Prevalence of Social Anxiety Disorder and Its Impact on Academic Performance among Female Secondary School Students in Saudi Arabia

Received: 29-Sep-2022, Manuscript No. ijmrhs-22-76218; Editor assigned: 01-Oct-2022, Pre QC No. ijmrhs-22-76218 (PQ); Reviewed: 03-Oct-2022, QC No. ijmrhs-22-76218 (Q); Revised: 15-Oct-2022, Manuscript No. ijmrhs-22-76218 (R); Published: 30-Oct-2022

Introduction

Social phobia is defined as a persistent and excessive fear of embarrassment of social situations while a person feels as he/she is being observed by others and negatively evaluated [1]. According to the WHO, 27% of the adult population had a psychiatric disorder including depression, anxiety, and drug abuse that causing disability in their lives. Anxiety disorders rank sixth and account for 4% of all disabilities [2]. SAD is one of the most common types of anxiety disorders worldwide and was estimated to be 7% in the US [1,3]. It is more common among females and among those who had low educational and socioeconomic status as well as among those who reported unhealthy parenting styles [4-6]. It was found that if not diagnosed and treated early, SAD can lead to other mental diseases like depression and alcohol and substance abuse [3,7]. The prevalence of SAD in Saudi Arabia ranged from 11.7% to 25.8% and was associated significantly with the parenting style [6,8]. Other previous studies from Ethiopia, Kurdistan, and Turkey found that the prevalence of SAD was 27.5%, 31.25%, and 20.9% respectively and SAD was higher among females [9-11].

This study aimed to measure the prevalence of SAD and its impact on academic performance among female secondary school students in Medina, Saudi Arabia.

Materials and Methods

Study Setting and Sample

This observational analytical cross-sectional study was conducted among 405 female secondary school students in Medina city, Saudi Arabia. Al Madinah was divided into four regions and two schools were selected randomly from each region. All students in the 8 governmental schools were approached.

Study Instruments

A self-administered questionnaire consisting of three parts was used in this study. The first part included questions on sociodemographic characteristics like age, school grade, family size, birth order, parental marital status, family income, and parenting style. The second part assessed SAD by using the Social Phobia Inventory (SPIN). The SPIN is a short, self-rating scale developed by Dr. K.M. Connor to capture the social phobia symptoms [12-14]. It consists of 17 items and each item is rated from 0 (not at all) to 4 (extremely) with a total score of 0-68. A score ≥ of 19 suggests SAD. It has good test-retest reliability, internal consistency, convergent and divergent validity. The Cronbach alpha was 0.85 [15,16]. The third part was the Leibowitz Social Anxiety Scale (LSAS) which is used to assess the severity of SAD. The LSAS is a self-rating scale developed by Dr. Michael Liebowitz to rate fear/anxiety and avoidance regarding 24 commonly feared performance or social situations [17]. It consists of 13 performance-related items and 11 social-related items which are rated from 0 (none/never) to 3 (severe/usually). The Cronbach alpha for the fear/ anxiety domain was 0.88 and for the avoidance, domain was 0.87 [15]. A score of <55 suggests mild SAD, 55-64 suggests moderate SAD, 65-79 suggests marked SAD, 80-94 suggests severe SAD, and >95 suggests very severe SAD. To evaluate the academic performance of the students, the last semester score of each student was obtained from the school.

Statistical Analysis

Analysis was performed using the Statistical Package for the Social Sciences (SPSS®) (version 22.0, IBM, Armonk, NY). Percentages and frequencies were obtained for the categorical variables. A Chi-square test was performed to assess the association between the categorical variables. The accepted level of significance was set below 0.05 (p<0.05).

Ethical Considerations

Ethical approval was obtained from the Ethics Committee of the Directorate of Health in Al-Madinah. The objectives and benefits of the study were explained to the participants. Participant’s confidentiality and anonymity were assured. Signed consents were obtained from the participants.

Results

The study included 405 female high school students. The age of 41.8% of them was ≥ 18 years whereas 58.2% aged ≤ 17 years. About half of them (48.1%) were in the third grade. The majority of them (84%) live with both parents whereas 16% live with one parent. The family size without counting parents ranged between 4 and 8 persons among 70.9% of the students. The first birth order was mentioned by 25.7% of them. Higher educated mothers and fathers (university) were reported among 32.6% and 38.5%, respectively. Family monthly income less than 6000 SR was reported by 51.3% of the students. Regarding performance, almost half of them (50.1%) got >90% in the last semester (Table 1).

Relationship with Parents

Parental anger was usually reported by 27.2% of the students. Usual parental criticism was reported by 23% of them and it was in front of others in 8.4% of cases. Usual parental over-protection was reported by 59% of them. Parental provocation was usual among 16% of the students. Parental abuse was reported by 27.4% of the students. The prevalence of parental physical, emotional abuse and parental neglect were 11.4%, 24.2%, and 8.6% respectively (Table 2).

Prevalence and Severity of SAD

Table 3 summarizes the response of the participants to the individual items of the Social Phobia Inventory scale.

Overall, the prevalence of social anxiety disorder among female high school students was 51.1%. Marked, severe, and very severe SAD were reported by 12.8%, 4.7%, and 3.7% respectively as obtained from the LSAS questionnaire.

Association between Social Anxiety Disorder and Socio-Demographic Factors

SAD was higher among first-order students (60.6%), (p=0.038), among students whose fathers were illiterates (80%), (p=0.041) and among those who had low income (55.8%), (p=0.022) (Table 4).

Association between Social Anxiety Disorder and Parental-Students Relationship

SAD was higher among those who reported their parents were angry with them usually (p<0.001), those who reported their parents criticized them usually (p<0.001), those who reported their parents criticized them in front of others (p<0.001) and those who reported usual parental provocation (p=0.005). SAD was also higher among those who reported parental physical abuse (p=0.019), emotional abuse (p=0.006), and neglect (p=0.031) (Table 5).

Discussion

The present study aimed to assess the prevalence and severity of SAD and determine its associated factors as well as its impact on the academic performance of secondary school girls in Medina city, Saudi Arabia [18,19].

In the present study, the prevalence of SAD among secondary school girls was 51.1%. Regarding its severity, it was mild among 31.4% and moderate among 17% of the students. Marked, severe and very severe form was reported by 21.2% of the students. The prevalence of SAD ranged from 6.2% to 32.4% in some Middle East countries, 14.1% to 10.3% in Asian countries, and 26.5% in Poland [20-30]. Moreover, in an earlier comparative study, the prevalence of social phobia in Saudi Arabia, the United Arab of Emirates, and Egypt were 9.8%, 7.8%, and 13%, respectively [30]. In a recent study carried out among undergraduate students at Jazan University, Saudi Arabia, the prevalence of SAD was 25.8%; it was mild in 47.2% of them, moderate, marked, severe/very severe in 42.3% and 10.5% of them, respectively [7]. The apparent difference in the rate of SAD between different studies could be related to some reasons; the demographic characteristics of the participants particularly age, gender, socio-cultural variations between different countries, and the utilization of different tools to assess the social phobia.

Relatively, few studies investigated social phobia in only one sex as a result of cultural issues and all were done in Saudi Arabia, as in the present study. For example, the prevalence of SAD among secondary school boys was 11.7% in Abha city and 14.1% in Khamis Mushait [8,23]. In Taif, the prevalence rate among female university students was 16.3% [31].

In agreement with others, the present study revealed that SAD was more reported among first birth order students than others [32-34], However, others reported that social phobia was more among children born later [35].

Lower educated fathers and lower family income, which indicate low socio-economic status, were associated with a higher rate and more severe form of SAD among female students in the present study. This is quite expected as it is known that low socioeconomic status is associated with many psychological problems including anxiety disorders, as low socio-economic status induces psychological problems, which in turn may cause individuals to become of low socioeconomic status [36, 37].

Additionally, higher grade students were more likely to have severe/very severe forms of SAD than their counterparts. However, Al-Qahtani didn’t find a relation between the school grade and the prevalence and severity of social phobia [32].

Regarding parental-students relationship, usual parental angry with students, criticizing them individually or in front of others, parental provocation, and parental abuse with its all types (physical, emotional, and neglect) were associated with a higher rate of SAD. In addition, a more severe form of SAD was associated with usual parental criticism of students either individually or in front of others, parental provocation, and parental abuse particularly, physical type. Similar findings were reported in two previous studies [8,38]. Bracik J, et al. found that the environmental factors of the school and family had an impact on the development of SAD of adolescents [23].

The present study and others didn’t observe an association between the SAD and self-reported academic performance of the students [10,39]. In the present study, academic performance was self-rated, Therefore further investigation using academic performance from students` records is recommended.

Two main limitations are present in this study. The first limitation is the inclusion of females only, which can’t give an overview of the problem among the adolescent population in Medina. The second limitation is the cross-sectional design of the study which can’t show the causal relationship between SAD and possible related factors. Despite those limitations, this study could be of usefulness for decision-makers as this is a hidden problem in our conservative society, particularly among female adolescents.

Conclusion

SAD is a common health problem among girls enrolled in secondary schools in Medina city as about half of them reported the problem. Although it was mainly mild in severity, a considerable proportion had severe/very severe levels. It was more reported among first birth order students and those with lower socioeconomic status. The parental style was associated with a higher rate of SAD.

Recommendations

Initial and regular periodic evaluation of secondary school girls in Medina city for SAD should be done to discover early enough cases. Health education is recommended for both parents and teachers regarding possible risk factors and early symptoms of social phobia to increase their awareness of the bad impacts of physical, emotional abuse and their effects on students` psychological health. Special attention should be given to students of low socioeconomic status, through providing more social and psychological support. Future studies are recommended to include male students and those in earlier school stages.

Declarations

Conflicts of Interest

The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

1. American Psychiatric Association, A. "Diagnostic and statistical manual of mental disorders." Vol. 3, Washington, DC: American Psychiatric Association, 1980.
   Google Scholar          Crossref
2. Murray, Christopher JL, et al. "The Global Burden of Disease 2000 project: Aims, methods and data sources." Geneva: World Health Organization, Vol. 36, 2001, pp. 1-57.
   Google Scholar
3. Mekuria, Kindie, et al. "High magnitude of social anxiety disorder in school adolescents." Psychiatry Journal, Vol. 2017, 2017.
   Google Scholar          Crossref
4. Spence, Susan H., and Ronald M. Rapee. "The aetiology of social anxiety disorder: An evidence-based model." Behaviour Research and Therapy, Vol. 86, 2016, pp. 50-67.
   Google Scholar          Crossref
5. Fors, Payton Q., and Deanna M. Barch. "Differential relationships of child anxiety and depression to child report and parent report of electronic media use." Child Psychiatry & Human Development, Vol. 50, No. 6, 2019, pp. 907-17.
   Google Scholar
6. Ghazwani, Jaafar Y., Shamsun N. Khalil, and Razia A. Ahmed. "Social anxiety disorder in Saudi adolescent boys: Prevalence, subtypes, and parenting style as a risk factor." Journal of Family & Community Medicine, Vol. 23, No. 1, 2016, pp. 25-31.
   Google Scholar          Crossref
7. Stein, Murray B., and Dan J. Stein. "Social anxiety disorder." The Lancet, Vol. 371, No. 9618, 2008, pp. 1115-25.
   Google Scholar          Crossref
8. Hakami, Ramzi M., et al. "Social anxiety disorder and its impact in undergraduate students at Jazan University, Saudi Arabia." Mental Illness, Vol. 9, No. 2, 2017, pp. 42-47.
   Google Scholar          Crossref
9. Stein, Dan J., et al. "The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative." BMC Medicine, Vol. 15, No. 1, 2017, pp. 1-21.
   Google Scholar
10. Gardi, Abdulqader H.H. "Prevalence of social phobia among high school students in Erbil, Kurdistan region." Zanco Journal of Medical Sciences, Vol. 20, No. 3, 2016, pp. 1497-504.
    Google Scholar          Crossref
11. Gultekin, Bulent K., and Ferhan I. Dereboy. "The prevalence of social phobia, and its impact on quality of life, academic achievement, and identity formation in university students." Turkish Journal of Psychiatry, Vol. 22, No. 3, 2011, pp. 150-58.
    Google Scholar     
12. Education M. Saudi Arabia-Ministry of Education, 2018. https://www.moe.gov.sa/ar /Pages/StatisticalInformation .aspx
13. Raosoft. "Sample size calculator." 2019. http://www.raosoft.com/samplesize.html
14. Connor, Kathryn M., et al. "Psychometric properties of the Social Phobia Inventory (SPIN): New self-rating scale." The British Journal of Psychiatry, Vol. 176, No. 4, 2000, pp. 379-86.
    Google Scholar          Crossref
15. Shah, P., and Lakhan Kataria. "Social phobia and its impact in Indian university students." The Internet Journal of Mental Health, Vol. 6, No. 2, 2010, pp. 1-8.
    Google Scholar          Crossref
16. Poormohammad, Ahmad, et al. "Social phobia in persian adults with stuttering." Journal of Rehabilitation Sciences & Research, Vol. 5, No. 1, 2018, pp. 13-17.
    Google Scholar          Crossref
17. Liebowitz, Michael R. "Social phobia." Modern Problems of Pharmacopsychiatry, Vol. 22, 1987, pp. 141-73.
    Google Scholar       
18. Charan, Jaykaran, and Tamoghna Biswas. "How to calculate sample size for different study designs in medical research?" Indian Journal of Psychological Medicine, Vol. 35, No. 2, 2013, pp. 121-26.
    Google Scholar          Crossref
19. Crome, Erica, Andrew Baillie, and Alan Taylor. "Are male and female responses to social phobia diagnostic criteria comparable?" International Journal of Methods in Psychiatric Research, Vol. 21, No. 3, 2012, pp. 222-31.
    Google Scholar          Crossref
20. Hummadi, Basheer F., and Abdulkareem Alobaidi. "Social phobia among secondary school students in Baghdad/Iraq." Journal of the Canadian Academy of Child and Adolescent Psychiatry, Vol. 23, No. 1, 2014, pp. 70-71.
    Google Scholar        
21. Hussein, Ahmed H., et al. "Social phobia among secondary school students in Babil, Iraq." Journal of the Faculty of Medicine Baghdad, Vol. 58, No. 4, 2016, pp. 354-56.
    Crossref
22. Jefferies, Philip, and Michael Ungar. "Social anxiety in young people: A prevalence study in seven countries." PLoS One, Vol. 15, No. 9, 2020, p. e0239133.
    Google Scholar          Crossref
23. Bracik, Joanna, Krzysztof Krysta, and Adam Zaczek. "Impact of family and school environment on the development of social anxiety disorder: A questionnaire study." Danubina Psychiatry, Vol. 24, No. 1, 2012, pp. 125-27.
    Google Scholar         
24. Mazhari, Shahrzad, Maryam Ekhlaspour, and Nabi Banazadeh. "Social phobia and its association with academic performance among student of Kerman University of Medical Sciences Iran." Strides in Development of Medical Education, Vol. 11, No. 2, 2014, pp. 227-35.
    Google Scholar         
25. Momani, F., and A. M. Jaradat. "Social phobia among university students: Prevalence and socio-demographic factors." Jordan Journal of Social Sciences, Vol. 4, No. 1, 2011, pp. 71-88.
    Google Scholar          Crossref
26. Jin, Yuelong, et al. "Prevalence and risk factors of anxiety status among students aged 13-26 years." International Journal of Clinical and Experimental Medicine, Vol. 7, No. 11, 2014, pp. 4420-26.
    Google Scholar         
27. Srinivasan, Manikandan, et al. "Comment on: Social anxiety disorder in Saudi adolescent boys: Prevalence, subtypes, and parenting styles as a risk factor." Journal of Family & Community Medicine, Vol. 23, No. 3, 2016, pp. 185-86.
    Google Scholar          Crossref
28. Burstein, Marcy, et al. "Social phobia and subtypes in the National Comorbidity Survey-Adolescent Supplement: Prevalence, correlates, and comorbidity." Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 50, No. 9, 2011, pp. 870-80.
    Google Scholar          Crossref
29. Dodangi, Nasrin, Nastaran Habibi Ashtiani, and Burhanoddin Valadbeigi. "Prevalence of DSM-IV TR psychiatric disorders in children and adolescents of Paveh, a western city of Iran." Iranian Red Crescent Medical Journal, Vol. 16, No. 7, 2014, p. e16743.
    Google Scholar         
30. Azab, Hemaid M. Mussttafa, Usama A. El-Khouli, and A. Magdi. "Social phobia among secondary school students: A comparative study between Egypt, Saudi Arabia and the United Arab Emirates." Egyptian Journal of Psychiatry, Vol. 26, No. 1, 2007.
    Google Scholar         
31. Taha, Azza Ali, et al. "Social anxiety disorder and its correlates among female students at Taif University, Saudi Arabia." Research in Psychology and Behavioral Sciences, Vol. 5, No. 2, 2017, pp. 50-56.
    Google Scholar         
32. Al-Qahtani, A. M., and A. B. F. M. Sbfm. "Prevalence and risk factors of social phobia among secondary school male students in Khamis Mushayt, Kingdom of Saudi Arabia." The Medical Journal of Cairo University, Vol. 80, No. 1, 2012, pp. 871-76.
    Google Scholar          Crossref
33. Voci, Sabrina C., et al. "Social anxiety in late adolescence: The importance of early childhood language impairment." Journal of Anxiety Disorders, Vol. 20, No. 7, 2006, pp. 915-30.
    Google Scholar          Crossref
34. Aljohani, Basem Musllam, and Amani Mahrus. "Prevalence and possible risk factor of social phobia among male secondary and intermediate school students in Al-Medinah, 2016." The Egyptian Journal of Hospital Medicine, Vol. 72, No. 7, 2018, pp. 4836-42.
    Google Scholar          Crossref
35. Hudson, Jennifer L., and Ronald M. Rapee. "The origins of social phobia." Behavior Modification, Vol. 24, No. 1, 2000, pp. 102-29.
    Google Scholar          Crossref
36. Bromet, Evelyn, et al. "Cross-national epidemiology of DSM-IV major depressive episode." BMC Medicine, Vol. 9, No. 1, 2011, pp. 1-16.
    Google Scholar         
37. Kawakami, Norito, et al. "Early-life mental disorders and adult household income in the World Mental Health Surveys." Biological Psychiatry, Vol. 72, No. 3, 2012, pp. 228-37.
    Google Scholar          Crossref
38. Abdallah, Eman Shokry, et al. "Association between social phobia and parenting styles among secondary school students." American Journal of Nursing Science, Vol. 5, No. 3, 2016, pp. 96-105.
    Google Scholar        
39. Strahan, Esther Y. "The effects of social anxiety and social skills on academic performance." Personality and Individual Differences, Vol. 34, No. 2, 2003, pp. 347-66.
    Google Scholar          Crossref