 21.1 (20.0-22.8) 21.1 (20.2-21.9) .956 20.9 (19.7-21.9) 21.8 (20.2-23.4) .308 .920 .491
preventing verbal
bullying
Regular self-efficacy 13.9 (13.1-14.8) 14.3 (13.5-15.1) .166 13.0 (11.5-14.6) 14.6 (13.9-15.3) .013 .203 .690
preventing verbal
bullying
Situational self- efficacy 17.7 (16.3-19.0) 18.5 (15.8-21.1) .191 17.2 (14.8-19.7) 18.9 (17.5-20.8) .043 .527 .705
preventing verbal
bullying
Intentions to not verbally 20.8 (20.6-21.1) 22.7 (21.3-24.0) .010 21.34 (17.9-24.69) 23.64 (20.6-26.7) .052 .936 .607
bully
Having an action plan 10.6 (9.9-11.1) 11.5 (10.8-12.2) .004 10.8 (9.8-11.8) 11.6 (10.7-12.4) .079 .728 .992
against verbal bullying
Having an action skill 3.8 (3.4-4.1) 4.1 (3.7-4.4) .066 3.5 (3.1-3.9) 3.9 (3.6-4.3) .015 .242 .584
against verbal bullying
Having an action goal 3.9 (3.7-4.1) 4.8 (3.9-4.4) .157 3.9 (3.7-4.2) 4.1 (3.7-4.4) .733 .786 .527
against verbal bullying
Experienced verbal 17.8 (16.6-19.0) 17.0 (16.0-18.0) .043 18.6 (10.8-26.4) 18.1 (16.5-19.6) .629 .935 .940
bullying in the past
month
Verbally bullied people in 31.5 (29.8-33.4) 29.6 (29.3-29.9) .030 30.2 (26.8-33.6) 31.1 (29.9-32.2) .936 .627 .136
the past month
∗ Survey weighted linear regression.
† Adjusted for age difference between trial arms.

positive attitudes toward victims, negative attitudes within social groups influence adolescent risk behavior
toward bullies, and less bullying behavior following such as substance abuse.42 Family, school, and peer
the intervention.40 Whereas one would have expected influences play an important role in the development
significant improvements in the intervention group as of prosocial norms in individuals. In childhood
compared with the control group, the improvements parental influences are far greater but in adolescence
in the attitudes against verbal bullying seen among the school environment has an important effect.43
controls may be as a result of increased awareness Thus, school-based interventions that can positively
following involvement in the baseline study. influence prosocial norms are important in reducing
The multivariable analysis suggests that improve-
antisocial behavior.
ments in social norms preventing verbal bullying were
Increasing age was significantly associated with a
associated with a decrease in the experiences of having
been verbally bullied. Social environments and norms decrease in verbal bullying experiences in our study
are important in shaping behavior among adolescents. population postintervention. Bullies are more likely
Spending time with parents and parental support is to be older and victims of bullying are younger.44,45
known to be protective against bullying behavior and With increasing age a student may be better equipped
victimization in youth.41 Studies have found that being to resist bullying, and thus, less likely to be a victim
exposed to negative experiences including community as opposed to younger counterparts who may find it
and domestic violence are significant predictors of difficult to stand up to older students in the school
bullying behavior.8,12 Furthermore peer influences setting. This points to the need for targeted programs

818 • Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association
Table 3. Multivariable Models of Having Experienced Verbal Bullying in the Past Month—Intervention Versus Control

Experienced Verbal Bullying in the Past Month

Model 1 Model 2 Model 3
Coeff. (95% CI) p-Value Coeff. (95% CI) p-Value Coeff. (95% CI) p-Value
Intervention (T2 versus T1) 0.2 (−4.9 to 5.3) .934 0.5 (−5.1 to 6.1) .842 0.2 (−4.5 to 4.9) .930
Sociodemographic (baseline predictors)
Age −0.7 (−1.1 to −0.2) .009 −0.7 (−1.2 to −0.1) .024
Sex (Female) 1.7 (0.2 to 3.3) .031 1.7 (0.3 to 3.2) .023
Location (Urban) 0.7 (−1.7 to 3.1) .537 0.9 (−1.7 to 3.7) .453
Person live with
At least one parent 1 1
Other family member −0.3 (−2.3 to 1.8) .766 −0.21 (−2.2 to 2.1) .945
Outsider −1.6 (−5.2 to 2.1) .371 −2.2 (−6.1 to 1.7) .241
Socioeconomic status∗
Low 1 1
Medium −0.3 (−2.0 to 1.4) .723 −0.3 (−2.1 to 1.6) .742
High 1.0 (−0.8 to 2.8) .260 1.0 (−0.9 to 3.0) .287
Mother not alive −0.2 (−2.5 to 2.2) .891 −0.2 (−2.7 to 2.3) .870
Father not alive 0.23 (−1.3 to 1.7) .746 −0.1 (−1.6 to 1.5) .939
Change in verbal bullying specific covariates
Knowledge of verbal bullying −0.1 (−0.4 to 0.2) .462
Cues about verbal bullying behavior −0.1 (−0.2 to 0.1) .004
Attitudes against verbal bullying 0.04 (−0.1 to 0.2) .454
Attitudes preventing verbal bullying 0.02 (−0.1 to 0.1) .791
Social norms preventing verbal bullying −0.1 (−0.2 to 0.03) .008
Social support preventing verbal bullying −0.01 (−0.1 to 0.04) .679
Modeling behavior preventing verbal bullying 0.1 (−0.1 to 0.2) .274
Regular self-efficacy preventing verbal bullying −0.1 (−0.2 to 0.04) .235
Situational self-efficacy preventing verbal bullying 0.1 (−0.03 to 0.3) .103
Intentions to not verbally bully 0.02 (−0.1 to 0.1) .688
Having an action plan against verbal bullying −0.04 (−0.3 to 0.2) .753
Having an action skill against verbal bullying −0.1 (−0.6 to 0.4) .691
Having an action goal against verbal bullying 0.3 (−0.6 to 1.2) .439
∗ Using multiple correspondence (MCA) to weight the following variables (employment, asset ownership, and hunger).

aimed at younger students so as to better equip them
with the skills to negotiate relationships at school.
In the intervention group of students in this study
there were improvements with intentions and action
planning against verbal bullying postintervention.
Action planning and intentions in other settings have
been shown to be important contributors to developing
and sustaining health protective behaviors among
participants.46,47 Having positive intentions against
verbal bullying lends itself to positive action planning
which is likely to reduce verbal bullying behavior and
protect against being victims of verbal bullying.
We found that girls were less likely to verbally bully
but they were more likely to be verbally bullied. A
study from Brazil found that adolescent girls were sig-
nificantly less likely to participate in verbal bullying as
compared with boys,9 while work among Indian youth
reported boys were more likely to be bullies and victims
(27.9%) when compared with girls (12.0%).7 In South
African schools Liang et al4 found that boys were sig-
nificantly more likely than girls to be bullies, victims
or bully-victims (p < .01 to .03). Boyes et al38 reported
more relational bullying victimization among South
African adolescent girls as compared to boys. Bullying
leads to increased anxiety, depression, and potential
suicidal tendencies among victims.14,38 Bullying of any
kind can lead to gender-based violence among adoles-
cents which may persist into adulthood. In South
Africa, the prevalence of gender-based violence is
estimated to be 20% and 30%.48 A consequence of
violence may be forced sex that increases the risk for
HIV transmission in endemic environments,49 which
has long-term implications for adolescents.
Postintervention there was a reduction in verbal
bullying of people in the past month (p = .042).
Students from urban schools were less likely to have
verbally bullied people following the intervention.
Rural youth in other populations have reported higher
levels of bullying as compared with urban youth.50
Our finding would suggest that future interventions
for verbal bullying among South African youth must
have a targeted intervention for rural schools.
The association between a father who had died
and increased verbal bullying was seen in this
study. Involvement of a father in a child’s life has
been associated with decreased bullying.10 This is an
important issue to consider among students in South
Africa in the presence of the HIV epidemic which is

Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association • 819
Table 4. Multivariable Models of Having Verbally Bullied People in the Past Month—Intervention Versus Control

Verbally Bullied People in the Past Month

Model 1 Model 2 Model 3
Coeff. (95% CI) p-Value Coeff. (95% CI) p-Value Coeff. (95% CI) p-Value
Intervention (T2 versus T1) −1.0 (−1.9 to 0.01) .052 −0.9 (−1.7 to −0.1) .030 −0.9 (−1.7 to −0.04) .042
Sociodemographic (baseline predictors)
Age −0.01 (−0.2 to 0.1) .823 −0.01 (−0.15 to 0.16) .942
Sex (Female) z−1.0 (−1.4 to −0.7) <.001 −1.1 (−1.4 to −0.7) <.001
Location (Urban) −0.54 (−1.1 to 0.02) .058 −0.6 (−1.1 to 0.01) .047
Student lives with at least one parent 1 1
Student lives with family member other than parent 0.04 (−0.7 to 0.7) .788 0.02 (−0.7 to 0.7) .950
Student lives with an outsider 0.2 (−0.4 to 8) .487 −0.2 (−0.4. to 0.8) .852
Socioeconomic status∗
Low 1 1
Medium 0.4 (−0.6 to 0.7) .888 0.02 (−0.67 to 0.71) .950
High 0.2(−0.4 to 0.78) .487 0.2 (−0.4 to 0.8) .520
Mother not alive −0.02 (−0.7 to 0.67) .958 −0.03 (−0.7 to 0.62) .932
Father not alive 0.2 (−0.02 to 0.5) .069 0.3 (0.02 to 0.5) .036
Change in verbal bullying specific covariates
Knowledge of verbal bullying −0.06 (−0.1 to −0.01) .016
Cues about verbal bullying behavior −0.02 (−0.1 to −0.03) .294
Attitudes against verbal bullying behavior −0.01 (−0.1 to 0.03) .640
Attitudes preventing verbal bullying behavior −0.01 (−0.1 to 0.02) .425
Social norms preventing verbal bullying behavior −0.01 (−0.04 to 0.02) .662
Social support preventing verbal bullying behavior 0 (−0.04 to 0.1) .904
Modeling behavior preventing verbal bullying 0.02 (−0.04 to 0.08) .477
Regular self-efficacy preventing verbal bullying −0.01 (−0.04 to 0.03) .706
Situational self-efficacy preventing verbal bullying 0.02 (−0.02 to 0.1) .241
Intentions to not verbally bully −0.02 (−0.1 to 0.02) .360
Having an action plan against verbal bullying −0.03 (−0.1 to 0.03) .245
Having an action skill against verbal bullying 0.04 (−0.23 to 0.32) .742
Having an action goal against verbal bullying 0.2 (−0.1 to 0.13) .725
∗ Using multiple correspondence (MCA) to weight the following variables (employment, asset ownership, and hunger).

leaving many children orphaned. There is a need for
positive male role models in such circumstances.
Although this study reported positive reductions
in verbal bullying among participants there were
several limitations which need to be addressed when
implementing a school-based intervention in the
South African context. More than one third of the
study population was lost to follow-up due to schools
leaving the study citing the pressure of examinations
as the reason for withdrawing. Our study did not
evaluate implementation of the program which may
have impacted on the loss to follow-up which was
witnessed in this study. The intervention was delivered
to a single class by facilitators who visited the school
as opposed to being delivered to the whole school, and
by staff based at the schools. There was no continuous
reinforcement and support for students in the school.
Schools do not provide counseling for students. The
class and school environment at large can contribute to
bullying behavior. Interventions which focused on the
whole school and made use of teachers and peers in
school antibullying programs have been successful.24
Low et al51 in the Steps to Respect project showed that
student engagement and support were very important
in achieving program outcomes. The South African
Department of Basic Education passed the Integrated
School Health Policy in 201252 which provides for the
appointment of school health teams comprising nurses
who support the school community creating safe
and secure environments for children. Gender-based
violence and bullying are among the core areas of focus
for the school health teams.52 Thus, using a school-
based educational program with teachers and peers
trained to deliver the intervention and school health
teams providing support for bully victims and trainers
is likely to be successful. This would also ensure
the sustainability of the program. This study was
designed to be completed within a year, and has shown
potential but it has not been able to demonstrate
long-term improvements nor whether the reduction in
bullying and attitudes to bullying will be sustained. In
conclusion, whereas a school-based training program
was shown to achieve a degree of success in this
study, teacher and school health team involvement is
necessary to ensure sustainability of the program.
IMPLICATIONS FOR SCHOOL HEALTH
Bullying in schools can be addressed by educational
programs such as this program. The implementation

820 • Journal of School Health • November 2016, Vol. 86, No. 11 • © 2016, American School Health Association
of such a program showed benefit and will assist in
increasing awareness of bullying among students. It
also improves skills and assist students in planning
to avoid being victims or perpetrators of bullying.
This would help make the school environment safe
and secure for students. Regular visits by the school
health teams can reinforce the school’s social norms
against bullying, gender violence and stigma against
people living with HIV/AIDS and counsel and support
students whose parents are deceased.
Human Subjects Approval Statement
This study was approved by the Biomedical Ethical
Research Committee of the University of KwaZulu-
Natal (BF 034/11).
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