Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13092 The impact of verbal bullying on the mental health of students at a senior high school in Be-kasi, Indonesia Nurhalimah Nurhalimah, Omi Haryati, Wartonah Wartonah, Adelia Adelia Department of Nursing, Politeknik Kesehatan Kemenkes Jakarta III, Indonesia Abstract Adolescent bullying is a global concern due to its profound impact on mental health. In particular, verbal bullying can lead to psychological consequences such as anxiety, depression, and low self-esteem, affecting social interactions and academic perfor- mance. Despite anti-bullying initiatives, the prevalence of bullying remains high, necessitating further research on protective factors. This study examined the relationship between self-confidence and anxiety among victims of verbal bullying. A quantitative research design was employed with a population comprising all male and female students aged 15-17 years in 10th grade at State Islamic Senior High School (Bekasi, Indonesia) who were victims of ver- bal bullying. The sampling technique used purposive sampling with 92 respondents. Data were collected using questionnaires on respondent demographics: the Olweus Bully/Victim Questionnaire, the Self-Rating Anxiety Scale, and the Self-Confidence Scale. Data were analyzed using chi-squared and Pearson product-moment cor- relation tests to determine the relationship between the two vari- ables. A significant negative correlation (r=-0.634, p=0.000) was found between self-confidence and anxiety among bullying vic- tims. This study showed that higher self-confidence was linked to lower anxiety levels, indicating an inverse relationship between self-confidence and anxiety among victims of verbal bullying. Enhancing self-confidence may act as a protective factor against anxiety in students who are bullied. Introduction Adolescent bullying is a significant global issue because of its detrimental effects on mental health.1 According to the United Nations (UN), more than 246 million children experience gender- based violence by their peers in or near school each year. In 2018, one in three young people across 30 countries reported being bul- lied, with Indonesia ranking fifth among the 78 countries.2 Research indicates that verbal bullying is one of the most common forms of bullying experienced by students, with detrimental effects on their emotional and psychological well-being.3,4 In Islamic educational contexts, such as the State Islamic Senior High School, the impact of verbal bullying can be particu- larly severe due to the close-knit nature of these communities and the cultural emphasis on respect and harmony.5 Studies have shown that victims of verbal bullying often experience decreased self-esteem and increased stress and anxiety levels, which can lead to long-term mental health issues.6,7 The emotional toll of verbal bullying is evident in the feelings of hurt and embarrassment reported by students, which can undermine their self-confidence and academic performance.3,7 Furthermore, psychological distress caused by verbal bullying can manifest as various mental health symptoms, including depression and anxiety, highlighting the urgent need for effective intervention strategies.8,9 Bullying prevention is essential due to its capacity to induce significant mental health problems that could jeopardize the future of a nation’s youth. Despite the implementation of various pro- grams to address this issue, bullying incidents have continued to occur frequently. While similar studies have been conducted, there is a paucity of research on schools incorporating religious values into their teaching and learning activities. Consequently, researchers are motivated to investigate the relationship between self-confidence and anxiety in bullying victims in a school in Bekasi, Indonesia. Correspondence: Nurhalimah Nurhalimah, Department of Nursing, Politeknik Kesehatan Kemenkes Jakarta III, Indo-nesia. E-mail: nurhalimahskm@yahoo.co.id Key words: anxiety; bullying; self-confidence; students. Contributions: NN, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; AA, conceptualization, methodology, formal analysis, valida- tion, and writing – original draft, review & editing; OH, resources, inves- tigation, and writing –review & editing; WW, formal analysis, validation, writing – review & editing. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: this research was approved by the Health Research Ethics Committee Politeknik Kesehatan Kemenkes Jakarta III (approval number LB.02.02/F.XIX.21/4258/2024) on April 5, 2024. Informed consent was obtained from all participants. Consent for publication: written informed consent was obtained from participants for anonymized information to be published in this article. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Acknowledgments: We thank the participants for their valuable insights and contributions to this study. Received: 13 September 2024. Accepted: 11 March 2025. Early access: 16 April 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13092 doi:10.4081/hls.2025.13092 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s1):13092 [page 113] Materials and Methods Research design This study employed a quantitative approach with a cross-sec- tional design to examine the impact of verbal bullying on students’ mental health in a school in Bekasi, Indonesia. Self-confidence was designated as the independent variable, whereas anxiety among students who were victims of bullying served as the depen- dent variable. Study participants This study involved 92 students from one senior high school in Bekasi who were identified as victims of verbal bullying. The par- ticipants were selected using purposive sampling. The inclusion criteria required students to be 15-17 years old, enrolled in 10th grade, identified as victims of verbal bullying, and willing to par- ticipate by providing informed consent. Students who were victims of physical or cyberbullying were excluded. Variables and instrument This study examined self-confidence as the independent vari- able and anxiety among students who were victims of verbal bul- lying as the dependent variable, which consisted of four compo- nents. The first component contained the respondents’ demograph- ic data; this section collected basic demographic information of the respondents, including age, gender, and grade level, to provide a contextual background for data analysis. The second component was the bullying questionnaire, which utilized the Olweus Bully/Victim Questionnaire-Revised, comprising 22 Likert-scale questions regarding experiences, involvement, and forms of bully- ing. The results of the validity and reliability tests demonstrated a Cronbach’s alpha value of 0.930 (>0.60). The third component was the anxiety questionnaire, which employed the Zung Self-Rating Anxiety Scale (SAS/SRAS) and consisted of 20 Likert-scale ques- tions. The results of the validity and reliability tests indicated a Cronbach’s alpha value of 0.861 (>0.60). The fourth component measured the respondent’s self-confidence and consisted of 20- item questions in the form of favorable and unfavorable state- ments. The results of the validity and reliability tests yielded a Cronbach’s alpha value of 0.744 (>0.60). Data collection Before data collection, ethical approval was secured, and all participants provided written informed consent. The questionnaires were administered in person at the school under the supervision of the research team to ensure clarity and completeness of responses. Participants were given adequate time to complete the question- naire, and anonymity was maintained to encourage honest respons- es. After data collection, responses were coded and analyzed quan- titatively to assess the relationship between self-confidence and anxiety among students who had experienced verbal bullying. Data analysis Data processing began with editing, coding, data entry, and cleaning to ensure accuracy and completeness. Univariate analysis was conducted to determine the frequency distribution of the vari- ables. Validity and reliability tests of the research instrument were performed first to confirm acceptable reliability levels. A normality test was conducted, yielding a p-value of 0.200 (p>0.05), indicat- ing that the data were normally distributed. A p-value of 0.056 was obtained for trustworthiness, confirming that the data met the assumptions for parametric testing. The Pearson product-moment correlation test was used to assess the relationship between self- confidence and anxiety. The linearity test results showed a signifi- cance value of 0.183, indicating the degree of association between the two variables. Ethical clearance The study was approved by the Health Research Ethics Committee Politeknik Kesehatan Kemenkes Jakarta III (approval number LB.02.02/F.XIX.21/4258/2024) on April 5, 2024. The researchers adhered to research ethics by respecting the dignity and confidentiality of the participants and considering the benefits of the research. Results Table 1 presents the demographic characteristics of the 92 respondents. Most respondents who were victims of verbal bully- ing were female (70.7%) and aged 16 years (55.4%). Most female bullying victims exhibited moderate self-confidence (43.1%). The data showed that the majority of female respondents had mild anx- iety (38.9%), with the highest age being 16 years, with mild self- confidence of 59.8% and moderate self-confidence of 66.3%. Chi-square analysis revealed a significant relationship between sex and self-confidence (p=0.004; OR=11.5). Males tended to have higher self-confidence than females. In contrast, for anxiety, although there were differences in proportions between males and females, the analysis did not show a significant association (p=0.13; OR=8.807). Additionally, age was significantly associat- ed with self-confidence (p=0.021; OR=10.826). Respondents aged 15 had lower self-confidence than those aged 16 and 17. Nonetheless, the relationship between age and anxiety levels was not significant (p=0.119; OR=5.994); however, younger respon- dents generally exhibited higher levels of anxiety (Table 2). The data in Table 3 shows a p-value of 0.000 (<0.05, <0.01), which indicates a significant relationship between self-confidence and anxiety levels among bullying victims. The correlation coeffi- cient (r=-0.634) suggests a moderate to strong negative correlation, indicating that higher self-confidence levels are associated with lower anxiety levels. Discussion The findings highlight the influence of gender and age on self- confidence, although these factors do not significantly affect anxi- ety levels. Additionally, there was a strong negative correlation between self-confidence and anxiety in bullying victims, indicat- ing that higher self-confidence is linked to lower anxiety. These Special issue Pathways of Change Table 1. Frequency distribution of respondent characteristics (age and gender). Characteristics (n=92) % Age 15 year 33 35.9 16 year 51 55.4 17 year 8 8.7 Sex Male 27 29.3 Female 65 70.7 [page 114] [Healthcare in Low-resource Settings 2025;13(s1):13092] results underscore the importance of fostering self-confidence as a protective factor against anxiety. The findings indicated that most respondents experiencing ver- bal bullying were female and 16 years old, suggesting that adoles- cent girls may be more susceptible to peer-related verbal aggres- sion due to higher social engagement and vulnerability to relation- al victimization. This aligns with studies showing that adolescent girls are more likely to engage in problematic online social net- working behaviors, which increases their exposure to cyberbully- ing and relational victimization. Research has shown that girls with high levels of problematic Internet use tend to report higher scores of relational victimization.10 Females also exhibited higher depres- sive symptoms than males, highlighting bullying’s mental health impact. A bidirectional relationship exists between bullying vic- timization and mental health issues, where bullying predicts later mental health problems like anxiety and depression. In contrast, pre-existing mental health issues increase victimization likelihood. Females with mental health problems are more likely to be victims, while distressed males face an increased risk of experiencing and perpetrating bullying.11,12 These findings emphasize the need for preventive interventions, including school-based mental health programs, digital literacy education, and early screening initia- tives, to support at-risk students and create a safer school environ- ment. The study’s results indicate that most students possess mod- erate self-confidence and a relatively positive, optimistic attitude, although not to a prominent extent. The respondents demonstrated the ability to think objectively and exhibit sufficient responsibility, which enabled them to make autonomous decisions. Furthermore, the findings highlight the influence of sex and age on self-confi- dence. Bullying victims often experience decreased self-confi- dence, leading to anxiety, diminished self-worth, and social with- drawal.13-15 Interventions to enhance self-confidence and self- esteem in bullying victims are crucial. Initiatives that emphasize building self-worth and equipping individuals with coping mecha- nisms can alleviate the negative impact of bullying on mental health.16 Furthermore, fostering supportive environments in which victims feel secure in expressing themselves and seeking assis- tance plays a vital role in reducing anxiety and enhancing self-con- fidence.13-15,17 These findings underline the importance of school- based intervention programs to enhance students’ self-confidence and bullying prevention strategies in order to create a safer and more supportive learning environment. The results indicated that 59.8% of the respondents experi- enced mild anxiety due to peer rejection, unaffected by gender and age. Verbal bullying, involving mockery and humiliation, signifi- cantly contributes to declining self-confidence in victims, causing anxiety, insecurity, and hesitation in social or academic activi- ties.14,15 The respondents’ psychological conditions, characterized by moderate dependency and mild anxiety, were attributed to a supportive school environment. This institution has implemented a curriculum that instills religious, moral, and ethical values, which includes regular religious practices such as morning Quran recita- tion, Asmaul Husna recitation, congregational prayer, listening to salawats, and additional religious instruction. Consistent with pre- vious studies, religious beliefs and practices positively impact psy- chology,16 and spirituality has a positive relationship with self- acceptance and happiness.18 Spirituality enhances personality har- diness, leading patients to apply coping techniques to life prob- lems.19 These results highlight the significance of including reli- gious and moral education in schools to help reduce anxiety and improve students’ psychological well-being. Schools also provide psychological and counseling support, including services for female bullying victims, to mitigate the emotional impact and enhance self-confidence. Previous research on religious support related to depression and anxiety indicates that it acts as a crucial moderator, with higher levels amplifying the indirect effects on these mental health issues symptoms.20 The product-moment correlation test revealed a strong nega- tive correlation between self-confidence and anxiety in bullying victims, indicating higher self-confidence is linked to lower anxi- ety. Self-confidence and anxiety were inversely proportional. Research shows verbal bullying undermines self-confidence and intensifies anxiety, as victims may worry about further humiliation or social exclusion.13,14 Studies have found bullying is directly linked to higher social anxiety and lower self-confidence,21,22 and that self-confidence can act as a protective factor against bullying’s adverse effects, mitigating its impact on social anxiety and enhanc- ing psychological resilience.16 A previous study highlighted that effective school-based anti-bullying programs should include training in emotional control, peer counseling, and the establish- ment of a school policy on bullying.23 Appropriate support and interventions can significantly assist bullying victims in overcom- ing negative impacts and rebuilding self-confidence.24 Additionally, communication with students’ parents is essential, as involving parents of bullying victims can enhance mental health outcomes.25 Families represent the closest support system for stu- dents, providing emotional, social, and spiritual support at home. Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13092] [page 115] Table 2. Relationship between respondents’ characteristics, self-confidence, and anxiety. Characteri-stics Self-confidence (n=92) Anxiety (n=92) Low Medium High p OR Normal Mild Moderate p OR Gender Male 6 (22.2%) 11 (40.7%) 10 (37%) 0.004* 11.5 8 (29.6%) 10 (37%) 9 (33.3%) 0.13 8.807 Female 7 (10.8%) 50 (43.1%) 8 (12.7%) 7 (10.6%) 45 (38.9%) 13 (15.5%) Age 15 years 8 (24.2%) 16 (51,5%) 10 (30.3%) 0.021* 10.826 6 (18.2%) 17 (51.5%) 10 (30.3%) 0.119 5.994 16 years 5 (9.8%) 40 (78.4%) 6 (11.8%) 6 (11.8%) 33 (64.7%) 12 (23.5%) 17 years 0 (0%) 5 (62.5%) 3 (37.5%) 3 (37.5%) 5 (62.5%) 0 (0%) *Significant using chi-squared test. Table 3. Relationship between self-confidence and anxiety of bul- lying victims. Variable N Correlation coefficient (r) p Self-confidence anxiety 92 -0.634 0.000* *Significant using Pearson product-moment test. This study was limited to a single school and 10th-grade students, which may restrict the findings’ generalizability to a broader stu- dent population. Conclusions An inverse relationship was found between anxiety levels and self-confidence. Victims of bullying experience significant adverse effects on their self-confidence, anxiety, self-image, and self- esteem, resulting in both short- and long-term consequences. Many believe that victims of bullying are weak, helpless, and incapable. This belief undermines their self-confidence. References 1. Yusuf A, Habibie AN, Efendi F, et al. Prevalence and correlates of being bullied among adolescents in Indonesia: Results from the 2015 Global School-based Student Health Survey. Int J Adolesc Med Health [Internet] 2022;34. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0- 85070644786&doi=10.1515%2Fijamh-2019-0064&partner ID=40&md5=2b916ab6bb7ef237e499cf4156e4d06d 2. UNICEF. 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