original Self-statements of medical students about the fear of speaking in public Autoavaliação

Objective: to evaluate the perception of medical students from two institutions in the north of Minas Gerais regarding the fear of public speaking and the association with sociodemographic, economic and anxiety level variables. Materials and Methods: cross-sectional, analytical study, consisting of 346 students using identification data, Self-Statements during Public Speaking Scale (SSPS) and Beck Anxiety Inventory. Results: the mean age was 22.36 years with a predominance of females. The total SSPS score was 17.72 for the positive rating subscale and 5.28 for the negative subscale. Academics over 22 years old, with more than six minimum wages and with minimal to mild anxiety had a higher average on the positive subscale and those aged up to 22 years, less than six minimum wages, with moderate to severe anxiety and those in the initial periods had a higher average on the negative subscale. The practice of public speaking carried out in the first period was evaluated as positive. Conclusion: the variables age, income and level of anxiety were statistically significant for the positive and negative subscales of fear of public speaking, and academics in the initial periods of the course were significant for the negative subscale.


Introduction
Modern society has been increasingly demanding that university students have social skills, including the ability to speak in public 1 . This demand is even greater in undergraduate courses in which practice requires the professional's capacity for social interaction 2 .
People with severe fear of public speaking are highly prevalent and lack of preparation for this activity can function as a psychosocial stressor, as the anxiety that develops in such situations causes many different symptoms that can have a negative impact on academic education 3,4 . The fear that is triggered during public speaking is responsible for a series of neuroendocrine, metabolic, immunologic, and cardiovascular responses, and causes great anxiety in public performance situations 5 .
Activities developed during the undergraduate course, like expressing opinions within a group and giving seminars, can contribute to students' qualification in such situations, reducing the reactions triggered by anxiety 6 . The greater the ability to speak in public, the lower the frequency with which the speaker averts his/her eyes and the shorter the avoidance time, that is, time during which the speaker remains in silence. Moreover, the time available for the presentation is better used and, consequently, assessment will be better 6 .
Training communication skills helps to enhance public presentations. Fear is mentioned with greater intensity by people who have less experience in speaking to an audience 7 . Communication techniques can be learned and improved, which can minimize negative impacts on communication 8 .
This study aimed to evaluate the perception of medical students from two institutions in the north of Minas Gerais regarding the fear of public speaking and the association with sociodemographic, economic and anxiety level variables.

Materials and Methods
A cross-sectional, analytical study was carried out with undergraduate medical students from two colleges, one private and one public, located in Montes Claros, a city in the north of the state of Minas Gerais. The sample was constituted of 346 students: 223 from the private college and 123 from the public college, randomly selected.
Medicine students from two colleges have, in the first period of the course, the Module of Communication Skills and Attitudes. In addition to group discussions about subjects extracted from papers and books -activities that enable students to develop the ability to speak in public -, there are two sessions at the end of the semester in which students deliver an oral and individual presentation that lasts three minutes, using a multimedia projector. The student chooses the theme based on specific subjects previously discussed in the tutorial sessions. The presentation is filmed so that it can be subsequently evaluated and feedback can be provided by the student him/herself, the colleagues and the teacher, reinforcing the positive points and raising awareness of the negatives. In the second session, the presentation is performed so that students can master the skill of using a microphone and a laser pointer.
A questionnaire containing identification data such as gender, age and course semester was administered to the students. The other aspects that were approached in the questionnaire were family income, city of origin, housing situation, developed activities (jobs or previous undergraduate courses), and one question referring to the Module of Communication Skills and Attitudes. In addition, the Beck Anxiety Inventory 9 was administered to measure students' level of anxiety, as well as the Self-Statements during Public Speaking scale (SSPS).
The dependent variable of the study was fear of public speaking, assessed by the Self-Statements during Public Speaking scale, which was developed by Hofmann and DiBartolo 10 and translated and adapted to Portuguese by Osório, Crippa and Loureiro 11 . It is formed by a positive assessment subscale and a negative assessment, each composed of five items that range from zero to five, where zero means "totally disagree" and five "totally agree with the statement. Items 1, 3, 5, 6 and 9 compose the positive assessment subscale, and items 2, 4, 7, 8 and 10, compose the negative assessment subscale.
The Beck Anxiety Inventory (BAI) 9 is an instrument used to assess typical somatic symptoms of anxiety. Each of the twenty-one symptoms is scored from 0 (absent) to 3 (severe), which reflects the increasing level of severity. The score ranges from 0 to 63 points. The anxiety level is classified according to the score: 0 to 10 -minimal anxiety, 11 to 19 -mild anxiety, 20 to 30 -moderate anxiety, 31 to 63 -severe anxiety.
The categorical variables were dichotomized to investigate possible associations, with a level of significance p≤0.05. The data were processed in the statistical program Predictive Analytics Software (PASW® STATISTIC) version 18.0, using descriptive statistics such as absolute and relative frequency, mean and standard deviation. The Kolmogorov-Smirnov test was performed and, as the dependent variable is not normally distributed, the nonparametric Mann-Whitney U test was performed.
The study was explained to the students and they were invited to participate in it. After they agreed and signed a consent document, they filled in the questionnaires. Throughout the study, the

Results
The study's sample was composed of 346 students from the Medicine course. The mean age was 22.36 years (SD±3.96), the minimum age was 18 and the maximum, 50 years.
Concerning city of origin, 168 students (48.6%) are from Montes Claros and the other participants come from many other cities located in the states of Minas Gerais, Bahia, Goiás, São Paulo, Rio de Janeiro, Pará and Espírito Santo.
The sociodemographic and economic characteristics of the studied sample are presented on Table 1.  The data obtained from the Self Statements during Public Speaking Scale were organized according to the mean score of the items of the positive and negative assessment subscales and presented according to the semester in which the students were. This information is provided by Table   3. There was a difference in the negative subscale between the initial and final periods of the course, both for public and private institutions. It can be observed that for both the positive and negative subscales there was a statistically significant difference with regard to age, income and anxiety level. Academics aged over 22 years, with more than six minimum wages and those with minimal to mild anxiety had a higher average on the positive subscale and those aged up to 22 years, less than six minimum wages and with moderate to severe anxiety had a higher average on the negative subscale. Regarding the semester, the result was statistically significant in the negative subscale, students from the first semesters obtained higher scores. This information is presented on  Table 5 presents the students' opinion about the public speaking activities performed in the Module of Communication Skills and Attitudes. The 91 students who were in the first period were excluded because when the data were collected, this activity had not been performed yet. The activity in the first period contributed both didactically and to reduce anxiety about public speaking for 40.8% of students, and for 40.0%, it didactically contributed to future presentations.

Discussion
In the analysis of the data in the present study, we observed that the general mean is similar to the one obtained by Osório, Crippa and Loureiro 11 , whose mean ranged from 0.72 to 3.80 and the mean total score was 17.32 for the positive evaluation subscale and 5.08 for the negative subscale.
Furthermore, the items with the highest scores of the positive and negative subscales were the same in both studies.
The results were better than another study carried out with undergraduate students from a higher education institution (health sciences, humanities, exact sciences and fine arts) whose average score for the positive scale was 16.73 and for the negative assessment scale was 9.34 8 . Probably, this difference is due to the active methodology in the Medicine course, of both institutions, as well as the experiences of presentations carried out that help to minimize the negative impacts.
Analyzing the answers obtained in the periods, we observed a more negative assessment in the first period of the course. In a study carried out with people in the city of São Paulo (state of São Paulo), it was found that the people who had a substantial fear of speaking in public had a lower level of schooling compared to the people who did not have this fear 4 .
Older students presented a higher mean score in the positive assessment subscale and a lower score in the negative subscale compared to the younger ones. In the study conducted by D'El Rey et al (2005) 4 , of the people who had a substantial fear of speaking in public, more than half were in the age group 30-44 years and the mean age for the onset of the fear of speaking for a large audience was 15 years.
A positive assessment was found among those whose family income was higher than six minimum salaries. The study carried out by D'El Rey et al (2005) 4 found that, among the individuals with a substantial fear of speaking in public were people without paid activities and with no monthly earnings.
The moderate to severe anxiety of the Beck Anxiety Inventory 9 was associated with the most negative assessment. This result was expected, as in moderate and severe anxiety, there is a reduction in the perceptual field, attention ranges from reduced to limited, the person has a sensation of dissatisfaction and cannot concentrate. Furthermore, in severe anxiety, feelings of fear or terror are involved 12 .
A study conducted with female students showed that higher levels of anxiety were reported by those with high scores in the negative assessment subscale. Moreover, these students reported low satisfaction and expectation concerning their own performance in public speaking situations 10 . As in research with university students from various areas (humanities, health, exact sciences and arts) 13 , the result of the present study was not statistically significant between the gender, but it can be observed that women tended to have a greater negative impact than men. Public speaking seems to be more challenging for women, they feel insecure and tense, probably because they perceive more negative elements during communication 14,15 .
As for the practice of public speaking in the Module of Communication Skills and Attitudes, which is offered in the first semester of Medicine, the balance was positive. Similar data was found in a study carried out with students in which 89.3% would like to include classes on public speaking 8 .
Students can develop communication skills by watching peers perform, as well as being instructed by teachers on assertive behaviors 16 . Research found that individuals with a fear of public speaking benefited from the practice of brief presentations and should be put into practice at various times and in different contexts to reduce fear 17 . The more communicative skills the individual acquires, the lower the chances of fear of public speaking 13,16,18 leading to a positive assessment of their own performance 19 . It is important to identify positive points to be strengthened and negative points to be improved.
Very few studies in Brazil have evaluated the prevalence of fear of speaking in public and its impact on university students' psychosocial sphere. This study aims to provide new information on the matter and to stimulate further research in the area.

Conclusion
Students over 23 years of age, with a family income of six or more minimum wages and those with minimal/mild anxiety had a higher mean on the positive subscale, and those aged 22 years or less, with an income of less than six minimum wages, with moderate/severe anxiety and first semesters of graduation had the highest average in the negative subscale. The practice of public speaking performed in the first semester was evaluated as positive.