Social Anxiety Disorder

Research Article
High Magnitude of Social Anxiety Disorder in
School Adolescents

Kindie Mekuria,1 Haregwoin Mulat,2 Habtamu Derajew,3 Tesfa Mekonen,4

Wubalem Fekadu,4 Amsalu Belete,5 Solomon Yimer,6 Getasew Legas,5 Melak Menberu,7

Asmamaw Getnet,8 and Simegnew Kibret5

1Woldia Hospital, Woldia, Ethiopia
2Psychiatry Department, University of Gondar, Gondar, Ethiopia
3Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia
4Psychiatry Department, Bahir Dar University, Bahir Dar, Ethiopia
5College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
6Psychiatry Department, Dilla University, Dilla, Ethiopia
7College of Health Sciences, Mizan-Tepi University, Mizan-Tepi, Ethiopia
8Finote Selam Hospital, Finote Selam, Ethiopia

Correspondence should be addressed to Amsalu Belete; [email protected]

Received 20 October 2016; Revised 14 January 2017; Accepted 29 January 2017; Published 16 February 2017

Academic Editor: Arif Khan

Copyright © 2017 Kindie Mekuria et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. Social phobia is the most prevalent and chronic type of anxiety disorder worldwide and it affects occupational,
educational, and social affairs of the individual. Social phobia is also known for its association with depression and substance
use disorder. Objective. The aim of this study was to assess the prevalence and associated factors of social phobia among high school
students in Ethiopia. Methods. Cross-sectional study was conducted among 386 randomly selected students. Data were collected
using pretested and self-administered questionnaire. Social phobia was assessed by using Social Phobia Inventory (SPIN). Logistic
regression was used to analyze the data with 95% confidence interval and variables with? value less than 0.05 were considered as
statistically significant. Results. From 386 study participants, 106 (27.5%) of them were positive for social phobia. Being female (AOR
= 3.1; 95% CI: 1.82–5.27), current alcohol drinking (AOR = 1.75; 95% CI: 1.03–2.98), poor social support (AOR = 2.40; 95% CI: 1.17–
4.92), and living with single parent (AOR = 5.72; 95% CI: 2.98–10.99) were significantly associated with social phobia. Conclusion.
The proportion of social phobia was higher compared to previous evidences. School-based youth-friendly mental health services
might be helpful to tackle this problem.

1. Introduction

DSM-V defines social phobia as marked or intense fear or
anxiety of social situations in which the individual may be
scrutinized by others and this situation interferes significantly
with routines, occupational (academic) functioning, social
activities, and relationships [1]. Though it is a debilitating
psychiatric condition which is treatable, it often remains
undetected and untreated. Individuals will have reduced
quality of life, disturbed social interactions, poor daily func-
tioning, and poor treatment adherence for other medical or
psychiatric conditions [2–4].

The prevalence of social phobia among school adolescents
varied from country to country [5]. For instance, in high-
income countries, the magnitude ranges from 3.5% to 21% [6–
10]. Even though there is scarcity of evidence in developing
countries, the available literatures suggested that social pho-
bia is higher, which ranges from 10.3% to 27% [11, 12].

Students with social phobia have difficulty of speaking
in front of a group of people and fail or drop out of school
due to fear [13]. Students’ attention to academic information
may be distracted by an excessive focus on their anxiety
[14]. The ability to monitor and modify communication with
colleagues and teachers may be vague by fear of negative

Hindawi
Psychiatry Journal
Volume 2017, Article ID 5643136, 5 pages
https://doi.org/10.1155/2017/5643136

https://doi.org/10.1155/2017/5643136

2 Psychiatry Journal

evaluation and when participating in a seminar, socially
anxious students judge their competence poorly [15], which
leads to academic underachievement [16].

Evidences showed that social phobia was associated with
20% of cases of adult depression [17] and 17% of cases of alco-
hol and drug dependence [18]. Low socioeconomic status,
being unmarried, unemployment, low level of education, and
poor social support were identified as a risk factor for social
phobia [19]. Society’s attitude towards shyness and avoidance
as a measure of politeness is also an important factor associ-
ated with students’ ability to build social interaction [20].

Despite the high worldwide burden of social phobia,
limited evidence is available, particularly in developing coun-
tries. This study tried to assess factors (social support and
wealth index) which were previously not well addressed.
The purpose of this study was to assess the prevalence and
associated factors of social phobia among school adolescents
in Ethiopia.

2. Methods and Materials

School-based cross-sectional study was conducted at Woldia
preparatory school. A total of 1516 regular students in 11th and
12th grades in 2015 academic year were enrolled. The school is
located in Woldia town, Amhara regional state, 521 kilometers
away from Addis Ababa. There is one general hospital and two
health centers in the town. All students who were enrolled at
Woldia preparatory school in 2014/2015 academic year were
included in the study. The sample size for this study was
calculated by using single population proportion formula and
424 students were recruited randomly.

Social phobia was the dependent variable and the pre-
dictors were sociodemographic variables (sex, age, religion,
wealth index, relationship status, current living condition,
and origin of residence), clinical factors (past history of
psychiatric illness, past history of chronic medical illness,
and family history of mental illness), substance use (cigarette,
Khat chewing, and alcohol use), and social support. Khat
(also called Catha edulis) is a local green leaf plant which had
amphetamine-like stimulating effect after chewing due to the
active ingredient called cathinone.

Data was collected by pretested self-administered ques-
tionnaire and the data collection was facilitated by trained
data collectors and supervisors. Social phobia was assessed by
using the Social Phobia Inventory (SPIN) which is a 17-item
self-rating scale developed by Connor and his colleagues [21].
It shows the symptom domains of social phobia (fear, avoid-
ance, and physiological arousal) and appears to have reliable
and valid psychometric properties of screening social phobia
in adolescents and other populations [21–24]. It was rated
from 0 (not at all) to 4 (extremely) and the sum score ranged
from 0 to 68 [21]. A student with a score of 20 and above on
SPIN was considered as having social phobia.

Oslo 3-item social support scale was used to determine
the level of social support. The total score ranged from 3 to 14
and was categorized into poor support (3–8 scores), moderate
support (9–11 scores), and strong support (12–14 scores) [25].
Students’ substance use was explained by verbal report of
consuming of any alcohol, cigarette, and Khat in the previous

three months. Presence and absence of major illness (medical
or psychiatric) were also based on report of the participants.

Data were entered by Epi-Info 3.5.3 analyzed by SPSS-21
for Windows version. Factors association was done by run-
ning bivariate and multivariable logistic regression. Strength
of the association was presented by odds ratio with 95%
confidence interval and ? value <0.05 was used to identify statistically significant variables. Ethical clearance was obtained from Institutional Review Board (IRB) of University of Gondar and Amanuel Mental Specialized Hospital. Confidentiality of the participants was maintained by anonymous questionnaire. Participants were fully informed about the purposes of the study prior to the data collection and informed consent (assent) was obtained. 3. Results 3.1. Sociodemographic Characteristics of Respondents. A total of 424 students were included in the study, of which 386 completed the questionnaires with the response rate of 91.03%. 233 (60.4%) of the participants were males and 346 (89.6%) were between the ages of 16 and 19 years. The mean age of the respondents was 18.15± 1.24 years (Table 1). 3.2. Clinical and Psychosocial Characteristics of the Respon- dents. Fourteen (3.6%) students had past psychiatric history and 18 (4.7%) of them had family history of mental illness. About one-third of the participants reported that they did not use any mass media (Table 2). 3.3. Prevalence and Associated Factors of Social Phobia. The overall prevalence of social phobia was 27.5%. In multivari- able logistic regression analysis, sex, current use of alcohol, social support, and students raised by single parent were significantly associated with social phobia (Table 3). 4. Discussion The overall prevalence of social phobia was 27.5% and it was consistent with the study done elsewhere which was 26.5% [26]. However, the present study was higher than the study conducted in Nigeria, 9.4% [27], Swedish high school students, 21% [9], Iran, 6.2% [6], Delhi, 10.3% [11], and china, 14.1% [12], as well as the national comorbidity survey in USA, 9% [8]. It was also higher compared to a comparative study among high school students in Egypt, Saudi Arabia, and United Arab Emirates where the percentages were 13%, 9.8%, and 7.8%, respectively [28]. This discrepancy might be due to sociocultural differences between those countries and Ethiopia. For instance, in Ethiopia, shyness as a measure of politeness has been emphasized as a dominant cultural norm [23]. The other possible reason for this difference might be the tool used in the current study, which is nondiagnostic self- administered tool, and this might overestimate the prevalence of social phobia among students [21, 22, 24]. In this study, social phobia had significant association with sex, current alcohol drinking, social support, and stu- dents’ living status. In female students, the odds of having social phobia were 3 times more than those of male students Psychiatry Journal 3 Table 1: Sociodemographic distribution of the respondents (? = 386). Sociodemographic variables Frequency Percent Sex Male 233 60.4 Female 153 39.6 Age 16–19 346 89.6 >19 40 10.4

Relationship status
Single 350 90.4
Married 36 9.6

Ethnicity
Amhara 377 97.7
Others 9 2.3

Religion
Orthodox 304 78.8
Muslim 71 18.4
Protestant 11 2.8

Place of upbringing
Urban 236 61.1
Rural 150 38.9

Lived with
Both parents 267 69.2
Single parent 61 15.8
Relative/alone 58 15

Semester result (performance)
Low 236 61.2
Medium 119 30.8
High 31 8.0

Wealth index
Lowest (poor) 35 9.1
Second 151 39.1
Medium 46 11.9
Fourth 109 28.2
Highest (rich) 45 11.7

Note. Ethnicity (others) = Tigre, 6, and Afar, 3; performance (average
academic score): low≤70, medium = 70–84.99, and high≥85.

and this was supported by the study done in Poland [26] and
Baghdad [29]. The community’s perception towards shyness
and politeness as a measure of predominant cultural norm
might have high influence on female students’ social phobia
status [23]. Students who were current alcohol users were
about 2 times more likely to have social phobia as compared
with their counterparts. Students with social phobia tend
to engage themselves into heavy drinking and alcohol use
problems [30]. This finding was consistent with previous
studies conducted in Nigeria [27] and USA [10]. The students

Table 2: Clinical conditions of respondents (? = 386).

Variables Frequency (?) Percent (%)
Past psychiatric history
Yes 14 3.6
No 372 96.4

Family psychiatric history
Yes 18 4.7
No 368 95.3

Previous medical illness
Yes 37 9.6
No 349 90.4

Social support
Poor 65 16.8
Moderate 159 41.2
Strong 162 42.0

Using mass media
Yes 274 71.0
No 112 29.0

Using social media
Yes 220 57.0
No 166 43.0

Alcohol
Yes 135 34.9
No 251 65.1

probably use alcohol as self-medication for their fear and for
their concerns of negative evaluation by others [18].

Social support was another important factor associated
with social phobia. Students with poor and moderate social
support had about two times more odds to have social phobia
as compared with students who had strong social support and
the finding was in line with the study done in Iran [7]. Social
connectedness is important for the development of confi-
dence and positive social skills. In addition to poor social sup-
port, students who lived with single parent were more than 5
times more likely to have social phobia as compared with stu-
dents who lived or were raised by both parents. This finding
was supported by study done in Saudi Arabia [31]. However,
students’ media usage, wealth index, past psychiatric history,
and family history of mental illness did not show any
association with social phobia in this study.

5. Limitations of the Study

The first limitation of the study may be the fact that we used
nondiagnostic self-rating screening tool; the prevalence of
social phobia might be overestimated. The other limitation
is that we did not measure substance use by a standard tool
and consuming a substance for one day and daily use of a
substance were reported as substance use, and the association
may not be real if standard tool has been used. The last
limitation is our design which cannot show the direction of
association.

4 Psychiatry Journal

Table 3: Factors associated with social phobia.

Variables Social phobia COR (95% CI) AOR (95% CI)
Yes No

Sex
Male 41 192 1.00 1.00
Female 65 88 3.44 (2.17, 5.51) 3.10 (1.82,5.27)∗

Age (years)
16–19 102 244 3.76 (1.31, 10.84) 2.02 (.66, 6.26)
>19 4 36 1.00 1.00

Alcohol (current use)
Yes 47 88 1.74 (1.10, 2.75) 1.75 (1.03,2.98)∗∗

No 59 192 1.00 1.00
Psychiatric history

Yes 7 7 2.76 (.94, 8.06) 3.15 (.97, 10.29)
No 99 273 1.00 1.00

Social support
Poor 25 40 2.75 (1.45, 5.20) 2.40 (1.17,4.92)∗∗

Moderate 51 108 2.08 (1.24, 3.49) 2.14 (1.20,3.80)∗∗

Strong 30 132 1.00 1.00
Living status (students were raised by or lived with)

Both parents 53 214 1.00 1.00
Single parent 38 23 6.67 (3.67, 12.14) 5.72 (2.98,10.99)∗

Alone/others 15 43 1.41 (.73, 2.73) 1.86 (.91, 3.82)
Note:∗?< 0.001 and∗∗?< 0.05. 6. Conclusion The proportion of social phobia was higher which was predicted by female gender, current alcohol use, living with single parent, and having poor social support. School and community intervention on students’ alcohol use is impor- tant. Moreover, school-based youth-friendly mental health service might be very helpful to tackle this problem and to help students with this problem. Further longitudinal and interventional studies are needed to describe the longitudinal nature of the illness and to identify risk factors. Competing Interests All authors declared that they have no competing interests regarding the publication of this paper. Authors’ Contributions Kindie Mekuria conceived the original idea and partic- ipated in proposal development, data collection, analysis of the data, and preparation of the manuscript and in all stages of the project. Haregwoin Mulat, Habtamu Derajew, Tesfa Mekonen, Wubalem Fekadu, Amsalu Belete, Solomon Yimer, Getasew Legas, Melak Menberu, Asmamaw Getnet, and Simegnew Kibret participated in proposal development, design, analysis, interpretation of data, and preparation of the manuscript and in all stages of the research. Acknowledgments The authors would like to thank the study participants for their unlimited cooperation and Amanuel Mental Specialized Hospital for the financial support. They also would like to thank Woldia preparatory school staff members for their support during the data collection. References [1] American Psychiatric Association, “Anxiety disorders,” in Diag- nostic and Statistical Manual of Mental Disorders, American Psychiatric Association, Washington, DC, USA, 5th edition, 2013. [2] S. M. Valente, “Social phobia,” Journal of the American Psychi- atric Nurses Association, vol. 8, no. 3, pp. 67–75, 2002. [3] D. 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