Introduction
Bullying among schoolchildren is a pervasive phenomenon that significantly impacts their mental and physical health. Dentofacial features often make children targets for bullying, leading to psychosocial distress. This study aimed to examine the prevalence of bullying related to dentofacial features among adolescents in public schools in Jeddah, Saudi Arabia, and to identify its predictors.
Methods
A cross-sectional study was conducted involving sixth-grade and high school children in Jeddah, Saudi Arabia. Data were collected using a self-administered questionnaire. Logistic regression analysis was performed for predicting bullying.
Results
In total, 1149 schoolchildren (mean age, 13.3 years) participated in this study. The prevalence of experiencing some form of bullying was 45.9%. Bullied adolescents reported higher rates of absenteeism, a negative effect on their academic grades, and being unhappy in their school environment. Among the physical characteristics, teeth ranked third as a predictor of being bullied, after height and weight. Specific dentofacial features such as protruding teeth were the most common target. Male students were more likely to be bullied (odds ratio = 1.5; P = 0.002) than female students. Sixth-grade children experienced more bullying than high school students (odds ratio = 2.2; P <0.0001).
Conclusions
Bullying is prevalent among schoolchildren in Jeddah, and physical and dentofacial features are common targets, especially a prominent overjet and a gummy smile. Male and younger-grade children experienced significantly more bullying. These findings highlight the need for comprehensive antibullying programs and support systems that address both physical and emotional aspects of well-being.
Highlights
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Bullying significantly affects schoolchildren’s mental and physical health.
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Dentofacial features are common targets for bullying, leading to psychosocial distress.
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Male students were more likely to be bullied than female students.
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Teeth, height, and weight are the main predictors of being bullied.
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Male and younger-grade children experience significantly more bullying.
Bullying is a pervasive global phenomenon that profoundly impacts the psychological, social, and academic domains of children’s lives. The World Health Organization and American Association of Orthodontists classify bullying in childhood as a major public health problem. Victims frequently experience elevated levels of anxiety, depression, and diminished self-esteem, which may extend well into adulthood. Chronic exposure to bullying has been associated with the development of severe psychological conditions such as posttraumatic stress disorder. Academically, children subjected to bullying often demonstrate impaired concentration, declining academic performance, absenteeism, and, in severe instances, complete disengagement from formal education. , These disruptions can have long-lasting effects, impacting future career paths and socioeconomic well-being. Bullying is characterized by “repeated aggressive behaviors predicated on a power imbalance, encompassing physical aggression, verbal harassment, relational exclusion, and cyberbullying.” Prevalence rates vary widely, from 2% to 32%, depending on demographic, cultural, and methodological factors. ,, Abdulsalam et al reported a bullying prevalence of 30.2% among Kuwaiti adolescents, underscoring significant gender and age disparities. Studies conducted in Saudi Arabia have highlighted a high prevalence of bullying among schoolchildren, particularly verbal and physical forms. In Saudi Arabia, Bamalan et al reported a bullying prevalence of 86.1%.
Among the various factors contributing to bullying, dentofacial features have been identified as a significant target, impacting adolescents’ self-esteem and well-being. These features significantly influence oral health–related quality of life (OHRQoL), a multidimensional construct encapsulating the impact of oral health on daily activities such as eating, speaking, and social interactions, as well as psychological well-being ,, and may eventually extend to self-harm. The stigma associated with dentofacial deformities often isolates affected children, compelling them to withdraw from social participation, including smiling or laughing in public. , The association between bullying and dentofacial characteristics has been investigated across varied cultural contexts, with significant impacts on the victims’ quality of life and academic performance. ,,,,,, A systematic review by Tristão et al rated the existing evidence as characterized by very low certainty regarding the link between malocclusion and bullying, suggesting the need for further investigation into this pressing issue. Given the visibility of dentofacial features and their potential impact on self-esteem, it is crucial to investigate the prevalence and predictors of bullying related to these characteristics. Despite the growing body of research on bullying associated with dentofacial features, significant gaps persist in understanding its prevalence and factors related to it within the Middle East region, particularly in Saudi Arabia, especially because bullying is affected by the social context. Although bullying can take many forms, the focus of this study is on bullying related to dentofacial features, an important aspect of adolescent self-esteem and social interaction. The objectives of this study were to determine the prevalence of bullying related to dentofacial features among adolescents in public schools in Jeddah, Saudi Arabia, and identify its predictors in this context. However, there is a lack of research specifically examining the prevalence and predictors of bullying related to dentofacial features in Saudi Arabia.
Material and methods
This study employed a cross-sectional design among schoolchildren in the governorate of Jeddah, Saudi Arabia, involving a self-administered questionnaire. Data collection took place over 2 years, starting in February 2019. The study received ethical approval from the research ethics committee at King Abdulaziz University Faculty of Dentistry (protocol No. 010-01-19). All procedures adhered to the ethical standards of the Declaration of Helsinki.
The study targeted schoolchildren in grade 6 and high schools from various public schools in Jeddah using stratified random sampling to ensure a representative sample. Schools in the governorate of Jeddah were stratified by gender (male and female) to include 16 targeted schools. The approval process to visit the schools involved first the Ministry of Education and then school principals, per local regulations. This Parental opt-out consent was implemented for this minimal risk survey research. Parents received information about the study and could withdraw their child from participation. Each adolescent who participated provided assent, and completing the self-administered questionnaire was considered an indication of informed consent/assent. The survey was administered to schoolchildren who agreed to participate, who were deemed to have consented by completing the survey. Students identified by the school as having special health care needs or learning disabilities, as well as those who declined to participate in the survey, were excluded from the study. The survey was administered in person, in the teachers’ presence, and team members were available to answer any questions the children had.
Data were collected using a self-administered anonymous survey adapted from Shaw et al and Al-Bitar. The survey comprised 4 sections: demographics, personal experience of bullying, school environment and feelings toward school, and dentofacial and physical characteristics targeted among victims of bullying. The adapted survey demonstrated good internal consistency, with a Cronbach α value of 0.86. Photographs representing each of the dentofacial features were added to illustrate the features to this age group. Content validation was performed by 2 experts in the field, certified by the American Board in Orthodontics and Dental Public Health. Face validation was performed by consulting dental public health professionals in the field. The pilot study was conducted with 15 subjects from the same age group as the target population, ensuring a reflection of the diversity in demographics, experiences, and perceptions within the group. On the basis of the feedback received, we made several modifications to the survey questions to improve their clarity, readability, and specificity. These modifications involved rephrasing questions and clarifying terminology to align more closely with the understanding of the respondents’ age group. For instance, the original question, “Do you have a nickname?” led to confusion among respondents about whether it referred to nicknames they gave themselves or those used by family members and peers. To clarify, we revised the question to, “Does anyone call you by a nickname?” and added a follow-up question, “Who calls you by this nickname?” In addition, participants were unclear about the term “ephelides”; therefore, we replaced it with the more commonly understood “freckles” and provided a descriptive clarification as “brownish spots on your skin.” These adjustments resolved ambiguities and ensured that the final survey instrument was both valid and reliable, effectively serving the study objectives. For test-retest reliability, the survey was administered to the same pilot sample again after a 2-week interval.
The sample size for this study was determined using G∗Power software (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). Given the large population size of 633,792 schoolchildren aged 11-14 years in Jeddah and a prevalence rate of 64.7% for bullying because of dental features, a confidence level of 99% and a margin of error of 5% were specified. These parameters were input into G∗Power to calculate the required sample size, which was determined to be 606 participants per group, which required a total sample size of 1212.
Statistical analyses
Data were analyzed using SPSS software (version 23; IBM, Armonk, NY). A P value of ≤0.05 was considered statistically significant. The area of residence was used as a proxy for socioeconomic status (SES) by classifying Jeddah into low and high SES areas. This classification was based on the findings from a study by Alkhaldy and Barnett, which employed the Delphi method to categorize districts of Jeddah by SES. Descriptive statistics were calculated to summarize the prevalence and types of bullying as well as the participants’ characteristics. Multivariate logistic regression was used to determine the predictors of being bullied. The model controlled for potential confounding variables, such as age and gender, and area of residence, using forward stepwise methodology for building the model. The variables included in the regression models were gender, grade level, and area of residence, which served as a surrogate for SES.
Results
A total of 1149 schoolchildren were recruited in this study (mean age, 13.3 ± 1.9; range 11-19 years; 54.4% female). Of the total number, 811 (70.6%) were grade 6 children and 338 were grade 10 high school students ( Table I ). The prevalence of experiencing some form of bullying was 45.9% (95% confidence interval [CI], 43.0-48.8). Table II illustrates the relationship between bullying experiences and various school environment factors. Skipping school because of bullying was strongly associated with being bullied, with those being bullied having an odds ratio (OR) of 25.8 of skipping school (95% CI, 10.4-64.1; P <0.0001) compared with those who did not report being bullied. Disliking nicknames was also a significant predictor, with children being bullied having an OR of 3.1 of expressing dislike for their nicknames (95% CI, 2.2-4.2; P <0.0001). Moreover, those who reported being bullied were more likely to report both being unhappy at school and a profound impact on their academic grades.
Table I
Prevalence of being bullied by gender, grade, and area of residence among participating school children (n = 1149)
| Variable | Bullied | Not bullied | P value | Total |
|---|---|---|---|---|
| Gender | ||||
| Male | 260 (50.0) | 260 (50.0) | 0.01 | 520 (45.3) |
| Female | 267 (42.4) | 362 (57.6) | 629 (54.7) | |
| Grade | ||||
| Sixth grade | 418 (51.5) | 393 (48.5) | <0.0001 | 811 (70.6) |
| High school | 109 (32.2) | 229 (67.8) | 338 (29.4) | |
| Area of residence | ||||
| High SES | 264 (42.6) | 355 (56.4) | 0.004 | 619 (53.9) |
| Low SES | 263 (49.6) | 267 (50.4) | 530 (46.1) |
Note. Values are presented as number (percentage).
SES, socioeconomic status.
Table II
The association between being bullied and factors related to the school environment in the study sample
| Variable | n (%) | Being bullied | ||
|---|---|---|---|---|
| Crude OR | 95% CI | P value | ||
| Skipped school because of bullying | <0.0001 | |||
| No | Reference | |||
| Yes | 92 (94.8) | 25.8 | 10.4-64.1 | |
| Bullying affects academic grades | 0.01 | |||
| Not at all or very little | Reference | |||
| A lot | 37 (66.1) | 2.1 | 1.2-3.6 | |
| Happiness at school | ||||
| Happy/neutral | Reference | 0.02 | ||
| Unhappy | 55 (57.9) | 1.7 | 1.1-2.6 | |
| Happiness outside school | 0.2 | |||
| Happy/neutral | Reference | |||
| Unhappy | 44 (52.4) | 1.3 | 0.8-2.0 | |
| Nickname | <0.0001 | |||
| Like or do not mind | Reference | |||
| Do not like nickname | 171 (72.2) | 3.1 | 2.2-4.2 | |
| No. of persons bullying | <0.0001 | |||
| 1 | Reference | |||
| ≥ 2 | 335 (65.9) | 9.0 | 2.6-31.8 | |
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