Social Phobia (SP) or Social Anxiety Disorder (SAD) is defined as an overwhelming fear of shame, disgrace, or rejection when exposed to potential unfavorable appraisal by others during a public performance or social engagement [1]. The contribution of genetic elements as an etiological component in SAD is thought to be heavily influenced by environmental circumstances [2].   Individuals with SAD dread responding in a certain way that would be shameful and unpleasant, such as presenting noticeable anxiety symptoms, which may result in avoidance of social and performance situations [3]. Situations might be classified as either social or performance based. Meeting strangers, speaking with someone in authority and being the focus of attention are all examples of social settings. Examples of performance circumstances include public speaking, workplace observation and public eating and drinking. Individuals in jobs that demand regular public speaking, such as musicians, dancers and sports, may have special anxieties of performance-only scenarios [4].   SAD is marked by exaggerated sympathetic excitement, resulting in symptoms including perspiration, tremors, trouble speaking, tachycardia and apparent flushing. These symptoms can produce feelings of embarrassment and discomfort [3,4].   The global prevalence of SAD is reported to be 8.3% in adolescents and 17% in young adults [2]. The prevalence of SAD has been shown to vary greatly among medical students in various nations and cultures.   In Western nations, such as the UK, the prevalence is 10%, but in Saudi Arabia it is 60% and in India it is 31% among medical students. 56% of medical students in a Malaysian institution showed symptoms of SAD, while prior research done in Oman reported that 37% of college students showed SAD symptoms, with 8% supporting severe symptoms.   The occurrence of SAD has been shown to vary substantially among medical students from different countries and cultures. In Western nations such as the UK, the prevalence is 10%, however in Saudi Arabia it is 60% [5] and in India it is 31% [6]. About 56% of medical students at a Malaysian school showed signs of SAD [7], whereas a previous study done in Oman revealed that 37% of college students showed SAD symptoms [8].   SAD is a common mental health problem that severely hinders social relationships, academic achievement and professional functioning in adolescents and young people [2].   The current research aimed to assess the prevalence of SAD and its potential demographic correlates among medical students at Northern Border University in Saudi Arabia.

Setting and Design A cross-sectional study was undertaken at the College of Medicine, Northern Border University, during this time from March 1, 2023, to June 30, 2023.   Sample Size The sample size was calculated using the Epi Info software statistical package version 7.0.2.0. The criteria for estimating sample size were the following: Confidence level 95%, expected prevalence of SP16.3% from a previous study [9] and 5% margin of error. Using the previous defined parameters, the sample size was estimated to be 148. We raised the sample size to 150.   Sampling Method The study included students from the second to sixth years, both males and females. Participants answered an online questionnaire using Google Forms sent by WhatsApp and Telegram. To avoid duplicate responses, this survey was intended to accept only one response per participant.   Study Tool An anonymous, self-administered questionnaire was employed. The questionnaire consisted of two components. The first portion contains sociodemographic data such as age, gender, marital status, education year, Grade Point Average (GPA), birth order, housing arrangement, smoking habits and family income.   The 2nd section is the validated Social Phobia Inventory (SPIN) questionnaire [10]. The SPIN questionnaire has a 5-point Likert scale that includes 17 items. It is designed to assess SP symptoms such as dread and avoidance. The answers range from 0, indicating not at all, to 4, which means extremely. The inventory allows for a maximum score of 68. The severity of SAD is determined as follows: 0-20 (none), 21-30 (mild), 31-40 (moderate), 41-50 (severe) and 51-68 (extremely severe) [11].   Statistical Analysis This study employed the Statistical Package for Social Sciences, version 26 (IBM SPSS Statistics for Windows, Version 26.0, Armonk, NY: IBM Corp). The descriptive statistics were reported as frequencies and percentages. A chi-square test examined the association between SP and sociodemographic factors.   Ethical Issue The approval by the local bioethical committee at Northern Border University (HAP-09-A-034) was obtained with decision no. 32-44-H dated 03/05-2023. The participants provided informed consent by including a statement describing the study aim at the start of the questionnaire and asking them to complete the sheet if they agreed to share. The data was utilized solely for scientific purposes. Anonymity and confidentiality were assured during every stage of the study.

A total of 150 students participated in the survey, with a mean age of 22.5±1.6(19-26), more than half males (54%), the majority unmarried (90.7%), more than two-thirds from the clinical years (70.6%), more than half (53.3%) with GPA 3.5-4.49, slightly less than quarter smokers (23.3%), more than 60% with monthly income more than 15000 SAR and the majority living with their family (Table 1).   Figure 1 displays the prevalence and the intensity of social phobia among the examined participants; more than half (56%) experienced social phobia, with 21.3, 20 and 14.7% suffering from mild, moderate and severe social phobia, respectively.   Table 2 shows the association of SP and different demographic features of the studied participants. Female students significantly experienced social phobia compared to males (p-value = 0.03), while clinical years (4th, 5th, 6th) had more SP compared to academic years (2nd, 3rd)   Figure 1: The distribution of SP among respondents studied   Table 1: Sociodemographic characteristics of the participants studied Items No. Percentage Gender Male 81 54 Female 69 46 Marital Status Married 14 9.3 Single 136 90.7 Educational grade 2nd 13 8.7 3rd 31 20.7 4th 36 24 5th 27 18 6th 43 28.6 GPA* 2.5-3.49 21 14 3.5-4.49 80 53.3 4.5-5 49 32.7 Birth order First 46 30.7 Middle 83 55.3 Last 21 14 Family income per month 5000 SR or less 8 5.3 5000-10000 SR 25 16.7 1000-15000 24 16 More than 15000 SR 93 62 Smoking habit Smoker 35 23.3 Not smoker 115 76.7 Accommodation With family 128 85.3 Apartment 22 14.7 *GPA: Grade point average   Table 2: Association between severity of social phobia and demographic characteristics Variable Categories Present N = 84 Absent N = 66 p-value No. (%) No. (%) Gender Male 39(46.4) 42(63.6) 0.036 Female 45(53.6) 24 (36.4) Marital Status Married 5(6) 9(13.6) 0.1 Single 79(94) 57(86.4) Educational grade 2nd 9(10.7) 4(6.1) 0.003 3rd 12(14.3) 19(28.8) 4th 29(34.5) 7(10.6) 5th 11(13.1) 16(24.2) 6th 23(27.4) 20(30.3) GPA 2.5-3.49 12(14.3) 9(13.6) 0.7 3.5-4.49 47(56) 33(50) 4.5-5 25(29.8) 24(36.4) Birth order 1st 26(31) 20(30.3) 0.4 Middle 45(53.6) 38(57.6) Last 13(15.5) 8(12.1) Income 5000 SR or less 5(6) 3(4.5) 0.19 5000-10000 SR 18(21.4) 7(10.6) 1000– 15000 15(17.9) 9(13.6) More than 15000 SR 46(54.8) 47(71.2) Smoking Yes 17(20.2) 18(27.3) 0.3 No 67(79.8) 48(72.7) Living arrangement Living with family 72(85.7) 56(84.8) 0.8 Apartment 12(14.3) 10(15.2) p-value = 0.003). However, there was no significant association between SP and marital status, GPA, birth order, income, smoking, or housing situations.

Regarding the prevalence of social phobia, more than half (56%) of the students had social phobia, with mild, moderate and severe cases accounting for 21.3, 20 and 14.7%, respectively.   Previous research in Saudi Arabia revealed similar findings. A survey done by Al-Johani et al. [12], found 51% of Saudi medical students had SP, with mild, moderate and severe categories corresponding to 20.2, 18.3 and 12.5%, respectively [12]. Al-Hazmi et al. [13] in Madinah, discovered that among medical students 51% of participants had SP, with 18.8% mild, 19.6% moderate and 13.5% severe. Alhazmi in Riyadh revealed that 47.5% of nursing students exhibited SP, with 22% mild, 16.3% moderate and 9.2% severe [11]. In Makkah, Quronfulah et al. [14] observed that 56.2% of health profession students experienced SP, with 39.3% having mild to moderate and 16.9% having severe to very severe SP. In Jazan, southern Saudi Arabia, Hakami et al. [15] reported that 25.8% of university students showed social anxiety disorder. In Oman, Kadhim et al. [16] identified a substantial prevalence of SAD among medical students (64%).   In Turkey, Alnemr et al. [17] discovered that 61% of the non-Turkish university students suffered from social phobia. 23.7% had mild symptoms, 21.3% had moderate symptoms and 15.6% had severe or very severe symptoms.   Many comparable studies have been undertaken in Ethiopia to determine the prevalence of social phobia, including one by Reta et al. [3], who found that 32.8% of medical students suffer from social phobia. Desalegn et al. [18] 31.1%; Nakie et al. [19] 40.2%, Hajure and Abdu [20] 26 percent.   According to an Indian study, 37% of school-age teenagers suffered from SP. Additionally, slightly less than a quarter (23.7%) of the research respondents exhibited mild SP. Moderate and severe SP were detected by 11.5% and 2.3%, respectively [21].   In Palestine, Ayed et al. [22] noticed that among undergraduate nursing students, 29% demonstrated social anxiety disorder, with 19% mild, 6.1% moderate and 3.1% severe social anxiety.   Concerning the relationship between SP and the demographic characteristics, the study reveals that female students had significantly greater SP than males (p-value = 0.03) as we expected and clinical years (4th, 5th, 6th) had more SP than academic years (2nd, 3rd) (p-value = 0.003). This is in line with Al-Johani et al. [12], who reported similar results in Saudi Arabia, this result is pertinent in light of the diagnostic and statistical manual of mental disorders, 5th edition (DSM-5) argument, which found that the frequency of SAD is greater in females, with this difference being more prominent among teenagers [23]. In Oman, Kadhim et al. [16], observed that SAD is more frequent among female university students than males. In Ethiopia, Nakie et al. [19] found that SAD is significantly more frequent among females (60%) than males (60%). Furthermore, research in the Canadian populations provided comparable findings [24]. Additionally, Anderson et al. [25], in the USA indicated that anxiety disorders are more frequent in females than males.   A vulnerability stress perspective may help explain why females are more likely to get SAD. Exposure to diverse psychosocial stresses and a greater physiological and psychological predisposition to anxiety in females might explain the gender variations in anxiety-related conditions [26].   Taha et al. [9] in Taif, Saudi Arabia, observed a negative correlation between SP, age and educational years.

Our findings revealed a significant prevalence of SAD (56%) among the medical students at Northern Border University, most of them had a mild degree of illness. Personal characteristics were strongly related to SAD in univariate analysis, including female gender and students in the academic years compared to the clinical years.   Study Limitations The study has a few limitations, including a lack of temporality and causality between the factors and the outcome because it is a cross-sectional design; additionally, the possibility of response bias is unavoidable; and at last, the SPIN test employed in the study is a method for screening and high-risk cases require additional diagnostic steps.