Use of a Mixed-Methods Approach to Evaluate the Implementation of Violence and Bullying Prevention Programs in Schools

Abstract

School violence and bullying are considered a serious concern worldwide. Evidence shows that applying the Health Promoting Schools (HPS) framework could be effective in reducing school bullying. While there have been significant efforts to evaluate school-based anti-bullying interventions in the world, the implementation process and the effectiveness of this framework in reducing bullying in schools have not been previously evaluated in Iran. This mixed methods study was carried out using simultaneously a cross-sectional (900 students, 104, teachers/school executive staff, and 563 parents) and qualitative study (24 policy makers and teachers/school executive staff) to examine the implementation and effect of counseling and mental health services component of the Iranian Health Promoting School (IHPS) in 2017–2018. Results revealed that there were weaknesses in the implementation of all six elements of anti-bullying programs. A lack of any clean policy toward school violence and bullying, lack of priority set by local decision makers and principals of schools, logistical problems with providing training and supplying counseling resources, limited funding, and presence of competing issues and problems facing the schools were identified as barriers to implement violence and bullying prevention programs in schools. Results also showed that there were no significant differences between non-IHPS and IHPS in students’ bullying behaviors (p = .228) and scores of leadership, the school environment, capacity, partnership, services and support, and evidence (p > .05). It is essential to revise the content and how to implement anti-bullying programs in schools.

Keywords

violence bullying students elementary school whole school approach health promoting schools

Introduction

School violence and bullying is considered a serious concern around the world due to its high prevalence (Maniglio, 2017). Bullying is defined as any unwanted aggressive behaviors in school that committed regularly and repeated multiple times by youth or group of youths against a victim who cannot easily defend him or herself (Farrington, 1993; Olweus, 1978). Bullying prevalence estimates vary by country, ranging from less than 10% to over 65%. (Attawell, 2017). Most of this variation is accounted for by differential definitions of violence, bullying, and other related terms (Garmaroudi et al., 2014). According to UNESCO figures about 30% of students reported that they have been bullied by their peers in the past month (“United Nations Educational, Scientific, and Cultural Organization. School violence and bullying: global status and trends, drivers and consequences. Paris: UNESCO, 2018”). The proportion of violence and bullying is significantly higher in some regions, including the Middle East (“United Nations Educational, Scientific, and Cultural Organization. School violence and bullying: global status and trends, drivers and consequences. Paris: UNESCO, 2018”). There is no national statistic available that outline the prevalence of violence and bullying among Iranian students. However, individual studies show that bullying is a pervasive issue among Iranian students (Garmaroudi et al., 2014; Rezapour et al., 2014).

Both bullies and victims are subject to various psychosocial problems such as depression, anxiety, suicidal thoughts and behaviors, and violent and criminal behavior (Cross et al., 2018; Terry, 2018). School bullying also has an adverse effect on student satisfaction with school, regular attendance in class and academic achievement (Arslan et al., 2012). Evidence suggests that bullying and victimization in children and adolescents may have persistent effects into adulthood (Moore et al., 2017).

Over and above the individual—level factors (such as knowledge and attitude toward bullying), there are various dimensions of the school environment such as school management policies, school safety, positive peer interactions, adult and peer support that predispose students to engage in bullying behaviors in schools (Acosta et al., 2019; Chan & Wong, 2015; Kapari, 2019; Konishi et al., 2017). Therefore, it is unlikely that this problem will be reduced without addressing the multilevel factors. Accordingly, among other models, the whole-school approach is a widely used and popular strategy for tackling school bullying all over the world (Chan & Wong, 2015). This model affirms that social, political, economic, and demographic contexts of schools have an influence on health. To reduce the violence and bullying in schools, accordingly, it is necessary to take into account the role of potential actors and factors, including students, teachers, school executive staff, parents, school management policies, and related upstream policies. Such an approach can reduce not only bullying, but also increase job opportunities, academic achievement, social skills, and the well-being of children and adolescents (Attawell, 2017). Over the last two decades, there have been significant efforts to implement and evaluate whole-school interventional programs to combat bullying behaviors. In order to operationalize the whole-school approach in violence and bullying issue, it is suggested that the education sector of countries apply a six-element strategy to reduce bullying among students (Attawell, 2017). This strategy consisted of leadership, the school environment, capacity, partnership, services and support, and evidence (Attawell, 2017). Leadership refers to develop and administer national anti-bullying policies in schools and assigning sufficient resources to address school violence and bullying. School environment focuses on making safe and inclusive learning environments; developing and enforcing school-wide policies. Capacity includes improving teachers and students’ capacity by modifying their knowledge, attitudes, and skills regarding violence and bullying. Participation involves strengthening of collaboration between sectors at the national and local level; engaging teachers and school executive staff, families, and students. Services and support emphasis on making available proper counseling and referral to health and other care for students and families and providing confidential reporting mechanisms. Evidence refers to research and evaluation of the progress of related programs (Attawell, 2017).

Considering the important role of schools in students’ health and the limited success of traditional activities focusing on health education in schools, HPS was developed in the late 1980s to empower students and staff to take actions for healthier behaviors and provide a supportive environment to a healthy lifestyle (Langford et al., 2014). Health Promoting Schools (HPS) apply a whole-school approach to implement a structured and systematic plan for the health and well-being of students (Health Promoting Schools, 2018). Iranian Health Promoting School (IHPS) established through signing a joint operating agreement between the Ministry of Education (MOE) and Ministry of Health and the Medical Education (MOHME). Following a pilot phase, this initiative was launched and implemented as an eight-component national program in 2011–2012 (Fathi et al., 2014). IHPS apply a top-down approach and schools are accredited through an internal and external audit to be ranked as a health promoting school (Yazdi-Feyzabadi et al., 2017). One of the key components of IHPS focuses on counseling and mental health services. This component aims to improve students’ mental health quality, including reducing school violence and bullying (Motlagh et al., 2011). Despite about a decade of experience in implementation of IHPS, only a few limited studies investigated the challenges and the effects of IHPS (Alikhani & Alikhani, 2014; Fathi et al., 2014), and there is not sufficient evidence to support or refuse the effectiveness of this program, particularly in addressing indicators of students’ mental health.

Reviewing the previous studies conducted on school violence and bullying in Iran highlights that these studies are often narrowly-focused and mainly addressed the individual factors, so that they cannot illustrate the status of implementation of interventions and efforts of the education sector in reducing school bullying in Iran. In order to fill this gap, in this study, we applied an ecological approach using a mixed-method to investigate the multilevel influencing factors to preventing and reducing student bullying.

This study aimed to answer the following questions:

What strategies have been formulated and implemented in the educational systems to control and reduce bullying?

How are the perceptions of students, parents, teachers, and school executive staff about elements of the whole-school approach?

What is the effect of IHPS in terms of students’ bullying and victimization rates

Materials and Methods

Because of complexity and multiple elements intended to address in this study, we conducted a partially mixed concurrent equal status design to collect data and capture the varied points of view. In partially mixed concurrent equal status design, quantitative and qualitative phases occur at approximately the same point in time, with both phases being given approximately equal weight and mixing occurring at the data interpretation stage (Powell et al., 2008).

This mixed methods study included a cross-sectional survey and an individual interview conducted in Kermanshah (west of Iran) in 2018. Although according to Iran’s constitution, education for everyone at all levels is free and primary education is compulsory, there are both public and private schools at all levels. There are social differences between students who attended private and public schools; however, there is a national curriculum for all schools to provide similar education. In Iran, the school year begins in September and ends in June. The elementary level is composed of 6 years and starts at the age of 6. Since 41 years ago, boys and girls go into separate schools, although there are no prohibitions on the teaching of female teachers at boys in elementary school. Since 2010, IHPS has been launched in Kermanshah. Out of 263 elementary schools with about 77,000 students in Kermanshah, IHPS is implementing in 87 schools. This study was approved by the Ethics Committee of Hamadan University of Medical Sciences.

Qualitative method: The qualitative data were collected in a review of documents and semi-structured, one-on-one interviews. Review of documents was conducted to examine the policies at provincial and national level to reduce the bullying among school students in Iran and consisted of reviewing the related legislation, executive orders, regulations, reports, and meeting minutes.

Interviews were conducted with six decision makers identified and selected purposively by the research team to represent key decision makers of the process of development and implementation of IHPS particular component of counseling and mental health service. These individuals were at the national (n = 1) and provincial (n = 5) level and were mapped out based on their leadership position and/or programmers relevance (i.e., head of the program). We also interviewed with 18 teachers and school executive staff (such as the principal, deputy principal, or assistant principal), intentionally selected from 12 elementary schools. To recruit teachers and school staff, principals were consulted to find out which people were deemed able to provide deep views into all aspects of IHPS implementation. Sampling was continued until saturation was reached.

All participants provided an active informed consent form before data collection. The moderator guided the interviews according to an interview guide. The interview guide (Table 1) was developed to reflect six suggested elements. In developing this instrument, we used literature in the area, related gaps and, the indicators emphasized in the checklist developed to audit the IHPS schools on the components. Interviews were conducted, by the first author, in private spaces and recorded. Each interview lasted 40 to 70 minutes. In order to ensure mutual understanding, the interviewer repeated the question or repeated their interpretation of the participants’ answers.

Table 1.

Interview Questions.

• Are there any national laws and policies about protecting students from violence and bullying in schools? If so, Please explain about it.

• How are the laws and policies applied and evaluated?

• Do other sectors at the national and local level play a role in reducing violence and bullying in schools? If yes, please explain it.
• Do teachers, staff, and principals collaborate with families and communities to reduce the violence and bullying in schools?

• Are there adequate resources to address school violence and bullying?

• What barriers are there to develop and implement the national laws and policies to reduce violence and bullying in schools?

• Are there statistics on the prevalence of bullying among students based on age, academic background, and bullying type (physical, verbal, and social)?

• Are there any school-level interventional programs to reduce violence and bullying in schools?

• Are there any evaluation procedures to evaluate the interventional programs?

• What are your suggestions to improve the effectiveness of interventional programs addressing violence and bullying in schools?

A summary, including a brief description of contents was generated for each document. Then the summary was encoded to reflect the related elements (i.e., leadership, school environment, capacity, services and support, partnership, and evidence). To evaluate the qualitative data, we applied an inductive approach and used thematic content analysis. At first, we reviewed the transcripts in their entirety and assigned codes to the emerging concepts. In order to reflect the meaning of our context, we labeled the findings with appropriate terms and extracted the dominant findings. Then we examined the relationships between the labels assigned during the open-coding step. Consequently, some labels were collapsed. The identified codes were refined until a hierarchy of conceptual codes, and sub-codes emerged. Also following the review of the transcripts obtained from interviews key themes and patterns within the data were identified and coded by two independent reviewers. Then, we organized data into accounts of six elements.

The quantitative method: The design consisted of a cross-sectional study conducted in 12 elementary schools of Kermanshah. Schools were selected applying a proportional stratified random sampling method. We defined strata by type of schools (IHPS/non IHPS), gender, and socioeconomic status of the area where the schools were located. First, we provide a list of 263 elementary schools in Kermanshah, and then, we selected randomly 12 elementary schools. Finally, a list of students in 4th to 6th grade was obtained and 445 female students and 455 male students were randomly selected to participate in the survey that they were from varied socioeconomic areas: 28% affluent areas, 39% semi-affluent regions, and 33% deprived areas. About 60% of students were selected from non-IHPS. The mean age of students participated in the survey was 11.16 (SD = 0.96) years. Written informed consent was obtained from the parents of students. Data collected during school hours and it took about 40 minutes. To fill out the questionnaires, one of the investigators (the first author) read the questions aloud and students ticked their answers in the questionnaires. In order to obtain data on the viewpoints of parents and teachers/school executive staff, we asked selected students’ parents (n = 900) and all teachers/school executive staff of the selected schools (n = 180) to participate in the survey. The response rate for students, parents, and teacher/school executive staff were 100%, 62%, and 58%, respectively.

Items of questionnaires were developed applying reviewing the existing literature and team member’s experiences. The procedure of developing the instrument has been described elsewhere (Salimi et al., 2019). Briefly, after generating the question items, we requested 15 specialists in health education and promotion and one psychologist to review the questionnaire for face and content validity. The value of CVR (content validity ratio) and CVI (Content Validity Index) were 0.8 and 0.9, respectively. Reliability of the questionnaire was evaluated through internal consistency assessments by a pilot study. Ninety elementary students, 54 parents, and 15 teachers participated in a pilot study. The Cronbach alpha coefficient of all variables ranged from .70 to .87. We used Adolescent Peer Relations Instrument (APRI) to measure the students’ engaging in bullying-victimization behaviors on a 6-point Likert scale (from 1 = never to 6 = every day). APRI was developed as a scale to measure of bully/victim behaviors in children and adolescents (Finger et al., 2008; Marsh et al., 2011). APRI consisted of 36 items, six items for each of three bullying behaviors (i.e., verbal, social, and physical) and six items for each of three victimization behaviors (i.e., verbal, social, and physical). APRI has been used in studies around the world. Cronbach’s alpha coefficient for the total score of the questionnaire has been reported to be .89 (Parada, 2000). In Iran, the validity and reliability of APRI have been approved (Hashemi et al., 2015).

Students were provided a definition of bullying and they were asked to complete the questionnaire including knowledge (11 items, for example: is the huffing considered a form of bullying?), outcome expectations (five items for example: bullying made me a stronger person) and outcome expectancies (five items for example: it is important for me that others think I am strong), perceived self-efficacy to control bullying behavior (seven items for example: I can control myself when someone harass me), and perceived situational (seven items, for example: in our school, fighting among students is common).

We asked selected students’ parents and teachers/school executive staff to complete a questionnaire to measure their knowledge (11 items) attitude toward bullying (five items) and their self-efficacy to control bullying behaviors (seven items). Moreover, teachers/school executive staff were asked to complete a questionnaire regarding the school environment (eight items), partnership (nine items), and services and supports (seven items).

We assumed that students, teachers/school executive staff, and parents’ appropriate knowledge, attitude toward bullying, outcome expectancies/expectations, and their self-efficacy to prevent bullying behavior are the capacities of education sector in reducing the bullying in schools. So, we used these variables as a proxy for the capacity component. All missing data (less than 15%) were replaced by the mean of observed values. Descriptive statistical tests were calculated for each independent and dependent variable. Differences between IHPS and non-IHPS in terms of students’ bullying and victimization behaviors, school environment, capacity, partnerships, and services and support were analyzed using t-test (two-tailed significance <.05).

Results

Since we applied triangulation in the analysis and interpretation of findings, the results obtained from qualitative and quantitative are arranged to reflect and descript the overall findings related to each of the elements. The findings of the qualitative section of this study were used to assess all six elements and results of the survey of students, parents, and teachers/school staff contributed in assessing the bullying and victimization behaviors and school environment, capacity, partnerships, and services and support elements as well as to comparing of HPS and non-HPS.

Participants in qualitative study included 24 policy makers and teachers/school executive staff (56% male and 44% female) that their average length of time working was 16.82 years (SD = 7.70).

Participants in quantitative study included 900 students, 563 parents, and 104 teachers/school executive staff. Most parents (35%) had a diploma education degree and 13.6% of mothers were employee. Average length of time working for 104 teachers/school executive staff (56% male and 44% female) was 15.65 years (SD = 7.50).

Leadership

Reviewing the documents showed that Iran had no single anti-bullying policy to outline procedures for preventing bullying among students. We identified that in 2000, school disciplinary regulations have stipulated that any punishment by teachers/school staff is prohibited, and the punishment must be carried out step by step beginning with warning and notice in private, followed by oral warning in the presence of other students, change of class, written notice to the student’s parents, temporary expulsion from the school with the parents’ notice for 3 days and finally transfer to another school. Moreover, findings of reviews revealed that only limited funding has been allocating to programs addressing the prevention of violence and bullying in schools, that resulted in restricting the schools activates to short term and occasionally educations. Expression of participants and reviewing the documents showed that recently two initiatives have been launched by MOE to assess the needs regarding social harms among students The first one called “Payesh” assesses the situation of six types of social harms, including poverty, divorce, bad parenting, addiction, bullying, and suicide at the school level. All schools across the country have been asked to report on these six issues. In comparison with the other five issues, key decision makers at province level stated that bullying is ranked as one of the most important needs in Kermanshah. The second national initiative called “NAMAD” has been started since 2018. This intersectional project aims to protect students against the negative effects of social harms through screening and empowering them. Because the program is new in Kermanshah, there are no identified outcomes yet. From the viewpoint of the decision makers, one of the obstacles to developing and implement the anti-bullying policies was that bullying issue is integrated into other programs and there is not a stand-alone plan addressing school violence and bullying. This resulted in a lack of practical guidelines and adequate funding to prevent bullying in schools.

The majority of teachers/school staff mentioned that there was no regulation to control and reduce bullying among students, and schools act on their own manners:

“We do not have a specific regulation on students’ bullying. If bullying is superficial, we will use advice, and if it is acute, we will refer the student to counseling” (teacher/male).

“In my opinion, every school copes with bullying in its own way. For example, some schools use punishment, some other schools use education and counseling. In our school, this is done through the broadcast of happy songs during break time and celebrations” (teacher/female).

Partnership

Overall, our findings revealed weak coordination among key stakeholders of the MOE and other sectors such as health, and social services. NAMAD is the only intersectional program in this area. This program was developed to co-operate with nine varieties of governance systems, including the MOE, MOHME, ministry of cooperative labor and social welfare, the Police, the Imam Khomeini Relief Committee (IKRC), and the Barekat foundation. However, it seems that cooperation is a week and the most important role is played by the MOE and the judiciary. Decision makers emphasized the judicial’ role in funding and coordination with other sectors. In reducing the school violence and bullying, an important dimension of partnerships is the active involvement of students, teachers, families, and community. The review of documents showed that the most important role is played by the MOE and the judiciary. Decision makers emphasized the judicial’ role in funding and coordination with other sectors. In reducing the school violence and bullying, an important dimension of partnerships is the active involvement of students, teachers, families, and community.

“Some school staff and teachers partially implement the anti-bullying program, and the rest of the school employees do not have much collaboration.” (School staff/male).

Capacity

Generally, the findings of our study showed that limited activities have been done to provide training and support for students, families, and teachers/school staff to ensure they have better knowledge about bullying, favorable attitude toward bullying, and skills to counter bullying.

In order to increase the capacity of the education system to reduce the school violence and bullying, decision makers at province level stated that recently four experienced and enthusiastic teachers have been sent for refresher and/or training courses regarding ways of control anger and bullying and eventually they provide workshops for other teachers, parents, and students. This finding was somewhat supported by the results obtained from the survey. The survey revealed poor students’ knowledge of bullying (mean score: 6.33 ± 2.22 out of 11), favorable attitude toward bullying behavior (mean score of outcome expectation: 18.46 ± 4.54 and outcome expectancies: and 12.51 ± 4.37, out of 25), and a relatively low self-efficacy (mean score: 24.69 ± 7.05 out of 35). Assessing knowledge, attitude, and self-efficacy of parents and teachers/school staff showed that they had relatively poor knowledge about bullying (parents’ mean score: 7.49 ± 1.91; teachers school staff’ mean score: 7.17 ± 2.01 out of 11), favorable attitude toward bullying behavior (parents’ mean score: 32.29 ± 5.41; teachers school staff’ mean score: 30.53 ± 4.85, out of 40), and relatively low self-efficacy to control their childs/students’ bullying (parents’ mean score: 20.17 ± 3.31; teachers school staff’ mean score: 19.60 ± 3.16, out of 25).

School Environment, Services, and Support

Decision makers at the province level stated that there is a counseling center in each educational district that provides free counseling services addressing students’ psychological needs. If necessary, students are referred to more specialized centers. However, they believed that due to the lack of a proper referral system, many referral cases are not tracked. Moreover, based on the results of the survey, it seems that the majority of students were not aware of the counseling center and the services offered. Teachers/school staff widely expressed concerns about limited education and counseling services at the school level. They believed that factors such as inadequate funding, restricted time, a large population of students, and lack of skilled educators and counselors contribute to this challenge.

“Most of the education budget is spent on something else, and no particular attention is paid to bullying” (school staff/ male).

Decision makers and teachers/school staff believed that beyond school environment, there are a number of contextual variables—such as the high rate of unemployment, poverty, and vulnerability to poverty—cause the high rate of violence and bullying in Kermanshah:

“There is usually more violence and bullying in families with problems (economic and relationship issues), and these families themselves have abundant violence which is manifested in the student’s behavior” (Teacher/female)

The results of the survey confirmed the finding of qualitative data. In that way, the lack of attention to providing proper counseling services and a supportive environment were reflected in students’ perceived situational. The survey showed that students perceived their school environment as relatively unsupportive (mean score: 18.80 ± 4.67 out of 35).

Evidence

Decision makers at both provincial and national level noted that there are no statistics regarding the rate of bullying among students. They believed that the “Payesh” system does not provide comprehensive data to monitor and follow the rate of bullying among students. They stated that the payesh system just reports the rate of bullying in comparison with other social harms. Regarding Namad system, decision makers believed that if it implemented throughout the country, may be helpful to provide valid evidence of rate and effectiveness of activity addressed the school violence and bullying.

In addition, reviewing the documents revealed that there are only limited data on types, causes, nature, and impact of school violence and bullying interventions. This little evidence was obtained from individual studies that have been conducted across the country. These findings reflect that education system lacked the well-designed interventions and rigorous monitoring and evaluation to track progress and impact of activities in the area of school violence and bullying.

Assessing the Effects of IHPS

Assessing the effects of IHPS on students’ engagement in bullying showed that there was no significant difference between students’ bullying behaviors of HPS and non-HPS (p = .228). In contrast, it was shown that rate of victimization in students of non-HPS schools was significantly higher than that of students of HPS (p < .001). The results showed that there was no significant difference between HPS and non-HPS in terms of elements of the whole school approach (p > .05) (Table 2).

Table 2.

Survey of the Elements of the Whole School Approach and Bullying/Victimization in Schools.

Variables		Total schoolStudents N = 900Teachers/school staff N = 104Parents N = 563	HPSStudents N = 296Teachers/school staff N = 41Parents N = 161Mean ± SD	Non-HPSStudents N = 604Teachers/school staff N = 63Parents N = 402Mean ± SD	t-testsig
School environmen (perceptions of students)	Perceived situational	18.80 ± (4.671)	19.01 ± (4.903)	18.69 ± (4.553)	0.342
School environment (perceptions of teachers and school staff)		27.04 ± (3.501)	26.82 ± (3.688)	27.21 ± (3.369)	0.581
Capacity of students	Knowledge	6.33 ± (2.225)	6.58 ± (2.232)	6.21 ± (2.213)	0.070
	Outcome expectancies	12.51 ± (4.371)	12.83 ± (4.503)	12.35 ± (4.299)	0.120
	Outcome expectations	18.46 ± (4.542)	19.42 ± (4.174)	18.00 ± (4.644)	0.000
	Self-efficacy	24.69 ± (7.053)	25.20 ± (7.015)	24.44 ± (7.063)	0.133
Capacity of teachers	Knowledge	7.17 ± (2.017)	7.13 ± (2.074)	7.20 ± (1.989)	0.862
	Attitude	30.53 ± (4.857)	30.73 ± (5.047)	30.37 ± (4.745)	0.710
	Self-efficacy	19.60 ± (3.167)	19.49 ± (3.245)	19.68 ± (3.132)	0.765
Capacity of parents	Knowledge	7.49 ± (1.910)	7.48 ± (1.873)	7.50 ± (1.927)	0.916
	Attitude	32.29 ± (5.411)	32.55 ± (5.101)	32.19 ± (5.538)	0.475
	Self-efficacy	20.17 ± (3.317)	20.28 ± (3.380)	20.12 ± (3.294)	0.519
Partnerships (perceptions of teachers and school staff)		23.46 ± (6.878)	22.24 ± (7.123)	24.43 ± (6.578)	0.113
Services and support (perceptions of teachers and school staff)		15.95 ± (4.584)	16.16 ± (4.940)	15.79 ± (4.321)	0.691
Physical bullying		11.28 ± (6.277)	10.66 ± (5.430)	11.59 ± (6.636)	0.026
Verbal bullying		10.47 ± (4.997)	10.15 ± (4.186)	10.63 ± (5.346)	0.147
Social bullying		10.56 ± (5.013)	10.66 ± (4.331)	10.51 ± (5.319)	0.683
Physical victimization		12.49 ± (6.423)	11.18 ± (5.547)	13.13 ± (6.723)	0.000
Verbal victimization		14.38 ± (7.000)	13.29 ± (6.245)	14.92 ± (7.287)	0.001
Social victimization		12.06 ± (6.425)	10.85 ± (5.288)	12.65 ± (6.842)	0.000
Overall bullying		32.31 ± (14.643)	31.47 ± (12.178)	32.73 ± (15.704)	0.228
Overall victimization		38.89 ± (18.081)	35.32 ± (15.576)	40.65 ± (18.958)	0.000

Discussion

We applied triangulation in the analysis and interpretation of findings by mapping quantitative and qualitative results. The qualitative findings derived from interviews and reviewing document were supported and triangulated by quantitative results obtained from the survey among students, decision-makers, teacher/school staff, and parents. The findings offer insight into the implementation and effects of violence and bullying prevention programs in schools in Iran. Mixed methods research allowed us to consider several information sources and to provide a comprehensive picture of the issue.

We found that there were weaknesses in the implementation of all six elements of anti-bullying programs. A lack of any clean policy toward school violence and bullying, lack of priority set by local decision makers and principals of schools, logistical problems with providing training and supplying counseling resources, limited funding, and presence of competing issues and problems facing the schools were identified as barriers to implement violence and bullying prevention programs in schools in Iran. The engagement of a wide variety of stakeholders with different priorities and area of knowledge make difficult to implement an integrated plan to reduce the school violence and bullying.

Formulating and implementing anti-bullying national laws and policies is an essential part of leadership. Many countries have laws and policies to control and reduce bullying, such as the National Secure Schools Framework (NSSF) in Australia, the Safe School Law in Peru, and the Mexican Children and Adolescents’ Rights Protection Act. However, some other countries, especially developing ones, the reduction of bullying among students has been rarely addressed by policymakers (Attawell, 2017; Wei & Kutcher, 2012). The findings of our qualitative study showed that only one clause in the education legislation addressed this issue and recent measures in this area were mainly focused on assessment and screening. Regardless of policymakers’ role, schools alone cannot solve the mental health problems of students and active participation and responsibilities of potential stakeholders including parents and students play an important role in the improvement of the social behavior of students (Cushman & Clelland, 2011). Indeed, the active participation of students and parents in designing, implementation, and evaluation of school-based anti-bullying programs may be accompanied by benefits such as increased satisfaction and capacity, motivation, ownership, and sustainability of the program. It is essential for families to cooperate with schools to prevent and control bullying. Parents can influence their children by modeling positive social behaviors, advising on appropriate responses to bullying and encouraging asking for help (Lester et al., 2017). Despite the importance of parental roles, our results showed that many parents lacked accurate information about bullying and self-efficacy in coping with bullying situations and had a desirable attitude to bullying behaviors. From this view of point, children who bully may be considered as strong.

In our study, the score of partnership in coping with bullying was not satisfactory from the perspective of participants. Most of them believed that in many cases parents did not consider themselves responsible for controlling and reducing the bullying among students. Along with the education system’s failure to facilitate the interactive process of participation, this finding can be explained, at least to some extent, by this fact that parents did not have enough capacity to engage in anti-bullying programs.

Salimi et al. study showed that bullying and victimization behaviors are high among elementary students of Kermanshah. This study reported that about 40% and 76% of elementary students were involved in bullying and victimization behaviors, respectively (Salimi et al., 2019). Given the nature of violence and bullying problem and vast adverse effects of bullying and victimization behaviors, creating intensive participation and collaboration with other sectors at the national and local level are vital to address the issue. Teachers and school staff’ knowledge, beliefs/attitudes, and self-efficacy/skills are the important aspects of schools capacity to reduce the violence and bullying behavior among students. Evidence acknowledges that teachers and school staff’s capacity to management and response to students’ bullying behaviors have a critical role in creating a supportive learning environment (Pedro, 2012; Veenstra et al., 2014). Consisted with previous studies (Bauman & Del Río, 2005; Lester et al., 2018; Warwick et al., 2009), results of the current study showed that teachers and school staff’ knowledge regarding bullying was poor, their attitudes toward controlling bullying were relatively unfavorable, and their self-efficacy in coping with students’ bullying behavior was relatively low. Teachers and school staff’ lack of information, undesirable attitude low self-efficacy to control the bullying situation can result in confusion and normalize or minimize bullying behaviors. Providing training for teachers and school staff on normal students’ development is critical to improving their understanding of the differences between normal behavior and problematic behavior.

Interestingly, the results of influencing factors in teachers and school staff were somewhat reported by studied students. That way, the results of our study showed that students’ knowledge about definition, types, and consequences of bullying was poor. Also, they had a relatively positive attitude toward bullying and low self-efficacy to control their behaviors in bullying situations. For example, most students believed that bullying makes them more popular and powerful and it was very important for them. Most students believed that they were not able to control their anger in the face of bullying situations and exhibited countermeasures. The results of studies show that high self-efficacy plays an important role in coping with bullying (Marchant, 2017; Yadav, 2016). Promoting students’ knowledge and changing their attitudes toward bullying can lead to positive changes in their behavior (Zareipour et al., 2017). Many programs and initiatives are underway to improve the capacity of students and teachers worldwide. For example, in Norway, the Zero program has been implemented to guide teachers and school staff to identify bullying and manage the bullying behaviors of students (Roland et al., 2010). The KiVa program in Finland focuses on investing in teachers and school staff through training them before and during the service so that they can take the necessary action (Attawell, 2017). Lee et al in their meta-analysis reported that school-based anti-bullying programs involving training in emotional control and establishing school policy on bullying were more effective than studies that did not involve these strategies (Lee et al., 2015). Based on policymakers’ expression, these kinds of programs are very new in Iran and a limited number of teachers and school staffs are provided training programs regarding emotional and social skill such as how to control anger. Lack of strong predisposing factors (i.e., knowledge, attitude, and self-efficacy) had led to inadequate support in a bullying situation and engagement of teachers and school staff engagement in anti-bullying activates including playground supervision.

Our quantitative results showed that students believed that physical fighting among students was common in the school environment without effective intervening of teachers and school staff. Flaspohler et al. (2009) showed that students with low levels of support from teachers are more likely to be victims of bullying and bullies have the least relationship with their school and teachers.

While providing services such as confidential and effective reporting, counseling services, and referral mechanisms are needed to address school bullying, our qualitative and quantitative findings revealed that easily-accessible and child-sensitive counseling services were not offered in schools.

Participants in this study described the inadequate funding, restricted time, large population of students, and lack of skilled educators and counselors as barriers to providing effective counseling services. In this regard, various programs are being implemented successfully in the world, such as the 24-hour free telephone line for children and teenagers in Kenya and the Netherlands and report boxes of bullying in Malawi (Attawell, 2017). It is revealed that the existence of an advisor to coping with bullying is essential in every school and the counseling provided by school teachers and employees does not have an adequate impact on bullying (Bauman et al., 2008; Foody et al., 2018).

Although evaluation of complex programs, such as school-based one, is difficult and complex, we tried to evaluate one out of eight component of IHPS through comparison the rate of bullying and victimization in HPS and non-HPS. Our results revealed that there was no significant difference between students of HPS and non-HPS in bullying. However, the rate of victimization in non-HPS was significantly higher than that in HPS. Consistently, some previous studies have shown that the whole school approach, which is often used in the form of an HPS, has failed to produce the desired outcomes (Kochaki et al., 2011; McIsaac et al., 2017; Toolabifard et al., 2016; Quirke, 2015). In this regard, studies in Iran also showed that the program of HPS did not have any effect on students’ mental health (Kochaki et al., 2011; Zareipour et al., 2017).

The effectiveness of the programs depends largely on the fidelity of the implementation framework. Fidelity defined as adherence to program content and the degree to which a program is delivered as intended. Due to a large number of interacting institutional components, the school is a complex setting and hence school-based interventions are complex. This character of programs often leads to poor implementation. Findings of this study indicated that all six suggested elements have been implemented poorly and there were no significant differences between HPS and non-HPS in terms of suggested elements. These findings are consistent with some previous studies. For example study by John-Akinola and Nic-Gabhainn (2014) showed that students’ partnership in school was not significantly different between HPS and non-HPS, while HPS are expected to have a higher level of student partnership.

This study was the first in Iran to systematically evaluate the implementation and effects of violence and bullying prevention programs in schools. Given that there is limited evidence on the status of school bullying and effective intervention to address this issue in Iran, the findings of this study may be helpful to inform policy making on this issue.

There were some limitations for this study. First, this study used a self-reported measure to collect data on students’ bullying behaviors and has the risk of overestimating or underestimating the results. Second, our sample was restricted to grades 4 to 6 students that limit the ability to generalize results to other age groups of students.

Conclusion

Given the high prevalence of school bullying and its outcomes, it is essential to design, implement and evaluate an anti-bullying program in Iran based on the elements of the whole school approach. The results of this study showed that there was no significant difference between HPS and non-HPS in bullying and whole school approach’ elements. It is necessary to revise the content and how to implement this plan to achieve more effectiveness.

Footnotes

Acknowledgements

We would thank sincerely the staff in the Department of Education of Kermanshah, all teachers, school staffs, parents, and elementary school students who participated in this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is part of the PhD thesis, which was approved and supported by the Research and Technology Deputyship of Hamadan University of Medical Sciences (30.01.2018: No. 9611107173).

ORCID iD

Nooshin Salimi

Author Biographies

Nooshin Salimi, recently has completed her PhD in Health Education and Promotion at the Hamadan University of Medical Sciences. Her research interests include health issues of adolescents and youth including mental health and healthy eating.

Akram Karimi-Shahanjarini, PhD, is a Professor in Health Education at the Department of Public Health, School of Public Health, Hamadan University of Medical Sciences. She got her Ph. D degree from Teheran University of Medical Sciences. Her research interests focus on developing and evaluating interventions to promote health behaviors, measurements in health behaviors, and systematic reviews.

Forouzan Rezapur-Shahkolai, PhD, is an Associate Professor in Health Promotion with a specialty in Safety Promotion and Injury Prevention at Hamadan University of Medical Sciences, Hamadan, Iran. She did her Ph.D. at Karolinska Institutet, Stockholm, Sweden. She was involved in different research projects mostly on safety, unintentional, and intentional injury areas, including violence both in adults and in school students.

Behrooz Hamzeh, PhD, is an Associate Professor in Health Promotion at Kermanshah University of Medical Sciences, Kermanshah, Iran. His research interests include violence, mental health and well-being, substance use, and non-communicable diseases. He has published widely in the field of mental health and young people.

Ghodratollah Roshanaei, PhD, is an Associate Professor in Biostatistics at Hamadan University of Medical Sciences, Hamadan, Iran. He got his Ph.D. degree from Tarbiat Modares University, Tehran. He is head of Modeling of Noncommunicable Disease Research Center. His research interests are in survival analysis and longitudinal data.

Mohammad Babamiri, PhD, is an Assistant Professor in psychology at Hamadan University of Medical Sciences. He is interested in all aspects of human factors and ergonomics, particularly those which are related to cognitive and psychological issues such as job stress, bullying, burnout, and workload.

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