Abstract

This study aimed to understand the impact of victimization caused by bullying on the mental health of adolescents. It is a qualitative investigation conducted with 55 students from 11 public schools in a city of Minas Gerais State, Brazil. The data were collected through semi-structured interviews and reviewed according to content analysis using Atlas TI software. A total of 19 students participating in the study reported having already suffered bullying at school. It was verified in the narratives that the victimization by bullying represents a threat to the health and mental well-being of the students, characterizing itself as a painful, daily and lasting experience in the school trajectory. Four thematic categories were identified: 1) Mental illness attributed to the aggressions suffered; 2) Negative emotions associated with school and peer relationships; 3) Impotence and passivity; and 4) distrust of weak institutional responses. The results can support interventions to promote mental health at school with victimized students.

Keywords:
mental health; school violence; victimization; qualitative research

Resumo

Este estudo objetivou compreender o impacto da vitimização por bullying na saúde mental de adolescentes. Trata-se de uma investigação qualitativa, desenvolvida junto a 55 estudantes de 11 escolas públicas de uma cidade do interior de Minas Gerais. Os dados foram coletados por meio de entrevistas semiestruturadas e analisados segundo a análise de conteúdo no software Atlas.TI. No grupo de participantes, 19 estudantes revelaram já ter sofrido bullying na escola. Verificou-se nas narrativas que a vitimização por bullying representa uma ameaça à saúde e bem-estar mental, caracterizando-se como uma experiência negativa, cotidiana e duradoura na trajetória escolar. Quatro categorias temáticas foram identificadas: 1) Sofrimentos mentais atribuídos às agressões sofridas; 2) Emoções negativas associadas à escola e aos relacionamentos com pares; 3) Impotência e passividade; e 4) Desconfiança diante das fracas respostas institucionais. Os resultados podem subsidiar intervenções com foco na promoção da saúde mental na escola junto aos estudantes vitimizados.

Palavras-chave:
saúde mental; violência escolar; vitimização; pesquisa qualitativa

Resumen

Este estudio tuvo por objetivo comprender el impacto de la victimización por acoso escolar en la salud mental de los adolescentes. Se trata de una investigación cualitativa, desarrollada junto a 55 estudiantes de 11 escuelas públicas brasileñas. Los datos fueron recolectados por medio de entrevistas semiestructuradas y analizadas según el análisis de contenido en el software Atlas.TI. 19 estudiantes revelaron ya haber sufrido acoso en la escuela. Se verificó que la victimización representa una amenaza para la salud mental y el bienestar, caracterizándose como una experiencia negativa, cotidiana y duradera en la trayectoria escolar. Se identificaron cuatro categorías temáticas: 1) las enfermedades mentales atribuidas a las agresiones sufridas; 2) Emociones negativas asociadas a la escuela y a las relaciones con pares; 3) Impotencia y pasividad; y 4) Desconfianza ante las débiles respuestas institucionales. Los resultados pueden subsidiar intervenciones con foco en la promoción de la salud mental en la escuela.

Palabras clave:
salud mental; violencia escolar; victimización; investigación cualitativa

Introduction

Bullying is considered one of the main hardship faced by adolescents in their daily school life and has emerged as an important public health problem in recent decades. It is a type of violence characterized by the intentionality and repetition of aggressions, as well as by the imbalance of power among the students involved (Olweus, 2013Olweus, D. (2013). School bullying: development and some important challenges. Annual Review of Clinical Psychology, 9(1), 751-780. https://doi.org/10.1146/annurev-clinpsy-050212-185516
https://doi.org/10.1146/annurev-clinpsy-... ). The complex dynamics of the development of bullying situations is based on the action of participating subgroups in the occurrence of aggressions and students are identified as: aggressors (who adopt aggressive behavior towards their colleagues), observers, victim-aggressors (who adopt reactive aggressive behaviors to react to the violence suffered) and victims (Olweus, 2013Olweus, D. (2013). School bullying: development and some important challenges. Annual Review of Clinical Psychology, 9(1), 751-780. https://doi.org/10.1146/annurev-clinpsy-050212-185516
https://doi.org/10.1146/annurev-clinpsy-... ; Salmivalli & Voeten, 2004Salmivalli, C., & Voeten, M. (2004). Connections between attitudes, group norms, and behaviour in bullying situations. International Journal of Behavioral Development, 28(3), 246-258. https://journals.sagepub.com/doi/10.1080/01650250344000488
https://journals.sagepub.com/doi/10.1080... ).

In the present study, the focus is on the subgroup of the victims who, according to the scientific literature, are unable to resolve the issue alone (Chester et al., 2015Chester, K. L., Callaghan, M., Cosma, A., Donnelly, P., Craig, W., Walsh, S., & Molcho, M. (2015). Cross-national time trends in bullying victimization in 33 countries among children aged 11, 13 and 15 from 2002 to 2010. The European Journal of Public Health, 25(suppl 2), 61-64. https://doi.org/10.1093/eurpub/ckv029
https://doi.org/10.1093/eurpub/ckv029... ; Srabstein, 2013Srabstein, J. C. (2013). News reports of bullying-related fatal and nonfatal injuries in the Americas. Revista Panamericana de Salud Pública, 33(5), 378-382. https://scielosp.org/pdf/rpsp/2013.v33n5/378-382/en
https://scielosp.org/pdf/rpsp/2013.v33n5... ). Victimization rates vary according to countries and socio-cultural contexts (Chester et al., 2015Chester, K. L., Callaghan, M., Cosma, A., Donnelly, P., Craig, W., Walsh, S., & Molcho, M. (2015). Cross-national time trends in bullying victimization in 33 countries among children aged 11, 13 and 15 from 2002 to 2010. The European Journal of Public Health, 25(suppl 2), 61-64. https://doi.org/10.1093/eurpub/ckv029
https://doi.org/10.1093/eurpub/ckv029... ; Srabstein, 2013Srabstein, J. C. (2013). News reports of bullying-related fatal and nonfatal injuries in the Americas. Revista Panamericana de Salud Pública, 33(5), 378-382. https://scielosp.org/pdf/rpsp/2013.v33n5/378-382/en
https://scielosp.org/pdf/rpsp/2013.v33n5... ). In Brazil, the National School-based Health Survey (PeNSE), performed in 2009, 2012 and 2015 with 9^th grade elementary school students from all States in the country, identified a prevalence rate of approximately 7% of bullying victims (Brasil, 2016Brasil. (2016). Pesquisa Nacional de Saúde do Escolar. Rio de Janeiro: IBGE; Malta et al., 2010Malta, D. C., Silva, M. A. I., Mello, F. C. M. d., Monteiro, R. A., Sardinha, L. M. V., Crespo, C., ... Porto, D. L. (2010). Bullying nas escolas brasileiras: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE), 2009. Ciência & Saúde Coletiva, 15, 3065-3076. http://dx.doi.org/10.1590/S1413-81232010000800011
http://dx.doi.org/10.1590/S1413-81232010... , 2014Malta, D. C., Porto, D. L., Crespo, C. D., Silva, M. M. A., Andrade, S. S. C., Mello, F. C. M., ... Silva, M. A. I. (2014). Bullying in Brazilian school children: analysis of the National Adolescent School-based Health Survey (PeNSE 2012). Revista Brasileira de Epidemiologia, 17, 92-105. http://dx.doi.org/10.1590/1809-4503201400050008
http://dx.doi.org/10.1590/1809-450320140... ). According to the scientific literature, victimized students exhibit less feeling of belonging in the school institutions, accumulate reports of failure or history of school dropout and, psychologically, when compared to non-victimized students, they indicate lower social self-concept, feeling of loneliness, symptoms of anxiety and depression, in addition to suicidal ideation (Binsfeld & Lisboa 2010Binsfeld, A. R., Lisboa, C. S. M. (2010). Bullying: um estudo sobre papéis sociais, ansiedade e depressão no contexto escolar do Sul do Brasil. Interpersona, 4(1), 74-105. https://interpersona.psychopen.eu/article/view/44
https://interpersona.psychopen.eu/articl... ; Hase, Goldberg, Smith, Stuck, & Campain, 2015Hase, C. N., Goldberg, S. B., Smith, D., Stuck, A., & Campain, J. (2015). Impacts of traditional bullying and cyberbullying on the mental health of middle school and high school students. Psychology in the Schools, 52(6), 607-617. https://doi.org/10.1002/pits.21841
https://doi.org/10.1002/pits.21841... ).

This scenario reveals the impact of victimization on mental health and quality of life of school-age children and adolescents, and is considered a serious public health problem (Wu, Luu, & Luh, 2016Wu, W. C., Luu, S., & Luh, D. L. (2016). Defending behaviors, bullying roles, and their associations with mental health in junior high school students: a population-based study. Bmc Public Health, 16(1). https://doi.org/10.1186/s12889-016-3721-6
https://doi.org/10.1186/s12889-016-3721-... ). In this connection, interest in the subject within the field of health has increased in recent years and a school-based health promotion strategy is indicated with view at assisting victims in the process of empowerment to deal with the issue or seek help from other colleagues and adults (Dresler-Hawke & Whitehead, 2009Dresler-Hawke, E., & Whitehead, D. (2009). The behavioral ecological model as a framework for school-based anti-bullying health promotion interventions. Journal of School Nursing, 25(3), 105-204. https://doi.org/10.1177/1059840509334364
https://doi.org/10.1177/1059840509334364... ; Oliveira, Silva, Querino, & Silva, 2016Oliveira, W. A., Silva, J. L., Querino, R. A., & Silva, M. A. I. (2016). Experiences and perceptions of discrimination related to bullying among Brazilian students. Maltrattamento e Abuso all’infanzia, 18(1), 29-57. https://www.francoangeli.it/Riviste/Scheda_Rivista.aspx?IDarticolo=56270&lingua=en
https://www.francoangeli.it/Riviste/Sche... ; Silva, Silva, Pereira, Oliveira, & Medeiros, 2014Silva, M. A. I., Silva, J. L., Pereira, B. O., Oliveira, W. A., & Medeiros, M. (2014). The view of teachers on bullying and implications for nursing. Revista da Escola de Enfermagem da USP, 48(4), 723-730. http://dx.doi.org/10.1590/S0080-623420140000400021
http://dx.doi.org/10.1590/S0080-62342014... ).

This approach is important when considering that the impact of the victimization experience on mental health involves the intra-individual, inter-relational or inter-subjective fields besides the social level (Fernandes, Yunes, & Finkler, 2020Fernandes, G., Yunes, M. A. M., & Finkler, L. (2020). The social networks of adolescent victims of domestic violence and bullying. Paidéia (Ribeirão Preto), 30, e3007. https://dx.doi.org/10.1590/1982-4327e3007
https://dx.doi.org/10.1590/1982-4327e300... ; Freitas, Coimbra, & Fontaine, 2017Freitas, D. F., Coimbra, S., & Fontaine, A. M. (2017). Resilience in LGB youths: a systematic review of protection mechanisms. Paidéia (Ribeirão Preto), 27(66), 69-79. https://dx.doi.org/10.1590/1982-43272766201709
https://dx.doi.org/10.1590/1982-43272766... ; Wu et al., 2016Wu, W. C., Luu, S., & Luh, D. L. (2016). Defending behaviors, bullying roles, and their associations with mental health in junior high school students: a population-based study. Bmc Public Health, 16(1). https://doi.org/10.1186/s12889-016-3721-6
https://doi.org/10.1186/s12889-016-3721-... ). Thus, it is noted that schools should become settings that facilitate respect and protect people’s basic civil, political, socioeconomic and cultural rights so that the children and adolescents’ mental health is favored (O’Reilly, Svirydzenka, Adams, & Dogra, 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ). Deprivation of security, diversity tolerance and freedom are all aspects that characterize aggressive settings in schools, and allows to state, in line with the literature, that it is difficult to maintain good levels of mental health in those conditions (O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ; Wu et al., 2016Wu, W. C., Luu, S., & Luh, D. L. (2016). Defending behaviors, bullying roles, and their associations with mental health in junior high school students: a population-based study. Bmc Public Health, 16(1). https://doi.org/10.1186/s12889-016-3721-6
https://doi.org/10.1186/s12889-016-3721-... ).

In this connection, health promotion in schools is a strategy that aims to improve and / or protect the health of all members of the school community (students, teachers, families) (Naidoo & Wills, 2016Naidoo, J., & Wills, J. (2016). Foundations for health promotion (4 ed.). London: Elsevier.). This is a broader concept than the well-known notion of health education, as it includes the provision and development of activities related to healthy school policies, the physical and social environment of the school, school curriculum, relations with the community, families and other existing services in the locality (Horta et al., 2017Horta, R. L., Andersen, C. S., Pinto, R. O., Horta, B. L., Oliveira-Campos, M., Andreazzi, M. A. R. d., & Malta, D. C. (2017). Health promotion in school environment in Brazil. Revista de Saúde Pública, 51(27). http://dx.doi.org/10.1590/s1518-8787.2017051006709
http://dx.doi.org/10.1590/s1518-8787.201... ; Naidoo & Wills, 2016Naidoo, J., & Wills, J. (2016). Foundations for health promotion (4 ed.). London: Elsevier.). According to the logic of health promotion, the school must become a setting conducive to the development and creation of learning about quality and healthy living habits, as well as training for self-care (Casemiro, Fonseca, & Secco, 2014Casemiro, J. P., Fonseca, A. B. C., & Secco, F. V. M. (2014). Promover saúde na escola: reflexões a partir de uma revisãosobre saúde escolar na América Latina. Ciência & Saúde Coletiva, 19(3), 829-840. http://dx.doi.org/10.1590/1413-81232014193.00442013
http://dx.doi.org/10.1590/1413-812320141... ; O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ).

Health promotion involves behavioral changes that are related to people’s belief systems (Casemiro et al., 2014Casemiro, J. P., Fonseca, A. B. C., & Secco, F. V. M. (2014). Promover saúde na escola: reflexões a partir de uma revisãosobre saúde escolar na América Latina. Ciência & Saúde Coletiva, 19(3), 829-840. http://dx.doi.org/10.1590/1413-81232014193.00442013
http://dx.doi.org/10.1590/1413-812320141... ; Naidoo & Wills, 2016Naidoo, J., & Wills, J. (2016). Foundations for health promotion (4 ed.). London: Elsevier.; O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ). An approach to tackle bullying in schools, within this perspective and considering the peculiarities, would be no different. Therefore, anti-bullying intervention programs must first identify the relevant individual levels, followed by the contingencies of victimization experiences, so that relational and social changes be made among students through actions implemented with these students (Dresler-Hawke & Whitehead, 2009Dresler-Hawke, E., & Whitehead, D. (2009). The behavioral ecological model as a framework for school-based anti-bullying health promotion interventions. Journal of School Nursing, 25(3), 105-204. https://doi.org/10.1177/1059840509334364
https://doi.org/10.1177/1059840509334364... ; O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ). Thus, the starting point for anti-bullying health promotion programs should be individual events and situations, weighing their main consequences.

However, although the literature on the phenomenon in question is exponential, there is still no effective theoretical-methodological framework capable of guiding comprehensive interventions against bullying from the perspective of promoting students’ mental health, so that the problems identified remain untouched (Dresler -Hawke & Whitehead, 2009Dresler-Hawke, E., & Whitehead, D. (2009). The behavioral ecological model as a framework for school-based anti-bullying health promotion interventions. Journal of School Nursing, 25(3), 105-204. https://doi.org/10.1177/1059840509334364
https://doi.org/10.1177/1059840509334364... ). In addition, a literature review revealed a scarcity of studies promoting mental health in the school framework at national level (Cid & Gasparini, 2016Cid, M. F. B., & Gasparini, D. A. (2016). Ações de promoção à saúde mental infanto-juvenil no contexto escolar: um estudo de revisão. Revista FSA, 13(1), 97-114. http://www4.fsanet.com.br/revista/index.php/fsa/article/view/968
http://www4.fsanet.com.br/revista/index.... ). It is also considered that bullying affects students’ mental health, and the interface between these two variables is also little explored in the scientific literature (Silva, Soares, Sousa, & Kusano, 2019Silva, G. V., Soares, J. B., Sousa, J. C., & Kusano, L. A. E. (2019). Promoção de saúde mental para adolescente em uma escola de ensino médio - Um relato de experiência. Revista do NUFEN, 11(2), 133-148. https://dx.doi.org/10.26823/RevistadoNUFEN.vol11.nº02rex28
https://dx.doi.org/10.26823/RevistadoNUF... ). These are aspects that reveal the need to move forward from the understanding of school bullying through qualitative research, particularized according to one type of involvement in its occurrence and with a focus on health promotion. In this connection, this study aimed to understand the impact of bullying victimization on adolescents’ mental health.

Method

Study scenario

We should underscore that the present study is part of a broader investigation, with a mixed design, on bullying and family interactions. This study was conducted in a city in the interior of the State of Minas Gerais, Brazil. The city was selected for convenience. At the time of the study, in that city, there were 34 public schools in the urban environment that offered elementary and high school classes in the morning shift, with 12,140 students enrolled. Through the Proportional Size Sampling method (Bolfarine & Bussab, 2005Bolfarine, H., & Bussab, W. (2005). Elementos de amostragem (1 ed.). São Paulo: Egard Blucher.) it was defined that the study should cover 11 schools in the municipality to ensure the population representation defined by the selection of strata, and not of participants.

Participants

A total of 55 adolescents aged 11 to 19 years participated in the general study, but this study considers the results of investigations that reported victimization experiences. The selection and definition of the number of participants were guided by the maximum variation sampling strategy, which allows the documentation of the largest possible number of experiences, information and the dimensions and properties of the phenomenon and context investigated (Wuest, 2010Wuest, J. (2010). Grounded theory: The method. In P. L. Munhall (Ed.), Nursing research: a qualitative perspective (5 ed., pp. 239-271). Sudbury: Jones & Bartlett Learning.). The characterization of the total group of participants, by gender and according to age, school year and the type of involvement in bullying situations, is shown in the Table 1.

In this study, the results of the interviews about the experiences of victims of bullying are reported, with the purpose of exploring how this type of violence is experienced by students. In total, 19 students stated they were victims of bullying and made up the final group of the investigation participants. The interest in focusing on the particularities of the victims’ experiences is justified by the consequences of violence on mental health, as well as by the difficulty that these students find to face, alone, the aggressions they are subjected to. Aside from that, the literature indicates that interventions with victims require less expenditure of human and financial resources (Vreeman & Carroll, 2007Vreeman, R. C., & Carroll, A. E. (2007). A systematic review of school-based interventions to prevent bullying. Archives of Pediatric and Adolescent Medicine, 161(1), 78-88. https://doi.org/10.1001/archpedi.161.1.78
https://doi.org/10.1001/archpedi.161.1.7... ), a relevant aspect to be considered in the Brazilian reality, which suffers from insufficient investments in education and health, in addition to the qualification deficiencies of professionals for the development of more complex interventions, also considering the approach of the issue from the perspective of health promotion.

Data collection instruments

A script was developed based on studies in the field of qualitative research (Minayo, 2010Minayo, M. C. S. (2010). Los conceptos estructurantes de la investigación cualitativa. Salud colectiva, 6(3), 251-261. http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S1851-82652010000300002
http://www.scielo.org.ar/scielo.php?scri... , 2012Minayo, M. C. S. (2012). Qualitative analysis: theory, steps and reliability. Ciência & Saúde Coletiva, 17(3), 621-626. http://dx.doi.org/10.1590/S1413-81232012000300007
http://dx.doi.org/10.1590/S1413-81232012... ; Thornberg, 2011aThornberg, R. (2011a). Informed Grounded Theory. Scandinavian Journal of Educational Research, 56(3), 243-259. https://doi.org/10.1080/00313831.2011.581686
https://doi.org/10.1080/00313831.2011.58... , 2011bThornberg, R. (2011b). ‘She’s weird!’ - The social construction of bullying in school: A Review of Qualitative Research. Children & Society, 25(4), 258-267. https://doi.org/10.1111/j.1099-0860.2011.00374.x
https://doi.org/10.1111/j.1099-0860.2011... ) to guide semi-structured interviews. Examples of questions in the script are: Have you ever been threatened, humiliated, excluded or assaulted at school? What did they do to you? Take a moment and tell me all you remember about this episode. Follow-up questions were also used (How come? Could you tell me more about this? What do you mean by that? Could you give me examples?) to clarify, illustrate or deepen the participants’ responses.

Data collection

Data collection was carried out between August and October 2014. Semi-structured interviews were conducted at the students’ schools, by the first author of the study, in private rooms, without the presence of teachers or other students. The average time for each interview was 12 minutes. The interviews were audio recorded and transcribed in full.

Data analysis

The transcripts were imported into the Atlas.TI Version 7 software and the analysis process involved two levels: 1) code development based on the reading of the bullying victims interviews; and 2) categorization of codes according to the thematic analysis proposed by Braun and Clarke (2006Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://www.tandfonline.com/doi/abs/10.1191/1478088706qp063oa
https://www.tandfonline.com/doi/abs/10.1... ). From the data set, four thematic categories emerged: 1) Mental suffering attributed to the aggressions suffered; 2) Negative emotions associated with school and peer relationships; 3) Impotence and passivity; and 4) Distrust in the face of weak institutional responses.

In the interpretation of the results, the expressive-creative technique “whirlwind of ideas” was used. This is a metaphor based on a teaching-learning pedagogical proposal (Ontoria, Gómez, & Luque, 2014Ontoria, A., Gómez, J. P. R., & Luque, A. (2014). Aprendizaje centrado en el alumno (3 ed.). Madrid: Narcea.). From the conception of a whirlwind, people’s meanings, impressions and feelings are entered into a chart in which there is a specific condition (“being familiar with”) and elements that indicate a lack of control over what happens (“As a nature’s catastrophe”). As in the case of bullying, the results of a whirlwind, in general, are suffering, helplessness, sadness, feelings that can encompass other dimensions of life and extend to different stages of the life cycle. As noted, this technique allows development of analyses, syntheses, comparisons and construction of complex hypotheses about the ideas expressed in the interviews.

Ethical issues

The study was approved by Research Ethics Committee of the Ribeirão Preto School of Nursing, University of São Paulo. The adolescents and their guardians also provided, in writing, the terms of minors’ assessment and their consent, respectively, for participation in the investigation. In addition, to protect the identity of the participants, their names were replaced by fictitious names, randomly.

Results

This study contributes with information that allow us to understand the impact of bullying victimization on adolescents’ mental health. Data analysis revealed the participants’ victimization experiences. In this connection, the students stated that they were exposed to different types of violence situations, which ranged from being called pejorative nicknames, being the target of prejudiced comments and gossip that involved their names in supposedly derogatory facts, to physical assaults, threats and exclusion from peer groups. Reports on the type of verbal aggression stood out compared to other types of violence suffered, both for boys and for girls. Boys reported having suffered more physical aggression from other boys.

In general, being excluded was the most mentioned psychological violence. Bullying was justified mainly in terms of discrimination based on the perception of some characteristics of the victims, understood as a difference in relation to the peer group. In other words, difference is identified and used as a pretext to justify inequality, and inequality gives rise to the direct and practically non-mediated expression of violence. From the data set, four thematic categories were identified, which will be presented below.

Thematic category 1: Mental illnesses caused by the aggressions suffered

The mental health repercussions of exposure to situations of violence emerged in the statements of the group of participants. Being a bullying victim was considered as an important theme in the students’ narratives. The emotional and psychological problems derived therefrom are understood as common effects resulting from recurrent victimization, including reports of serious symptoms, such as anxiety crisis, somatization, sadness and suicidal ideation, as can be inferred in the sections of the following narratives:

In addition, being a victim of bullying directly impacted the students’ relationship with the school and the way the teaching-learning process was perceived:

Thematic category 2: Negative emotions about school and relationships with peers

The students’ narratives described the school experiences, which, in general, is marked by adverse and traumatic emotions in response to a culture of generalized bullying and impervious to reflection. Feelings of hurt, sadness, disbelief, anger at oneself and others’, as well as shame and emptiness were reported:

It is possible to interpret that the narratives produced explain the individual suffering of the victims in terms of emotional scars, lack of confidence, emotional exhaustion and low self-esteem.

Thematic category 3: Impotence and passivity

Victimized students reported feeling increasingly the lack of personal resources and a growing inability to deal with the aggressive acts and behaviors they were subjected to in their daily lives at school. The increased feeling of helplessness generates passivity in the face of the aggressions suffered, as the victims are unable to envision ways out or ways to resolve the issue, as noted in the following excerpts:

The passivity in the face of aggression is enhanced by families that instruct students not to react. This type of experience favors the identification of individuals with the role of victim, which keeps them in the position of impotent and passive individuals:

Thematic category 4: Distrust weak institutional responses

In the data set, disbelief in the protection of the school institution for students who were victims of bullying was an outstanding aspect. There was a strong perception among participants that schools not only tolerated bullying, but also protected aggressors to some extent. The following interview excerpts capture the essence of this theme:

It was observed that, when they attempted to follow, the institutional procedures to solve the problem, there was a delay or denial that bullying existed or even responses that did not mitigate its occurrence. Often, the response to violence should come from the victim himself/herself through the disapproval caused or the result of the aggressions as narrated by one of the participants:

Interpretative synthesis: the whirlwind metaphor

The set of data presented was interpreted according to the expressive-creative technique “whirlwind of ideas” (Ontoria et al., 2014Ontoria, A., Gómez, J. P. R., & Luque, A. (2014). Aprendizaje centrado en el alumno (3 ed.). Madrid: Narcea.). In this connection, the dynamics of victimization was evidenced at two levels. On the first level the impact of the aggressions on the students’ mental health and the triggered negative feelings materializes. At the other level, there is the helplessness experienced in school institutions and the maintenance of victim status through the feeling of helplessness and frequent passivity. These interpretations are synthesized and represented in Figure 1 by means of the whirlwind metaphor.

According to this interpretive process model, the victims are at the core of the whirlwind. Support is small and, since the cause of the violence is deposited at the individual level, there is no indication that the situation is temporary, but rather cyclical and permanent in the students’ life history. The vicious circle of victimization is nourished by social issues and norms, largely discrimination and prejudice that feed its dynamics. On the other hand, the perpetuation of bullying occurs due to the uncertainty of not knowing what to do and because of individual negative feelings, of impotence, passivity and failure. There is, actively, a cognitive elaboration, which is made collective, in which the victim acknowledges the issue and the self as in a cause and effect relationship, incorporating this type of experience into his/her daily life. This perception is nurtured by the understanding that adults and schools also have very little to do with the situation or do not engage in solving the issue (structural violence).

Discussion

This study aimed to understand the impacts of victimization caused by bullying on adolescents’ mental health. The reports of mental suffering and the negative feelings experienced by students allow us to infer how bullying victimization in schools is harmful to the health and well-being of students. The experiences with bullying are current or past episodes that marked the school trajectory and the personal history of each of the students. Victims seem to feel responsible for the aggressions suffered, in a process of internalization of guilt. This dimension will be related to the evaluation of perspectives and repercussions on their lives. The picture presented enhances the victims’ position of students who cannot find answers to the issue personally, while experiencing a limited faith in the school responses against bullying.

It should be pointed out that the results presented in this paper are well in line with the existing literature on the impact of bullying on students’ mental health (Benedict, Vivier, & Gjelsvik, 2015Benedict, F. T., Vivier, P. M., & Gjelsvik, A. (2015). Mental health and bullying in the United States among children aged 6 to 17 years. Journal of Interpersonal Violence, 30(5), 782-795. https://doi.org/10.1177/0886260514536279
https://doi.org/10.1177/0886260514536279... ; Wu et al., 2016Wu, W. C., Luu, S., & Luh, D. L. (2016). Defending behaviors, bullying roles, and their associations with mental health in junior high school students: a population-based study. Bmc Public Health, 16(1). https://doi.org/10.1186/s12889-016-3721-6
https://doi.org/10.1186/s12889-016-3721-... ). Directly, the impact of victimization’s experience affects students’ quality of life to a greater extent than students without reports of involvement in bullying situations (Frisén & Bjarnelind, 2010Frisén, A., & Bjarnelind, S. (2010). Health-related quality of life and bullying in adolescence. Acta Pædiatrica, 99(4), 597-603. https://doi.org/10.1111/j.1651-2227.2009.01664.x
https://doi.org/10.1111/j.1651-2227.2009... ). In general, victimized students report feeling less energy for daily life activities, have more limitations in physical activities and negatively evaluate psychological well-being (Frisén & Bjarnelind, 2010Frisén, A., & Bjarnelind, S. (2010). Health-related quality of life and bullying in adolescence. Acta Pædiatrica, 99(4), 597-603. https://doi.org/10.1111/j.1651-2227.2009.01664.x
https://doi.org/10.1111/j.1651-2227.2009... ). Suicidal ideations are also common among victims, just as there is a negative impact in the teaching-learning process (Olweus, 2013Olweus, D. (2013). School bullying: development and some important challenges. Annual Review of Clinical Psychology, 9(1), 751-780. https://doi.org/10.1146/annurev-clinpsy-050212-185516
https://doi.org/10.1146/annurev-clinpsy-... ). In a literature review on the connections between multiple forms of violence, bullying was associated with poor school performance; impairment in non-violent social skills; substance use and peer violence (Wilkins, Tsao, Hertz, Davis, & Klevens, 2014Wilkins, N., Tsao, B., Hertz, M., Davis, R., & Klevens, J. (2014). Connecting the dots: an overview of the links among multiple forms of violence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Oakland, CA: Prevention Institute.).

On the other hand, students demonstrate a greater load of conflict and frustration in remaining in an educational system that does not offer answers to violence (Pereira, Silva, & Nunes, 2009Pereira, B., Silva, M. A. I., & Nunes, B. (2009). Descrever o bullying na escola: estudo de um agrupamento de escolas no interior de Portugal. Revista Diálogo Educacional, 9, 455-466. https://www.redalyc.org/articulo.oa?id=189114443004
https://www.redalyc.org/articulo.oa?id=1... ). These findings, in line with the scientific literature, suggest that institutional and formal responses against bullying are urgent demands, as the results presented revealed that the initiatives adopted by schools or education professionals are, in part, creating the conditions for further victimization and exacerbation of mental suffering already caused by bullying (Thornberg, Waenstroem, Pozzoli, & Gini, 2018Thornberg, R., Waenstroem, L., Pozzoli, T., & Gini, G. (2018). Victim prevalence in bullying and its association with teacher-student and student-student relationships and class moral disengagement: A class-level path analysis. Research Papers in Education, 33(3), 320-335. https://doi.org/10.1080/02671522.2017.1302499
https://doi.org/10.1080/02671522.2017.13... ).

Given this scenario, considering that quality of life and health are holistic concepts and related to the subjective well-being of people in different contexts and everyday situations, all these dimensions (the experience of violence itself, the victimization process, protection and helplessness, subjective aspects and repercussions) are understood as deleterious elements. Students’ mental health is threatened by aggressiveness of all kind, especially those based on paradigms that enhance impotence and passivity, and the malaise installed in social relations with schoolmates gains contours of final truths, which can be perpetuated as revealed and noted in other studies (Araújo, Coutinho, Miranda, & Saraiva, 2012Araújo, L. S., Coutinho, M. P. L., Miranda, R. S., & Saraiva, E. R. A. (2012). Universo consensual de adolescentes acerca da violência escolar. Psico-USF, 17(2), 243-251. http://dx.doi.org/10.1590/S1413-82712012000200008
http://dx.doi.org/10.1590/S1413-82712012... ; Rech, Halpern, Tedesco, & Santos, 2013Rech, R. R., Halpern, R., Tedesco, A., & Santos, D. F. (2013). Prevalence and characteristics of victims and perpetrators of bullying. Jornal de Pediatria, 89(2), 164-170. http://dx.doi.org/10.1016/j.jped.2013.03.006
http://dx.doi.org/10.1016/j.jped.2013.03... ; Silva, Oliveira, Bazon, & Cecilio, 2014Silva, J. L., Oliveira, W. A., Bazon, M. R., & Cecilio, S. (2014). Bullying: conhecimentos, atitudes e crenças de professores. Psico, 45(2), 147-156. http://revistaseletronicas.pucrs.br/ojs/index.php/revistapsico/article/view/12683
http://revistaseletronicas.pucrs.br/ojs/... ). It is in this specific area that the implications for health promotion at school are explored in this study.

Health promotion involves behavioral changes that may be inconsistent with people’s central belief system (Dresler-Hawke & Whitehead, 2009Dresler-Hawke, E., & Whitehead, D. (2009). The behavioral ecological model as a framework for school-based anti-bullying health promotion interventions. Journal of School Nursing, 25(3), 105-204. https://doi.org/10.1177/1059840509334364
https://doi.org/10.1177/1059840509334364... ). Therefore, intervention programs in this perspective must first identify individual levels that are relevant and need to be addressed to facilitate the desired changes (Horta et al., 2017Horta, R. L., Andersen, C. S., Pinto, R. O., Horta, B. L., Oliveira-Campos, M., Andreazzi, M. A. R. d., & Malta, D. C. (2017). Health promotion in school environment in Brazil. Revista de Saúde Pública, 51(27). http://dx.doi.org/10.1590/s1518-8787.2017051006709
http://dx.doi.org/10.1590/s1518-8787.201... ; O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ). In addition, health promotion presupposes the development of people’s self-care and protagonism (Casemiro et al., 2014Casemiro, J. P., Fonseca, A. B. C., & Secco, F. V. M. (2014). Promover saúde na escola: reflexões a partir de uma revisãosobre saúde escolar na América Latina. Ciência & Saúde Coletiva, 19(3), 829-840. http://dx.doi.org/10.1590/1413-81232014193.00442013
http://dx.doi.org/10.1590/1413-812320141... ; O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ). Thus, if the goal of a change intervention based on health promotion is to mitigate the occurrence of bullying behavior, one of the first steps could be to steer the action towards the empowerment of victims.

In this connection, a quasi-experimental study focusing on the development of victims’ social skills revealed that victimization decreased among students who participated in the intervention (Silva et al., 2018Silva, J. L., Oliveira, W. A., Carlos, D. M., Lizzi, E. A. S., Rosário, R., & Silva, M. A. I. (2018). Intervention in social skills and bullying. Revista Brasileira de Enfermagem, 71, 1085-1091. http://dx.doi.org/10.1590/0034-7167-2017-0151
http://dx.doi.org/10.1590/0034-7167-2017... ). Although the authors’ proposal was not referenced from the perspective of health promotion, it is clear that the qualification or training of social skills included items related to empowerment and the ability of victims to respond in an assertive or directed way to seek a solution to the problem (Silva et al., 2018Silva, J. L., Oliveira, W. A., Carlos, D. M., Lizzi, E. A. S., Rosário, R., & Silva, M. A. I. (2018). Intervention in social skills and bullying. Revista Brasileira de Enfermagem, 71, 1085-1091. http://dx.doi.org/10.1590/0034-7167-2017-0151
http://dx.doi.org/10.1590/0034-7167-2017... ). At the same time, the intervention allowed the development of moments to express emotions, affections and anxieties, factors that converge with the proposals for promoting mental health reported in the literature (Cid & Gasparini, 2016Cid, M. F. B., & Gasparini, D. A. (2016). Ações de promoção à saúde mental infanto-juvenil no contexto escolar: um estudo de revisão. Revista FSA, 13(1), 97-114. http://www4.fsanet.com.br/revista/index.php/fsa/article/view/968
http://www4.fsanet.com.br/revista/index.... ; O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ).

When school cannot take on the task of ensuring students’ safety and mental health, it fails in its essential aspects and requires the help of other functions, such as health. Thus, the Health at School Program (PSE) proposes intersectoral actions in the fields of health and education in the development of cross-sectional themes (Brasil, 2011Brasil. (2011). Instrutivo PSE. Brasília). Among the themes to be covered by the program is bullying that must be addressed by primary care health teams with schools and their members. The direction for the development of the program suggests that the actions be based on the perspective of health promotion and intersectoriality (Brasil, 2011Brasil. (2011). Instrutivo PSE. Brasília). By necessity, programs such as the PSE and initiatives of this nature must also target aspects that are part of the contextual and community levels, including families and other settings that can contribute to the improvement of the school climate with the consequent decrease in school bullying and the improvement in students’ mental health rates (Dresler-Hawke & Whitehead, 2009Dresler-Hawke, E., & Whitehead, D. (2009). The behavioral ecological model as a framework for school-based anti-bullying health promotion interventions. Journal of School Nursing, 25(3), 105-204. https://doi.org/10.1177/1059840509334364
https://doi.org/10.1177/1059840509334364... ; O’Reilly et al., 2018O’Reilly, M., Svirydzenka, N., Adams, S., & Dogra, N. (2018). Review of mental health promotion interventions in schools. Social Psychiatry and Psychiatric Epidemiology, 53(7), 647-662. https://doi.org/10.1007/s00127-018-1530-1
https://doi.org/10.1007/s00127-018-1530-... ). Despite these indications, schools still present important weaknesses in their institutional structure to face school violence, in general (Ferriani, Carlos, Oliveira, Esteves, & Martins, 2017Ferriani, M. G. C., Carlos, D. M., Oliveira, A. J., Esteves, M. R., Martins, J. E. (2017). Institutional links to cope with school violence: an exploratory study. Revista de Enfermagem Escola Anna Nery, 21(4), e20160347. http://dx.doi.org/10.1590/2177-9465-ean-2016-0347
http://dx.doi.org/10.1590/2177-9465-ean-... ).

Final considerations

This study considered the harmful influence of bullying on the mental health of victimized adolescents. Negative feelings related to the phenomenon were revealed, as were impotence and passivity as characteristics of victims of bullying, who expected institutional answers to the issue that, in general, were inadequate or insufficient. Among the study’s strong points are: 1) the qualitative approach of victimization experiences among students, and 2) the complementary perspective of health promotion focused on the need to empower students to assume self-care and responsibilities to get out of the condition of victims . On the other hand, institutional responses should also be reviewed, such as the reporting of the occurrence of aggressions to school authorities which, so far, did not lead to the resolution of the problem, as mentioned by the participants.

However, the study has some limitations, which must be considered when interpreting the results. First, the qualitative nature of the investigation does not allow producing results regarding the analyzed variables that could be generalized; rather, it illustrates the particular and contextual experience of a group of bullied students. Other designs, mainly longitudinal studies, can be used to investigate the effects of victimization on students’ mental health. Second, the technique used in data collection - semi-structured interviews - increases the possibility of response bias according to the phenomenon of social desirability. Thus, future studies can minimize the effects of this limitation by adopting observational methods or the inclusion of other informants. Third, it is emphasized that the general objective of the expanded study, from which this manuscript is derived, did not specifically address aspects of mental health or health fostering, because it investigated the relationship between family interactions and bullying. In this connection, it is also considered as a limitation the sample trimming adopted in this study and that did not include the other characters involved in bullying situations (aggressors, observers and individuals without involvement with the phenomenon).

References

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