Social anxiety disorder among university students in Sri Lanka : prevalence, associated risk factors, and culturally adapted cognitive behavioural group therapy

Abstract

Social Anxiety Disorder (SAD), one of the most common mental health disorders globally, demonstrate early-onset, chronic course, and debilitating dysfunction in all social spheres, especially in education. There is a scarcity of information on SAD in Sri Lanka, and none among university students. Therefore, the study objectives were to determine prevalence and associated risk factors among university students in Sri Lanka. A cross-sectional study was conducted among 1137 students from five state universities. The Liebowitz Social Anxiety Scale — Sinhala version and a Psychosocial Correlates Questionnaire for SAD developed for this study, were used as instruments. The analysis included bivariate analysis such as chi-square tests for independence, and Spearman’s r correlations to identify significant associations. Identified variables at p<0.05 were entered in to binary logistic regression models to determine factors associated with social anxiety disorder. Of the 985 who completed the questionnaires, 57.1% screened positive for SAD. In terms of demographic factors and _ clinical characteristics, female gender(AOR=1.41,95%CI 1.10-1.84, p= 0.01) and a history of mental health issues(AOR=2.79, 95%CI 1.90-4.10, p<0.001), and in terms of negative family and adverse childhood experiences, experiences of emotional abuse(AOR=1.31, 95% CI 1.11- 1.54, p=0.001), parent dissatisfaction (AOR=1.07, 95% CI 1.01- 1.13, p<0.05) and overcontrol by parents(AOR=1.08,95%CI1.02-1 .15,p<0.05) remained significantly associated risk factors for SAD. Further, | body dissatisfaction (AOR=1 .05, 95% CI 1.05 — 1.10, p<0.05) , and dissatisfaction with breasts (AOR=.60, 95% CI .46 — .77, p<0.001) were identified as associated significant factors of SAD. Additionally, in terms of school experiences, experiences of humiliation, not being accepted or rejection by school friends (AOR=1.63,95% Cr 1.29-2.05, p<0.001) and rejection, invalidation or isolation due to social connections(AOR=1.3, 95% Cl 1.08- 1.58, p<0.001) , while in university experiences, experiences of humiliation, not being - accepted or rejection by friends(AOR=1.31,95%CI1.09-1.60,p<0.05), experiences of mental harassment(AOR=1.47,95%CI 1.12-1.92,p<0.05), and viewing the medium of study as a challenge,(AOR=1.55,95%CI1.16-2.10,p<0.05) remained independently and significantly associated with SAD. The study recognizes a high prevalence rate of SAD and associated risk factors among university students in Sri Lanka. Although, diagnostic interviews were not conducted — and the actual prevalence rates may be lower, this is an under-recognized issue which needs further exploration as students with SAD will be challenged in their academic and occupational pursuits.

Social Anxiety Disorder (SAD), one of the most common mental health disorders globally, demonstrate early-onset, chronic course, and debilitating dysfunction in all social spheres if left untreated. While previous research notes high prevalence of SAD among university students in Sri Lanka, there is a dearth is culturally valid psychological treatment. Further, cultural adaptation of psychotherapy notes high engagement and effectiveness of treatment outcomes among non-western cultures. Therefore, the objectives of this study were to identify and evidence-based treatment and to culturally adapt it to suit the local university student context. The methodology constituted of six steps. Step one to identify the intervention and protocol information, step two to carry out discussions with experts in the field and to review the identified intervention for validity in the local university student context, step three to incorporate modifications and address any implications to protocol. Step four was to review the treatment for validity with stakeholders and integrate cultural elements, step five to translate and review of material, and finally the sixth step to test the culturally adapted treatment for effectiveness. The Cognitive Behavioral Group Therapy (CBGT) protocol developed by Heimberg & Becker (2002) was identified as an evidence-based treatment for SAD. Then, modifications were made to program length and time, facilitators, clients, language to Sinhala, and an addition of a psychoeducation module. Following which, modifications were reviewed with implications addressed for each proposed change in protocol. In step four, cultural elements were developed in terms of an ice breaker, psychoeducation content, metaphors, mindfulness-based activity, and an ending ritual. Complementary worksheets were also developed in the Sinhala language. Validity of the newly development content was reviewed with a cohort of Sinhala literate university students. In step five, intervention manual was translated to Sinhala, and subjected to a Delphi validation methodology with bilingual mental health experts in Sri Lanka, Finally, the culturally adapted treatment was administered within a randomized waitlisted control study and determined as an effective treatment. While providing an effective culturally valid psychological treatment for SAD among Sri Lankan university students, the study creates a foundation for future studies related to cultural adaption of psychotherapy in Sri Lanka.