EDITORIALS
Prevention of bullying-related morbidity and mortality: a call for public health policies
Jorge C SrabsteinI,* ; Bennett L LeventhalII
IChildren's National Medical Center, Department of Psychiatry and Behavioral Sciences, 111 Michigan Avenue, Washington, DC, 20010, United States of America
IINathan S Kline Institute for Psychiatric Research, Orangeburg, USA
Bullying is a major public health problem that demands the concerted and coordinated time and attention of health-care providers, policy-makers and families. Evolving awareness about the morbidity and mortality associated with bullying has helped give this psychosocial hazard a modest level of worldwide public health attention.1-5 However, it is not enough.
Bullying is a multifaceted form of mistreatment, mostly seen in schools and the workplace. It is characterized by the repeated exposure of one person to physical and/or emotional aggression including teasing, name calling, mockery, threats, harassment, taunting, hazing, social exclusion or rumours.6,7 A wide range of bullying prevalence has been documented among students and in labour forces worldwide.5,8
A growing body of research is highlighting the range of significant morbidities affecting individuals involved in bullying whether as bystanders, bullies and/or victims. Students involved in bullying are at a significant risk of experiencing a wide spectrum of psychosomatic symptoms, running away from home, alcohol and drug abuse, absenteeism and, above all, self-inflicted, accidental or perpetrated injuries.1,2 The consequences of bullying extend into adulthood, as there is evidence of a significant association between childhood bullying behaviour and later psychiatric morbidity.3 Moreover, adults bullied in the workplace are prone to suffer from a variety of health risks, including depression and cardiovascular problems.4
Multiple reported cases of death associated with bullying have led to legislative initiatives around the world.9 Enacted legislation has placed the responsibility of prevention on the shoulders of organizational (educational or workplace) management with no apparent input expected from the public health sector.10 As we recognize the health and safety hazards linked to bullying across the lifespan, we are challenged with the need to develop health policies for bullying prevention. The school milieu is functionally an occupational environment, where future employees and employers develop their physical, cognitive, social, moral and ethical skills. Moreover, students and workers are exposed to similar physical and psychological hazards. This notion is reflected in the Swedish Work Environment Authority Act which is focused on preventing ill-health and accidents in the workplace. This statute considers students, prison inmates and members of the armed forces as employees.11 Some may argue that the approaches for eradicating school bullying should be different from those addressing bullying at the adult workplace. Although there are differences in the developmental and legal status of students and adult workers, as well as in the socio-ecological aspects of schools and industry, both environments may benefit from the same approach to prevent bullying and its associated health risks.
The scientific literature suggests that preventative interventions should include whole community awareness campaigns about the nature of bullying and its dangers.12 Efforts should also be made to enhance the emotional and organizational environments in school and work settings by promoting sensitivity, mutual respect and tolerance to diversity while prohibiting bullying. Bullying incidents should be reported to organizational leadership which should ensure a consistent and organized response, including support of the victim and counselling for the perpetrator by sensitizing him or her to the harm they have inflicted. Referral to appropriate health services will be required to alleviate the physical and emotional consequences of bullying, as well as to help those who continue bullying behaviour in spite of organizational counselling. The efficacy of this public health approach should be monitored by a periodic assessment of the prevalence of bullying-related morbidity and mortality.
Policy-makers could create advisory groups to provide recommendations and develop guidelines for a whole-community strategy for the prevention, intervention and treatment of bullying-related public health risks.
Bullying prevention strategies can help governments to ensure safe and healthy learning and working conditions, while reducing expenditure on bullying-related injuries and ill health. Furthermore, they can reduce disrupted student achievement and worker ineffectiveness, due to absenteeism; expenses in social welfare/benefits and other costs related to loss of productive workers at a premature stage. Fewer "dropouts" linked to bullying mean a healthier, happier and more productive population.
References
1. Gini G, Pozzoli T. Association between bullying and psychosomatic problems: a meta-analysis. Pediatrics 2009;123:1059-65. doi:10.1542/peds.2008-1215
2. Srabstein J, Piazza T. Public health, safety and educational risks associated with bullying behaviors in American adolescents. Int J Adolesc Med Health 2008;20:223-33.
3. Sourander A, Klomek AB, Niemelä S, Haavisto A, Gyllenberg D, Helenius H et al. Childhood predictors of completed and severe suicide attempts: findings from the Finnish 1981 Birth Cohort Study. Arch Gen Psychiatry 2009;66:398-406. doi:10.1001/archgenpsychiatry.2009.21
4. Kivimäki M, Virtanen M, Vartia M, Elovainio M, Vahtera J, Keltikangas-Järvinen L. Workplace bullying and the risk of cardiovascular disease and depression. Occup Environ Med 2003;60:779-83. doi:10.1136/oem.60.10.779
5. European working conditions survey: violence, harassment and discrimination in the workplace. Dublin: European Foundation for the Improvement of Living and Working Conditions; 2005. Available from: http://www.eurofound.europa.eu/docs/ewco/4EWCS/ef0698/chapter4.pdf [accessed 5 May 2010] .
6. Olweus D. Norway. In: Smith PK, Morita Y, Junger-Tas J, Olweus D, Catalano R, Slee Pl, editors. The nature of school bullying: a cross-national perspective, 1st edition. London: Routledge; 1999. p. 31.
7. Einarsen S, Hoel H, Zapf D, Cooper CL. The concept of bullying at work. In: Einarsen S, Hoel H, Zapf D, Cooper CL, editors. Bullying and emotional abuse in the workplace: international perspectives in research and practice, 1st edition. London: Taylor and Francis; 2003. p. 6.
8. Due P, Holstein BE, Soc MS. Bullying victimization among 13 to 15-year-old school children: results from two comparative studies in 66 countries and regions. Int J Adolesc Med Health 2008;20:209-21.
9. Bernasconi C. Chile schools to get state help to fight bullying, The Santiago Times, 13 October 2008. Available from: http://www.santiagotimes.cl/index.php?option=com_content&view=article&id=14859: CHILE-SCHOOLS-TO-GET-STATE-HELP-TO-FIGHT-BULLYING&catid=31:editorial-and-opinions&Itemid=143 [accessed 6 May 2010] .
10. Srabstein JC, Berkman BE, Pyntikova E. Antibullying legislation: a public health perspective. J Adolesc Health 2008;42:11-20. doi:10.1016/j.jadohealth.2007.10.007
11. The Work Environment Act, Chapter 1, Purpose and Scope of the Act, Section 3. Stockholm: Swedish Work Environment Authority; 2009. Available from: http://www.av.se/inenglish/lawandjustice/workact/chapter01.aspx [accessed 5 May 2010] .
12. Srabstein J, Joshi P, Due P, Wright J, Leventhal B, Merrick J et al. Prevention of public health risks linked to bullying: a need for a whole community approach. Int J Adolesc Med Health 2008;20:185-99.
* Correspondence to Jorge C Srabstein (jsrabste@cnmc.org).