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\begin{document}

\title{Bullying in individuals with cleft lip and palate: A Twitter analysis}



\author[1]{Yasemin Nur Korkmaz}%
\author[1]{Semiha Arslan}%
\author[2]{Suleyman Kutalmış Buyuk}%
\affil[1]{Abant Izzet Baysal University Faculty of Dentistry}%
\affil[2]{Ordu University}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objectives: To evaluate the bullying in individuals with cleft lip
and/or palate (CLP) by Twitter analysis. Materials and Methods:
Twitter's advanced search function was used while the term `cleft lip
and palate' was kept constant, and the selected keywords were `bully',
`bullying', `bullied' and `teased'. A total of 150 tweets that met the
criteria were selected. The data were qualitatively evaluated by
thematic analysis and the themes were determined based on this analysis.
Results: Most of the tweets were posted by a layperson (76\%). Also,
nearly half of the tweets were categorized in the theme `personal
experience of being bullied' (43\%). The tweets were distributed
according to their uploader status as CLP subjects (46\%), irrelevant
individuals (28\%), and parents of CLP subjects' (26\%). Of the 150
tweets evaluated, 74 were identified as negative, while 25 were
identified as neutral and 51 as positive. No significant differences
were detected in retweet and like numbers between negative, neutral, and
positive comments (P \textgreater{} .05). Conclusions: This is the first
study in the literature regarding the bullying suffered by individuals
with CLP using Twitter data. Twitter is a social media platform for
bullying victims with CLP to share their experiences and seek for social
support.%
\end{abstract}%



\sloppy


\textbf{Bullying in individuals with cleft lip and palate: A Twitter
analysis}

\textbf{ABSTRACT}

\textbf{Objectives:} To evaluate the bullying in individuals with cleft
lip and/or palate (CLP) by Twitter analysis.

\textbf{Materials and Methods:} Twitter's advanced search function was
used while the term `cleft lip and palate' was kept constant, and the
selected keywords were `bully', `bullying', `bullied' and `teased'. A
total of 150 tweets that met the criteria were selected. The data were
qualitatively evaluated by thematic analysis and the themes were
determined based on this analysis.

\textbf{Results:} Most of the tweets were posted by a layperson (76\%).
Also, nearly half of the tweets were categorized in the theme `personal
experience of being bullied' (43\%). The tweets were distributed
according to their uploader status as CLP subjects (46\%), irrelevant
individuals (28\%), and parents of CLP subjects' (26\%). Of the 150
tweets evaluated, 74 were identified as negative, while 25 were
identified as neutral and 51 as positive. No significant differences
were detected in retweet and like numbers between negative, neutral, and
positive comments (\emph{P} \textgreater{} .05).

\textbf{Conclusions:} This is the first study in the literature
regarding the bullying suffered by individuals with CLP using Twitter
data. Twitter is a social media platform for bullying victims with CLP
to share their experiences and seek for social support.

\textbf{KEY WORDS} \emph{:} Cleft lip and palate; Bullying; Twitter;
Social media

\textbf{What is already known about this topic?}

In the literature, studies have been conducted on the topic of bullying
in individuals with cleft lip and palate and it has been shown that
bullying is a major problem in their lives and result in various
difficulties. With the increasing usage of social media nowadays,
cyberbullying has also become a major problem. However, no studies have
yet investigated the role of social media on bullying in individuals
with cleft lip and palate. Therefore, this study aimed to analyze the
bullying these people experienced through Twitter.

\textbf{What does this article add?}

This article investigates the bullying that individuals with cleft lip
and palate are exposed to on Twitter, bringing a new perspective to
cyberbullying on social media.



\textbf{INTRODUCTION}

Dental patients interact with other users to get and share information
on the network in the healthcare system. More than two-thirds of online
people in the world use social media platforms. Awareness campaigns and
groups formed for social support through social media are increasing.
Like many social media sites, Twitter has been quite popular for some
time. Approximately 350,000 tweets are shared every minute. Twitter
allows users to share photos and videos as well as text posts which
could contain up to 280 characters. The unfollowing and being followed
relationship in Twitter don't need to be reciprocal, making it different
from some other popular social media platforms. Therefore, it allows
patients to examine the ideas and experiences shared by different
people. Therefore, Twitter is popular for use in public health
research.\textsuperscript{1-3}

Bullying is repetitive and deliberate negative behavior towards an
individual who is incapable of defending him or herself. It is a very
common occurrence in schoolchildren with a prevalence of 5\% to 58\%
globally. Bullying can occur relationally, verbally, or
physically.\textsuperscript{4,5} In addition to these, online aggressive
behavior can be defined as cyberbullying.\textsuperscript{6} Being
bullied has many negative effects on the emotional state of an
individual, which could be lifelong. Those who are bullied may
experience negative physical, mental, social, and spiritual effects in
their lives.\textsuperscript{7} As students who are being bullied often
fear school, their absenteeism and drop-out rates were shown to be
increased. The victims often feel anxious, insecure, and lonely and have
low self-esteem with a generally negative evaluation of
themselves.\textsuperscript{8} It has been observed that those who are
bullied have a high risk of experiencing severe mental health
problems.\textsuperscript{9} Suicidal thoughts and self-harming
behaviors have been found to increase in victims who are constantly
bullied.\textsuperscript{10} Therefore, the execution of bullying
prevention programs is necessary to break the cycle that causes
emotional stress and negative feelings in bullying victims that may
continue throughout their lives.

Dentofacial anomalies can lead to an increment in bullying among
children and adolescent.\textsuperscript{7} In the orthodontic
literature, the teasing people are exposed to because of their teeth and
facial features have been an issue that has been emphasized. Previously,
a significant relationship was detected between bullying, malocclusion,
and self-esteem in adolescents in the UK.\textsuperscript{11} Cleft lip
and/or palate (CLP) are congenital malformations that can affect the
head, lips, and intraoral structures. The incidence of CLP is quite
common with 1 in 700\textsuperscript{12} and varies depending on
genetic, and environmental factors. Children with CLP have some
functional and aesthetic problems such as trouble in mouth closing,
feeding difficulties at birth, hearing problems, speech difficulties,
and dental problems.\textsuperscript{13,14} Due to such difficulties,
individuals with CLP are at increased risk of being bullied. A team of
medical and dental specialists is required to treat these problems.
Delayed treatments may cause potential adverse psychological effects on
the child due to CLP-related malocclusions.

Although the relationship between bullying and dentofacial
features/orthodontic treatment was previously investigated by analyzing
Twitter\textsuperscript{7}, no studies were detected regarding the
bullying experienced by individuals with CLP using Twitter data.
Therefore, we aimed to evaluate the bullying on Twitter experienced by
individuals with CLP.

\textbf{MATERIALS AND METHODS}

\textbf{Data Collection}

The online microblogging platform Twitter
(\emph{http://www.twitter.com/}) was scanned on December 06, 2020 to
identify tweets that concerned CLP and bullying. Twitter's advanced
search function was used for scanning using four keywords, while the
term `cleft lip and palate' was kept constant at each search. The
selected keywords were `bully', `bullying', `bullied' and
`teased'.\textsuperscript{7} English was selected as the search
language. The exclusion criteria were the identical tweets of the same
user which were detected in different searches, unrelated tweets,
non-English tweets, and tweets including unclear letters and words.
Since only publicly available data were included in this study, ethics
committee approval was not required. A total of 150 tweets posted
between March 17, 2012 and November 21, 2020 that met the criteria were
selected.

\textbf{Data analysis}

Manual encoding of Twitter content is more accurate than automatic
encoding because humans can perceive linguistically refined text more
efficiently than computer-based systems.\textsuperscript{15} Therefore,
data were recorded and evaluated manually in this study. The data were
recorded using the Microsoft Excel program and qualitatively evaluated
by thematic analysis\textsuperscript{16} and the themes were determined
based on this analysis.

The tweets were recorded under the following codes: (1) date, (2) number
of retweets, (3) number of likes, (4) tweet source, (5) tweet, (6)
theme, (7) positive/negative/neutral, (8) tweet uploader status. The
tweets were posted by 3 different groups of people: (1) community, (2)
layperson, (3) news. 5 themes were identified: (1) criticism of
bullying, (2) news about bullying in CLP, (3) parental experience of a
child being bullied, (4) personal experience of being bullied, (5)
social support against bullying. Tweet uploader status was classified
into 3 groups: (1) CLP subjects, (2) CLP subjects' parents, (3)
irrelevant individuals (individuals who were unaffected). All tweets
were evaluated by 2 experienced orthodontists who worked independently.
When a case of conflict existed, two investigators exchanged ideas and
determine the final theme together after the first evaluation.

\textbf{Statistical Analysis}

Statistical analysis was carried out using the SPSS software (SPSS for
Windows version 20.0; SPSS Inc, Chicago, Illinois). Kruskal Wallis test
was used to compare the retweets and likes between negative, neutral,
and positive comments. The threshold for statistical significance was
set at \emph{P} \textless{} .05.

\textbf{RESULTS}

The percentage distributions of the tweets according to their sources
were presented in Figure 1. Most of the tweets were posted by a
layperson (76\%), while the others were posted by the community (online
community pages that are related to CLP) (18.7\%) and news (5.3\%)
sources.

Figure 2 displays the percentage distribution of the themes of the
tweets. Nearly half of the tweets were categorized in the theme personal
experience of being bullied (43\%), while the rest were identified in
the following themes: the parental experience of a child being bullied
(17\%) -in which the family members of the bullying victim were
considered as parents-, criticism of bullying (17\%), news about
bullying in CLP (14\%), and social support against bullying (9\%).

The percentage distribution of the tweet uploader status about CLP was
given in Figure 3. The tweets were distributed according to their
uploader status as CLP subjects (46\%), irrelevant individuals (28\%),
and parents of CLP subjects' (26\%). Figure 4 displays the word cloud of
all posts on Twitter about bullying in individuals with CLP.

The comparison of retweets and likes between negative, neutral, and
positive comments were shown in Table 1. Of the 150 tweets evaluated, 74
were identified as negative, while 25 were identified as neutral and 51
as positive. No significant differences were detected in retweet and
like numbers between negative, neutral, and positive comments
(\emph{P}\textgreater{} .05). Descriptive Tweets for each of the themes
were given in Table 2.

\textbf{DISCUSSION}

This is the first study to investigate bullying in individuals with CLP
on Twitter. Considering the impact of social media on today's society
and its capacity to reach everyone with internet access, the importance
of the subject of this study will emerge.

Teasing and bullying are two major problems in the daily life of an
individual with CLP due to the multitude of visible implications of
cleft such as facial scarring, speech and hearing loss, which can be
easily identified by peers. These individuals were shown to experience
bullying at a higher rate than those who were non-CLP and that it
results in psychosocial problems that start in the early
ages.\textsuperscript{17} It has been reported by the parents of
children with CLP that their children have various psychosocial
problems.\textsuperscript{18} Nicholls et
al.\textsuperscript{19}reported that subjects with CLP frequently
experienced teasing and bullying and that it peaked in adolescence and
decreased in adulthood. They also stated that adults with a CLP defined
the need for psychological support as a required but inaccessible
service that could have helped them develop a coping mechanism for
teasing earlier.

The findings of our study are important in terms of showing the bullying
that individuals with CLP are exposed to and its effects. Most tweets
posted by individuals with CLP and their relatives were about their
personal experiences of being bullied and how it affected their lives.
This finding was in accordance with the previous studies of Twitter
posts regarding orthodontic treatment, retention, and aligners in which
most of the tweets also belonged to individuals sharing their
experiences.\textsuperscript{1,20,21} Our findings showed that
individuals with CLP who experienced bullying and tweeted about it
shared their opinions and feelings in their tweets. We observed that
bullying caused individuals with CLP to feel sad and hopeless, with many
expressing difficulties in coping with their experiences. Although these
personal experiences might be helpful for some individuals to cope with
their experience, others might be influenced negatively.

A greater proportion of the analyzed tweets were categorized as negative
(49.3\%), while less were identified as positive (16.7\%) and neutral
(34\%). The fact that many of the tweets in which bullying victims share
their story of being bullied reflects a negative tone is the clearest
example of the destructive effect of bullying on individuals. Even if
the bullying had occurred years ago, it could be observed that the
emotional effects of it continue. Tweets with a positive sense were
mostly about social support and overcoming bullying.

Most of the tweets in this study reflected personal experiences of being
bullied (43\%), followed by the parental experience of a child being
bullied (17\%) and criticism of bullying (17\%), news about bullying in
CLP (14\%), and social support against bullying (9\%), in descending
order. Our findings showed that individuals with CLP who are being
bullied and their parents use Twitter as a platform where they can share
their experiences. Chan et al. (2017) showed that people feel
comfortable sharing their own stories of being bullied on Twitter and
different social media sites could be valuable sources of data regarding
causes of bullying due to oral health and its consequences. It may be
more comfortable to tweet about their personal experiences of bullying
rather than talking about it directly for individuals with CLP too.
However, most of the tweets did not include the type of bullying
suffered.

It could be seen that most of the tweets (46\%) belonged to individuals
with CLP. While it is encouraging to see that the tweets containing the
selected keywords are not owned by the individuals intending to
victimize people with CLP, it is worth noting that they are less likely
to use those words in their tweets. Furthermore, the tweets posted by
bullies are difficult to detect, since they do not have a specific
pattern and could contain a wide variety of words.

The number of tweets included in this study was comparable with previous
relevant studies.\textsuperscript{1,22} We used both qualitative and
quantitative methods to evaluate the tweets. This methodology employed
both qualitative and quantitative approaches and the validity and
trustworthiness of our results enhanced since two different
investigators identified the themes of the tweets separately at first
and then, they exchanged ideas in cases of conflict to determine the
final theme. A manual coding process was used in this study rather than
sentiment analysis software to identify tweets as positive, neutral, or
negative, as the analysis is not able to identify irony and sarcasm and
comprehend unusual phrases.\textsuperscript{23}

It was previously shown that 64\% of teen users of Twitter prefer public
tweets and 24\% choose private tweets, while 12\% don't know if their
tweets are public or private.\textsuperscript{24} A limitation of the
current study was that the tweets that could be evaluated were only the
public ones. The inability to access the tweets which were posted by the
protected profiles prevented access to all tweets about bullying in
individuals with CLP.

The popularity of social media sites is very high, and it seems that it
will continue to increase in the years to come. Today, social media
sites are a part of the daily lives of many people, including children
and adolescents. Therefore, these sites provide important data about
society's perspective on bullying and their experiences. However, it is
usually not possible to obtain much information about the demographic
data of Twitter users. This was because unlike other social media
platforms, fewer Twitter users share private information such as age,
gender, and ethnicity.\textsuperscript{25}

Social media sites could be used by individuals with CLP for many
different purposes. Considering that dental and medical professionals
frequently use social platforms today, they provide the advantage of
facilitating communication with an orthodontist for patients with CLP.
They also provide individuals with CLP and their parents' quick
information. Individuals with CLP who are being bullied want emotional
support and seek it on social media.\textsuperscript{26} Twitter enables
victims of bullying to interact with each other and with different
people from all around the world, which is of great importance as it
provides psychological support and could make them feel that they are
not alone. Since 9 percent of the tweets examined in our study consisted
of support tweets, it is pleasing to see that individuals with CLP can
find this support on Twitter if they search for it. The dental and
medical team should be sharing links to sources of
professional/regulated support for those experiencing bullying in their
profiles to raise awareness of the issue and encourage those who
have/are experiencing bullying to seek support. This will increase
social awareness and highlight the availability of support that these
individuals seek.

When patients with CLP are referred to the clinic for orthodontic
treatment, the approach of the orthodontist is very important as these
patients require psychological assessment. It should be taken into
consideration that these patients may have been bullied in the past or
may be potential victims of bullying. If they have not yet received such
support, CLP patients who are victims of bullying should be directed to
get psychological help so that they can get adequate emotional and
psychological support.

\textbf{CONCLUSIONS}

\begin{itemize}
\tightlist
\item
  It has been seen that Twitter is a platform where not only victims of
  bullying but also many different segments of the society share tweets
  with different content about bullying in CLP.
\item
  Twitter is an important platform for bullying victims with CLP to
  share their experiences and seek social support.
\item
  Dental professionals, especially orthodontists, who have an important
  place in the treatment of patients with CLP from their early ages,
  should be aware of the bullying experienced by these patients and
  should determine their patient approaches and treatment options by
  considering this situation.
\end{itemize}

\textbf{Funding}

No funding was received for this study.

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\textbf{FIGURE LEGENDS}

\textbf{Figure 1.} The \% distributions of the tweets according to the
source.

\textbf{Figure 2.} The \% distributions of the tweet's themes.

\textbf{Figure 3.} The \% distributions of tweet uploader status about
CLP.

\textbf{Figure 4.} Word cloud of all posts on Twitter about bullying
CLP.\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/24283-0-fig-2-qsmk3r/24283-0-fig-2-qsmk3r}

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\includegraphics[width=0.70\columnwidth]{figures/24283-0-fig-3-qsmk3r/24283-0-fig-3-qsmk3r}

\end{center}
\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/24283-0-fig-4-qsmk3s/24283-0-fig-4-qsmk3s}

\end{center}
\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/24283-0-fig-5-qsmk3s/24283-0-fig-5-qsmk3s}

\end{center}
\end{figure}

\textbf{Hosted file}

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\textbf{Hosted file}

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