Impostorism among the undergraduate students of Bangladesh: A cross-sectional study

Imposter Phenomenon (IP) is a highly prevalent behavioural health issue affecting individual professional performance and regular activity. The current study focused on evaluating IP prevalence and assessing the factor contributing to IP among undergraduate students of Dhaka city. This was an analytical cross-sectional survey performed among undergraduate students between August to December 2020. The Young Imposter Scale (YIS) was used to determine the dichotomous assessment for the presence or absence of IP. Among the recruited 1,139 students, 378 (33%) had imposter syndrome. The prevalence was relatively higher (34%) among males compared to females (32%). Around one third (31.6%) reported that they face problems in sleeping. Our analysis shows that the sleeping problem of the student (p=<0.01) and academic year (p=0.04) had a statistically signicant association with IP. Students who completed two academic years were more likely to have IP (AOR:1.18; 95% CI: 1.01-1.41). There was a statistically signicant difference in the experience of IP across who had a sleeping problem than those who didn’t (AOR: 1.54; 95% CI: 1.25-1.90). Our study revealed a relatively high prevalence of IP among undergraduate students, affecting their professional lives. Awareness-raising programmes should be arranged at the university level to help students to cope up with IP.


Introduction
Imposter phenomenon (IP) refers to a sensation of not belonging, out-of-place-ness, and the conviction that one's competence, success is fraudulent and inauthentic. It's often enclosed as an individual problem to be overcome, for example, by keeping a list of achievements to remind oneself of evidenced accomplishments, by talking about one's confusions and precariousness [1][2][3] . It was rst cited by two clinical psychological researchers Pauline Clance and Suzanne Imes, in late 1970 4 .
The most recent systemic review of the literature in 2020 revealed that, prevalence of IP varies widely from 9-82% 5 . In the same year, two studies identi ed that 57% of computer science students and 57.5% of pharmacy students had IP in the USA 6,7 . On the other hand, 15% of female medical and dental students reported IS in the USA and 57.8% of young adults had IP in the Kingdom of Saudi Arabia 8, 9 .
A review article published in 2019 observed the prevalence of IP among medical students was 22%-60%, and among trainees were 33%-44% 10 . In the same year, a survey showed that 44.7% of medical internees had IP 11 . In 2018, two studies conducted Pakistan and Malaysia among medical students found that the prevalence of IP had 47.5% and 45.7%, respectively 12,13 . Simultaneously, another survey conducted in the USA found that 14.5% of health science librarians indicated IP 14 . A study conducted among undergraduate students found 35% of them suffered from IP 15 . Another research article also showed a higher prevalence of IP among medical students and relevant subjects 16 .
Clance and Imes (1978) described the IP as a female phenomenon, but it appears in both men and women 17 . Many studies showed the females had a higher risk of IP, while another study showed the opposite result where the male had a higher score of IP [17][18][19][20] . However, a few studies found no signi cant differences in IP between males and females 13,21 .
A new study has shown that most medical students experienced moderate-to-strong IP 22 . The preclinical move to the clinical phases can be particularly challenging and exhibit low con dence during this time among medical students 23,24 . A study reported that IP fully mediated the link between perfectionism and anxiety and served as a partial mediator between perfectionism and depression 25 . Meanwhile, several studies evaluated that having frequent IP harms medical students' wellness [11][12][13] .
There have been a number of studies on IP among students conducted across the world. Unfortunately, no study has been published on IP among students in Bangladesh yet. This study could be able to draw attention of the authorities and policymakers of Bangladesh. The study focused on evaluating the prevalence of IP, explore the frequency distribution among categories, and assess the factor contributing to IP among medical college and university students.

Study design & participants
This was an analytical cross-sectional survey conducted among the undergraduate students from universities and medical colleges of Dhaka city between August to December 2020. The sample size was calculated using the cross-sectional survey formula 26 , using a 95% con dence level, assuming a signi cance level of 5% (i.e., Zα/2 = 1.96), design effect of 2, and the error margin of 4% (0.04).
We have considered the prevalence of IP 50%, as wide variance of prevalence observed in various studies.
So, the calculated sample size was 601 and after multiplication by design effect, the nal sample size was 1,202. Finally, we were able to collect information from 1,139 undergraduate students, which was considered for the analysis.
Sampling technique and data collection A multistage cluster sampling technique was used for the selection of samples from target population.
First of all, 6 area (thana) were randomly selected from Dhaka city corporation (3 from north city corporation and 3 from south city corporation). Data were collected from randomly selected one ward from these selected areas. The nal samples were selected by systematic sampling technique from the households. Before distributing the questionnaire, all respondents were well informed of the study's purposes and methods.
Questionnaire A self-administrated questionnaire containing socio-demographic variables, lifestyle related factors, and academic information used to collect information from the respondents. The Young Imposter Scale (YIS) was used to measure imposter phenomenon. The scale is an eight-item instrument with maximum score 8 and minimum score 0. Answering "Yes" was coded as 1; "No" was coded as 0 in the analysis and a score of ≥5 was considered as having IP 16 . An easy-to-understand questionnaire was used to gather information on sociodemographic details (i.e., gender, age, BMI, currently living with family or not), lifestyle factors (i.e., smoking habit, having best friends, sleeping problem), academic information (i.e., institution, institution type, completed years, study preference).

Statistical analysis
Data were collected by the researcher himself and a group of research assistant. The collected data were checked for consistency and entered in Microsoft excel 2013. The data were then analyzed by R version 3.5.3. Various descriptive statistics like frequency and percentage were calculated to summarize the data.
A multiple logistic regression analysis was carried out to determine the strength of association between IP and independent variables. The data were examined at a 95% CI, and P<0.05 was considered as statistically signi cant.

Results
Socio-demographic characteristics Among 1,139 students, majority (59%) were male, 53.3% aged between 22 to 25 years, while 37.9% had healthy weight (37.9%). Most of the students were from a private institution (80%). More than half of the participants (56.1%) were from university and remaining 43.9% were medical college students. More than half of the respondents (52.3%) had completed at least two academic years. Majority of the participants lived with their family (55.6%), and 68.6% were non-smokers. Sleeping problem was found highly prevalent as 31.6% face problem regarding sound sleep and 56.9% participants had at least one best friend (Table 1).

Imposter phenomenon
The gure 1 indicates, the overall prevalence of IP was 33.19% (n=378) among study participants. Prevalence of IP was slightly higher among males, 34% (n=227) compared to females, 32% (n=151). A relatively higher prevalence was also observed among university students (34%) compared to medical college students (32%). The prevalence was also higher in public institutions (36%) compared to private institutions (33%) also increase with the academic years.

Association of imposter phenomenon with various factors
Our analysis has revealed, IP increases with advances of academic years and the association was statistically signi cant (p=0.04). Students who have passed at least two academic years were more likely to have IP than others (AOR:1.18; 95% CI: 1.01-1.41). We also observed a statistically signi cant difference in the experience of IP across who had a sleeping problem than those don't had sleeping problem (AOR: 1.54; 95% CI: 1.25-1.90) ( Table 1).

Discussion
This study has revealed the prevalence and associated factors of IP among medical college and university students. The overall prevalence of IP was 33%, which also varies among various categories. Despite some differences in the targeted groups, methodology, and scale used, the study results are comparable with previous conducted studies 6, 9,13 . The difference in prevalence might be because of the study pressure, success, and evaluation anxiety. Findings from this study showed that respondents' academic year and having sleeping problems in uenced students' likelihood of being subjected to impostors. IP is nurtured within the discourse of academic environments. Academic pressure usually increases with advancement of academic year and previous study identi ed a positive association between academic pressure and IP 27 . A recently conducted study in India also identi ed a statistically signi cant association between IP and sleep, which supports our ndings 11 .
The research reveals that IP phenomenon is more common amongst male compared to female. The higher percentage of IP among males than females support other research ndings that were conducted in the USA and Austria [17][18][19] . In contrast, we did not found any signi cant relationship between gender and IP, supporting other studies' results in the USA and Malaysia 13,21 .
A recent review of the literatures supports our results that age has no effect on IP 28 . Although a few studies showed that IP affects individuals across the age spectrum and the older had more prone to IP than the younger. Prior studies did not show IP's association with BMI, current living history with the family, category of institution, study preference, and smoking habit. However, our study showed a higher percentage of having IP among overweight, currently living with family, studying at the public institution, and smokers.
Many studies conducted in the USA, Saudi Arabia, and India showed that medical students had a greater risk of IP than non-medical students 7,9,11 . In contrast, we found that university students were more prone to IP than medical students. The possible explanation could be the relationship between student background, study aims, academic environment, and duration of studies.
In this study, students who completed at least two or more academic years were signi cantly more likely to have experienced IP, supporting a previous pilot study conducted in the USA 16 . It may be due to the students preparing for a highly competitive academic and stressful time. IP is associated with increasing academic year students than in prior years because they are closest to their career goal.

Strength & Limitation
This survey is possibly the rst comprehensive study on IP among Bangladesh students and successfully revealed the prevalence of IP and factors signi cantly associated with it. Besides this, our research comes up with some limitations, including a cross-sectional study design, which does not establish a causal relationship with variables. This study was only conducted among undergraduate students of Dhaka city, which is not enough to describe the country's entire trend. As Imposter syndrome mainly affect individual's professional life, a more comprehensive study should be conducted among peoples from various profession.

Conclusions
Imposter phenomenon (IP) among students appears to peak in the higher academic year and afterwards the professional life might be hampered. University authorities should work collaboratively to ensure a safe study environment for better mental health. A more comprehensive and countrywide study would be conducted, including all educational institutions, to know Bangladesh's overall situation. Study also essential to determine the status of IP among professional peoples. Mental health professionals, students and faculty member must be educated about imposter syndrome to take steps to mitigate the psychological impact of this condition. We recommend a prospective evaluation of the use of individual and group cognitive behavioral therapy focused on addressing imposter feelings on clinical and institutional outcomes for students and faculties. Awareness rising programme should arranged in university level to help students to cope up with IP.
Abbreviations IP Imposter Phenomenon BMI Body mass index Declarations Ethics approval and consent to participate Ethical approval was taken from the Institutional Review Board of North South University before data collection commenced. Before data collection, written consent was taken from each participant after explaining the research's objectives, procedures, con dentiality, and the study's bene ts.

Consent for publication
Not applicable Availability of data and material The datasets used in the current study will be made available on reasonable request.

Competing interests
The author(s) declare that in any steps of this research there were no con icts of interest.

Funding
This research did not receive any funding from any agency in the public, commercial, or not-for-pro t sectors.
Authors Prevalence of Imposter Phenomenon among undergraduate students of Dhaka city.