Abstract
Background:
The relationship between childhood bullying and healthcare adherence in adulthood has been rarely studied, but one published study suggests that being bullied in childhood is related to lower healthcare adherence among adolescents. This previous study examined few adherence variables and was limited to youths.
Aims:
In this study, we assessed five variables for childhood bullying as related to seven measures of healthcare adherence among a cohort of adult primary care outpatients.
Method:
Using a cross-sectional, self-report survey methodology in a sample of 263 consecutive internal medicine outpatients, we examined five aspects of bullying and seven aspects of adherence with general healthcare.
Results:
Being a victim of bullying, type of bullying (emotional, physical), number of years bullied and number of bullies each evidenced no statistical relationships with healthcare adherence. However, being a bully demonstrated several statistical relationships with healthcare adherence, indicating less adherence to instructions provided by healthcare professionals.
Conclusions:
Despite all of the deleterious psychological and physical effects of being bullied in childhood, there was no evidence that non-adherence with healthcare in adulthood is one of them. In contrast, bullies evidenced several areas of reduced healthcare adherence.
Introduction
Victims of bullying may suffer a variety of psychological and somatic sequelae. With regard to psychological sequelae, victims may incur social difficulties, internalizing symptoms, anxiety, depression, suicidal ideation or attempts, eating disorders and multiple psychiatric disorders (Sansone & Sansone, 2008) as well as greater rates of treatment for psychiatric disorders (Sourander et al., 2009). Victims of bullying may also demonstrate subsequent behavioral problems (Arseneault et al., 2006), including smoking (Zaborskis & Vareikiene, 2008), borderline personality symptoms (Sansone, Lam, & Wiederman, 2010), difficulty in controlling anger (Hampel, Dickow, Hayer, & Petermann, 2009) and externalizing behaviors such as aggression, delinquency, hyperactivity and alcohol and substance misuse (Berry-Krazmien, 2007; Campfield, 2009; Kim, Leventhal, Koh, Hubbard, & Boyce, 2006).
With regard to somatic sequelae, victims may incur sore throats, cough, colds, poor appetite, headaches, sleep disturbances, abdominal pain, musculoskeletal pain, dizziness and fatigue and overall increased somatic symptoms (Nixon, Linkie, Coleman, & Fitch, 2011) as well as greater medication use (Sansone & Sansone, 2008) and possible alterations in neurohormonal functioning (Knack, Jensen-Campbell, & Baum, 2011). The preceding findings suggest that being bullied in childhood has diffuse and significant effects on emotional and physical functioning (Allison, Roeger, & Reinfeld-Kirkman, 2009), with possible outcomes being poor levels of overall psychological well-being and social adjustment (Rigby, 2003).
In contrast to the findings described thus far, the relationship between bullying or being bullied in childhood and adherence with healthcare in adulthood has been rarely studied. Indeed, we were able to locate only two studies in this regard. In the first, Nogueira and Zambon (2013) reported that being a bully was associated with follow-up non-adherence at a specialized outpatient clinic for weight loss for obese children and adolescents in Brazil. In the second study of 167 youths in the United States with type 1 diabetes, Storch et al. (2006) reported that being bullied, which was defined for participants as repeated exposure to a negative action on the part of one or more peers in response to diabetes self-management tasks, was associated with non-adherence with both glucose testing and dietary management. Note that both studies entailed youths as well as narrow clinical populations. In addition, outcome variables for adherence were limited in nature.
Given the diffuse psychological and somatic effects of being bullied in childhood, examination of the relationship between being bullied in childhood and adherence with healthcare in adulthood appears salient. For example, if being bullied in childhood affects a sense of self-worth in adulthood that culminates in an indifference to securing healthcare, such a relationship has relevance to clinicians for querying and managing patient non-adherence with healthcare in the medical setting.
In this study, we examined five variables of bullying in childhood in relationship to three measures (seven variables) of healthcare adherence in adulthood in a primary care sample of internal medicine outpatients. We hypothesized that having been bullied in childhood would be negatively related to healthcare adherence in adulthood.
Method
Participants
Participants in this study were men and women, aged 18 years or older, being seen at an internal medicine outpatient clinic for nonemergent medical care in a US clinic staffed predominantly by residents in the Department of Internal Medicine. We excluded individuals with compromising medical (e.g. debilitating pain), intellectual (e.g. mental retardation), cognitive (e.g. dementia) or psychiatric symptoms (e.g. psychotic) of a severity to preclude the candidate’s ability to successfully complete a survey (n = 5; two with vision impairment, two with cognitive impairment and one with mental retardation).
At the outset, 354 individuals were approached and 300 agreed to participate (84.7%). As for the 54 individuals who did not participate, 17 stated they were feeling too ill to participate, 19 indicated not enough time, 14 stated ‘don’t like surveys’, 3 stated ‘pleased with current care’ (?) and 1 stated ‘too angry’ to participate. Of the 300 participants, 263 completed the items for analysis. The effective sample thus consisted of 207 (78.7%) women and 56 (21.3%) men, ranging in age from 18 to 82 years (M = 45.33, standard deviation (SD) = 13.67). Most participants were White (85.2%); however, 8.7% of participants were African-American, 2.3% Native American, 0.4% Asian, 0.8% Hispanic and 2.6% ‘Other’. With regard to educational attainment, all but 5.7% had at least graduated high school, yet only 9.9% had earned at least a bachelor’s degree.
Measures
The survey consisted of three sections. The first section was a demographic query, followed by assessments for bullying or being bullied and healthcare adherence.
Bullying assessment
The bullying assessment consisted of an author-developed measure to assess five aspects of bullying in childhood, beginning with, ‘When you were growing up, were you ever a victim of bullying?’ with yes or no response options. If respondents endorsed bullying, they were then asked about: (1) the type of bullying (physical and/or emotional), (2) number of years bullied and (3) number of individual bullies during this time period. Finally, participants were asked if while growing up they had been a bully, with yes or no response options.
Healthcare adherence assessment
The healthcare adherence assessment consisted of three measures related to adherence to medical treatment. The first measure in this section was a one-item author-developed query, ‘In general, how conscientious are you about following through with medical treatment?’ with Likert-style response options from 1 (very conscientious) to 5 (not conscientious at all). We recoded responses to this item such that a higher score was indicative of higher adherence.
The second measure in this section was a 5-item author-developed query about various healthcare behaviors (e.g. regular dental check-ups, arrival to doctors’ appointments on time, completion of laboratory work, adherence with exercise instructions, and adherence with diet instructions), with 5 Likert-style response options from 0 (never) to 4 (always) as well as ‘not applicable’.
The third measure in this section was the Medical Outcomes Study (MOS) General Adherence Items (Hays, n.d.). The MOS explores general medical adherence with ‘my doctor’ over the past 4 weeks and consists of five items related to adherence with physician recommendations: I had a hard time doing what the doctor suggested I do; I followed my doctor’s suggestions exactly; I was unable to do what was necessary to follow my doctor’s treatment plan; I found it easy to do the things my doctor suggested I do; Generally speaking, how often during the past 4 weeks were you able to do what the doctor told you?
The scale has six Likert-style response options from 1 (none of the time) to 6 (all of the time). In initial examination of the psychometric properties of the scale, Hays (n.d.) reported that the five general adherence items were well distributed, the internal consistency reliability of the scale was α = .81, and during a 2-year period, adherence measurements were fairly stable. In this study, after recoding two of the items on the MOS, scores were summed across items to comprise a single composite score.
From these three assessments, we subsequently analyzed seven variables: overall conscientiousness with healthcare, the five items of various healthcare behaviors and the MOS composite score. We retained the five items of the various healthcare behaviors to detail these behaviors in analyses.
Procedure
During clinic hours, one of the authors (R.J.B.) positioned in the lobby of the outpatient clinic, approached incoming patients following registration and informally assessed exclusion criteria (i.e. exclusions were based upon observations by the recruiter, not through objective screening). With potential candidates, the recruiter reviewed the focus of the project and then invited each to participate. Each participant was asked to complete a five-page anonymous survey, which took about 10 minutes. Surveys were completed onsite in the lobby. Participants were asked to place completed surveys into sealed envelopes and then into a collection box in the lobby. This project was reviewed and exempted by the institutional review boards of the sponsoring hospital and the local university. Completion of the survey was assumed to be implied consent, which was explained to participants on the cover page of the survey.
Results
Of the 263 respondents, 124 (47.1%) indicated having been a victim of bullying in childhood: 64 indicated that the bullying was emotional in nature, 7 indicated physical bullying, 50 indicated both emotional and physical bullying, and 3 did not complete the item. The number of years of being bullied ranged from less than a year to 12+ years, with an average of 5.75 years (SD = 3.67 years). Similarly, the number of different bullies spanned from 1 to 6+, with an average of 3.39 (SD = 1.76). Of the 263 respondents, 24 (9.1%) reported having been a bully during childhood.
Due to the relatively large number of variables, we performed a large set of analyses. Concern over Type I error was offset by the exploratory nature of the project given the relative lack of research on this topic. Accordingly, we chose not to correct the effective probability level considered statistically significant (e.g. Bonferroni correction).
We began by examining each of the seven healthcare adherence measures as a function having been a victim of bullying in childhood; none of the analyses of variance (ANOVAs) were statistically significant (p values = .10–.82). We next examined potential differences in healthcare adherence as a function of having experienced emotional bullying only compared to emotional and physical bullying combined, and again none of the seven ANOVAs were statistically significant (p values = .24–.95). We also examined simple correlation coefficients representing the relationship between the healthcare adherence variables and the number of years bullied and the number of different bullies. None of those 14 correlation coefficients were statistically significant (p values = .11–.96).
Last, we examined each of the seven healthcare adherence measures as a function of whether the respondent reported having been a bully in childhood. With regard to self-rated conscientiousness, frequency of dental check-ups, frequency of arriving on time for medical appointments and frequency of getting laboratory work done in a timely manner, none of the ANOVAs were statistically significant (p values = .07–.44). However, there was a statistically significant difference with regard to the remaining three medical adherence variables. Respondents who reported having been bullies rated themselves as less likely to follow their physicians’ advice with regard to exercise (M = 2.13, SD = 1.22) compared to respondents who denied having been bullies (M = 2.60, SD = 1.04), F(1, 240) = 4.17, p = .02. Similarly, those who reported having been bullies rated themselves as less likely to follow their physicians’ advice with regard to diet (M = 2.10, SD = 1.17) compared to respondents who denied having been bullies (M = 2.60, SD = 0.95), F(1, 235) = 7.94, p = .006. Last, respondents who reported having been bullies scored lower on the MOS (M = 14.91, SD = 4.98) compared to respondents who denied having been bullies (M = 18.05, SD = 4.85), F(1, 247) = 8.69, p = .002.
Discussion
According to the findings in this study, being a victim of bullying was not associated with healthcare adherence as measured by these assessments. In addition, type of bullying, duration of bullying and number of bullies were each unrelated to healthcare adherence in this study. Given all of the negative psychological and physical risks of bullying, these findings are particularly salient – that is, being a victim of bullying may not impair one’s perception of adherence with healthcare in adulthood – a finding that was unexpected in terms of our hypothesis.
Recall that Storch et al. (2006) found that victims of bullying were less likely to be compliant with diabetes care. However, participants in that study were children aged 8–17 years, and victimization was based upon the management of diabetes (i.e. ‘in response to diabetes self-management tasks’). Therefore, participants were bullied because of diabetes management and understandably would be less likely to follow healthcare directives as a means to avoid being bullied. As opposed to this disease-specific and contemporaneous design, we examined relationships between being a victim of bullying in childhood and nonspecific healthcare adherence in adulthood. The differences in design likely account for the differences in findings.
In contrast to having been a victim of bullying, having been a bully was associated with several adherence issues with healthcare (similar to findings by Nogueira & Zambon, 2013). This self-reported non-adherence, which was predominantly related to following physician directives, may be directly related to the psychology of the bully. For example, psychiatric disorders (e.g. attention-deficit hyperactivity disorder, conduct disorder), lack of coaching or mentoring from another human being, temperamental disinhibition and impulsivity and perhaps problems with authority may partially explain findings. While speculative, all of these factors might affect one’s willingness and/or ability to cooperate in the management of healthcare.
This study has a number of potential limitations. First, all data are self-report in nature and subject to the limitations of this type of methodology. Second, the sample size is relatively small. Third, this sample is from a resident clinic (50% of the patients in this clinic have government insurance) and findings may not generalize to other types of clinical populations. Fourth, we did not assess participants’ type of medical illness for the current visit or level of treatment required – influences that may have affected treatment adherence. Fifth, our use of two author-developed nonvalidated measures to assess healthcare adherence may have compromised some results. Sixth, being a survey-based study, patient factors such as recollection, willingness to be candid, concerns about consequences despite reassurances of anonymity and so on may have influenced results. However, to our knowledge, this is the first study to examine bullying in relationship to healthcare adherence in a primary care population. The study entailed multiple queries about bullying as well as multiple queries about healthcare adherence. Findings indicate that victimization by childhood bullies may not affect healthcare adherence, but being a bully may be an indicator of several deficits with healthcare adherence.
Footnotes
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) received no financial support for the research, authorship, and/or publication of this article.