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Understanding adolescent bystander behavior

in cyberbullying and the potential of serious
digital games to promote prosocial behavior
and other healthy lifestyles

THESIS SEPTEMBER 2015

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Ann DeSmet
Ghent University
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 Understanding adolescent bystander behavior in cyberbullying and the potential
of serious digital games to promote prosocial behavior and other healthy lifestyles

Ann DeSmet

Thesis submitted in fulfilment of the requirements for the degree of

Doctor in Health Sciences

Ghent, 2015
Supervisor: Prof. dr. Ilse De Bourdeaudhuij (Universiteit Gent)
Co-supervisor: Prof. dr. Heidi Vandebosch (Universiteit Antwerpen)

Supervisory board:
Prof. dr. Greet Cardon (Universiteit Gent)

Examination board:
Prof. dr. Kristiane Van Lierde (Universiteit Gent)
dr. Pepijn Van Empelen (TNO Nederland)
Prof. dr. Michel Walrave (Universiteit Antwerpen)
dr. Veerle Stevens (CGG Passant)
Prof. dr. Els Clays (Universiteit Gent)
Prof. dr. Leen Haerens (Universiteit Gent)

Acknowledgment:
The original research included in this doctoral thesis was conducted as part of the Friendly Attac project.

The Friendly Attac project was financially supported by the Flemish Agency for Innovation through Science

and Technology (IWT).

Illustrations by Pol Berlamont

2015 Department of Movement and Sport Sciences, Watersportlaan 2, 9000 Gent, Belgium
All rights reserved. No parts of this book may be reproduced, or published, in any form or in any way, by
print, photo print, microfilm, or any other means without prior permission from the author.
 TABLE OF CONTENTS

Summary .................................................................................................................................................1
Samenvatting ..........................................................................................................................................3

PART 1: GENERAL INTRODUCTION .............................................................................................7

PART 2: ORIGINAL RESEARCH ....................................................................................................79

Chapter 1: Understanding cyberbullying and cyberbullying bystander behavior.....................81
1.1. Study 1: Traditional and cyberbullying victimization as correlates of psychosocial distress
and barriers to a healthy lifestyle among severely obese adolescents a matched casecontrol
study on prevalence and results from a cross-sectional study ...............................................83
1.2. Study 2: Comparing associated harm with traditional bullying and cyberbullying: a narrative
overview of mental, physical and behavioral negative outcomes ...........................................97
1.3. Study 3: Determinants of self-reported bystander behavior in cyberbullying incidents
amongst adolescents .............................................................................................................125
1.4. Study 4: Deciding whether to look after them, to like it, or leave it: a multidimensional
analysis of predictors of positive and negative bystander behavior in cyberbullying among
adolescents ............................................................................................................................137
1.5. Study 5: Secondary school educators perceptions and practices in handling cyberbullying
among adolescents: a cluster analysis ....................................................................................187

Chapter 2: Understanding the potential of serious games to promote healthy lifestyles ........199
2.1. Study 6: A meta-analysis of serious digital games for healthy lifestyle promotion .............201
2.2. Study 7: The effect of behavioral change techniques and game features in serious digital
games for healthy lifestyle promotion: a meta-analysis ........................................................217
2.3. Study 8: Assessing the moderating role of participatory design in serious game effectiveness:
a meta-analysis of serious games for healthy lifestyle promotion ........................................257

Chapter 3: Using the Intervention Mapping Protocol in the design of a serious game to
promote positive bystander behavior among adolescents ..........................................................287
3.1. Study 9: Bridging behavior science and gaming theory: using the Intervention Mapping
Protocol in the design of a serious game to promote positive bystander intervention in
cyberbullying among adolescents .........................................................................................289

PART 3: GENERAL DISCUSSION.................................................................................................341

Appendices ..........................................................................................................................................373
Publications and conference contributions ......................................................................................461
Acknowledgments...............................................................................................................................471
 SUMMARY

Cyberbullying entails bullying, an intentional act to cause repeated harm or distress to the victim, using
electronic or digital media. Cyberbullying among adolescents can be considered a public health problem
that warrants specific research attention and interventions. The quality-of-life and health problems that
youngsters who are involved in cyberbullying experience, may be reduced by promoting positive
bystander behavior. Positive bystander behavior includes comforting the victim or giving advice,
reporting it to adults or assertively defending the victim. Passive bystanding, reinforcing or joining the
bully is considered negative bystander behavior that can sustain or aggravate the cyberbullying and its
harm. Serious digital games are interventions which are both engaging and educational, and may hold
promise to address cyberbullying, since the appeal of this medium to adolescents. This doctoral thesis
aims to contribute to literature by addressing the development of interventions to end cyberbullying and
reduce its harm. The aims of the original research included in the thesis were threefold. A first aim was
to improve the understanding of health problems related to cyberbullying in adolescents, and to
understanding cyberbullying bystander behavior. A second aim related to the potential of serious digital
games to improve social behavior and other healthy lifestyles. A third aim was to describe the
development of a serious digital game to promote positive bystander behavior among adolescents.
The results of studies addressing the first aim showed that cyberbullying relates to some different health
problems than traditional bullying and warrants specific attention in research and interventions.
Bystander behavior plays a role in cyberbullying, and is a context-dependent form of behavior
determined by several factors, such as intentions, attitudes, self-efficacy, skills and environmental
facilitators. These findings support the use of a behavior change and socio-ecological theoretical
perspective. Considering bystander behavior as fixed, stable roles does not seem endorsed. Adolescents
need support from educators and parents to act as a positive bystander, whereas this support is currently
largely lacking. Educators, especially teachers, are in need of training on how to handle cyberbullying.
The studies addressing the second aim showed that serious digital games are on average effective in
promoting social behavior and other healthy lifestyles. Although effects on behavior were small, they
were significant and in line with effects of other computer-delivered interventions. Effects were largest
on knowledge, also consistent with findings from computer-delivered interventions. Efforts are needed
to increase the effectiveness of serious games on other determinants of behavior, such as behavioral
intention and self-efficacy. Several moderators exist that can increase games effectiveness. Games that
were developed using a gaming theory, or both gaming theories and behavioral prediction theories were
more effective than other games. This underlines the specificity of games as a health promotion tool
compared to other interventions which can be effective when only using behavior change theories. The
higher effectiveness of using theories that can increase games motivational appeal, combined with
theories that can effectively change health behavior, shows the need for a sound theoretical foundation
of fun and learning, which are considered the main characteristics of serious games, to deliver that

1
promise. Next, games were more effective when they were tailored or adapted to the individual users
characteristics, confirming findings from other computer-delivered and print interventions. Serious
games were more effective if they had simpler challenges, with fewer game levels and used fewer game
features that are considered to be highly immersive (i.e. that may increase the fun, but could distract
from the learning content). This means that serious digital games may not need all the bells and
whistles of commercial games to be effective, and that simpler designs may in fact yield better learning
or behavior change outcomes. Unlike other health promotion interventions, the use of personal goal-
setting or planning techniques was related to lower effectiveness, where more research is needed to
understand this finding. Some game characteristics related to higher effectiveness only for certain
outcomes (e.g. knowledge, skills) but not for others, emphasizing that game design should be specific
for a certain health behavior or behavioral determinant in mind. Active involvement of users in the game
design, which may be important to ensure reach and adoption during implementation of the intervention,
was associated with less effective games. Based on the research findings, some recommendations were
made for active user involvement that can improve effectiveness: involving users as informants instead
of in co-design, involving them in decisions on the challenge, levels, rewards, game dynamics, and not
involving them in game aesthetics.
The research addressing the third aim described the development of a serious digital game to promote
positive bystander behavior. Although no effectiveness data are yet available, the evidence- and theory-
based intervention development increases the chances of reaching the desired effects on the program
outcomes, and may serve as a starting point for the design of other anti-cyberbullying programs.

2
 SAMENVATTING

Pesten is een doelbewust gedrag waarbij een pester het slachtoffer herhaaldelijk wil kwetsen. Als dit
pesten via digitale of elektronische media gebeurt, wordt het cyberpesten genoemd. Bij adolescenten is
cyberpesten een maatschappelijk gezondheidsprobleem dat specifieke aandacht vereist in onderzoek en
interventies. De gezondheids- en levenskwaliteitsproblemen die jongeren ervaren als ze betrokken zijn
bij cyberpesten, kunnen mogelijk begrensd worden door het positieve gedrag van toeschouwers. Positief
toeschouwersgedrag kan bestaan uit het slachtoffer te troosten of advies te geven, het cyberpesten te
melden aan volwassenen, of uit het assertief verdedigen van het slachtoffer. Passief
toeschouwersgedrag, de pester aanmoedigen of met het cyberpesten meedoen, wordt beschouwd als
negatief gedrag dat het cyberpesten en de problemen die er mee samengaan in stand kan houden of kan
verergeren. Serious digital games, of serieuze digitale spelletjes, zijn interventies die zowel educatief
als onderhoudend zijn, en hebben als interventievorm veel potentieel om cyberpesten aan te pakken,
aangezien serious digital games adolescenten bijzonder aanspreken. Dit doctoraat wil een bijdrage
leveren aan de literatuur, door de ontwikkeling te bespreken van interventies die het cyberpesten en zijn
gerelateerde problemen willen verminderen. Het onderzoek dat in het kader van dit doctoraat werd
uitgevoerd, heeft drie doelstellingen. Een eerste doelstelling was een beter inzicht te verkrijgen in de
gezondheidsproblemen die samenhangen met cyberpesten bij adolescenten en in het
toeschouwersgedrag van cyberpesten. Een tweede doelstelling bestond uit het vaststellen van het
potentieel van serious digital games om sociaal gedrag en andere gezonde levensstijlen te verhogen.
Als derde doelstelling had dit doctoraat de ontwikkeling van een serious digital game te beschrijven
dat positief toeschouwersgedrag in cyberpesten bij adolescenten wil verhogen.
De resultaten van het onderzoek dat aan de eerste doelstelling wou tegemoet komen, toonden aan dat
sommige gezondheidsproblemen die met cyberpesten samenhangen anders zijn dan diegene die met
klassiek pesten samenhangen. Cyberpesten vereist dus specifieke aandacht in onderzoek en interventies.
Het onderzoek toonde verder aan dat toeschouwersgedrag een rol speelt in cyberpesten, en dat dit gedrag
afhangt van de context waarin het cyberpesten optreedt. Bovendien wordt het toeschouwersgedrag
bepaald door verscheidene factoren, zoals intenties, attitudes, eigen-effectiviteit, vaardigheden en
faciliterende omgevingsfactoren. Deze bevindingen benadrukken dat het belangrijk is om dit gedrag te
bestuderen vanuit gedragsveranderingstheorien en vanuit een socio-ecologisch theoretisch kader. Het
toewijzen van toeschouwers aan vaststaande, stabiele rollen die ze in elk cyberpest-incident zouden
aannemen is mogelijk minder aangewezen, gezien het gedrag context-afhankelijk is. Adolescenten
hebben steun nodig van hun ouders en van onderwijzend en opvoedkundig schoolpersoneel om positief
toeschouwersgedrag te vertonen. Deze steun ontbreekt momenteel grotendeels. Er is een nood aan
opleiding voor schoolpersoneel, en vooral voor leerkrachten, om cyberpesten aan te pakken.
Het onderzoek naar de tweede doelstelling toonde aan dat serious digital games globaal gezien effectief
zijn in het bevorderen van sociaal gedrag en andere gezonde levensstijlen. Hoewel de effecten op gedrag

3
klein waren, waren ze wel significant en van gelijke grootte als de effecten van andere
computergestuurde interventies. De effecten waren het hoogst in het verhogen van kennis, wat ook
overeenstemt met bevindingen van andere computergestuurde interventies. Er is ruimte voor verbetering
wat betreft de effectiviteit van serious games op andere gedragsdeterminanten, zoals gedragsintenties
of eigen-effectiviteit. Verscheidene kenmerken kunnen de effectiviteit van deze spelen verhogen. Spelen
die ontwikkeld werden op basis van een bepaalde theorie, met name een gaming theorie, of de
combinatie van een gaming theorie en een gedragsveranderingstheorie, waren effectiever dan andere.
Dit benadrukt het unieke aan serious digital games als een middel in gezondheidspromotie vergeleken
met andere types interventies, die namelijk ook effectief kunnen zijn als ze enkel op
gedragsveranderingstheorien gebaseerd zijn. De hogere effectiviteit die verbonden is aan het gebruik
van theorien om de motivationele aantrekking van spelen te verhogen, in combinatie met theorien die
effectief gedrag kunnen veranderen, wijst op de nood aan een goede theoretische fundering van zowel
plezier als leren, de twee basiskenmerken van serious games. De games waren vervolgens ook meer
effectief als ze op maat van de individuele kenmerken van de speler aangepast werden. Dit bevestigt
resultaten van zowel computergestuurde interventies als schriftelijke interventieprogrammas. Spelen
waren effectiever als ze een eenvoudige uitdaging aanboden, met minder spelniveaus en ze minder
spelelementen gebruikten die beschouwd werden als immersie-verhogend (m.n. die het pleziergehalte
kunnen verhogen, maar zouden afleiden van de leerinhoud). Dit betekent dat serious digital games
mogelijk niet alle toeters en bellen nodig hebben zoals in commercile spelen om effectief te zijn, en
dat eenvoudigere ontwerpen zelfs tot betere leer- of gedragsveranderingsuitkomsten kunnen leiden. In
tegenstelling tot andere interventies in gezondheidspromotie, waren spelen die gebruik maakten van
goal-setting en planning minder effectief. Verder onderzoek is nodig om dit verschil te duiden.
Sommige kenmerken hielden enkel verband met een hogere effectiviteit op bepaalde uitkomsten (bijv.
kennis, vaardigheden) maar niet voor andere. Het is daarom belangrijk dat de keuzes in het ontwerp en
de ontwikkeling van het spel specifiek gemaakt worden met het oog op het gezondheidsgedrag of
gedragsdeterminant dat men wil benvloeden. Actieve betrokkenheid van de gebruiker in het ontwerp
en de ontwikkeling van het spel, wat tijdens de implementatie belangrijk kan zijn om het bereik en
adoptie van de interventie te verhogen, hing samen met een lagere effectiviteit van het spel. Op basis
van de onderzoeksbevindingen werden aanbevelingen gemaakt over hoe gebruikers actief kunnen
betrokken worden op een manier die met een hogere effectiviteit gepaard gaat, namelijk: het betrekken
van gebruikers als informanten en niet als mede-ontwikkelaars; hen betrekken in beslissingen over de
uitdaging, beloningen, speldynamiek; en hen niet betrekken in de uiterlijke, esthetische kenmerken van
het spel.
Het onderzoek in verband met de derde doelstelling van het doctoraat, beschreef de ontwikkeling van
een serious digital game om positief toeschouwersgedrag te bevorderen. Hoewel hiervoor nog geen
effectiviteitsdata beschikbaar zijn, kan de fundering van de interventie-ontwikkeling in evidentie en

4
theorien de kans verhogen dat de interventie zijn doelen en uitkomsten bereikt, en kan dit een basis
vormen voor de ontwikkeling van andere interventies tegen cyberpesten.

5
6
Part 1 GENERAL INTRODUCTION

7
8
 PART 1: GENERAL INTRODUCTION

The overall aim of this doctoral dissertation is to contribute to the development of evidence-based
interventions to change bystander behavior in cyberbullying among adolescents, and to the development
of evidence-based serious digital game interventions to promote social behavior and healthy lifestyles.

A need for more research on cyberbullying founded in behavior change theories was recently
recognized, to increase the effectiveness of cyberbullying prevention and intervention programs
(Tokunaga, 2010). The precise application of theories in behavior change programs is, however, often
problematic (Michie et al., 2011). The Intervention Mapping protocol aids in the theory- and evidence-
based development of health promotion programs (Bartholomew, Parcel, Kok, Gottlieb, & Fernndez,
2011). The protocol consists of six steps, of which the first four will be addressed in this dissertation.
These four steps (1. needs assessment; 2. determinants and change objectives; 3. change methods and
practical applications, and 4. program development), also structured the introduction and provided the
rationale for the research aims stated at the end of the introduction.

As this dissertation is framed within the objective to design a serious digital game to promote positive
bystander behavior in cyberbullying among adolescents, the introduction first presents an overview of
current literature on cyberbullying and serious digital games. This comprises definitions, current
prevalence data, risk factors and health consequences related to cyberbullying, the role of bystanders,
current evidence on cyberbullying intervention programs and the potential of serious games to promote
social behavior and healthy lifestyles (part 1). A second part describes original research conducted
within this dissertation. A first chapter in this second part further explores the needs assessment and
change objectives, by describing at-risk groups, negative health and behavioral outcomes of
cyberbullying, and individual and environmental behavioral determinants of bystander behavior in
cyberbullying. The potential of serious digital games to promote social behavior and other healthy
lifestyles, and moderators of serious game effectiveness are discussed in chapter 2. Chapter 3 presents
the development of an evidence-based serious game to change bystander behavior in cyberbullying
among adolescents. A final part addresses the need for theory- and evidence-based intervention
development in cyberbullying research and serious health games, and provides a synthesis of the
literatures on programs aiming to reduce cyberbullying and its harm, and on serious digital games to
promote healthy lifestyles.

9
General introduction

1. Bullying and cyberbullying among adolescents

1.1. Definition of bullying

Bullying is commonly considered as an intentional and repeated act to hurt, socially isolate or cause
distress to a victim. The victim is perceived to have less power than the perpetrator(s) and to have
difficulties in defending him- or herself (Olweus, 1997). These criteria of intentionality, repetition and
power imbalance are used to distinguish bullying from other forms of social interactions or aggressive
acts. First, intentionality reflects a persistence in negative acts on behalf of the perpetrator, despite being
aware that these acts cause distress to the victim. The offensive and hurtful nature of bullying
differentiates it from teasing, which is relatively friendly and not intended to hurt (Olweus, 1997).
Second, the criterion of power imbalance between perpetrator and victim is used to set aside bullying
from other forms of peer aggression, such as having an argument or conflict (Olweus, 1997).
Furthermore, the power imbalance creates a fear among victims to react, and exacerbates their
defenseless position. Their lack of response thus enables the bullying to continue (Smith & Brain, 2000).
Third, the criterion of repetition is imposed to indicate a level of psychosocial harm which may result
from the bullying incident. Both repetition and differential power, indeed, related to higher psychosocial
harm for victims of bullying (Ybarra, Espelage, & Mitchell, 2014). A number of studies have, moreover,
documented a dose-response relationship between the frequency of being bullied and psychosocial
harm: when a victim was bullied more frequently, psychosocial functioning was more impaired (Evans,
Smokowski, & Cotter, 2014; Gmez-Guadix, Orue, Smith, & Calvete, 2013; Natvig, Albreksten, &
Qvarnstrom, 2001). These studies, however, also showed that even infrequent victimization related to a
certain level of psychosocial harm. Some have, therefore, advocated not to apply the criterion of
repetition too strictly when defining bullying (Gmez-Guadix et al., 2013).

Several participants can be involved in bullying: those who are bullied (victims), those who bully
(perpetrators), those who are both bullied and bully others themselves (victim-bullies, or aggressive
victims) and bystanders. Bystanders can further be identified by the role they take in the bullying
incident: passive bystanders or outsiders (who have witnessed the incident but take no action, or
withdraw from the bullying incident), assertive defenders (who support the victim, report the incident
or confront the bully), joiners and assistants (who join, help or assist the bully), or reinforcers (who
reinforce the bullying, e.g. by laughing) (Gini, Albiero, Benelli, & Alto, 2008; Salmivalli, 2010).

Bullying has generally been classified in one of the following types: physical (e.g. hitting), verbal (e.g.
threatening), or relational (e.g. social exclusion) (Stassen Berger, 2007). Apart from classification by
type, bullying can also be described by its contact or attack mode. Direct bullying refers to a face-to-
face contact between perpetrator and victim that is directly observable, whereas indirect bullying

10
involves contact with a third party via whom the bullying occurs (Marini, Dane, Bosacki, & YLC-
CURA, 2006; Rivers & Smith, 1994). Connections between these classifications exist. Physical bullying
is often direct, whereas verbal bullying may be direct (e.g. threatening) or indirect (e.g. gossiping)
(Rivers & Smith, 1994). Relational bullying is usually performed via an indirect or covert mode of
contact (e.g. excluding someone from groups) (Marini et al., 2006). Although relational bullying is often
used as a synonym for indirect bullying (Dukes, Stein, & Zane, 2009; Scheithauer, Hayer, Petermann,
& Jugert, 2006; Woods & Wolke, 2004), it is imaginable that relational bullying could also be directly
observable to the victim, e.g. when a bully tells a victim he or she is not allowed to stand or sit with
them. These categorizations have proven useful, since the bullying categories related to different risk
factors (Marini et al., 2006; Rivers & Smith, 1994; Wang, Iannotti, & Nansel, 2009) and several types
of emotional (Ortega, Elipe, Mora-Merchan, Calmaestra, & Vega, 2009) or psychosocial harm (van der
Wal, de Wit, & Hirasing, 2003). These categorizations mainly stem from descriptions of bullying
involving face-to-face contact with a victim, or with a third party (e.g. in case of indirect bullying).

The rise of new digital media, such as social networking sites and mobile phones, created the opportunity
to conduct bullying via other means than face-to-face communication, i.e. cyberbullying. Since the
arrival of cyberbullying, the earlier form of bullying conducted in face-to-face contact has commonly
been referred to as traditional or offline bullying.

1.2. Definition of cyberbullying

Cyberbullying is generally defined as a form of bullying performed via electronic or digital media, such
as e-mail, cell phone, or social network sites, although variations in definitions exist (Tokunaga, 2010).
Some examples of cyberbullying are provided below, in comparison to traditional bullying forms
(Feinberg & Robey, 2009; Nocentini et al., 2010; Smith et al., 2008; Vandebosch & Van Cleemput,
2009):

11
Table 1. Examples of traditional bullying and cyberbullying
Traditional bullying examples
Direct forms
Physical / property Hitting, kicking, damaging property
Relational Telling a victim directly he/she is
not welcome to join
Verbal Insulting (e.g. calling names) or
threatening
Non-verbal Making obscene gestures
Indirect forms
Physical / property Inciting others to physically bully a
victim; involving others to secretly
hide objects belonging to the
victim; placing stolen objects in the
possession of the victim
Relational Excluding from groups, not inviting
to events; spreading rumors and
gossip
Verbal Creating nicknames for a victim in
group
Non-verbal Making insulting, denigrating or
obscene drawings of the victim
visible to others (e.g. paper, board,
graffiti)
How cyberbullying relates to traditional bullying, has been a topic of much debate. Some have
considered cyberbullying as an entirely new type of bullying, that shares certain characteristics with
Cyberbullying examples
Purposively sending computer
viruses
Visibly removing someone from an
online group
Sending insults or threats via
Internet or mobile phone
Sending threatening or obscene
images, using nasty emoticons
Hacking the victims social media
profile; posting images online of
physical bullying (happy
slapping)
Excluding someone from an online
group, asking others not to invite
someone; spreading gossip or
rumors via Internet or mobile
phone
Outing of confidential email
information; creating a fake profile
for the victim with unfriendly or
deceitful content; masquerading,
pretending to be someone else
Taking part in a voting on a
defamatory polling website ;
sending embarrassing (naked)
images of the victim to others
without the victims consent
(sexting)
12
traditional bullying, but substantially differs on some defining elements, and they mainly emphasize
cyberbullyings uniqueness (Patchin & Hinduja, 2010; Patchin & Hinduja, 2011). Others have mostly
considered it as form of indirect bullying, and classified cyberbullying as another, but distinct, category
next to traditional forms of verbal, physical and relational bullying (Wang et al., 2009; Wang, Iannotti,
Luk, & Nansel, 2010). Some studies emphasized generic bullying that may take place in several
locations, for example, at school (traditional bullying) or from behind the computer at home
(cyberbullying). In this case, cyberbullying is viewed as just an electronic extension of school bullying,
which may take place in a different location (Juvonen & Gross, 2008; Olweus, 2012).

Defining elements
Multiple definitions of cyberbullying exist, which mostly differ in their specification of repetition and
power imbalance (Tokunaga, 2010). There appears to be a consensus on the need for cyberbullying to
be an intentional act (Kiriakidis & Kavoura, 2010; Tokunaga, 2010), although one study reports
adolescents judged cyberbullying also by the impact it had on the victim, and not only by the intentions
of the bully (Nocentini et al., 2010).

Several authors argued that the victim does not need to be targeted in repeated incidents of cyberbullying
to qualify as bullying, since cyberbullying can result in repeated harm without re-occurring incidents
(Dooley, Pyzalski, & Cross, 2009; Grigg, 2010; Kowalski & Limber, 2007; Vandebosch & Van
Cleemput, 2008). In some forms of cyberbullying, such as when posting content online, a single act can
result in exposure that is repeated, and can reach a large audience, leading to significant psychosocial
harm (Slonje & Smith, 2008). For example, posting an embarrassing picture online, which is a single
act with a large audience, was considered to be most harmful by youngsters (Smith et al., 2008).
Repeated exposure resulting from a single cyberbullying incident may furthermore occur when a
message is shared by others (Grigg, 2010), or when traditional bullying preceded or followed the single
act of cyberbullying (Vandebosch & Van Cleemput, 2008). This last conclusion was made in qualitative
research among 279 Flemish youngsters between the age of 10 and 19 years. Repetition could thus arise
from several forms of bullying. Victimization from several forms of bullying was, indeed, more harmful
than victimization by only one form (Wang et al., 2010). Since the notion of repetition is mainly included
in a bullying definition as a predictor of psychosocial harm, using a more lenient definition on repetition
and frequency can be defended given the potential for serious harm from a single act of cyberbullying.
In adolescents views, however, the repeated nature also helps to distinguish between a joke and a bullys
intention to hurt (Nocentini et al., 2010).

Next, the power differential between perpetrator and victim may be harder to detect in cyberbullying.
In bullying, power differences may relate to physical, psychological or social characteristics. The
perpetrator may be bigger or stronger than the victim (Ybarra et al., 2014), may be older (Arseneault,
Bowes, & Shakoor, 2010), may be perceived as mentally more resilient (Olweus, 1997), may be more

13
popular, have more friends (Ybarra et al., 2014), or as a group of perpetrators may outnumber the victim
(Smith & Brain, 2000). This defining criterion of power imbalance has been questioned in
cyberbullying, since physical superiority would be harder to detect (Kiriakidis & Kavoura, 2010).
However, youngsters themselves indicated that most bullies are known by victims in real-life and their
physical power is determined offline (Vandebosch & Van Cleemput, 2009). Power imbalance in
cyberbullying may also stem from other differences than physical power between bullies and victims.
First, victims may be less popular than bullies. Research showed that victims of cyberbullying were
significantly less popular online than those non-victimized, but this was not significantly different for
their social popularity at school (Katzer, Fetchenhauer, & Belschak, 2009). Second, bullies may be older
than their victims. Perpetrators of cyberbullying were on average found to be slightly older than victims
of cyberbullying (Van Cleemput et al., 2013). When the perpetrator was an adult, cyberbullying was
especially distressing for the victim (Ybarra, Mitchell, Wolak, & Finkelhor, 2006). Third, the bully
exerts some power from being able to remain anonymous in cyberbullying (Dooley et al., 2009), which
may increase the victims fear and insecurity (Nocentini et al., 2010). Most perpetrators, however,
choose not to remain anonymous, since only 35% of victims did not know the identity of the bully
(Dehue, Bolman, & Vllink, 2008). Public cyberbullying, visible to a large number of people, may also
provide more power to the bully (Nocentini et al., 2010). While anonymity and visibility may support
power differences between bully and victim, these were not considered to be key defining elements
necessary for all types of cyberbullying (Nocentini et al., 2010). Some suggested perpetrators of
cyberbullying may derive their power from having more technological skills, also named the revenge
of the nerds (Ybarra & Mitchell, 2004a). While in one study adolescents who perceived their Internet
skills to be excellent were more often perpetrators of cyberbullying (Ybarra & Mitchell, 2004b), other
research among 2052 primary and secondary Flemish schoolchildren did not support this hypothesis
(Vandebosch & Van Cleemput, 2009). Many cyberbullying acts indeed do not require advanced
technological skills (Dooley et al., 2009). In sum, regardless of physical power imbalances, there may
still be a power differential between perpetrators and victims of cyberbullying based on other criteria,
such as online popularity (Katzer et al., 2009), age (Van Cleemput et al., 2013), numbers (Nocentini et
al., 2010), anonymity (Dooley et al., 2009; Nocentini et al., 2010), or mental resilience (Gmez-Guadix
et al., 2013; Yang et al., 2013). Adolescents themselves, indeed, considered power imbalance as a crucial
criterion to define cyberbullying (Menesini et al., 2012).

To conclude, both intentionality, repetition, and power imbalance may be present in cyberbullying as in
traditional bullying, but can manifest themselves in different ways than in traditional bullying.

Bullying types and contact modes

Not all categories of the previously mentioned categorization by bullying type were considered
applicable to cyberbullying. Cyberbullying conducted on the Internet has been linked to verbal and
psychological bullying, whereas physical bullying was considered impossible online (Katzer et al.,

14
2009). Both perpetration and victimization in cyberbullying were strongest correlated with the relational
form of traditional bullying, compared to other forms of bullying (Modecki, Minchin, Harbaugh, Guerra,
& Runions, 2014).

Also not all contact modes were considered applicable to cyberbullying. Cyberbullying may seem to be
a form of covert, indirect bullying, but examples of bullying clearly intended as direct, overt
communication, such as hate mail, also exist (Spears, Slee, Owens, & Johnson, 2009). Vandebosch &
Van Cleemput (2009) provided a comparison of direct and indirect bullying types in traditional bullying
and cyberbullying, and concluded, based on research among 2052 primary and secondary Flemish
schoolchildren, that both direct and indirect bullying can take place in cyberbullying, in similar ways as
in traditional bullying (Vandebosch & Van Cleemput, 2009). Examples of cyberbullying incidents (both
Internet and mobile phone devices) could be found for all abovementioned types and contact models. In
spite of earlier mentions of cyberbullying as non-physical and as indirect (Katzer et al., 2009), this
overview also included examples of physical-direct cyberbullying (e.g. by damaging the victims
property when deliberately sending a computer virus).

Categorizing cyberbullying as a distinct form, next to physical, relational and verbal bullying, or as only
an indirect contact mode of bullying, does therefore not appear to be supported by research evidence.

Specifically for cyberbullying, the electronic device through which the bullying takes place, may also
be used as a way to describe bullying by contact mode (Smith et al., 2008). Harm related to
cyberbullying, indeed, differed by electronic contact mode (Smith et al., 2008). But when defining
cyberbullying, a definition should not restrict to certain electronic contact modes, since these modes
may evolve quickly due to technological innovations (Slonje & Smith, 2008).

Location where bullying takes place

Traditional bullying may happen in several places, such as school, family or leisure context. Bullying
in family life is, however, more often referred to as abuse (Smith & Brain, 2000). The most frequent
location for traditional bullying among youngsters is school bullying, taking place between peers at
school (Smith et al., 2008). Cyberbullying is also assumed to occur mostly among peers who know each
other from school, since electronic communication is conducted mostly with schoolmates (Juvonen &
Gross, 2008). Although victimization of cyberbullying often occurred outside of school (Slonje & Smith,
2008), 72% of victims who knew their bullies, knew them from school (Smith et al., 2008). In these
cases, it has been considered by some as the cyberspace extension of school bullying (Kubiszewski,
Fontaine, Potard, & Auzoult, 2015). Support for this view is drawn from the substantial overlap in
involvement in school bullying and cyberbullying: 85% of those who were cyberbullied, were also
victims of school bullying (Juvonen & Gross, 2008; Raskauskas & Stoltz, 2007). Inconsistent results
have, however, been reported in this overlap between traditional and cyberbullying victimization, with
much smaller percentages of overlap (i.c. 38%-40%) reported in other studies (Kowalski & Limber,

15
2013; Ybarra, Diener-West, & Leaf, 2007). It is furthermore possible that adolescents do not fulfill the
same participant roles in traditional bullying and cyberbullying, and that victims from traditional
bullying show an increased risk of being a perpetrator from cyberbullying (Jang, Song, & Kim, 2014;
Kubiszewski et al., 2015). Other counterarguments for considering cyberbullying as an extension of
school bullying are, for example, also found in differences between traditional bullying and
cyberbullying related to their harm and to communication-technology related motives for perpetration
(e.g. lack of moral inhibition due to anonymity and low emotional reactivity) (Kubiszewski et al., 2015).

In sum, traditional (school) bullying and cyberbullying share common defining elements (i.c.
intentionality, repetition and power imbalance), which may manifest themselves in different ways in
traditional bullying or cyberbullying. A substantial group of adolescents is involved in both types of
bullying, although the size of overlap is as yet unclear and may differ between participant roles. As
related phenomena, they should be studied jointly, to allow a detailed assessment of causes and
consequences for separate and combined roles. Current cyberbullying research, indeed, appears to
recognize the importance of studying cyberbullying together with traditional bullying, while also paying
attention to the specificities afforded by the electronic means, such as anonymity and lack of adult
supervision, visibility, and specific (electronic) contact mode (Kowalski, Giumetti, Schroeder, &
Lattaner, 2014).

1.3. Prevalence of cyberbullying

Systematic reviews reported that around 9-49% of youngsters experienced cyberbullying as victims
(Kiriakidis & Kavoura, 2010; Tokunaga, 2010; Hinduja & Patchin, 2012), and that around 4-21% of
youngsters were involved in cyberbullying as perpetrators (Hinduja & Patchin, 2012; Kiriakidis &
Kavoura, 2010). These figures indicate that wide variations exist in the rates of cyberbullying
involvement among youngsters. Variations may firstly stem from sample differences, for example in the
age of participants, since older adolescents report less cyberbullying involvement than younger
adolescents (Tokunaga, 2010). Secondly, variations can result from measurement differences (Vivolo-
Kantor, Martell, Holland, & Westby, 2014), such as 1) divergences in using single-item or multiple-
item scales (Gradinger, Strohmeier, & Spiel, 2010); 2) whether or not a definition of cyberbullying was
provided to participants (Kiriakidis & Kavoura, 2010; Tokunaga, 2010; Olweus, 2012); 3) whether the
definition related to all potential electronic means, or restricted these to just one or some (Juvonen &
Gross, 2008; Kubiszewski et al., 2015); and 4) differences in the timeframe provided to participants
when asking about their cyberbullying involvement (e.g. lifetime experience, experience in past 6
months) (Olweus, 2012; Tokunaga, 2010).

These varying prevalence rates were summarized in a recent meta-analysis across 80 studies in
adolescents (aged 12-18 years), to a rate of 15% for victimization and to 16% for perpetration of

16
cyberbullying (Modecki et al., 2014). With prevalence rates of 36% for victimization of traditional
bullying, and of 35% for traditional bullying perpetration, it is clear that cyberbullying is a less common
phenomenon than traditional, offline bullying. These prevalence rates for cyberbullying involvement
have furthermore been relatively stable in recent years (since 2007). Reporting of cyberbullying
incidents may have increased over the years, but in recent years, no increase in cyberbullying incidents
has been noted when assessed with a consistent measure and in similar populations (Olweus, 2012;
Hinduja & Patchin, 2012).

In Flanders, the most recent prevalence rates come from a longitudinal survey conducted over 2 years
(2011-2013), among 10-14 year old children. This survey is part of the DICA study (Developmental
Issues in Cyberbullying amongst Adolescents). The reported prevalence of cyberbullying perpetration
at least once in the past 6 months, ranged from 5% to 8% between the 4 time points, and from 8% to
22% for traditional bullying perpetration (Pabian & Vandebosch, 2014a). Victimization rates were
reported in another paper on the same study, only including the first two time points. Victimization rates
of traditional bullying ranged from 22% to 28% between these time points, and from 10% to 11% for
cyberbullying victimization. In comparison, between 15% to 23% of adolescents reported perpetration
of traditional bullying for these first two time points, and 10% reported cyberbullying perpetration
(Pabian & Vandebosch, 2015).

As mentioned above, a degree of overlap between victimization rates of cyberbullying and traditional
bullying exists, which ranges from 38 to 85% (Juvonen & Gross, 2008; Kowalski & Limber, 2013;
Raskauskas & Stoltz, 2007; Ybarra et al., 2007). A meta-analysis of 80 studies indicated that correlations
for involvement as perpetrators of traditional bullying and cyberbullying were stronger (average r=0.47,
95% CI 0.47;0.47) than the correlations between victimization of traditional bullying and of
cyberbullying (average r=0.40, 95% CI 0.40;0.41) (Modecki et al., 2014). A recent study surveyed
samples large enough to distinguish between pure victims and victim-bullies (or aggressive victims) for
traditional bullying and/or cyberbullying (Campbell, Spears, Slee, Butler, & Kift, 2012). Of the 3112
adolescents surveyed, 58% was not involved in any type of bullying as victim or victim-bully; 5% were
victim-bullies of both cyber- and traditional bullying; 5% were pure victims of both cyber- and
traditional bullying; 5% were victim-bullies only of traditional bullying; 16% were pure victims only of
traditional bullying; 2% were victim-bullies only of cyberbullying; and 5% were pure victims only of
cyberbullying. Unfortunately, no data were available in this study on the pure perpetrator role.

1.4. Theoretical foundation in cyberbullying studies

Reviews on cyberbullying have remarked a general lack of theoretical foundation when studying this
phenomenon (Kowalski et al., 2014; Tokunaga, 2010). Where theories are used, these can be roughly
classified in five types: 1) behavior prediction theories that explain cyberbullying behavior from a

17
personal deficit perspective; 2) behavior prediction theories that explain cyberbullying or victimization
behavior from a personal reaction to experiencing stress; 3) behavior prediction theories that predict
cyberbullying or victimization behavior from individual and social influences; and 4) behavior change
theories that explain cyberbullying or victimization behavior from individual and social influences,
driven by evidence-base on how to change behavior. 5) theories of computer-mediated communication,
that examine communication-specific characteristics that explain how social media are used.

First, an example of a personal deficit theory is the theory on Social-Cognitive Information Processing
(see e.g. Ang, Tan, & Mansor, 2011; Dooley et al., 2009). This theory states that five social-cognitive
processes are needed for appropriate social behavior (i.c. encoding of stimuli, interpreting and attributing
intent and causality, generating a social goal, generating responses in line with this goal, and choosing
the response with the highest value). People who tend to react aggressively to neutral situations, show
deficits in one or more of these social-cognitive processes. Applied to cyberbullying, approval of
aggression as an acceptable response to situations was higher among perpetrators compared to other
adolescents (Ang et al., 2011). Social intelligence was not found to be lower among perpetrators of
cyberbullying. On the contrary, Flemish results from the DICA study among 1103 adolescents aged 10-
14 years and followed-up over a 2 year-span, showed they had significantly higher levels of social
intelligence than non-cyberbullies (Pabian & Vandebosch, 2014a). Another example of a deficit theory
applied to cyberbullying is the self-control theory. This posits that cyberbullying is a form of
externalizing behavior, characterized by a lack of self-regulating capacity, which entails a search for
immediate gratification without considering long-term consequences, and low adherence to social norms
(Vazsonyi, Machackova, Sevcikova, Smahel, & Cerna, 2012).

Second, a theoretical framework used to study risk factors for cyberbullying involvement, is the General
Strain Theory. This theory is used to explain both externalizing (i.e. reacting to negative emotions with
harming others) behavior in perpetrators, as well as psychosocial problems among victims of
cyberbullying (Jang et al., 2014). In the first case, the strain or source of stress may relate to factors
external to the peer victimization (e.g. parental divorce) that contribute to cyberbullying behavior. In the
second case, the victimization of cyberbullying is considered as the strain or source of stress, which can
lead to additional psychosocial problems for the victim (e.g. depression, suicidal ideation). This is
sometimes also labeled the Stress Generation Model (Gmez-Guadix et al., 2013; Hammen, 1991).
Applied to cyberbullying, cyberbullying victimization was significantly related to problem behaviors
(e.g. substance abuse), but this relationship was fully mediated by the strain they experienced (Hinduja
& Patchin, 2007). Other examples are the Risk and Resilience framework (Tynes, Umaa-Taylor, Rose,
& Lin, 2012) and Stress Coping models (Vllink, Bolman, Dehue, & Jacobs, 2013), which mainly
explain mediators in the harm that is experienced related to cyberbullying.

18
Third, some theories have integrated personal factors as well as social influences in predicting
cyberbullying involvement or related harm, such as the Social Ecological framework (Bauman, 2010;
Hemphill et al., 2012), the Interpersonal Theory of Suicide (Bauman, Toomey, & Walker, 2013;
Litwiller & Brausch, 2013), and the General Aggression Model (Kowalski et al., 2014). For example,
the Interpersonal Theory of Suicide states that thwarted belongingness and perceived burdensomeness
cause suicidal desire, which only translates into suicidal behavior if the person becomes habituated to
self-harming behavior. Cyberbullying is considered one possible environmental cause of thwarted
belongingness and perceived burdensomeness (Litwiller & Brausch, 2013). The General Aggression
Model was used to summarize findings on predictors and psychosocial outcomes of cyberbullying
perpetration and victimization across 131 studies (Kowalski et al., 2014). This model identifies an
input, such as personal factors (e.g. gender, age), and situational factors (e.g. perceived support, school
climate) which can predict cybervictimization or -perpetration. Routes (e.g. cognition) and proximal
processes (e.g. decision-making on how to act), will lead to coping and psychosocial health outcomes
for victims, and to cyberbullying perpetration and psychosocial health outcomes for bullies. It relies
heavily on Social-Cognitive Information Processing theories. This model was used as a framework for
summarizing currently available research evidence on perpetration and victimization from
cyberbullying.

Fourth, behavior change theories have been used not only to predict cyberbullying and victimization
behavior, but also to provide levers for changing this behavior. Examples of these theories are Social
Cognitive Theory, Theory of Planned Behavior and Reasoned Action Approach. These theories not only
look for factors which predict the behavior, but for predictors that are both important and can be changed
(Bartholomew et al., 2011). In general, they recognize eight core determinants of behavior: cognitive
and affective attitudes, social and personal norm, perceived capability to perform the behavior, skills,
environmental constraints, and behavioral intention (Bartholomew et al., 2011). Most theories recognize
both individual and environmental determinants of behavior, in an ecological model of behavior
(Bartholomew et al., 2011). These have been applied to explain cyberbullying perpetrator behavior,
investigating changeable determinants of behavior that can be addressed with behavior change methods
(Doane, Pearson, & Kelley, 2014; Heirman & Walrave, 2012; Pabian & Vandebosch, 2013; Pabian &
Vandebosch, 2014b). Longitudinal research was conducted in Flanders, as part of the DICA project, and
studied cyberbullying perpetration in a 1-year follow-up design among 1606 students aged 11-17 years.
This study indicated that 29% of behavioral intentions to cyberbully others were predicted by attitudes
(e.g. considering cyberbullying others as exciting, as a good way to vent emotions), social norms (e.g.
social pressure, perceiving that others would approve of cyberbullying) and perceived behavioral control
(e.g. finding it easy to cyberbully) (Pabian & Vandebosch, 2014b). The authors conclude by
recommending specific behavior change strategies (e.g. anticipated regret) for the main behavioral
determinants, to achieve the desired change in behavior.

19
Fifth, some studies in cyberbullying have specifically focused on characteristics of information and
communication technologies (ICT), that can contribute to adolescents involvement in cyberbullying,
whereas they may otherwise not be involved in bullying without these technologies (Tokunaga, 2010).
Examples of these theories are the Affordances Theory, focusing on ICT features such as connectivity,
visibility, accessibility, persistence and social feedback (Bastiaensens et al., 2014a; Fox & Moreland,
2015); Routine Activities Theory (Navarro & Jasinski, 2013), suggesting that ICT habits may put
adolescents at risk for cyberbullying involvement; and Media Richness Theory (Brandtzg, Staksrud,
Hagen, & Wold, 2009), which posits that richer, more personal media allow for a higher psychological
presence and less rich media can lead to de-individuation and misunderstandings. The use of these
theories is advocated to better understand differences between traditional bullying and cyberbullying
(Tokunaga, 2010).
In sum, although many studies on cyberbullying may be conducted without a theoretical foundation,
studies founded on theories also exist. These theories mostly vary in their breadth (individual,
environmental factors), and their purpose of understanding behavior versus being action-oriented to
inform future behavior change interventions. In designing evidence-based behavior change programs,
the latter theories may be more functional.

1.5. Risk factors for cyberbullying and victimization

Several risk factors have been identified for involvement in cyberbullying as perpetrator or victim,
grouped below, in accordance to existing reviews, as individual or social/situational factors.

1.5.1. Individual factors

Involvement in other forms or other roles of bullying
A meta-analysis indicated that involvement in traditional bullying was a significant predictor of
involvement in cyberbullying. Being a perpetrator of traditional bullying moderately predicted
cyberperpetration, whereas being a victim of traditional bullying was a weak predictor of
cyberperpetration. Similarly, being a victim of traditional bullying moderately predicted
cybervictimization, whereas being a perpetrator of traditional bullying was a weak predictor of
cybervictimization. Furthermore, cybervictimization was a strong predictor of cyberperpetration
(Kowalski et al., 2014).

Age

A systematic review of research data showed a curvilinear relation between cyberbullying victimization
and age, with a peak in 7th and 8th grade (12-15 year olds), and decreasing towards later adolescence
(Tokunaga, 2010). With an increased use of new digital media at a younger age, the question arose
whether cyberbullying would peak in a younger population since this last review (2010). Prevalence
rates of cyberbullying among elementary school children are, however, not often studied (Kowalski &

20
Limber, 2007; Lee, 2015; Vandebosch & Van Cleemput, 2009; Williams & Guerra, 2007; Dehue et al.,
2008). One study found no significant differences between cyberbullying or victimization rates
between elementary and secondary school children (Dehue et al., 2008), whereas another study found
significantly lower rates of cyberbullying perpetration in elementary school than in secondary school
(Williams & Guerra, 2007). In other research dated from before 2010, 6th graders were less often
involved in cyberbullying than 7th-8th graders, and more specifically, were less often victims or
aggressive victims (Kowalski & Limber, 2007). Another study from the same time period, also reported
lower prevalence rates in 4-6th graders (3%) compared to 7th graders (11%) (Slonje, Smith, & Frisn,
2012).

A recent study showed prevalence of cyberbullying perpetration to be similar in 6th graders (11-12 year
olds) and 7th graders (12-13 year olds), but lower among 5th graders (10-11 year olds) (Lee, 2015). This
lower prevalence despite having the technological means to do so, may relate to a maturation effect in
cyberbullying. A maturation effect has been reported for perpetration of indirect bullying, but to our
knowledge, no research has yet been conducted on this regarding cyberbullying. The use of indirect
bullying was reported to depend on maturation, and was only developed at the age of 11 (in comparison
to 8-year olds) (Bjrkvist, Lagerspetz, & Kaukiainen, 1992). If cyberbullying indeed requires a certain
maturation only taking place towards the end of elementary school, an increased use of electronic media
among younger age children may not result in cyberbullying perpetration at a younger age. It may,
however, relate to victimization at a younger age. Perpetrators of cyberbullying have indeed been
reported to be older than their victims (Slonje, Smith, & Frisn, 2013). This warrants further
investigation.

Gender

In traditional bullying, boys are generally more often perpetrators, although girls are more often
perpetrators of indirect types of traditional bullying (Dooley et al., 2009). Expectations for cyberbullying
were that prevalence rates would also be higher among girls, when assuming a similarity between
indirect bullying and cyberbullying (Dooley et al., 2009). This was, however, not supported in
systematic reviews of research evidence (Dooley et al., 2009; Kowalski et al., 2014; Slonje et al., 2013).
While some research reported higher perpetration of cyberbullying among girls than boys (see e.g.
Kowalski & Limber, 2007), others reported the opposite trend (see e.g. Jang et al., 2014), and yet others
found no difference (Slonje & Smith, 2008). Also for victimization, findings on gender differences
remain inconclusive (Dooley et al., 2009; Kowalski et al., 2014; Slonje et al., 2013; Tokunaga, 2010).
Inconsistent findings are assumed to relate to different types of cyberbullying being measured (e.g. e-
mail bullying targets more girls, whereas boys are more often bullied via mobile phone text messages)
(Kowalski et al., 2014).

21
Physical appearance

In traditional bullying, obese adolescents are especially prone to being bullied for their appearance
(Brixval, Rayce, Rasmussen, Holstein, & Due, 2011; Eisenberg, Neumark-Sztainer, Haines, & Wall,
2006; Eisenberg, Neumark-Sztainer, & Story, 2003; Gray, Kahhan, & Janicke, 2009; Kukaswadia,
Craig, Janssen, & Pickett, 2011; Lunde, Frisn, & Hwang, 2006; Wardle & Cooke, 2005). This risk
factor, however, has not been studied in any of the current systematic reviews on cyberbullying (Dooley
et al., 2009; Kowalski et al., 2014; Slonje et al., 2013; Tokunaga, 2010).

Qualitative research on appearance-related cyberbullying indicated that being cyberbullied for their
higher weight (e.g. being fat) was common among girls, who received more body-related comments.
Boys were more often bullied online for their style, e.g. for looking gay (Berne, Frisn, & Kling, 2014).
Cybervictimization was examined in the US Health Behaviour in School-Aged Children (HBSC) study
in 2005-2006 (Wang, Iannotti, & Luk, 2010). They found no association between cybervictimization
and weight group. Differences between boys and girls were found for victimization from traditional
bullying, but not for cyberbullying victimization. In total, 10% of the teenagers were cyberbullied, this
was 12% among obese teens. A more recent study in the US investigated cybervictimization among
adolescents attending a weight-loss program (Puhl, Peterson, & Luedicke, 2013). They reported very
high cybervictimization rates among those ever victimized (59% to 61% of those ever victimized were
cyber-victimized in the past year), but when estimating the prevalence in the total surveyed sample,
cyberbullying represented only between 10 to 12%, similar to the rates found in the US HBSC survey.
They did not compare these results with a general population sample and therefore do not provide further
insight in cyberbullying prevalence rates among obese youth compared to adolescents who have not
experienced weight problems. Further research is needed to assess the relative risk of obese youth in
cyberbullying compared to normal-weight adolescents.

Sexual orientation

Lesbian, gay, bisexual and transgendered youth (LGBT) were expected to be at higher risk of
victimization from cyberbullying, as they are also more often targeted in other forms of aggression
(Hinduja & Patchin, 2011). The little research on this topic, indeed, shows LGBT youth are more often
the victim of cyberbullying (Hinduja & Patchin, 2011; Priebe & Svedin, 2012; Schneider, O'Donnell,
Stueve, & Coulter, 2012; Wiederhold, 2014), but are also more often perpetrators of cyberbullying than
non-LGBT adolescents (Hinduja & Patchin, 2011).

Psychological factors

Psychological risk factors for cyberbullying have been grouped as factors related to personality and
motives, and to psychological states, in accordance with a recent review (Kowalski et al., 2014).

22
Perpetrators motives for cyberbullying have been suggested as more intrapersonal (e.g. to relieve
negative emotions), than as interpersonal (e.g. to gain popularity), since the effects of the perpetrators
actions are less visible to them than in traditional bullying (Kowalski et al., 2014).

More specifically, cyberperpetration was thought to be driven by intrapersonal motives of retaliation

and anger relief, narcissism, or impulsivity. A meta-analysis indicated that anger and narcissism were
weakly but significantly correlated as predictors of cyberperpetration (Kowalski et al., 2014). This meta-
analysis, however, only assessed correlations and not causal relations. Neither narcissism nor
impulsivity were predictors of cyberperpetration in a longitudinal study with a one-year follow-up
(Fanti, Demetriou, & Hawa, 2012). Callous-unemotional traits (e.g. lack of remorse and empathy) did
significantly predict cyberperpetration at one-year follow-up (Fanti et al., 2012). Other studies confirm
low empathic skills to be related to cyberbullying perpetration (Ang & Goh, 2010; Steffgen, Knig,
Pfetsch, & Melzer, 2011).

Other potential intrapersonal factors for perpetrators of cyberbullying relate to moral values and moral
disengagement. Moral values (i.c. normative beliefs about aggression) and moral disengagement (i.c.
attitudes to justify aggressive behavior in spite of holding non-aggressive moral values) were moderately
correlated as predictors of cyberperpetration in the same meta-analysis as mentioned above. This
contradicts findings from some studies that perpetrators of cyberbullying used less moral disengagement
attitudes than in traditional bullying (Perren & Gutzwiller-Helfenfinger, 2012; Pornari & Wood, 2010),
since the anonymity and little confrontation with the caused harm created less need for using disengaged
justifications.

Some studies also showed the importance of interpersonal motives for cyberperpetration. As in
traditional bullying, bullies and bully-victims were perceived as more popular (but not necessarily liked)
(Festl & Quandt, 2013; Vanden Abeele & De Cock, 2013), and may use the cyberbullying as a strategy
to maintain their social status. A Flemish study among 264 adolescents in 9th- 12th grade noticed this
was especially the case among girls (Vanden Abeele & De Cock, 2013). Longitudinal studies showed
that perceived popularity of cyberbullying perpetrators indeed increased over time (Wegge,
Vandebosch, Eggermont, & Pabian, 2014; Wright, 2014), for both boys and girls (Wegge et al., 2014).
These last data are derived from a Flemish study among 154 secondary-school aged children, between
the age of 12-14, who were followed-up after 8 months. Also in longitudinal research, intrapersonal
factors, such as moral disengagement, empathy and self-esteem, did not contribute independently to
predict cyberperpetration, when interpersonal factors, such as involvement in traditional bullying or
other antisocial behavior, were taken into account (Sticca, Ruggieri, Alsaker, & Perren, 2013).
Adolescents themselves reported they cyberbully others to get attention, feel better about themselves,
get their way, pick on someone who is different, and to be able to behave as someone else (Wilton &
Campbell, 2011).

23
In sum, there is little support so far for the statement that cyberbullying perpetration would be driven
mostly by intrapersonal motives, and less so by interpersonal motives.

Cyberbullying perpetration also correlated with several psychological states. In a longitudinal study,
depressive symptoms, anxiety and low self-esteem were predictive of cyberbullying perpetration (Yang
et al., 2013). It is, however, possible that much of these associations were due to internalizing problems
that victim-bullies experience. While pure cyberbullies did not experience more emotional problems
than non-involved youth, victim-bullies were 3 times more likely to experience emotional problems
compared to non-involved youth (Sourander, 2010). Other research confirmed that victims and victim-
bullies of cyberbullying experienced lower self-esteem, but that this was not the case for pure
cyberbullies (Chang et al., 2013). In line with the earlier reported finding that impulsivity did not predict
cyberbullying, a longitudinal study also found no predictive association between Attention Deficit
Hyperactivity Disorder (ADHD) symptoms and cybervictimization or perpetration at two-year follow-
up (Yang et al., 2013). Substance abuse was higher among perpetrators of cyberbullying than among
other youngsters, but it was unclear from the associations whether this could predict perpetration
(Sourander, 2010; Vieno, Gini, & Santinello, 2011).

Less research is available on motives, personalities and psychological states as predictors of

victimization in cyberbullying. Victims' personalities were characterized by higher neuroticism and
openness compared to adolescents who were not victimized by cyberbullying (Festl & Quandt, 2013).
Victim-bullies were less agreeable than others, and more extravert than pure victims (Festl & Quandt,
2013). They were also more connected with peers, both within their own circle of friends as outside of
this circle, giving them a central position in peer communication (Festl & Quandt, 2013). Cyberbullying
victimization was weakly but significantly correlated with predictors of anger, social anxiety, moral
disengagement and hyperactivity (Kowalski et al., 2014). A bidirectional relationship between
cybervictimization and depressive symptoms has been noted: cybervictimization increased depressive
symptoms, which in turn increased the risk of being cyberbullied (Gmez-Guadix et al., 2013).

Longitudinal data showed that lower self-esteem (Yang et al., 2013), more anxiety (van den Eijnden,
Vermulst, van Rooij, Scholte, & van de Mheen, 2013; Yang et al., 2013) and more substance abuse
(Gmez-Guadix et al., 2013) at baseline, were associated with cybervictimization at follow-up.
Substance abuse and anxiety were only predictors, and not consequences of cybervictimization. The
relations between these problems and cybervictimization were considered to be mediated by stressful
life events (Hinduja & Patchin, 2007; Yang et al., 2013). Online victimization was also significantly but
not very strongly related to ADHD symptoms (Helwig-Larsen, Schtt, & Larsen, 2012).

Internet use

Victims and perpetrators of cyberbullying use the Internet more intensively than those not involved in
cyberbullying as victims or bullies (Kowalski et al., 2014; Vandebosch, Van Cleemput, Mortelmans, &

24
Walrave, 2006). For Flanders, this was confirmed in the study commissioned by viWTA (Vlaams
Instituut voor Wetenschappelijk en Technologisch Aspectenonderzoek), which was conducted among a
sample of 2052 children and adolescents aged 9-19 year. One study found that time spent on the Internet
was a significant predictor of performing negative online behaviors such as cyberbullying. However,
dependency on Social Networking Services (SNS) (e.g. SNS use having a negative impact on their life
balance) and the use of advanced social networking features (e.g. creating video clips) were stronger
predictors of perpetration of negative online behaviors such as cyberbullying (Lee, 2015). Similarly for
victimization of cyberbullying, both time spent online and Internet dependency were significant
predictors, but Internet dependency explained more variance (Leung & Lee, 2011). A longitudinal study,
however, reported that problematic Internet use was a consequence of being cybervictimized, instead of
a predictor. Victims of cyberbullying may turn to increased use of social media to reduce feelings of
isolation and anxiety (Gmez-Guadix et al., 2013). This was the case for both victims and victim-bullies,
but was not investigated for pure perpetrators.

1.5.2. Social factors

Socio-economic status

Inconsistent results have been reported on the relation between socio-economic status (SES) and
adolescents involvement in cyberbullying. A study in Hong-Kong among 9-19 year olds showed that
cybervictims were more represented in high-income families than in lower-income families (Leung &
Lee, 2011). A US study among 7182 6th-10th graders also found that cybervictims had higher family
affluence (measured using the Family Affluence Scale) than non-cyber victims, but reported no
differences on cyberperpetration involvement (Wang et al., 2009). Another US study among 10-17 year
olds, however, found a significantly higher rate of cyberperpetration among high-income families than
among low-income families (Ybarra & Mitchell, 2004b).

A study from the UK among 12-13 year olds, showed no relation between ever having cyberbullied
someone and parental employment (Fletcher et al., 2014). In Turkey, SES (family income) was a
significant predictor of cybervictimization among 15-18 year olds, in which youngsters from high-
income families were more often cybervictimized than middle-income families, but there were no
differences with low-income families (Akbulut, Sahin, & Eristi, 2010).

In Flanders, cyberbullying perpetration and victimization were more prevalent among adolescents in the
vocational and technical education track, than in the general academic track (Vandebosch & Van
Cleemput, 2009). These conclusions were drawn from the adolescent subsample of the viWTA study,
consisting of 1416 adolescents, aged 12-18 years. The first two educational tracks show a considerable
overlap with a lower to medium socio-economic family background, whereas children in the general
academic track come more from families with a medium to high SES. These are data from the Flemish

25
Health Behaviour in School-Aged Children (HBSC) study, consisting of 10772 youngsters between ages
of 5th grade in primary school and 7th year in secondary school, or 13th grade (Hublet, Vereecken, &
Maes, 2012). An EU Kids Online report (Paus-Hasebrink, Sinner, & Prochazka, 2014) mentioned that
socially disadvantaged children use the Internet less, less often have Internet access on their mobile
phone, and their Internet use occurs more outside of the home. Parenting practices are often more
restrictive and their Internet use is less supervised. The report emphasizes that being socially
disadvantaged should not only be considered by hard criteria such as income, but also by many forms
of socio-emotional family conditions related to disadvantaged conditions, such as lack of time and
leisure opportunities (Paus-Hasebrink et al., 2014).

Apart from some deviating results, these studies also show differences in how socio-economic
background was operationalized, which may have contributed to these differences. Country differences,
as found for school bullying, may also explain some of these contrasting results. Contexts (class, school,
region and countries) with more socio-economic inequalities showed a higher occurrence of school
bullying than contexts with less income inequality (Azaredo, Rinaldi, de Moraes, Levy, & Menezes,
2015).

School and class climate

School safety and a positive school climate correlated as weak but significant protective factors against
both perpetration and victimization from cyberbullying in a meta-analysis (Kowalski et al., 2014).
Among all those involved in cyberbullying (victims, perpetrators, victim-bullies), there was a
significantly lower perception that their teachers cared about them compared to those non-involved
(Sourander, 2010).

A high degree of bullying in class also related to a higher degree of cyberbullying (Festl & Quandt,
2013). A class where most adolescents were liked, with little clique-forming, related to a lower degree
of cyberbullying (Festl & Quandt, 2013). Similarly, classes with less centralization of friendships online
and offline (friendships are distributed among many class members) and higher clustering online
(connected with your friends friends) related to less cyberbullying in this class (Heirman et al., 2015).
These last findings were based on a Flemish study conducted among 1428 adolescents in 8 th grade,
sampled from 11 schools.

Family support

Perceived social support correlated to both perpetration and victimization of cyberbullying (Kowalski
et al., 2014).

Parental monitoring, but not parental control of technology, was a weak protective factor against both
perpetration and victimization from cyberbullying in a meta-analysis (Kowalski et al., 2014). One study
showed that both a strict, mediating or involved approach all related to lower cybervictimization (Leung

26
& Lee, 2011), whereas another study showed higher parental disciplining related to higher perpetration,
and higher parental monitoring to lower perpetration of cyberbullying (Ybarra & Mitchell, 2004b). In a
longitudinal study with a 2-year follow-up period, poor family management and high family conflict
was related to cyberbullying perpetration, but not when involvement in traditional bullying was taken
into account. These family factors, in other words, mainly explained why someone was more likely to
be a traditional bully, which in turn predicted involvement in cyberbullying perpetration (Hemphill et
al., 2012).

Rates of cybervictimization, but not perpetration of cyberbullying, were higher for adolescents living in
single-parent households (Fanti et al., 2012). Receiving social support from their family was a protective
factor, both for perpetration and victimization at one-year follow-up (Fanti et al., 2012). This protective
effect on victimization was especially high among adolescents living in one-parent households with little
support from their friends (Fanti et al., 2012). Receiving social support from friends did not protect
against cybervictimization at one-year follow-up, but did show an interaction with family support:
adolescents with the lowest support from both family and friends, were at the highest risk of being
victimized in cyberbullying (Fanti et al., 2012).

Peer support

Higher perceived peer support was associated with a significant decline in cyberbullying perpetration in
one longitudinal study. This decline was strongest for online bullying compared to other forms (verbal,
physical) of perpetration (Williams & Guerra, 2007). Another longitudinal study, however, reported no
effect from peer support on cyberbullying perpetration at one-year follow-up (Fanti et al., 2012).

The self-reported number of friends was found to be a protective factor for victimization from traditional
bullying, but not for victimization from cyberbullying. There were no significant differences in the
number of friends adolescents reported to have by their participant role in cyberbullying (Wang et al.,
2009). This may, nonetheless, relate to the self-reported nature of the friendship network size in this
study. A study using peer-nominations, on the other hand, showed cybervictims were the least often
mentioned by their classmates as their friend, whereas victims themselves indicated having the highest
number of friends in their class, and thus overestimated their circle of friends (Festl & Quandt, 2013).
This was confirmed in a social network analysis, showing that cybervictims have fewer reciprocal
friends than non-victims. There was, however, no significant difference for reciprocal best friends in
a Flemish study conducted among 174 pupils aged 12-13 year (Wegge, Vandebosch, & Eggermont,
2013). Furthermore, in traditional bullying, it mattered who their friends were. If these friends were also
victimized or had internalizing problems (e.g. depression, anxiety), or if they were perceived as not
supportive, the protective effect against victimization was much weaker (Hodges, Boivin, Vitaro, &
Bukowski, 1999). No information is yet available on this for victimization from cyberbullying.
Specifically for cyberbullying, there may be a protective effect of online friends. This can be assumed,

27
since 65% of adolescents had at least one online friend whom they had never met offline, 27% felt more
comfortable discussing emotions online than offline (Heirman & Vermeulen, 2015). These last findings
were based on a Flemish study conducted among 1428 adolescents in 8th grade, sampled from 11
schools. The online friendship quality was positively associated with psychosocial functioning, after
controlling for their involvement in traditional or cyberbullying (Leung & McBride-Chang, 2013).
Whether these positive effects of online friends also act as a buffer against cyberbullying involvement,
however, to our knowledge remains unexplored.

Culture and ethnicity

Country differences may exist in how cyberbullying occurs or is perceived (Kowalski et al., 2014).
Relationships between cyberbullying involvement (as victim or perpetrator), with certain measures of
psychosocial harm (i.c. self-esteem, loneliness) were indeed weaker in European countries and Australia
than in North-American countries (Kowalski et al., 2014). Also the relation between cyberbullying
involvement and involvement in traditional bullying was weaker in Europe and Australia, than in North
America (Kowalski et al., 2014). Cross-country differences may reflect methodological differences, but
could also be associated with cultural differences, e.g. a distinction between collectivistic cultures and
individualistic cultures (Kowalski et al., 2014). Other cross-country differences have been explained by
cultural variances in the importance attached to social relations online, and to differences in awareness
campaigns that would raise other sensitivities to cyberbullying between countries (Ortega et al., 2012).
Further investigation of cultural issues is needed to clarify these differences.
Some studies showed that cybervictimization was more prevalent among ethnic minorities (Wang et al.,
2009; Ybarra & Mitchell, 2004b). In Flanders, adolescents in a family with a non-Belgian background
had a higher risk to be cybervictimized than adolescents whose parents were born in Belgium, in a study
with a small sample, of 174 pupils aged 12-13 years (Wegge et al., 2013). This finding could,
nevertheless, not be replicated when considering the relation between ethnic composition of classes and
the degree of cyberbullying in these classes, in a larger sample of Flemish adolescents (Heirman et al.,
2015).

In sum, risk factors for perpetration and victimization of cyberbullying are diverse. This supports the
importance of investigating this phenomenon from a socio-ecological perspective, taking both
individual and environmental factors into account. Some risk or protective factors were, furthermore,
shared between victims and perpetrators of cyberbullying. Several factors are currently somewhat
understudied, such as the role of appearance and obesity, sexual orientation, socio-economic status,
ethnicity and culture, psychological risk factors for victimization, and examination of risk factors (e.g.
gender) by specific type of cyberbullying or electronic contact mode.

28
1.6. Associated harm with cyberbullying
Cyberbullying tends to persist after school hours and can reach victims 24 hours per day and 7 days per
week, remain visible for a long time, may reach a larger audience, and may be more intimidating when
cyberbullies remain virtually unknown by the victim (Slonje et al., 2013; Tokunaga, 2010). It has
therefore been suggested that its psychosocial effects may be more severe than those of traditional
bullying (Slonje et al., 2013). A meta-analysis of 131 studies showed cyberbullying was related to
several mental, physical or social health problems. Cyberbullying victimization was significantly
correlated with stress, suicidal ideation, depression, anxiety, loneliness, reduced life satisfaction,
conduct problems, somatic symptoms, emotional problems, reduced self-esteem, substance abuse, and
lower prosocial behavior (in decreasing order of strength of correlation) (Kowalski et al., 2014).
Cyberperpetration significantly related to substance abuse, anxiety, depression, reduced life satisfaction,
reduced self-esteem, lower academic achievement, and loneliness (in decreasing order of strength of
correlation) (Kowalski et al., 2014). As all of the studies included in the meta-analysis were cross-
sectional (Kowalski et al., 2014), some of the abovementioned problems may be antecedents rather than
outcomes of cyberbullying involvement. Some nuances to these findings need to be made based on
longitudinal data.

Longitudinal studies

Longitudinal studies showed that both anxiety (van den Eijnden et al., 2013), self-esteem (Yang et al.,
2013), and substance abuse (Gmez-Guadix et al., 2013) were not outcomes, but predictors of
victimization of cyberbullying. A bidirectional relationship was found for depression: depressed
adolescents had higher odds of being victimized by cyberbullying, but being cybervictimized also
increased depressive symptoms at follow-up (Gmez-Guadix et al., 2013). Also for perpetrators of
cyberbullying, certain mental health problems were antecedents rather than outcomes: depressive
symptoms, low self-esteem and anxiety were stable predictors of cyberbullying perpetration (Yang et
al., 2013).

Comparison with traditional bullying

Furthermore, given the strong overlap between traditional and cyberbullying, it is often unclear which
of these outcomes can be attributed to the experience of cyberbullying, and which are due to involvement
of traditional bullying. Some studies have measured both involvement in traditional bullying and
cyberbullying, in sufficiently large samples which allow to single out their respective effects.

Studies comparing cyber victims to victims of traditional bullying on the negative outcomes related to
mental health, such as depressive symptoms, stress and anxiety, concurred in their findings: the
relationship between victimization and these negative outcomes was indeed strongest for the combined
victim group (cyber and traditional victimization) (Campbell et al., 2012; Gradinger, Strohmeier, &
Spiel, 2009; Raskauskas, 2010; Schneider, O'Donnell, Stueve, & Coulter, 2012). Victims who were

29
bullied both in traditional bullying and cyberbullying, were more likely to suffer from psychological
problems than adolescents not involved, followed by pure cyber victims, and finally pure traditional
victims (Campbell et al., 2012; Gradinger, Strohmeier, & Spiel, 2009; Raskauskas, 2010; Schneider,
O'Donnell, Stueve, & Coulter, 2011). Moreover, victims had a two- to threefold increased risk for
psychosomatic problems, and victim-bullies experienced all problems that either pure victims and pure
bullies suffered from (Sourander, 2010). Especially victim-bullies of cyberbullying were more likely to
feel depressed, anxious and stressed compared to non-involved youth (Campbell et al., 2012; Sourander,
2010) and other participant roles in cyberbullying (Chang et al., 2013; Gmez-Guadix et al., 2013).

When examining studies controlling for traditional forms of victimization, one study showed that online
victimization was significantly related to a high substance use, even after adjusting for these victims
involvement in traditional victimization (Mitchell, Ybarra, & Finkelhor, 2007). Furthermore, victim-
bullies of cyberbullying showed the greatest behavioral or health problems, such as using aggression
(Gradinger et al., 2009), and suicidal ideation (Bonanno & Hymel, 2013), also after taking their
involvement in traditional bullying into account. In a recent large-scale study of adolescents, cyber
victimization remained associated with poorer physical health when controlling for traditional bullying
(Lftman, Modin, & stberg, 2013). Most cross-sectional studies have shown that cyber victimization
was a significant predictor for several mental health outcomes above and beyond the influence of
traditional victimization (Bonanno & Hymel, 2013; Campbell et al., 2012; Dempsey, Sulkowski,
Nichols, & Storch, 2009; Fredstrom, Adams, & Gilman, 2011; Juvonen & Gross, 2008; Machmutow,
Perren, Sticca, & Alsaker, 2012; Perren, Dooley, Shaw, & Cross, 2010; Wang, Nansel, & Iannotti,
2011). A longitudinal study indicated that cyber victimization is predictive of an increase in later
depressive symptoms in adolescents, also when taking traditional victimization into account
(Machmutow et al., 2012).

A cross-sectional study of Olweus (2012) came to the tentative conclusion that when a youngster is
exposed to both traditional and cyberbullying, the additional impact of cyber victimization on poor self-
esteem may be negligible (Olweus, 2012). Olweus finding, however, only related to one type of
psychosocial outcome (i.e. poor self-esteem), which several studies also found to be poorly related to
cyberbullying.

Mediators and moderators

Lastly, given large heterogeneity in the meta-analytic findings for most outcomes, some mediators and
moderators need to be examined.

The electronic contact mode of cyberbullying related to different health outcomes: computer-based
cyber victimization was a significant predictor of negative mental health outcomes, such as depressive
symptoms, anxiety and self-esteem, whereas phone-based cyber victimization was not (Fredstrom et al.,
2011).

30
Coping strategies played a role in the relation between cybervictimization and health problems: support
seeking form peers and family related to lower depressive symptoms, whereas helpless reactions related
to higher feelings of depression (Machmutow et al., 2012). Others, however, reported that peer support
did not protect against depressive feelings (Aoyama, Saxon, & Fearon, 2011). Additionally, victims
appeared to use more emotion-focused coping than not-involved youth, while emotion-focused coping
was regarded as not effective in reducing depressive feelings (Vllink et al., 2013).

A longitudinal study suggested that the relationship between anxiety and cyber victimization may be
explained by environmental factors, such as stressful life events, cyber perpetration, family situation,
social life, gender, or poor academic achievement (Yang et al., 2013). The relationship between cyber
victimization and problem behaviors was found to be fully mediated by the strain youngsters
experienced from various stressful life events (Hinduja & Patchin, 2007). Several mediators were also
reported in the relationship between cyber victimization and suicide, such as the level of depressive
symptoms (only among girls (Bauman et al., 2013)), and substance abuse and violent behavior (Litwiller
& Brausch, 2013). The relation between being a victim, self-harm (e.g., cutting, burning, deliberately
hurting yourself) and suicidal ideation was partially mediated by negative emotions (anxiety, depression
and low self-esteem), and partially moderated by highly authoritative parenting and high self-control
(Hay & Meldrum, 2010). However, depression did not mediate the relationship between cyber-
perpetration and suicide attempts for either girls or boys (Bauman et al., 2013).

In sum, cyberbullying relates to several mental, social or physical health problems for both victims and
perpetrators, although fewer studies are available that examined these for perpetrators. Victim-bullies
experience the most mental, social or physical problems, as do victims who are bullied both via
traditional bullying and cyberbullying. There is a need for more longitudinal studies, as well as studies
with large sample sizes, which allow to assess a causal relationship, and distinguish the harm specifically
related to unique or combined traditional bullying and cyberbullying experiences.

1.7. Role of bystanders in cyberbullying

1.7.1. Importance of bystanders
So far, most cyberbullying research has focused on the roles of perpetrators and victims. In traditional
bullying, witnesses or bystanders are, nonetheless, considered to play an important role in ending or
sustaining bullying (Salmivalli, 2010). Firstly, their social support can attenuate the harm (e.g.
depressive symptoms, lower academic achievement) caused to the victim (Rothon, Head, Klineberg, &
Stansfeld, 2011; Tu, Erath, & Flanagan, 2012). Secondly, schools where bystanders defend rather than
stand-by passively are experienced as safer (Gini, Pozzoli, Borghi, & Franzoni, 2008), and benefit the
well-being of all adolescents at school. Furthermore, defending the victim and not reinforcing the bully

31
has been successful in reducing traditional bullying (Hawkins, Pepler, & Craig, 2001; Salmivalli,
Voeten, & Poskiparta, 2011). Defended victims were bullied less frequently than undefended victims
(Sainio, Veenstra, Huitsing, & Salmivalli, 2011). Further evidence on the advantages of positive
bystander behavior is found in anti-bullying intervention programs that targeted bystander behavior.
These were effective in reducing traditional bullying perpetration and victimization (Menesini,
Nocentini, & Palladino, 2012; Palladino, Nocentini, & Menesini, 2012; Salmivalli, Krn, & Poskiparta,
2011), and some traditional bullying interventions using bystander support showed effects on
cyberbullying victimization as well (Menesini et al., 2012; Palladino et al., 2012; Salmivalli et al., 2011).
It is, however, important that peer and bystander involvement is integrated in a whole-school approach,
since a meta-analysis of traditional bullying interventions indicated that only working with peers related
to an increase in bullying victimization instead of the desired decrease (Ttofi & Farrington, 2011).

Bystander action and general perceived peer support are considered distinct concepts, since general
perceived peer support may not relate specifically to help provided during a bullying incident (Sainio et
al., 2011).

Bystander behavior in bullying incidents that consists of reporting to adults, defending or comforting
the victim is considered to be helpful or positive bystander behavior. By reporting, defending or
comforting the victim, the bystander challenges the bullys power, which results in negative
reinforcement for the bullys actions (Salmivalli, 2010). These actions also strengthen the victims
mental resilience (Sainio et al., 2011), which may further decrease the power differential between victim
and bully.

Joining and assisting (e.g. forwarding, adding nasty comments), reinforcing (e.g. laughing), and passive
bystanding (e.g. doing nothing) are considered negative bystander behavior, since they sustain or
aggravate the bullying (Salmivalli, 2010; Salmivalli et al., 2011). Joining, assisting, and even subtle
signs of reinforcing, such as smiling, provide positive feedback, and encouragement to continue to the
bully (Salmivalli, 2010). Even passive bystanding provides positive feedback to the bully, since the
bully and victim may consider this as a silent form of approval of the bullying (Kowalski et al., 2012).

1.7.2. Theoretical foundation in studying bystander behavior

That some witness aggression and yet do nothing, has been reported in other contexts than bullying,
such as public violence (see e.g. Laner, Benin, & Ventrone, 2001). The Bystander Intervention Model
was designed after an early case of public violence that was witnessed by a substantial group of people
who did not intervene (Latane & Darley, 1970). This model states that a bystander experiences five
phases in the decision-making process on whether or not to intervene as a bystander: 1) awareness of
the incident; 2) interpretation of the incident as an emergency; 3) accepting the responsibility to
intervene; 4) knowledge and belief in the ability to intervene; and 5) performing the intervention. The

32
decision-process can moreover be influenced by contextual factors, often labeled as the bystander effect,
which are described in four mechanisms: self-awareness (e.g. who else is present), social cues (e.g. what
others are doing), blocking (e.g. others actions making their actions impossible) and diffusion of
responsibility (e.g. their actions are dependent on the size of bystander population) (Wong-Lo &
Bullock, 2014).

This model was previously applied to traditional bullying (Pozzoli & Gini, 2013; Nickerson, Aloe,
Livingston, & Feeley, 2014). Other theoretical frameworks used to study bystander behavior in
traditional bullying, are behavior change theories as Social Cognitive Theory (Espelage, Green, &
Polanin, 2012; Gini et al., 2008; Pyhnen, Juvonen, & Salmivalli, 2012; Thornberg & Jungert, 2013)
and Social Learning Theory (O'Connell, Pepler, & Craig, 1999; Rigby & Johnson, 2006), or the
Attachment Theory (Nickerson, Mele, & Princiotta, 2008).

In cyberbullying, bystander studies have focused on elements of the Bystander Intervention Model and
the bystander effect (Bastiaensens et al., 2014b; Bastiaensens et al., 2014a; Machackova, Dedkova,
Sevcikova, & Cerna, 2013; Obermaier, Fawzi, & Koch, 2014), or they have used Social Cognitive
Theory as a framework (Price et al., 2014; Van Cleemput, Vandebosch, & Pabian, 2014), and some
applied other theories such as Social Identity Approach (Jones, Manstead, & Livingstone, 2011) or
Attribution Theory (Holfeld, 2014).

Pozzoli and Gini mapped the Bystander Intervention Model on elements from Social Cognitive Theory,
such as attitudes, skills and self-efficacy to explain bystander behavior in traditional bullying (Pozzoli
& Gini, 2013). This approach combines the most often used theories in understanding and predicting
bystander behavior in bullying. Applying behavior change theories to this phenomenon, moreover, not
only explains what influences this behavior, but approaches it from where and how changes in this
behavior are most likely to occur. This is especially valuable when aiming to design interventions to
change bystander behavior. Behavior change programs which were founded on these behavior change
theories, recognizing both individual and environmental determinants, were indeed more effective than
those not applying these theories (Glanz & Bishop, 2010).

In their mapping of elements from Social Cognitive Theory on the Bystander Intervention Model,
Pozzoli and Gini considered attitudes to be related to step 2 of interpreting severity of the situation,
moral disengagement attitudes to step 3 of taking responsibility, and self-efficacy and coping
skills to step 4 of deciding how to help. They added perceived norm to this model, but did not test for
self-efficacy. The model explained 40% of the variance in defending behavior and 28% of passive
bystanding behavior.

Some determinants of bystander behavior, are, however still not captured in this combined model. We
therefore propose to extend this model by applying both the Reasoned Action Approach (TRA) and
other elements from Social Cognitive Theory (SCT) (Bandura, 2007) to the Bystander Intervention

33
Model. Reasoned Action Approach (TRA) merges the former Theory of Reasoned Action (TRA)
(Fishbein & Ajzen, 1975) and Theory of Planned Behavior (TPB) (Ajzen, 1991) and states that behavior
is determined by behavioral intention, on the condition that there is a facilitating environmental context,
and that sufficient personal skills are available to translate this intention into behavior. Intention is in its
turn influenced by attitudes, perceived norms and self-efficacy to perform the behavior (Fishbein &
Ajzen, 2010). This model also recognizes the importance of background variables, which may not be
changeable, but can influence beliefs and can therefore provide crucial information for a more targeted
approach to at-risk groups (Bartholomew et al., 2011). Compared to SCT, TRA pays more attention to
affective attitudes (e.g. liking), in addition to cognitive attitudes (e.g. outcome expectancies)
(Bartholomew et al., 2011). Perceived norms in TRA extend the concept in SCT of perceived behavior
of others, by assuming that not only seeing others perform a certain behavior will affect personal
behavior, but also whether people think others expect them to perform this behavior (Bartholomew et
al., 2011).

Several core determinants, such as self-efficacy, (cognitive) attitudes, skills and environmental context
are shared between SCT and TRA. SCT pays more attention to moral values, and adds to this model
the concept of moral disengagement attitudes (Bandura, 2002). Moral disengagement attitudes are used
by people to avoid self-condemnation, when their behavior is not in accordance with their moral values
(Bandura, 2004) and can, for example, consist of blaming the victim, minimizing the harm or by
displacing the responsibility to someone else. Furthermore, SCT directly connects determinants (e.g.
observing behavior of others) to methods to change this behavior (e.g. modeling) (Bartholomew et al.,
2011). Combining theories is encouraged in health promotion to grasp the complexity of behavior
change (Bartholomew et al., 2011; Lustria, Cortese, Noar, & Glueckauf, 2009).

Figure 1 proposes a model to study bystander behavior in cyberbullying, based on the Reasoned Action
Approach (Fishbein, 2008), Social Cognitive Theory (Bandura, 2007) and Bystander Intervention
Model (Latane & Darley, 1970). As suggested by Pozzoli and Gini (Pozzoli & Gini, 2013), attitudes
towards bullying (e.g. Cyberbullying is a normal part of a youngsters life) and to the victim (e.g. If
some youngsters wouldnt cry or give in so easily, they wouldnt be cyberbullied) may relate to step 2
interpreting severity of the situation of the Bystander Intervention Model. These differ from attitudes
towards the bystander behavior, part of step 3 taking responsibility, together with moral disengagement
attitudes and perceived norms. Self-efficacy, skills and environmental factors may be associated with
step 4 deciding how to help. The translation from intention to behavior may represent step 5
performing the behavior. The Reasoned Action Approach forms the backbone of this model. The
Bystander Intervention Model steps are indicated in red circles. Elements from SCT (moral
disengagement attitudes, potential change methods) are indicated in grey boxes.

34
 Fig. 1. Proposed theoretical model for studying bystander behavior in cyberbullying.
Legend: White boxes represent elements from Reasoned Action Approach (Fishbein, 2008).
Grey boxes are additions from Social Cognitive Theory (Bandura, 2007). The red circles
represent the stages in the Bystander Intervention Model (Latane & Darley, 1970).

Theory of Planned Behavior and Theory of Reasoned Action have previously been applied to
cyberbullying research, when explaining cyberbullying perpetrator behavior (Doane, Pearson, & Kelley,
2014; Heirman & Walrave, 2012; Pabian & Vandebosch, 2013; Pabian & Vandebosch, 2014b). Social
Cognitive Theory has been used in examining moral disengagement attitudes in cyberbullying (Perren
& Gutzwiller-Helfenfinger, 2012; Pornari & Wood, 2010; Renati, Berrone, & Zanetti, 2012).

1.7.3. Bystander behavior in cyberbullying

The question was raised whether bystander interventions would be important in cyberbullying as well.
First, it has been suggested that the motives of perpetrators are more related to the act itself than to
having bystanders witness the bullying (Kowalski et al., 2014). Evidence on interpersonal motives listed
above, however, does not support this and showed the peer group is important, also in cyberbullying
(Festl & Quandt, 2013; Sticca et al., 2013; Vanden Abeele & De Cock, 2013; Wegge et al., 2014). This
also applies to a Flemish context, as some findings were derived from studies among Flemish youngsters

35
(264 adolescents in 9th-12th grade in the study by Vanden Abeele & De Cock, 2013; and 154 adolescents
aged 12-14 years in the study by Wegge et al., 2014). Second, the role of bystanders may be more limited
in cyberbullying, if bystanders are not present in certain forms of cyberbullying, e.g. bullying via text
messages. A study conducted in Flanders among 174 12-13 year olds, however, showed that according
to victims, bystanders were present in 64% of the cyberbullying incident (Wegge, Pabian, &
Vandebosch, 2012), which was similar to the rate of bystanding in traditional bullying, as found in the
viWTA study among 2052 9-19 year olds (Vandebosch et al., 2006). Bystanders were present for
cyberbullying both via the Internet and text messages, presumably since bullies can forward text
messages or show them to others (Wegge et al., 2012).

The nature of bystander behavior in traditional bullying may, nevertheless, differ from that in
cyberbullying. Due to a reduced visibility of social cues online, bystanders may not see the harm for the
victim. They are also not able to provide small non-verbal feedback to a bully as in traditional bullying,
and a more determined action may be needed to show positive bystander behavior in cyberbullying. This
could reduce the likelihood of positive bystander behavior taking place (Obermaier et al., 2014). On the
other hand, precisely due to a larger physical distance from the bully in cyberbullying, bystanders may
be more willing to perform positive bystander behavior, since they fear less physical retaliation
(Obermaier et al., 2014).

In sum, as in traditional bullying, targeting bystanders may be a successful approach to end

cyberbullying and its harm. Some programs that used bystander or peer support were effective in
reducing victimization from cyberbullying (Menesini et al., 2012; Palladino et al., 2012; Salmivalli et
al., 2011). No research to date has, however, investigated the effect of specific bystander actions in
cyberbullying on the harm for the cybervictim or on the frequency of cyberbullying. Furthermore, few
studies have investigated the behavior of bystanders in cyberbullying, and what determines this
behavior. These will be summarized below.

Prevalence rates of bystander behavior in cyberbullying

Similarly to traditional bullying, high rates of passive bystanding were noted for cyberbullying: in
Flanders, 59% of youngsters aged 9-19 years who had witnessed cyberbullying did nothing, 9% joined
the bully and 32% helped the victim (Vandebosch et al., 2006). Comparable rates were found in a more
recent analysis of DICA study data in Flanders, among 2333 youngsters aged 9-16 years (Van Cleemput
et al., 2014). In a Facebook simulation of cyberbullying, a majority of (young adult) participants (91%)
had noticed the cyberbullying, but 52%-69% did nothing (Shultz, Heilman, & Hart, 2014). Negative
bystander behavior (e.g. forwarding) was, moreover, more prevalent when adolescents were provided
with an online bullying situation, than with a face-to-face (paper) situation (Barliska, Szuster, &
Winiewski, 2013). A study among secondary school-aged adolescents showed that 76% had provided
at least one type of support to the victim of cyberbullying, with as the least chosen option giving

36
technical advice (35%) and the most often form of support coming from telling them to ignore it (55%)
and trying to comfort the victim (54%) (Machackova et al., 2013).

Behavioral determinants

Behavioral determinants are discussed in the chronological steps of the proposed theoretical model in
Figure 1.

A first requirement for bystander action is considered the awareness of the incident taking place. An
experimental study among college students showed that the majority (between 53% and 75%) of the
participants had noticed the cyberbullying incident. But only 10% chose to intervene. This gap between
awareness and action suggests that, although awareness is a necessary step, the most important barriers
towards performing positive bystander behavior are not related to a lack of awareness (Dillon &
Bushman, 2015).

Several background variables, such as socio-demographics, attitudes towards the target (e.g. stereotypes
and stigma) and past behavior, were assessed in relation to bystander behavior in cyberbullying. While
these may influence several steps of the Bystander Intervention Model, they will be discussed here, to
follow the layout of the model in Fig. 1.

Age was not associated with bystander behavior among secondary school-aged adolescents
(Machackova et al., 2013), but was a significant predictor in another study among primary and secondary
school-aged children: bystanders who were standing by passively or who joined, were older, whereas
those helping the victim were younger (Olenik-Shemesh, Heiman, & Eden, 2015; Van Cleemput et al.,
2014). The Flemish data in which this difference was observed, were derived from 2333 youngsters
aged 9-16 years (Van Cleemput et al., 2014).

Gender was not associated with negative bystander behavior in some studies (Barliska et al., 2013;
Machackova et al., 2013; Van Cleemput et al., 2014). The Flemish data in which this association was
observed, were derived from 2333 youngsters aged 9-16 years (Van Cleemput et al., 2014). It did,
however, correlate with positive bystander behavior in other research: girls showed more positive
bystander behavior than boys (Bastiaensens et al., 2014b; Olenik-Shemesh et al., 2015). The Flemish
data in which this association was observed, were derived from 453 8th graders, and were collected as
part of the Friendly ATTAC (Adaptive Technological Tools Against Cyberbullying) project
(Bastiaensens et al., 2014b). This gender effect, however, disappeared in one study when the general
tendency for prosocial behavior was added as predictor (Machackova et al., 2013). Boys used more
moral disengagement attitudes, but the study did not assess how this related to their bystander behavior
(Holfeld, 2014).

37
How the bystanders involvement in other cyberbullying roles (e.g. victim, perpetrator) related to
bystander behavior was investigated in two studies. One Flemish study among 2333 elementary and
secondary school-aged children aged 9-16 years, found that perpetrators of either traditional or
cyberbullying were more likely to join in with the perpetrator. Victims of either forms of bullying were
more likely to help the victim, whereas victims of traditional bullying only, also more often responded
to witnessing cyberbullying with passive bystanding (Van Cleemput et al., 2014). Similarly, a study
among secondary-school aged adolescents only found a relation between involvement as a
cyberperpetrator, which was a predictor of negative bystander behavior (forwarding, posting), but
involvement as a cybervictim was not related to negative bystander behavior (Barliska et al., 2013).

The relation of the bystander with the bully or the victim did not affect positive bystander behavior in
one study among secondary school-aged adolescents, when adolescents general prosocial behavior was
taken into account (Machackova et al., 2013). Social anxiety was studied in relation to cyberbullying
bystander behavior, but was found not to predict any type of bystander behavior, based on the Flemish
DICA findings among 2333 9-16 year olds (Van Cleemput et al., 2014). Similarly, social self-efficacy
did not distinguish between active and passive bystander behavior in another study, whereas social
support did: active bystanders experienced more social support from friends and family than passive
bystanders (Olenik-Shemesh et al., 2015). Passive bystanders experienced more emotional loneliness
(Olenik-Shemesh et al., 2015).

Next, how the situation is interpreted may affect bystander intervention. For bystanders to act, the
incident would need to be perceived as an emergency. A Flemish experimental study among 453 8th
graders showed that witnesses of more severe cyberbullying incidents had higher intentions to intervene
in a positive way, compared to witnesses of a less severe incident (Bastiaensens et al., 2014b). This
study also manipulated mechanisms of the bystander effect that may influence the intentions of
youngsters to intervene. The identity of other bystanders played a role: if other bystanders were good
friends, adolescents were more inclined to positively intervene. These bystander effect mechanisms,
moreover, interacted with each other: when bullying was not severe, bystanders more often intended to
intervene by using positive bystander behavior when other bystanders were acquaintances. But when
bullying was severe, they were more inclined to positively intervene when other bystanders were good
friends. How other bystanders reacted (e.g. reinforce, defend), only affected bystander behavior if these
other bystanders were good friends, in which case the bystander would copy this behavior. The variance
explained by these variables in how bystanders behaved was, however, quite low, ranging from R=3%
(defending the victim), R=5% (giving advice); R=9% (reporting to adults) and R=10% (comforting
the victim). No information on explained variance was available for negative bystander behavior.
Bystanders, furthermore, had higher intentions to defend the victim in private, electronic ways (e.g.
sending message) compared to addressing the bully face-to-face, but only in severe cases of
cyberbullying. This preference was especially apparent when other bystanders reinforced the bully, and

38
even more so when these other bystanders were good friends (Bastiaensens et al., 2014a). This
preference to respond privately, was only noticed when bystanders were showing negative bystander
behavior (e.g. forwarding the message) (Barliska et al., 2013). Another context characteristic of the
incident that affected bystander behavior was the self-perceived bystander visibility to the bully, the
victim or others. When bystanders felt others could not detect their presence, e.g. by not being logged
into the chat on a social networking site, their inclination to defend the victim or provide social support
was lower, and the inclination to remain passive was higher (Brody, 2013). It can be hypothesized that
this self-perceived visibility of bystanders may differ between types of incidents (e.g. being directly
asked by the bully not to include someone or invited to a defamatory polling site versus seeing an
insulting reply in a message thread on a social networking site) and the media used (e.g. social
networking site or mobile phone), and that this may contribute to different bystander reactions in
different types of cyberbullying incidents. This has to our knowledge, however, not yet been studied.

Attitudes are the tendencies to respond positively or negatively to someone, something, or towards
performing a behavior (Bartholomew et al., 2011). Attitudes can be affective (e.g. anxiety towards the
behavior) or cognitive (e.g. expected instrumental outcomes of the behavior) (Lawton, Conner, &
McEachan, 2009). In deciding on the severity of a cyberbullying incident, the bystanders attitudes
towards cyberbullying play a role. Feeling upset after watching the cyberbullying incident was the
strongest predictor for positive bystander behavior (supporting the victim) in a study (Machackova et
al., 2013) among secondary-school adolescents that examined both socio-demographic, psychological
variables (self-esteem, prosocial behavior, problems with peers) and some contextual factors (e.g.
relation with victim and bully). They found that a substantial part of supportive behavior (R=39%)
could be explained by prosocial behavior, relationship with the bully or victim, affective attitudes to
bullying (feeling upset), and being asked by the victim for help (Machackova et al., 2013). Emotions
related to group membership (perpetrator, victim, non-involved), were investigated as a driver of
bystander behavior in an experimental study on text-message bullying among elementary school
children (Jones et al., 2011). Children were assigned to a scenario in which they belonged to a group
which had kind or unkind group norms, and this group played a role as perpetrator, victim or uninvolved
party in a cyberbullying case. The group norms and the childrens identification with these norms, were
expected to have an effect on bystander behavior through emotions, or affective attitudes, towards
cyberbullying. Anger and guilt related to the groups involvement predicted saying sorry to victim
(R=20%), and anger predicted telling an adult (R=37%). Shame and anger predicted staying away from
the perpetrator and his group (R=32%), whereas pride (R=5%) predicted telling friends about what the
bully and his group did.

When the bystander is aware of the cyberbullying situation and interprets this as severe, the bystander
subsequently needs to accept the responsibility to intervene. This concept of acceptance is similar to that
of attitudes towards performing the behavior in behavior change theories. Three steps in the Bystander

39
Intervention Model, following the stage of awareness, were studied jointly in a study among college
students (excluding step 1-awareness, and step 4-belief and knowledge on how to act) (Obermaier et al.,
2014). There was no evidence for a direct influence of the Bystander effect (i.c. number of bystanders)
on the intention to intervene. The number of other bystanders negatively affected the perceived
responsibility to intervene, which in its turn positively related to the intention to intervene. The severity
of the situation and interpreting it as an emergency, also showed no direct effects with the intention to
intervene, but did positively affect their perceived responsibility to intervene. This suggests that the
incident severity and contextual factors of other bystanders do not influence the intention to perform
positive or negative bystander behavior directly, but that this is mediated by their attitudes (e.g.
perception of responsibility) on how to respond as bystander. Obermaier et al. (2014) conclude that these
attitudes are the key elements in predicting cyberbullying bystander behavior.

One other type of attitudes studied in the context of bullying are moral disengagement attitudes. These
are ways to avoid self-condemnation when behavior is not in accordance with an individuals moral
values (Bandura, 2004). Literature documents the following moral disengagement attitudes: diffusion
(e.g. spread thinly across group members) and displacement (e.g. placed onto others) of responsibility,
moral justification (e.g. serving a higher purpose), euphemistic labeling (e.g. using terms that make it
sound better), advantageous comparisons (e.g. referring to other situations that are even worse), blaming
(e.g. considering the victim provoked it) or dehumanizing the victim (e.g. belief that they dont deserve
any better), and denying negative consequences (e.g. no harm results from bullying) (Bandura, 2002).
An experimental study among middle school adolescents examined attitudes of blaming the victim in
cyberbullying, and how these were influenced by the victims response. Male adolescents more often
blamed the victim and held the victim responsible for the incident, regardless of the victims response.
Furthermore, when victims responded by ignoring instead of reporting it to someone, they were
perceived as having more control over the situation and more to blame, regardless of the participants
gender. These moral disengagement attitudes were considered to reduce the willingness of the
participant to act as a bystander, but this was not investigated in the study (Holfeld, 2014). Moral
disengagement attitudes in cyberbullying bystander behavior were also examined in a qualitative study
among adolescents (Price et al., 2014). Several themes confirmed the presence of moral disengagement
attitudes (victim blaming, minimizing agency, cognitive restructuring of harmful behavior, diffusion of
responsibility to adults) and showed the importance of friendship, a link between offline and online
bystanding, and empathy in the use of moral disengagement attitudes.

Perceived responsibility to intervene may also be affected by bystanders perceived norm on how to
react (i.c. the perception of what others expect you to do). Perceived norm of parents approving of
cyberbullying positively influenced bystanders behavior of joining the bully. Perceived norm of friends
approving of cyberbullying influenced peer pressure, which in turn positively influenced joining
behavior (Bastiaensens et al., 2015). Two types of information may also be related to this concept, and

40
provide further insights. Firstly, how their friends behave (see e.g. Bastiaensens et al., 2014b), may
influence their perception of how their peers expect them to act. This indicates observational learning,
a main concept in SCT, whereas perceived norm in TRA reflects a personal appreciation of norms and
intentions to comply to these norms. Secondly, perceived norms are related to the norms on bullying
imposed by the group to which the adolescent belongs (e.g. social or group norms). Social norms and
emotions towards group membership and their actions, were investigated as a driver of bystander
behavior in an experimental study on text-message bullying among elementary school children (Jones
et al., 2011). These emotions about the groups involvement in bullying were influenced by the level of
identification with the group, the group norms as unkind or kind, and the perceived degree of group
responsibility for the cyberbullying case.

A next step in the Bystander Intervention Model is the knowledge on how to respond and the persons
own belief in their abilities to intervene using positive bystander behavior. This is associated with skills,
self-efficacy, and environmental constraints. To our knowledge, no study yet exists that has explored
self-efficacy or environmental constraints regarding cyberbullying bystander behavior. Some studies
did assess the role of skills in bystander behavior, more specifically, empathic skills.

Empathy is defined as being able to share another persons emotions. It is generally considered to have
a cognitive component, perspective taking (e.g. understanding others emotions) and an affective
component, empathic concern (feeling sympathy with others emotions) (Davis, 1983; Gini, Albiero,
Benelli, & Alto, 2007). Empathy with the victim was found to be associated with more positive
bystander behavior in one study among secondary-school adolescents (Barliska et al., 2013), but not
in another study among young adults (Shultz et al., 2014). In this last study, empathy was significantly
associated with identifying with the victim, which in turn related significantly to supporting the victim,
but no direct relations between empathy and positive bystander behavior were found (Shultz et al.,
2014). Showing a video to secondary school adolescents, that increases empathy for the victim was
significantly associated with lower reinforcing behavior immediately after, but not at one-week follow-
up (Barliska, Szuster, & Winiewski, 2015). Affective empathy was found a significant predictor also
in a Flemish (DICA) study among 2333 9-16 year olds: lower levels of affective empathy related to
more joining in with the bully and more passive bystanding, whereas higher levels of affective empathy
predicted more helping the victim (Van Cleemput et al., 2014).

Summarized, compared to literature on bystander behavior in traditional bullying, some determinants

remain largely unexplored. These are, for example, the relation between self-efficacy towards
performing positive bystander behavior and adolescents actions when they witness cyberbullying. Next,
quantitative studies are needed to establish the relation between other moral disengagement attitudes
(e.g. blaming the victim, minimizing the harm, rationalizing) apart from diffusing of responsibility, and
bystander behavior. Perceived norms have not yet been studied as such. As skills, coping skills played

41
a role in traditional bullying, and research is needed to assess whether these may be relevant in
cyberbullying bystander behavior as well. Furthermore, in traditional bullying, teacher and parental
support for positive bystander behavior played a role. Information on the role of these aspects in
cyberbullying bystander behavior is also still lacking.
From limited research currently available, it appears that those determinants often considered core
predictors of behavior, such as affective and cognitive attitudes, and skills (Bartholomew et al., 2011),
result in models which explain more of the bystander behavior, than studies which have focused mostly
on mechanisms of the bystander effect. This underlines the need to further explore determinants from
the perspective of behavior change theories, and to establish the core predictors of positive and negative
bystander behavior. Current research is, moreover, fragmented across studies each examining just a
couple of predictors. A study investigating a larger set of determinants and assessing the relative weight
of each predictor, can provide recommendations on where change is most needed, and can lead to the
highest gain in behavior change. These insights are required as building blocks for effective
interventions to promote positive bystander behavior in cyberbullying.

1.8. Interventions against cyberbullying

A recent systematic review, conducted as part of the Friendly ATTAC project, showed the existence of
15 cyberbullying programs, published in scientific or grey literature since 2003, and aimed at reducing
cyberbullying victimization or perpetration among youth aged 10-18 years (Van Cleemput et al., in
preparation). Most programs were aimed at 11-13 year olds. Unlike traditional bullying where most
programs are multi-component interventions, most intervention programs on cyberbullying only
consisted of one or two components. The most often used component was curriculum materials, to be
used in school (n=11 programs). Six programs included material for teachers, whereas only four
included a component on bystander behavior or working with peers. Only one whole-school approach
was found among cyberbullying programs.

A meta-analysis of cyberbullying interventions was performed, but only eight studies could be included
here, of which a small majority were multicomponent programs (five included several components, one
used two components, and two programs used only one component). This meta-analysis showed small,
significant effects on reducing victimization (g=0.135, n=9453, k=6, 95% CI 0.079; 0.190, p<.001), and
very small yet significant effects on reducing cyber perpetration (g=0.065, n=6373, k=6, CI 0.019;0.112,
p<0.001) (Van Cleemput et al, in preparation). The elements identified in traditional bullying prevention
programs as effective (Ttofi & Farrington, 2011), were not frequently incorporated in existing
cyberbullying prevention and intervention programs (i.e. whole school programs, programs which lasted
longer and consisted of more sessions, interventions using videos and devoting attention to
environmental factors, e.g. by providing teacher and parent training). With many elements shared

42
between cyberbullying and traditional bullying, it may be worthwhile to translate guidelines for handling
traditional bullying to managing cyberbullying, until more evidence becomes available (Cross, Monks,
Campbell, Spears, & Slee, 2011; Pearce, Cross, Monks, Waters, & Falconer, 2011).

In traditional bullying, it was reported that working with peers should be integrated in a broader
approach, since the component itself related to adverse effects on victimization (Ttofi & Farrington,
2011). This component working with peers included several types of peer involvement such as peer
mediation, peer mentoring or changing bystander behavior. It is unclear if interventions only focusing
on bystander behavior, and not on peer mediation or peer mentoring, would be associated with less
intervention effectiveness. A meta-analysis on programs aimed at changing bystander behavior in
traditional bullying, showed that these interventions were indeed successful at increasing bystander
intervention (Polanin, Espelage, & Pigott, 2012).

In sum, insights from traditional bullying suggest that bystander behavior in bullying can indeed be
changed. Higher positive bystander intervention was associated with lower mental health problems for
victims and lower rates of bullying. Programs may need to integrate components on increasing bystander
intervention within a broader approach, such as whole-school programs.

Although it is yet unclear if this also applies to cyberbullying, these insights might guide the design of
cyberbullying programs until more evidence becomes available. None of the interventions included in
the meta-analysis on cyberbullying, of which several used the component of working with peers,
reported negative effects.

1.9. Need for evidence-based cyberbullying interventions founded in behavior science

For cyberbullying prevention and intervention programs, no clear key success factors have yet been
established. One potential success factor that was suggested, was underpinning cyberbullying
intervention and prevention programs by behavior change theories (Tokunaga, 2010). Behavioral
change theories have, indeed, shown to be a lever in increasing intervention effectiveness in other health
promotion programs (Glanz & Bishop, 2010). Very few cyberbullying prevention and intervention
programs, included in a recent review, were founded in behavioral change theories (e.g. Social Cognitive
Theory, Theory of Planned Behavior), while a variety of other theoretical models were used by most
programs, such as peer support models, cooperative and constructive learning theories (Van Cleemput
et al, in preparation).

Apart from a theoretical underpinning, theories should be implemented using standardized definitions.
Indeed, the precise application of theories in behavior change programs has often shown to be
problematic, causing wide diversity in intervention effectiveness (Michie et al., 2011). Following
standardized definitions of theories (e.g. Social Cognitive Theory) and standardized applications of

43
theoretical concepts (e.g. guided practice), allows to assess the accurate implementation of scientific
evidence and allows a reliable linking of mechanisms of action to the intervention effectiveness (Michie
et al., 2011).

1.10. Intervention Mapping protocol

The Intervention Mapping Protocol (IMP) was designed by leading behavior change experts
(Bartholomew et al., 2011) to aid in the systematic and stepwise application of theory to behavioral
change programs. The systematic approach of the IMP necessitates a detailed description of intervention
content, which meets recent demands for more thorough reporting (Michie, Fixsen, Grimshaw, &
Eccles, 2009). It aims to increase both efficacy and effectiveness, by a reiterative process of evidence
review, application of theory-based strategies, and stakeholder consultation in six well-defined steps
(Bartholomew et al., 2011). The six different steps in the Intervention Mapping Protocol are: 1) needs
assessment, 2) preparing matrices of change objectives, 3) selection of theory-informed intervention
methods and practical strategies, 4) development of the intervention program, 5) planning for adoption,
implementation and sustainability, and 6) development of an evaluation design. These steps are often
described consecutively, although the process is in fact iterative.

The pillars of IMP are that intervention development should be evidence- and theory based, that users
and stakeholders should be involved throughout the development process, and that professionals should
apply an ecological approach to health problems (Bartholomew et al., 2011). The IMP recognizes both
individual and environmental, bi-directional, influences of behavior (e.g. peers, family relations, school
policy), in line with an ecological model of health behavior (Sallis, Owen, & Fisher, 2008). An
ecological model has also been acknowledged as important for studying bullying and peer victimization,
and for designing appropriate bullying prevention and intervention strategies (Hong & Espelage, 2012).
This protocol has been applied to several health behaviors, such as healthy diet and physical activity
(e.g. Verbestel et al., 2011), sexual health (e.g. Brown, Bayley, & Newby, 2013), mental health
promotion (e.g. Kraag, Kok, Abu-Saad, Lamberts, & Fekkes, 2005), and recently also to cyberbullying
(Jacobs, Vllink, Dehue, & Lechner, 2014). The latter intervention transformed an existing intervention
into an online tool, and aimed to enhance victims coping strategies. It was founded in Rational,
Emotional (Behavioral) Therapy. The program focused on improving individual coping behavior;
environmental level influences were not included (Jacobs et al., 2014).

2. Serious digital games

2.1. Introducing the Friendly Attac project
In 2012, The Flemish Agency for Innovation through Science and Technology (IWT, www.iwt.be)
commissioned a project to a consortium of researchers at the University of Antwerp, Ghent University,

44
Vrije Universiteit Brussel and the university college of HOWEST, to design a serious digital game
against cyberbullying. This project was named Friendly ATTAC (Adaptive Technological Tools
Against Cyberbullying, www.friendlyattac.be). Our project applied the IMP to design a serious digital
game against cyberbullying among young adolescents (12-14y). In line with the ecological model, this
game was intended as part of a wider school approach that would also address educator and parental
behavior. Its development was guided by the Reasoned Action Approach (Fishbein & Ajzen, 2010) and
by Social Cognitive Theory (Bandura, 2007).

2.2. Serious digital games to promote social behavior and other healthy lifestyles
Serious digital games are a form of organized play, using a digital device, and are intended to be both
entertaining and educational (Prensky, 2007). As they are designed to achieve both entertainment and
educational goals, they also derive methods from both entertainment theories (e.g. methods to create
immersion or transportation, and flow) (Annetta, 2010; Boyle, Connolly, Hainey, & Boyle, 2012;
Connolly, Boyle, MacArthur, Hainey, & Boyle, 2012; Kapp, 2012; Lu, Baranowski, Thompson, &
Buday, 2012), and from educational or behavior change theories (e.g. meeting self-determination needs,
applying tailoring, modeling, reinforcement and feedback, guided practice and goal-setting)
(Baranowski, Buday, Thompson, & Baranowski, 2008; Kato, 2010; Thompson et al., 2012; Thompson
et al., 2010).

Games differ from computer-delivered interventions by aspiring to be highly enjoyable, attention-

captivating and intrinsically motivating (Graesser, Chipman, Leeming, & Biedenbach, 2009; Prensky,
2007). Serious games differ from mere entertainment games in their aim to educate or promote behavior
change. In the context of health promotion programs, this may be achieved via the provision of health-
related information, modeling of positive health behaviors, the creation of opportunities to practice
healthy lifestyle skills (Kato, 2010), by changing mediators (e.g. self-regulatory skill development), and
by applying change procedures (e.g. tailoring and goal-setting) (Thompson et al., 2012; Thompson et
al., 2010). Serious games may furthermore create sustained effects by being intrinsically motivating to
play longer and repeatedly (Sitzmann, 2011; Wouters, van Nimwegen, van Oostendorp, & van der Spek,
2013).

Serious digital games have shown promising effects in promoting healthy lifestyles (Baranowski et al.,
2008; DeShazo, Harris, & Pratt, 2010; Gamberini, Barresi, Majer, & Scarpetta, 2008; Guse et al., 2012;
Guy, Ratzki-Leewing, & Gwadry-Sridhar, 2011; Kato, 2010; Kharrazi, Lu, Gharghabi, & Coleman,
2012; Lu et al., 2012; Papastergiou, 2009; Primack et al., 2012; Rahmani & Boren, 2012; Wilkinson,
Ang, & Goh, 2008), which can potentially modify a persons risk to a wide range of diseases, such as
some cancers, cardiovascular diseases, stroke, dementia, mental illness, and diabetes (Fratiglioni,

45
Paillard-Borg, & Winblad, 2004; Kim et al., 2012; Lopez, Mathers, Ezzati, Jamison, & Murray, 2006;
Peel, McClure, & Bartlett, 2005).

These comprised health games relating to diverse behaviors and populations, including games for
treatment, prevention, and professional education (Rahmani & Boren, 2012). Reviews on healthy
lifestyles mostly focused on a single health behavior (e.g. Guy et al., 2011), on obesity prevention) or
focused on one specific age group (e.g. Guse et al., 2012), on sexual health among adolescents). An
exception was the review of Baranowski et al. which included games for healthy diet, physical activity
and illness self-management (Baranowski et al., 2008).

Healthy lifestyle adoption and maintenance are often hindered by motivational issues, lack of time to
participate in health promotion programs, and the interventions low reach into the target group (Baert,
Gorus, Mets, Geerts, & Bautmans, 2011; McGuire, Anderson, & Fulbrook, 2013; Toobert, Strycker,
Glasgow, & Bagdade, 2002). Computer-delivered and computer-tailored interventions have been
successfully designed to overcome these obstacles by individual tailoring, being accessible whenever
the individual has time, and ensuring high availability at lower cost (Krebs, Prochaska, & Rossi, 2010;
Portnoy, Scott-Sheldon, Johnson, & Carey, 2008). Users have reported to prefer serious games above a
traditional educational approach (Vogel et al., 2006). Being highly enjoyable, attention-captivating and
intrinsically motivating (Graesser et al., 2009; Prensky, 2007), serious games may thus overcome
motivational barriers that many health promotion programs currently face (Baert et al., 2011; McGuire
et al., 2013; Toobert et al., 2002).

Serious games are theorized to derive their learning effects from at least three sources: 1) by creating
immersion or transportation, a state in which the player becomes absorbed in the play without disbelief,
while creating personally relevant experiences and deep affection for the characters; 2) by establishing
flow, a state of high concentration in which the player experiences a balance between skills and
challenge; and 3) by meeting the individuals needs for mastery, autonomy, connectedness, arousal,
diversion, fantasy, or challenge (Annetta, 2010; Boyle et al., 2012; Connolly et al., 2012; Kapp, 2012;
Lu et al., 2012).

2.3. Potential of serious digital games

Serious digital games have been suggested as a useful tool in bullying prevention and intervention, since
the full immersion in a narrative and interactive game play that players may experience can generate
positive emotions, attitude and social change (Nocentini, Zambuto, & Menesini, 2015). Serious games
furthermore provide a safe environment for trial-and-error practice of skills and behaviors, whereas
failures in the correct application of these skills in real-life may have considerable negative
consequences (Prensky, 2007). Some serious digital games have been designed and evaluated for

46
bullying (Rubin-Vaughan, Pepler, Brown, & Craig, 2011; Salmivalli et al., 2011; Sapouna et al., 2010),
but none so far were designed to address cyberbullying.
Given the limited research base on serious games for bullying, evidence from serious games in related
areas needed to be examined to assess their potential in addressing cyberbullying. Expanding the scope
to health-promoting games may be fruitful, since prosocial behavior is part of a healthy lifestyle that
also comprises other, associated health behaviors (Walker, Sechrist, & Pender, 1987). Indeed, some
school-based health promotion interventions target multiple health behaviors, such as bullying,
substance abuse, healthy diet, physical activity and sedentary behavior, since often determinants are
shared, health behaviors influence each other and these can be more effectively tackled in one
intervention (Busch, De Leeuw, & Schrijvers, 2013).

With a growing interest in using serious health games in recent years (Kharrazi et al., 2012),
professionals have called for more evidence on how to create effective serious games (Ritterfeld, Cody,
& Vorderer, 2009). Positive effects of health-promoting games have been reported by several systematic
reviews (Baranowski et al., 2008; DeShazo et al., 2010; Gamberini et al., 2008; Guse et al., 2012; Guy
et al., 2011; Kato, 2010; Kharrazi et al., 2012; Lu et al., 2012; Papastergiou, 2009; Primack et al., 2012;
Rahmani & Boren, 2012; Wilkinson et al., 2008), which, however, also noted large differences in these
games effectiveness. Although several hypotheses have been put forward to explain this heterogeneity,
these differences largely remain unexplained (Baranowski et al., 2008; DeShazo et al., 2010; Gamberini
et al., 2008; Guse et al., 2012; Guy et al., 2011; Kato, 2010; Kharrazi et al., 2012; Lu et al., 2012;
Papastergiou, 2009; Primack et al., 2012; Rahmani & Boren, 2012; Wilkinson et al., 2008).

First, several reviews suggest that a good theoretical blending of the fun and educational element is
critical in game effectiveness (Baranowski, Baranowski, Thompson, & Buday, 2011; DeShazo et al.,
2010; Kato, 2012; Kharrazi et al., 2012; Papastergiou, 2009). This is consistent with reviews on
computer-tailored interventions, showing higher effectiveness when using theories more extensively,
and more specifically so when using behavior change theories such as the Theory of Planned Behavior
(Webb, Joseph, Yardley, & Michie, 2010). This hypothesis also fits with the principle in IMP that in
order for health programs to be effective, they should be theory-based.

Second, it has been advocated that for games to be effective, a core list of game characteristics should
be considered (Cugelman, 2013). Several reviews suggested positive effects from using individually
tailored content (DeShazo et al., 2010; Wilson et al., 2009), realistic avatars (Bedwell, Pavlas, Heyne,
Lazzara, & Salas, 2012), goal setting (Baranowski et al., 2008; DeShazo et al., 2010), narrative, high
interactivity, fantasy, high player control (Baranowski et al., 2008; Wilson et al., 2009), assessment as
feedback or rewards (Biddiss & Irwin, 2010; Wilson et al., 2009), and how to progress to the goal, e.g.
by using scaffolding levels (Wilson et al., 2009). Furthermore, the relevance of these game
characteristics may differ whether targeting affective, cognitive or behavioral outcomes (Wilson et al.,

47
2009). Several of these characteristics or methods can moreover be seen as an operationalization of
behavior change theories (e.g. goal-setting, derived from Goal-setting Theory (Locke & Latham, 2006))
or gaming theories (e.g. fantasy and narratives, prominent in Transportation Theory (Green, Brock, &
Kaufman, 2004)). The first set of potential, theoretical, moderators is thus conceptually linked to this
second set of method moderators.

Third, games may be more effective if they intensively involve users and stakeholders. This assumption
is also in line with IMP principles. Game features should be adjusted to the target users (Cugelman,
2013) as the appreciation of game features differed by target group (Homer, Hayward, Frye, & Plass,
2012; Wang, Shen, & Ritterfeld, 2009; Yee, 2006). User testing (Baranowski et al., 2013; Cugelman,
2013) and user involvement in game design may thus increase the fit with user preferences and enhance
game effectiveness (Guy et al., 2011).

In sum, serious digital games can be effective in promoting healthy lifestyles. Their mechanisms of
effectiveness are, nevertheless, not yet well understood, since large variations exist between games in
their effectiveness. Several hypotheses have been put forward to explain differences in effects, which
have yet to be tested.

3. Intervention Mapping protocol to develop a serious digital game against cyberbullying

To our knowledge, three serious digital games have been evaluated that address traditional bullying.
FearNot! was aimed at reducing victimization rates among elementary school children, and was
designed in cooperation between several European countries (Germany, United Kingdom, Portugal).
Program objectives were to increase knowledge about bullying and relevant coping strategies. The game
is set in a school environment, and shows virtual actors in a cartoon-like episode of bullying. The player
assumes the role of a mentor and can suggest coping strategies to the victim by typing them in an instant
messenger- like interface. The game is played for three weeks, with each session comprising around five
bullying episodes. The program was founded on Cognitive Theory of Stress and Coping, and was shown
to be effective in reducing victimization (Sapouna et al., 2010).
The KiVA game was developed in Finland and is now used nationwide in all Finnish schools providing
education for grades 1 to 9 (n=888). The program is a whole-school approach, of which the game is
merely one component. The game is intended to elaborate on the learning process children started during
the 10 lessons and discussion groups, and to encourage children to apply their new skills in real-life
(Krn et al., 2011). It is aimed at grades 1 to 9 (children aged 8-16 years), but is only consistently
effective in elementary school-aged children, with mixed results in grades 7-9. It recently also showed
significant effects in reducing cybervictimization (Williford et al., 2013), and is currently being tested
in other countries, such as the Netherlands. The program is mentioned to be based on viewing bullying
as a group phenomenon, but mentions no other theoretical foundation (Salmivalli et al., 2011).

48
Quest for the Golden Rule was developed in Canada (Rubin-Vaughan et al., 2011) for the promotion of
social skills and prevention of bullying among children in grades 2-5. It is a web-based game,
accompanied by a teacher guide with curriculum and follow-up activities. The children learn new
strategies to cope with bullying and practice social problem-solving skills in virtual role-plays. The
intervention is founded in Vygotskys Zone of Proximal Development theory and was effective in
increasing knowledge, social skills and strategy identification, but did not investigate effects on
involvement in bullying.
Although all games mentioned above were only targeted at primary school children, or only found to be
effective in this age group, these did provide some insights for the design or the Friendly Attac game
against cyberbullying. The FearNot! study showed a dose-response relationship between higher use of
the intervention and effectiveness, and a presumed effect of low implementation fidelity due to a
mismatch between technological requirements and technological capabilities of supervising teaching
staff. The technical design was indeed ambitious. The open strategy-generation by the children (i.c.
children type in what the character should do, and based on word recognition, the game responds to this
input) seemed valuable, and seemed possible by their vast project infrastructure and organization. The
authors conclude implementation problems may have been better dealt with in a whole-school program
that also provided staff training.
The KiVA game precisely uses a whole-school approach, and also includes activities to increase
bystander behavior. It has been successfully applied in a large number of schools, but of interest is its
lower effectiveness in secondary school adolescents. The authors suggested this may be caused by
developmental difficulties in adolescence, where adolescents have more negative attitudes towards
victims, and that their program is less successful in addressing more indirect forms of bullying, which
occur to a larger degree in adolescence (Krn et al., 2013). This suggests KiVa would have limited
applicability to many forms of cyberbullying that are of indirect nature. It was unfortunately not clear if
the KiVA game had been fully adapted to this age group, and examined age-specific determinants of
their behavior, or if the changes had been limited to aesthetics and tools, and that this may also explain
a lower effectiveness for adolescents.
The last game, Quest for the Golden Rule, was presented as an individual e-learning preventive approach
to overcome the problem of insufficient teacher resources to provide support in bullying, although
companion guides with classroom material are also available. The game includes three components
matching different participant roles, of which one component also focuses on social dynamics and
bystander behavior. This particular component appeared to benefit girls more than boys, and attention
to gender differences in games for bystander behavior may be needed.

Some non-game interventions to tackle cyberbullying were designed using the Intervention Mapping
Protocol. A recent intervention against cyberbullying was developed in the Netherlands, using IMP
(Jacobs et al., 2014). The intervention Online Pestkoppenstoppen transformed an existing intervention

49
into an online tool, and aimed to enhance victims coping strategies. It was founded in Rational,
Emotional (Behavioral) Therapy. The program focused on improving individual coping behavior;
environmental level influences were not included. Despite being time-consuming, they perceived
several strengths of using IMP in the development of the program, such as having a solid framework
based on evidence, theory and practical guidelines; addressing multiple determinants found in research
to be relevant; and being tailored to the needs of specific target groups. No effectiveness data are yet
available on the intervention.
To our knowledge, IMP has so far only been applied to a few development processes of serious digital
games (Bartholomew et al., 2000; Brown et al., 2013; Shegog et al., 2007). One of these, the Watch,
Discover, Think and Act game, was intended to teach children (aged 6-17 years) in the United States
about asthma self-management (Bartholomew et al., 2000). The game was played during medical visits,
for on average 8 months, and was effective in improving asthma self-management. They suggested that
good program planning aids in communication with creative material designers.
The other two games were developed in the area of sexual health promotion. Prepare (Positive
Relationships: Eliminating Pressure and Sexual Coercion in Adolescent Relationships) is a game
targeting adolescents aged 13-14 years in the United Kingdom. It was intended to be played as a group
during class, under teacher guidance, and envisioned as an addition to existing Relationship and Sexual
Education material, which generally showed only limited effects. Using the Intervention Mapping
Protocol was reflected in iteratively consulting the planning group and working from existing and newly
collected evidence. Changing behavior and behavioral determinants was pursued by applying a
combination of methods to address each outcome. The game showed small but significant effects on
knowledge, attitudes and self-efficacy (Brown et al., 2012; Brown et al., 2013).
The Its Your Game intervention (United States) targeted 7th8th graders. Several game formats were
used, in addition to course material and parentchild activities. The game was part of a multicomponent
program, also consisting of small group classroom interactions such as role-play and group discussions,
and parentchild homework activities. In total, it consisted of 24 45-minute lessons. The lessons taught
decision-making skills to set personal limits, to detect risk situations in which their limits would be
challenged, and to protect these limits (Shegog et al., 2007). The game was effective in reducing sex
initiation (Tortolero et al., 2010).
All programs developed with Intervention Mapping Protocol concluded that using this method was time-
consuming, but resulted in an intervention based on a solid, evidence-based framework that provided a
good fit with the preferences and needs of users and stakeholders, thus increasing chances of being
adopted and implemented.
The Intervention Mapping protocol has been suggested as a method that can facilitate serious game
development, by elucidating objectives, methods and implementation plans in a way that can be
understood by both health professionals and game developers (Shegog, 2010). Supporting game

50
developers in creating an evidence- and theory-based serious game is an important challenge, where
IMP is considered a useful aid (Shegog, 2010).

In sum, the use of serious digital games has been effective in reducing bullying and cyberbullying. The
Intervention Mapping Protocol has been applied successfully to an intervention for cyberbullying, and
to serious games for health promotion. So far, no serious digital game to reduce cyberbullying has been
developed using IMP.

4. Research objectives and outline of the dissertation

The overall aim of this doctoral thesis is to contribute to the development of evidence-based
interventions to change bystander behavior in cyberbullying among adolescents, and to promote healthy
lifestyles using serious digital games.
Part II of this dissertation presents a collection of scientific articles that are published, under review or
submitted to international peer-reviewed journals or books. Based on the project goals, this dissertation
comprises three sets of articles. The first set aims to better understand bystander behavior in
cyberbullying among adolescents. This set consists of five articles presented in chapter 1. A second set
aims to assess the potential of serious games to promote social behavior and other healthy lifestyles.
Three articles were written on this topic, and are included in chapter 2. A last set, consisting of one
article, describes how a serious game can be developed using the Intervention Mapping Protocol, to
promote positive bystander behavior in cyberbullying among adolescents, described in chapter 3.
The first chapter of this dissertation covers the needs assessment, behavioral determinants and change
objectives in designing an evidence-based intervention to reduce cyberbullying and its harm. The first
article in this chapter examined whether severely obese adolescents can be considered at-risk for
cyberbullying and its related harm. Data from severely obese patients were matched with those of
normal-weight peers. The study aimed to examine differences in prevalence of cyberbullying and
traditional bullying between obese and normal-weight youth, and to assess whether obese victims of
cyberbullying reported lower psychosocial functioning and more barriers towards healthy lifestyles than
those non-victimized. These factors would hinder the effectiveness of weight-loss programs for severely
obese adolescents.
A second article summarized existing evidence on mental, physical, social and behavioral health
outcomes related to cyberbullying. A systematic review was conducted of 59 studies on cyberbullying,
and compared with current knowledge on traditional bullying. The review aimed to explore
consequences of cyberbullying by comparing findings from cross-sectional and longitudinal findings,
and to distill the unique consequences of cyberbullying, controlled for the involvement in traditional
bullying.

51
A third article explored adolescents bystander behavior in cyberbullying and its behavioral
determinants, using a behavior change theoretical framework. Nine focus groups were held with 61
young adolescents. The study aimed to explore themes related to cyberbullying bystander behavior, to
provide input for the design of a quantitative survey questionnaire.
A fourth article investigated adolescents bystander behavior in cyberbullying and its behavioral
determinants, using a behavior change theoretical framework, in a quantitative survey. A sample of 1979
adolescents was used. The study aimed to determine which factors predicted positive and negative
bystander behavior in cyberbullying.
A fifth article explored school educators practices and perceptions in handling cyberbullying. These
data provide insights in environmental influences on bystander behavior in cyberbullying among
adolescents. The study comprised 451 school educators, and aimed to detect clusters of educators who
were more or less inclined to use recommended strategies in handling cyberbullying.
The second chapter in the second part of this dissertation covers the potential of serious digital games
as a practical application to improve social behavior, and other healthy lifestyles. Whereas the first
chapter provided evidence-based content for the design of a game intervention against cyberbullying,
this second chapter provided insights on evidence-based methods to integrate this content in the
cyberbullying game.
A first article in this second chapter reported the average effectiveness of serious digital games to
improve healthy lifestyles. A meta-analysis of 54 game studies was used to examine this. The study
aimed to establish average effect sizes, and the moderating role of theory, individual tailoring, study and
sample characteristics in the games effects. A second article in this second chapter further elaborated
on this. An updated meta-analysis of 58 game studies was conducted. The meta-analysis aimed to find
behavior change techniques and game experience enhancing features which could moderate the games
effects. In a third article in this second chapter, the same meta-analytic data were used, to assess the
moderating role of user involvement and participatory design in serious game development.
The third chapter comprises one article, which discusses the evidence-based and theory-based
development, using the Intervention Mapping Protocol, of a serious digital game to promote positive
bystander behavior in cyberbullying among adolescents. This chapter thus integrates findings from
chapter 1 and chapter 2 and applies these to the concrete case of designing a serious digital game to
promote positive bystander behavior in cyberbullying.
Part III aims to tie together the insights from several original research findings in this dissertation. Given
the relatively novel area of research into bystander behavior in cyberbullying, and the lack of evidence-
based directions in designing effective games for health promotion, this part will also discuss
recommendations for future research and intervention development.

52
5. Overview of the original research studies

Chapter 1: Understanding cyberbullying and cyberbullying bystander behavior

Chapter 1.1: DeSmet et al. Traditional and cyberbullying victimization as correlates of psychosocial
distress and barriers to a healthy lifestyle among severely obese adolescents a matched casecontrol
study on prevalence and results from a cross-sectional study. BMC Public Health 2014, 14, 224-236

Chapter 1.2.: Gunther, N., DeSmet, A.(shared first authorship), et al. Comparing associated harm with
traditional bullying and cyberbullying: a narrative overview of mental, physical and behavioural
negative outcomes. Accepted for publication in the book Cyberbullying. From Theory to
Interventions, published by Psychology Press (October 2015).

Chapter 1.3.: DeSmet et al. Determinants of self-reported bystander behavior in cyberbullying

incidents amongst adolescents. Cyberpsychology, Behavior and Social Networking, 2014, 17 (4), 207-
215

Chapter 1.4. : DeSmet et al. Deciding whether to look after them, to like it, or leave it: a
multidimensional analysis of predictors of positive and negative bystander behavior in cyberbullying
among adolescents. Submitted

Chapter 1.5. : DeSmet et al. Secondary school educators perceptions and practices in handling
cyberbullying among adolescents: a cluster analysis. Computers & Education, 2015, 88, 192-201

Chapter 2: Understanding the potential of serious games to promote healthy lifestyles

Chapter 2.1.: DeSmet et al. A meta-analysis of serious digital games for healthy lifestyle promotion.
Preventive Medicine, 2014, 69, 95-107

Chapter 2.2. :DeSmet et al. The effect of behavioral change techniques and game features in serious
digital games for healthy lifestyle promotion: a meta-analysis. Submitted

Chapter 2.3.: DeSmet et al. Assessing the moderating role of participatory design in serious game
effectiveness: a meta-analysis of serious games for healthy lifestyle promotion. Submitted

53
Chapter 3: Using the Intervention Mapping Protocol in the design of a serious game to promote
positive bystander behavior among adolescents

Chapter 3.1. : DeSmet et al. Bridging behavior science and gaming theory: using the Intervention
Mapping Protocol in the design of a serious game to promote positive bystander intervention in
cyberbullying among adolescents. Submitted

Fig. 2. Graphical representation of the original research studies to complete the steps in the Intervention
Mapping Protocol

54
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Part 2 ORIGINAL RESEARCH

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 Chapter 1
Understanding cyberbullying and cyberbullying
bystander behavior

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 Chapter 1.1.
Traditional and cyberbullying victimization as correlates of psychosocial distress and barriers
to a healthy lifestyle among severely obese adolescents a matched case-control study on
prevalence and results from a cross-sectional study

This chapter was published as: DeSmet, A., Deforche, B., Hublet, A., Tanghe, A., Stremersch, E., & De
Bourdeaudhuij, I. (2014). Traditional and cyberbullying victimization as correlates of psychosocial distress
and barriers to a healthy lifestyle among severely obese adolescents a matched case-control study on
prevalence and results from a cross-sectional study. BMC Public Health, 14, 224-236

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 Chapter 1.2.
Comparing associated harm with traditional bullying and cyberbullying: a narrative overview
of mental, physical and behavioral negative outcomes

This chapter was accepted for publication as book chapter in: Gunther, N.*, DeSmet, A.*, Jacobs, N., & De
Bourdeaudhuij, I. (2015). Comparing outcomes of cyberbullying and traditional bullying: a narrative
systematic review of mental, physical and behavioural negative outcomes. In: Vllink, T., Dehue, F., and
McGuckin, C. Cyberbullying: from theory to interventions. In Press. Psychology Press

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 Chapter 1.3.
Determinants of self-reported bystander behavior in cyberbullying incidents amongst
adolescents

This chapter was published as: DeSmet, A., Veldeman, C., Poels, K., Bastiaensens, S., Van Cleemput, K.,
Vandebosch, H., & De Bourdeaudhuij, I. (2014). Determinants of self-reported bystander behavior in
cyberbullying incidents amongst adolescents. Cyberpsychology, Behavior and Social Networking, 17, 4,
207-215

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 Chapter 1.4.
Deciding whether to look after them, to like it, or leave it: a multidimensional analysis of
predictors of positive and negative bystander behavior in cyberbullying among adolescents

This chapter was submitted for publication as: DeSmet, A., Bastiaensens, S., Van Cleemput, K., Poels, K.,
Vandebosch, H., Cardon, G., & De Bourdeaudhuij, I. Deciding whether to look after them, to like it, or leave
it: a multidimensional analysis of predictors of positive and negative bystander behavior in cyberbullying
among adolescents

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 Chapter 1.5.
Secondary school educators perceptions and practices in handling cyberbullying among
adolescents: a cluster analysis

This chapter was published as: DeSmet, A., Aelterman, N., Bastiaensens, S., Van Cleemput, K., Poels, K.,
Vandebosch, H., Cardon, G., & De Bourdeaudhuij, I. (2015). Secondary school educators perceptions and
practices in handling cyberbullying among adolescents: a cluster analysis. Computers & Education, 88, 192-
201

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 Chapter 2
Understanding the potential of serious games to
promote healthy lifestyles

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 Chapter 2.1.
A meta-analysis of serious digital games for healthy lifestyle promotion

This chapter was published as: DeSmet, A., Van Ryckeghem, D., Compernolle, S., Baranowski, T., Thompson,
D., Crombez, G., Poels, K., Van Lippevelde, W., Bastiaensens, S., Van Cleemput, K., Vandebosch, H., & De
Bourdeaudhuij, I. (2014). A meta-analysis of serious digital games for healthy lifestyle promotion.
Preventive Medicine, 69, 95-107

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 Chapter 2.2.
The effect of behavioral change techniques and game features in serious digital games for
healthy lifestyle promotion: a meta-analysis

This chapter was submitted for publication as: DeSmet, A., Crombez, G., De Bourdeaudhuij, I., Baranowski,
T., Thompson, D., Poels, K., Bastiaensens, S., Van Cleemput, K., Vandebosch, H., & Van Ryckeghem, D. The
effect of behavioral change techniques and game features in serious digital games for healthy lifestyle
promotion: a meta-analysis.

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 Chapter 2.3.
Assessing the moderating role of participatory design in serious game effectiveness: a meta-
analysis of serious games for healthy lifestyle promotion

This chapter was submitted for publication as: DeSmet, A., Thompson, D., Baranowski, T., Palmeira, A.,
Verloigne, M., & De Bourdeaudhuij, I. Assessing the moderating role of participatory design in serious game
effectiveness: a meta-analysis of serious games for healthy lifestyle promotion

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 Chapter 3
Using the Intervention Mapping Protocol in the
design of a serious game to promote positive
bystander behavior among adolescents

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 Chapter 3.1.
Bridging behavior science and gaming theory: using the Intervention Mapping Protocol in
the design of a serious game to promote positive bystander intervention in cyberbullying
among adolescents

This chapter was submitted for publication as: DeSmet, A., Van Cleemput, K., Bastiaensens, S., Poels, K.,
Vandebosch, H., Malliet, S., Verloigne, M., Van Wolleghem, G., Mertens, L., Cardon, G., & De Bourdeaudhuij,
I. Bridging behavior science and gaming theory: using the Intervention Mapping Protocol in the design of
a serious game to promote positive bystander intervention in cyberbullying among adolescents.

289
Part 3 GENERAL DISCUSSION

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 PART 3: DISCUSSION

The third and final part of this doctoral dissertation starts with a summary of the findings of the nine
original research studies included. Detailed results and discussions are provided in the manuscripts. This
summary is followed by an overall discussion and conclusions, addressing how the findings across the
included research studies may aid in a better understanding of cyberbullying bystander behavior, and in
assessing the potential of serious digital games to promote healthy lifestyles. Some strengths and
limitations of our research will be noted, before deriving its implications for research and practice, and
formulating recommendations for future research.
Cyberbullying is considered a form of bullying performed via electronic or digital media, such as e-
mail, cell phone, or social network sites. As in traditional bullying which does not involve digital media,
cyberbullying is characterized by the intention of the bully to cause the victim harm, by harm that is
often repeated, and by a power imbalance between the bully and victim. Cyberbullying peaks in young
adolescence, among youngsters aged 12-14 years. In traditional bullying, the bullying and its harm were
successfully reduced by positive bystander behavior, such as active defending, comforting the victim or
giving advice, or reporting it to adults. It has been hypothesized that positive bystander behavior could
provide similar benefits in cyberbullying as in traditional bullying. Serious digital games may be a
valuable tool to address cyberbullying, since this medium is very appealing to this age group. Serious
digital games are games intended to be both educational and enjoyable, and which are used on a digital
device (e.g. computer, mobile phone).
With varying effectiveness of current serious games, there has been a call for more guidelines in
evidence-based serious game design. In designing a serious game against cyberbullying, only limited
research is available: some serious digital games have been designed for bullying (Rubin-Vaughan,
Pepler, Brown, & Craig, 2011; Salmivalli, Krn, & Poskiparta, 2011; Sapouna et al., 2010), but none
so far were designed to address cyberbullying. Given this limited research base on serious games for
bullying, evidence from serious games in related areas needed to be examined to assess their potential
in addressing cyberbullying. Expanding the scope to health-promoting games may be fruitful, since
prosocial behavior is part of a healthy lifestyle that also comprises other, associated health behaviors
(Walker, Sechrist, & Pender, 1987).
This doctoral dissertation aims to provide a better understanding of cyberbullying bystander behavior,
and of the potential of serious digital games to address cyberbullying behavior and other healthy
behaviors. Whereas the first chapter provided evidence-based content for the design of a game
intervention against cyberbullying, the second chapter provided insights on evidence-based methods to
integrate this content in the cyberbullying game. The third chapter integrates findings from chapter 1
and chapter 2 and applies these to the concrete case of designing a serious digital game to promote
positive bystander behavior in cyberbullying.

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1. Summary of main findings

1.1. Understanding cyberbullying and cyberbullying bystander behavior

The systematic review of studies investigating mental, physical and social health problems related to
cyberbullying involvement, described in chapter 1.2, established that cyberbullying relates to a plethora
of psychosocial and health issues for adolescents, and can be considered as a public health concern.
Longitudinal studies revealed that some psychosocial problems are antecedents rather than
consequences of cyberbullying involvement, and that for some problems, a bi-directional relationship
exists. Cyberbullying thus deteriorates psychosocial and health functioning in an already vulnerable
population.
A study among obese youth and their normal-weight peers, described in chapter 1.1, confirmed that
victimization from cyberbullying relates to psychosocial problems, and that peer victimization may lead
to situations further deteriorating these adolescents health. Cyberbullying was defined here following
the definition used in the HBSC study, to maximize comparability (including a criterion of doing or
saying unpleasant things, excluding someone, repetition, power imbalance, and differentiated from
friendly teasing or fights between friends of equal power, using either Internet or mobile phone). Obese
adolescents were more often the victim of cyberbullying than their normal-weight peers, and obese
victims of cyberbullying had a significantly higher risk of having had suicidal thoughts than those non-
victimized. Victimization from traditional bullying, but not from cyberbullying, was furthermore
associated with a higher avoidance of healthy lifestyles that are needed for successful weight-loss
interventions. To conclude, obese youngsters are at increased risk for being cyberbullied, and traditional
and cyberbullying pose a risk to the health of these youngsters.
Chapter 1.3 explored adolescents perceptions of bystander behavior and behavioral determinants,
using a Reasoned Action Approach framework. Adolescents reflected both on their own past
experiences as cyberbullying bystanders and on imaginary cases. Adolescents confirmed that bystanders
play an important role in cyberbullying. They described bystander behavior in cyberbullying not as fixed
roles, but as behavior that can vary depending on the context: what is the relation to and social status of
the victim, what is the relation to and social status of the bully, and how clearly does this incident qualify
as cyberbullying? This last contextual factor related mostly to the content of cyberbullying, e.g. racist
remarks or insulting the family, but did not distinguish much by incident types. Moral disengagement
attitudes were abundant in these discussions. Youngsters perceived little encouragement from their
environment to perform positive bystanding behavior, suggesting socio-ecological approaches for
cyberbullying bystander research and interventions are needed.
A quantitative study was conducted to elaborate and confirm these qualitative findings, and is discussed
in chapter 1.4. The repetition criterion was not used in the definition of cyberbullying here, since there
is uncertainty whether a cyberbullying act needs to be performed repeatedly to cause repeated harm

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(Dooley, Pyzalski, & Cross, 2009; Grigg, 2010; Kowalski & Limber, 2007; Vandebosch & Van
Cleemput, 2008) and comparability with HBSC data was no longer strictly required. The study used a
multidimensional and multilevel approach, based on a combined theoretical framework of the Reasoned
Action Approach, Social Cognitive Theory and the Bystander Intervention Model. The findings showed
that positive and negative bystander behavior and behavioral intentions were determined by many
factors, reflecting both attitudes, skills, self-efficacy, environmental facilitators, and background
elements, such as own victimization experiences or the friendship bond with the victim. There was some
evidence for a multilevel approach, but only few class and school variables contributed to explaining
differences in bystander behavior and behavioral intentions. No class or school-level factors influenced
negative bystander behavior. Findings diverged on some aspects from research on bystander behavior
in traditional bullying, and suggest specific attention to cyberbullying bystander behavior in research
and intervention is needed.
Chapter 1.5 examined one of the environmental barriers or facilitators in adolescents positive
bystander behavior, namely how educators respond to cyberbullying incidents. Research indicated that
adolescents do not report cyberbullying to educators, since educators are considered to not appropriately
handle these incidents. While recommended strategies (i.c. conversations with pupils, enlisting
professionals for support, parental involvement, providing supportive victim advice) were used most
often by educators, a cluster analysis revealed that the two largest educator clusters (the referrers, and
the disengaged) were less adept at handling cyberbullying and comprised mostly teachers, particularly
indicating a need for training teachers in how to address cyberbullying.

1.2. Understanding the potential of serious digital games to promote healthy lifestyles

Three meta-analyses were conducted to understand the potential of serious digital games in promoting
healthy lifestyles. These meta-analyses included studies in all age groups, and unlike results in chapters
1 and 3, did not exclusively relate to adolescents. Insufficient studies were available for analyses by
specific age category. Future meta-analyses, when a larger number of adolescent serious games are
available, may examine whether all findings would also apply when only studying games for
adolescents.
The aim of the meta-analyses was to provide suggestions for effective serious game development on a
higher level of generality. These suggestions are, evidently, not sufficient to create an effective health
promotion intervention. Additional information is needed at a lower level of generality, such as on
behavior-specific operationalization of the behavioral determinants, on the behavior-specific weights of
each determinant and on the relevance of using serious games in this context (Bartholomew, Parcel,
Kok, Gottlieb, & Fernndez, 2011; Fishbein, 2008). Furthermore, behavior-specific theories may be
needed to complement the general behavior change theories in intervention development, e.g. to

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understand environmental facilitators (Sallis, Owen, & Fisher, 2008), when the person has little control
over the behavior (Godin & Kok, 1996), and to translate intentions into behavior (Godin & Kok, 1996).
Effectiveness and moderators of effectiveness were investigated by specific primary outcomes of
behavior and behavioral determinants. The same core set of behavioral determinants was examined as
in the studies described in chapters 1.3, 1.4 and 1.5. This enables to apply these effective game
characteristics in the cyberbullying game design to each behavioral determinant found predictive of
cyberbullying bystander behavior.
In chapter 2.1, a first meta-analysis of 54 serious game studies for healthy lifestyle promotion confirmed
that overall, serious games are effective in promoting healthy lifestyles. The effect sizes on behavior or
behavioral determinants were small, and similar to those of computer-tailored interventions in other
meta-analyses. Long-term effects were maintained for all outcomes, except for behavior. Serious games
are best individually tailored to both socio-demographic and change need information, and benefit from
a theoretical focus on gaming theories or a dual theoretical foundation in both behavioral prediction and
gaming theories. They can be effective either as stand-alone or multi-component programs, and appeal
to populations regardless of age and gender, or health domain. Given that the effects of games remain
heterogeneous, further explorations of which game characteristics create larger effects are needed.
To follow up on this, a meta-analysis (updated search for recent papers) of 58 game studies was
conducted, and described in chapter 2.2. This meta-analysis investigated the moderating role of
behavior change techniques and game-experience enhancing features in games effectiveness. Using
more behavior change techniques did not significantly relate to game effectiveness on any outcome,
whereas using more game-experience enhancing features related to a lower game effectiveness for
behavior. Games were more effective at changing behavioral determinants if they had a simple
challenge, or a difficult adaptive challenge, compared to a difficult, non-adaptive challenge. Games were
also more effective in changing behavioral determinants if they did not use personal goal-setting and
planning compared to those who did. Results on personal goal-setting should however be interpreted
with caution since these consisted of few studies and may be related to other characteristics. Additional
moderators of game effectiveness were found when assessing outcomes separately (e.g. knowledge,
attitudes, skills), supporting the importance of designing games with the specific outcome in mind.
A third meta-analysis, described in chapter 2.3, examined the moderating role of user involvement, and
more specifically of participatory design (PD), in the effectiveness of 58 serious digital game studies for
healthy lifestyle promotion. Games developed in participatory design had a lower effectiveness on
behavior than games developed only by pilot-testing a finished version among users. However,
significant differences existed among PD games. More support was found for informant roles than for
co-design roles. When PD was applied to game dynamics, levels and game challenge, this was associated
with higher effectiveness than when applying PD to game aesthetics. Since user involvement may be
important in the reach, adoption and implementation of the intervention, further research and design
efforts are needed to enhance effectiveness of serious games developed with PD.

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1.3. Using the Intervention Mapping Protocol in the design of a serious game to promote positive
bystander behavior among adolescents
The manuscript in chapter 3.1 described the development of a serious digital game to promote positive
bystander behavior, using the Intervention Mapping Protocol. While no key success factors have yet
been identified for cyberbullying intervention and prevention programs, it has been hypothesized that a
theoretical underpinning in behavior change theories may aid in these programs effectiveness. Several
theories, such as the Reasoned Action Approach, Social Cognitive Theory and the MDA framework,
guided the intervention development. The Intervention Mapping protocol was used to aid in the
systematic and stepwise application of these theories to create a behavior change program. This was
described in the manuscript, reporting on results from systematic literature reviews, meta-analyses,
focus groups, survey studies and observational research. This chapter describes how effective game
characteristics (chapters 2.1, 2.2 and 2.3) can be applied to the determinants of bystander behavior
(chapters 1.3 and 1.4) and how this game can be integrated in a multilevel intervention also targeting
parents and educators (chapters 1.4 and 1.5).
This descriptive manuscript aimed to comply with recent demands for more thorough reporting of the
intervention development. It may, furthermore, shorten the development process for other programs, by
continuing from existing evidence.

2. Overall discussion and conclusions

2.1. Promoting positive bystander behavior in cyberbullying among adolescents

The studies included in chapters 1.1 and 1.2, demonstrated that various psychosocial and physical
health problems are associated with cyberbullying involvement. A first important finding was that
cyberbullying may relate to different health outcomes than traditional bullying. Some disputes exist on
whether cyberbullying constitutes a different concern to public health than traditional bullying, and
whether consequently a different approach is warranted for this phenomenon. These disputes are further
fueled by evidence that traditional bullying programs have shown reductions in cyberbullying as well,
and the opinion that a targeted approach for cyberbullying is hence unnecessary (Olweus, 2012;
Salmivalli et al., 2011). Our research findings in chapters 1.1 and 1.2 showed that victimization from
traditional bullying and from cyberbullying, related to some divergent health problems. For example,
cybervictimization appeared to be stronger associated with suicidal ideation than traditional
victimization did, and that some factors, such as self-esteem, anxiety and substance abuse, were only
antecedents of cybervictimization while a bidirectional relationship existed with traditional
victimization (chapter 1.2). Also among obese youth (chapter 1.1), victims from traditional bullying
experienced different psychosocial health problems (e.g. lower quality of life) than victims from

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cyberbullying (e.g. higher suicidal thoughts). The findings from these studies included in the dissertation
thus confirm other research findings showing associations between health problems and cyberbullying
involvement (Kowalski, Giumetti, Schroeder, & Lattaner, 2014; Suzuki, Asaga, Sourander, Hoven, &
Mandell, 2012), but contribute to this literature by examining different patterns between cyberbullying
and traditional bullying, and by reviewing longitudinal studies to establish the direction of these
associations (chapter 1.2). Most recently summarized information drew only on cross-sectional studies
(Kowalski et al., 2014), examined only one of these forms (Gini & Pozzoli, 2009; Suzuki et al., 2012),
or did not single out associations by type of bullying (Arseneault, Bowes, & Shakoor, 2010). This
research further contributed to literature by investigating an at-risk group of obese adolescents, where
very limited and inconsistent evidence is available related to cyberbullying (chapter 1.1) (Puhl,
Peterson, & Luedicke, 2013; Wang, Iannotti, & Luk, 2010).
Although more longitudinal research on both traditional and cyberbullying is needed, these potentially
different antecedents and outcomes may imply that different target groups and psychosocial warning
signals should be identified for cyberbullying and for traditional bullying. Cybervictimization,
furthermore, had its own unique contribution to negative health outcomes, and thus warrants specific
attention in research and interventions. It may, however, still be recommended to address both
cyberbullying and traditional bullying in one integrated program (Pearce, Cross, Monks, Waters, &
Falconer, 2011) to avoid a shift from one bullying type to another (Elledge et al., 2013). Some studies
have furthermore shown that bullying victimization relates to avoidance of healthy lifestyles also among
normal-weight adolescents (Faith, Leone, Ayers, Heo, & Pietrobelli, 2002; Vartanian & Shaprow,
2008). Multi-behavioral whole-school programs, that address both bullying and other healthy lifestyles,
such as physical activity and a healthy diet, may prove to be an effective approach to target health and
social behavior among adolescents (Busch, De Leeuw, & Schrijvers, 2013).

A second important finding of the studies included in this dissertation was the potential to address
cyberbullying by increasing positive bystander behavior (chapters 1.3, 1.4, 3.1). As stipulated in the
Intervention Mapping Protocol, the development of a health promotion intervention should focus on
restating a problem situation (bullying) into risk-reducing or health-promoting behaviors, which may
not necessarily be the negation of the problem situation (e.g. not bullying). The descriptive paper on the
development of the Friendly Attac game showed that to reach the desired health and quality-of-life
outcomes for adolescents, addressing bystander behavior may be a viable approach (chapter 3.1). In
traditional bullying, meta-analyses demonstrated that bystander behavior can be changed (Polanin,
Espelage, & Pigott, 2012), but that anti-bullying programs should include peer interventions in a whole-
school program to be effective (Ttofi & Farrington, 2011).

At the onset of our project, to our knowledge, no research among adolescents existed on what determines
bystander behavior in cyberbullying. Our qualitative research findings (chapter 1.3) confirmed that

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bystander behavior does play a role in cyberbullying. These focus groups, moreover, showed bystander
behavior is not a fixed role and is context-dependent, as has been suggested in some research on
bystander behavior in traditional bullying (Espelage, Green, & Polanin, 2012; Espelage & Swearer,
2003; Gini, Albiero, Benelli, & Alto, 2007; Salmivalli & Voeten, 2004). This has important
implications for intervention programs. Rather than applying a personal deficit model, and assuming
that with sufficient empathic or social skills adolescents will always defend, our findings show that a
broader set of contextual factors needs to be considered. For example, even those nominated as
defenders, may not defend loners, since everyone mostly stands up for their own friends.

A fourth finding showed the relative importance of attributes in predicting bystander behavior, which
also has important implications for interventions (chapter 1.4). Since we executed this qualitative study,
a few other studies on adolescent bystander behavior in cyberbullying have been published, each
focusing on a limited set of determinants (Barliska, Szuster, & Winiewski, 2013; Barliska, Szuster,
& Winiewski, 2015; Bastiaensens et al., 2014b; Bastiaensens et al., 2014a; Bastiaensens et al., 2015;
Holfeld, 2014; Machackova, Dedkova, Sevcikova, & Cerna, 2013; Obermaier, Fawzi, & Koch, 2014;
Olenik-Shemesh, Heiman, & Eden, 2015; Price et al., 2014; Van Cleemput, Vandebosch, & Pabian,
2014). The study in chapter 1.4 used a multidimensional model, which examined a broad set of
behavioral determinants and included context variables. A recent systematic review of cyberbullying
prevention and intervention programs showed that most programs had a narrow scope and mostly
focused on increasing knowledge (Van Cleemput et al., in preparation). Knowledge is, however, known
as a necessary but insufficient condition for behavior change (Bartholomew et al., 2011). Several
behavior change theories suggest that most behavior is determined by a core set of eight factors, namely
attitudes, outcome expectations, self-efficacy, skills, social norm and personal norm, intentions and
environmental constraints or facilitators (Bartholomew et al., 2011). Not all determinants may apply to
the same strength for every target behavior. In designing an intervention, it is therefore crucial to first
assess the weight of each predictor in a multidimensional model, and to next target the determinants
which predict the behavior the most (Bartholomew et al., 2011). Our study reported in chapter 1.4 was
the first to examine cyberbullying bystander behavior using this approach.
This multidimensional model, based on behavior change theories, fit well in explaining positive and
negative bystander behavior. The study contributed to literature by establishing the predictive value of
factors that had not been studied in previous quantitative studies (e.g. moral disengagement attitudes,
self-efficacy to end cyberbullying, coping skills, and parental monitoring of Internet activities), and by
including a broad set of predictors, which allowed to control for the influence of predictors that would
only explain behavior via shared predictive power. Most support was found for the influence of personal
factors and the relationship with the victim as a situational factor in predicting positive and negative
bystander behavior. Other situational factors, e.g. fear of the bully, other bystanders behavior and
uncertainty about the incident, did not significantly contribute to explaining bystander behavior,

349
consistent with small explained variances in other research (Bastiaensens et al., 2014b; Obermaier et al.,
2014). It is, however, possible that this would differ by incident type, not investigated here. These
findings can provide directions in intervention development, since influencing the strongest predictors
among the modifiable determinants is most likely to result in a change in the target behavior
(Bartholomew et al., 2011). Our findings show a high importance of attitudes in creating a positive
behavioral intention for bystander behavior. This element was included in only four of fifteen
cyberbullying programs (Van Cleemput et al., in preparation). Although most programs did not target
bystander behavior and our findings cannot determine what predicts bullying perpetration behavior, a
multidimensional model for cyberbullying perpetration behavior did, however, confirm the highest
importance of attitudes also for this type of behavior (Heirman & Walrave, 2012). This indicates that
the effectiveness of cyberbullying prevention and intervention programs may be enhanced by shifting a
strong focus from knowledge to attitudes. Also in predicting bystander behavior, attitudes were
important in the form of outcome expectations, and adding a component to target these attitudes, as well
as components on social skills, coping skills and empathic skills may increase positive bystander
behavior and reduce negative bystander behavior. The multidimensional nature of predictors, in our
study and also in the findings from predictors on cyberbullying perpetration (Heirman & Walrave, 2012)
would lend most support to the very few cyberbullying programs which target several behavioral
determinants, namely the KiVA program (Williford et al., 2013) and the MediaHeroes program (Wlfer
et al., 2013).
Since few current cyberbullying programs have targeted bystander behavior (Van Cleemput, in
preparation), and no evidence yet exists on effective components of interventions to change bystander
behavior, neither from cyberbullying, nor from traditional bullying (Polanin et al., 2012), our research
findings can, therefore, aid in future evidence-based interventions to change bystander behavior in
cyberbullying. Prevention and intervention programs to increase positive bystander behavior should thus
focus on the outcome expectations of benefiting the victim and supporting also those who are not good
friends, and on increasing intentions to act as a positive bystander by increasing social skills, attitudes
supporting positive behavior and condemning negative behavior, maternal awareness of Internet
activities, coping skills and self-efficacy (chapter 1.4).
The findings from chapter 1.4 may also be understood within a framework of moral development. The
expectation of obtaining personal benefits, as was the case in the intention for negative bystander
behavior (e.g. expecting personal protection and gains), may reflect a moral development stage of self-
interest orientation (Kohlberg, 1971), or of hedonistic, self-serving reasons (Daniel, Dys, Buchmann,
& Malti, 2014). Conversely, the expectations of benefiting the victim and the importance of standing up
for a friend, as related to positive bystander behavior and behavioral intentions, may indicate a moral
development stage of interpersonal accord and conformity (Kohlberg, 1971) or indicate moral
reasons (Daniel et al., 2014). Despite conceptual differences between cognitive-developmental stage
models and models emphasizing both cognitive and affective factors (Gibbs, 2013), both seem to agree

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that self-serving motives occur more in childhood, whereas moral, interpersonal motives often appear
in adolescence (Daniel et al., 2014; Fabes, Carlo, Kupanoff, & Laible, 1999; Kohlberg, 1971). Some
studies have shown that moral reasoning and emotions increase with age in adolescence (Daniel et al.,
2014; De Caroli & Sagone, 2014), and become less self-serving. A meta-analysis, however, showed no
relation with age, suggesting differences in moral reasoning and emotions result more from individual
differences than from natural maturation processes (Malti & Krettenauer, 2013). Our study results in
chapter 1.4 showed a negative association between age and the intention for positive bystander
behavior, within our sample of early adolescents. This may fit with the suggestion that moral
development is not merely a linear maturation process and may be impacted by other factors.
Nevertheless, early adolescence is a phase in which moral functioning can be impacted by hormonal and
physical changes, and by a growing importance of the peer context (Fabes et al., 1999; Hart & Carlo,
2005). Support in fine-tuning their moral functioning for young adolescents, e.g. via guided classroom
discussions on moral dilemmas while modeling a moral norm or empathic approach (Enright, Lapsley,
Harris, & Shawver, 1983), may thus aid their moral development towards a socio-centric perspective.
Moreover, adolescents should learn to expand prosocial behavior beyond their circle of friends, as also
suggested in the study results in chapter 1.4 for positive bystander behavior. Showing prosocial
behavior in situations related to strangers was shown to be more related to a pro-social value orientation
and moral identity at one year follow-up than intervening for people who are close to them (Padilla-
Walker & Fraser, 2014). This aligns with the development of social justice values, in which rules of
fairness are applied to all individuals, and which should emerge in adolescence (Daniel et al., 2014).
Since especially these prosocial behaviors for out-group members are related to more positive
developmental outcomes in adolescence and better moral functioning in adulthood (Padilla-Walker &
Fraser, 2014), supporting these may be of great importance. This will be one of the learning objectives
for the adolescents in the game, as mentioned in chapter 3.1.
The intervention will furthermore need to tailored by gender, since studies have shown gender
differences in moral functioning (Daniel et al., 2014; De Caroli & Sagone, 2014; Fabes et al., 1999;
Thornberg & Jungert, 2013), and our own study results in chapter 1.4 showed less positive behavior
among boys. One review suggested the gap between boys and girls to be widening during adolescence
(Fabes et al., 1999), whereas a longitudinal study showed lower moral competence in boys than in girls,
but their developmental paths to be the same (Daniel et al., 2014). Boys appear to be sensitive in
adolescence to gender-specific socialization values, which do not support a caring attitude (Fabes et al.,
1999). The intervention described in chapter 3.1 aims to take into account that boys may need to find
ways to support and comfort a victim in line with their gender-specific identity.

A last finding from both the quantitative and qualitative study on bystander behavior in this dissertation
(chapters 1.3 and 1.4), showed the need for support from parents and educators for positive bystander
behavior, and emphasized the importance of a socio-ecological perspective in studying cyberbullying

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bystander behavior. A socio-ecological perspective of health behavior recognizes interacting influences
of both personal and environmental factors, and interventions based on these perspectives may yield
larger community effects (Sallis et al., 2008). Qualitative findings described in chapter 1.3, indicated
that apart from the peer context, support from parents and educators mattered, and was perceived to be
largely lacking for positive bystander behavior. The quantitative study on bystander behavior (chapter
1.4) confirmed that maternal awareness of Internet activities was a significant predictor of the intention
for positive bystander behavior, and that class (i.c. class moral disengagement norms) and school factors
(i.c. information days for pupils) also play a role. This study employed a multilevel analysis, which is
the first study on bystander behavior in cyberbullying to do so. This analysis showed an influence of the
class that adolescents belonged to on their intention to act as a negative bystander, which related to
aggregated class norms on cyberbullying and should be addressed at this class level by educators. The
study among educators (chapter 1.5) confirmed the perceptions of adolescents in the qualitative study
(chapter 1.3), that there is room for improvement in how educators handle cyberbullying. Although
educators more often used recommended strategies than not recommended strategies, they did not apply
these most recommended basic strategies, such as talking with pupils about cyberbullying, consequently
in every incident. This was mostly the case among teachers, who also felt less capable to handle
cyberbullying compared to other educators. The perceived lack of competence in handling cyberbullying
among teachers was consistent with other research (Cassidy, Brown, & Jackson, 2012; Eden, Heiman,
& Olenik-Shemesh, 2013; Huang & Chou, 2013; Li, 2008; Stauffer, Heath, Coyne, & Ferrin, 2012;
Vandebosch, Poels, & Deboutte, 2014), but the study reported in chapter 1.5 extended existing research
by exploring other behavioral determinants, such as attitudes and outcome expectations. Incorporating
staff training and school policies are integral parts of a whole-school program against bullying (Olweus,
2004), which tackles bullying from several socio-ecological levels, is considered the most effective
approach in traditional bullying (Ttofi & Farrington, 2011) and has shown effects on cyberbullying as
well (Williford et al., 2013).

Findings showed that more transfer is needed between principals and school counselors to teachers on
how to handle cyberbullying. Having a school policy may also provide a firmer ground for educators to
intervene in cyberbullying, as shown in traditional bullying research (Bauman, Rigby, & Hoppa, 2008).
Although some recommendations exist in papers (see e.g. (Pearce et al., 2011), little directions are
provided for school staff on how to intervene in cyberbullying in current evidence-based cyberbullying
prevention and intervention programs (Van Cleemput et al., in preparation). This component needs to
be strengthened in future anti-cyberbullying programs as a facilitator of positive bystander behavior.
Also for these environmental agents behavior, most significant and changeable determinants need to be
identified in order to effectively address these in a cyberbullying program (Bartholomew et al., 2011).
These have been reported in the descriptive paper on the Friendly Attac game development (chapter
3.1).

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In sum, cyberbullying related to some different health outcomes than traditional bullying, and may
warrant specific attention in research and interventions. The Intervention Mapping Protocol encourages
an analysis of which behaviors can improve these health outcomes. Promoting positive bystander
behavior can be a viable approach to address cyberbullying and its health outcomes. Bystander behavior
is context-dependent, and influenced by adolescents relation with peers, and support from parents and
educators. Educators, and especially teachers, are in need of training to suitably support adolescents in
their positive bystander behavior, and reduce intentions for negative bystander behavior. Bystander
behavior is determined by a multitude of factors. A multidimensional model, grounded in behavior
change theories and corresponding with a socio-ecological framework, aided in explaining bystander
behavior in adolescents. Behavior change theories were also applied to explaining educator and parental
behavior, and described in change matrices following the approach posited in the Intervention Mapping
Protocol. These findings may inspire programs to intervene at several levels of the socio-ecological
model, of which a suggested elaboration can be found in chapter 3.1.

2.2. The potential of serious digital games to promote healthy lifestyles

Several systematic reviews suggested that serious digital games may be effective in promoting healthy
lifestyles. The meta-analysis in chapter 2.1 was the first to confirm that, on average, serious digital
games are effective in promoting healthy lifestyles. Although effects on behavior were small, they were
significant and in line with effects of other computer-delivered interventions. Effects were largest on
knowledge, also consistent with findings from computer-delivered interventions. Efforts are needed to
increase the effectiveness of serious games on other determinants of behavior, such as behavioral
intention and self-efficacy.
Effects at follow-up measurement were significant but smaller, except for clinical outcomes. Moderator
analyses indeed indicated that as time until follow-up increased, the effectiveness of the games on
behavior and behavioral determinants was reduced. Additional efforts may be needed in the design of
serious games to sustain their effects in the longer term, for example by using techniques proven to
increase long-term effectiveness in other interventions such as booster sessions, tailored reminders and
reinforcement, Motivational Interviewing, using proactive coping techniques to prevent relapse, and
facilitating environmental changes (Jacobs et al., 2004; Lustria, Cortese, Noar, & Glueckauf, 2009;
Martins & McNeil, 2009; Norris, Engelgau, & Venkat Narayan, 2001; Orleans, 2000).
Large differences between the game studies, however, existed. Several moderators, hypothesized in
earlier reviews, were explored to explain these differences (chapters 2.1, 2.2 and 2.3). The meta-
analyses provided the first validation of these hypotheses.

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The theoretical foundation of the game development was examined in relation to game effectiveness
(chapter 2.1). The first meta-analysis showed that games developed when using a gaming theory, with
or without a behavior change theory, were more effective, whereas games developed solely based on
behavior change theories were least effective. This may conflict with the findings of the second meta-
analysis (chapter 2.2), where the role of game-experience enhancing features in effectiveness was
explored. Using more gaming features assumed to increase immersion related to lower effectiveness.
Applying a gaming theory can thus contribute to game effectiveness, but should not result in a stacking
of highly immersive gaming features. Highly immersive games may increase cognitive load, and
consequently reduce effectiveness (Schrader & Bastiaens, 2012). Many gaming theories focus on player
motivation and on maintaining an optimal balance between mastery and curiosity (Kapp, 2012).
Possibly, these theories aided in a better selection of gaming features, to avoid cognitive overload and
maintain a sense of control for the player. The combined findings of these meta-analyses underline the
need for a gaming theoretical grounding of the choice of gaming features.
A conceptual model on how to combine behavior prediction theories and gaming theories was proposed
by Baranowski et al. (Baranowski, Baranowski, Thompson, & Buday, 2011). In this model, gaming
theories, such as Transportation Theory and Elaboration-Likelihood Theory, increase the chance that
the person will be exposed to, interested in and motivated to (repeatedly) play the game. Whereas
gaming theories can raise interest and attention to the message in the game, behavior predictor and
change theories, such as Social Cognitive Theory, need to ensure that what is contained in this message
can change behavior. First, these behavior prediction and change theories can aid in determining which
mediating variables, such as knowledge, skills, self-efficacy, to target, based on an analysis of behavioral
determinants. These theories next provide directions on which behavior change techniques are best fit
to change these mediators, e.g. modelling to change skills. For example, based on behavioral
determinant analyses inspired by Social Cognitive Theory, it may be decided that increasing skills is
needed to improve bystander assertive defending behavior. Modelling this behavior in the game could
demonstrate to adolescents how to successfully perform this behavior. Guided by Transportation
Theory, a story may be designed in which a character models the behavior. This story could help increase
the players immersion and attention of the player for the game character who is modelling the assertive
defending behavior.

A higher effectiveness of games that used fewer gaming features (chapter 2.2), and more particularly
that had simpler challenges or consisted of only one level, may also suggest that serious digital games
do not require all the bells and whistles from commercial games to be effective. This would lend
support to a gamification approach (Deterding, Dixon, Khaled, & Nacke, 2011; Deterding, 2012), where
a few game elements, such as a simple challenge and rewards or feedback, are applied to a non-game
intervention (e.g. mobile applications or apps, real-life activity). These simpler games may, moreover,

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present a more cost-effective approach, if their development requires fewer resources. To our
knowledge, no cost-effectiveness study on this topic has yet been undertaken.

Only applying behavior change theories related to lower game effectiveness (chapter 2.1). This
demonstrates differences between serious digital games and other digital health promotion programs,
such as computer-tailoring interventions, where these theories were associated with moderately high
effectiveness (Webb, Joseph, Yardley, & Michie, 2010). Similarly, some behavior change techniques
(BCT), such as personal goal-setting and planning were found to be highly effective in other health
promotion interventions (Dusseldorp, van Genugten, van Buuren, Verheijden, & van Empelen, 2014;
Michie, Abraham, Whittington, McAteer, & Gupta, 2009), but related to lower effectiveness in serious
digital games (chapter 2.2).

Several hypotheses can be formulated to explain the relatively low importance of behavior change
theories and BCTs in serious game effectiveness. First, since techniques and theories were derived from
reports in the game study papers, it is unclear if the behavior change theories and techniques were
correctly applied. Techniques and behavior change theories are known to be incorrectly interpreted and
applied, which can cause variety between interventions effectiveness (Michie et al., 2011). Moreover,
this correct application may have been further complicated by the game context. Digital serious games
are assumed to partially derive their value from being fun (Prensky, 2007), which implies that using
theoretical concepts and BCTs also needs to guarantee an enjoyable game experience. This may have
resulted in an adjustment of BCTs to less optimal conditions for their effects. For example, for feedback
to be effective, it should be immediate, specific, and positive (Baranowski, Bower, Krebs, Lamoth, &
Lyons, 2013). In games, however, feedback that meets all theory-based principles is assumed to break
the flow and increase player fatigue (Lyons, 2015). Whether the standard feedback provided in games
that shows players how they are performing, e.g. via visual or auditory cues, can attain the same
outcomes as feedback meeting theory-based recommendations, was raised as a question for future
research (Lyons, 2015). A similar adjustment may have been made, or may be required to provide goal-
setting techniques in an engaging way in the game. More research is needed on how to select and
translate behavior change techniques in a game, while retaining both their effectiveness and the
enjoyable game experience. During the serious game development in the Friendly Attac project, a lack
of direction was experienced in the Intervention Mapping Protocol on how to use BCTs in specific
applications, such as serious digital games (chapter 3.1). More detailed descriptions and evaluations
are needed of how BCTs were integrated with gaming theories and features, to identify application-
specific considerations when using the Intervention Mapping Protocol. The descriptive manuscript
(chapter 3.1) included in this dissertation aims to add to this beginning literature. Second, it is possible
that certain combinations of BCTs may relate to game effectiveness, whereas individual BCTs or other
combinations would not be effective. This was demonstrated for other types of health promotion

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programs (Dusseldorp et al., 2014; van Genugten, Dusseldorp, Webb, & van Empelen, 2015), and would
need further investigation for serious digital games.

Conversely, the effectiveness of BCTs and immersive game features differed by specific target outcome,
such as behavior, behavioral intentions, knowledge, attitudes, skills or self-efficacy (chapter 2.2).
Serious games should therefore be designed with the specific target outcome in mind. Behavior change
theories are needed to establish which outcomes to target, in order to attain the desired health and
quality-of-life outcomes (Bartholomew et al., 2011). Despite a lower effectiveness of only using
behavior change theories in current serious game design (chapter 2.1), these findings in chapter 2.2
indicate behavior change theories are needed in serious game design, to guide the selection of BCTs and
gaming features for an optimal fit with the behavior and behavioral determinants to be changed.

A behavior change technique that did relate to game effectiveness was individual tailoring (chapter
2.1). Tailoring of the content to users (socio-demographic/+needs) characteristics related to higher
game effectiveness, as in non-game interventions (Bridle et al., 2005; Krebs, Prochaska, & Rossi, 2010;
Noar, Benac, & Harris, 2007). Personalization of the looks of the game to user characteristics, however,
related to lower effectiveness on some outcomes. Similarly, involving users in the design of the looks
related to lower game effectiveness, whereas their involvement in design of the content (e.g. challenge)
did relate to higher game effectiveness (chapter 2.3). Although the meta-analyses did not investigate
the role of graphics and visuals in game effectiveness, the findings suggest that matching these features
to user traits is not beneficial. We may also hypothesize that visuals and graphics are, in general, less
strongly associated with game effectiveness. This is in line with a meta-analysis on educational serious
games, which showed that games with more realistic visuals were less effective than simple text or
cartoon-like games (Wouters, van Nimwegen, van Oostendorp, & van der Spek, 2013). Involving users
in these irrelevant aspects may therefore not benefit game effectiveness. The Intervention Mapping
Protocol emphasizes the importance of user and stakeholder involvement throughout the planning and
implementation process (Bartholomew et al., 2011). Benefits of this involvement lie not only in the
interventions effectiveness, but also in the reach and adoption of the intervention during implementation
(Bartholomew et al., 2011). In the Friendly Attac game (chapter 3.1), users and stakeholders were
involved from the start. Although our meta-analytic findings indicated that only pilot-testing a finalized
version of the game is more effective than involving users as informants or co-designers during design
(chapter 2.3), users were still actively involved in the design of the Friendly Attac game, since this may
be of value in later project stages, during implementation. The meta-analytic insights, nevertheless,
aided in choosing a specific approach of user involvement (e.g. users involved as informants, in game
decisions on challenge and levels) which, when using active user involvement, related to higher
effectiveness (chapters 2.3 and 3.1). Since early user involvement is important to achieve reach,
adoption, and sustained implementation of a health-promotion intervention (Compernolle et al., 2014),

356
it is essential to optimize the effectiveness of active user involvement in serious games, as all these
elements together (see e.g. RE-AIM framework) determine the public health impact of health-promoting
interventions (Glasgow, Vogt, & Boles, 1999; Glasgow, Lichtenstein, & Marcus, 2003).
It can be assumed that relations exist between several variables which were studied in these univariate
moderator analyses. For example, a theoretical foundation may almost be a linear combination of several
techniques or features. A game which was pilot-tested with end users may, for example, be less likely
to contain a large number of gaming features which would distract from the educational content. Which
game characteristics would influence effectiveness the most while controlling for other predictors,
cannot be deducted from our findings and would need to be tested in multivariate analyses. Furthermore,
synergistic effects may be expected from certain characteristics, and the effects of these interactions also
deserve further research attention.

In sum, serious digital games can be effective to promote healthy lifestyles. Several moderators of game
effectiveness were identified, that can aid in future evidence-based serious game design. These meta-
analyses were the first to validate certain hypotheses for variability in game effectiveness formulated in
literature. In this relatively novel area of health promotion interventions, however, many hypotheses on
the effective mechanisms of serious digital games remain to be explored in future research.

3. Strengths and limitations

In this section, the major strengths and limitations of the original research studied included in this
doctoral thesis will be discussed, relating to study design and methodology.

3.1. Strengths

- The intervention design used a systematic theory- and evidence-based approach, and was informed
by a multidimensional and socio-ecological model. The multidimensional model, based on
behavior change theories, allowed to assess relative weights of predictors and to set priorities for
the factors on which to intervene first. Research was conducted among groups at several layers of
the socio-ecological model (bystander, parent, educator), rather than only assessing educator and
parental influences as perceived by the bystander. To change the environmental influences into a
supportive context, determinants of their behavior need to be assessed as well, and used as starting
points to address environmental influences in a multilevel intervention. This information was still
largely lacking in research until now. Since current cyberbullying interventions that pay attention
to the environment, did not describe the basis for these components and are often limited to
awareness raising (Van Cleemput et al., in preparation), the multidimensional and socio-ecological

357
 approach in our studies provide a sound basis for a multilevel intervention, which may have a higher
chance of yielding larger community effects (Sallis et al., 2008).
- The research among bystanders first used a qualitative approach, to inform the design of the
quantitative study, as recommended when designing health promotion interventions (Bartholomew
et al., 2011).
- We chose not to use peer nominations of bystander roles. Although self-reported bystanding
behavior may result in more socially desirable answers, as shown by higher defending rates in
studies using self-reports than when using peer nominations (Nickerson, Mele, & Princiotta, 2008;
Salmivalli, Lappalainen, & Lagerspetz, 1998), self-reported behavior allowed adolescents to take
on several roles, depending on the context. This was in line with our findings from the qualitative
study. Furthermore, using peer nominations was reported to only reflect the extremes: pupils are
considered to fall in a particular role category, when the number of nominations they have received
lies above an (arbitrary) cut-off point (Solberg & Olweus, 2003).
- The meta-analysis was able to test the most prevailing hypotheses in literature on variability in
game effectiveness at the time of the study, thanks to a large sample of game studies and total
number of respondents. The meta-analysis was the first on this topic, and advanced research on
serious health game effectiveness by substantiating or disproving certain hypotheses, and
formulating new directions for research. Only rigorous methodological designs using a control
condition were included, to provide strong support for the meta-analytic findings. Several
sensitivity analyses were conducted to rule out influences of methodological differences between
studies. Categories with an insufficient number of studies were not included in any of the moderator
analyses in chapters 2.1, 2.2 or 2.3.

3.2. Limitations

- Our study among obese adolescents and their normal-weight peers did not assess the relations
between victimization and barriers or facilitators towards healthy lifestyles among normal-weight
adolescents. Other studies have, however, shown that also normal-weight adolescents experience
avoidance towards healthy behaviors after being teased about weight (Faith et al., 2002; Vartanian
& Shaprow, 2008). It can, furthermore, be assumed that a bi-directional relation exists between
unhealthy lifestyles and peer victimization, which warrants further investigation.
- Our study among 1979 adolescents provided limited insights in the class or school characteristics
that influenced bystander behavior. Apart from aggregated class pro-bullying norms used in our
study, perceived norms at class level could have contributed to a better understanding of class
differences. Research from traditional bullying suggests that also a lack of teacher support for
positive bystander behavior (Hektner & Swenson, 2012) contributes to class influences in bystander

358
 behavior. At school-level, perceived school climate may have also contributed to a better
understanding of school differences (Gini, Pozzoli, Borghi, & Franzoni, 2008). This warrants
further research for cyberbullying.
- Our study among 1979 adolescents investigated determinants of bystander behavior in
cyberbullying in general. It can, however, be expected that bystander behavior would differ by
types of incident, similarly to what was found for bystander behavior in traditional bullying (Oh &
Hazler, 2009). In traditional bullying, bystanders showed more passive bystander behavior when
multiple bullying types were combined in the bullying of one victim. It may be that bystanders are
uncertain which strategy to use when several types are combined, or that they feel there is a greater
threat. Our study assessed having witnessed cyberbullying in the past six months on a scale using
several incident types, but did not assess the specific type for the most recent incident for which
they reported their behavior, precluding an analysis of bystander behavior by incident type. This
warrants further research applied to cyberbullying. Additionally, context factors, such as the
visibility of the bystander, may differ between several incident types. These factors need to be
included in future research to explain potentially different bystander reactions to different incident
types.
- Our results from the study among 1979 adolescents showed an influence of moral disengagement
attitudes, but revealed little about what may underlie a different need to use moral disengagement
attitudes, such as moral sensitivity (Thornberg & Jungert, 2013) and moral emotions other than
empathy, such as shame and guilt (Eisenberg, 2000). These will need to be explored in future
research.
- Educators are potentially influenced by their own past victimization or bullying experiences in how
they view and handle cyberbullying among adolescents, as was the case for in traditional bullying
(Kokko & Prhla, 2009). This was not included in our research and should be investigated in
future studies.
- The educators in our study were younger and comprised slightly more female educators than in the
population of Flemish secondary school educators (Vlaamse Overheid, 2011). As was mentioned
in the papers limitations, since the sample is younger, they may represent the views of educators
who are already more comfortable using digital media. Since the cluster of referrers, who showed
less recommended behavior, consisted of less experienced educators, the study may have, despite
this unrepresentativeness of the population, reached those most in need of professional
development.
- It has been suggested that a comprehensive list of behavior change techniques should be used to
reflect intervention content (Michie et al., 2009). Our meta-analyses only used a small list,
representing what was most prevalent in serious health game literature. While a more extensive list
of behavior change techniques may be recommended in future meta-analytic research, its practical
use remains limited by the BCTs sufficiently reported in papers, to allow moderator analyses.

359
 Alternatively, more elaborate design papers describing BCTs, or a playable version allowing an in-
vivo coding, would be warranted to allow the investigation of an extensive set of BCTs.
- Our meta-analyses did not distinguish between health-promoting behaviors and risk-reducing
behaviors, whereas other types of interventions have proven to be more effective at increasing
healthy behaviors, than at reducing unhealthy behaviors (Adriaanse, Vinkers, De Ridder, Hox, &
De Wit, 2011). This may be a source of heterogeneity between the games effectiveness that was
not examined, and that should be addressed in future meta-analytical or experimental research.
Similarly, distinguishing between serious games intended for indicated or universal health
promotion may further contribute to explaining heterogeneity in serious games effects.
- Our meta-analyses did not use a multivariate approach and therefore did not take the influence of
third variables into account, as mentioned in the papers limitations. Such an analysis, as well as
studying interactions to find synergetic effects, should be the topic of future research.
- Due to few game studies on bullying, we were not able to analyze effective components specific to
bullying interventions, such as e.g. the content of the narrative in relation to bullying, or which non-
game components contributed to their effects. When more serious game studies against
(cyber)bullying are available, this would be interesting for future research and may provide more
specific guidelines on cyberbullying intervention content and components.
- The Friendly Attac serious game against cyberbullying was developed following a systematic
evidence- and theory-based approach. This procedure increases the chance that the intervention
will be effective, but this cannot be assumed until confirmed in a (group-) randomized-controlled
trial.

4. Implications for research and practice

Based on the study findings in this dissertation, the following research and practice recommendations
were made:
- When studying bystander behavior in cyberbullying, the variations in bystander behavior and
intentions based on context characteristics should be taken into account. Peer nominations resulting
in strict role categories thus do not reflect the complex reality. Findings, furthermore, showed that
adolescents would always defend their good friends, which implies that someone with more friends
will be more often designated as a defender, while this may not reflect their behavior when a loner
is cybervictimized. This loner may, however, be more in need of defending. Given these limitations,
peer nominations resulting in strict role categories, may not be a recommended approach when
studying bystander behavior in cyberbullying.
- A personal deficit model in interventions to promote positive bystander behavior is not
recommended, since bystander behavior is influenced by a multitude of factors that surpass a lack
of skills. Similarly, investigating a small set of predictors in relation to bystander behavior may

360
 give biased results due to shared variance with other, stronger, predictors. Interventions promoting
positive bystander behavior should incorporate the following components: outcome expectations
of benefiting the victim, support for those who are not good friends, social skills, attitudes
supporting positive behavior and condemning negative behavior, maternal awareness of Internet
activities, coping skills and self-efficacy to show positive bystander behavior.
- Interventions to promote positive bystander behavior should moreover create a facilitating
environment, by improving educator self-efficacy, attitudes, outcome expectations and use of
appropriate strategies in dealing with cyberbullying. This, in turn, needs to be facilitated by a school
policy and transfer of knowledge from principals and counselors to teachers. Also parental support
for positive bystander behavior needs to be increased by e.g. emphasizing the importance of a
positive class climate for their childrens development rather than a protective perspective.
- Serious digital game development for healthy lifestyle promotion should be founded on gaming
theories, complemented with behavior change theories that aid in selecting outcome-specific
features and correct translations of BCTs, such as individual tailoring and immediate feedback.
Simple games, that are low in immersive features, are preferred. Certain BCTs, such as personal
goal setting and planning, are less advised in serious digital games and warrant further investigation
on how to increase their effectiveness in a serious game context.
- Users should be involved in competence-related areas, such as the game dynamics, challenge and
levels, and not in visual aspects of character design or the game world. Involving users as
informants may be more beneficial than as co-designers.

5. Directions for future research

Since both bystander behavior in cyberbullying and serious games for health promotion are relatively
novel research areas, this dissertation also raised many questions that may be addressed in future
research. Listed below are some suggestions based on this dissertations findings that may further
advance research on these topics.

- Further, longitudinal, research is needed that investigates the relation between (cyber)bullying
victimization and several healthy lifestyles. These insights may provide further directions or
support for a multibehavioral health program in a whole-school approach.
- Parental support for positive bystander behavior was reported by adolescents to be low, and our
findings indicated an influence of maternal awareness of cyber-activities on bystander behavioral
intention. In traditional bullying, positive bystander behavior was associated with the open and
warm relation adolescents had with their mother. Indeed, merely increasing supervision and
monitoring in an authoritarian manner may not yield the desired effect. The mediating role that
parenting and communication styles, and family attachment have in the link between awareness

361
 and positive bystander behavior should be explored in further research. These insights could
provide directions for the parental component in interventions, in particular on how to promote
awareness and communication on cyber-activities with their adolescent child.
- When comparing predictors of bystander behavior in cyberbullying to findings from traditional
bullying bystander behavior, several emotional correlates, such as empathy, were less important for
cyberbullying. This may indicate that bystanders are less emotionally disturbed by cyberbullying
than by traditional bullying, and could relate to the online physical distance and lower availability
of social cues from the victim. Further research is needed to confirm this, and to assess ways to
increase this emotional involvement for bystanders in interventions.
- Research on the role of bystander interventions in ending cyberbullying or decreasing its harm is
currently based on qualitative, self-reported information by the adolescents. Studies are needed that
can single out the influence of bystander interventions on reductions in cyberbullying,
cybervictimization and its associated health problems, in cross-sectional and longitudinal
quantitative studies.
- More research is needed on class influences on positive bystanding, such as the role of perceived
class norms and teacher support.
- Further research is also needed that can explain potential differences in bystander reactions by
cyberbullying incident type. These may provide useful directions in interventions to encourage
bystander strategies that are best fit for each particular situation. It is furthermore possible that not
only adolescents, but also educators would respond differently depending on the specific incident
type. This would also warrant further research.
- Adolescents reported that both negative and positive bystander behavior can co-occur in the same
incident. Preliminary investigation of our data indeed showed that around one third of those
witnessing a cyberbullying incident had responded with both positive and negative bystander
behavior. Further research is needed to examine if this combined behavior can be explained by
different determinants than the exclusive positive or negative types of bystander behavior in an
incident.
- Future meta-analyses on the role of game characteristics in its effectiveness should investigate the
synergetic or cumulative effects of these features, with a larger set of BCTs, in as much as is
allowed by reports in design papers, or by in-vivo coding of the game.
- More research is needed into effective techniques to maintain serious game effectiveness on
behavior and behavioral determinants in a longer term.
- A borderline positive effect was shown of intervention duration on game effectiveness on
behavioral determinants. Extended game interventions may thus also increase effectiveness. More
research is needed to validate this hypothesis.
- The meta-analytic results indicated a negative effect of games with more immersive features, or a
higher challenge. This may relate to a cognitive load, and indicates that more research is needed

362
 into cognitive psychological processing of the game and educational content and challenges, and
whether a benefit can be expected of games which require more serial or parallel mental processing.
- Only few papers in our meta-analysis measured game experience or enjoyment with a validated
scale that would allow comparison across studies. The use of validated game experience and
enjoyment questionnaires in studies assessing serious health game effectiveness, should be
advocated. This would allow to assess the moderating role of game experience in game
effectiveness.
- The meta-analysis on participatory design provided information on moderating influence of the
area in which users were involved, and the role they were assigned, but did not study the specific
approach for user involvement. Detailed process descriptions of active user involvement in the
development of serious digital games should be made available to distill the approaches of user
involvement, which may be more effective in future research.
- More research is needed on how BCTs may have been watered down to fit within an entertainment
approach of games, and how this affects the effectiveness of the change techniques. On the other
hand, certain BCTs, such as personal goal-setting and action planning, may need to be adjusted to
incorporate a fun element, in order to be effective in a game context. Guidelines on game
applications of these techniques that maintain an optimal balance of theoretical fidelity and game
experience are needed.
- Since simpler gamified applications may relate to higher effectiveness and may require less
resources to create, a cost-effectiveness study on serious digital games is warranted.
- While the Friendly Attac game was designed using an evidence-based and theory-based approach,
its effectiveness in increasing positive bystander behavior, and reducing cyberbullying,
cybervictimization and psychosocial harm, is yet to be investigated.

363
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Obermaier, M., Fawzi, N., & Koch, T. (2014). Bystanding or standing by? How the number of
bystanders affects the intention to intervene in cyberbullying. New Media & Society, published
ahead of print, 1-17.

Oh, I. & Hazler, R. J. (2009). Contributions of Personal and Situational Factors to Bystanders' Reactions
to School Bullying. School Psychology International, 30, 291-310.

Olenik-Shemesh, D., Heiman, T., & Eden, S. (2015). Bystanders' Behavior in Cyberbullying Episodes:
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in Whole-School Bullying Intervention and Its Potential to Inform Cyberbullying Interventions.
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Polanin, J., Espelage, D., & Pigott, T. D. (2012). A Meta-Analysis of School-Based Bullying Prevention
Programs' Effects on Bystander Intervention Behavior. School Psychology Review, 41, 47-65.

Prensky, M. (2007). Digital Game-Based Learning: Practical Ideas for the Application of Digital
Game-Based Learning. (Edition 2007 ed.) St. Paul, MN: Paragon House.

Price, D., Green, D., Spears, B., Scrimgeour, M., Barnes, A., Geer, R. et al. (2014). A Qualitative
Exploration of Cyber-Bystanders and Moral Engagement. Australian Journal of Guidance and
Counselling, 24, 1-17.

Puhl, R. M., Peterson, J. L., & Luedicke, J. (2013). Weight-Based Victimization: Bullying Experiences
of Weight Loss Treatment-Seeking Youth. Pediatrics, 131, e1.

Rubin-Vaughan, A., Pepler, D., Brown, S., & Craig, W. (2011). Quest for the Golden Rule: an Effective
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Sallis, J. F., Owen, N., & Fisher, E. B. (2008). Ecological models of health behavior. In K.Glanz, B. K.
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Salmivalli, C., Krn, A., & Poskiparta, E. (2011). Counteracting bullying in Finland: The KiVa
program and its effects on different forms of being bullied. International Journal of Behavioral
Development, 35, 405-411.

Salmivalli, C., Lappalainen, M., & Lagerspetz, K. (1998). Stability and Change of Behavior in
Connection With Bullying in Schools: A Two-Year Follow-Up. Aggressive Behavior, 24, 205-
218.

Salmivalli, C. & Voeten, M. (2004). Connections between attitudes, group norms, and behaviour in
bullying situations. International Journal of Behavioral Development, 28, 246-258.

Sapouna, M., Wolke, D., Vannini, N., Watson, S., Woods, S., Schneider, W. et al. (2010). Virtual
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cognitive load and learning outcomes in educational computer games. Computers in Human
Behavior, 28, 648-658.

Solberg, M. E. & Olweus, D. (2003). Prevalence Estimation of School Bullying With the Olweus
Bully/Victim Questionnaire. Aggressive Behavior, 29, 239-268.

Stauffer, S., Heath, M. A., Coyne, S. M., & Ferrin, S. (2012). High School Teachers Perceptions of
Cyberbullying Prevention and Intervention Strategies. Psychology in the Schools, 49, 353-367.

Suzuki, K., Asaga, R., Sourander, A., Hoven, C. W., & Mandell, D. (2012). Cyberbullying and
adolescent mental health. International journal of adolescent medicine and health, 24, 27-35.

Thornberg, R. & Jungert, T. (2013). Bystander behavior in bullying situations: Basic moral sensitivity,
moral disengagement and defender self-efficacy. Journal of Adolescence, 36, 475-483.

Ttofi, M. M. & Farrington, D. P. (2011). Effectiveness of school-based programs to reduce bullying: a

systematic and meta-analytic review. J Exp Criminol, 7, 27-56.

Van Cleemput, K., Vandebosch, H., & Pabian, S. (2014). Personal Characteristics and Contextual
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Perceptions of Youngsters. CyberPsychology & Behavior, 11, 499-503.

Vartanian, L. R. & Shaprow, J. G. (2008). Effects of Weight Stigma on Exercise Motivation and
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development and psychometric characteristics. Nursing Research, 36, 76-81.

Wang, J., Iannotti, R. J., & Luk, J. W. (2010). Bullying Victimization among Underweight and
Overweight U.S. Youth: Differential Associations for Boys and Girls. Journal of Adolescent
Health, 47, 99-101.

Webb, T. L., Joseph, J., Yardley, L., & Michie, S. (2010). Using the Internet to Promote Health Behavior
Change: a Systematic Review and Meta-Analysis of the Impact of Theoretical Basis, Use of
Behavior Change Techniques, and of Mode of Delivery on Efficacy. J Med Internet Res, 12,
e4-e29.

Williford, A., Elledge, L. C., Boulton, A. J., DePaolis, K. J., Little, T. D., & Salmivalli, C. (2013).
Effects of the Kiva Antibullying Program on Cyberbullying and Cybervictimization Frequency
Among Finnish Youth. Journal of Clinical Child & Adolescent Psychology, 42, 820-833.

Wlfer, R., Schultze-Krumbholz, A., Zagorscak, P., Jkel, A., Gbel, K., & Scheithauer, H. (2013).
Prevention 2.0: Targeting Cyberbullying @ School. Prev Sci, 1-9.

Wouters, P., van Nimwegen, C., van Oostendorp, H., & van der Spek, E. D. (2013). A Meta-Analysis
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APPENDICES

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 PUBLICATIONS AND
CONFERENCE CONTRIBUTIONS

461
462
 PUBLICATIONS AND CONFERENCE CONTRIBUTIONS

Journal articles

(A1)

DeSmet, A., Aelterman, N., Bastiaensens, S., Van Cleemput, K., Poels, K., Vandebosch, H.,
Cardon, G., & De Bourdeaudhuij, I. (2015). Secondary school educators perceptions and
practices in handling cyberbullying among adolescents: a cluster analysis. Computers &
Education, 88, 192-201

Bastiaensens, S., Vandebosch, H., Poels, K., Van Cleemput, K., DeSmet, A., & De
Bourdeaudhuij, I. (2015). Can I afford to help?: how affordances of communication
modalities guide bystanders helping intentions towards harassment on social network sites.
Behaviour and Information Technology, 34, 4, 425-435.

Bastiaensens, S., Pabian, S., Vandebosch, H., Poels, K., Van Cleemput, K., DeSmet, A., & De
Bourdeaudhuij, I. (2015). From normative influence to social pressure: how relevant others
affect whether bystanders join in cyberbullying. Social Development, ahead of print.

Plaete, J., Crombez, G., DeSmet, A., Deveugele, M., Verloigne, M., & De Bourdeaudhuij, I.
(2015). What do general practitioners think about an online self-regulation programme for
health promotion?: focus group interviews. BMC Family Practice, 16, 1, 3-14.

DeSmet, A., Van Ryckeghem, D., Compernolle, S., Baranowski, T., Thompson, D., Crombez,
G., Poels, K., et al. (2014). A meta-analysis of serious digital games for healthy lifestyle
promotion. Preventive Medicine, 69, 95107.

DeSmet, A., Veldeman, C., Poels, K., Bastiaensens, S., Van Cleemput, K., Vandenbosch, H.,
& De Bourdeaudhuij, I. (2014). Determinants of self-reported bystander behavior in
cyberbullying incidents amongst adolescents. Cyberpsychology, Behavior and Social
Networking, 17(4), 207215.

DeSmet, A., Deforche, B., Hublet, A., Tanghe, A., Stremersch, E., & De Bourdeaudhuij, I.
(2014). Traditional and cyberbullying victimization as correlates of psychosocial distress and
barriers to a healthy lifestyle among severely obese adolescents: a matched case-control study
on prevalence and results from a cross-sectional study. BMC Public Health, 14, 224-236.

Bastiaensens, S., Vandebosch, H., Poels, K., Van Cleemput, K., DeSmet, A., & De
Bourdeaudhuij, I. (2014). Cyberbullying on social network sites: an experimental study into

463
bystanders behavioural intentions to help the victim or reinforce the bully. Computers in
Human Behavior, 31, 259271.

Verlinde, E., Poppe, A., DeSmet, A., Hermans, K., De Maeseneer, J., Van Audenhove, C., &
Willems, S. (2013). Social differences in postponing a General Practitioner visit in Flanders,
Belgium: which low-income patients are most at risk? Health and Social Care in the
Community, 21(4), 364372.

De Lepeleere, S., DeSmet, A., Verloigne, M., Cardon, G., & De Bourdeaudhuij, I. (2013). What
practices do parents perceive as effective or ineffective in promoting a healthy diet, physical
activity, and less sitting in children: parent focus groups. BMC Public Health, 13, 1, 1067-1078.

Bleyen, L., Van Landeghem, P., Pelfrene, E., De Vriendt, M., DeSmet, A., & De Backer, G.
(1998). Screening for breast cancer in Ghent, Belgium: first results of a programme involving
the existing health services. European Journal of Cancer, 34, 9, 14101414.

(A2)

Baranowski, T., Blumberg, F., Buday, R., DeSmet, A., Fiellin, L.E., Green, S., Kato, P.M., Lu,
A.S., Maloney, A.E., Mellecker, R., Morrill, B.A., Peng, W., Shegog, R., Simons, M., Staiano,
A.E., Thompson, D., Young, K. (2015). White Paper: Games for Health for ChildrenCurrent
Status and Needed Research. Games for Health Journal, 4, 6, ahead of print.

DeSmet, A., Palmeira, A., Beltran, A., Brand, L., Fernandes Davies, V., & Thompson, D.
(2015). The Yin and Yang of formative research in designing serious (exer-)games. Games for
Health Journal, 4, 1, 63-66.

DeSmet, A., Shegog, R., Van Ryckeghem, D., Crombez, G., & De Bourdeaudhuij, I. (2015). A
systematic review and meta-analysis of interventions for sexual health promotion involving
serious digital games. Games for Health Journal, 4, 2, 78-90.

Knaeps, J., DeSmet, A., & Van Audenhove, C. (2012). The IPS fidelity scale as a guideline to
implement Supported Employment. Journal of Vocational Rehabilitation, 37(1), 1323.

(A4)

De Cocker, K., DeSmet, A., Verloigne, M. (2015). De relatie tussen sedentaire tijd en
morbiditeit, mortaliteit en hospitalisatie. Minerva 14, 6, 72-73

DeSmet, A., Degroof, M., & Van Audenhove, C. (2011). Kleur je gemeente Geel: de toekomst
van de psychiatrische gezinsverpleging in Vlaanderen. Psyche, 23(1), 1214.

464
Book chapters

Gunther, N.*, DeSmet, A*, Jacobs, N., & De Bourdeaudhuij, I. (2015). Comparing associated
harm with traditional bullying and cyberbullying: a narrative overview of mental, physical and
behavioural negative outcomes. In T. Vollink, F. Dehue, & C. McGuckin (Eds.),
Cyberbullying: from theory to intervention (pp. 5481). Abingdon, UK: Psychology Press.

Van Cleemput, K., Vandebosch, H., Poels, K., Bastiaensens, S., DeSmet, A., & De
Bourdeaudhuij, I. (2015). The development a serious game on cyberbullying: a concept test. In
T. Vollink, F. Dehue, & C. McGuckin (Eds.), Cyberbullying: from theory to intervention (pp.
106124). Abingdon, UK: Psychology Press.

Conference contributions

(C1)

Bastiaensens, S., Vandebosch, H., Poels, K., Van Cleemput, K., DeSmet, A., & De
Bourdeaudhuij, I. (2015). Online peer support in cyberbullying: investigating online fora of
youth helpline organisations. In Selected Papers of Internet Research 16: The 16th Annual
Meeting of the Association of Internet Researchers. Phoenix, Arizona USA.

DeSmet, A., Van Lippevelde, W., Van Ryckeghem, D., Compernolle, S., Bastiaensens, S.,
Poels, K., Vandebosch, H., et al. (2014). A systematic review and meta-analysis of serious
digital games for healthy lifestyle promotion. ICA, 64th Annual conference, Papers. Presented
at the ICAs 64th Annual conference: Communication and the good life, International
Communication Association (ICA), Seattle, Washington, USA.

Bastiaensens, S., Vandebosch, H., Poels, K., Van Cleemput, K., DeSmet, A., & De
Bourdeaudhuij, I. (2014). For your eyes only, or for the crowd to see?: bystander behaviour
towards SNS harassment. ICA, 64th Annual conference, Papers. Presented at the ICAs 64th
Annual conference: Communication and the good life, International Communication
Association (ICA), Seattle, Washington, USA.

DeSmet, A., Bastiaensens, S., Van Cleemput, K., Poels, K., Vandebosch, H., & De
Bourdeaudhuij, I. (2013). Determinants of bystander behaviour in cyberbullying incidents
amongst adolescents. International Communication Association, 63rd Annual conference,
Proceedings. Presented at the 63rd International Communication Association (ICA) annual
conference: Challenging communication research, London, UK.

DeSmet, A., Bastiaensens, S., Van Cleemput, K., Poels, K., Vandebosch, H., & De
Bourdeaudhuij, I. (2012). Mobilizing bystanders of cyberbullying: an exploratory study into

465
behavioural determinants of defending the victim, Brussels, Belgium. In B. K. Wiederhold &
G. Riva (Eds.), Studies in Health Technology and Informatics (Vol. 181, pp. 5863). Presented
at the 17th Annual CyberPsychology and CyberTherapy Conference, Amsterdam, The
Netherlands: IOS Press.

(C3)

DeSmet, A. (invited speaker) (2015). Meta-analysis and moderator analyses of serious digital
games for healthy lifestyle promotion. Symposium Serious Games, Wageningen, Netherlands.

DeSmet, A. (invited speaker) (2015). The effectiveness of serious digital games for healthy
lifestyle promotion. Journes de Prvention et de la Sant Publique (INPES), Paris, France.

DeSmet, A., Bastiaensens, S., Van Cleemput, K., Poels, K., Vandebosch, H., & De
Bourdeaudhuij, I. (2014). Applying the Intervention Mapping Protocol to the design of a
serious game against cyberbullying among young adolescents. European Health Psychology
Society, 28th Conference, Abstracts. Presented at the 28th Conference of the European Health
Psychology Society (EHPS 2014), Innsbrck, Austria.

DeSmet, A., Van Ryckeghem, D., Compernolle, S., Van Lippevelde, W., Bastiaensens, S., Van
Cleemput, K., Poels, K., et al. (2014). Meta-analytic review of serious games for healthy
lifestyle adoption: comparison of single level and multilevel programs. European Health
Psychology Society, 28th Conference, Abstracts. Presented at the 28th Conference of the
European Health Psychology Society (EHPS 2014), Innsbrck, Austria.

DeSmet, A., Bastiaensens, S., Van Cleemput, K., Poels, K., Vandebosch, H., & De
Bourdeaudhuij, I. (2013). Importance of theory in creating effective serious video games for
health promotion. International Society for Behavioral Nutrition and Physical Activity, Annual
conference, Abstracts. Presented at the 2013 Annual conference of the International Society for
Behavioral Nutrition and Physical Activity (ISBNPA), Ghent, Belgium.

De Lepeleere, S., DeSmet, A., Verloigne, M., Moens, E., Soenens, B., Cardon, G., & De
Bourdeaudhuij, I. (2013). What strategies do parents perceive as effective or ineffective in
promoting a healthy diet, physical activity, and less sitting in children: findings from focus
groups with parents. International Society for Behavioral Nutrition and Physical Activity,
Annual conference, Abstracts. Presented at the 2013 Annual conference of the International
Society for Behavioral Nutrition and Physical Activity (ISBNPA), Ghent, Belgium.

Bastiaensens, S., DeSmet, A., Vandebosch, H., De Bourdeaudhuij, I., Poels, K., & Van
Cleemput, K. (2012). Friendly attac: the development of an online intervention tool against

466
cyberbullying. Conference internationale sur le cyberharclement (pp. 1516). Presented at the
International conference on Cyberbullying; 8th Meeting of COST IS0801, Paris, France:
Ministre de lducation nationale (Dgesco).

DeSmet, A., Hermans, K., & Van Audenhove, C. (2011). The importance of social community
factors as buffers against depressive symptoms among social service users with chronic illness.
PSYCHOLOGY & HEALTH (Vol. 26, pp. 116116). Presented at the 25th European Health
Psychology Conference: Engaging with other health professions: challenges and perspectives,
Crete.

DeSmet, A., Hermans, K., & Van Audenhove, C. (2011). Participation, collaboration,
empowerment and equity in holistic primary health care. PSYCHOLOGY & HEALTH (Vol. 26,
pp. 115116). Presented at the 25th European Health Psychology Conference: Engaging with
other health professions: challenges and perspectives, Crete.

DeSmet, A., De Groof, M., & Van Audenhove, C. (2011). Psychiatric foster homes as care in
the community: the view of the community and relevant stakeholders. European Network for
Mental Health Service Evaluation, 9th International conference, Abstracts. Presented at the 9th
International conference of the European Network for Mental Health Service Evaluation
(ENMESH), Ulm, Germany.

DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J., & Van Audenhove, C.
(2011). Integrated care in mental health: need for collaboration, communication and
customisation. In B. Puschner, M. Ruggeri, & T. Becker (Eds.), PSYCHIATRISCHE PRAXIS
(Vol. 38). Presented at the 9th International conference of the European Network for Mental
Health Service Evaluation (ENMESH), Ulm, Germany.

Knaeps, J., DeSmet, A., & Van Audenhove, C. (2011). Supported employment fidelity in
Flemish vocational programs. European Network for Mental Health Service Evaluation, 9th
International conference, Abstracts. Presented at the 9th International conference of the
European Network for Mental Health Service Evaluation (ENMESH), Ulm, Germany.

Schrijvers, J., DeSmet, A., Haustermans, K., Van Poppel, H., & Van Audenhove, C. (2011).
Implementation and evaluation of a web-based decision aid in the decision making process of
newly diagnosed patients with localized prostate cancer. Shared Decision Making, 6th
International conference, Abstracts. Presented at the 6th International Shared Decision Making
conference (ISDM 2011): Bridging the gap between research and practice: patient pull or
clinician push?. Amsterdam, Netherlands

467
Schrijvers, J., DeSmet, A., Haustermans, K., Van Poppel, H., & Van Audenhove, C. (2011).
Internet use and the use of web-based decision aids by general practitioners in Flanders. Shared
Decision Making, 6th International conference, Abstracts. Presented at the 6th International
Shared Decision Making conference (ISDM 2011): Bridging the gap between research and
practice: patient pull or clinician push?. Amsterdam, Netherlands

DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J., & Van Audenhove, C.
(2010). The potential role of social services in providing integrated care on mental health and
welfare. Presented at the Regions for Health Network Conference, Genk, Belgium.

Verstraete, A., & DeSmet, A. (2001). Abuse of ecstasy and related compounds in the Benelux.
American Academy of Forensic Sciences, 53rd Annual meeting, Abstracts. Presented at the 53rd
Annual meeting of the American Academy of Forensic Sciences. Seattle, Washington, USA.

Bleyen, L., Myny, K., DeSmet, A., De Vriendt, M., Van Landeghem, P., & De Backer, G.
(1998). Patient-physician interaction in referral and result communication concerning
mammography screening in women aged 40 to 70 years. Psychosocial Impacts of Breast
Cancer, Abstracts. Presented at the International meeting on the Psychosocial Impacts of Breast
Cancer, Lucerne, Switzerland.

Research reports

DeSmet, A., Vandebosch, H., Van Cleemput, K., Bastiaensens, S., Poels, K., Deboutte, G., &
De Bourdeaudhuij. (2013). Computergestuurde interventies voor de bevordering van
gezondheid bij jongeren: programmas op maat en het gebruik van videospelletjes. (White
Paper Friendly Attac, IWT-SBO). Universiteit Gent, Universiteit Antwerpen.

Van Cleemput, K., Bastiaensens, S., Vandebosch, H., Poels, K., Deboutte, G., DeSmet, A., &
De Bourdeaudhuij. (2013). De internationale aanpak tegen cyberpesten. Een overzicht van
wetenschappelijke studies waarin programmas rond cyberpesten gevalueerd worden. (White
Paper Friendly Attac, IWT-SBO). Universiteit Antwerpen, Universiteit Gent.

Van Cleemput, K., Bastiaensens, S., Vandebosch, H., Poels, K., Deboutte, G., Pabian, S.,
DeSmet, A., & De Bourdeaudhuij. (2013). Zes jaar onderzoek naar cyberpesten in Vlaanderen,
Belgi en daarbuiten: een overzicht van de bevindingen. (White Paper Friendly Attac, IWT-
SBO). Universiteit Antwerpen, Universiteit Gent

De Jaegere, V., Knaeps, J., De Groof, M., De Coster, I., DeSmet, A., & Van Audenhove, C.
(2012). Begeleid Werken en Begeleid Leren: een transnationaal project. Leuven: LUCAS.

468
Poppe, A., DeSmet, A., Verlinde, E., Hermans, K., Willems, S., Van Audenhove, C., & De
Maeseneer, J. (2012). KANS cijferrapport: beschrijvende analyse van de gegevens uit de eerste
bevraging: socio-demografisch profiel, zorggebruik, zorgtevredenheid, gezondheid, welzijn en
sociale contacten van maatschappelijk kwetsbare welzijnszorggebruikers. SWVG-rapport.
Leuven: Steunpunt Welzijn, Volksgezondheid en Gezin.

Bijlhout, D., DeSmet, A., Schrijvers, J., & Van Audenhove, C. (2011). Psychosociale
ondersteuning bij noden van mannen met prostaatkanker. Leuven: LUCAS.

Willems, Sara, DeSmet, A., Poppe, A., Hermans, K., Verlinde, E., Van Audenhove, C., & De
Maeseneer, J. (2011). Kans theoretische achtergronden en onderzoeksopzet. Leuven: Steunpunt
Welzijn, Volksgezondheid en Gezin.

Poppe, A., Verlinde, E., Willems, S., DeSmet, A., Hermans, K., Van Audenhove, C., & De
Maeseneer, J. (2011). Beschrijving van de KANS steekproef: representativiteit, demografische
en socio-economische kenmerken, gezondheidstoestand en zorggebruik. SWVG Feiten &
Cijfers. Leuven: Steunpunt Welzijn, Volksgezondheid en Gezin.

Poppe, A., Verlinde, E., Willems, S., DeSmet, A., Hermans, K., Van Audenhove, C., & De
Maeseneer, J. (2011). Kennis over zorgvoorzieningen bij welzijnszorggebruikers in de eerste
lijn. SWVG Feiten & Cijfers. Leuven: Steunpunt Welzijn, Volksgezondheid en Gezin.

Poppe, A., Verlinde, E., Willems, S., DeSmet, A., Hermans, K., Van Audenhove, C., & De
Maeseneer, J. (2011). Op bezoek bij de huisarts: gerapporteerd gebruik, gepercipieerde
kwaliteit en toegankelijkheid van de huisartsenzorg bij financieel kwetsbare
welzijnszorggebruikers. SWVG Feiten & Cijfers. Leuven: Steunpunt Welzijn,
Volksgezondheid en Gezin.

De Jaegere, V., DeSmet, A., De Coster, I., & Van Audenhove, C. (2010). Een starterskit voor
betere GGZ: visie en methodieken. Leuven: LUCAS.

De Groof, M., DeSmet, A., & Van Audenhove, C. (2010). De plaats van de psychiatrische
pleegzorg binnen het toekomstig GGZ beleid. Leuven: LUCAS.

DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J., Van Audenhove, C., &
Onderzoeksgroep KANS, de. (2010). Het hulpaanbod voor mensen met depressieve klachten
in (I)CAW en OCMW: beantwoordt het aanbod aan de vraag? SWVG Feiten & Cijfers. Leuven:
Steunpunt Welzijn, Volksgezondheid en Gezin.

DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J., & Van Audenhove, C.
(2010). The potential role of social services in providing integrated care on mental health and

469
welfare. Regions for Health Network Conference, Abstracts. Presented at the Regions for
Health Network Conference: Reducing health inequalities from a regional perspective: what
works, what doesnt work?

DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J., Van Audenhove, C., &
Onderzoeksgroep KANS, de. (2010). Depressieve klachten en sucidaliteit in de (I)CAW en
OCMW: onderzoek naar de ernst en de relatie tot armoede. SWVG Feiten & Cijfers. Leuven:
Steunpunt Welzijn, Volksgezondheid en Gezin.

Leus, E., DeSmet, A., & Walckiers, D. (2001). Development of the early warning system on
new synthetic drugs at public health level in Belgium. Brussels, Belgium: Scientific Institute
of Public Health.

Sartor, F., Vanderlinden, H., DeSmet, A., Leurquin, P., & Walckiers, D. (2000). Transformatie
van het Belgisch Focal Point voor drugs en drugsverslaving in een Belgisch
Waarnemingscentrum voor Drugs en Drugsverslaving: haalbaarheidstudie. Brussel:
Wetenschappelijk Instituut Volksgezondheid.

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ACKNOWLEDGMENTS

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 ACKNOWLEDGMENTS

Ten slotte wil ik graag een aantal mensen bedanken. Eerst en vooral dank aan de leden van de lees- en

examencommissie: Prof. Kristiane Van Lierde, Prof. Michel Walrave, dr. Pepijn van Empelen, dr.

Veerle Stevens, Prof. Els Clays en Prof. Leen Haerens. Het is altijd bang afwachten welke kritische

vragen er zullen komen, maar jullie vragen, suggesties en de discussie rond het doctoraat waren absoluut

een bron van inspiratie om de huidige bevindingen in een bredere context te bekijken, en om in

toekomstig onderzoek een aantal nieuwe pistes te bewandelen. Hartelijk dank hiervoor.

Vervolgens wil ik mijn promotoren en begeleidingscommissie bedanken: Prof. Ilse De Bourdeaudhuij,

Prof. Heidi Vandebosch en Prof. Greet Cardon. Jullie enthousiasme en positieve, ondersteunende

aanpak deden me geloven dat het allemaal nog wel goed zou komen. Ilse, ik kwam ongeveer 20 jaar

geleden bij jou binnengewandeld met een interesse in eetstoornissen, wat dan door praktische

omstandigheden uitmondde in een thesis naar stigmatisering in de geestelijke gezondheidszorg. Vele

jaren later nog kwam ik met vragen omtrent een onderzoek naar psychosociale aspecten van kanker bij

je terecht, en ben ik uiteindelijk bij jou aan een doctoraat begonnen over cyberpesten en videogames.

Wat het thema ook was, ik kon altijd rekenen op supersnel, grondig, onderbouwd en eerlijk advies dat

meer dan eens tot Aha-erlebnissen leidde. De begeleiding hield altijd een perfecte balans tussen het

ondersteunen van zelfstandigheid en creativiteit, en het geven van sturing waar nodig. En dat is dan nog

maar alleen mijn appreciatie over de professionele babbels. Mijn appreciatie voor de niet-professionele

babbels blijkt vermoedelijk al voldoende uit het feit dat ik er meestal een uur nadat ik rap eens ging

binnenspringen nog altijd sta ... Bedankt voor alle kansen die je me geboden hebt om van jou te leren

en ik kijk er naar uit om nog wat langer met jou, Greet en de rest van de onderzoeksgroep te kunnen

samenwerken. Heidi, ik wil jou en je onderzoeksgroep verder ook nog bedanken voor de gastvrije

opvang in de sympathieke MIOS-bende als ik weer eens als enige HILOer op een congres van de

communicatiewetenschappen beland was. Greet, je ondernemende en rustige ingesteldheid werkt zeer

motiverend, niet alleen in het doctoraat, maar ook in de samenwerking rond projectvoorstellen. Hopelijk

krijgen we in de toekomst verdere kansen om aan gelijkaardige initiatieven samen te werken.

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Dank ook aan alle Friendly Attac collegas voor de aangename en boeiende samenwerking: Edgar,

Frederik, Gaetan, Gie, Karolien, Katrien, Koen, Laura, Olga, Olivier, Steven, Samantha, Sara B., Sara

P. en Sofie. Verder wil ik ook alle vorige en huidige co-auteurs bedanken die ik nog niet vermeld heb,

voor hun inbreng en feedback die elke paper beter maakte: Benedicte, Anne, Ann, Evie, Nicole, Niels,

Charlene, Nathalie, Wendy, Antnio, Mat, Griet, Lieze, Jan en Anissa. Geert Crombez en Dimitri Van

Ryckeghem wil ik hier in het bijzonder bedanken voor hun geduld om mij te proberen inwijden in de

methoden van een meta-analyse, en om te tonen hoe je op een beknopte, wetenschappelijke en duidelijke

manier kan schrijven. Aan de dikte van het doctoraat te zien, heb ik nog wel wat bij te leren op dat vlak.

A special thank-you goes out to Tom and Janice Baranowski and Debbe Thompson. Tom, Janice and

Debbe, I was fortunate to get the opportunity to work closely with you for some weeks in Texas. Your

energy and enthusiasm, open-mindedness, kindness, hospitality, and willingness to educate newcomers

to health game research such as me, are truly amazing. I learned a great deal from all of you, on behavior

change theories, game design and gaming experience, and methodological aspects to name just a few.

Thanks for involving me in many of your interesting papers and inspirational activities, and I sincerely

hope to continue and deepen our collaboration in the future. Debbe, thanks also for sending your

positive vibes in our frequent, so enjoyable email conversations . Yan, thank you so much for your

help and tremendous patience in working with me on the analysis of the Squires Quest II data!

Ik wil eveneens de thesisstudenten bedanken die hebben bijgedragen tot het verzamelen van de

onderzoeksgegevens in dit doctoraat: Celine, Katrien, Lore M., Lore V., Marilyn, Margot, Sarah, Sara,

en Evelien. Dank ook aan de scholen die hebben meegewerkt aan de studies, aan het Zeepreventorium

De Haan, en aan het HBSC project. In dit kader wil ik ook mijn vorige werkgever GfK bedanken, voor

hun bereidheid mee te werken aan onze studies en hun werknemers als vrijwillige proefkonijnen

beschikbaar te stellen, ook al is hun tijd zo kostbaar. Bedankt, Kris en Christine!

Andere ex-collegas die ik absoluut wil bedanken zijn Tom en Jeroen. In Leuven zorgden jullie voor

sociale steun bij de koffie of lunch, en voor instrumentele steun zoals het minstens wekelijks repareren

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van mijn nietjesmachine. Het was leuk om te zien hoe dit in de afgelopen 4 jaar gewoon online is verder

gegaan, en ik steeds bij jullie terecht kon voor de soms dagelijkse vragen naar papers die niet in onze

bib zaten, hulp bij alles dat mijn digitale capaciteiten te boven ging, en om af en toe gewoon eens te

zagen of onnozel te doen. Merci!

Ook mijn huidige collegas wil ik uiteraard bedanken. Bedankt aan iedereen in de onderzoeksgroep voor

de steun en inspiratie, en in het bijzonder aan mijn (ex-) eilandgenoten Charlene, Sara en Sofie. Ondanks

de halve generatiekloof en mijn nogal afwijkend onderzoeksthema van dat van jullie, stonden jullie altijd

open voor mijn verhalen en hebben we op ons eiland veel plezier beleefd. Vooral de periode van

Charlenes natuurgebonden stage was memorabel . Bedankt ook aan Jolien, Marieke en Freja voor de

morele en praktische steun bij de laatste loodjes van het doctoraat, en aan Johan om me het gevoel te

geven een jonge doctoraatstudente te zijn.

Thanks to our friends, for once in a while asking about the PhD progress, but mostly for not asking and

instead offering a welcome distraction over kaffeeklatsch, drinks, and parties. Thanks, An & Danne,

Christine & Stephen, Erica & Ray, Jo & Trevor, Mia & Pol, Sabine & Detlef, Sabine & Steven, Sally &

Stephan, Wolfgang & kids. Special thanks to Pol for designing the cover, and to Sally & Stephan and

Christine & Stephen for looking after our boys later tonight.

Ik wil ten slotte nog mijn familie bedanken om hier te zijn als steun. Bedankt aan mijn vader en zus om

het doctoraat na te lezen op taal- en tikfouten, wat ze vermoedelijk dachten eens op een avondje te doen

en wat dan toch dik tegenviel. Bedankt, papa en Els. Thanks, Dan, for looking after our boys when I

was preoccupied with finishing the PhD, and for escaping upstairs and leaving me in my own thoughts

until I had time again to socialize. Vooral bedankt aan mijn twee kinderen, Dylan en Torsten, die altijd

vol enthousiasme en interesse vroegen naar de laatste update van het game. Om zeker te zijn dat ze een

plaats zouden krijgen in het boek, hebben ze me zelf gedicteerd wat ik in mijn dankwoord over hen

moest schrijven. Bedankt aan mijn twee zoontjes, die me de hele tijd aan het opjagen waren om samen

UNO te kunnen spelen, waardoor dit boek nu sneller klaar is.

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