RESEARCH ARTICLE
Association of Being Bullied in School With Suicide Ideation and Planning Among Rural Middle School Adolescents MADHAV P. BHATTA, PhD, MPHa SUNITA SHAKYA, MPHb ERIC JEFFERIS, PhDc
ABSTRACT BACKGROUND: This study examined the association of ever being bullied in school with suicide ideation (ever thinking about killing oneself) and ever seriously making a plan to kill oneself (suicide planning) among rural middle school adolescents. METHODS: Using the US Centers for Disease Control and Prevention’s Middle School Youth Risk Behavior Survey instrument, 2 cross-sectional surveys were conducted among middle school adolescents (N = 1082) in a rural Appalachian county in Ohio in 2009 and 2012. Multivariable logistic regression models assessed the relationship of ever being bullied in school with suicide ideation and planning. RESULTS: Overall, a total of 468 participants (43.1%) reported ever being bullied in school, and 22.3% and 13.2% of the adolescents surveyed reported suicide ideation and planning, respectively. In the multivariable analyses, ever being bullied in school was significantly associated with both suicide ideation (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.7-3.5) and planning (OR = 2.5; 95% CI: 1.6-3.8). CONCLUSIONS: The results show a strong association between being bullied in school and suicide ideation and planning among rural middle school adolescents. Prevention of bullying in school as early as in middle school should be a strategy for reducing suicide ideation and planning among adolescents. Keywords: adolescents; suicide; ideation; planning; bullying. Citation: Bhatta MP, Shakya S, Jefferis E. Association of being bullied in school with suicide ideation and planning among rural middle school adolescents. J Sch Health. 2014; 84: 731-738. Received on June 13, 2013 Accepted on April 13, 2014
S
uicide among adolescents and young adults is a serious public health problem in the United States. It is the third leading cause of death in the United States among adolescents aged 10-19 years. In 2010, 267 and 1659 adolescents aged 10-14 and 15-19 years, respectively, died as a result of suicide.1 Completed suicide is just the tip of the epidemiologic iceberg of suicide and suicidal behaviors among adolescents. For every completed suicide there are about 25 attempted suicides and an even greater number of individuals exhibiting nonfatal suicidal thoughts and behaviors.2 These nonfatal suicidal thoughts and behaviors are classified into the categories of suicide ideation, suicide plan, and suicide attempt.3 Suicide ideation is defined as having thoughts of engaging in behavior intended to end one’s life; suicide plan is defined as the formulation
of a specific method through which one intends to die; and suicide attempt is defined as engagement in potentially self-injurious behavior in which there is at least some intent to die.4 According to the national Youth Risk Behavior Survey (YRBS) from 2011, 15.8% and 12.8% of high school-aged adolescents (15-18 year olds) had seriously considered attempting suicide (suicide ideation) or had made a plan about how they would attempt suicide (suicide plan) during the 12 months prior to the survey, respectively.5 These statistics clearly highlight the extent to which suicidal behaviors are a public health problem among high school-aged US adolescents. Data on suicide and suicidal behaviors among middle school-aged adolescent students (1114 year olds), however, are limited.6,7
a Assistant Professor of Epidemiology, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242. bGraduate Assistant, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242. c Associate Professor of Social and Behavioral Sciences, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242.
Address correspondence to: Madhav P. Bhatta, Assistant Professor of Epidemiology, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242.
Journal of School Health
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November 2014, Vol. 84, No. 11
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© 2014, American School Health Association • 731
The epidemiology of suicide and suicidal behaviors among adolescents involves a complex set of individual, family, social, and environmental risk factors.8-10 Individual level risk factors include sex; perceived body weight; gay or bisexual orientation; a history of physical or sexual abuse; mental health issues including depression; a history of aggression, impulsivity, or severe anger; and substance abuse or dependence.8-10 Family-level risk factors include parental mental health problems; family history of suicide or suicide attempts; and impaired parent-child relationship.8-10 Social and environmental risk factors include presence of firearms in the home; living outside of the home (homeless, in a corrections facility or a group home); difficulties or perceived low academic performance in school; social isolation; and presence of stressful life events such as legal or romantic difficulties or an argument with a parent.8-10 Bullying and peer victimization as contributing factors for suicide and suicidal behaviors have received greater media attention in recent years in the United States due to some highly publicized suicides among adolescents and young adults. Bullying and peer victimization in adolescents is correlated with adverse mental and physical health and engagement in other risky behaviors.11-13 Previous studies among adolescents have found that the victims of bullying are more likely be depressed or anxious, report having fair or poor health, and more likely to carry weapons and be in physical fights, and exhibit self-harming behaviors (nonsuicidal) than nonvictims.7,11-16 Moreover, several studies from various subpopulations of adolescents within and outside the United States have shown a relationship between bullying and suicide and suicidal behaviors.17-23 For example, a 2009 study among 12to 18 year-old adolescents in the United States found that peer victimized adolescents were 2.4 times and 3.3 times more likely to report suicidal ideation and a suicide attempt, respectively, than those not victimized.18 Bullying involvement in childhood and adolescence also have been shown to have a long-term influence on suicidal behaviors into adulthood. Two longitudinal studies have found that involvement in bullying in adolescence as a victim or a perpetrator is a risk factor for suicidal ideation, suicide attempts, and suicide deaths in adulthood.24,25 Bullying among the US adolescents is a prevalent phenomenon. According to the 2011 YRBS survey, 20.1% of high school students have been bullied on school property and 16.2% of students have been cyberbullied through e-mail, chat rooms, instant messaging, websites, or texting, during the 12 months before the survey.5 Involvement in bullying behaviors is higher among girls, younger (middle school) students, and rural adolescents.5,7,26 In addition, certain subgroups of adolescents such as gays and 732 •
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lesbians, and those born outside the United States are more likely to be bullied than heterosexual or native born youths.22,27 The high prevalence of bullying in adolescents and its short- and long-term consequences make bullying a significant public health problem in the United States. Therefore, understanding how bullying and peer victimization in adolescents contribute to suicide and suicidal behaviors remains an important area of research.28 The studies of adolescent suicidal behaviors in the United States have focused primarily on high school-aged adolescents. Studies examining the risk factors for suicide ideation and planning among middle school-aged adolescents, particularly in rural areas, are limited. The geographical, economic, social, and cultural uniqueness of rural communities necessitates research in rural populations, including the risk factors for suicidal behaviors among adolescents. Therefore, the purpose of this study was to examine the relationship between being bullied in school and suicide ideation and suicide planning among middle school-aged adolescents in a rural Appalachian county in Ohio.
METHODS Study Setting and Participants The study setting was a rural Appalachian county in Ohio. The Appalachian region in the United States, covering 420 counties in 13 states from New York to Mississippi, is home to approximately 25 million people and is a predominantly rural and medically underserved region. The region is categorized into 5 subregions: Northern, North Central, Central, South Central, and Southern.29 According to the US Census Bureau, the study county located in the Northern subregion of Appalachia had a population of 28,836 in 2010 and 22.2% were under the age of 18.30 As part of the Community Health Needs Assessment in 2009 and 2012, the local County Health Department and the County Family and Child First Council administered the US Centers for Disease Control and Prevention’s (CDC) Middle School YRBS31 to the students in sixth to eighth grades in the county. In the 2009 Survey, both public school systems within the county agreed to participate in the study and the only private school in the county declined to participate. In 2009, there were 771 middle school students in the public school system and 490 participated in the survey (participation rate: 63.6%).32 In 2012, there were 722 public middle school students and 599 participated in the survey (83.0%).32 For both years, nonparticipants were either the students in the private school, those who declined to participate, or were absent from school on the day of the survey. The 3-year interval between the 2 surveys ensured a minimal, if any, chance of a student repeating the survey as a middle school student in 2009 •
© 2014, American School Health Association
and 2012. To ensure anonymity of the participants, written consent from the parents and assent from the students were not obtained. However, the parents were notified in writing of the survey administration date so they could give their child oral permission to participate in the survey or opt out. Prior to survey administration, students were given the option of not participating. Participation in the anonymous survey was taken as the consent from the parents and the assent from the student.31 We analyzed the data from the 2 cross-sectional surveys to examine the relationship of being bullied in school with suicide ideation and planning. Instrument The CDC’s Middle School YRBS includes 50 questions on demographics and several categories of health-risk behaviors including tobacco, alcohol, and drug use; safety and violence-related behaviors; sexual risk behaviors; perception of weight and other health related question; bullying experience; and suicidal behaviors (ideation, planning, and attempt).
Primary outcomes of interest. The primary outcomes of interest in the study were ever having had suicide ideation and ever making a suicide plan. To measure suicide ideation, the participants were asked to provide a ‘‘yes’’ or a ‘‘no’’ response to the question: ‘‘Have you ever seriously thought about killing yourself ?’’ To measure suicide plan, the participants were asked to provide a ‘‘yes’’ or a ‘‘no’’ response to the question: ‘‘Have you ever made a plan about how you would kill yourself ?’’ Primary exposure of interest. The primary exposure of interest in the study was ever being bullied in school. The participants were asked to respond to the question: ‘‘Have you ever been bullied on school property?’’ with a ‘‘yes’’ or a ‘‘no’’ response. Potential confounders. Potential confounders selected for adjustment in the multivariate analyses were based on their known association with suicide and suicidal behaviors among adolescents from prior studies.6-8,10,24,33 The potential demographic confounders included age, grade, sex, and ethnicity/race. Ever being in a physical fight, ever smoking cigarettes, ever using marijuana, ever using cocaine, ever sniffing glue, and ever having had sex were other potential confounders measured as dichotomous variables (‘‘yes’’ or ‘‘no’’). Finally, self-perception of weight as a potential confounder was measured using the question: ‘‘How do you describe your weight?’’ with the following options for response: ‘‘about the right weight,’’ ‘‘very underweight,’’ ‘‘slightly underweight,’’ ‘‘slightly overweight,’’ and ‘‘very overweight.’’ Journal of School Health
•
Data Analysis The overall frequency distributions of the primary outcomes (suicide ideation and suicide planning) and the potential risk factors were calculated. We assessed any differences in the outcomes and exposure variables between the 2009 and 2012 survey years using Pearson’s chi-square test. We then assessed the relationship of the primary exposure (ever being bullied in school) with other risk factors/potential confounders using the Mantel-Haenszel chi-square test to adjust for survey year. To assess the individual relationship of being bullied in school and the potential confounders with suicide ideation and suicide planning, we performed univariate logistic regression analysis and report the crude odds ratio (OR) and the associated 95% confidence intervals (CIs). We performed multivariable logistic regression analysis to assess the independent effect of the primary exposure variable (being bullied in school) with suicide ideation and suicide planning, respectively, while controlling for the effect of the potential confounders. Survey year, age, sex, grade, race/ethnicity, self-perception of weight, being sexually active, being in physical fights, cigarette smoking, marijuana use, cocaine use, and sniffing glue were the potential confounders adjusted in the multivariable models. For the multivariate analyses, complete case analysis was used and the effective sample size 830. There was no significant difference between the participants excluded from the multivariate analysis due to missing predictor variable values and those included in terms of sociodemographics, bullying experience, and suicidal behaviors. Sex has been shown as a potential effect modifier of the relationship between bullying and suicidal behaviors in previous studies.24,33 Therefore, we assessed for the 2-way interaction of sex and bullying in explaining suicide ideation and planning by analyzing the significance of product term of bullying and sex in the logistic regression models.34 We report the results of the overall and sex-stratified models of the association between ever being bullied in school and suicide ideation and suicide planning. All ® data analyses were performed with SAS 9.3.1 (SAS Institute, Cary, NC).
RESULTS Sample Characteristics Table 1 presents the overall frequency distribution of the demographics, health risk behaviors, and suicide ideation and planning stratified by the year of survey. The combined total study sample size was 1082 with 487 (45.0%) and 595 (55.0%) middle school adolescents participating in the 2009 and 2012 surveys, respectively. Overall, 531 (49.2%) participants were girls and 911 (88.8%) were non-Hispanic Whites. About 90% of the respondents were 12-14 years
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© 2014, American School Health Association • 733
Table 1. Frequency Distribution of Demographic Characteristics, Suicidal Behaviors, and Health Risk Behaviors Among Middle School Adolescents in a Rural Ohio County by Year of Survey (N = 1082)∗ Total N (%) 1082 (100)
2009 N (%) 487 (45.01)
2012 N (%) 595 (54.99)
Age (years) 11-12 364 (33.6) 147 (30.2) 13 399 (36.9) 194 (39.8) 14-15 339 (29.5) 146 (30.0) Sex Girls 531 (49.2) 235 (48.5) Boys 549 (50.8) 251 (51.4) Grade 6th 320 (29.7) 129 (26.6) 7th 404 (37.4) 193 (39.7) 8th 355 (32.9) 164 (33.7) Race/ethnicity White 911 (88.8) 399 (86.5) 115 (11.2) 62 (13.5) Other§ How do you describe your weight? Very underweight/slightly underweight 215 (20.3) 110 (22.9) About the right weight 562 (53.1) 244 (50.8) Slightly overweight/very overweight 281 (26.6) 126 (26.3) Have you ever been in a physical fight? Yes 566 (52.6) 259 (53.3) No 510 (47.4) 227 (46.7) Have you ever been bullied on school property? Yes 468 (43.4) 228 (47.1) No 610 (56.6) 256 (52.9) Have you ever seriously thought about killing yourself? Yes 236 (22.3) 108 (22.3) No 822 (77.7) 376 (77.7) Have you ever made a plan about how you would kill yourself? Yes 140 (13.2) 65 (13.5) No 920 (86.8) 416 (86.5) Have you ever tried cigarette smoking, even 1 or 2 puffs? Yes 291 (27.4) 143 (29.8) No 771 (72.6) 337 (70.2) Have you ever had a drink of alcohol, other than a few sips? Yes 361 (33.9) 191 (40.0) No 703 (66.1) 287 (60.0) Have you ever used marijuana? Yes 96 (9.0) 44 (9.2) No 972 (91.0) 437 (90.8) Have you ever used any form of cocaine, including powder, crack, or freebase? Yes 35 (3.3) 17 (3.5) No 1034 (96.7) 465 (96.5) Have you ever sniffed glue, or breathed the contents of spray or aerosol cans, or inhaled any paints or sprays to get high? Yes No Have you ever had sexual intercourse? Yes No
p-Value† .070
217 (36.4) 205 (34.5) 173 (29.1) .629 296 (49.8) 298 (50.2) .137 191 (32.2) 211 (35.6) 191 (32.2) .054 512 (90.6) 53 (9.4) .142 105 (18.2) 318 (54.9) 155 (26.9) .681 307 (52.0) 283 (48.0) .027 240 (40.4) 354 (59.6) .996 128 (22.3) 446 (77.7) .789 75 (13.0) 504 (87.0) .113 148 (25.4) 434 (74.6)
Association of Being Bullied in School With Suicide Ideation and Planning Among Rural Middle School Adolescents MADHAV P. BHATTA, PhD, MPHa SUNITA SHAKYA, MPHb ERIC JEFFERIS, PhDc
ABSTRACT BACKGROUND: This study examined the association of ever being bullied in school with suicide ideation (ever thinking about killing oneself) and ever seriously making a plan to kill oneself (suicide planning) among rural middle school adolescents. METHODS: Using the US Centers for Disease Control and Prevention’s Middle School Youth Risk Behavior Survey instrument, 2 cross-sectional surveys were conducted among middle school adolescents (N = 1082) in a rural Appalachian county in Ohio in 2009 and 2012. Multivariable logistic regression models assessed the relationship of ever being bullied in school with suicide ideation and planning. RESULTS: Overall, a total of 468 participants (43.1%) reported ever being bullied in school, and 22.3% and 13.2% of the adolescents surveyed reported suicide ideation and planning, respectively. In the multivariable analyses, ever being bullied in school was significantly associated with both suicide ideation (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.7-3.5) and planning (OR = 2.5; 95% CI: 1.6-3.8). CONCLUSIONS: The results show a strong association between being bullied in school and suicide ideation and planning among rural middle school adolescents. Prevention of bullying in school as early as in middle school should be a strategy for reducing suicide ideation and planning among adolescents. Keywords: adolescents; suicide; ideation; planning; bullying. Citation: Bhatta MP, Shakya S, Jefferis E. Association of being bullied in school with suicide ideation and planning among rural middle school adolescents. J Sch Health. 2014; 84: 731-738. Received on June 13, 2013 Accepted on April 13, 2014
S
uicide among adolescents and young adults is a serious public health problem in the United States. It is the third leading cause of death in the United States among adolescents aged 10-19 years. In 2010, 267 and 1659 adolescents aged 10-14 and 15-19 years, respectively, died as a result of suicide.1 Completed suicide is just the tip of the epidemiologic iceberg of suicide and suicidal behaviors among adolescents. For every completed suicide there are about 25 attempted suicides and an even greater number of individuals exhibiting nonfatal suicidal thoughts and behaviors.2 These nonfatal suicidal thoughts and behaviors are classified into the categories of suicide ideation, suicide plan, and suicide attempt.3 Suicide ideation is defined as having thoughts of engaging in behavior intended to end one’s life; suicide plan is defined as the formulation
of a specific method through which one intends to die; and suicide attempt is defined as engagement in potentially self-injurious behavior in which there is at least some intent to die.4 According to the national Youth Risk Behavior Survey (YRBS) from 2011, 15.8% and 12.8% of high school-aged adolescents (15-18 year olds) had seriously considered attempting suicide (suicide ideation) or had made a plan about how they would attempt suicide (suicide plan) during the 12 months prior to the survey, respectively.5 These statistics clearly highlight the extent to which suicidal behaviors are a public health problem among high school-aged US adolescents. Data on suicide and suicidal behaviors among middle school-aged adolescent students (1114 year olds), however, are limited.6,7
a Assistant Professor of Epidemiology, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242. bGraduate Assistant, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242. c Associate Professor of Social and Behavioral Sciences, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242.
Address correspondence to: Madhav P. Bhatta, Assistant Professor of Epidemiology, ([email protected]), College of Public Health, Kent State University, PO Box 5190, Kent, OH 44242.
Journal of School Health
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November 2014, Vol. 84, No. 11
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© 2014, American School Health Association • 731
The epidemiology of suicide and suicidal behaviors among adolescents involves a complex set of individual, family, social, and environmental risk factors.8-10 Individual level risk factors include sex; perceived body weight; gay or bisexual orientation; a history of physical or sexual abuse; mental health issues including depression; a history of aggression, impulsivity, or severe anger; and substance abuse or dependence.8-10 Family-level risk factors include parental mental health problems; family history of suicide or suicide attempts; and impaired parent-child relationship.8-10 Social and environmental risk factors include presence of firearms in the home; living outside of the home (homeless, in a corrections facility or a group home); difficulties or perceived low academic performance in school; social isolation; and presence of stressful life events such as legal or romantic difficulties or an argument with a parent.8-10 Bullying and peer victimization as contributing factors for suicide and suicidal behaviors have received greater media attention in recent years in the United States due to some highly publicized suicides among adolescents and young adults. Bullying and peer victimization in adolescents is correlated with adverse mental and physical health and engagement in other risky behaviors.11-13 Previous studies among adolescents have found that the victims of bullying are more likely be depressed or anxious, report having fair or poor health, and more likely to carry weapons and be in physical fights, and exhibit self-harming behaviors (nonsuicidal) than nonvictims.7,11-16 Moreover, several studies from various subpopulations of adolescents within and outside the United States have shown a relationship between bullying and suicide and suicidal behaviors.17-23 For example, a 2009 study among 12to 18 year-old adolescents in the United States found that peer victimized adolescents were 2.4 times and 3.3 times more likely to report suicidal ideation and a suicide attempt, respectively, than those not victimized.18 Bullying involvement in childhood and adolescence also have been shown to have a long-term influence on suicidal behaviors into adulthood. Two longitudinal studies have found that involvement in bullying in adolescence as a victim or a perpetrator is a risk factor for suicidal ideation, suicide attempts, and suicide deaths in adulthood.24,25 Bullying among the US adolescents is a prevalent phenomenon. According to the 2011 YRBS survey, 20.1% of high school students have been bullied on school property and 16.2% of students have been cyberbullied through e-mail, chat rooms, instant messaging, websites, or texting, during the 12 months before the survey.5 Involvement in bullying behaviors is higher among girls, younger (middle school) students, and rural adolescents.5,7,26 In addition, certain subgroups of adolescents such as gays and 732 •
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lesbians, and those born outside the United States are more likely to be bullied than heterosexual or native born youths.22,27 The high prevalence of bullying in adolescents and its short- and long-term consequences make bullying a significant public health problem in the United States. Therefore, understanding how bullying and peer victimization in adolescents contribute to suicide and suicidal behaviors remains an important area of research.28 The studies of adolescent suicidal behaviors in the United States have focused primarily on high school-aged adolescents. Studies examining the risk factors for suicide ideation and planning among middle school-aged adolescents, particularly in rural areas, are limited. The geographical, economic, social, and cultural uniqueness of rural communities necessitates research in rural populations, including the risk factors for suicidal behaviors among adolescents. Therefore, the purpose of this study was to examine the relationship between being bullied in school and suicide ideation and suicide planning among middle school-aged adolescents in a rural Appalachian county in Ohio.
METHODS Study Setting and Participants The study setting was a rural Appalachian county in Ohio. The Appalachian region in the United States, covering 420 counties in 13 states from New York to Mississippi, is home to approximately 25 million people and is a predominantly rural and medically underserved region. The region is categorized into 5 subregions: Northern, North Central, Central, South Central, and Southern.29 According to the US Census Bureau, the study county located in the Northern subregion of Appalachia had a population of 28,836 in 2010 and 22.2% were under the age of 18.30 As part of the Community Health Needs Assessment in 2009 and 2012, the local County Health Department and the County Family and Child First Council administered the US Centers for Disease Control and Prevention’s (CDC) Middle School YRBS31 to the students in sixth to eighth grades in the county. In the 2009 Survey, both public school systems within the county agreed to participate in the study and the only private school in the county declined to participate. In 2009, there were 771 middle school students in the public school system and 490 participated in the survey (participation rate: 63.6%).32 In 2012, there were 722 public middle school students and 599 participated in the survey (83.0%).32 For both years, nonparticipants were either the students in the private school, those who declined to participate, or were absent from school on the day of the survey. The 3-year interval between the 2 surveys ensured a minimal, if any, chance of a student repeating the survey as a middle school student in 2009 •
© 2014, American School Health Association
and 2012. To ensure anonymity of the participants, written consent from the parents and assent from the students were not obtained. However, the parents were notified in writing of the survey administration date so they could give their child oral permission to participate in the survey or opt out. Prior to survey administration, students were given the option of not participating. Participation in the anonymous survey was taken as the consent from the parents and the assent from the student.31 We analyzed the data from the 2 cross-sectional surveys to examine the relationship of being bullied in school with suicide ideation and planning. Instrument The CDC’s Middle School YRBS includes 50 questions on demographics and several categories of health-risk behaviors including tobacco, alcohol, and drug use; safety and violence-related behaviors; sexual risk behaviors; perception of weight and other health related question; bullying experience; and suicidal behaviors (ideation, planning, and attempt).
Primary outcomes of interest. The primary outcomes of interest in the study were ever having had suicide ideation and ever making a suicide plan. To measure suicide ideation, the participants were asked to provide a ‘‘yes’’ or a ‘‘no’’ response to the question: ‘‘Have you ever seriously thought about killing yourself ?’’ To measure suicide plan, the participants were asked to provide a ‘‘yes’’ or a ‘‘no’’ response to the question: ‘‘Have you ever made a plan about how you would kill yourself ?’’ Primary exposure of interest. The primary exposure of interest in the study was ever being bullied in school. The participants were asked to respond to the question: ‘‘Have you ever been bullied on school property?’’ with a ‘‘yes’’ or a ‘‘no’’ response. Potential confounders. Potential confounders selected for adjustment in the multivariate analyses were based on their known association with suicide and suicidal behaviors among adolescents from prior studies.6-8,10,24,33 The potential demographic confounders included age, grade, sex, and ethnicity/race. Ever being in a physical fight, ever smoking cigarettes, ever using marijuana, ever using cocaine, ever sniffing glue, and ever having had sex were other potential confounders measured as dichotomous variables (‘‘yes’’ or ‘‘no’’). Finally, self-perception of weight as a potential confounder was measured using the question: ‘‘How do you describe your weight?’’ with the following options for response: ‘‘about the right weight,’’ ‘‘very underweight,’’ ‘‘slightly underweight,’’ ‘‘slightly overweight,’’ and ‘‘very overweight.’’ Journal of School Health
•
Data Analysis The overall frequency distributions of the primary outcomes (suicide ideation and suicide planning) and the potential risk factors were calculated. We assessed any differences in the outcomes and exposure variables between the 2009 and 2012 survey years using Pearson’s chi-square test. We then assessed the relationship of the primary exposure (ever being bullied in school) with other risk factors/potential confounders using the Mantel-Haenszel chi-square test to adjust for survey year. To assess the individual relationship of being bullied in school and the potential confounders with suicide ideation and suicide planning, we performed univariate logistic regression analysis and report the crude odds ratio (OR) and the associated 95% confidence intervals (CIs). We performed multivariable logistic regression analysis to assess the independent effect of the primary exposure variable (being bullied in school) with suicide ideation and suicide planning, respectively, while controlling for the effect of the potential confounders. Survey year, age, sex, grade, race/ethnicity, self-perception of weight, being sexually active, being in physical fights, cigarette smoking, marijuana use, cocaine use, and sniffing glue were the potential confounders adjusted in the multivariable models. For the multivariate analyses, complete case analysis was used and the effective sample size 830. There was no significant difference between the participants excluded from the multivariate analysis due to missing predictor variable values and those included in terms of sociodemographics, bullying experience, and suicidal behaviors. Sex has been shown as a potential effect modifier of the relationship between bullying and suicidal behaviors in previous studies.24,33 Therefore, we assessed for the 2-way interaction of sex and bullying in explaining suicide ideation and planning by analyzing the significance of product term of bullying and sex in the logistic regression models.34 We report the results of the overall and sex-stratified models of the association between ever being bullied in school and suicide ideation and suicide planning. All ® data analyses were performed with SAS 9.3.1 (SAS Institute, Cary, NC).
RESULTS Sample Characteristics Table 1 presents the overall frequency distribution of the demographics, health risk behaviors, and suicide ideation and planning stratified by the year of survey. The combined total study sample size was 1082 with 487 (45.0%) and 595 (55.0%) middle school adolescents participating in the 2009 and 2012 surveys, respectively. Overall, 531 (49.2%) participants were girls and 911 (88.8%) were non-Hispanic Whites. About 90% of the respondents were 12-14 years
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© 2014, American School Health Association • 733
Table 1. Frequency Distribution of Demographic Characteristics, Suicidal Behaviors, and Health Risk Behaviors Among Middle School Adolescents in a Rural Ohio County by Year of Survey (N = 1082)∗ Total N (%) 1082 (100)
2009 N (%) 487 (45.01)
2012 N (%) 595 (54.99)
Age (years) 11-12 364 (33.6) 147 (30.2) 13 399 (36.9) 194 (39.8) 14-15 339 (29.5) 146 (30.0) Sex Girls 531 (49.2) 235 (48.5) Boys 549 (50.8) 251 (51.4) Grade 6th 320 (29.7) 129 (26.6) 7th 404 (37.4) 193 (39.7) 8th 355 (32.9) 164 (33.7) Race/ethnicity White 911 (88.8) 399 (86.5) 115 (11.2) 62 (13.5) Other§ How do you describe your weight? Very underweight/slightly underweight 215 (20.3) 110 (22.9) About the right weight 562 (53.1) 244 (50.8) Slightly overweight/very overweight 281 (26.6) 126 (26.3) Have you ever been in a physical fight? Yes 566 (52.6) 259 (53.3) No 510 (47.4) 227 (46.7) Have you ever been bullied on school property? Yes 468 (43.4) 228 (47.1) No 610 (56.6) 256 (52.9) Have you ever seriously thought about killing yourself? Yes 236 (22.3) 108 (22.3) No 822 (77.7) 376 (77.7) Have you ever made a plan about how you would kill yourself? Yes 140 (13.2) 65 (13.5) No 920 (86.8) 416 (86.5) Have you ever tried cigarette smoking, even 1 or 2 puffs? Yes 291 (27.4) 143 (29.8) No 771 (72.6) 337 (70.2) Have you ever had a drink of alcohol, other than a few sips? Yes 361 (33.9) 191 (40.0) No 703 (66.1) 287 (60.0) Have you ever used marijuana? Yes 96 (9.0) 44 (9.2) No 972 (91.0) 437 (90.8) Have you ever used any form of cocaine, including powder, crack, or freebase? Yes 35 (3.3) 17 (3.5) No 1034 (96.7) 465 (96.5) Have you ever sniffed glue, or breathed the contents of spray or aerosol cans, or inhaled any paints or sprays to get high? Yes No Have you ever had sexual intercourse? Yes No
p-Value† .070
217 (36.4) 205 (34.5) 173 (29.1) .629 296 (49.8) 298 (50.2) .137 191 (32.2) 211 (35.6) 191 (32.2) .054 512 (90.6) 53 (9.4) .142 105 (18.2) 318 (54.9) 155 (26.9) .681 307 (52.0) 283 (48.0) .027 240 (40.4) 354 (59.6) .996 128 (22.3) 446 (77.7) .789 75 (13.0) 504 (87.0) .113 148 (25.4) 434 (74.6)
