Correlation between anxiety scores and academic performance among adolescent schoolchildren in Northern Sudan: A cross-sectional study

Abstract

BACKGROUND

The impact of mental health, including anxiety, on academic performance has been studied in several countries, but few data exist for Sudan.

AIM

To investigate the correlation between anxiety scores and academic performance among adolescent schoolchildren in Northern Sudan.

METHODS

This cross-sectional study was carried out during the 2021–2022 academic year among schoolchildren from randomly selected schools in Almatamah locality, River Nile State, Northern Sudan. A questionnaire was used to collect the participants’ sociodemographic data. Anxiety levels were assessed using the questionnaire tools of the General Anxiety Disorder 7-item scale. Students’ academic performance scores were obtained from school records. Multivariate linear regression was performed.

RESULTS

A total of 328 students participated in this study, comprising 156 boys (47.6%) and 172 girls (52.4%). The median [interquartile range (IQR)] age of the students was 14.9 years (13.9–15.6 years). The median (IQR) of the students’ academic scores was 27.6% (22.2%–48.1%). The median (IQR) of the students’ anxiety scores was 0 (0–3). In univariate linear analysis, anxiety scores were positively associated with academic performance scores (coefficient = 1.19, P value < 0.001). In multivariate linear analysis, after controlling for age, sex, parental education, occupation, and body mass index-Z-score, anxiety scores were positively associated with academic performance scores (coefficient = 0.60, P value < 0.001).

CONCLUSION

The current study revealed a positive correlation between anxiety scores and students’ academic performance scores. However, the association between mental health disorders, including anxiety, and academic performance is a complex issue. Therefore, further studies are recommended.

Key Words: Adolescent; Anxiety; Age; Academic performance; Sudan

Core Tip: This cross-sectional study was carried out during the 2021/2022 academic year among schoolchildren in River Nile State, Northern Sudan. A questionnaire was used to collect the participants’ sociodemographic data. Anxiety levels were assessed using the questionnaire tools of the General Anxiety Disorder 7-item scale. Students’ academic performance scores were obtained from school records. In multivariate linear analysis, after controlling for age, sex, parental education, occupation, and body mass index-Z-score, anxiety scores were positively associated with academic performance scores (coefficient = 0.60, P value < 0.001).

INTRODUCTION

There is a rapidly declining trend in students’ academic performance worldwide, especially in Africa[1,2]. Researchers have attributed this decline to various factors, including the low quality of education and limited resources[2]. Several factors have been reported to be associated with academic performance, including student gender[1,3], parental education and occupation[4,5], socioeconomic status[6], school type (governmental or private)[1], and anthropometric measurements[3,6]. Recently, more attention has been paid to the impact of mental health disorders, including anxiety[7], on students’ academic performance[8-12]. An increasing trend in adolescent mental health disorders, including anxiety, has been observed globally, mirroring poor academic performance. It has been estimated that around one in seven adolescents in the world suffers from a mental disorder[13]. Sub-Saharan Africa is not an exception to this trend[14,15], which has both short-term and long-term impacts, such as poor academic performance and, as a consequence, increased school dropout rates[16–18], smoking[17,19], and alcohol consumption[17].

Existing research has shown inconsistent results regarding the association between anxiety and academic performance. While some studies have shown a significant negative association between anxiety and students’ academic performance[11,20], others have found a positive association or none at all[12]. Such inconsistency in the findings regarding the association between anxiety and students’ academic performance calls for further research, especially in a country such as Sudan, where both poor academic performance and poor mental health have been documented[16,18].

Moreover, both education and health are key objectives of the United Nations Sustainable Development Goals, and the heavy burden of mental health disorders on children’s and adolescents’ health, especially in Africa, is prominent[14,15]. Therefore, a thorough understanding of the local context is needed to provide adequate resources and support to improve adolescents’ mental health and academic performance. First, it is essential to understand students’ current academic performance and its association with mental health. Stakeholders can only apply a holistic program approach to improve the current situation.

Although the impacts of certain diseases, such as sleeping disorders and type 1 diabetes mellitus, on the academic performance of schoolchildren and medical students[21,22] have been investigated in Sudan, mental health disorders have not. Moreover, limited data exist on adolescent mental health in Sudan[16,18], especially in the studied area, such as Northern Sudan. This is not to mention the ongoing war and its adverse impacts on both education and mental health[23], especially among children and adolescents. However, the association between anxiety and students’ academic performance has not been explored in Sudan. Hence, this association needs to be explored before these issues (anxiety and academic performance) can be effectively addressed. Thus, this study aimed to investigate the correlation between anxiety scores and academic performance among Northern Sudanese schoolchildren.

MATERIALS AND METHODS

The details of the methods of the current study were reported in previous work by the present authors[24]. In addition, this study adheres to the reporting of observational studies in epidemiology systems[25].

Study area

River Nile State is one of the 18 states in Sudan. According to the 2008 census, the total population of River Nile State was 1120441. This state is comprised of seven localities, Sudan’s smallest administrative unit.

Study population and design

This cross-sectional study was conducted during the 2021/2022 academic year at four primary and secondary schools in the Wad Hamid District, Almatamah locality, River Nile State, Northern Sudan. Almatamah is a neighboring locality of Khartoum State, about 150 kilometer from Khartoum, the capital of Sudan.

The Almatamah locality was selected from the seven localities. From a total of 16 public schools in the Wad Hamid District, four schools (two for each gender) were randomly selected. The total list of students in these four schools was obtained from the schools’ managers. Then, a specific number of students from each school was randomly selected from the list, based on each school’s total number of enrolled students, to achieve the desired sample size (n = 328). The authors trained four medical officers, two of each gender, to gather the data. After signing an informed consent form, the trained medical officers completed the questionnaires (for each student). The questionnaire[7-9] was based on similar previous studies[10–12,20]. It consisted of questions designed to collect sociodemographic data, including gender, age in years, parents’ education (less than secondary level or at or above secondary level), and parents’ occupations.

All students who provided consent were between 10 years and 19 years old and were healthy and eligible to participate in the study. Students with learning disabilities and pregnant or lactating girls were excluded from the study.

Procedures

The students’ weights were measured in kilograms using standard procedures, with well-calibrated scales adjusted to zero before each measurement. Shoes and excess clothing were removed, and while being weighed, the students stood with minimal movement and their hands by their sides. Then, the students’ heights were measured in centimeters, during which they were asked to stand straight with their feet together and their backs against a wall. Finally, the body mass index (BMI) for the age Z-score was determined according to World Health Organization standards[26].

Academic performance assessment

The student’s academic performance was assessed using the combined scores from all nine academic subjects, including mathematics, sciences, and English, using the most recent marks available. Each subject had 100 marks; the total score (900) across all subjects was converted to a percentage out of 100. The scores were obtained from the schools in which the students were enrolled.

Anxiety measurement

Students’ recent anxiety symptoms were evaluated using the General Anxiety Disorder 7-item (GAD-7) questionnaire, a seven-item tool developed by Spitzer et al[27]. The items of the GAD-7 evaluate the symptoms of panic disorder and generalized anxiety disorder over the past two weeks. The responses to the GAD-7 items were measured using a four-point Likert-type scale, scored between 0 (“not at all”) and 3 (“almost every day”). The total score ranged from 0 to 21. Higher GAD-7 scores indicate higher levels of anxiety, and vice versa[27]. The GAD-7 demonstrates good reliability, construct validity, and procedural validity. In addition, the GAD-7 has been widely used in similar contexts, including African and Arab countries[28–32].

Sample size calculation

As mentioned, a sample of 328 students was computed to detect a significant minimum correlation difference (r = 0.12) between anxiety and academic performance[33]. This size of 328 allows the detection of a 5% difference at α = 0.05, with a power of 80%.

Statistical analysis

IBM Statistical Package for the Social Sciences software for Windows (version 22.0; SPSS Inc., NY, United States) was used to analyze the collected data. Continuous data were evaluated for normality using the Kolmogorov–Smirnov test, which showed a non-normal distribution. Therefore, the non-normally distributed data were expressed as a median [interquartile range (IQR)]. Categorical data were expressed as frequencies and percentages. Spearman’s rank test was used to determine the correlations between anxiety and academic performance scores. Univariate linear regression analysis was performed with academic performance scores as the dependent variable and age, sex, parental education and occupation, BMI-Z-score, and anxiety scores as independent variables. Independent variables with P < 0.20 were shifted to the multivariate linear regression to control for confounders. Multicollinearity was checked for by the variance inflation factor, but it was not detected. A two-sided P value of < 0.05 was considered statistically significant.

RESULTS

General characteristics of the studied students

A total of 328 students were included in this study, comprising 156 boys (47.6%) and 172 girls (52.4%). The students’ median (IQR) age was 14.9 years (13.9–15.6 years). The median (IQR) of the BMI-Z-score was -0.65 (-1.68 to 0.36). The median (IQR) of the students’ academic scores was 27.6% (22.2%–48.1%). The median (IQR) of the students’ anxiety scores was 0 (0–3). Of the 328 participants, 207 (63.1%) participants had mothers with a secondary education or higher, and the remaining 121 (36.9%) participants had mothers with less than a secondary education. Of the total of 328212 (64.6%) participants had fathers with a secondary education or higher, and the remaining 116 (35.4%) participants had less than a secondary education. Approximately 1 in 10 of their mothers (32% or 9.8%) were employed. Of the 328189 (57.6%) had fathers who were laborers, and the remaining 139 (42.4%) were employed. Of the total of 328, about 1 in 10 adolescents [31 (9.5%)] had a positive family history of mental disorders (Table 1).

Table 1 General characteristics of the studied adolescent schoolchildren in Northern Sudan, 2022 (n = 328).

Variable		Median	Interquartile range
Age in years		14.9	13.9–15.9
Body mass index for age Z-score		-0.65	-1.68 to 0.36
Academic performance (%)		27.6	22.2–48.1
Anxiety score (range = 0-21)		0	0-3
		Frequency	%
Gender	Male	156	47.6
	Female	172	52.4
Mother’s education level	≥ Secondary	207	63.1
	< Secondary	121	36.9
Father’s education level	≥ Secondary	212	64.6
	< Secondary	116	35.4
Mother’s occupation	Employed	32	9.8
	Housewife	296	90.2
Father’s occupation	Employed	139	42.4
	Laborer	189	57.6
Cigarette smoking	No	318	96.9
	Yes	10	3.1
Family history of mental disorders	No	297	90.5
	Yes	31	9.5

The correlation between anxiety and academic performance

Spearman’s rank test indicated a significant correlation between anxiety and academic performance scores in all subjects (correlation coefficient = 0.220, P value < 0.001, Figure 1) and science, mathematics, and English (Table 2).

Figure 1 Correlation between anxiety scores and academic performance among adolescent schoolchildren in Northern Sudan.

Table 2 Correlations between anxiety scores and academic performance.

Variables	Coefficient	P values
All the scores of academic performances	0.220	< 0.001
Mathematics	0.182	0.001
Science	0.201	< 0.001
English	0.182	0.001

In univariate linear analysis, anxiety scores were positively associated with academic performance scores (coefficient = 1.19, P value < 0.001). In multivariate linear analysis, after controlling for age, sex, parental education, occupation, and BMI-Z-score, anxiety scores were positively associated with academic performance scores (coefficient = 0.60, P value < 0.001) (Table 3).

Table 3 Univariate and multivariate linear analysis of the factors associated with academic performance among schoolchildren in Northern Sudan, 2022 (n = 328).

Variables		Univariate linear analysis		Multivariate linear analysis
		Coefficient (standard error)	P value	Coefficient (standard error)	P value
Age (years)		4.42 (0.62)	< 0.001	3.76 (0.62)	< 0.001
Body mass index for age Z-score		2.50 (0.70)	< 0.001	1.97 (0.64)	0.002
Anxiety score		1.19 (0.31)	< 0.001	0.60 (0.29)	< 0.001
Sex	Male	Reference		Reference
	Female	6.8 (2.06)	0.001	3.6 (1.9)	0.057
Mother’s education	≥ Secondary	Reference
	< Secondary	-1.13 (2.35)	0.603
Mother’s occupation	Housewife	Reference		Reference
	Employed	11.38 (3.47)	0.001	10.26 (3.15)	0.001
Father’s education	≥ Secondary	Reference		Reference
	< Secondary	-5.7 (2.17)	0.08	-4.78 (1.9)	0.057
Father’s occupation	Laborer	Reference
	Farmer	-1.33 (2.11)	0.528

DISCUSSION

The main finding of the present study is the significant positive correlation between anxiety scores and academic performance scores among adolescents in Northern Sudan. Previous studies from different countries support this positive association between anxiety and academic performance[34,35]. In Spain, transversal descriptive research involving 98 secondary school students aged 12–16 found a correlation between moderate anxiety levels and improved academic performance[34]. In the United Kingdom, a study involving 96 adolescents aged 12–14 found that anxiety had a negative influence on cognitive test performance only when memory was impaired; however, increased anxiety was associated with improved cognitive test performance when memory was intact[35]. The negative association found in some studies could be attributable to cognitive memory rather than anxiety.

In contrast to our study and the previously mentioned similar studies, other studies have reported no association[12] or an inverse association between anxiety and academic performance[11,20]. A descriptive study in Kosovo that included 219 students aged 10–18 years revealed no significant correlation between anxiety and depression and academic performance[12]. Conversely, in Northern Iran, a study that included 666 secondary school students aged 13–19 years reported a significant negative correlation between anxiety and academic performance[11]. However, a weak negative correlation was reported between anxiety symptoms and school performance among 432 public school students aged 15–18 years[20].

It is worth emphasizing that the association between anxiety and academic performance is highly complex; therefore, further research is needed to explore this association. For example, a recent study showed a positive association between anxiety scores and higher language course marks[36]. No such association was found with math marks, despite anxiety scores being negatively associated with math marks when no other mental health disorder scores were included[36]. However, it has been reported that anxiety was positively predictive of math scores among underserved schoolchildren aged 8–11 years when considered simultaneously with other mental health problems (i.e., depression and attention problems)[37]. Anxiety seems to influence academic performance differently, depending on each subject rather than overall subject scores.

Various reasons could explain the positive correlation between anxiety and academic performance. Anxiety in students can manifest as worries concerning competence in achieving high marks, often to the extent that they redo tasks due to excessive dissatisfaction with academic performance. For example, in a study among 643 adolescents aged 13–15 years, it was verified that anxiety was positively related to academic motivation in both genders[38]. Academic performance also depends on several factors beyond mental health disorders. These include educational behaviors, such as low attendance and poor homework completion due to other health reasons[36]. Additional factors include the presence of different mental health disorders, such as depression[36], and the interaction of anxiety with other mental health problems (e.g., depression and attention problems)[37]. Research approaches differ, ranging from students self-reporting their academic performance scores to obtaining scores directly from school administrations. This study, which focuses on governmental schools, involved participants in such institutions.

Our results showed low values for both the academic performance and the anxiety score compared with the results from Kenya, which showed that 48.8% and 12.1% of the adolescents had average and good school performance, respectively[39]. Moreover, in Kenya, 65.1% of adolescents had a moderate anxiety level[39]. The unusually low value of the anxiety score in our study raises fundamental questions about whether the participants fully understood the instrument or whether cultural stigma affected the self-reporting of anxiety symptoms. Translation issues or contextual interpretations of anxiety manifestations might have influenced the responses. A future qualitative validation component would strengthen confidence in these metrics. The academic performance median of 27.6% is unusually low; thus, there is a need to clarify grading systems and contextualize them against national/regional benchmarks.

The present results have significant public health implications, addressing two key concerns: (1) Adolescents’ mental health; and (2) Academic performance. This study can serve as a basis for further extensive studies to tackle the impact of mental health on academic performance, and vice versa. The ongoing war in Sudan is having severe adverse effects on the population’s mental health and education, especially among the most vulnerable groups, including children and adolescents[23]. Moreover, further high-quality research is required to explore the association between academic performance and mental health disorders, including anxiety and depression, taking into account the limitations of the current study. To involve the community at large in improving education and mental health across all population groups, the results of this study will be shared with policymakers, healthcare professionals, and school administrations, especially in Sudan, to address children’s and adolescents’ mental health and academic performance.

Strengths and limitations of the study

To the best of the authors’ knowledge, this study is the first to investigate the association between mental health and academic performance among Sudanese adolescents in Northern Sudan. The data represent a valuable contribution to the existing literature on the association between anxiety and academic performance, particularly because the records of student performance were obtained directly from school administrations. The study has an adequate sample size and power. This is reflected in the anticipated power (r = 0.12); The observed correlation was 0.22. Hence, a smaller sample size (n = 185) would have been adequate if the observed correlation had been used (r = 0.22). However, this study also has some limitations that need to be mentioned to improve the design of future studies. As the present study is cross-sectional, it is difficult to establish a causal association between anxiety and academic performance. Therefore, the authors recommend future prospective longitudinal studies to clarify such associations. In addition, this study was conducted on adolescents in only one region of Sudan (Northern Sudan); this might limit the generalization of its findings to all Sudanese students. Moreover, the study did not collect information on educational behaviors (e.g., attendance and homework completion) or peer relationships, which are known to mediate or moderate the relationship between anxiety and academic performance[40]. The study relies solely on the GAD-7 to measure anxiety, which focuses on symptoms over the past two weeks. This may not capture chronic anxiety or situational anxiety related to academic pressures (e.g., exams), potentially underestimating the full spectrum of anxiety experiences. The GAD-7 relies on self-reported symptoms, which may be subject to underreporting due to stigma around mental health in the Sudanese context or misunderstanding of the questions among adolescents.

CONCLUSION

The current study revealed a positive association between anxiety scores and students’ academic performance scores in Northern Sudan. However, the association between mental health disorders, including anxiety, and academic performance is a complex issue. Therefore, further studies are recommended.

ACKNOWLEDGEMENTS

The authors would like to thank the students and their parents for their cooperation in the study.