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.17 It has been reported by the parents of children with CLP that their children have various psychosocial problems.18 Nicholls et al.19reported 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.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.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.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.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.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.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.