STRENGTHS AND LIMITATIONS OF THIS STUDY

The study used a validated and reliable tool (Depression Anxiety Stress Scale-21) to assess depression, anxiety and stress.

The study focuses specifically on female adolescents, who are considered more vulnerable to cyberbullying and its psychological effects, allowing for targeted insights into this group.

The exclusion of male adolescents means the findings do not account for the experiences of male victims, which could be explored in future studies.

The data were collected using self-reported questionnaires, which may introduce recall bias or social desirability bias.

Introduction

Cyberbullying is an aggressive and intentional act of maltreatment and harassment using any form of digital technology. It is a deliberate act intended to frighten, provoke or shame the target and can occur in numerous ways, such as hacking into a person’s social media account(s); impersonating them on social media platforms; spreading rumours and lies about them; sending offensive, irritating and threatening texts, posts or sexual contents; or making threatening prank calls.1 2 Globally, cyberbullying is emerging as a public health problem, irrespective of national economy, with the potential to cause severe physical, mental and social distress among the victims.

While initially more prevalent in Western countries, cyberbullying has increasingly become an issue in developing nations, largely due to the widespread use of internet and digital devices.3 Several studies around the world have shed light on the prevalence of cyberbullying and its impact on adolescents. In Canada, a study conducted in 2017 found that 12.2% of adolescents experienced both cyberbullying and traditional bullying.4 A study from North America revealed that nearly 20% of women received sexually obscene messages online, causing anxiety in 34.9% of cases.5 A study from India reported 10.5% of late adolescents being cyberbullied,3 while another study from Bangladesh found that 32% of adolescents aged 14–17 were victims of cyberbullying, with 27% experiencing psychological distress.6

Adolescence is a critical developmental stage, marked by significant physical and psychological changes as adolescents transition from puberty to legal adulthood, making them more likely to experience mental distress.7–9 According to WHO, one in seven adolescents worldwide are affected by mental disorders, contributing to 13% of the global burden of disease and injury among adolescents aged 10–19.10 Globally, it has been observed that cyberbullying has a significant negative impact on the overall development of adolescents, with victims of cyberbullying being more likely to experience depression and anxiety, as well as to engage in self-harm and exhibit suicidal behaviours.11–14

In the context of Nepal, adolescents aged 10–19 years make up a significant portion of the national population, accounting for approximately 20% of the total population, of whom 10.2% are male adolescents and 9.8% are female adolescents.15 Recent studies indicate a high prevalence of mental health issues among Nepalese adolescents, with depression rates ranging from 27% to 56.5%,16–18 anxiety from 10.0% to 55.6%16 19 20 and stress from 27.5% to 32.9%.16 20 These studies suggest female adolescents are more vulnerable to experiencing psychological distress compared with their male counterparts.16 18 20 Additionally, a study among young female students in Kathmandu found that 66.5% had experienced online sexual harassment at least once, with 73.2% experiencing it multiple times.21 The rapid increase in smartphone usage, now reaching 73% of the national population, and internet access, which has expanded to 37.8%, as recorded in the 2021 census of Nepal,15 has increased the relevance of cyberbullying, particularly among female adolescents.22–24 However, despite these technological advancements, there is a lack of studies that assess the prevalence of cyberbullying and its association with psychological distress among Nepalese adolescents.

There is a significant research gap, given the rising concern about cyberbullying in Nepal and its potential impact on adolescent mental health, particularly among female adolescents. This study aims to address this gap by examining the prevalence of cyberbullying and its effects on the psychological well-being of female adolescents in Nepal and to identify the factors associated with depression, anxiety and stress. By focusing specifically on this vulnerable demographic, the study seeks to provide valuable insights into the extent of cyberbullying and its consequences, thereby contributing to the development of targeted interventions and support mechanisms.

MethodsStudy design and setting

This was an institution-based, cross-sectional study conducted among female adolescents attending grades 11 and 12 of six available higher secondary schools in Deumai Municipality from February to April 2022. The higher secondary school education system started in Nepal in 1992, consisting of grades 11 and 12. It is governed by the Higher Secondary Education Board and focuses on certain specialised subject areas, such as science, management, humanities and education.25 The usual age to start grade 11 is around 15 years, with no upper age restrictions for enrolment; thus, this setting mostly covers late adolescents aged 15–19 years.25 26

Participants

All female adolescents enrolled in grades 11 and 12 of all available higher secondary schools in Deumai Municipality, Ilam District, Koshi Province, Nepal, were eligible to be included in the study population. Adolescents below the age of 18 were required to provide both parental consent and their assent as part of the informed consent process, while those aged 18 and above were required to provide informed consent. Of all eligible participants, those who did not provide informed consent (or parental consent, if applicable) and those who were not present at school on the day of data collection were excluded.

Sample size determination and sampling technique

The sample size was determined using Cochran’s formula for estimation of proportion, n=z2pq/d2, where p is the prevalence of depression among higher secondary school adolescents, q is 1−p and d is the allowable error. A study from Pokhara in a similar urban setting, conducted in 2018, reported 44.2% of adolescents experienced depression, whereas 52.2% of female adolescents reported being depressed.8 Taking this prevalence of 52.2% at a 95% CI and 5% allowable error (d), the sample size was estimated at 384, which was optimised to 512 considering a 25% non-response rate. As the total number of female adolescents enrolled in the six higher secondary schools that granted permission to conduct the study was close to the calculated sample size, all available female adolescents present on the day of data collection were approached until the target sample size of 512 participants was reached.

Data collection

Data were collected using a self-administered questionnaire after obtaining parental consent and assent from adolescents below the age of 18 and informed consent from those aged 18 and above, along with permission from the academic institutions. The schoolteachers assisted in the data collection by arranging a data collection session in the classroom. The researcher distributed the questionnaire and oriented the students about each question to ensure they understood it properly. The students completed the survey in their classrooms within the provided 1-hour timeframe. The questionnaire was divided into three sections. The first section consisted of general information about the student’s sociodemographic profiles. The second section consisted of questions related to cyberbullying victimisation. The third section is the Depression Anxiety Stress Scale-21 (DASS-21),27 which is used to assess the level of depression, anxiety and stress among adolescents.

Study variables

The outcome variables for this study were depression, anxiety and stress, which were assessed using the DASS-21. The DASS-21 is a standard tool consisting of 21 items measured on a 4-point rating scale (0–3), with ‘0’ denoting ‘did not apply to me at all’ and ‘3’ denoting ‘applied to me very much, or most of the time’.27 The translation and back translation of the DASS-21 (English–Nepali–English) was performed in a previous study from Pokhara, where the translated version illustrated good internal consistency with a Cronbach’s alpha of 0.92.28 This study used the same translated Nepalese version of the DASS-21 to ensure reliability and translation validity. Following the original scoring guidelines, the scores for the three subscales were calculated by summing the scores of the relevant items and multiplying by 2, where higher scores on each subscale reflect greater levels of depression, anxiety and stress.29 The depression subscale of the DASS-21 was categorised into normal (0–9), mild (10–13), moderate (14–20), severe (21–27) and extremely severe (28 and above). The anxiety subscale of the the DASS-21 was categorised into normal (0–7), mild (8–9), moderate (10–14), severe (15–19) and extremely severe (20 and above). The stress subscale of the DASS-21 was categorised into normal (0–14), mild (15–18), moderate (19–25), severe (26–33) and extremely severe (34 and above).27 29 For bivariate and multivariable analyses, scores within the normal range were considered to indicate absence of depressive, anxiety or stress symptoms, while scores above the normal range indicate presence of these symptoms, consistent with previous studies.16 28

The exposure variable was cyberbullying victimisation, measured using a self-developed tool that was developed following an extensive literature review and consultations with experts in public health, psychology and journalism. Initially, the adolescents were asked if they had experienced any form of cyberbullying in the past 12 months. To validate their response, the follow-up question enquired about the nature of the bullying they experienced through online mediums, presenting the list of different forms of electronic bullying commonly reported in Nepal. Further questions asked whether they could identify the bully, their immediate reaction to the incident and whether they were aware of any laws against cyberbullying. Participants who reported being cyberbullied and could specify the nature of the bullying were classified as cyberbullying victims. All the questionnaires used in this study were pretested among 50 female adolescents enrolled in the higher secondary school of Bhaktapur Municipality, where cognitive interviews were also taken for the DASS-21 and cyberbullying to ensure that the participants understood the questions. The questionnaire used in the survey is provided in online supplemental file 1.

Data processing, management and analysis

The collected data were carefully reviewed for completeness and were coded on the same day of data collection. For data entry, data entry marks were created in EpiData V.3.1 software, while the Statistical Package for Social Sciences (SPSS) V.20 was used for analysis. A total of 10% of the randomly selected data were manually rechecked for accuracy. The data were summarised in terms of frequency, percentage, mean and SD. Bivariate analysis was carried out by applying χ2 test to identify the factors associated with depression, anxiety and stress at a 5% level of significance. Variables found to be significant in the bivariate analysis were considered for multivariable analysis using binary logistic regression to determine the adjusted effect of each factor on the dependent variable. Multicollinearity between the independent variables was tested using the variance inflation factor (VIF) test before logistic regression analysis was performed. A VIF greater than 5 was taken to indicate multicollinearity.18 30 31

Patient and public involvement

None.

Results

A total of 512 female adolescent students were approached for data collection, of whom 8 did not provide parental consent and 3 chose not to complete the questionnaire. As a result, 501 students provided complete responses to all the questions, yielding a response rate of 97.85%. In terms of sociodemographic profile, participants’ age ranged between 16 and 19 years, with a mean age of 17.51±1.04 years. Almost half (50.5%) were below the age of 18 years. In terms of living companionship, most adolescents (70.1%) lived with their family, while only a small percentage lived alone (5.2%) or with friends (8.8%). In terms of parental education, almost three-quarters of the participants reported that both their parents had a formal education and agriculture was their main occupation (table 1).

Table 1

Sociodemographic characteristics of the participants

Out of a total of 501 participants, 163 (32.5%) reported being cyberbullied in the past 12 months. Of those who reported experiencing cyberbullying, 90 (55.2%) were adolescents below 18 years of age and 73 (44.8%) were ≥18 years of age. The most common forms of bullying experienced include receiving hurtful and threatening messages (27%), use of their photographs without consent (17.8%) and people asking for their nude photos (14.1%). Among the bullied adolescents, only 56 (34.4%) were able to identify their bullies, who were either their friends or individuals known to them. Only around a tenth (11.4%) of the adolescents knew about the laws governing cyberbullying in Nepal (table 2).

Table 2

Cyberbullying-related characteristics

The overall prevalence of depression, anxiety and stress among female adolescents was found to be 46.5%, 52.7% and 34.9%, respectively. Most participants experienced mild levels of depression, anxiety and stress. Details on the level of severity of depression, anxiety and stress are depicted in table 3.

Table 3

Prevalence of depression, anxiety and stress among participants (N=501)

The bivariate analysis revealed a statistically significant relationship between participants’ sociodemographic characteristics, such as age and living companionship, and depression, anxiety and stress status (p<0.05). Moreover, participants’ parental education was also found to be associated with depression, whereas ethnicity was found to be associated with participants’ stress (table 4).

Table 4

Association of sociodemographic variables with depression, anxiety and stress (N=501)

For the multivariate analysis, VIF test was performed among the independent variables, where the highest reported VIF was 2.830, indicating no issue of multicollinearity. It was observed that adolescents aged below 18 years had higher odds of experiencing depression (adjusted OR (aOR): 1.468, 95% CI 1.019 to 2.114), anxiety (aOR: 1.513, 95% CI 1.058 to 2.165) and stress (aOR: 1.470, 95% CI 1.008 to 2.144) than those aged 18 and above. In reference to adolescents living with their family, those who lived alone were twice more likely to be depressed (aOR: 2.473, 95% CI 1.073 to 5.700), anxious (aOR: 2.423, 95% CI 1.022 to 5.744) and stressed (aOR: 2.520, 95% CI 1.120 to 5.691). Parental education was also found to have an important role in participants’ depression levels. Furthermore, in terms of cyberbullying victimisation, adjusting it with other variables, the aOR for depression, anxiety and stress remained significant. Cyberbullying victims were seen to have higher odds of experiencing depression (aOR: 1.64, 95% CI 1.11 to 2.42), anxiety (aOR: 2.49, 95% CI 1.67 to 3.70) and stress (aOR: 2.59, 95% CI 1.74 to 3.86) in comparison with non-victims (table 5).

Table 5

Factors associated with depression, anxiety and stress (N=501)

Discussion

This study examined the prevalence of cyberbullying victimisation and psychological distress among female adolescents in Deumai Municipality, Ilam, Nepal. It was noted that 32.5% of female adolescents experienced cyberbullying in the past 12 months. This aligns with a study conducted in Pokhara Metropolitan, Nepal, which reported a lifetime prevalence of cybervictimisation of 42.2% among adolescents, with 24.2% experiencing victimisation in the 30 days prior to data collection.32 Similarly, our observed prevalence is slightly higher than a previous study in urban Nepal, where 10.2% of adolescents reported to have been bullied electronically.16 However, another study from Kathmandu, Nepal reported that 66.5% of female students had experienced online sexual harassment in their lifetime.21 In a systematic review based in Southeast Asian countries, the prevalence of cyberbullying was reported to range from 14.9% to 80%.33 Cyberbullying is an increasing concern throughout the world, regardless of national economy' is good, with an alarming rate of cyberbullying victimisation being reported among adolescents of developed as well as developing nations.3 6 34–36

This study found the overall prevalence of depression to be 46.5%. A similarly higher rate of prevalence was also noted by a previous study in urban Nepal, where 56.5% of high school adolescents were screened to have depressive symptoms.16 Similarly, in the context of rural Nepal, the rate of depression among adolescents was noted at 27%.17 These variations can be attributable to differences in sample size and study setting. This observed rate of depression highlights the fact that mental well-being is emerging as an important issue in Nepal. In the context of the Southeast Asian region, its prevalence lies between 17.7% and 41.1%.37–39 In the context of developing countries, around 36%–51.6% of adolescents are reported to experience depressive symptoms.40 41

In this study, 52.5% of the adolescents were reported to have anxiety. This is in line with a previous study from Kathmandu where the rate of anxiety among high school adolescents was 55.6%.16 On the contrary, a study among adolescent schoolgoers in India reported the rate of anxiety to be as high as 80.85%.42 In Southeast Asian countries, studies have reported that the rate of anxiety among adolescents could range from 3.9% to 22.8%.38 39 43 Likewise, the prevalence of stress among the adolescents observed in our study is almost similar to the prevalence reported by a previous study in Kathmandu Metropolitan, where 32.9% of high school adolescents were stressed.16 These prevalence rates of depression, anxiety and stress among school adolescents indicate an alarming concern for adolescent psychological well-being affecting the youths globally regardless of any national boundaries and economy.

In this study, sociodemographic factors such as age, living companionship and parental education were observed to have a significant relationship with depression, anxiety and stress status. It was found that adolescents aged below 18 years had higher odds of experiencing depression, anxiety and stress than adolescents above 18 years. Contrary to these findings, previous studies from Nepal revealed that age was not associated with depression, anxiety and stress among adolescents.16 17 Early adolescence is a period of transition where an individual undergoes numerous physical and psychological development, making it an anxious and stressful period.8 Similarly, this study revealed that adolescents who lived alone were twice more at odds of experiencing depression, anxiety and stress than those living with their families. This finding is supported by a previous study in Nepal and India reporting that adolescents staying away from home had higher levels of depression and stress.16 42 Meanwhile, adolescents living with family members have a strong support system, providing them better opportunities to share their emotions and issues with others, which may then serve as a protective factor against depression and stress.16

It was observed that parental education had an important role in participants’ depression status. This finding is supported by a previous study from Nepal stating that the educational status of parents was associated with depression, as students whose parents have higher levels of education were more likely to experience depression. Educated parents usually have higher expectations of their children in terms of good academic performance, which might be stressing to children who would want to keep up with such expectations.17 41 However, parental education might also contribute to positive health behaviours and better mental health in children, as parents with better health literacy might be more conscious about the mental health and well-being of their children.41 44 45

Cyberbullying victims were observed to have higher odds of experiencing depression (aOR: 1.64, 95% CI 1.11 to 2.42), anxiety (aOR: 2.49, 95% CI 1.67 to 3.70) and stress (aOR: 2.59, 95% CI 1.74 to 3.86) in comparison with non-victims. Similar to the findings of a previous study in Nepal, it was also indicated that the risk of developing depression, anxiety and stress was higher among those bullied via electronic means.16 A 3-year cohort study in India reported that adolescents experiencing cyberbullying victimisation were twice more likely to suffer from depressive symptoms than their counterparts.14 Cyberbullying has been suggested to have a significant negative impact on adolescents’ mental health.46 It can also lead to the development of pessimistic traits in an individual with feelings of loneliness, dehumanisation and helplessness, which might be major contributors to experiencing depression, anxiety and stress.47 There can also be a vicious cycle of psychological distress and bullying victimisation as those with higher anxiety, depression, loneliness and stress might be more engaged in social media and the internet as a way to divert their emotional struggles to other matters, while consequently being more at risk of internet addiction as well as being more vulnerable to cyberbullying.47 48 This marks an important concern towards cybersecurity, and more studies might be needed to better understand this scenario. This phenomenon could be better understood by qualitative studies exploring the true experiences of victims and their mental health.

Although this study is one of the few studies that have assessed cyberbullying and its relationship with depression, anxiety and stress among Nepalese female adolescents, it has certain limitations that should be considered when interpreting the findings. In an attempt to enhance the representativeness of the study, all the available higher secondary schools in Deumai Municipality were included in the study; however, being a culturally diverse nation, the study still could not capture the cultural, racial and ethnic diversity of Nepal. Although we took measures to reduce reporting biases in this self-reported survey, such as social desirability, recall bias or differing interpretations of symptoms, by providing a private setting at schools during data collection and by conducting an orientation session to clarify the survey questions, it is important to recognise that these biases may remain. While the DASS-21 is an effective screening tool for symptoms of depression, anxiety and stress, it should be noted that it is not a diagnostic instrument and therefore cannot provide a definitive diagnosis of these conditions. In addition, this is an institution-based, cross-sectional study and thus we might have missed some of the female adolescents experiencing cyberbullying and/or mental distress who were absent during the time of data collection. Moreover, this study only focused on female adolescents, considering their higher vulnerability to cyberbullying; however, male adolescents might also get victimised and this is something that needs to be explored further by other studies.

Conclusion

The study revealed that nearly one-third of adolescent girls experienced cyberbullying in the past year, whereas nearly half experienced depression, anxiety and stress. Cyberbullying victims were significantly more likely to experience psychological distress. Similarly, factors such as age, living accommodation and parental education play an important role in adolescents’ mental well-being. These findings underscore the urgency of addressing the growing menace of cyberbullying, which is becoming increasingly pervasive and detrimental to the mental well-being of adolescents. This highlights the need for better cybersecurity and strong legislative measures to address cyberbullying in order to safeguard the mental health of adolescents in the digital age.

Data availability statement

Data are available upon reasonable request. The data sets used in this study are available from the corresponding author upon reasonable request.

Ethics statementsPatient consent for publication

Not required.

Ethics approval

Ethical approval for this study was obtained from the Institutional Review Committee of CiST College (ref no: 04/077/078). Approval was acquired from the Deumai Municipality Office. Parental consent and participant assent were obtained from students below the age of 18 as part of the informed consent procedures, while informed consent was obtained from participants aged 18 and above. Students were provided with a consent form a few days prior to data collection and were requested to submit the form to the school if their parents agreed to their participation. Confidentiality of the collected information and the participants was maintained, for which unique participant code was used instead of the name of the participant.

Acknowledgments

The authors would like to thank the study participants who provided their valuable time and information. The authors are also grateful to the higher secondary schools and the teachers for their support, without which this study would not have been possible.