Association of socioeconomic variables with bullying, being a victim, life dissatisfaction, and poor self-rated health in Iranian children and adolescents: the CASPIAN-V study CURRENT

Background Bullying, being a victim of violent behaviors, life satisfaction (LS) and self-rated health (SRH) in children and adolescents, all have consistently been recognized as vital factors in school performance and future individual life. In this study we examined the association of some socioeconomic variables with bullying, being a victim, life dissatisfaction (LDS), and poor self-rated health (SRH) in Iranian children and adolescents. Methods This cross-sectional data secondary study was a part of the fifth Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable disease (CASPIAN-V) in 2015. A total of 14,400 students 7-18 years and their parents living in 30 provinces in Iran were studied. A validated questionnaire of the World Health Organization on Global School-based Health Survey (WHO-GSHS) was used to measure the outcomes and socioeconomic variables. Family’s socioeconomic status (SES) was determined using principle component analysis (PCA).The crude and adjusted odds ratios (95%CI) were estimated using multiple logistic regression for each outcome. Results A total of 14,274 students (50.6% boys, 49.4% girls)) completed the study. The prevalence of bullying, being a victim, LDS, and poor SRH was 35.6%, 21.4%, 21.1%, and 19.0% respectively. In multiple-logistic regression analysis, mother illiteracy (versus college degree) increased the odds of bullying (Adj.OR (95%CI), 1.77(1.45-2.16), being a victim (Adj.OR (95%CI),1.58(1.26-1.98), LDS (Adj.OR (95%CI),1.64 (1.30-2.08)) and Poor-SRH (Adj.OR (95%CI), 1.60(1.25-2.04). Students with illiterate father(Adj.OR (95%CI), 1.28(1.03-1.61) or unemployed father (Adj.OR (95%CI),1.58(1.29-1.81)) had a higher odds of Poor-SRH. Moreover, family size > 4 members

were estimated using multiple logistic regression for each outcome.
Results A total of 14,274 students (50.6% boys, 49.4% girls)) completed the study. The prevalence of bullying, being a victim, LDS, and poor SRH was 35.6%, 21.4%, 21.1%, and 19.0% respectively. In multiple-logistic regression analysis, mother illiteracy (versus college degree) increased the odds of Background Among many topics that are important to any discussion of the interface between early life experience and total health, bullying at the school setting, life dissatisfaction (LS) and self-rated health (SRH) are increasingly documented as predictors to instant and long-run health outcomes [1][2][3].
Despite the fact that bullying, formerly regarded as a normal part of children's growing up [4], previous studies have explained a negative association between bullying and health outcomes [5,6].
A study in the 21 European rich countries composing the Organization for Economic Co-operation and Development (OECD) verified that 1 out of 3 of children have been bullied at least once during the last two months [7]. In Iran, a study in a sample of middle school students revealed that 79.6% of students are involved in bullying and 81% are suffered bullying [8].
Life satisfaction (LS) is referred to the subjectively perceived quality of life according to the personal preferences of several life domains and the satisfaction in these domains [9]. Life dissatisfaction (LDS) has been closely related to a range of negative personal, behavioral, psychological and social outcomes [10,11]. The majority of previous researches on LS (or LDS) has been conducted primarily with adult participants [10], and relatively limited studies have investigated in childhood and adolescence [12].
Self-rated health (SRH), as a single-item health predictor [1], is to ask about an individual's perception of their own overall health status [13]. Because of SRH consequences in adult life, exploring the SRH and its associated factors in early life may be of particular interest in health researches. Previous studies suggest that conceptualizing health [14] and establishing healthy behaviors [15,16] begin from early childhood and adolescence. Further, studies indicate that it can be regarded as the predictor of mortality [17], morbidity [18] and use of health care services [16,19].
Given that bullying, being a victim, LDS, and SRH have consistently been recognized as vital factors associated with positive growth, good health and well-being in adulthood period, understanding of socioeconomic variables attributed to them in childhood and adolescence is important. Limited information is available on the socio-economic determinants of childhood and adolescence self-rated health [20,21], bullying, being a victim of violent behavior and LDS at a school settings, especially in low and middle-income countries. Furthermore, as childhood and adolescents groups are often overlooked in health policy [21], this study allows policymakers to broaden their focus and to better develop early life-related health policies. Our objectives were to examine some socioeconomic variables on 1) bulling, 2) being victim, 3) LDS and 4) Poor SRH among Iranian children and adolescents.

Methods
This is the multicentric cross-sectional fifth survey of a surveillance program entitled "Childhood and Adolescence Surveillance and Prevent‫ه‬on of Adult Non-communicable disease" (CASPIAN V) study (2015). Detailed methodology and executive procedures described previously [22], here we point to essential subjects.

Study participants
Using a multistage, stratified cluster sampling method, the study participants consisted of children and adolescents aged 7-18 years from primary and secondary schools of urban and rural areas of the country. We designed the proportional to size sampling method with equal sex ratio. Aim to that, within each province; the student's place of residence (urban or rural) and level of education (primary and secondary) applied.

Questioning procedures
Based on the World Health Organization-Global School-based student Health Survey (WHO-GSHS), two specific sets of questionnaires were developed for students and their parents. The student's questionnaire was obtained from the WHO-GSHS that was translated into Persian. The validity and reliability of questionnaires have been confirmed previously. After explaining the aims of the study and executive procedure, we obtained written informed consent from the parents and oral agreement from the students.

Bullying:
Bullying assessed through questioning about: "During the past 3 months, how often did you bully at school?". The possible choices defined as: "None" (considered as no), "One to two times" (considered as yes), "Two to three times" (considered as yes) and "Four times or more" (considered as yes) [23,24].

Being Victim
According to the Global School-based Student Health Survey (GSHS) questionnaire of psychiatric distress and violent behaviors, victim detected by questioning on "During the past 3 months, how often did you get bullied at school?" The response choices categorized as; "None" (considered as no), "One to two times" (considered as yes), "Two to three times" (considered as yes) and "Four times or more" (considered as yes) [23,24].

Socioeconomic status
The methods and variables of calculating the family SES selected based on the categories approved in the Progress International Reading Literacy Study (PIRLS) for Iran [25]. The SES data was extracted from the parents' questionnaire. The participants' SES was determined based on the results of principle component analysis (PCA) variables of parents' education, occupation, possessing a private car, their school type (public/private), home type (private/rented) and having a personal computer at home. The SES score was a weighted average of the SES variables that were summarized under one main component of SES score. A lower score corresponded to a lower SES. The calculated score was categorized into tertiles to define SES levels. The first tertile was considered 'low', and the second and third ones as 'middle' and 'high' SES, respectively [24].

Life dissatisfaction (LS)
To evaluating the Life dissatisfaction (LDS), the participants were asked to express their degree of life satisfaction according to a tenth-point scale from 1= very dissatisfied to 10 = very satisfied.

Self -rated health (SRH)
Self -rated health (SRH) of students were assessed through questioning about "How would you describe your general state of health?" The response choices categorized as; "perfect," "good," "moderate," and "bad" [26,27]. We summarized the responses as either 'not poor' (perfect or good) or 'poor' (moderate or bad) SRH

Statistical analysis
Quantitative variables are expressed as mean and standard deviation (SD) and qualitative variables as number (%). Chi-square test was used to compare the self -rated health, life satisfaction, and violent behaviors across the socioeconomic status variables. The association of socioeconomic status variables and violent behaviors, self -rated health, life satisfaction, evaluated using different logistic regression models. Model I was a crude model (without adjustment); in model II, the association was adjusted for all socioeconomic status variables and age, simultaneously. All statistical analyses were conducted based on survey data analysis methods. Data were analyzed using the STATA package V.11.0 (Stata Statistical Software: Release 11. College Station, Texas, USA: StataCorp LP Package) and a p-value <0.05 was considered significant.

Results
A total of 14,274 students (50.6% boys, 49.4% girls) and one of their parents (out of 14,400, participation rate) completed the survey (participation rate: 99%) . Table 1 shows the demographic and family characteristics of students, totally and by sex group.
The mean ± SD age of students was 12.3 ± 3.2 years, with no significant difference between girls and boys. In girls compared to boys, a higher percentage of mothers had college degree (14.7% vs. 12.8%, p= 0.009) and were employed (13.7% vs. 11.8%, p < 0.001). There were any significant differences in other demographic and family characteristics between boys and girls.
All our outcomes including bullying, being victim, life dissatisfaction, and poor Self-rated health were more frequent among individuals with socioeconomic status low (versus higher levels of SES) , and those who their mother were illiterate (versus other levels of education). (all p <0.05).
A higher percentage of individuals with family size more than four members (versus family size ≤ 4), single-parent family (versus two parents), and unemployed father (versus employed) were dissatisfied in their life. (all p-value < 0.05) Poor health status was less reported among those who their father had a college degree (versus less than college) or were employed (versus unemployed). (both p-value <0.05) A lower percentage of individuals with single parents (versus two parents) and academic education level of a father ( versus less than a college degree) described being a victim during the past 3 months . In addition, a lower percentage of students who their mother were employed (versus unemployed) or their father had a college degree (versus less than college degree),  (Table 3).
As presented at Table 4 There was not a significant association between other socioeconomic variables with the assessed outcomes. The crude and adjusted odds ratios were generally similar (as in Table 3&4).

Discussion
In this study, using a nationally representative dataset from CASPIAN V, we focused on socioeconomic variables of bullying, being a victim, life dissatisfaction (LDS) and poor SRH among students aged 7 to 18 years in Iran. We mainly tried to clarify attributed socioeconomic variables of the mentioned outcome variables. To our knowledge, this is the first attempt to declare socioeconomic attributions European and North American countries showed that the most deprived students (i.e. students with a low level of parental education and occupation) had an odds ratio for self-rated poor health nearly three times higher than the least deprived students [50].

Strengths And Limitations Of The Study
The main strengths of the study lie on the quantity and quality of the data, collected in a large nationally representative sample size and designed and conducted according to standardized questionnaire of the World Health Organization on Global School-based Health Survey (WHO-GSHS).
As data were drawn from a cross-sectional study, causal interpretations should be made with caution.
In fact, attribution of causality might be better discovered with prospective longitudinal research in the future studies.

Conclusions
According to the findings, some socioeconomic variables can be proposed as the main attributions of bullying, being victim, LDS and poor-SRH in children and adolescents. Namely, parental education, father's occupation, family size as well as family's SES can be taken into account in anti-bullying initiatives and programs related to LS and SRH promotion.

Funding :
This research received no specific grant from any funding agency, commercial or not-for-profit sectors

Availability of data and materials:
The data used in the current study are available from the corresponding authors on reasonable request.

Ethics approval and consent to participate:
The Research and Ethics Council of Isfahan University of Medical Sciences approved the study (Project Number: 194049).

Consent for publication:
Not applicable.