Adolescence is a critical developmental period marked by rapid cognitive, emotional, and social changes that shape personality and psychosocial functioning. During this stage, peer relationships play a central role in adolescents' mental well-being, academic performance, and social adjustment. However, unhealthy peer interactions and exposure to peer bullying significantly increase the risk of adverse physical, psychological, and social outcomes, including anxiety, depression, low self-esteem, academic difficulties, and risky health behaviors, making bullying a major public health concern. Recent evidence indicates a rising prevalence of peer bullying, particularly among middle school students, highlighting the need for effective school-based interventions. Previous programs have demonstrated reductions in bullying behaviors and improvements in school adjustment and self-confidence, yet meta-analytic findings suggest that existing educational interventions have limited effectiveness, underscoring the need for innovative and theory-driven approaches. The PRECEDE-PROCEED Model offers a comprehensive framework for designing sustainable health promotion interventions by addressing predisposing, enabling, and reinforcing factors influencing behavior. In this context, a laughter yoga-supported education program grounded in this model aims to increase adolescents' awareness of peer bullying, enhance physiological, psychological, and social well-being, strengthen social interaction, and improve quality of life. To date, no studies have examined the effects of a PRECEDE-PROCEED Model-based laughter yoga intervention on peer bullying. The aim of this study is to examine the effect of the "Laughter Yoga-Supported Education Program," developed based on the PRECEDE-PROCEED Model, on peer bullying among adolescents. Objectives: To improve adolescents' levels of awareness regarding peer bullying through the PRECEDE-PROCEED Model-based "Laughter Yoga-Supported Education Program," To enhance adolescents' awareness of health behaviors related to peer bullying through the PRECEDE-PROCEED Model-based "Laughter Yoga-Supported Education Program," To develop adolescents' social skills through PRECEDE-PROCEED Model-based laughter yoga educational practices, To significantly reduce the post-test mean peer bullying scores of adolescents in the intervention group compared with their pre-test mean scores, To ensure that the findings of the study contribute to the literature and guide future research on PRECEDE-PROCEED Model-based interventions. Hypotheses: H0-1: There is no significant difference in Peer Bullying Identification Scale scores between adolescents who receive the PRECEDE-PROCEED Model-based Laughter Yoga-Supported Education Program and those who do not. H1-1: There is a significant difference in Peer Bullying Identification Scale scores between adolescents who receive the PRECEDE-PROCEED Model-based Laughter Yoga-Supported Education Program and those who do not.
Study Population The study population consists of middle schools located in the Altındağ district of Ankara. According to the Socio-Economic Development Index (SEGE) report, Altındağ has a low development score. The literature indicates that students living in socioeconomically disadvantaged areas are more likely to be involved in bullying as perpetrators and/or victims (Chen et al., 2024; Qorbani et al., 2022). Therefore, Altındağ was selected as the study setting. Study Sample The literature reports that peer bullying is most prevalent at the middle school level among 8th-grade students and that the proportions of both bullies and victims are higher in this grade compared with other grade levels (Gökkaya \& Tekinsav-Sütcü, 2020; Li et al., 2024). This age group, corresponding to middle adolescence, is characterized by more pronounced socio-emotional factors such as peer relationships, social status, gender roles, and physical changes, which increase the likelihood of conflict and bullying behaviors in peer interactions. Therefore, selecting 8th-grade students allows for a more comprehensive observation of different dimensions of peer bullying (bully, victim, and bully-victim). In this study, one middle school will be selected from those in Altındağ using a simple random sampling method. The 8th-grade students in the selected school will be randomly assigned to intervention and control groups. Before the study begins, a power analysis (G\*Power 3.1.9.7) will be conducted to determine the required sample size for the intervention and control groups. Based on this analysis, with 95% power, an effect size of 0.66, and a 95% confidence interval, the sample size for each group will be determined. Randomization and Prevention of Bias Students who consent to participate in the study will be assigned to the intervention and control groups using a simple random allocation method. With this approach, each student will have an equal probability of being assigned to either group. This will minimize the impact of baseline individual differences between groups and help preserve the internal validity of the study. The primary reason for selecting the sample from the same school is to prevent interschool differences (e.g., teacher profiles, physical conditions, socioeconomic status) from influencing the study outcomes, thereby enabling a more accurate evaluation of the intervention's effects. Inclusion Criteria Voluntary participation of both the student and their parent/guardian; being an 8th-grade student; and having no hearing, visual, or comprehension impairments that would interfere with completing the data collection forms. Exclusion Criteria Having any health condition that contraindicates exercise; having undergone abdominal surgery within the past three months; or having diagnoses of diabetes, glaucoma, hypertension, epilepsy, hernia, or asthma. Study Variables Dependent Variables The dependent variables of the study include the total mean scores of the "Laughter Yoga-Supported Education Program Evaluation Questionnaire," the "Peer Bullying Identification Scale," the "Peer Bullying Knowledge Form," and the "Adolescent Empathy and Sympathy Scale." Independent Variable The independent variable of the study is the PRECEDE-PROCEED Model-based "Laughter Yoga-Supported Education Program." Data Collection Instruments Data will be collected using the "Personal Information Form," the "Laughter Yoga-Supported Education Program Evaluation Questionnaire," the "Peer Bullying Identification Scale," the "Peer Bullying Knowledge Form," and the "Adolescent Empathy and Sympathy Scale." Personal Information Form This form consists of 25 items developed based on the literature and includes sociodemographic data such as the student's year of birth and gender, parental education and occupation, family income status, family structure and number of siblings, as well as academic performance and peer relationships (Gökkaya \& Sütcü, 2020; Gültekin \& Sayıl, 2005). Laughter Yoga-Supported Education Program Evaluation Questionnaire This questionnaire was developed by the researcher to evaluate the Laughter Yoga-Supported Education Program. The 15 items assess participants' satisfaction with the program and the challenges encountered during the intervention. Peer Bullying Identification Scale The Peer Bullying Identification Scale was developed by Mynard and Joseph (2000). Its Turkish validity and reliability were established by Gültekin and Sayıl (2005). The scale consists of 27 items and five subscales: Intimidation/Threatening, Teasing, Overt Aggression, Relational Aggression, and Attacks on Property. Items are rated on a three-point Likert scale: "more than once" (2 points), "once" (1 point), and "never" (0 points), yielding a total score ranging from 0 to 54. The Cronbach's alpha coefficient for the overall scale is 0.86, with subscale coefficients of 0.73, 0.68, 0.72, 0.72, and 0.67, respectively (Gültekin \& Sayıl, 2005). Higher scores indicate more frequent experiences of peer bullying, whereas lower scores indicate fewer or no such experiences. Pekel and Uçanok (2005) adapted this scale by adding the question, "How often do you engage in this behavior?" and developed the "Peer Bullying Identification Scale" for assessing both victimization and perpetration (Pekel Uludağ \& Uçanok, 2005). The overall Cronbach's alpha coefficient was 0.89, with subscale coefficients of 0.71, 0.67, 0.86, 0.80, and 0.76, respectively. Permission to use the scale in this study was obtained from the corresponding author and is provided in the appendix. Peer Bullying Knowledge Form This form was developed by Yavuz and Özdemir in 2024 to assess middle school students' knowledge of peer bullying before and after the intervention. The form consists of eight items rated on a three-point Likert scale ("I don't know = 0," "incorrect = 1," "correct = 2"), with total scores ranging from 0 to 16. Higher scores indicate greater knowledge about peer bullying. Content and language validity were assessed by six experts, and the Content Validity Index (CVI) was calculated as 0.95. Reliability analysis yielded a Cronbach's alpha coefficient of 0.85 (Yavuz \& Çevik Özdemir, 2024). Permission to use the form was obtained from the corresponding author and is provided in the appendix. Adolescent Empathy and Sympathy Scale This scale was developed by Vossen et al. (2015) to assess empathy and sympathy levels in adolescents, distinguish between these two constructs, and equally address cognitive and emotional empathy dimensions. The Turkish adaptation, validity, and reliability study was conducted by Zengin et al. (2018). The scale consists of 12 items rated on a five-point Likert scale and comprises three subscales: cognitive empathy, emotional empathy, and sympathy. Each subscale contains four items. Higher scores indicate higher levels of empathy or sympathy, whereas lower scores indicate lower levels. Cronbach's alpha reliability coefficients were 0.63 for cognitive and emotional empathy and 0.75 for sympathy (Zengin et al., 2018). Permission to use the scale in this study was obtained from the corresponding author and is provided in the appendix. Study Plan and Implementation Process Pre-test: Before the intervention, the "Personal Information Form," the "Peer Bullying Identification Scale," the "Peer Bullying Knowledge Form," and the "Adolescent Empathy and Sympathy Scale" will be administered to both the intervention and control groups. Intervention: Following the pre-test, students in the intervention group will receive the PRECEDE-PROCEED Model-based "Laughter Yoga-Supported Education Program." No intervention will be applied to the control group during the study period. The program, developed based on the PRECEDE-PROCEED Model, includes laughter yoga practices and educational sessions on the health effects of laughter yoga and peer bullying. The program was prepared in line with the literature by three researchers who are professors and PhD holders in public health nursing and certified in laughter yoga. In collaboration with school administration, the program is planned to be implemented over six weeks, two days per week, during suitable class hours. Each week, one session will consist of 30-40 minutes of theoretical health education, and informational brochures will be distributed to families (Appendix). On another day, a 40-45-minute laughter yoga session will be conducted by a certified researcher. Make-up sessions will be arranged for students who miss any session. Post-test: At the end of the 6-week program, the "Laughter Yoga-Supported Education Program Evaluation Questionnaire" will be administered to the intervention group to assess satisfaction with the intervention. Both the intervention and control groups will complete the "Peer Bullying Identification Scale," the "Peer Bullying Knowledge Form," and the "Adolescent Empathy and Sympathy Scale." Follow-up Test: Three months after completion of the Laughter Yoga-Supported Education Program, data collection forms will be re-administered to both groups. To ensure ethical equity, a single-session laughter yoga and health education presentation will be provided to the control group after data collection. Implementation Plan of the PRECEDE-PROCEED Model-Based "Laughter Yoga-Supported Education Program" The PRECEDE-PROCEED Model is an effective approach that guides all stages of developing sustainable health behaviors and provides a systematic framework for designing, planning, implementing, and evaluating interventions targeting specific populations (Kim et al., 2022). In the first phase of the study, a literature review revealed that peer bullying tendencies among middle school adolescents have been high in recent years (CDC, 2024; Cosma et al., 2024; Grant et al., 2019; Stubbs-Richardson \& May, 2021). Unhealthy peer relationships and limited social support significantly increase the likelihood of bullying among adolescents. Based on this problem, the "Laughter Yoga-Supported Education Program," developed in line with the PRECEDE-PROCEED Model, aims to increase adolescents' awareness of peer bullying, reduce bullying behaviors, strengthen social skills, and support psychological well-being. In addition, the program seeks to contribute to the development of healthy lifestyle behaviors, serve as a guiding resource for educators and families, and foster a positive school culture. In the second phase, factors contributing to the identified problem were determined through a literature review (Ahmed et al., 2022; D'Urso \& Symonds, 2023; Farrington, 2020; Özer \& Haspolat, 2024; Zych et al., 2021). Peer bullying is a multidimensional phenomenon shaped by both individual characteristics and environmental factors. Individual factors include age, gender, grade level, socioeconomic status, academic achievement, and social skills, while environmental factors encompass peer relationships, adolescent-parent relationships, family structure, and local and societal-level influences (Özer \& Haspolat, 2024). Protective factors against bullying play a significant role in reducing adolescents' risk of victimization. These factors include trust-based and non-intrusive parent-child relationships, secure attachment styles, affectionate and warm peer relationships, high levels of psychosocial well-being and self-esteem, positive relationships with teachers, academic success, and gender (being male) (D'Urso \& Symonds, 2023; Özer \& Haspolat, 2024). Moreover, intervention programs that involve all stakeholders in the educational environment (teachers and parents) are known to be effective in preventing bullying and victimization. Such programs enhance adolescents' critical thinking, social responsibility, ethical awareness, socio-emotional skills-particularly empathy-and strengthen prosocial behaviors and social cohesion among peers (D'Urso \& Symonds, 2023). After identifying the factors influencing peer bullying, the third phase classified the predisposing, reinforcing, and enabling factors aimed at creating change in bullying behavior and supporting the sustainability of this change. Predisposing factors include the knowledge, attitudes, beliefs, and values that motivate the target population toward behavior change (Porter, 2016). In this study, predisposing factors were defined to include adolescents' lack of knowledge about the definition, effects, and negative consequences of peer bullying; negative attitudes; low levels of empathy; deficiencies in critical thinking, social responsibility, and ethical awareness; and their recognition of the potential of laughter yoga to enhance socio-emotional skills. These factors will be measured in the pretest and compared with subsequent follow-up assessments. Through the Laughter Yoga-Supported Education Program implemented for adolescents, changes in predisposing factors are intended to be achieved. Reinforcing factors are elements that encourage and support the repetition of a behavior (Crosby \& Noar, 2011). In this study, reinforcing factors include influences that shape adolescents' behaviors through social support providers such as parents, peers, teachers, and counselors. Teachers, classmates, and parents will be included in the Laughter Yoga-Supported Education Program. The laughter yoga program will be implemented in the school setting under the leadership of teachers and a researcher certified in laughter yoga, thereby ensuring peer and counselor support. Adolescents will share the knowledge and skills they acquire through the program with their parents via brochures prepared by the researcher, reinforcing learning through family support. Enabling factors refer to the conditions necessary for the behavior to occur (Crosby \& Noar, 2011). In this study, enabling factors include the design of the Laughter Yoga-Supported Education Program implemented to support adolescents in developing positive behaviors toward peer bullying and the environment in which adolescents can demonstrate their socio-emotional skills. The Laughter Yoga-Supported Education Program, covering a total duration of six weeks, was developed by expert researchers and includes laughter yoga practices, knowledge- and skills-based education on peer bullying, and informative brochures. The fourth phase involves identifying predisposing (knowledge, attitudes), reinforcing (rewards, support), and enabling (resources, skills) factors that influence behavior change and designing the education program accordingly. Predisposing factors include the preparation of a health education program on peer bullying; reinforcing factors include group activities, social support, and collaboration with school administrators; and enabling factors include the development of the laughter yoga program by experts. The fifth phase involves identifying the necessary resources, potential institutional barriers, and relevant policies to implement and sustain the planned Laughter Yoga-Supported Education Program. After obtaining ethical approval, institutional permission will be secured. Before initiating the program, students will be informed about the study, and informed consent forms will be sent to parents, who will be asked to sign and return them. Verbal consent will also be obtained from the students. Permission has been obtained from the scale owners for the instruments used in the study. The days and times of program implementation will be determined in collaboration with school administrators. The laughter yoga-supported education program has been designed by expert researchers, and the necessary equipment and materials (brochures, posters, etc.) have been prepared. The sixth phase includes the implementation and maintenance of the Laughter Yoga-Supported Education Program under the leadership of a researcher certified in laughter yoga. The seventh phase covers process evaluation, in which the planned interventions will be assessed, potential implementation problems will be monitored, and the quality of implementation and participant satisfaction will be determined. The eighth phase involves impact evaluation, in which short-term effects (increased knowledge, attitude change) will be measured. In the ninth phase, outcome evaluation will assess long-term effects (reduction of the problem, behavior change) and examine whether the planned interventions were implemented as intended. Implementation of the Study The study will commence after obtaining approval from the ethics committee and the necessary permissions from the Ankara Provincial Directorate of National Education. Once voluntary students who meet the inclusion criteria are identified, students and their parents will be informed about the study prior to implementation, and written informed consent will be obtained from parents. The Laughter Yoga-Supported Education Program, developed based on the PRECEDE-PROCEED Model, includes education on the health effects of laughter yoga and peer bullying. The program is planned to be implemented over six weeks, two days per week, during suitable class hours in collaboration with school administrators. Students in the intervention group will receive 30-40 minutes of theoretical health education once per week, in line with the planned curriculum, and brochures will be distributed to families. On the other day, a researcher certified in laughter yoga will conduct 40-45 minute laughter yoga sessions with the students. The health education implementation schedule is presented in Table 2, and the laughter yoga implementation schedule is presented in Table 3. Classroom teachers and school administrators will also participate in the laughter yoga sessions. The educational materials prepared for the program will be presented by the researcher via smart boards in the classroom and will be sent to students and their families. Active participation of teachers and parents in the implementation process is intended to reinforce the attitudes and behaviors targeted for development among students. The prepared educational brochures are provided in the appendix. No intervention will be administered to the control group during the implementation and data collection phases of the study. However, after data collection is completed, in accordance with ethical principles, a single session of health education and laughter yoga will be provided to the control group. Ethical Considerations The study will be conducted in accordance with the principles of the Declaration of Helsinki. To obtain institutional permission, ethics committee approval must first be secured (Appendix). Following ethics approval, implementation permission will be obtained from the Ankara Provincial Directorate of National Education. Before initiating the Laughter Yoga-Supported Education Program, detailed information about the purpose, potential benefits, and procedures of the study will be provided to students and their parents who are willing to participate. It will be clearly stated that participation is entirely voluntary and that no coercion or financial compensation will be involved. Subsequently, verbal consent will be obtained from students and written informed consent will be obtained from parents. Permission has been obtained from the scale owners for the instruments used in the study and included in the application file. Data Analysis Study data will be analyzed using the Statistical Package for Social Sciences (SPSS) version 25.0. Continuous variables will be reported as mean (x̄) and standard deviation (SD). Categorical variables will be reported as frequency (n) and percentage (%). For variables with two groups, the independent samples t-test and the non-parametric Mann-Whitney U test will be used. For variables with three or more groups, one-way analysis of variance (ANOVA) and the non-parametric Kruskal-Wallis H test will be used. Reliability analyses for total scale and subscale scores will be calculated using Cronbach's alpha. A p-value of \<0.05 will be considered statistically significant in all analyses.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
SINGLE
Enrollment
80
Participants will receive face-to-face health education over 6 weeks,
The intervention groups will receive a total of 6 sessions of laughter yoga, delivered by the researcher over 6 weeks, once a week, each lasting 40-45 minutes.
Ankara University. Nursing Fakulty
Ankara, Mamak, Turkey (Türkiye)
Adolescent Empathy and Sympathy Scale
This scale, developed by Vossen et al. (2015), was designed to assess levels of empathy and sympathy in adolescents, to distinguish between these two constructs, and to address cognitive and emotional empathy dimensions equally (Vossen et al., 2015). The Turkish adaptation, validity, and reliability study was conducted by Zengin et al. (2018). The scale is rated on a 5-point Likert type and consists of a total of 12 items across three subscales: cognitive empathy, emotional empathy, and sympathy. Each subscale includes four items; the first four items measure emotional empathy, the next four measure cognitive empathy, and the final four measure sympathy. Higher scores indicate higher levels of empathy or sympathy, while lower scores indicate lower levels. Cronbach's alpha reliability coefficients for the subscales were reported as 0.63 for cognitive empathy, 0.63 for emotional empathy, and 0.75 for the sympathy subscale (Zengin et al., 2018). P
Time frame: 1 month
Peer Bullying Scale
The Peer Bullying Scale was developed by Mynard and Joseph (2000). Its Turkish validity and reliability study was conducted by Gültekin and Sayıl (2005). The scale used in this study consists of five subdimensions and a total of 27 items. The subdimensions are defined as Intimidation/Threat, Teasing, Physical Aggression, Relational Aggression, and Attacks on Personal Property. The items are rated on a 3-point Likert scale as "more than once" (2 points), "once" (1 point), and "never" (0 points). The total score ranges from 0 to 54. The Cronbach's alpha coefficient for the overall scale is 0.86, and for the subscales, the values are 0.73, 0.68, 0.72, 0.72, and 0.67, respectively (Gültekin \& Sayıl, 2005). The scale identifies victims of bullying. Higher scores indicate more frequent experiences of peer bullying, whereas lower scores indicate fewer or no such experiences. Pekel and Uçanok (2005) adapted this scale by adding the question, "How often do you engage in t
Time frame: 1.5 months
Peer Bullying Knowledge Form
The form was developed by Yavuz and Özdemir in 2024. It was designed to assess middle school students' knowledge levels regarding peer bullying before and after the educational intervention. The form consists of eight items, each rated on a 3-point Likert scale ("I don't know = 0," "incorrect = 1," "correct = 2"). Total scores range from 0 to 16, with higher scores indicating increased knowledge about peer bullying. To evaluate content and language validity, expert opinions were obtained from six specialists and analyzed using the Content Validity Index (CVI) method. The calculated CVI value was 0.95. In addition, the reliability of the form was examined, and the Cronbach's alpha internal consistency coefficient was found to be 0.85 (Yavuz \& Çevik Özdemir, 2024). Permission to use the scale in this study was obtained from the corresponding author and is included in the appendix.
Time frame: 1.5
Laughter Yoga-Supported Education Program Evaluation Questionnaire
The questionnaire designed to evaluate the Laughter Yoga-Supported Education Program was developed by the researcher. This form consists of 15 items aimed at assessing participants' satisfaction with the program implemented during the study and identifying any problems encountered.
Time frame: 1.5 month
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