Introduction

Adolescents can be exposed to different forms of interpersonal violence such as peer violence or self-directed violence. Peer violence involves acts that are intentionally exercised to harm others on purpose (Karmaliani et al. 2017), being ‘unwanted, aggressive behavior among school-aged children that involves a real or perceived imbalance of power’ (Attawell, 2017). Self-directed violence refers to acts that are self-directed and deliberately result in injury or the potential for injury to oneself, including death (Crosby et al. 2011).

Peer violence may be exerted direct through physical aggression (physical violence), yelling, threats, and name-calling (verbal violence) or indirect through spreading of rumors and exclusion (social violence) (Inchley et al. 2016; Cramer et al. 2017; Lotrean et al. 2010; Karmaliani et al. 2017). In the last years, as a consequence of spread and more and more frequent use of different types of technology (e.g. mobile phones, internet, social platforms) a new type of violence emerged—cyber-violence which refers to messages containing nasty or unpleasant words or threats sent by peers by test messaging, emails or social media platforms (Lotrean et al. 2011; Wilton and Campbell, 2011; Carter et al. 2015). Cyberbullying acts are indirect, no face-to-face so that cyberbullies can stay unseen and maybe even unidentified. Moreover, it is the risk of repeated exposure to aggression by a wider audience due to the lack of space and time boundaries on the internet and social networks, the content reaching several people and leading to persistent traumatization of victims (Kowalski and Limber, 2013).

Peer violence among adolescents has serious consequences on their academic performance (poor concentration at school, lower interest in learning and decreased involvement in performing school activities, less interest in schooling and poorer performance, truancy), health (fatigue, sleep disturbance, nervousness, hopelessness, depression, somatic symptoms such as head, back and stomach aches) and psycho-social development (loneliness, loss of confidence, distrust of others, social anxiety) (Kowalski et al. 2014; Trifescu et al. 2017; Modecki et al. 2014; Sharp et al. 2014; Aparisi et al. 2021;Due et al. 2005).

The prevalence of different forms of peer violence among adolescents and the associated factors vary between different countries and regions and although they have been described in several countries few information is available for Romania with regard to this among high school students (Inchley et al. 2016; Lotrean et al. 2010; Lotrean et al. 2011; Wilton and Campbell, 2011; Carter et al. 2015; Kowalski et al. 2014; Trifescu et al. 2017; Modecki et al. 2014; Álvarez-García et al. 2015; Probst et al. 2021).

The Health behavior in school aged children study from 2021 showed that in Romania the percentage of students who have been bullied others at school at least 2–3 times per month in the last couple of months were 10% for girls and 12% among boys for 11 year old students; it increased to 13% (girls) and 16% (boys) for the 13 years old students and then decreased for those being 15 years old (8% of girls, 11% of boys). With regard to being victim of bullying at school at least 2–3 times per month in the last couple of months we noticed the following data: among 11-year-old students 12% among girls, 13% among boys; for 13 years students 16% and 14% respectively; among 15 years students 11% and 9% respectively. On the other side, the prevalence cyber-aggressor at least once or twice during the last couple of months varied between 15 and 24% among girls and 20–26% among boys. The percentage of students who have been cyberbullying at least once or twice during the last couple of months varied among the three age groups from 17 to 24% among girls and from 17% to 22% among boys (Cosma et al. 2024).

Moreover the interrelationship between the different forms of traditional violence and cyber-violence as well as the dynamic regarding involvement as victim, perpetrator or both in different forms of peer violence are raising questions of interests worldwide. Several studies showed there is ample co-occurrence between the two phenomena, either in the same role or a different one (e.g., traditional victim and cyberaggressor); (Kowalski and Limber, 2013; Cosma et al. 2024), with no studies available for Romania.

Being a period of transition characterized by various physical and psychological transformations, adolescence is also characterized by higher vulnerability to everyday difficulties, leading for some adolescence to psychological distress or unpredictable behavior such as suicidal behavior (Lim et al. 2019; Kim and Young, 2021). Suicide is the result of suicidal process which starts with suicidal ideas that are usually intermittent, at a certain moment can intensify and even become permanent and invasive. The move from suicide ideation to the behavior itself can take place very quickly over time giving it an impulsive character, while the suicide ideation themselves, even if they will not lead to the behavior, will interfere significantly with mental and social health of the adolescence (Tekari et al. 2019; Hong et al. 2015; Kim and Young, 2021; Hay and Meldrum, 2010). A meta-analyse of studies performed between 1989 to 2018 with regard to prevalence of self-directed violence among children and adolescents showed that lifetime and 12-month prevalence of suicidal ideation was 18% and 14.2%, respectively, with country and geographical location of residence influencing them (Lim et al. 2019).

Even if interpersonal peer violence (both victimization and perpetration) and self-directed violence among adolescents represent important problems of public health they are many times addressed as separate topics. Hence, this study focuses on Romanian high school students and aims to assess the prevalence of different forms of interpersonal peer violence and self-directed violence, their interrelationship and factors associated with them.

The study will try to answer to the following research questions:

  1. 1.

    Which is the prevalence of involvement as victim or/and perpetrator in different forms of traditional interpersonal violence (physical, verbal or social) and cyber-violence and how these behaviors correlate with each other’s among Romanian adolescents?

  2. 2.

    How frequent Romanian adolescents encounter self-harm thoughts and which is the relationship with traditional and cyber-violence?

  3. 3.

    How personal factors (age, gender, residence in rural or urban areas) and familiar factors (parents’ level of education, family structure and functionality) influence interpersonal violence as well as self-harm thoughts among the Romanian adolescents?

Material and methods

Study sample and procedure for data collection

A cross sectional study was performed in February- March 2019 in an area situated in the North-East part of Romania within a distance of 60 km around the Botosani city ;this area is located in a region with one of the lowest socio-economical development in the country, while several logistic facilities made possible data collection in this area. It was performed in the city of Botosani, a small town with low urbanization (Liteni) and one village (Vorona). The study involved high school students aged 15–19 from grades IX-XII of 4 schools −2 from Botosani city, one from Liteni, one from Vorona. All schools, especially from Liteni and Vorona have high school students from the same place, as well as from small rural localities from the surroundings. In each school the study included 2 classes of students for each grade.

The study was conducted according to the guidelines of the Declaration of Helsinki, and it is part of a research project approved by Ethic board of the University of Medicine and Pharmacy from Cluj-Napoca, Romania (ethical approval 194/ 19.04.2018). The study received also informed consent for school participation from the directors of the 4 high schools in order to be able to perform the data collection among the high school students (based on the educational agreement with the parents the school directorate could implement several health promotion educational activities, including needs assessments for appropriate development of such activities).

Data were collected by means of anonymous questionnaires filled in by high school students. All students from the participating classes were invited to fill in the questionnaire after being informed that participation is voluntary. Students who did not want to participate did not fill in the anonymous questionnaire; the refusing rate was below 2%. The final sample consisted of 781 participants.

Instruments for data collection

The study used a questionnaire developed based on data from literature as well as other studies performed in Romania (Lotrean et al. 2010; Lotrean et al. 2011; Inchley et al. 2016). The questionnaire assessed several socio-demographic characteristics (age, gender, residence, family structure, educational level of mother, educational level of father) as well as several health risk behaviors. The present study is presenting data regarding the following issues:

  • Physical violence-being involved in a physical fight by a peer in the last 3 months (never, once, 2–3 times, more than 3 times) or aggressing other peer physically in the last 3 months (never, once, 2–3 times, more than 3 times)

  • Verbal violence- being aggressed verbally (there were said nasty or unpleasant things, there were verbal threats or yelling) by peers in the last 3 months (never, once, 2–3 times, more than 3 times) or aggressing other peer in the last 3 months (never, once, 2–3 times, more than 3 times)

  • Social violence through peer exclusion –being excluded by peers at school from their group (they were avoided, ignored, left behind) in the last 3 months (never, once, 2–3 times, more than 3 times) or excluded from their group other peers at school in the last 3 months (never, once, 2–3 times, more than 3 times)

  • Cyber-violence -being aggressed in the last 3 months through messages containing nasty or unpleasant words or threats sent by peers by phone, emails or social media platforms (never, once, 2–3 times, more than 3 times) or sending to other peers messages containing nasty or unpleasant words or threats by phone, emails or social media platforms (never, once, 2–3 times, more than 3 times)

  • Suicide ideation (declared having serious thought about suicide at least once during lifetime)

  • Opinion regarding the frequency of peer violence in day by day life (frequent, rare, I do not know)

  • Family relationships (harmonious, tensioned, indifferent)

Statistical analyses

The prevalence of the investigated behaviors was calculated for the whole sample as well as for different groups based on their involvement in physical, verbal, social violence, cyber-violence (both as victim or perpetrator) and suicide ideation; chi 2 tests were used to compare different groups with regard the prevalence of different forms of violence.

At the same time, the co-occurrence of different forms of violence was calculated by summing all the violence related behaviors both as victim or perpetrator (minimum 0, maximum 9 violence related behaviors representing the violence index).

Pearson bivariate correlation was used to assess the association between exposure to different forms of violence as well as between different forms of violence on one side and gender, age, residence, educational level of mother and father, family structure (intact family-both parents alive and living together vs non-intact family–family with only one or no parents), presence of tensioned family relationships (tensioned versus harmonious) or indifferent family relationships (indifferent versus harmonious) on other side.

Data analysis was performed with SPSS-26 statistics program. Statistical significance is reported at p < 0.05.

Results

Characteristics of the study sample

The study involved 781 participants with the following socio-demographic characteristics: 41.9% boys and 58.1% girls, 58.7% from rural and 41.3% from urban areas. Table 1 shows educational level of parents, family structure and family relationships.

Table 1 Socio-demographic characteristics.
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Prevalence of different forms of violence and their interrelationship

The results of the study show that around one quarter of the high school students was a victim of a physical fight with a peer in the last three months, while 15% recognized they perpetrated physical fight among peers during the last 3 months (see Table 2). Around half of the participants declared that in the last 3 months they were aggressed verbally by peers at least once, while around one third of the participants said they have done so. In the same period of time one third of the high school students were excluded by peers at school and 43% excluded others. With regard to exposure to cyber-violence in the last 3 months, almost one third were victim of it and one out of 5 students were perpetrators of this form of violence (see Table 2). A percentage of 17% of the students declared that they had serious thought about suicide at least once during lifetime. The verbal and social violence were the most prevalent both as victim and perpetrator.

Table 2 Exposure to peer violence and self-directed violence.
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Repeated victimization (more than three times in the last 3 months) was varying between 3% for physical violence to around 7% for social and cyber-violence and 13% for verbal violence. Repeated involvement as perpetrator (more than three times in the last 3 months) was declared by fewer students (less than 4% for physical violence and cyber-violence, while between 7–10% of students declared being aggressors repeatedly for verbal and social violence).

Table 3 presents the relationship existing between different forms of violence and shows that for all investigated forms of violence being a victim or perpetrator of one type of violence was statically significant increasing the risk of being exposed in different ways to all the other types of violence investigated by the study.

Table 3 Co-occurrence of different forms of violence.
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Among students who were victim of physical violence two thirds were also victim of verbal violence and around half were victim of social or cyber violence; one out of two students from this group were also perpetrators of physical or social aggression, almost two thirds declared verbal violence and more than one third cyber-violence as aggressors. Students who were perpetrators of physical violence were also perpetrators of verbal violence (more than 77%), social (58%) and cyber- violence (44%), but were also victims of physical violence (74%) or other forms of violence- around 74% verbal violence and around 44% or even more cyber-violence and social violence.

Half of the students who were victim of verbal aggression were also victim of social and cyber-violence, while more than one third were involved in physical fight; the percentage of those who declared also being perpetrators of violence varied from around one quarter for physical violence to almost one third for cyber-violence and half for social aggression while 60% were also perpetrators of verbal violence. A similar situation was noticed for perpetrators of verbal violence, but among this group the prevalence of physical and cyber-violence as agressor was higher than among those who declared being a victim with around 9% for each of the 2 behaviors.

Victims of social violence were victims of other forms of violence in proportions which varied from one third for physical violence to half for cyber-violence and around 70% for verbal violence. For people who declared being perpetrators of social violence similar results were also obtained, except the fact that cyber-violence victimization was a bit less frequent.

Students who declared being victims of cyber-violence were in 84% of the cases victims of verbal violence while around one out of two were declaring being victims of social violence and around 43% of physical violence; one quarter of these students were also aggressors of physical violence, half of them were aggressors of social or cyber-violence and two thirds of perpetrated verbal violence. Among perpetrators of cyber-violence more than 80% were also cyber-violence victim, as well as both victim and aggressor of verbal violence, while almost two thirds were social violence perpetrators, around half physical violence and social violence victims and one third physical violence aggressors.

Suicide ideation were declared by around one quarter of victims of different forms of violence, while one out of 5 of the perpetrators of different forms of violence declared this, except the cyber-violence aggressors who declared suicide thoughts in a percentage of 32%.

At the same time, 82% of the students believe that peer violence is frequent among adolescents, while 7.1% think it is rare, and 10.9% did not know what to answer.

With regard to co-occurrence of violence related behaviors the results show that only 21.7% were not exposed to any form of violence, 31.5% declared involvement in 1–2 behaviors, 24.7% in 3–4 behaviors, while 22.1% admitted involvement in 5 or even more behaviors (1.1% declared exposure to all 9 forms of violence investigated by the study).

The results of the bivariate correlation shows that all form of peer- violence were correlated with each other, the correlation being strong for being involved in physical violence as victim and perpetrator, being exposed to verbal violence as victim and perpetrator, being involved in cyber-violence as victim and perpetrator, as well as between being perpetrator of verbal violence and cyber-violence and between being victim of verbal violence and victim of cyber-violence. The strongest association was found between being victim and being perpetrator of cyber-violence (see Table 4).

Table 4 Correlation between different forms of violence.
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Suicide ideation was also associated with all forms of traditional and cyber-violence, the strongest association being with being victim of verbal and social violence as well as aggressor of cyber-violence.

Factors associated with different forms of violence

The results of the bivariate correlations presented in Table 5 show that being a victim of physical violence was more frequent among boys, younger students, participants from rural areas and not living in intact families, while being a perpetrator of physical violence was associated with being a boy, living in rural areas and having mother and father with a lower educational level.

Table 5 Factors associated with different forms of violence.
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Verbal violence (both as victim and aggressor) was more frequent among boys and those having tensioned or indifferent relationships (only for perpetrators) in their families.

Students being victim of social aggression were coming more frequent from families with tensioned relationship, as did those who were perpetrators of social violence, while this form of violence was also more frequent among girls than boys.

Cyber-violence in both forms was more frequent among boys and those living in families with tensioned relationships or indifferent relationships (only for perpetrators).

Suicide ideation was associated with living in urban areas, having mothers with higher educational level, as well as living in families which are not intact, with tensioned or indifferent relationships. The co-occurrence of more violence related behaviors was also more frequently noticed among boys and participants having tensioned or indifferent relationships in their families.

Discussions

The study offers information regarding the prevalence of different forms of traditional interpersonal violence and cyber-violence in the last 3 months as well as self-directed violence (suicide ideation) during lifetime among high school students from one area situated in North-East part of Romania which has the lowest socio-economical development in the country.

The results show that more than 80% of the participants consider peer violence as appearing frequently among adolescents, while around 78% of the students admitted being exposed as victims or perpetrators to at least one form of the investigated forms of violence.

With regard to traditional interpersonal violence in the last three months the prevalence of being a victim varied between one quarter of the students for physical violence to one third of them for social violence and half of them for verbal violence, while the percentages of students recognizing being a perpetrator was 16% for physical violence, 38% for verbal violence, and 42% for social violence as exclusion. The cyber bulling in the last three months was affecting one third of the participants as victims and around one out of five participants as perpetrators.

Repeated victimization (more than three times in the last 3 months) or repeated involvement as perpetrator (more than three times in the last 3 months) was declared by percentages varying between 3–13% for different types of traditional violence and for cyberbullying was 7%, and 4% respectively. Even these percentages seem low, they indicate that there are students who have already established patterns of perpetrators or are frequently exposed to peer violence with increased mental, health, school and social consequences and are really in need for help to break this cycle.

On the other hand, it is concerning that 17% of the high school students declared serious suicidal thoughts at least once during lifetime. These data call for comprehensive programs in schools and communities for prevention and reduction of peer violence and self-directed violence.

At the same time, the study shows a co-occurrence of several violence related behaviors. For all types of traditional interpersonal violence more than half of the victims are also perpetrator of the same forms of violence, the highest percentage being noticed for social violence (two thirds of victims are also perpetrators), while more than half of perpetrators were also victims of the same type of violence, the highest percentage being noticed for physical violence (more than two thirds of perpetrators are also victims of the same form of violence). Studies from other countries also showed a robust, substantial and reciprocal relationship between victimization and offending, the explanations being the fact that both are the result of a similar social process which implicate adolescents’ peers and social context but also the cognitive characteristics or changes which might happend-knowledge, attitudes, skills, which are favorable or prevent involvement as victim or perpetrator or both, involvement in one creating for some adolescents the vulnerability or motivation which lead to overlapping of both forms of violence (Karmaliani et al. 2017; Shaffer, 2003; Hamburger et al. 2011).

On the other hand, several forms of traditional interpersonal violence correlated with each other, showing the risk of adolescents to be victims or perpetrators or both for physical, verbal or social violence. This, as studies from other countries also underlined, increases the negative effects on physical and psychological development and well-being (Choe et al. 2008; Luk et al. 2016).

In the last years a new theme of research emerged with regard to relationship between traditional violence and cyber-violence, the questions being if or not the same individuals who perpetrate traditional forms of violence perpetrate cyber-violence and if internet offer a new place for antisocial individuals to carry out a new form of aggression or it creates a distinct group of aggressors, who are violent exclusively online (Modecki et al. 2014; Pham and Adesman, 2015).

A review of 80 studies that reported corresponding prevalence rates for cyber and traditional bullying in adolescents showed that traditional bullying was twice as common as cyber bullying; cyber and traditional bullying were also highly correlated, suggesting that polyaggression involvement should be a primary target for interventions and policy (Modecki et al. 2014).

In our study almost one third of students declared being victims of cyber-violence, being less frequent than verbal and social violence, but a bit higher than physical violence. The involvement in cyber bulling as perpetrator was declared by one of five participants, but was lower than the perpetuation of other forms of violence.

It was noticed a strong association between the two forms of cyber-violence and the association was even stronger as in the case of the other forms of violence. At the same time, both are associated with the other forms of violence, the strongest association being noticed with verbal violence, showing that those who are victims of verbal violence receive more frequent also on-line nasty messages, while those who are perpetrators of verbal continue or combine this with cyber-violence. Other studies also showed that people experience reduced inhibition and personal responsibility in situations when they are more anonymous or when they are not face to face with the targeted persons (Carter et al. 2015; Kowalski et al. 2014).

The study is also showing the association between suicide ideation and other forms of violence, the strongest association being with involvement in verbal violence as victim and cyber-violence as aggressor. This underlines the devastated effect which might happened on short and long term of different forms of peer violence both on victims and perpetrators. Many studies documented the association between traditional bullying and suicidal risk and recently several have also examined the effect of cyber bullying, some of them indicating that the harm caused by cyber bullying was comparable to traditional bullying, but there were also studies which reported that cyber bullying may be even more dangerous in terms of causing distress and psychological impairment, including self-harm ideation and behavior. At the same time, studies from other countries found that those who experienced both traditional and cyber bullying were the most vulnerable group because they have higher emotional difficulties, pressure, pain, and the feeling that there is no escape for them, leading to suicide ideation and risk (van Geel et al. 2014; Beckman et al. 2012; Kowalski et al. 2014; Peng et al. 2019). In our study the association was greater for being victim of verbal or social violence or perpetrator of cyber-violence. These underlines the risk of both victims and aggressors to have suicide ideation, the involvement in different forms of violence being also an indicator of several vulnerabilities and problems, challenges which influence mental health and wellbeing.

The majority of students declared involvement in at least one form of violence and almost half more than two forms of violence, showing, similar with other studies the risk for several health and developmental consequences (Ramya and Kulkarni, 2011; Horton, 2011; Hong et al. 2014).

With regard to gender differences, our results show that boys were more frequent involved in physical, verbal and cyber-violence and girls in social violence. Moreover, among boys was noticed a co-ocurrence of more violent related behaviors. Other studies also showed that peer violence is gendered, to the extent that it is more highly prevalent among boys than girls and often rooted in ideas of socially appropriate boyish behavior as well as risk tacking behavior such as smoking, alcohol consumption and bravery (Karmaliani et al. 2017; Shaffer, 2003; Hong et al. 2014).

No age differences were found in our study, except that physical violence was more frequent among younger ages, probably as part of their psychological development. Our sample was represented by high school students and the results shows that for this group involvement in several forms and types of traditional and cyber-violence or self-directed harm ideation are quite similar to all students, independent of grade.

Students from rural areas were more frequent involved in physical violence in both forms, while student from urban areas were declared more frequently suicidal reactions. The rural-urban differences with respect to different forms and types of violence is varying between countries, age groups, studies (Peng et al. 2019; Samanta et al. 2012). In our study the differences might be in relationship with the social norms, family bonds, but also to the fact that loneliness and as a consequence suicidal thoughts of young people might be higher in urban areas in contrast with rural areas where traditionally the community is more supportive for its families and members.

Moreover, with regard to family influences, in our study a lower educational level of mother or father was associated with a higher involvement in physical violence as aggressors, while suicide ideation were more frequent among those whose mothers had a higher educational level. The findings indicate once again that socioeconomic inequalities exist in the risk of intentional injuries among adolescents.

Children with an intact family structure were less frequent victims of physical violence and less affected by suicide ideation. Moreover, declaring tensioned family relations was associated with almost all type of violence (except physical violence), while having indifferent family relationships was associated with higher involvement in verbal and cyber-violence as aggressor as well as with suicide ideation. At the same time, participants having tensioned or indifferent relationships in their families had a higher co-ocurence of several violence related behaviors. Studies from other countries also found that poor emotional bonds with parents and a lack of parental monitoring is related to traditional as well as cyber aggression (van Dijk et al. 2021; Escortell et al. 2020). Our results, similar with studies from other countries, pointed the importance of exposure to family violence in perpetration of peer violence and the challenge of breaking with the social learning from the family regarding the use of violence (Karmaliani et al. 2017; Kim and Young, 2021; Escortell et al. 2020; Zhang et al. 2019).

This study is subject of several limitations. It included adolescents from one area of Romania, limiting the generalization of results, but it included adolescents from both urban and rural areas allowing for a good understanding of the magnitude of the problem among the studied population. The information is based on what children have declared, but the use of anonymous questionnaire increased the chance of students declaring the real situation. The study investigated the association of different socio-demographic factors with peer and self-directed violence, but future studies should analyze in more depth the effects of adolescent ‘emotions, attitudes and behaviors as well as adolescent social environment.

Conclusions

The study assesses for the first time in Romania the co-occurrence of different forms of interpersonal and self-directed violence among high school students, offering useful information for health promotion actions.

They underline the need to develop appropriate school based educational program in Romania which should have a comprehensive approach for prevention of both traditional and cyber-violence as well as self-directed violence.

The educational activities should be supported by school policies and appropriate training and motivation of school staff (directors, teachers, medical and social workers) to assess and identify different forms of peer-violence, including their co-occurrence, among school students, support those who need help, understanding that both victims and perpetrators might be at risk for physical, mental and social problems. Students exposed to different forms of peer violence should be routinely screened for suicidal risk.

At the same time, school education as well as community interventions should empower adolescents to rise above the problems and social norms from their home and help them to develop communication skills, self-control, emotion management, coping mechanisms in several stressful situations, correct adjustment of their reaction in case of exposure as victim or whiteness of different forms of violence. Moreover, beside the direct targeting of adolescents several interventions directed to parents should be developed in order to address positive parenting skills and behaviors as well as resources and counseling they could use for helping them in good communication and rising of their children.

Future research as well as educational activities should address the complex relationship existing between different forms of violence by strong cooperation between schools-adolescents-parents-stakeholders, exploring the need and solutions for developing, implementation and evaluation of interventions which have an approach and content paying attention to the gender and residence differences, socio-economical and cultural characteristics.