Social Anxiety

O R I G I N A L R E S E A R C H

Social Phobia and Its Impact on Quality of Life

Among Regular Undergraduate Students of Mettu

University, Mettu, Ethiopia This article was published in the following Dove Press journal:

Adolescent Health, Medicine and Therapeutics

Mohammedamin Hajure

Zakir Abdu

Department of Psychiatry, Mettu

University, Mettu, Oromia, Ethiopia

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Background: Social anxiety disorder is a serious and disabling mental health problem that

begins before or during adolescence, with the potential to significantly interfere with an

individual’s daily functioning and overall quality of life.

Objective: The aims of this study were to assess the prevalence, severity, and quality of life

towards social anxiety disorder among students of Mettu University, Ethiopia.

Subjects and Methods: A cross-sectional study was conducted among a stratified sample

of 523 undergraduate students to identify the prevalence, correlates of social anxiety dis-

order, and impacts on quality life. All participants completed the Social Phobia Inventory,

Liebowitz Social Anxiety Scale, and World Health Organization Quality of Life-Brief Form,

Turkish Version (WHOQOL-BREF-TR). Of 523 students, 26% were screened positive for

social anxiety disorder. About 69.4% and 17.4% of the students had mild and moderate

symptoms of social anxiety disorder, respectively. WHOQOL BREF-TR scores showed that

students with social phobia had significantly lower quality of life quality than those without

social phobia. Being criticized by others or fear of parties was the most commonly feared

situations. Talking to strangers was the most commonly avoided situations. Being females,

current tobacco use, and family history of psychiatric illness were factors significantly

associated with social phobia symptoms using logistic regression analysis.

Conclusion: The current study shows high prevalence of social phobia among the university

students and its significant negative effects on quality of life which require prompt identi-

fication and treatment.

Keywords: social anxiety, university, quality of life

Background Social phobia or social anxiety disorder is a serious and disabling mental health

problem that begins before or during adolescence, has a chronic course, is asso-

ciated with significant impairment in social functioning and work, and reduced

quality of life.1 Among university, social phobia symptoms arise in a great number

of students or existing symptoms increase.2 During this period, students go into the

effort of having himself or herself accepted by others as a self-governing person

and showing himself or herself. Performing or giving a talk in front of an audience

was the most commonly feared situations and also showed an association with

increased disability, and impaired quality of life.3,4

It is generally estimated that 13% of the population will meet the diagnostic criteria

for lifetime social phobia with onset typically occurring in adolescence or early

Correspondence: Mohammedamin Hajure Email [email protected]

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adulthood.5 However, recent studies suggest that lifetime

prevalence rates may be much higher.6,7 After major depres-

sion disorder and alcohol dependence, social anxiety disorder

is the third most common disorder in the general population

and it is also the most prevalent anxiety disorder.8

A cross-sectional study conducted in Swedish, Jordan

University, Saudi Arabia (2014), and University of

Parakuo students showed that about 9–16.1% of partici-

pants were positive of social phobia.9–12 Research con-

ducted in Nigeria shows SAD in about 9.4% which states

that there will be a significant difference in the phobic

health of adolescents in the selected private and public

Nigerian universities.13

In Ethiopia, research conducted on prevalence of social

phobia among high school students in Woldia, Gondar and

Hawassa was 27.5%, 31.2%, 32.8%.14–16 Factors have shown

to have an association include being the first or only child,17

medical science faculties,18,19 being female, younger age, reli-

gion, marital status (unmarried), the presence psychiatric ill-

ness, having a positive family history of mental disorder had

a significant role for development of social phobia.16,20

Evidence showed that social phobia was associated with sub-

stance use,21 low socioeconomic status, unemployment, low

level of education, and social support.22 Also decreased aca-

demic achievement, poor clinical exam performance,11 and

impaired quality of life23 also shown to have associated with

social phobia.

Despite the high worldwide burden of social phobia,

like shy, withdraw, unfriendly, and disinterested in social

activity and limited evidence is available, particularly in

developing countries. To the best of the author’s knowl-

edge, no study has investigated the effects of social phobia

on quality of life in Ethiopia. The present study aimed to

determine the prevalence of social phobia among univer-

sity students, its correlate, and impacts on quality of life.

Subjects and Methods An institution based cross-sectional study conducted at Mettu

University from May to April, 2019. Mettu University is one

of the higher institutions in Ethiopia, which is a third

Generation University. It is located at 600 km southwest of

Addis Ababa. Mettu University established in 2011. Mettu

University currently has two campuses. Main campus was

study area containing 7 faculties. Those are faculty of health

science, faculty of natural and computational science, faculty

of social science and Humanity, school of law. The campus has

a total of 43 departments and 8290 regular undergraduate

students.

This study included 8290 undergraduate students at

Mettu University during the 2019–2020 academic years.

Using a confidence interval of 95%, 5% margin of error,

design effect of 2, the prevalence of social phobia of

19.9%16 and adding 10% non-response rate of 10%, mak-

ing a final number of participants to be 523. As such, 523

students were selected as the study group.

A study is part of a mega project undertaken in among

regular undergraduate students of Mettu University and

previously published study assessing suicidal behavior

among this population were also part of the project.24

Multistage stratified sampling technique was used to

select the study participants. Stratification was first done

on the faculty/college level, then by department and by

the year of study. Finally, taking students from registration

as a sampling frame a random selection was done. All

regular undergraduate students aged 18yrs old and above

were included, while critically ill students were excluded.

A self-administered structured questionnaire was used

to collect information. Questionnaires about demographic,

family and campus related and clinical factors were devel-

oped after an extensive review of literatures and similar

study tools. Rating instruments included the Social Phobia

Inventory to detect Social Phobia, the Liebowitz Social

Anxiety Scale to measure the severity of Social Phobia

and the WHO Quality of Life – BREF questionnaire to

assess Quality of Life. The questionnaire was translated to

Amharic and Afaan Oromo language, and then retranslated

back to English so as to see and keep the consistency.

Pretest was done on 26 students in Bedele agricultural

campus whose completed the questionnaires beforehand

and the questions were evaluated and re-arranged accord-

ingly before actual data collection.

Ethical clearance was obtained from the ethical review

board of Mettu University and permission was obtained

from the concerned body.

Rating Instruments Social Phobia Inventory (SPIN, a 17-item self-rating scale

developed to measure social phobia). It shows the symp-

tom domains of social phobia (fear, avoidance, and phy-

siological arousal) and has reliable and valid psychometric

properties in screening social phobia in adolescents and

other populations. The Cronbach’s α in this study was 0.87. Subjects are asked to rate symptoms occurrences as

0 (not at all), 1 (a little bit), 2 (somewhat), 3 (very much),

or 4 (extremely during the past week) and the sum score

ranged from 0 to 68. A student with a score of 20 and

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above on SPIN will be considered as having social

phobia.25

Liebowitz Social Anxiety Scale is a self-rating scale

used to rate fear/anxiety and avoidance regarding com-

monly feared performance or social situations. The scale

includes 24 items and 2 subscales. The first subscale has

11 items and investigates social relationships. The second

subscale has 13 items and investigates performance. The

4-point Likert-type scale measures the intensity of fear and

avoidance behaviour during the previous week. It has

a good internal consistency and evaluates the severity of

fear and avoidance in common social situations. A score of

<55 suggests mild social anxiety disorder, 55–64 suggests

the moderate social anxiety disorder, 65–79 suggests

marked social anxiety disorder, 80–94 suggests severe

social anxiety disorder, and >95 suggests very severe

social anxiety disorder. It is validated in and reliable for

measuring the severity of social phobia26. The Cronbach’s

α in this study was 0.98. World Health Organization Quality of Life Scale –

Brief version (WHOQOL – BREF) which is a 26-item self-

administered generic questionnaire. It produces a profile

with four domain scores: physical health (7 items), psy-

chological health (6 items), social relationships (3 items),

environmental domain (8 items) as well as two separately

scored items about the individuals‟ perception of their

quality of life (QI) and health (Q2). Each item was scored

in a Likert format from 1 (very dissatisfied) to 5 (very

satisfied) in a positive direction, which means that higher

scores indicate a higher quality of life. The scores of ques-

tions 3, 4 and 26 are reversed, so as to transform these

negatively framed questions to positively frame. The

Turkish version of the form had an internal validity score

of 0.83 (Cronbach’s alpha) in physical terms, 0.66 in men-

tal terms, 0.53 in social terms, and 0.73 in both environ-

mental and environment-national terms27. The Cronbach’s

α in this study was 0.82

Statistical Analysis The data were analyzed using SPSS version 21. Descriptive

(frequency and percentage) and inferential statistics (chi

square test was used for categorical variables, and ANOVA

(analysis of variance) were used to compare groups in terms

of SPIN and LSAS scores).

An independent samples t-test was used to analyze the

difference between the two groups (students with/without

social anxiety disorder). Logistical regression analysis was

used to evaluate the significance of the relationship between

two dependent and independent variables. The Pearson cor-

relation coefficient was used for correlation analysis.

Result Socio-Demographic Characteristics of

the Study Participants A total of 523 participants were recruited for the study,

which makes the response rate 100%. The results show

that 270 (51.6%) of respondents were males and 253

(48.6%) were females. The mean age of students was

22.07 (SD = 2.36), with ages ranging from 18 to 32

years and the majority of them (61.0%) were at the age

of 22 years or below. The sample consisted of different

faculties with the highest number of engineering faculty

(110, 21.0%) and the lowest number from Institute of

education (42, 8.0%) which was proportionally recruited

from each stratum. Also the study has revealed that 351

(67.1%) of the participants had one of two siblings and

most perceived that their family income as bad (58.9%).

The majority of the participants 319 (61.0%) were from

rural backgrounds and first-year students comprises the

majority of participants (222, 42.4%) (Table 1).

Social Phobia The regarding students’ reports of their social phobia

symptoms, the analysis (Table 2) showed that the mean

score for students in general was 13.08 (SD = 9.24), with

scores ranging from 0 to 43. About, 70% (n = 361) had

a score of 16 or less.

Further analysis using LSAS score, for the levels of

social anxiety symptoms showed that the majority of uni-

versity students had mild symptoms, 69.4% (n = 363)

followed by moderate symptoms 91 (17.4%), and those

with marked to severe represented about 13.2% (n = 69).

The Cronbach’s alpha for LSAS scale obtained in this

sample was 0.976.

As shown in Table 2, 25.8% of the subjects had a SPIN

score of 19 (Connor et al, 2000), and more which accounted

for about one-fourth of participants, ie, There was

a statistically significant difference in the prevalence of

SAD regarding the age category, birth order, faculties, family

history of mental illness. Being a younger age18–20 group was

associated with higher prevalence of SAD (26.7%) and being

in the age group of 21–23years was associated with lower

prevalence of SAD (9.6%) (X2= 0.24, P<0.05). There is

a higher prevalence of SAD among students in Engineering

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faculties, while lower prevalence is seen in the faculty of

social science and humanities (X2=0.163, P<0.05).

The results of the present study show that significantly

more of the students without social phobia have a family

history of psychiatric illness than those with social phobia.

Table 1 The Basic Sociodemographic, Clinical and Substance Use Characteristics of the Participants (n= 523)

Variables Categories Frequency Percentage

Sex Male 270 51.6

Female 253 48.6

Age 18–20 148 28.3

21–23 87 16.6

24–26 149 28.5

≥27 139 26.6

Ethnicity Oromo 321 61.4

Amhara 117 22.4

Gurage 41 7.8

Tigre 25 4.8

Others* 19 3.6

Faculty Engineering 110 21.0

Health sciences 97 18.5

Social science and

humanities

85 16.3

Natural and

computational

89 17.0

Business and

economics

52 9.9

School of Law 48 9.2

Institute of

education

42 8.0

Residence

before campus

Urban 204 39.0

Rural 319 61.0

Birth order Frist or only child 123 23.5

Middle 320 61.2

Last 80 15.3

Year of study First 130 24.9

Second 133 25.4

Third 107 20.5

Fourth 77 14.7

Fifth 76 14.5

Alcohol use Yes 299 57.4

No 127 42.5

Cigarette use Yes 78 14.9

No 53 67.9

Khat use Yes 98 18.3

No 67 68.4

Note: *Wolayta, Dawuro, Kefa, Sidama, Gurage, Silte.

Table 2 Comparing Social Phobia with Demographic and Clinical Variables

Variables Categories Frequency Percentage

Sex Male 270 51.6

Female 253 48.6

Age 18–20 148 28.3

21–23 87 16.6

24–26 149 28.5

≥27 139 26.6

Ethnicity Oromo 321 61.4

Amhara 117 22.4

Gurage 41 7.8

Tigre 25 4.8

Others* 19 3.6

Faculty Engineering 110 21.0

Health sciences 97 18.5

Social science

and humanities

85 16.3

Natural and

computational

89 17.0

Business and

economics

52 9.9

School of Law 48 9.2

Institute of

education

42 8.0

Residence before

campus

Urban 204 39.0

Rural 319 61.0

No. of siblings Mean ±SD (1.98±1.16)

Birth order Frist or only

child

123 23.5

Middle 320 61.2

Last 80 15.3

Fathers education No formal

education

50 9.6

Primary school 217 41.5

Secondary

school

137 26.2

Above

secondary

119 22.8

Mothers’

education

No formal

education

62 11.9

Primary school 187 35.8

Secondary

school

235 44.9

Above

secondary

39 7.5

Perceived family

monthly income

Bad 308 58.9

Moderate 127 24.3

(Continued)

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However, with respect to gender, ethnicity, year of study,

family educational status, perceived family income, and

residency, there was no statistically significant difference

in the prevalence of SAD (all P values >0.05).

Using logistical regression analysis, three independent

variables that were significantly shown to have association

in the final model. The risk of social phobia was 1. Ninety-

five-fold higher among female students than male students, 1.

Eighty-four-fold higher among those with a family history of

psychiatric illness than those without, and 2. Ninety-five-fold

higher among students who smoked cigarettes in the past

3months compared to those who did not (Table 3).

Using item analysis to examine the items that had the

highest and lowest scores (Table 4), the analysis showed

that the mean items ranged from 0.56 (SD = 0.81) (item

13: Heart palpitations bother me when I am around peo-

ple) to 0.99 (SD = 1.07) (item 2: I am bothered by blush-

ing in front of people).

The highest three items in addition to item 2 were item

10 (M = 0.96, SD = 1.10: Talking to strangers scares me)

and item 7 (M = 0.85, SD = 1.009: Sweating in front of

people causes me distress). This also goes for the highest

three items that students reported being very much to

extremely experiencing social phobia symptoms over the

past week as items 2, 10, and 7 had the highest percentage

among all other items.

Table 2 (Continued).

Variables Categories Frequency Percentage

Good 88 16.8

Year of study First 130 24.9

Second 133 25.4

Third 107 20.5

Fourth 77 14.7

Fifth 76 14.5

Alcohol use Yes 299 57.4

No 127 42.5

Cigarette use Yes 78 14.9

No 53 67.9

Khat use Yes 98 18.3

No 67 68.4

Note: *Wolayta, Dawuro, Kefa, Sidama, Gurage, Silte.

Table 3 Logistical Regression Analysis Showing Factors Associated with Social Phobia Among Students in Mettu Health

Science Students, Mettu, Ethiopia, 2019 (n=523)

Variables Category COR (95% CI) AOR (95% CI)

Sex Male ®

Female

1.78 (1.20–2.64) 2.04 (1.26–3.28)*

Previous history of

chronic physical

illness

No ®

Yes

1.83 (1.02–3.30) 1.84 (1.01–3.35)*

Current tobacco

use

No ®

Yes

1.27 (.74–2.2) 2.95 (1.36–6.40)**

Lifetime khat use No ®

Yes

1.99 (1.00–3.99) 1.52 (0.68–3.37)

Residence Urban ®

Rural

4.52 (2.69–7.7) 1.24 (.494–3.12)

Notes: *P value < 0.05, **P value < 0.01, VIF 1.06–2.10. Hosmer–Lemeshow - goodness of fit test corresponding, P value = 0.77, Reference =

® .

Abbreviations: COR, crude odds ratio; AOR, adjusted odds ratio.

Table 4 Item Analysis of SPIN Among University Student in Mettu (n= 523)

Item Mean SD

1 I am afraid of people in authority. 0.68 0.976

2 I am bothered by blushing in front of people. 0.99 1.073

3 Parties and social events scare me. 0.82 0.957

4 I avoid talking to people I do not know. 0.75 0.961

5 Being criticized scares me a lot. 0.85 0.959

6 Fear of embarrassment causes me to avoid doing

things or speaking to people.

0.80 0.921

7 Sweating in front of people causes me distress. 0.85 1.009

8 I avoid going to parties. 0.79 0.892

9 I avoid activities in which I am the center of attention. 0.79 0.993

10 Talking to strangers scares me. 0.96 1.109

11 I avoid having to give speeches. 0.83 0.990

12 I would do anything to avoid being criticized. 0.65 0.925

13 Heart palpitations bother me when I am around

people.

0.56 0.811

14 I am afraid of doing things when people might be

Watching.

0.59 0.885

15 Being embarrassed or looking stupid is my worst

fears.

0.67 0.931

16 I avoid speaking to anyone in authority. 0.72 0.888

17 Trembling or shaking in front of others is distressing

to me.

0.78 0.955

Notes: Copyright ©, Jonathan Davidson. 1995, 2008, 2015. All rights reserved. Permission to use the SPIN must be obtained from the copyright holder at

[email protected]. The SPIN may not be reproduced or transmitted in any form,

or by any means, electronic or mechanical, or by any information storage or

retrieval system without permission in writing from the copyright holder.

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The highest mean item scores varied among the two

subscales (more among physiological discomfort) and also,

two of lowest mean item scores (item 1,14) belong to fear of

the social situation subscale. The results do not strictly

support the mean scores of the subscales mentioned above

in Table 2 that physiological discomfort in social situation

was the lowest reported subscale among the three subscales.

The Cronbach’s alpha for SPIN scale obtained in this study

sample was 0.869. Generally, about one-fourth of the stu-

dents showed positive symptoms of social phobia (score of

>19) and the majority of them present with mild category.

Quality of Life of Students with and

Without Social Phobia Study participants’ quality of life was assessed by the

world health organization quality of life brief version

scale (WHOQOL-BREF) and the mean total quality of

life score was found to be (70.87+16.22). The highest

QOL domain of the students with social phobia in the

current study was environmental health domain mean

score of (23.55 ± 3.46), followed by physical health

domain mean score of (22.34±3.76), psychological health

domain mean score of (17.67±2.62) and social relation-

ships domain mean score of (6.87±2.27). The WHOQOL-

BREF scale demonstrated a high internal consistency

reliability coefficient (Cronbach’s alpha=0.821).

WHOQOL-BREF-TR scores showed that students with-

out social phobia had significantly higher quality of life scores

in all areas than the students with social phobia (Table 5).

Correlating SPIN and LSAS with QOL

Scores As seen in Table 6. Regarding correlation of LSAS scores

to QOL scores, they were negatively correlated with

respect to physical health, psychological health, social

relationship and environment, although not significant in

majority of the domains, except the psychological domain.

Again, SPIN scores were also negatively correlated

with QOL scores in all areas. Thus, social phobia was

associated with reported deterioration in physical, psycho-

logical health, social relationship and environmental func-

tioning. SPIN and LSAS scores were found to be more

strongly correlated with psychological domain scores and

SPIN score were more strongly correlated with physical

health domain compared to other domain (Table 6).

Discussion This study aims on the prevalence of social phobia and its

impact on quality of life among university students in

Mettu, South western, Ethiopia. The prevalence of social

phobia varies widely among different countries. In this

study, social phobia was found in 26% of subjects, much

more than other studies among undergraduate university

students in different settings.18,28-31 Regarding the severity

of social phobia, using LSAS score, the majority of the

students have mild forms of social anxiety disorder. In

other words, levels of social anxiety symptoms show

about 17.4% of them had moderate symptoms, which is

in line with the study undertaken at the University of

Jordan (6.8%). However, the finding was lower than

study done in Woldia, Ethiopia (27.5%),15 Saudi Arabia,

Table 5 Mean Distribution of QOL of Students with and Without Social Phobia at Mettu University, 2019

Areas Students with

Social Phobia

(χ ± SD)

Students

Without Social

Phobia (χ ± SD)

Analysis*

T P

Physical 22.34±3.76 21.55±4.49 −1.821 < 0.01

Psychological 17.67±2.62 16.03±4.03 −4.42 < 0.001

Social 6.87±2.27 5.59±2.93 −4.59 < 0.001

Environmental 23.55±3.46 22.01±5.02 −3.32 < 0.001

Notes: ANOVA, χ ± SD (arithmetic mean ± standard deviation). *For all analyses the degree of freedom was 522.

Abbreviation: QOL, quality of life.

Table 6 Correlating SPIN and LSAS with QOL Scores

Instrument Domain of Quality of Life

Physical Health Psychological Health Social Relationship Environmental

LSAS score R −0.010 −0.168 −0.019 −0.053

P value 0.820 0.000 0.662 0.227

SPIN score r −0.199 −0.102 −0.082 −0.013

P value 0.000 0.020 0.062 0.768

Note: r = Pearson correlation coefficient. Abbreviations: SPIN, Social Phobia Inventory; LSAS, Liebowitz Social Anxiety Scale; QOL, quality of life.

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Riyadh (24.3%).32 Different studies have shown an asso-

ciation of social phobia with gender. The results of the

current study, which showed higher social phobia scores of

female students compared to their counterparts. This was

in line with the international report of different countries

such as India,11 Turkey,33 German.3 However, in one study

social phobia prevalence is found to be higher in men in

studies of prevalence conducted with clinical samples.34

The current study shows an association of cigarette

smoking and social anxiety disorder. This finding was in

agreement with international report such as in the USA35

and Turkey.36 The reason behind might be related to

smoking, which used for its reinforcing effect, by socially

anxious people to elevated negative affect especially for

social interaction.37

In contrast to studies done in Australia18 and Swedish,9

SAD was more prevalent among students of engineering

faculties than students of social science and humanities

faculties. It may be related to the consequences of social

anxiety on academic performance during pre-engineering

years and career choices made thereafter, in addition to

a larger quota of students in the school, as this stage

greatly matters their life on the campus, particularly.

Considering birth order, SAD was more prevalent

among first or only child than being middle or last child.

Which was in agreement with study done in Egypt (birth

order).17 It was hypothesized that the first-born child will

have a higher level of social anxiety than a non-first born

child.38

In terms of age, the current study shows significant

association, with higher prevalence of SAD among stu-

dents in the age group of 18–20 years as compared to older

age groups. The finding was in accordance with many of

the prior studies, shown an early onset of social anxiety

symptoms.20

Family history of psychiatric illness was found to have

significant association with SAD. This could be explained

by studies showed association of social phobia and genetic

inheritability, although the underlying mechanisms remain

unclear.39

The most commonly reported feared social situations in

the target sample were being criticized by others or fear of

parties and social events, followed by doing things or speak-

ing to people and the most commonly avoided situations

were talking to strangers followed by being a center of

attention. These findings were consistent with result of earlier

studies.4 This is because college years are a critical period to

socialize themselves, particularly via social interaction.

Again their expectation matter the way they interact, they

may avoid such interaction because of negative evaluation.

The Effects of Social Phobia on Quality of

Life To the best of the author’s knowledge, the present study is

the first to investigate the direct relationship between social

phobia and its impact on quality of life among university

students in Ethiopia. In the present study students with social

phobia had lower scores on all areas of life quality, including

physical and psychological health, social relationships, and

the environment than those without social phobia.

Results of an epidemiological study from report that

students with social phobia have reduced quality of life in

all domains as compared to those without social phobia as

in Swedish,9 and California,6 and Canada.40 Similarly, in

the current study, students with SAD were more likely

than students without SAD to be unsatisfied with their

health, suffer from depression and psychological distress,

rate their quality of life as poor, and to be unsatisfied with

many aspects of life. For example, mean ± standard devia-

tion score of students (2.96 ± 1.42) and (2.11 ±1.24) with

SAD reported dissatisfaction with personal relationship

and health, respectively.

In sum, our study reported high level of social phobia.

These have an impact on impairing health status. Particularly

mental health, and predispose students to more complicated

dysfunction in different areas of functioning, dropping out of

school and letting them disable or dependent.

Study limitations included that this sample was only

for university students and did not represent the general

population. From an epidemiological perspective, it is

necessary to study a community representative sample

that best represents the entire population.

Conclusions The current study shows high prevalence of social phobia

among the university students and its significant negative

effects on quality of life. These findings necessitate more

extra efforts in recognizing and treating social anxiety

disorder in higher academic institutions. Prompt identifica-

tion and treatment will help in reducing the bad conse-

quences of this common condition.

Abbreviations ANOVA, analysis of variance; CI, confidence interval;

DSM-5, Diagnostic and Statistical Manual of mental

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disorders Fifth Edition; OR, odds ratio; MINI, Mini

International Neuropsychiatric Interview; LSAS, Liebowitz

Social Anxiety Scale; SAD, Social Anxiety Disorder; SPIN,

Social Phobia Inventory; SPRQ, Social Phobia Screening

Questionnaire; SPSS, Statistical Package for Social

Science; UK, United Kingdom; USA, United States of

America; WHOQOL-BREF, World Health Organization

Quality of Life Scale – Brief Version.

Data Sharing Statement The data that support the findings of this study are available

from the Mettu University, but restrictions apply to the

availability of these data, which were used under license

for the current study and so are not publicly available. Data

are however available from the authors upon reasonable

request and with permission of Mettu University.

Ethics Approval and Consent to Participate The study was carried out in accordance with the princi-

ples of the Declaration of Helsinki. Ethical clearance is

obtained from the ethical review board of faculty of health

and medical sciences of Mettu University. An official

letter was obtained from Mettu University president’s

office, and an approbation letter was obtained from the

head of the department of psychiatry. Selected students

were informed about the nature, purposes, benefits and

adverse effects of the study and invited to participate.

Confidentiality was ensured and all related questions they

raised were answered. Participation was completely volun-

tary, with no economic or other motivation, and each

participant signed written informed consent for their parti-

cipation. Participants had the right to refuse or discontinue

participation at any time according to their choice.

Acknowledgments We would like to thank Mettu University for providing

ethical approval to conduct this research. Our deepest

thanks go to all study participants, data collectors and

supervisors who spent their valuable time for the good

outcome of the research work.

Author Contributions MAH wrote the protocol, design the study, organized the

data collection process, analyzed the data, and reviewed

and edited the manuscript. ZA revised and approved the

protocol, participated in data analysis, reviewed and edited

the manuscript. MAH and ZA contributed to an analysis of

the data, drafted the manuscript, critically reviewed and

approved the manuscript for publication. All authors con-

tributed to data analysis, drafting or revising the article,

gave final approval of the version to be published, and

agree to be accountable for all aspects of the work.

Funding No institution or organization funded this study.

Disclosure The authors declare that they have no competing interests,

financial or otherwise.

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