Assessment of post-traumatic stress disorder and well-being among Sudanese during the ongoing war: a cross-sectional study | BMC Psychology

Conflict can lead to a wide range of mental health consequences, including PTSD, resulting from violence, displacement, and multiple losses commonly experienced during war. These factors significantly contribute to poor well-being [26]. In 2019, an estimated 316 million adult war survivors worldwide suffered from PTSD and/or depression, highlighting the severity of the issue and the urgent need for international cooperation to prevent and address the psychological impact of war [27]. This study examined the mental health impact of the ongoing war in Sudan with special focus on HCWs, focusing on PTSD and overall well-being. The results revealed a high prevalence of PTSD (56.9%) among Sudanese civilians while 60.5% of HCWs had PTSD. This rate was comparable to other studies conducted in conflict zones in Darfur, Sudan. For example, Hamid et al. [28] found a similar prevalence (54%) among internally displaced persons, while Badri et al. [29] reported a significantly higher rate (80.9%) among displaced female university students. However, our results remain substantially higher than global PTSD prevalence (3.9%) [30] and exceed estimates for conflict-affected populations (15.3–36.9%) [31, 32]. These findings highlight the severe mental health crisis in Sudan and emphasize the urgent need for targeted interventions to address the psychological toll of the conflict.

Our study found that women were more likely to experience PTSD than men. Initially, younger individuals (under 31 years) appeared to have higher PTSD rates than older adults, but this association did not hold in the regression analysis. In the same vein, a systematic review conducted by Tortella-Feliu et al. [33] in 2019, identified female gender as a risk factor for PTSD. Kongshøj and Berntsen [34] also stated that younger individuals were more susceptible to PTSD than older adults. Women are at greater risk due to higher exposure to high-impact trauma, such as sexual violence, often at a younger age [30, 35]. While some studies suggest that older adults may be more vulnerable to PTSD due to declining health, cognitive decline, and social isolation [36,37,38], others support our finding that younger individuals may struggle more with the overwhelming stress of war. Their limited coping experience can make it harder to manage the emotional and psychological consequences of trauma [11, 35].

The current study found that people living in urban areas like Khartoum were less likely to experience PTSD compared to those in desert areas. This may be due to better access to healthcare, stronger social support networks, and improved infrastructure in urban areas [39]. However, the ongoing war has severely disrupted these resources, particularly in Khartoum.

Several factors may contribute to the lower PTSD rates in urban areas, including larger and more diverse social support systems, potentially reduced direct exposure to trauma, and different cultural coping mechanisms. In contrast, rural and desert areas often face more intense and prolonged exposure to violence and displacement, which is frequently underreported in media. This sustained exposure to conflict may lead to more severe and persistent trauma, contributing to higher rates of PTSD [40,41,42].

The current work showed that the employed population experienced PTSD more than those who were unemployed. This contrasts with previous research, where unemployment was identified as a risk factor for PTSD [43, 44]. One possible explanation is that certain professions involve direct exposure to the violence of war, such as soldiers and emergency responders, placing them at higher risk. Additionally, civilian jobs that require emotional resilience or involve exposure to suffering, such as HCWs and social workers, may also contribute to elevated PTSD risk [45].

As shown in this study, housing overcrowding increases mental illness and aggravates PTSD. While extended family living arrangements are a significant aspect of Sudanese culture, often providing social support and helping to buffer against the negative effects of trauma and PTSD [46,47,48,49], our study suggests that the specific context of war and displacement can weaken these protective factors.

Overcrowding, a common consequence of displacement, can lead to increased stress, limited privacy, and heightened interpersonal conflict. Lack of privacy also can make it harder for people with PTSD to cope with symptoms like flashbacks or nightmares. Additionally, war and displacement can disrupt strong family bonds, leading to isolation and reduced social support. In addition, living in crowded conditions may increase exposure to traumatic events, such as violence or the suffering of others, and can limit opportunities for relaxation and self-care [50,51,52].

In the present study, living in a conflict area and refugee resettlement significantly increased the risk of developing PTSD. These findings align with the results of a previous research carried out in Syria, which identified living in a conflict zone and being displaced due to war, along with exposure to battle sounds, as the primary contributors to PTSD experienced by participants [32]. Witnessing violence, experiencing injuries or threats, and losing loved ones are all common during war, and these traumas can trigger PTSD. The constant stress and fear of war can also increase PTSD symptoms. Refugee resettlement during war can be a necessary way to escape immediate violence, providing some safety and reducing the risk of witnessing traumatic events. However, the forced displacement itself can be stressful and disruptive, leading to feelings of loss, isolation, and uncertainty. Additionally, resettling in a new area often means unfamiliar surroundings, limited social support networks, and potential cultural or language barriers [27, 53].

People with insufficient incomes were more likely to suffer from PTSD, as shown in our study. Low economic stability can worsen the psychological impact of war. Poverty can lead to further stress and insecurity, especially concerning housing or basic needs. The ongoing stress can make it harder for individuals to cope with the emotional triggers and flashbacks associated with PTSD. So, those struggling financially may have limited access to mental health care, making it harder to get treatment for PTSD symptoms [10, 54, 55].

The prevalence of PTSD among HCWs in our study (60.5%) was significantly higher than reported in many other studies. For instance, a meta-analysis by Jacob Sendler et al. [56] found a 14.8% prevalence of PTSD among physicians, while a cross-sectional study among Chinese HCWs during the coronavirus diseases 2019 (COVID-19) pandemic reported a prevalence of 9.3% [57]. These findings highlight the profound impact of traumatic experiences on HCWs’ mental health and consequently their ability to provide effective patient care [56, 57]. The notably higher PTSD prevalence in our study is likely attributable to the more severe and frequent traumatic events faced by HCWs in a war context, as opposed to the challenges faced during the COVID-19 pandemic or in non-war settings. This highlights the unique and heightened psychological burden on HCWs in conflict zones.

According to the present study, there is a clear association between PTSD and well-being. This aligns with a German study conducted by Eiche et al. [58] who found that people with PTSD reported significantly lower well-being. PTSD symptoms like flashbacks and nightmares can significantly disrupt a person’s ability to function and feel good in their daily life. Regarding well-being, our study found that overall 27% of participants reported poor well-being while 27.5% of HCWs had poor well-being, with 13% scoring very low on the WHO-5 Well-Being Index (indicating possible depression). This is in line with similar studies on war-affected populations. For example, a study by Rizkalla and Segal [59] found that 42.5% of Syrian refugees in Jordan showed poor well-being. Research suggests depression rates can be as high as 27% for civilians living in war zones [43, 60]. The lower prevalence of depression in our study may be because the WHO 5 Questions of Well-Being questionnaire is not specific to depression, and the cultural norms in Sudan might influence how people express or perceive depression. Social support networks or coping mechanisms within the community could be playing a protective role [60, 61].

Our study found that factors such as overcrowding, low income, and living in a war zone were associated with poor well-being. Similarly, Rizkalla and Segal [59] highlighted the negative impact of poverty and poor health and living conditions on the well-being among refugees. Overcrowding, in particular, can lead to stress, and privacy issues, and makes social interactions within the household difficult, which in turn contributes to poor well-being [62]. However, it’s important to note that living with others can also have positive effects on well-being. Strong social connections and support networks can buffer against stress and improve mental health [63, 64]. The impact of living with others depends on various factors, including the quality of relationships, the level of social support, and individual differences. In the context of war and displacement, the quality of social interactions within crowded living situations can significantly influence mental health outcomes [65, 66].

We found that HCWs suffered from lower well-being compared to other professions or unemployed people. This result was supported by several studies carried out during catastrophic events like the COVID-19 pandemic or war, where HCWs were among the most affected categories by these disasters. Disasters place a unique burden on HCWs’ well-being. They witness trauma and suffer directly while providing care in often chaotic conditions. Second, HCWs themselves may be personally affected by the disaster, experiencing displacement, loss, or property damage [67, 68].

This study provides key insights and novel contributions to understanding the mental health impact of war. By quantifying the prevalence of PTSD and poor well-being among Sudanese civilians, including HCWs, our findings offer valuable data to help policymakers and aid organizations assess the scale of the problem and allocate resources effectively. Identifying key risk factors—such as living in conflict zones, displacement, low income, and overcrowded housing—enables targeted interventions and support services for vulnerable populations. Additionally, our study highlights the unique mental health challenges faced by HCWs during conflict, emphasizing the need for specialized support systems. These findings can guide future research on the long-term consequences of war and inform effective strategies to promote mental health and well-being in conflict-affected regions.

Strength and limitations

A major strength of this study lies in its use of face-to-face interviews (44.0% responses) alongside online data collection. This approach was particularly valuable in the challenging context of the ongoing conflict. A face-to-face interview goes beyond online surveys by allowing us to pick up on non-verbal clues, build trust with participants, clarify questions and ensure their understanding, and observe participants’ behavior during the interview. This enhances response rate and provides deeper insight into participants’ experiences. The mixed-method approach and relatively large sample size enhance the study validity. However, several limitations apply to this study. First, as a cross-sectional study, it only captures the short-term psychological effects of the ongoing Sudanese conflict limiting conclusions about long-term impacts. Second, confounding factors such as lifestyle and genetic predisposition, could not be assessed due to the challenging circumstances. Moreover, our analysis did not account for military personnel, who may be exposed to more severe mental stress and, as a result, are at a higher risk of developing PTSD. Finally, some important variables, such as having chronic medical conditions or a previous history of psychiatric problem, were not assessed. These limitations necessitate cautious interpretation of the results, as they may not fully capture the complexity of factors influencing PTSD and well-being in conflict settings.