Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13494 Changes in bullying behavior through agents of change using the balinese fable animation "Tat Twam Asi" in Jembrana regency Putu Sukma Megaputri,1 Putu Dian Prima Kusuma Dewi,1 Made Bayu Oka Widiarta,2 Made Padmarani Sudewiputri3 1Bachelor Midwifery Study Program, Buleleng Health Science, Bali; 2Bachelor Nursing Study Program, Faculty of Medicine, Universitas Pendidikan Ganesha, Bali; 3Bachelor Elementary School Education Study Program, Faculty of Education, Triatma Mulya University, Bali, Indonesia Abstract Bullying was a pervasive and urgent issue, often referred to as an iceberg phenomenon, with many cases remaining hidden beneath the surface. Its consequences, including mental health deterioration, physical harm, and, in extreme cases, death, high- lighted the critical need for effective intervention, particularly among adolescents. This study aimed to develop and evaluate the effectiveness of change agents—students empowered to influence their peers—using the Balinese fable animation «Tat Twam Asi» to reduce bullying behavior in schools. A mixed-methods approach was employed. The qualitative phase focused on the development of change agents through animation media, empha- sizing cultural relevance and student engagement. This was fol- lowed by a quantitative phase, involving 930 students across 23 selected schools. A one-group pre-test and post-test design was implemented to assess changes in students’ understanding of bul- lying before and after the intervention. The analysis was conduct- ed in two stages and statistical analysis using the Wilcoxon signed-rank test, following a normality test of the data. The inter- vention using the «Tat Twam Asi» animation significantly improved students’ understanding of bullying. This improvement was statistically significant (p < 0.05). The use of culturally grounded animation media to develop change agents proved effec- tive in enhancing students’ awareness and bullying prevention behaviors. This type of intervention had not previously been implemented in Indonesian elementary schools, particularly in Bali, and showed promising results. Introduction Bullying, a prevalent issue among Indonesian students, has become a permissive culture with serious consequences for victims.1 It often involves intimidation and seniority, both physical- ly and psychologically, making schools a primary setting for such incidents.2,3 Recognized as a mental health concern, UNICEF data from 2014 revealed that eight out of ten Indonesian children expe- rienced bullying, ranking the country fourth in child violence cases.4 The Sustainable Development Goals (SDGs) aim to reduce child violence by 2030 and improve adolescent mental health5. Bullying has evolved globally, extending into cyberbullying.6–8 Many bullies were once victims themselves, learning intimidation through per- sonal experiences.9,10 The contributing factors include school and social environments, peer influence, family dynamics, personality, and media exposure.11–15 Jembrana Regency, with its diverse cultur- al and religious backgrounds, is particularly vulnerable, with report- ed cases in Bali. However, the absence of specific reporting tools makes it difficult and ineffective to address bullying. Trend data from 2025 to 2020 show that the prevalence of bul- lying incidents in Indonesia has decreased from 50% to 41% of bullying cases in schoolchildren aged 15 years. These data indi- cate that the rate of bullying among school children in Indonesia remains relatively high.16–18 A 2016 study in Buleleng Regency showed that 53% of students in elementary, junior high, and senior high schools experienced verbal bullying from fellow students and school authorities, such as insults and derogatory remarks, from both fellow students and school authorities.19 Research in the Jembrana Regency found that 64.1% of children had experienced Correspondence: Putu Sukma Megaputri, Study Program of Midwifery, Buleleng Health Science, Bali, Indonesia E-mail: sukmamegaputri26@gmail.com Key word: animation; media; bullying; Bali. Conflict of interest: there is no potential conflict of interest among authors. Ethical approval and consent to participate: this study was approved by the Ethics Committee of STIKes Buleleng, Indonesia (certificate 7670824-KEPK). During the study, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Availability of data and materials: research data were generated and ana- lyzed during the study and included in this article. Funding: this research was funded by the DRTPM Ministry of Education and Culture of the Republic of Indonesia under the fundamental research scheme. Acknowledgements: the author would like to express gratitude to the DRTPM Ministry of Education and Culture of the Republic of Indonesia for facilitating the research funds that were provided so that this research was successfully carried out until it was published. The author also expresses gratitude to the Head of Buleleng Health Sciences for support- ing the facilities provided during the data collection. Furthermore, the researcher did not forget to express thanks to the Principal of the Elementary School in Jembrana Regency as the sample for this research. Received: 12 December 2024. Accepted: 31 March 2024. Early view: 8 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; 12(s2):13494 doi:10.4081/hls.2025.13494 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(s2):13494] [page 1] bullying.9 Indonesian children face bullying emergencies with seri- ous consequences if they are untreated. Reports have shown poten- tial impacts, including decreased academic performance, suicide, smoking, drug use, alcohol consumption, and criminal activity.1 This has also contributed to the increasing number of juvenile crimes. Efforts and regulations to address bullying without early child- hood prevention education remain insufficient, as both victims and perpetrators are children, requiring unique intervention approach- es. Psychoeducation, empathetic therapy, picture storybooks, reproductive health education, and Rational Emotive Behavior Therapy (REBT)-based counseling have been proven effective in reducing bullying behaviors in children.20–25 Programs like «Dat-e Adolescence» help reduce sexual harassment, while «Serious Games» enhance strategies against cyberbullying, fostering aware- ness and empathy.26 In Indonesia, bullying prevention models include self-esteem building,20 design thinking,27 education, posters, games,1 counselling booklets28 and the «Roots» program, which targets junior high and high school students through online anti-bullying campaigns facilitated by UNICEF and the Peduli Indonesia Foundation.29 Additionally, The Sistem Informasi Anti Perundungan (SIAP) program, currently in testing, aims to estab- lish a student database for bullying reports in Buleleng Regency.30 Globally, Spain’s Cyberprogram 2.0, Cyberduca 2.0, and videogame raise awareness through interactive games,6 while Malaysia’s Olweus Bullying Prevention Program (OBPP) is also adopted in South Africa.5 In addition, machine learning aids in detecting cyberbullying through adolescent social media networks.31 One strategy to help children avoid bullying is to establish change agents among the students themselves. These change agents, drawn from the community, will introduce change through Balinese fables themed «Tat Twam Asi.» Fables are a long-stand- ing tradition in Bali and are often conveyed through storytelling. These fables incorporate Balinese culture and folklore, conveying moral messages about good and bad behavior. They also aim to increase awareness of Balinese heritage among younger genera- tions, which is gradually being neglected. The culture of story- telling is overshadowed by cartoons and animation. The rationale for choosing Balinese fables and their alignment with the local cul- tural philosophy of «Tat Twam Asi” because in Balinese people have tradition name was “Mesatua” and this integrated with cur- riculum elementary school in Bali. Tat Twam Asi as one of cultural and general philosophy from Sanskerta language was mean toler- ance and make peace live Unlike previous research, this study focuses on elementary school students and applies a behavioral change agent approach to create a database for reporting and classifying bullying incidents in the Buleleng Regency. While aligned with UNICEF’s Roots pro- gram, it uniquely integrates a Balinese fable-based module in a video format, making it the only bullying prevention initiative in Bali that incorporates local wisdom. Rooted in the Balinese philos- ophy of Tat Twam Asi—which means «I am You»—this approach emphasizes empathy and cultural relevance. Bullying contradicts this philosophy, highlighting the need for interventions that reflect local traditions. However, no existing programs utilize Balinese storytelling (meSatua) or animation to prevent bullying, thus pre- senting a research gap. This study introduces an innovative inter- vention using fable-based animation to foster behavioral change among students, reinforcing the values of Tat Twam Asi. Material and Methods Design, population, and sample This study employed a mixed-methods design, beginning with a qualitative approach to developing Balinese fable animation media, followed by a quantitative phase to assess its impact. The qualitative stage involved expert reviews and small-scale trials to validate animation media before its implementation. The quantita- tive phase utilized a one-group pretest-post-test design to evaluate the effectiveness of behavior-change agents in reducing bullying behavior. The study was conducted across 23 elementary schools in the Jembrana Regency and was selected using cluster random sampling. A total of 930 students (aged 10-12 years) participated in this study. Each school selected two students as behavior-change agents and one teacher as a facilitator. These agents received train- ing on bullying prevention using Balinese fable animation «Tat Twam Asi.» Variables This study included both the independent and dependent vari- ables. Independent Variables: Implementation of the «Tat Twam Asi» animation media, participation in behavior change agent training, and facilitator involvement. Dependent Variables: Changes in students’ knowledge, attitudes, norms, self-esteem, self-efficacy, and bullying behavior. Development of animation media The development phase involved collaborating with animation media experts to create characters and storylines. The script was developed and refined using feedback from content experts, media specialists, and elementary school students. Five student enumera- tors assisted with dubbing the animation. The final product under- went a media expert test involving two content experts, five media experts, and a trial with ten elementary school children aged 10-12 years. Content validity was assessed using Gregory’s formula, with a threshold of >0.6. Data collection procedures Stage 1 Stage 1 begins with creating animation media, which involves conducting expert reviews. Coordinating with the Jembrana District Education Office: This includes all 23 schools in Jembrana District. Meeting with school principals: This meeting discusses the formation of behavior-change agents. Each school sent two representatives to receive the Balinese fable animation and assess their bullying behavior before and after the intervention. Forming behavior change agents: These agents will be deployed to schools to deliver the Balinese fable animation «Tat Twam Asi.» Stage 2 Stage 2 involves deploying the change agents. Agents are deployed in 23 randomly selected schools, with a total of 930 respondents. Pre-test: A pre-test questionnaire was administered to assess knowledge, attitudes, norms, self-esteem, self-efficacy, and bullying behavior before the intervention. Intervention: Change agents implement the Balinese fable animation «Tat Twam Asi.» Post-test: A post-test questionnaire was administered to reassess the same variables as in the pre-test. Pathways of Change, Part II [page 2] [Healthcare in Low-resource Settings 2025;13(s2):13494] Data analysis Qualitative-quantitative (stage 1) After collecting content validity data from experts and users, a qualitative review was conducted on media improvements for chil- dren aligning with their daily lives. This review assessed the valid- ity in terms of content, language, visuals, and material delivery. Expert validity was evaluated using Gregory’s formula with a score of >0.6, and content expert validity was assessed using Lawshe’s formula with the aim of CVR >0.6. The analysis involved two expert evaluations, two learner evaluations, and a small-group evaluation with 10 elementary school students. The questionnaire gathered feedback on media for improvement. Before being designated as change agents, they underwent a pre-post questionnaire analysis using a one-group pre-test–post- test design. Normality tests were determined using a parametric test if the p-value was >0.05; otherwise, a non-parametric Wilcoxon test was used. Quantitative (stage 2) Quantitative analysis using pre- and post-intervention ques- tionnaires assessed the media’s effectiveness in the student group. After data collection, the prerequisites for the homogeneity and distribution of the research data were tested. The data was not nor- mally distributed (p<0.05), necessitating the use of the non-para- metric Wilcoxon test to examine differences in bullying actions before and after implementing the Balinese Satua-based behavior change agent «tat twam asi.» To address potential shortcomings of the Wilcoxon test, researchers conducted univariate and bivariate analyses, and tested differences in each independent and dependent variable. Ethical consideration This study was approved by the Ethics Committee of STIKes Buleleng in Indonesia (KEPK ID 7670824). Results Stage 1: development of Balinese fable animation media This research consists of two stages: the development of Balinese animation media used form behavioral change agents and teacher facilitators. The result of developing the media used Balinese Satua animation. The e-module provided during the behavioral change agent and teacher facilitator training used a flip PDF-based e-module. The media can be accessed online, where viewers can directly watch the Balinese Satua animation used for forming the change agent. The results of the media expert test show that the Balinese Satua animation was evaluated by two media experts, yielding a Gregory test validity score of 0.78, indicating high validity for the media tested by a Balinese media expert. After the media expert test, the researcher also conducted a content or subject matter expert test for the Balinese Satua animation. The content expert test results showed that expert 1 found the clarity of voice and the accuracy of writing and information in the animation video to be somewhat lacking. Furthermore, expert 2 noted that the accuracy of the writing and information in the animation video, as well as the layout and design, were still somewhat inadequate. From the calculation above, a result of 0.78 was obtained, indi- cating that the media has high validity based on the expert evalua- tion. Following the media expert test, the researcher also conduct- ed a content test, which was analyzed by four experts in their respective fields, including psychology and psychiatric nursing experts. The results showed a CVR value of >0.6. The form of the developed media is an e-module, which also includes the Balinese Satua animation to help clarify students’ understanding in bullying prevention. This module starts with a cover that depicts the characters in the animation story. It is fol- lowed by a certification page and module content. Each module contains a Balinese Satua animation video related to bullying pre- vention. Based on the validity results from the media and content experts, the behavioral change agents were then formed. These change agents were created in accordance with the planned sample size, forming 46 change agents from 23 schools. The analysis results in Table 1 show that the average age of a behavioral change agent is 11 years, with the majority being female, accounting for 69.6%. Most of the participants are in grade 5, comprising 60.9%. The pre-test results, or the test given before participating in the behavioral change agent training, had an aver- age score of 81.3. After receiving the training, the score increased to 82.6. This indicates that the participants, as behavioral change agents, have improved their understanding of bullying in schools, peer relationships, and the actions they can take as behavioral change agents through the Balinese Satua animation media. Stage 2: media effectiveness test This stage began with the formation of Behavioral Change Agents in 23 schools, with each school sending 2 students, result- ing in 46 behavioral change agents for this study. The results of the univariate analysis and effectiveness test of the training show that most of the behavioral change agents were in the age range of 11 years, with the majority being female at 69.6%. Of the selected agents, 60.9% were in grade 5, and 39.1% were in grade 6. The cri- teria for participating as a change agent in the selected schools were that two students from either grade 5 or 6 had to be chosen. Next, a knowledge difference test was conducted before and after becoming a change agent, following a normality test of the data. The results showed a p-value of <0.05, indicating that the data did not follow a normal distribution. Therefore, the analysis used was the Wilcoxon test. The knowledge difference test before and after participating in the Behavior Change Agent program reports the results of the knowledge difference test before and after receiving training as a Behavior Change Agent (Table 2). The results were statistically significant with a p-value < 0.05. Subsequently, an effectiveness test was conducted to assess the impact of Behavior Change Agents in schools. This stage aimed to evaluate the effectiveness of the provided module and the formed agents. A total of 930 sam- ples were collected, distributed across 23 schools according to the distribution data. Table 3 reports that the majority of students in stage 3 are female, accounting for 55.1%. Most students are in the 6th grade of elementary school, making up 37.8%. Univariately, 32.7% of students reported having been victims of bullying at school, while 17.3% reported having been perpetrators of bullying. Next, the effectiveness of the pre- and post-tests was examined by compar- ing the conditions before the introduction of Behavior Change Agents and the Satua Bali animation module with the conditions after their implementation. Before conducting the analysis, a nor- mality test was performed. The results indicated that the pre- and post-test data were not normally distributed, as the p-value was <0.05. Therefore, a non-parametric test using the Wilcoxon analy- Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13494] [page 3] sis was applied to assess effectiveness. The results in Table 4 indi- cate that students’ understanding of bullying improved after the introduction of Behavior Change Agents and the Satua Bali anima- tion module. The increase in understanding was observed com- pared to the period before these interventions. This result is also statistically significant, with a p-value < 0.05. This means that H0 is rejected, indicating a difference in students’ understanding of bullying before and after the establishment of Behavior Change Agents using the Satua Bali animation in Jembrana District. Similarly, self-efficacy, attitudes, and self-esteem also showed sta- tistically significant differences before and after the implementa- tion of Behavior Change Agents, with a p-value < 0.05. The vari- ables that simultaneously contributed to the improvement of anti- bullying behavior can be observed. Table 5 shows that the independent and dependent variables account for 78% of the effect, while 22% is attributed to other fac- tors not included in this study. The linier regression equation obtained is Y = 35.05 + 3.28 (Attitude) + 6.05 (Self-Esteem). This means that for every 1-unit increase in attitude, the attitude vari- able increases by 3.28 units, assuming other independent variables remain constant. Similarly, for every 1-unit increase in self-esteem, the self-esteem variable increases by 6.05 units, assuming other independent variables remain constant. Discussion Behavior Change Agents are expected to reduce bullying inci- dents in schools. This study adopts the fundamental philosophical values of Tat Twam Asi and integrates them into animated films as a trigger medium for the formation of anti-bullying change agents. The findings revealed that Behavior Change Agents play a highly effective role in enhancing the literacy and understanding of stu- dents, particularly those targeted for intervention, to further increase their knowledge about bullying and its prevention in schools. This aligns with previous research, which found that a key indicator of success in forming Behavior Change Agents in schools is the reduction in bullying incidents and an increase in students’ awareness of the types and classifications of bullying.32 This high- lights the strong correlation between the establishment of change agents and the prevention of bullying behavior in schools. Additionally, one study found that animation media can enhance empathy, thereby encouraging the prevention of bullying behaviors among teenagers in Madura.33 To address bullying behavior, the values of tolerance embedded in Tat Twam Asi can be packaged into an animated medium to develop anti-bullying agents in schools. Tat Twam Asi is a Sanskrit phrase where «Tat» means «he/she/they,» «Twam» means «you,» and «Asi» means «is.» Thus, in essence, it conveys the meaning: I am you, and you are me, signifying that all beings are equal.34 Based on this philosophy, this study sought to adopt animation as a means of shaping anti- bullying change agents. A literature review found that one of the educational models Pathways of Change, Part II Table 1. Results of the analysis of respondent characteristics who entered as behavioral change agents. Variables f (%) Age (Mean±SD) 11.3 ± 0.4 Sex Male 14 (30.5) Female 32 (69.6) Class 5 (five) 28 (60.9) 6 (Six) 18 (39.1) Pre-test (Mean±SD) 81.3 ± 10.8 Post-Test (Mean±SD) 82.6 ± 18.5 Table 2. Difference test of knowledge before and after attending the behavior change agent program. Result Mean rank Z value p Pre-test 20.9 -2.58 0.01 Post-test 28.83 Table 3. Student characteristic analysis. Variable f (%) Sex Male 418 (44.9) Female 512 (55.1) Class 4 228 (24.5) 5 350 (37.6) 6 352 (37.8) Victim Yes 304 (32.7) No 626 (67.3) Bully Yes 161 (17.3) No 769 (2.7) Table 4. Results of descriptive analysis of difference test. Results Mean rank Z Value p Pre-test Knowledge 398.9 -23.94 <0.0001 Post-test Knowledge 440.4 Pre-test Self Efficacy 406.1 -2.48 0.013 Post-test Self Efficacy 431.1 Pre-test Attitude 198.1 -23.79 <0.0001 Post-test Attitude 496.1 Pre-test Self Esteem 400.8 -5.08 <0.0001 Post-test Self Esteem 553.6 Table 5. Multivariate analysis of variables that increase the non- occurrence of bullying cases in schools. Results R B p Constanta 0.78 35.05 Knowledge 0.09 0.3 Self Efficacy 0.01 0.7 Attitude 3.28 <0.0001* Self Esteem 6.05 0.003* [page 4] [Healthcare in Low-resource Settings 2025;13(s2):13494] for bullying prevention in schools includes the use of comic media, educational videos, and peer tutoring38. This review discusses that for students aged 11–16 years, the peer tutoring program known as Tutoria Entre Iguales (TEI), which originates from Spanish, is effective in reducing both conventional bullying and cyberbully- ing. These suggest that the TEI program is effective in reducing bullying and cyberbullying behaviors.39 The findings indicated support the effectiveness of forming anti-bullying Behavior Change Agents through the Satua Bali animation media, which is based on the Tat Twam Asi philosophy, as a preventive measure against bullying among school-aged adolescents. The philosophy of Tat Twam Asi teaches human equality, emphasizing that bullying or oppression of others is not permitted. Instead, Tat Twam Asi pro- motes compassion and mutual care among individuals. The core principle embedded in this philosophy encourages people to treat others with the same kindness and respect they would wish for themselves. Harmony, generosity, virtue, and wisdom—values instilled in Tat Twam Asi—serve as guiding principles for adoles- cents in fostering relationships with their peers.40 The psychoeducation efforts undertaken were not only directed at students but also involved parents and teachers. This approach helps them develop awareness of the severe consequences of bul- lying in both the short and long term. Additionally, teachers and parents have begun to recognize the symptoms experienced by bul- lying victims, allowing them to provide timely intervention with- out significant delays.41 These align with the empowerment efforts conducted by Divayana,42 which found that bullying prevention can be achieved through digital literacy empowerment based on the Tat Twam Asi philosophy. In this study, attitude was identified as a key multivariate factor that enhanced bullying prevention among students. A positive attitude toward bullying prevention was also found to increase students’ willingness to actively prevent bullying.43 Positive prosocial attitudes significantly influences stu- dents’ motivation to engage in bullying prevention efforts at school. In addition to the variables mentioned above, self-esteem also plays a crucial role in bullying prevention. These findings indicate that individuals with high self-esteem are more capable of prevent- ing bullying. This aligns with previous research, which found that students with higher self-esteem are more likely to prevent bully- ing among their peers. High self-esteem is influenced by various factors, including family support, media exposure, and peer sup- port.9 As a result, students with high self-esteem were less likely to engage in bullying behaviors. A limitation of this study is the absence of a control group to compare the effectiveness of forming Behavior Change Agents through the Satua Bali animation. Future research should incorporate a comparative study using Satua Bali animations or expand the sample size. This would allow for the potential integration of this media into the bullying prevention cur- riculum in Jembrana, Bali, and in Indonesia. Conclusions There was a difference in bullying prevention behavior before and after the formation of the behavioral change agents. This result seems to be highly effective, as can be seen from the statistical value. The behavioral change agents formed had a positive impact on increasing the preventive behavior of bullying among elemen- tary school students in Jembrana District. Despite the limitations of not having a control group, this did not affect the results of the effectiveness test between the groups before and after being given the behavior change agent using the Satua Bali animation. Next, researchers hope to redevelop the research to reach a wider popu- lation. 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