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Self-Assessed Anxiety and Physical Fitness in South African University Students: In collaboration with the Department of Physiotherapy, University of the Western Cape

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UPPSALA UNIVERSITY Department of Neuroscience Physiotherapy Programme

Bachelor Thesis, 15 hp, Bachelor level

Self-Assessed Anxiety and Physical Fitness in South

African University Students

In collaboration with the Department of Physiotherapy, University of the Western Cape

Självskattad ångest och fysisk kondition bland

sydafrikanska universitetsstudenter

I samarbete med institutionen för fysioterapi, University of the Western Cape

Authors Mentor

Aronsson, Gabriella Henrik Johansson

Ågren, Hampus Phd, senior lecturer and reg.

physiotherapist

Department of Neuroscience,

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Acknowledgements: The authors of this bachelor thesis would like to give a special thanks to Professor Joliana Phillips, for her support and help in the making of this study. We would also like to thank her and the University of the Western Cape for assuring the well-being of the author who was on-site in South Africa. A special thanks to the students: Liam Fabrik, Tucker Ampo, Kegan Hunt, and Nadia Marais for their help in the data collection, without you it would not have been possible. At last, but not least, also a big thanks to our supervisor Henrik Johansson for guidance and support.

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Sammanfattning

Bakgrund: Mental ohälsa, till exempel ångest, är ett hälsorelaterat problem som drabbar cirka 10-20% av ungdomar i världen över. Studier har visat att en persons fysiska kondition (physical fitness) kan kopplas till mental hälsa och välmående, men de flesta studier har gjorts i västvärlden och det råder brist på forskning i länder söder om Sahara. Dessutom har afrikanska länder söder om Sahara få och inkompletta riktlinjer gällande fysisk aktivitet trots att betydelsen av fysisk aktivitet är väl etablerad.


Syfte: Att undersöka om och till vilken utsträckning fysisk kondition (innefattande grepp styrka, beep-test, BMI och midjemått) korrelerar med självskattad ångest (GAD-7) hos Sydafrikanska studenter vid University of the Western Cape (UWC).

Metod: En kvantitativ tvärsnittsdesign användes och korrelationer studerades. Deltagarna rekryterades genom ett icke randomiserat bekvämlighetsurval. Datan för fysisk kondition och hälsa samlades in genom en greppstyrka-dynamometer, beep-test samt genom

antropometriska mätningar för att mäta midjemått och räkna ut BMI. Självskattad ångest samlades in genom en elektronisk version av GAD-7 formuläret.

Resultat: Resultaten visade en statistiskt signifikant, positiv korrelation mellan BMI och ångest bland kvinnor. Inga signifikanta korrelationer kunde i övrigt ses i gruppen som helhet eller hos kvinnor respektive män.


Konklusion: Ingen signifikant korrelation fastslogs mellan fysisk kondition och ångest. Svår ångest rapporterades av 25% av deltagarna, vilket stödjer tidigare forskning på området som indikerar att studenter är en grupp utsatt för ångest.

Sökord: physical fitness, anxiety, mental health, grip strength, BMI, 20 meter shuttle run test, waist circumference, South Africa.

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Abstract

Background/problem definition: Mental illness, such as anxiety, is a health problem affecting about 10-20% of adolescents worldwide. Studies have found a person’s physical fitness to be associated with their mental health, but most studies have been done in the western world and few have investigated sub-Saharan African (SSA) countries. It has also been found that SSA countries’ guidelines regarding physical activity are few and incomplete, although the importance of it is well known.

Aim: To investigate to what extent physical fitness: grip strength (GS), 20 meter shuttle run test (20MSRT), body mass index (BMI) and waist circumference (WC) correlate to self-assessed anxiety in South African students at the UWC.

Methods: The study had a quantitative, cross-sectional and correlational research design with a non-randomized convenience sampling. The physical fitness data were collected through a hydraulic grip strength dynamometer, 20MSRT and by measuring anthropometric

measurements in order to calculate BMI and WC. An electronic version of the GAD-7 form was used for self-assessed anxiety.

Results: The results showed a significant positive correlation between BMI and levels of anxiety in women, but not in men. The correlation of anxiety related to WC, GS and 20MSRT showed no significance for the whole sample or related to gender, respectively.


Conclusion: No significant correlation could be determined between physical fitness and anxiety. Severe anxiety affected 25% of the population, supporting previous research indicating that students are a group prone to anxiety.

Keywords: physical fitness, anxiety, grip strength, BMI, 20 meter shuttle run test, waist circumference, South Africa.


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INDEX

BACKGROUND 1

Physical Fitness 1

Mental Health and Anxiety 1

Mechanisms of Exercise on Mental Health 2

Obesity 3 PROBLEM STATEMENT 4 Aim 5 RESEARCH QUESTION 5 METHOD 6 Design 6 Selection 6 Measurements 7 Execution 8 Statistics 9 Ethical Considerations 11 RESULTS 11 Sample 11

Recorded Quantitative Scores and Values 12

Anxiety 13

Correlation with Anxiety 14

DISCUSSION 14

Result Conclusion 14

Result Discussion 14

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Generalizability 18

Ethical Discussion 19

Clinical and Beneficial Discussion 20

CONCLUSION 21 REFERENCES 22 APPENDIX 1 APPENDIX 2 APPENDIX 3 APPENDIX 4

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BACKGROUND

It has been shown that a person’s mental health correlates to their physical fitness, with a low physical fitness often corresponding to lower mental health and high physical fitness

corresponding to higher mental well-being (1, 2). One issue is that most studies have been carried out on participants in the western world, with high socioeconomic status (1, 3, 4) whereas not as many have investigated individuals living under low socioeconomic circumstances or in countries south of the Sahara. It has also been shown that sub-Saharan African (SSA) countries have a scarce number of guidelines regarding physical activity even though the importance of it is established (5, 6).

Physical Fitness

The term “physical fitness” is determined by different attributes possessed or achieved by an individual in the context of physical activity. Being physically fit can be described as: “The ability to carry out daily tasks with vigour and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and to meet unforeseen emergencies.'' As the term includes alertness and enjoyment, these kinds of variables are not easily measured. However, there are several components within the term that can be measured objectively through standardized tests. The main health related components are cardiorespiratory endurance, muscular endurance, muscular strength, body composition and flexibility (7). Based on this definition anthropometric measurements will be included in the term physical fitness when mentioned in this thesis.

Mental Health and Anxiety

Mental illness, such as anxiety or depression, is a health problem affecting about 10-20% of children and adolescents worldwide. This number is not definitive, since data from low income countries is lacking (8).

Mental health is defined as: ”A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” according to the World Health Organization. Health on its own is defined as “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (9).

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Anxiety can be defined as: “... an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure.” (10). Anxiety is common among all humans, as it was crucial when it came to survival. Anxiety is a broad term and its spectrum includes everything from anxiety in life-threatening situations to anxiety disorders, such as General Anxiety Disorder (GAD), where a person has an idiopathic general anxiety (11). There are well known treatments for anxiety such as medication and psychotherapy, although exercise is mentioned as one self-help technique to manage the anxiety,

physiotherapy itself is not considered to be a main treatment but rather a possible complementary option (12).

Mechanisms of Exercise on Mental Health

Different hypotheses exist about why exercise improves mental health. Some of the

biological mechanisms include: the endorphin hypothesis, neurotransmitter dysfunction and the hypothalamic pituitary-adrenal (HPA) axis. In addition, the distraction hypothesis and self-efficacy theory are two hypotheses based on psychological mechanisms.

The endorphin hypothesis explains well-being through the fact that the function of

endorphins is to aid the body when under pain or stress for long periods of time. It is well documented that endorphin levels are raised post-exercise contributing to a state of well-being. Previous studies have shown that mildly depressed males who performed moderate to high exercise reported to feel less depressed after six weeks compared to the males who only performed physical exercise at a low level (13).

Mental health problems, for example depression or anxiety, have been found to correlate strongly with an imbalance in the neurotransmitters serotonin, dopamine, noradrenaline and glutamate (14). Serotonin is the most common imbalance to be treated, and depression is in some patients successfully treated through selective serotonin reuptake inhibitors (SSRI), which work by inhibiting the reuptake of serotonin in the brain (15). When it comes to exercise, it is believed that it can increase the levels of serotonin and adrenaline in the brain, thus working in a similar way as SSRI (16).

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The hypothalamic pituitary-adrenal (HPA) axis adapts the body to physical and psychological stressors. HPA dysfunction, and especially hyperactivity (of the HPA response), has been found to correlate largely with mental health problems such as depression (17–19) . The HPA dysfunction associated with depression and anxiety is characterized by either too high or too low production of cortisol, hypersecretion of corticotropin-releasing hormone (20) and a reduced sensitivity to glucocorticoids (21). It has been found that exercise adjusts both the release of corticotropin-releasing factor from the hypothalamus as well as the release of adrenocorticotropic hormone from the anterior pituitary gland (22, 23). Thus, changes in the HPA-axis occur, which modulates stress and anxiety (24).

Exercise has been shown to distract the mind from negative thoughts as well as heighten a person’s self-efficacy and self-esteem (4). The distraction hypothesis is based on the thought that a mental “timeout” can be the reason for the positive mood effects of exercise. It is believed that getting distracted from negative thoughts can be a technique to help one cope with anxiety and depression (25).

The theory of self-efficacy implicates that by completing an important task or by successfully finishing something effortful, for example an exercise session, a sense of pride is

experienced, which will elevate mood levels. Performing exercise has been found to also heighten the self-efficacy levels, that is a person’s belief in one’s ability to succeed in daily tasks, and a higher self-efficacy has been found to correlate negatively with depressive symptoms (26). Physical fitness has long been seen to correlate with positive self-esteem and people with high self-esteem have been found to be less prone to anxiety and depressive behaviour (27).

Obesity

Obesity is a non-communicable disease defined as abnormal excessive fat accumulation. Obesity is a risk factor for many chronic diseases, especially metabolic related diseases such as diabetes but also cardiovascular diseases and cancer. In order to measure obesity on a population basis, body mass index (BMI) is generally used (28).

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Furthermore, waist circumference, waist to height ratio and waist-to-hip ratio are

measurements which seem to have similar precision in predicting cardiometabolic risk factors compared to BMI. Waist circumference has the advantage of pinpointing visceral adiposity, which by itself is a risk factor. Nevertheless all of these measurements have their usefulness in clinical practice and research (29).

Obesity has been shown to have a strong correlation with a low physical activity level. Studies have shown that a low amount of steps per day is associated with a higher BMI and waist circumference, higher diastolic blood pressure and other metabolic risk factors (30). Additional research has confirmed that people who are overweight or obese have a lower activity level, more specifically they spend less time performing moderate to high levels of physical activity compared to people who are not overweight (31).

A study carried out on European adolescents has shown that frequency of activity was positively correlated with well-being and was negatively correlated with depression and anxiety. In addition, it showed that participation in sports and more frequent physical activity both led to greater well-being and less anxiety and depressive symptoms (32).

PROBLEM STATEMENT

The amount of physical activity performed has globally decreased during the 21st century, which in fact could lead to higher rates of obesity and several other health complications such as depression, diabetes type II, high blood pressure and respiratory problems (33).

Studies have found a person’s physical fitness to be associated with their mental health and mental well-being (1, 2). However, most studies have been carried out on participants in the western world, with a high socioeconomic status (1, 3, 4) and not as many have

investigated countries south of the Sahara. In addition it has been found that SSA countries’ guidelines regarding physical activity are few and incomplete, even though the importance of physical activity is well known (5, 6). Investigating the possible correlation between physical fitness and anxiety in countries outside the western world is not only beneficial for

physiotherapists in the country where the research takes place, in this case SA, but also for physiotherapists in the western world. As the world becomes more integrated, the importance

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of understanding other nationalities increases and is necessary in order to be able to provide equal and high-level care for all.

Although it is known that exercise is associated with a person's mental health,

physiotherapy is not considered to be one of the primary treatment options with the two most common treatments being medication or psychotherapy (12, 34). Establishing if there is a possible link between anxiety and physical fitness and integrating mental health into the field of physiotherapy would not only widen the field of physiotherapy in both SA and Sweden, but also give patients another possible treatment option.

From a pure physiotherapeutic point of view, identifying possible correlations between different physical fitness attributes and anxiety may help gain a deeper understanding of different aspects in the treatment of patients. Furthermore, studying this possible correlation may lead discussions and hypotheses around causality and potential confounding variables between exercise, physical activity and anxiety.

AIM

The aim of this study was to investigate to what extent physical fitness (Grip strength, 20 meter shuttle run test, BMI and waist circumference) correlate to self-assessed anxiety (GAD-7) in South African Students at the University of the Western Cape (UWC) as a whole group and to investigate possible differences and/or similarities in the results for men and women.

RESEARCH QUESTIONS

● Measured at one point in time, what were the recorded values for the whole sample, for males and for females respectively for the self-assessed anxiety (GAD-7), BMI, waist circumference (WC), grip strength (GS) and 20 meter shuttle run test (20MSRT) in South African university students 18 years or older?

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● Measured at one point in time, what was the correlation between self-assessed anxiety (GAD-7) and BMI in South African university students above the age of 18 for the whole sample, for males and for females respectively?

● Measured at one point in time, what was the correlation between self-assessed anxiety (GAD-7) and waist circumference in South African university students above the age of 18 for the whole sample, for males and for females respectively?

● Measured at one point in time, what was the correlation between self-assessed anxiety (GAD-7) and grip strength in South African university students above the age of 18 for the whole sample, for males and for females respectively?

● Measured at one point in time, what was the correlation between self-assessed anxiety (GAD-7) and the VO2 max (estimated from the 20MSRT) in South African university students above the age of 18 for the whole sample, for males and for females

respectively?

METHOD Design

The study was based on a quantitative, cross-sectional and correlational research design. A quantitative design was chosen in order to get an objective view of the students’ fitness level and also as it allows for a potential generalizability to the population of interest. The study was cross-sectional since the sample was studied during a specific point in time within a short period (35). As mental health and physical fitness intertwine, a correlational design was suitable for this study in order to determine the interrelationship between variables.

Selection

Selection of participants was accomplished in cooperation with Professor Phillips and a research group of four final year physiotherapy students at the UWC. The sampling method is considered a non-randomized convenience sampling since participants were selected through these four students and Professor Phillips respectively.

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Inclusion criteria: University students at the University of the Western Cape, ages 18 and above, independent of their gender or socioeconomic background.

Exclusion criteria: Pregnancy, inability to run, no hand-grip capacity or the inability to fill out the GAD-7 form, for any reason.

Professor Phillips and the four students aimed to find ten participants each with the given criteria. Each person reached out to ten participants by phone in order to invite them to participate in the study and to schedule when the tests were to be conducted if the participant accepted.

This resulted in a total of 50 participants as the total amount of participation requests. The information was clarified that no particular quality was desired but rather a variety of

participants representing the population of interest. Thereafter a group of participants were called upon to attend on a measurement occasion. The number of participants that attended the different measurement occasions varied.

Measurements

In order to retrieve the basic characteristics and background information of the sample all participants had to fill out their gender, age and what faculty they belong to at the university.

GS was measured through a hydraulic grip strength dynamometer. The participants were seated in a chair with armrests and were instructed to press the dynamometer handle as hard as possible until the examiner said stop. Three trials per hand were conducted and the highest score in kilograms out of the six trials were used in the analysis. GS has shown to be an accurate representation of one's general general body strength (36–38). The GS test has also shown an established test-retest reliability, inter-rater reliability and intra-rater reliability (39).

To calculate the BMI of the participants a combined scale and height device from the UWC sports facility was used. Weight in kilograms divided by the square of the participants height in meters was used for the BMI calculation. A person with a BMI with equal or more than 25

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is considered overweight and a person with a BMI equal or more than 30 is considered obese (28). A person with a BMI lower than 18.5 is considered underweight (40).

The WC was measured with a measuring tape in a standing position in the middle between the hip bone and the lowest rib of the participant aiming for the navel. The participant was urged to relax and to breathe normally before the measurement was taken. WC has been found to be a good indicator of obesity but also specifically visceral adiposity (41-43). Waist circumference, together with other anthropometrics, has shown excellent reliability according to previous research (44).

To measure cardiorespiratory performance the 20MSRT was used. The 20MSRT took place at an athletics outdoor running track. The participants were to run between two lines 20 meter apart guided by beeps from a pre-recorded tape. Before the trial started instructions and practical details were explained by the author. Thereafter participants were given five minutes to warm up. The level and shuttle achieved by each participant were then documented on the recording sheet when the participant could not keep up to the set pace.

Studies have shown that not only has the 20MSRT high validity when it comes to measuring aerobic capacity, but it is also more valid compared to other similar tests, such as the Cooper test for estimating VO2max (45, 46). 


To collect data for the self-assessed anxiety an electronic version of the GAD-7 form was used, created in google forms. The GAD-7 form has reportedly shown to be a valid and reliable measurement for measuring anxiety in both field research as well as in primary clinical settings. It has been found to have a specificity of 82% and a sensitivity of 89% which had the same equivalence as an interview done by mental health professionals (47-49).

Execution

The measurements took place over a four-week period during the months of February and March 2020. During this time eight occasions were completed in order to measure 40 participants' physical fitness. Different amounts of participants attended, varying between 1-13 participants between occasions. The measuring took place at the UWC sports stadium

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on campus. Professor Phillips and the research group, consisting of four final-year

physiotherapy students, assisted in the measuring. The research group was informed about the standardization and measurement protocols by the author on site (Appendix 1). The main part of the measuring was executed by the author, the final-year students mainly assisted in documentation, arranging equipment and measuring WC.

Before the measuring, participants filled in the background data on a sheet and were given verbal information by the author together with a participant number. This number was then presented on the recording sheet of measurements in order to secure anonymity. The participants' WC, height and weight and GS were measured one at a time in a medical room. After GS and anthropometric measurements were finished the 20MSRT was initiated for the whole group attending that particular measuring occasion. After the 20MSRT the participants were given two weeks to fill out the Online GAD-7 form (Appendix 2) together with a

consent form (Appendix 3) and written information about the study. The form was sent out via email by the author on site and a reminder email was sent every third day to those who had not answered.

STATISTICS

The data was recorded and compiled using Microsoft Excel. In the same program descriptive data was analyzed, analytical statistics were accomplished through e-labbet which is an electronic software appurtenant to Björk. J Praktisk statistik för medicin och hälsa (50).

The background variable age was presented with mean and standard deviation as it was considered to be normally distributed. The values were determined to be normally distributed by observing the graphs and comparing the mean to the median. Gender and university faculty were presented with frequency and percentage respectively to get an overview of the distribution.

The GAD-7 form generated a number between 0 and 21. The participants were divided into four different classifications by using the cut-off scores the GAD-7 form provided to classify the amount of anxiety. According to the GAD-7 form 0-4 was considered to be no anxiety,

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5-9 was considered to be mild, 10-14 points the person had moderate levels of anxiety and 15-21 was considered to be severe anxiety. These cut-off scores were then used in the correlation analysis.

The quantitative variables are on a ratio scale. GS was presented in kilograms, BMI in kg/m2,

waist circumference in centimetres and the result of the 20MSRT was converted into a VO2 MAX (ml.kg-1 .min-1 ) estimate using the following formula (51):

VO2max = 31.025 + (3.238 × velocity) - (3.248 × age ) + (0.1536 × age × velocity)

VO2max = (vel × 6.65 - 35.89 × 0.95 + 0.182

predicted VO2max = (6.0 × vel) - 24.4

To answer the first research question quantitative variables were presented with means and standard deviation as they were all considered to be normally distributed. To determine differences between men and women for BMI and VO2max the Mann-Whitney U test was

used due to small group sizes. For WC and GS men and women respectively were categorized as within reference values or outside reference values. For WC ≥80cm for

women and ≥96cm for men were used (52). For GS the participants highest recorded value of the dominant hand was used in the analysis. The reference value used was determined by the participants age and gender (53-55). The differences in proportions of individuals within or outside reference values between men and women were analysed through a chi-squared test.

The qualitative variable GAD-7 was presented with frequency and percentage in the respective category (none/mild/moderate/severe). Anxiety data were then dichotomised into no anxiety (none) and anxiety (mild/moderate/severe), differences between men and women were analysed through a chi-squared test.

To answer research question 2-5 Spearman’s ranging correlation coefficient was used. Spearman's correlation coefficient is a non-parametric rank of measure, describing a growing or decreasing correlation between two variables using a monotonic function.

BMI, GS, WC and estimated VO2max were correlated to the GAD-7 cut-off scores

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correlation was done for women and men respectively in order to detect any gender

difference, resulting in eight scatterplots. The correlation generated an r-value describing the strength of the correlation and a p-value describing the level of significance.A grading system was used as a guidance for assessing the strength of the correlation coefficient

applicable for medical research as following: 0.1 to 0.3 (-0.1 to -0.3) = negligible correlation, 0.3 to 0.5 (-0.3 to -0.5) = low positive (negative) correlation, 0.5 to 0.7 (-0.5 to -0.7) =

moderate positive (negative) correlation, 0.7 to 0.9 (-0.7 to -0.9) = high positive (negative) correlation, 0.9 to 1.0 (-0.9 to -1.0) = very high positive (negative) correlation (56). Statistical significance was set to p≤0.05.

Ethical Considerations

Participation in this study was voluntary, participants had the option to withdraw at any point of time. Information about the study and the procedure was given both verbally by the author and in a written information document (Appendix 4). Reading the written information was compulsory in order to sign the consent form. To secure anonymity participants were given a number on a participant sheet where the measurements were documented. Participants had the option to withdraw at any point of time during the study. Participants were summoned one at a time to a medical room with screens to assure privacy when measures of GS, height, weight and WC were collected.

RESULTS Sample

The initial request of 50 participants resulted in a final sample consisting of 40 participants attending on measuring occasions and answering the GAD-7 form and consent form through email with no internal dropouts.23 (57.5%) were men and 17 (43.5%) were women, from six different university faculties, between the ages of 18-40 with a mean age of 21.8 years. All participants identified themselves as either male or female (table I).

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Recorded Quantitative Scores and Values

The population had an average BMI of 24.24 kg/m2. The men had a higher mean compared to

the women, putting them in the overweight category and the women within the normal weight-range but there was no significant difference in BMI between men and women (p=0.15).

The mean WC was 80.02 centimetres for the whole sample, with the average for men being about ten centimetres more than the average for women. Five women and five men had a WC outside the reference values and there was no significant difference between men and women (p=0.58)

The group's average GS was 36.3 kilograms, one woman and seven men scored lower than their respective reference values and there was no significant difference between men and women (p=0.055).

The average VO2max was 36.2 ml.kg-1.min-1 (table I). There was a significant higher

VO2max in men than in women (p<0.001).

Table I: Participant background information and recorded quantitative values. Number of participants and gender distribution is presented by percentage. Age, BMI, WC, GS and VO2max is presented as a mean and standard deviation (m ± SD).

In total, participants from six different faculties took part in the study: Community of Health Science Faculty (n = 17), Arts Faculty ( n = 7), Law Faculty ( n = 6), Economics and

Management Science ( n = 6), Education Faculty ( n = 2), and Science Faculty (n = 2) (figure 1).

All (n=40) Women (n=17) Men (n=23) No. of participants (%) n = 40 (100%) n = 17 (42.5%) n = 23 (57.5%) Age (m ± SD) 21.8 ± 4.3 20.5 ± 2.5 22.8 ± 5.1 BMI (kg/m2) 24.2 ± 3.9 23.0 ± 2.8 25.2 ± 4.4 Waist Circumference (Cm) 79.9 ± 11.8 74.6 ± 7.8 84.4 ± 12.7 Grip Strength (Kg) 36.4 ± 10.6 28.4 ± 4.9 42.9 ± 9.9 VO2max (ml.kg-1.min-1) 36.5 ± 6.9 31.9 ± 3.8 39.7 ± 6.9

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Figure 1: Distribution of students in the different faculties presented in percentages (%).

Anxiety

Out of all participants, 55% reported to have some level of anxiety and 45% reported to have no anxiety. Out of the group that reported anxiety 25% had mild, 12.5% had moderate and 17.5% reported severe anxiety.

Women generally reported to have more anxiety (76.5%) compared to men (39%). There was a significantly larger proportion of anxiety (mild, moderate or severe) compared to no anxiety (none) in women than in men (p=0.019). Men either reported to have none to mild anxiety or severe, while women had a more even distribution between none, mild, moderate and severe.

Table II: Results from the GAD-7 form presented as percentages and quantity (n=x) between the cut-off scores for all participants, for men, and for women.

GAD-7 cut-off All (n=40) Women (n=17) Men (n=23)

None 45% (n=18) 23.5 % (n=4) 61% (n=14)

Mild 25% (n=10) 29.4 % (n=5) 22% (n=5)

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Correlation with Anxiety

The correlation found between anxiety cut-off scores and BMI, WC, GS and VO2max

respectively are presented in table III.

Table III: The correlation between anxiety cut-off scores (0=none, 1=mild, 2=moderate, 3=severe) and BMI (kg/m2), WC (cm), GS (Kg) and VO2max presented with correlation

coefficient and p-values of university students at the University of the Western Cape divided into the whole sample (n = 40), men (n = 23) and women (n = 17).

DISCUSSION Result Conclusion

The recorded values of self-assessed anxiety (GAD-7) showed that 55% of the participants had some level of anxiety. A significantly larger proportion of women reported anxiety

compared to men. The results showed a moderate and significant positive correlation between BMI and levels of anxiety in women. The correlation between anxiety and WC, GS and 20MSRT were weak and not statistically significant either for the whole population or for men or women, respectively.

Result Discussion

Anxiety

The amount of self-reported anxiety presented in this study is comparable to the results found in previous research on students. The results indicated that the amount of anxiety experienced was significantly higher in women than in men and that 55% of the whole sample had some

Severe 17.5 % (n=7) 17.7% (n=3) 17% (n=4)

Anxiety and correlation with All Women Men

BMI 0.13 (p=0.41) 0.55 (p=0.04) 0.07 (p=0.76)

WC -0.01 (p=0.54) 0.26 (p=0.34) -0.07 (p=0.77)

GS -0.19 (p=0.25) 0.14 (p=0.61) 0.03 (p=0.89)

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level of anxiety. In a cross-sectional study on medical students of the University of Cape town, diagnosed anxiety or depression was found in 25% of the population and females were overrepresented (57). A global prevalence study on anxiety in medical students showed a prevalence of around 33% (58). In another study on South African first year students of historically black universities a total of 17.8% of the population had severe anxiety (59), thus being in coherence with the 17.5% in this study reporting severe anxiety. These are studies which have similar findings to this study, thus contributing to verify that students as a population and especially women may be a group more prone to anxiety.

BMI

The average BMI for all participants was 24.2. With a BMI of ≥25 considered to be overweight (28), the mean BMI in this study is in the upper range of what is considered normal and thus quite high. The women had an average BMI of 23.0 and the men of 25.20, thus the men’s combined average BMI is considered to be in the overweight category, but not the women’s. Previous research has shown that SA has the highest rates of obesity among the SSA countries and that higher BMI often corresponds with a higher socioeconomic status (60, 61). Although the socioeconomic background of the participants was not taken into consideration in this study, they are not likely to belong to the lowest income group of the country as they very rarely have the amount of money required to pay for university fees.

Waist Circumference and Grip Strength

The average WC for the population was 79.90 centimetres. The risk for metabolic related diseases increases at a WC of 80 cm for women and 94 cm for men, especially in a

combination with a BMI ≥25 (52). This would mean that the women are almost on the limit of having an increased risk of weight related diseases, however when looking at only women, their average WC was 74.59 cm, thus putting them nowhere near the limit. These results indicate the importance of not only studying the sample as a whole but also looking at differences in gender.

The mean GS of the population was 36.43 kilograms. Women had a mean of 28.41 kg and men 42.18 kg. The reference values from the test for men ages 20-24 is a GS between

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41.3-75.8 kg and for women the same ages a GS between 20.9-43.1 kg (53-55), thus the women in this study were well within the normal range and the men just above the normal limit. Similar results have been found, where female students had a mean GS of 27.7 kg and male students 44.8 kg (62) thus corresponding with the results found in this study.

VO2max

The estimated mean VO2max can be considered to be low in the population of this study.

Among the men the mean value was 39.7 kg-1.min-1 which is low compared to the results of a

large study on European male adults between 20-29 years of age where the VO2max was 54

ml.kg-1.min-1. The same is true for the women in the present study, where the mean was 31.9

ml.kg-1.min-1 compared to 42.8 ml.kg-1.min-1 in the above mentioned study (63).

There are established mechanisms of the environmental temperature effects on aerobic performance. Elevated cardiovascular strain, increased respiratory strain, dehydration, decreased stroke volume, muscular metabolic function deficiency and decreased drive from the central nervous system to name some (64). These effects usually become a factor in higher temperatures and longer distances, for example among endurance athletes. Therefore they are not crucial in this case as the participants were in a temperature between 25-30 degrees and a duration lower than 20 minutes (65).

Another reason for the low VO2max results could be that the participants were not used to

performing at a maximum level. Therefore, they may have ended the run when it began to feel exhausting or they may have been unable to recognise when they could have put in even more effort to push themselves to their limit.

Correlation with Anxiety

The results showed a significant correlation between BMI and levels of anxiety in women, but not in men. There are many reasons this could be and, as mentioned above, is also interesting since the women as a group are not considered to be overweight, but the men are. The reason for this outcome could be that women generally tend to report more anxiety compared to men (66, 67). The reason for this could be that women in general have more

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anxiety than men. A different hypothesis is that men under-report their levels of anxiety or that women over-report.

When it comes to the other measurements, they did not show a significant correlation with anxiety. This is not in line with previous research (1-4) and there are different reasons this could be. One possible reason could be the sample itself. As it was a convenience sampling and the participants were recruited by physiotherapy students it could have been that the student only reached out to people they thought were interested in physical fitness or that the participants would not agree to participate if they were not interested in physical fitness. Another indication that this could have been the case is that out of the 50 participants that were asked to take part, 40 agreed and followed through. Another reason could be that the sample was small, only consisting of 40 participants. In addition, out of these 40 participants 42.5% were from the “community of health” faculty, which could mean that they are more interested in both mental and physical health than the average student. Thus, potentially having more knowledge of the importance of exercise or about symptoms of anxiety and how to handle it.

Method Discussion

The design used to answer the research questions was considered to be appropriate and fulfil the purpose of the study. A cross-sectional study has been proven to describe and analyse a population at a specific point in time (35) which for this study was optimal. The quantitative design increased the possibility for potential generalization. The choice of measurement for physical fitness ensured objectivity since the factors of self-assessment were excluded.

When it comes to the sampling method, a convenience sampling method has some flaws when it comes to getting a representative sample of the population of interest as it is not a randomized method. The sampling method might also have impacted the outcome as one can assume that physiotherapy students have a tendency to recruit people who are more aware of their physical fitness than the average student. However, the convenience sampling method did allow for a time efficient recruitment and ensured that the time plan of the study was held.

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One can argue that BMI does not take into consideration the different tissues of mass. It is therefore in some cases a weak and indirect measurement of body composition. Athletes and fit individuals might have a high BMI, thus making BMI an unreliable measurement in a population where the majority are well trained and muscular (68). However, this was overcome as the WC of all participants was taken as a way to see whether a high BMI was due to high fat accumulation or high muscle mass, thus making it possible for the researchers to know the reason and interpret the results.

The 20MSRT as a way of estimating VO2max in a population of students inexperienced to

exercise tests can be criticised since reaching total fatigue is required to measure VO2max, no

matter the test protocol. Furthermore, VO2max as a variable is complex to measure even

under more controlled procedures such as treadmill incremental tests (69). This may have had an influence on the low VO2max results presented in this study. Despite this, all participants

were performing under the same conditions, thus resulting in a fair estimate for within-group analysis even though the VO2max estimate might be an underestimate of the actual aerobic

fitness of the population.

Generalizability

The generalizability of this study can be questioned as it was not randomized, but a convenience sample was used. Therefore, it may not be a representative sample of the population of interest. Six different faculties were represented, but as 42.5% of the sample were students from the Community of Health Science Faculty it could indicate that the participants were more fit than the average student, thus affecting the generalizability. In addition, the sample size was relatively small as the amount of time, resources and

researchers available did not allow for more participants. Under optimal circumstances the sample would have been randomized and contained more participants. Therefore, this study can only somewhat be generalized to another similar group containing students at similar ages, from similar faculties.

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Ethical Discussion

There are some limitations to this study. One of them was that the 20MSRT was performed in groups containing between 2-12 people, this may have caused discomfort for some

participants as everyone in the group notices who finishes the test first, thus performs the worst. However, the participants were briefed both in text and verbally and informed that it was voluntary and that they could leave and withdraw their participation at any time. They also had to give their informed consent. The 20MSRT would also have been very difficult to execute individually for each participant since it would have been very time consuming, thus most probably resulting in a smaller sample. With the pros and cons taken into account, it was found that a group setting was the best option and with the participants being well aware of their rights to not participate this limitation is defended.

Another ethical consideration, which is a limitation as well as a strength, is that the GAD-7 form was sent out by e-mail for the participants to fill in. In terms of limitation the

participants were not able to ask questions about the form and receive a direct answer. However, by sending it out via email it did give the participants more privacy as they could fill it out in the comfort of their own home without a researcher there waiting to collect the paper, which is considered a strength. It also made it easier for them to drop out of the study if they did not want to participate anymore, as all they had to do was to not answer. The participants were also able to ask questions via email and were given two weeks to fill out the form, thus the limitation of not being able to ask direct questions was considered to be

outweighed by the advantages.

The GAD-7 survey in this study was used in an online format. This may have affected the results retrieved since participants may have had a different approach when answering the survey on an electric device compared to answering the survey on a handout. The setting in which they answered was thus not controlled and may also have changed the participants' approach compared to if it had been done at a clinical practice or in other research

circumstances. In fact, studies on validity are often executed in a clinical environment and thus might restrict the transferability to an online version (47–49). However, as mentioned in the paragraph above, the advantages of an online format were considered to outweigh the disadvantages.

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Clinical and Beneficial Discussion

Anxiety is something all humans experience to different extents and finding ways to cope with and handle anxiety is of importance when it comes to health on a societal level as well as on an individual level. At the same time inactivity and sedentary behaviour increase the risk of health related problems (33). The benefit of this study is mainly that it combines two health issues in society by investigating a possible correlation, which in some parts and to some extent was found in this study and also has been found in previous research (1, 2, 24). This would be beneficial for both physical and mental health, as interventions can be done to improve students' and the general population's health.

Further investigation of the possible correlation between physical fitness and anxiety in students is needed in order to determine whether or not exercise as a prevention and treatment should be considered. Despite lack of studies on the topic in SSA countries and

methodological flaws, there is some evidence pointing towards exercise as an alternative or complementary treatment for people with anxiety (70–72). There is also a substantial amount of potential mechanisms behind the effect of exercise on mental health and anxiety (4).

One advantage with this study was the cooperation with physiotherapy students. This created fruitful discussions about the usefulness of measurements in clinical practice. Another benefit of the study was that the participants were given general advice and health recommendations about exercise, thus receiving some personal gain when taking part. This is also a strength as it is a step in the right direction regarding improving both physical and mental health.

From a physiotherapeutic perspective, more knowledge about to what extent physical fitness and mental health, in this case anxiety, correlate to each other would provide a base to possibly be able to treat not only biological aspects of a person's health but also

psychological. If a link is found it would provide patients with another treatment option and would broaden the field of physiotherapy As physiotherapists base their work on evidence-based knowledge the investigation of the possible connection between psychological factors and exercise is of importance and would in the long term benefit the whole medical field.

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CONCLUSION

No significant correlation could be determined between physical fitness and anxiety. Severe anxiety affected 25% of the population, thus supporting previous research indicating that students are a group prone to anxiety. Data analysed within genders showed a moderate and significant positive correlation between BMI and anxiety in women, and women reported significantly more anxiety compared to men. The reason for this is difficult to determine, it is an area to further investigate since the research available to date points towards exercise as a potential alternative in treatment of anxiety. More studies, with greater sample sizes and randomized sampling methods, have to be carried out in SSA countries in order to study possible correlations between physical fitness and anxiety.

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Appendix 1 - Measurement instructions

Measurement instructions


Grip strength

Equipment

❖ Chair with forearm support

❖ Hydraulic grip strength dynamometer Instructions

1. Sit down in the chair.

2. Keep your feet on the ground, back against the backrest and forearms against the arm support during the whole procedure.

3. When I say “squeeze” I want you to squeeze the handle as hard as possible until I say “stop”. 4. Each hand will be tested three times resulting in a total of six trails.

- Ask the participant of his/her hand dominance, document it on the participant sheet - Give the participant the dynamometer starting with the right hand

- Reset the indicator to 0

- Urge the participant to “squeeze… squeeze… squeeze…STOP” - Switch hand and repeat until six trails is reached

- Record each value in kilograms on the participant recording sheet - Record the highest value in the left column to be used in analysis

Weight

Equipment

❖ Electronic body weight scale Instructions

1. Place the scale on a hard surface, avoid soft surfaces such as carpet 2. Urge the participant to remove shoes and heavy clothing and jewellery


- Preferably only: socks, trousers/jeans, T-shirt - Remove: shoes, sweaters, jacket, watch, belt 3. Urge the participant to stand on the scale

4. Record the weight to the nearest decimal fraction in kilograms in the participant sheet (e.g 60.1 or 20.6)

Height

Equipment

❖ A standardized height measuring device Instructions

1. Urge the participant to remove his/her shoes and hair ornaments or unbraid hair that interferes with the measurement

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2. Urge the participant to keep his/her feet together, hand along the side of the body and look straight forward

3. Bring the headpiece down until it lightly touches the top of the participants head 4. Record the height to the nearest centimetre on the participant sheet

Waist Circumference

Equipment

❖ Measuring tape Instructions

1. Urge the participant to either remove his/her shirt or lift the shirt up 2. Instruct the patient to breath normally and relax

3. Start at the top of the Iliac crest, bring the tape measure all the way around your body, level with the belly button

4. Record the waist circumference to the nearest centimetre on the participant sheet

20-Meter shuttle run test

Equipment

❖ A non-slippery surface with 20 meters apart ❖ Pre-recorded tape

❖ Speaker

❖ Recording sheets Instructions

1. Give the participants 5 free minutes to warm up

2. Read the information about the shuttle runt test according to: 


Leger, L. A., et al. The multistage 20 metre shuttle run test for aerobic fitness emphasize:


- Run until you can’t run no more for the result to be a valid representation of your oxygen uptake!


- Make sure you don’t start running before the signal sounds!
 - Leave the track when you are done!

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Appendix 4 - Written information

Written Information

To the students at the University of the Western Cape who want to partake in our study.

We are Gabriella Aronsson and Hampus Ågren, two physiotherapy students at Uppsala University in Sweden. Hampus will be in South Africa from the end of January 2020 to the end of March 2020. During the eight weeks of his stay he will conduct the 20-meter shuttle run test, measure BMI, waist circumference and grip strength at the University of the Western Cape and collect information about the students self-assessed anxiety. We hope to increase the exchange of knowledge regarding physical fitness and mental health between South Africa and Sweden and increase cooperation between the two countries.

Our study is called:” Self-Assessed Anxiety and Physical Fitness in South African University Students”. With this letter we ask for your participation in the study and that you read the information about the study following below.

Mental illness, such as anxiety or depression, is a health problem affecting about 10-20% of adolescents worldwide. This number may also be higher, since data from low income countries is lacking. It has been shown that a person’s mental health correlates to their physical fitness. One issue is that most studies have been carried out on participants in the western world, with high socioeconomic status whereas not as many have investigated

countries south of the Sahara. It has also been shown that sub-Saharan African countries have a scarce number of guidelines regarding physical activity even though the importance of it is established. With this study we aim to investigate the correlation between different aspects of one’s physical fitness and one’s self-assessed anxiety.

As tests are being done that require some basic skills, there are some inclusion criteria and some exclusion criteria to make sure the results are not faulty.

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Inclusion criteria: Participants in this study will be university students at the University of the Western Cape, ages 18 and above, independent of their gender or socioeconomic background.

Exclusion criteria: pregnancy, inability to run, no hand grip capacity, or the inability to fill out the GAD-7 form, for any reason.

Are you interested in helping us investigate physical fitness and mental health as well as helping us to include South Africa to fill the knowledge gap in research regarding sub-Saharan African countries? By partaking in this study, you will do just that.

Participation in this study includes attending on one occasion for physical testing and answering an email in order to fill out the GAD-7 survey and the informed consent. The physical testing will consist of waist circumference, grip strength, as well as your weight and height will be measured. The weight and height in order to be able to calculate BMI. When the waist measurement is taken you are required to preferably remove clothing around your waist (by pulling up your shirt above your navel), or wear a tight, top of thin fabric. This, as bulky or excess clothing will not give a fair measurement. The waist measurement will be conducted on the participant by a same sex researcher if desired. These measurements will take approximately 5-15 minutes. secondly you will be asked to perform a 20-meter shuttle run test to be able to estimate your cardiovascular fitness performance. We only ask that you do your best and we do not expect any particular performance. The shuttle run test will take between 5-25 minutes, you should have comfortable clothing as you will be running, and you will receive water and a snack afterwards.

You will remain anonymous as you will be given a specific number to be used throughout the study which only the authors, Professor Joliana Phillips and you will know. The data will be collected and recorded on a password protected computer. The list on which number each participant has been given will be kept in a separate folder on the same

computer and will be deleted when the study is finished.

Participation in the study is completely voluntary and you can withdraw your participation at any time during the course of the study without having to give a reason. When the study has been completed and published, the result will be presented in a bachelor

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thesis with data belonging to the Physiotherapy program, department of Neuroscience at Uppsala University. The results will also be shared with the University of the Western Cape.

If you have any questions you are welcome to contact us by e-mail at the address below.

Kind regards,

Gabriella and Hampus

References

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