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Prevalence of social anxiety disorder and its determinants in school going adolescents in rural population of Ramnagara district.

INTRODUCTION

The physiological development during adolescence or puberty leads to changes in emotional and physical reaction to the socio-environmental situations. There are evidence that the type of personality, type, moral support at home, interaction with peer group and physical activities lessens those emotional reactions and psychological disorders. Some of the problems will start as anxiety or phobia that are termed social anxiety disorder (SAD) at early or mid-adolescence phase and may remain for temporary duration. In some individuals, it may be more in severity that may disturb their routine activities. [1-3]

There are several methods and scales available to measure the SAD problems among school children and adolescents. [4,5] Based on these scales, it was assumed that the prevalence of severe SAD was 4.3-20% worldwide. [1,2,5,6] There are differences in rural and urban areas in the prevalence of SAD or social phobia among school children in India. The children are exposed to various kinds of electronic gadgets and virtual play games and social network or media. This kind of exposure will influence in an increase or reduce the problem is not really known, and early intervention is necessary to reduce the late effects of severe social phobia or SAD among school children. [3] This study was carried out with the objective to estimate the prevalence and determinants of SAD (social phobia) among school children aged 11-16 years in Sathanur, Ramnagara district, Karnataka.

MATERIALS AND METHODS

This community-based, cross-sectional, and descriptive study was conducted in the month of August 2016 among the school children studying 6-10th standard from randomly selected six schools in Sathanur, Hobli of Ramnagara district. The schools were three government and three privately owned. Children present on the days of the survey were included for the study and covered more than 90% of the students. The total number of 446 students were interviewed using a semi-structured oral questionnaire.

Informed consent was obtained from Headmaster/Principal of the schools before conducting study in premises. Data on sociodemographic factors, morbidity status, physical activity, yoga, and meditation were collected.

SAD (social phobia) was evaluated using social phobia inventory (SPIN) scale. The scale is rated over the past week and includes items assessing each of the symptom domains of SAD (fear, avoidance, and physiologic arousal). The SPIN is a 17-item self-rating scale with minimum score as "0" and maximum score as "68".

The information thus collected was entered into a spreadsheet using Microsoft Excel and analyzed with the help of Statistical Package for the Social Sciences (SPSS) version 18.0. The prevalence of social phobia was estimated. Chi-square test was applied to test the statistical association between SAD and age, gender, family type, and physical activity. ANOVA was applied to test the statistical association between age, gender and different grades of SAD.

The severity of SAD was categorized on scale as follows:

None: <20

Mild: 21-30

Moderate: 31-40

Severe: 41-50

Very severe: >50.

The students with severe SAD were referred for counselling and psychotherapy to the health-care facility.

RESULTS

There were 446 students from six selected schools, 232 were males, and 214 were females as shown in Table 1. Two-thirds of adolescents (66.6%) were in the age group of 11-13 years and one-third (33.4%) in the age group of 14-16 years. The mean age of the total adolescents was 12.9 ([+ or -] 1.2) years, among boys and girls was 12.8 ([+ or -] 1.1) years and 12.9 ([+ or -] 1.3), respectively.

The majority of the adolescents were from nuclear family, and nearly 90% of them had at least one sibling.

Table 2 shows 269 (60.3%) students were free from SAD with a cutoff score of 20 on the SPIN. The proportion of SAD prevalence was more in female adolescents (47.7%) with mean score of 20.14 ([+ or -] 10.7), and one-fourth of the adolescents had mild SAD. Out of 177 students with social phobia, seven students were found to be suffering from severe social phobia in the age group of 11-13 years.

The association was statistically significant with SAD prevalence and other variables except for number of siblings and physical activity. More number of adolescents aged 11-13 years are suffering from SAD and most of them were girls. The prevalence of SAD was showing decline as the number of family members is more as witnessed in different types of families. Irregularity or absence of playing games/ sports accounted high prevalence of SAD. The number of adolescents doing yoga were less, and the prevalence of SAD was high among them (Table 3).

Bivariate analysis of SAD was performed using variables such as age, siblings, type of family with regularly playing, and presence or absence of physical activity among males and females. Girls who were playing regularly but not having regular physical activity were two times more risk of having SAD when compared to those who were playing regularly. Girls having one or more siblings and who were playing regularly but not having regular physical activity were 2.21 times more risk of having SAD when compared to those who were playing regularly. Girls belonging to nuclear family and who were playing regularly but not having regular physical activity were 2.13 times more risk of having SAD when compared to those who were playing regularly (Table 4).

Multiple logistic regression analysis was used to predict the determinants of SAD after dichotomizing the SAD scores with cutoff score 20. Independent variables were dichotomised and were included in the univariate analysis. Variables which were significant in the univariate analysis were age, type of family, and yoga among males. All the three variables (age, type of family, and yoga) turned out to be significant in the multiple logistic regression analysis. Of these three variables, a greater change was seen in terms of odds ratio (OR) for yoga which decreased from 2.8 (1.46-5.51) to 0.3 (0.17-0.69) after adjusting for age and type of family. Type of family, playing sports/games, and physical activity was significant in the univariate analysis among females. Only one variable (type of family) turned out to be significant in the multiple logistic regression analysis and the adjusted OR was 0.39 (0.20-0.75) (Table 5).

DISCUSSION

Social phobia or SAD refers to an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to a particular situation or social interactions. It may manifest specific physical symptoms including sweating, blushing and difficulty in speaking. The extent to which the children suffer is determined by schooling, cultural factors, environmental and lifestyle prevalence.

The prevalence of SAD among rural adolescents was 39.7% (32.3% in males and 47.7% in females) by administering SPIN, and the mean scores without SAD and with SAD were 10.8 ([+ or -] 4.8) and 29.5 ([+ or -] 6.4), respectively. In our study, out of 39.7% of those screened to be positive for SAD, most belonged to the mild (24.2) and moderate (13.9) social anxiety category, the percentage of school going adolescents belonging to the severe (1.6), and very severe (0%) category was very less which might be due high absenteeism as these children often avoid social situations and high dropout rate among these students.

The prevalence and the mean score were less compared to the study by Soohinda and Sampath. [2] The prevalence was higher among females than males in this study which is similar to the findings of the other studies with a range of 9.6-16.5%. [1,4,7]

The incidence of social anxiety in the sample of the population of school going children under the age group 14-17 years to be 10.3% by liebowitz social anxiety scale. [4] The age distribution clearly showed that the level of social anxiety was higher in children in their early teens, standing at 11.9% in 14 years old, 17.0% in 15 years, 6.4% in 16 years, and 0% in 17 years old children (P < 0.05) and similar observation was found in our study.

Rakhee and Aparna in their study showed the prevalence of social anxiety was 15.6% using screen for child anxiety related disorders tool. They found a significant association between SAD and poor academic performance and limitation in involvement in extracurricular activities and no association of SAD with the type of family, number of siblings, birth order and parents educational and vocational status was found. [5]

The limitation of the study is that some determinants such as financial status, socioeconomic and cultural factors and academic performance of the students were not assessed which could have had impact on SAD. The strength of this study is that it was based on "rural adolescents".

This study was carried out among adolescents of the rural area to know the prevalence of SAD and associated factors. This study highlights the necessities of counseling facilities in the school or nearby health facilities after identification of early manifestations.

CONCLUSION

The prevalence of SAD was 39.7%, and one-fourth of the adolescents had mild grade SAD. It was more in the female adolescents (47.7%) and age group of 11-13 years (43.4%). The important determinants of SAD were age, type of family, and yoga. Parents and teachers should be aware of SAD and children should be screened for SAD at earlier stage for counseling or treatment.

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Website: http://www.ijmsph.com

DOI: 10.5455/ijmsph.2017.0513413062017

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ACKNOWLEDGMENT

The authors sincerely thank Dr. Rohan Philip Varghese, Dr. Reshma C Patil, Dr. Ashish Chandra V, Dr. Srinidhi Murthy, Dr. Ramkishore E.S, Dr. Pallavi D, Dr. Niveditha M of Dr. B. R. Ambedkar Medical College for helping in collection of information from school children and acting as a liaison staff.

REFERENCES

[1.] Kumar P, Babu N, Anandan H, Sathyamurthi B. A study to screen social anxiety disorder among higher secondary school students. Indian J Res. 2016; 5(5):545-6.

[2.] Soohinda G, Sampath H. Social phobia among school students--Prevalence, demographic correlates and socioacademic impairment. J Indian Assoc Child Adolesc Ment Health. 2016; 12(3):211-29.

[3.] Sharan P, Sagar R. The need for national data on epidemiology of child and adolescent mental disorders. J Indian Assoc Child Adolesc Ment Health. 2008; 4(2):22-7.

[4.] Chhabra V, Bhatia MS, Gupta S, Kumar P, Srivastava S. Prevalence of social phobia in school-going adolescents in an urban area. Delhi Psychiatry J. 2009; 12(1):18-25.

[5.] Rakhee AS, Aparna N. A study on the prevalance of anxiety disorders among higher secondary students. GESJ Educ Sci Psychol. 2011; 1(18):33-7.

[6.] Uzonwanne FC. Prevalence of social phobia, gender and school type among young adults in Nigerian universities. Int J Soc sci Humanit Res. 2014; 2(8):36-45.

[7.] Nair MK, Russell PS, Mammen P, Abhiram Chandran R, Krishnan R, Nazeema S, et al. ADad 3: The epidemiology of anxiety disorders among adolescents in a rural community population in India. Indian J Pediatr. 2013; 80 Suppl 2:S144-8.

Source of Support: Nil, Conflict of Interest: None declared.

Archana S, Prasad K N, Bushra Jabeen

Department of Community Medicine, Dr. B. R. Ambedkar Medical College, Bengaluru, Karnataka, India Correspondence to: Archana S, E-mail: archanadr987@gmail.com

Received: May 19, 2017; Accepted: June 13, 2017
Table 1: Sociodemographic factors of the study
population

Variables                     n (%)

Age group (years)
  11-13                     297 (66.6)
  14-16                     149 (33.4)
Gender
  Male                      232 (52.0)
  Female                    214 (47.9)
Family type
  Nuclear family            319 (71.5)
  Joint family               43 (9.6)
  Three generation family   84 (18.8)
Number of siblings
  None                       41 (9.2)
  One or more               405 (90.8)

Table 2: Age and gender wise distribution of SAD score

Factors                                 n (%)

                 None ([less than    Mild SAD     Moderate
                 or equal to] 20)    (21-30)     SAD (31-40)

Age in years
  11-13             168 (56.6)      72 (24.2)     50 (16.8)
  14-16             101 (67.8)      36 (24.2)     12 (8.0)
  Total             269 (60.3)      108 (24.2)    62 (13.9)
P value--0.011
Gender
  Male              157 (67.7)      47 (20.3)     25 (10.8)
  Female            112 (52.3)      61 (28.5)     37 (17.3)
  Total             269 (60.3)      108 (24.2)    62 (13.9)
P value--0.011

Factors                        n (%)                 Mean score
                                                    ([+ or -] SD)
                    Severe SAD        Total
                  ([greater than
                 or equal to] 41)
Age in years
  11-13              7 (2.4)        297 (100)   19.14 ([+ or -] 11.2)
  14-16               0 (0)         149 (100)   16.43 ([+ or -] 9.3)
  Total              7 (1.6)        446 (100)   18.23 ([+ or -] 10.7)
P value--0.011
Gender
  Male               3 (1.3)        232 (100)   16.48 ([+ or -] 10.4)
  Female             4 (1.9)        214 (100)   20.14 ([+ or -] 10.7)
  Total              7 (1.6)        446 (100)   18.23 ([+ or -] 10.7)
P value--0.011

P value was estimated using ANOVA. SD: Standard deviation, SAD:
Social anxiety disorder

Table 3: Sociodemographic factors and physical activities of
students with and without SAD

Factors                                  n (%)                P value

                           SAD          SAD         Total
                         present       absent
Age in years
  11-13                 129 (43.4)   168 (56.6)   297 (100)    0.022
  14-16                 48 (32.2)    101 (67.8)   149 (100)
Gender
  Male                  75 (32.3)    157 (67.7)   232 (100)    0.001
  Female                102 (47.7)   112 (52.3)   214 (100)
Family type
  Nuclear family        147 (46.1)   172 (53.9)   319 (100)   <0.001
  Joint family          11 (25.6)    32 (74.4)    43 (100)
  3 Generation          19 (22.6)    65 (77.4)    84 (100)
  family
Number of siblings
  One or more           159 (39.3)   246 (60.7)   405 (100)    0.563
  None                  18 (43.9)    23 (56.1)    41 (100)
Playing sports/ games
  Regularly             158 (38.2)   256 (61.8)   414 (100)    0.018
  Irregularly           19 (59.4)    13 (40.6)    32 (100)
Yoga
  Yes                   33 (28.7)    82 (71.3)    115 (100)    0.005
  No                    144 (43.5)   187 (56.5)   331 (100)
Meditation
  Yes                    8 (72.7)     3 (27.3)    11 (100)     0.023
  No                    169 (38.9)   266 (61.1)   435 (100)
Physical activity
  Yes                   85 (40.5)    125 (59.5)   210 (100)    0.748
  No                    92 (39.0)    144 (61.0)   236 (100)
  Total                 177 (39.7)   269 (60.3)   446 (100)

SAD: Social anxiety disorder

Table 4: Bivariate analysis of SAD among adolescents playing
regularly

Factors               Levels                     Male

                               SAD present   SAD absent     OR

Gender
 Physical activity     Yes      32 (28.3)    81 (71.7)      1
 Physical activity      No      39 (35.1)    72 (64.9)     0.73
 Total                          71 (31.7)    153 (68.3)
Age
11-13
 Physical activity     Yes      29 (36.7)    50 (63.3)      1
 Physical activity      No       27 (36)      48 (64)      1.03
 Total                          56 (36.4)    98 (63.6)
14-16
 Physical activity     Yes       3 (8.8)     31 (91.2)      1
 Physical activity      No      12 (33.3)    24 (66.7)    0.19 *
 Total                          15 (21.4)    55 (78.6)
Siblings none
 Physical activity     Yes       3 (30)        7 (70)       1
 Physical activity      No       4 (40)        6 (60)      0.64
 Total                           7 (35)       13 (65)
One or more
 Physical activity     Yes      29 (28.2)    74 (71.8)      1
 Physical activity      No      35 (34.7)    66 (65.3)     0.74
 Total                          64 (31.4)    140 (68.6)
Family type nuclear
 Physical activity     Yes      27 (35.5)    49 (64.5)      1
 Physical activity      No       32 (40)      48 (60)      0.83
 Total                          59 (37.8)    97 (62.2)
Nonnuclear
 Physical activity     Yes       5(13.5)     32 (86.5)      1
 Physical activity      No      7 (22.6)     24 (77.4)     0.54
 Total                          12 (17.6)    56 (82.4)

Factors                                Female

                      SAD present   SAD absent     OR

Gender
 Physical activity     48 (55.2)    39 (44.8)      1
 Physical activity     39 (37.9)    64 (62.1)    2.02 *
 Total                 87 (45.8)    103 (54.2)
Age
11-13
 Physical activity     36 (57.1)    27 (42.9)      1
 Physical activity     26 (41.9)    36 (58.1)     1.85
 Total                 62 (49.6)    63 (50.4)
14-16
 Physical activity      12 (50)      12 (50)       1
 Physical activity     13 (31.7)    28 (68.3)     2.15
 Total                 25 (38.5)    40 (61.5)
Siblings none
 Physical activity         0         3 (100)       1
 Physical activity      4 (40)        6 (60)
 Total                 4 (30.8)      9 (69.2)
One or more
 Physical activity     48 (57.1)    36 (42.9)      1
 Physical activity     35 (37.6)    58 (62.4)    2.21 *
 Total                 83 (46.9)    94 (53.1)
Family type nuclear
 Physical activity     43 (62.3)    26 (37.7)      1
 Physical activity     31 (43.7)    40 (56.3)    2.13 *
 Total                 74 (52.9)    66 (47.1)
Nonnuclear
 Physical activity     5 (27.8)     13 (72.2)      1
 Physical activity      8 (25)       24 (75)      1.15
 Total                  13 (26)      37 (74)

SAD: Social anxiety disorder, OR: Odds ratio, * P < 0.05
significant

Table 5: Multiple logistic regression analysis of SAD

Factor                 Level                Unadjusted OR

Males
Age in years           11-13                    0.46
                       14-16
Sibling                None                     0.82
                       One or more
Family type            Nuclear                  0.35
                       Non-nuclear
Playing sports/games   Irregular                2.15
                       Regular
Yoga                   No                       2.84
                       Yes
Meditation             No                       0.47
                       Yes
Physical activity      No                       1.43
                       Yes
Females
Age in years           11-13                    0.73
                       14-16
Sibling                None                     0.80
                       One or more
Family type            Nuclear family           0.39
                       Non-nuclear family
Playing sports/games   Irregular                1.97
                       Regular
Yoga                   No                       0.95
                       Yes
Meditation             No
                       Yes
Physical activity      No                       0.577
                       Yes

Factor                 Level                  95% CI      P value

Males
Age in years           11-13                 0.24-0.88     0.018
                       14-16
Sibling                None                  0.33-2.05     0.671
                       One or more
Family type            Nuclear               0.18-0.69     0.002
                       Non-nuclear
Playing sports/games   Irregular             0.52-8.86     0.287
                       Regular
Yoga                   No                    1.46-5.52     0.002
                       Yes
Meditation             No                    0.09-2.37     0.359
                       Yes
Physical activity      No                    0.82-2.48     0.207
                       Yes
Females
Age in years           11-13                 0.42-1.29     0.283
                       14-16
Sibling                None                  0.31-2.06     0.650
                       One or more
Family type            Nuclear family        0.20-0.75     0.005
                       Non-nuclear family
Playing sports/games   Irregular             0.82-4.73     0.128
                       Regular
Yoga                   No                    0.47-1.90     0.884
                       Yes
Meditation             No                                  0.999
                       Yes
Physical activity      No                   0.335-0.995    0.048
                       Yes

Factor                 Level                Adjusted OR     95% CI

Males
Age in years           11-13                   0.43       0.22--0.85
                       14-16                     1
Sibling                None                     --            --
                       One or more
Family type            Nuclear                 0.32       0.16--0.65
                       Non-nuclear               1
Playing sports/games   Irregular                --            --
                       Regular
Yoga                   No                      0.35       0.18--0.69
                       Yes                       1
Meditation             No                       --            --
                       Yes
Physical activity      No                       --            --
                       Yes
Females
Age in years           11-13                    --            --
                       14-16
Sibling                None                     --            --
                       One or more
Family type            Nuclear family          0.39       0.20--0.75
                       Non-nuclear family        1
Playing sports/games   Irregular                --            --
                       Regular
Yoga                   No                       --            --
                       Yes
Meditation             No                       --            --
                       Yes
Physical activity      No                       --            --
                       Yes

Factor                 Level                P value

Males
Age in years           11-13                 0.014
                       14-16
Sibling                None                   --
                       One or more
Family type            Nuclear               0.002
                       Non-nuclear
Playing sports/games   Irregular              --
                       Regular
Yoga                   No                    0.003
                       Yes
Meditation             No                     --
                       Yes
Physical activity      No                     --
                       Yes
Females
Age in years           11-13                  --
                       14-16
Sibling                None                   --
                       One or more
Family type            Nuclear family        0.005
                       Non-nuclear family
Playing sports/games   Irregular              --
                       Regular
Yoga                   No                     --
                       Yes
Meditation             No                     --
                       Yes
Physical activity      No                     --
                       Yes

CI: Confidence interval, OR: Odds ratio, SAD: Social anxiety
disorder
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Title Annotation:Research Article; Ramnagara, India
Author:Archana, S.; Prasad, K.N.; Jabeen, Bushra
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Geographic Code:9INDI
Date:Aug 1, 2017
Words:3204
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