Psychological impact and coping mechanisms among sudanese medical students: a study on anxiety, depression, behavioral, and cognitive changes post COVID-19 lockdown and ongoing conflict

Abstract

Introduction

Mental health is crucial for overcoming obstacles, completing tasks, and contributing to society. Mental, social, and cognitive healths are included. In demanding fields like medicine, academic pressure can cause exhaustion, poor performance, and behavioral changes. Mental health must be addressed to improve student success and well-being. Medical students’ coping strategies, anxiety, depression, and behavioral changes in uncontrollable situations will be studied.

Methodology

A cross-sectional study involved 393 medical students from various universities in Khartoum. Data was collected using an online questionnaire to assess mental health responses during both controllable and uncontrollable situations across all academic years.

Results

Data analysis using SPSS 27 indicated minimal missing data (0.25%) among the 393 participants. PHQ-4 scores assessed psychological distress, anxiety, and depression. The study found that 74.2% of participants experienced behavioral, cognitive, and emotional changes. Significant associations were observed between PHQ-4 scores and these changes (p < .05) using Chi-Square testing. Most participants were females aged 20 to 22, primarily from the Medicine and Pharmacy departments. The study revealed that most individuals utilized pharmacological coping strategies following significant life changes due to uncontrollable situations.

Conclusion

The study highlights that women experienced stress, dissatisfaction, concern, and anger more frequently than men during ongoing war and the post-COVID-19 lockdown. Medical students faced substantial challenges in behavior, emotions, and cognition during societal unrest, including fatigue, feelings of failure, and sleep disturbances. Over 74% reported multiple changes in their emotions and behaviors. Coping strategies included nicotine, sleeping aids, socializing, exercise, venting, meditation, and journaling.

Introduction

Students pursuing health professions often face significant stress, primarily stemming from the academic demand for high performance, intense competition for top grades, and other factors that can negatively impact their mental well-being [1]. Medical students may experience considerable stress and depression due to the demanding expectations, extensive study and clinical hours, and the emotionally challenging nature of patient care. In recent years, there has been an increasing recognition of the pressures that come with medical training. Untreated or undiagnosed mental distress can result in enduring and deteriorating consequences [2]. These effects may lead to a higher dropout rate, poor academic performance, limited opportunities for professional advancement, and a lower quality of life [2]. Moreover, an abundance of stress can detrimentally affect an individual’s physical and mental health, diminish their self-esteem, and negatively influence their academic achievements [3]. There is an increased susceptibility to suicide, as well as a greater likelihood of resorting to detrimental coping mechanisms such as alcohol and drug misuse [2].

Sudanese medical students grapple with more intricate matters. After a three-month period of fighting that started on April 15, 2023, military attacks were initiated on more than 34 universities [4]. Following more than a year of conflict, universities are presently striving to continue with the delivery of education. Nevertheless, due to the displacement and scattering of students across various countries, the situation is increasingly difficult and burdensome for both universities and students. Conducting on-site assessments was difficult due to the dispersion of medical students across multiple nations and centers as a result of the war, with some students being present in conflict-affected areas. To assess the mental well-being and coping strategies utilized by medical students after more than a year of conflict and the COVID-19 pandemic, we utilized an online survey in this study. Our objective was to address an area of insufficient knowledge by providing insight into a specific aspect of the war’s impact on education that has not been examined in prior research. Additionally, we aimed to equip decision-makers with information that will assist in ensuring the continuity of education.

Literature review

Medical students are considered psychologically vulnerable to mental health disorders, such as anxiety, depression, and stress, due to the demanding nature of studying medicine field and the emotional trauma facing them in clinical training [5, 6]. Medical students have been under a lot of stress during the COVID-19 pandemic due to the threatening nature of the disease itself and the enforced social isolation that causes medical education activities to be discontinued [7].

A study in Sudan’s neighboring country, Egypt during the lockdown period shows that 75.2% of medical students have experienced depression [8]. Malaysian medical students revealed that 44.6% express anxiety reactions [9]. The use of both adaptive and maladaptive coping strategies has been documented in response to these challenges. Common adaptive strategies include engaging in hobbies, exercising, and practicing mindfulness or meditation. However, maladaptive methods, such as substance use and withdrawal, were also prevalent.

Tools such as the Brief Resilience Scale and the COPE Inventory have been employed to assess coping strategies, revealing that approach-oriented strategies (e.g. problem-solving) are more effective than avoidance-based ones in mitigating psychological distress.

The psychological challenges faced by Sudanese medical students are further intensified by ongoing conflicts, which compound the stress experienced during the pandemic.

Behavioral and emotional disruptions among this demographic are consistent with global findings, yet the unique socio-political environment necessitates tailored interventions. Addressing gender-specific vulnerabilities and enhancing access to psychological support systems could significantly improve outcomes in this population [10, 11].

Methods

Study participant, sampling and setting

An online descriptive university-based cross-sectional study was conducted among Medical Students from different medical faculties including Medicine, Dentistry, Pharmacy, Nursing and other medical faculties at all studying levels. The faculties are located in the state of Khartoum in the area affected by the current war in Sudan, which started on April 15th 2023.

A stratified sampling method was used to guarantee a representative and diverse cohort of Sudanese medical students. The target population was initially identified across multiple universities in Sudan and subsequently categorized into predefined strata based on essential characteristics, including age, gender, academic major, and semester. The differentiation between pre-clinical and clinical phase students facilitated the identification of variations in psychological distress associated with academic advancement. A proportional random sample was subsequently extracted from each stratum to accurately represent the distribution of the overall population. This methodology guaranteed the generalizability of the results and enabled data collection.

The sample size was calculated using Cochran’s formula, which provides an ideal sample size given a desired level of precision, confidence level, and estimated population proportion:

$$\begin{array}{c}\mathrm{N}=(1.96)\widehat{\phantom{0}}2(0.5)(0.5)(0.05)\widehat{\phantom{0}}2=385\hfill \\ \mathrm{N}=\backslash \text{frac}\left\{(1.96),\widehat{\phantom{0}},2,(0.5),,(0.5),\}\{,(0.05),\widehat{\phantom{0}},2\right\}=385\hfill \\ \mathrm{N}=(0.05)2(1.96)2(0.5)(0.5)=385\hfill \end{array}$$

Cochran’s formula is widely used in survey research to calculate the sample size needed for estimating proportions in a population with a given level of confidence and precision [12].

Research instrument

A semi-structured, self-administered questionnaire was used to collect the data. The questionnaire was piloted by a sample of twelve students with similar characteristics to the targeted population and edited according to their feedback. Seven trained medical student’s data collectors distributed the questionnaire online among student’s faculty groups and societies, in addition to personalized messages using social media platforms including Facebook, WhatsApp and Telegram.

The questionnaire is composed of four main domains, first one about the demographics and general students’ characteristics, second domain represented the validated Patient Health Questionnaire-4 scale (PHQ-4) [13, 14], which purpose is for ultra-brief and accurate measurement of core symptoms and signs of depression and anxiety, by combining the two-item measure (PHQ–2), consisting of core criteria for depression, as well as a two-item measure for anxiety (GAD–2), third domain included the validated ten indicators of change scale with good Cronbach’s alpha (α = 0.74) score, that explored the concerns of uncontrollable situations on students emotional, thinking, and behavioral changes, and the last domain was about the coping strategies followed by students to deal with any psychological distress or changes in their life. Data were collected in April, 1st and 30 May 2024.

Statistical analysis

Data was cleaned and entered into Microsoft excel data sheet and analyzed using Statistical Package of Social Sciences (SPSS) version 27. Categorical data was represented in the form of frequencies and proportions. The Chi-Square Test was used to assess the association between different variables.

Results

Demographics

A total of 393 medical students participated in the study from different medical specialties and academic stages; 266 (67.7%) of the participants were female and 127 (32.3%) male; 230 (58.5%) were aged between 20 and 22 years. The majority of participants, 272 (69.2%), were enrolled in the Pharmacy and Medicine departments, followed by 85 (21.6%) in Dentistry and Nursing, and 36 (9.2%) in other medical fields. 17 (4.3%), 42 (10.7%), 89 (22.6%), 119 (30.3%) and 126 (32.1%) students from first, second, third, fourth and fifth year respectively. Three quarters of students 297 (75.6%) are still enrolled in academic institutions. 331 (84.2%) of students resided in Khartoum before the war; however, after the war those residing in Khartoum decreased to 17 (4.3%). Financially, 30 (7.6%) participants reported insufficient income to meet basic needs, whereas 136 (34.6%) indicated sufficient income for both basic and additional needs.160 (40.7%) considered seeking mental health care services in the past year and 175 (44.5%) out of the whole students aware where to seek mental health care services (Table 1).

Table 1.

Demographic data (n = 393)

General characteristics		Frequency (%)
Gender	Male	127 (32.3%)
	Female	266 (67.6%)
Age	16–19	36 (9.2%)
	20–22	230 (58.5%)
	23–25	127 (32.3%)
Faculty	Pharmacy	106 (27%)
	Dentistry	74 (18.8%)
	Medicine	166 (42.2%)
	Nursing	11 (2.8%)
	others	36 (9.2%)
Academic year	First year	17 (4.3%)
	Second year	42 (10.7%)
	Third year	89 (22.6%)
	Fourth year	119 (30.3%)
	Fifth year	126 (32.1%)
Financial status	Not enough for basic needs	30 (7.6%)
	enough for some basic needs only	81 (20.6%)
	enough for all basic needs only	146 (37.2%)
	enough for all basic and additional needs	136 (34.6%)
Residence before war	In Khartoum	331 (84.2%)
	Outside Khartoum	62 (15.8%)
Residence after war	In Khartoum	17 (4.3%)
	Outside Khartoum	376 (95.7%)
Current enrollment in academic institution	Yes	297 (75.6%)
	No	96 (24.4%)
Aware where to seek mental health care	Yes	175 (44.5%)
	No	218 (55.5%)
Seeking mental health care services in the past year	Yes	160 (40.7%)
	No	233 (59.3%)

Effect of war on medical students personal life

Theft or loss of personal belongings was the most frequently reported issue affecting students 273 (33.70%), while physical injury had the lowest proportion reported by 25 (3.10%) students.

Contributing factors behind the non-enrollment in medical institute

Below 15 (21.7%) of students complained that the most contributing factor behind the Non-enrollment in medical institute was the lack of communication between students and their medical institute, followed by facing difficulties in continuing the educational journey by 13 (18.80%) students, where the rest of factors got very close percent of contributing ranging from (14.5%) to (15.9%) of students (Fig. 1).

Fig. 1.

Factors contributing for medical students non- enrollment in medical institutes (n = 393)

Anxiety and depression screening

A total of 393 students were asked to answer 14 questions divided in two domains; the first domain result showed a total score of PHQ-4 which was recorded into four groups: None (0-2), Mild (3-5), moderate (6-8) and severe (9-12). Over the whole students, 113 (28.8%) and 141 (35.9%) had anxiety and depression scores less than three indicating negative further screening. However, 372 (94.7%) had psychological distress scores in the mild, moderate and severe categories (Table 2).

Table 2.

PHQ-4 scale (n=393)

PHQ-4 scale		Frequency (%)
Participants’ psychological distress categories	None	20 (5.1 %)
	Mild	115 (29.3 %)
	Moderate	140 (35.6 %)
	Severe	117 (29.8 %)
Anxiety-screening	Negative for screening purposes	113 (28.8 %)
	Positive for screening purposes	279 (71 %)
Depression-screening	Negative for screening purposes	141 (35.9 %)
	Positive for screening purposes	252 (64.1 %)

Behavioral, thinking and emotional changes

Nearly all students (96.9%) reported fatigue and low energy, and 83.4% expressed feelings of inadequacy or failure. 79.3% of students had their ability to get basic daily activities affected post [Revolutions] and 78.5% had trouble falling or staying asleep (Table 3).

Table 3.

Indicators of change (n = 393)

Indicators of change	Yes (%)	No (%)
Have you ever thought of dropping out of school?	43.2%	56.8%
Have you had trouble falling or staying asleep?	78.5%	21.5%
Have you felt tired or had low energy?	96.9%	3.1%
Have you felt bad about yourself or felt like a failure?	83.4%	16.6%
Do you think your physical health state change badly after COVID-19?	61.9%	38.1%
Do you think your physical health state change badly after Revolutions?	71.1%	28.9%
Did your ability to get basic daily activities been affected post COVID-19?	66.0%	34%
Did your ability to get basic daily activities been affected post Revolutions?	79.3%	20.7%
Did your relationships been affected post COVID-19?	61.1%	38.9%
Did your relationships been affected post Revolutions?	70.8%	29.2%

292 (74.2%) of students experienced more than five changes under uncontrollable situations, where each 10% indicated one change in students’ emotional, thinking and behavior against these ten indicators (Table 4).

Table 4.

Medical students experienced behavioral, thinking and emotional changes (n=393)

Behavioral, thinking and emotional change	Medical students experienced behavioral, thinking and emotional change
Percentage	Frequency (%)
0	2 (0.5 %)
10%	4 (1 %)
20%	13 (3.3 %)
30%	18 (4.6 %)
40%	24 (6.1 %)
50%	40 (10.2 %)
60%	39 (9.9 %)
70%	59 (15 %)
80%	53 (13.5 %)
90%	76 (19.3 %)
100%	65 (16.5 %)

Pharmacological and non-pharmacological coping strategies

Percentages of 331 and 61 students follow pharmacological and Non-pharmacological coping strategies respectively after they undergo change in many aspects in their life under uncontrollable situations. The two most preferable strategies regarding pharmacology were taking nicotine by 45% of students, and sleeping aids by 41.7% (Fig. 2). Non-pharmacological strategies, including exercise (54.5%) and socializing (50.9%), were used by 61 students (Fig. 3).

Fig. 2.

Pharmacological strategies followed by 331 medical students in the study

Fig. 3.

Non-Pharmacological strategies followed by 61 medical students in the study

Relationship between different variables

The relationship between psychological distress categories (as measured by the total score of PHQ-4 scale) and behavioral, emotional and thinking change (as measured by total score of validated ten indicators of change questions) was investigated using a Pearson product-moment correlation coefficient. Preliminary analyses were performed to ensure no violation of the assumptions of normality and linearity. Results showed that there was a medium positive correlation between the two variables, r = + 0.46, n = 393, p = .01 with high scores of PHQ-4 associated with a high number of positive change indicators.

A Chi-Square Test for independence indicated significant association between psychological distress level and medical students’ coping strategies, χ² (3, n = 392) = 18.42, p = < 0.001, where students who followed pharmacological strategies (49.2%) classified under severe psychological distress category, result supported by the adjusted residual value which is (3.6), in contrary to students who followed non-pharmacological strategies where (38%) classified under None and mild classes. For more specification we test the association between categories under both pharmacological and non-pharmacological classes; result showed significant association between Alcohol and psychological distress classes, χ² (3, n = 392) = 8.2, p = .04, again significant association between Ashwagandha and psychological distress classes, χ² (3,n = 392) = 9.6, p = .032, and regarding Non-pharmacological strategies first significant association between Sports/Exercise and psychological distress classes, χ² (3,n = 392) = 12.46, p = .01 and second one between Socializing and psychological distress classes, χ² (3,n = 392) = 10.12, p = .02, where all rest categories p-value more than 0.05 indicating non-significant association. Another significant association between experienced Challenges in obtaining necessary medications and psychological distress classes, χ² (3, n = 392) = 18.34, p = < 0.001 (Table 5).

Table 5.

Chi-Square Test results between psychological distress level and different variables (n=393)

Variables	Categories		Frequency			P-value
		None	Mild	Moderate	Severe
Gender	Male	10	41	41	35	.93
	Female	10	74	99	82
Age	16-19	1	10	14	11
	20-22	12	71	83	64	.23
	23-25	7	34	43	42
	First	0	3	5	9
	Second	2	11	15	14
Academic year	Third	7	30	30	22	.43
	Fourth	5	41	38	35
	Fifth	6	30	52	37
	Pharmacy	6	33	37	30
	Dentistry	5	16	26	27
Faculty	Medicine	7	48	58	52	.59
	Nursing	1	3	6	1
	others	1	15	13	7
Residence before	In Khartoum	17	100	116	97
war	Outside Khartoum	3	15	24	20	.80
Residence after	In Khartoum	2	8	3	4
war	Outside Khartoum	18	107	137	113	.15
Current enrollment in academic institution	Yes	19	87	109		.09
	No	1	28	31
	Not enough for	1	5	10	14
	basic needs
	enough for some	2	20	32	26
	basic needs only
financial Status	Not enough for	1	5	10	14
	basic needs					.25
	enough for some	2	20	32	26
	basic needs only
	pharmacologically	3	6	22	30
Coping strategies	Non-pharmacologically	17	109	118	87	<.001
Pharmacological and Non-Pharmacological strategies
Sports/Exercise	No	9	62	83	86
	yes	11	53	57	31	.006
Socializing	No	13	65	84	88	.02
	yes	7	50	56	29
Ashwagandha	No	19	114	140	117	.02
	yes	1	1	0	0
Factors experienced by medical students during a war
Challenges in obtaining Necessary medications	No	19	107	117	86
	yes	1	8	23	31	<0.001
Theft or loss of personal belongings	No	9	38	47	26	.08
	yes	11	77	93	91
Death of a relative	No	15	79	90	65	.13
	yes	5	36	50	52
Loss of an occupation or financial status	No	12	71	71	60	.27
	yes	8	44	69	57
Inability to have access to basic needs (food, water, electricity, etc)	No	16	83	93	75
	yes	4	32	47	42	0.36
Physical injury	No	20	109	131	107	.47
	yes	0	6	9	10

Discussion

During periods of worldwide emergencies such as the COVID-19 epidemic, war, and revolutions, the mental health of medical students emerges as a significant issue. These occurrences have precipitated novel obstacles, heightening anxiety, sadness, and precipitating substantial alterations in behavior among students [15]. This study is not the first on these topics, but the first in complex situations including war, post COVID-19 lockdown and several political events in Sudan. All of them directly or indirectly affect the mental health of students. As shown in this study an unprecedented elevation in the prevalence of mental health disorders among medical students compared to previous studies conducted in Sudan [7, 16–18].

Our findings revealed a high prevalence of psychological distress symptoms among medical students, 372 (94.7%) student had at least three indicators for psychological distress. The screening for anxiety and depression revealed that 279 (71.0%) and 252 (64.1%) student had positive screening for anxiety and depression respectively. This is higher than that in a study conducted during COVID-19 pandemic in Sudan that revealed 81.6% of the students reported symptoms of psychological distress. Same study reported an anxiety prevalence 55.3% among medical students which is less than our findings where the depression was 75% higher than in our study [7]. The findings seem to be higher than the aggregate prevalence of 45% for anxiety and 48% for depression reported by Yen Ku Lin et al. [19] in their systematic review covering 130 studies, involving 132,068 medical students. Compared to countries suffering from war like Ukraine, a study conducted after 6 months of war with the same assessment tool (PHQ-4) showed a prevalence of depression and anxiety among Ukrainian citizens 35.5% and 42.3% with taking into account the difference between the two countries [20], and the prevalence of depression was high among women living under the government of the Taliban in Afghanistan, depression symptoms was 80.4%, and the prevalence of mild to extremely severe anxiety was 81.0% [21].

The prevalence level of anxiety and depression observed in our study were also higher to those reported in neighboring countries: Egypt anxiety 64.3% and 60.8% for depression [22], Ethiopia anxiety 30.10% and depression 51.30% [23], Syria during the conflict anxiety and depression was 35.1% and 60.6% [24], China after COVID-19 with a comparable assessment tool (PHQ-9) anxiety 37.8% and depression 39.3% [25], Ecuador anxiety 30.3% and depression was 37.8% [26], and Sudan [27].

Previous research has shown that fatigue in students majoring in the medical fields is often linked to poor academic performance and associated issues, such as nonattendance and leading an inactive lifestyle [28]. On the other hand, fatigue was positively associated with the ability to recognize, understand and control emotions [29]. However, almost all students in our study experienced low energy and felt tired and 78.5% of the students had trouble falling or staying asleep. Factors such as online learning as the best alternative method used by universities during the war to complete education may influence the prevalence of fatigue, in a study conducted among medical students in Brazil about half of the students felt tired from zoom fatigue [30].

Regarding the impact of war on the students, 273 students were exposed to theft or looted during the war, 25 students were injured, and about quarter of them experienced inability to get the basic needs. It is not surprising that looting was most frequently experienced by students, during crises such as wars, safety declines and looting increases with the already high poverty rates in African countries. As in a previous study in Sudan 25 of 34 (73.5%) medical faculties in Khartoum were looted during the current war [4]. In addition, in the Ethiopian conflict a study conducted on more than 12,000 internally displaced people about 69% of them were looted during the conflict [31]. Quarters of the students were delayed or unable to enroll in medical institutions to complete their education. Various reported factors contributed to this issue, including lack of financial aid, poor mental health, and insufficient basic needs. However, the primary reason was the lack of communication between the institutions and students. The fluctuation of communications networks and the Internet in Sudan reinforced this reason [32], as well as the looting of university and student equipment during the war, including communications equipment may also participate.

Most of the students in our study (331) use pharmacological strategies to cope with psychological distress (anxiety, depression). It wasn’t not expected that pharmacological strategies would be widely used among students, given that Sudan is an Islamic country where the consumption of drugs and cannabis and other drugs is not allowed in Islamic religion, and medical students are more knowledgeable than others about their dangers. However, a number of students were taking marijuana and opioids as coping 25% and 16.7% respectively.

There was an increase in cigarette consumption by 9.1% after COVID-19 lockdown as reported; it was commonly associated with deterioration in quality of life, increased anxiety and depressive symptoms [33]. A study in Germany indicated that half of the participants (45.8%) increased the amount of smoking during the pandemic [34]. However, half of the students were taking nicotine as a coping mechanism. In a study conducted among school students in California with more than 11,600 active nicotine vape smokers, 37% of the students reported the reason for taking nicotine was to relieve anxiety and stress [35]. There has also been a high level in the use of sleep aids such as antihistamines and anti-cough syrup. 41.70% of the students who used pharmacological strategies reported they used sleeping aids compared with Saudi Arabian medical students of 338 students, 84 (24.85%) using sleeping pills [36]. Using exercise and sports as a coping mechanism was highly prevalent among Non-pharmacological users, more than half doing exercises and socializing. As Sharon-David mentioned exercise may reduce stress and its manifestations like anxiety and depression [37], the regression analysis stated by Amamou B considered physical activity as a protective factor against depression [38], and Anna Rosiek stated physical activities eliminate the effects of chronic stress and suicidal thinking among students [39]. Journaling, meditation and venting was also used by many students in small proportions 19%, 16.8% and 26.5% respectively of 61 medical students following non-pharmacological coping strategies.

A Chi-square test was used to determine the association between psychological distress and different variables. A significant association was found with coping strategies using by medical students p = < 0.001, consume Alcohol p = .04, taking Ashwagandha p = .032, Sports/Exercise p = .01, Socializing p = .02, challenge in obtaining necessary medications during the war p = < 0.001. No significant association was found with age, gender, academic year, and type of the faculty, residence before and after war, enrollment in academic institutions or financial status. Other studies multiple regression analysis revealed several noteworthy associations. Father’s education level and exposure to violence showed significant correlations with heightened anxiety, suggesting that educational background and traumatic experiences may play a pivotal role in mental health outcomes. Additionally, age, economic status, and parental employment status were significantly associated with sleep disturbances. This implies that socioeconomic factors and life stage can impact sleep quality, potentially due to stressors associated with financial instability or developmental pressures [40], mother’s education level was significantly associated with depression symptoms and low-income economic status was significantly associated with self-esteem [41].

This study contributes to a deeper understanding of psychological distress among medical students in conflict settings offering empirical evidence on the prevalence and determinants of anxiety, depression, and stress in conflict areas, highlighting environmental stressors, socioeconomic factors, and coping mechanisms, and offering practical insights for educational institutions and policymakers to develop context-specific interventions aimed at enhancing student well-being.

Theoretical implications

The study contributes to the existing theoretical frameworks on stress and coping by highlighting the complex relationship between external stressors and coping mechanisms, particularly in the context of medical students during crises. Drawing on Lazarus and Folkman’s transactional model of stress and coping, which emphasizes the role of an individual’s appraisal of stressors and their coping resources, this research reinforces the idea that coping is a dynamic process [42]. In this study, medical students exposed to the COVID-19 lockdown and ongoing conflict in Sudan engaged in both adaptive (exercise, socializing) and maladaptive (nicotine use, sleeping aids) coping strategies. The findings suggest that contextual factors such as political instability and societal unrest play a significant role in shaping coping behaviors, which may not be fully accounted for in existing stress models. Additionally, the results point to the need for the revision and expansion of current theories to integrate the influence of societal stressors such as war and pandemics on mental health, particularly for students in high-pressure academic environments [43]. The findings indicate that coping strategies and stress responses may differ based on regional and cultural factors, suggesting that future theoretical models should consider these elements as critical contributors to psychological distress.

Practical implications

The findings of the current study have important practical implications for universities, policymakers, and mental health professionals, especially in regions affected by crises like war or pandemics. Medical students’ mental health is integral to their academic success, personal well-being, and future healthcare roles. Addressing mental health challenges early can help mitigate the long-term effects of psychological distress, supporting students in both their academic pursuits and overall life satisfaction [44]. To improve medical students’ well-being, universities should integrate mental health support into the curriculum, offering workshops focused on stress management, coping strategies, and psychological resilience. Establishing comprehensive mental health services, including counseling, peer support groups, and mental health workshops, will provide students with the necessary tools to manage academic and personal stressors. Given the challenges posed by ongoing conflict and societal unrest, universities should also consider flexible academic policies during crises, such as extended deadlines and reduced coursework intensity, to alleviate pressure on students [45]. Policymakers and university leaders should prioritize mental health by allocating resources for student wellness programs and creating institutional policies that address mental health as a key component of student success [46]. Furthermore, promoting healthy coping mechanisms, such as physical activity, mindfulness, social engagement, and relaxation techniques, is essential to combat maladaptive behaviors like substance use or isolation. Providing targeted interventions and fostering a supportive environment will help medical students navigate stress, improve their mental well-being, and enhance their academic performance, particularly in times of crisis [47].

Limitations

This study has limitations that may affect the interpretation of its findings. First, the cultural stigma surrounding mental health in Sudan may have influenced participants to provide socially desirable responses, potentially compromising the validity of the data. Additionally, the study relied solely on self-reported questionnaires, which may not fully capture the complexity of participants’ mental health experiences.

Conclusion

This study demonstrates that medical students in Sudan experienced profound behavioral, emotional, and cognitive changes during societal unrest, including fatigue, feelings of failure, impaired functioning, and sleep disturbances. The findings underscore the combined impact of the COVID-19 pandemic and the ongoing conflict, which have heightened the need for accessible mental health services.

It is critical that institutions provide targeted mental health support, including psychiatric counseling, cognitive-behavioral therapy, and helplines, to address the significant distress reported by students. Future interventions should aim to promote both pharmacological and non-pharmacological coping strategies that are evidence-based and culturally sensitive.

While the study highlights these critical issues, further research is needed to explore long-term mental health outcomes and to design effective interventions tailored to the unique challenges faced by students in conflict zones.

Authors’ contributions

Conceptualization, Ali Awadallah Saeed, Abrar Abdu Abass, Aisha Ahmed Mohammed and Hiba Elhadi Ali; methodology, Ali Awadallah Saeed, Fidaaldeen Adil Abdallh, Raad Mohammed Osman and Toga Abdelmutaal Mohammed; software, Lamya Bashir Eisa; validation, Abrar Abdu Abass, Azza Osman Yousif, Hiba Elhadi Ali; formal analysis, Lamya Bashir Eisa; investigation, Ali Awadallah Saeed, Ahmad Mohammad Al Zamel, Aisha Ahmed Mohammed; resources, Toga Abdelmutaal Mohammed, Raad Mohammed Osman, Toga Abdelmutaal Mohammed, Nooralain Mohammed Hassan; data curation, Lamya Bashir Eisa; writing—original draft preparation, Ahmad Mohammad Al Zamel; writing—review and editing, Ali Awadallah Saeed, Ahmad Mohammad Al Zamel; supervision, Ali Awadallah Saeed. All authors have read and agreed to the published version of the manuscript.

Funding

The authors received no funding for conducting this research.

Data availability

Data is provided within the manuscript.

Declarations

Ethical approval and consent to participate

Ethical approval was obtained from Research Ethical Committee (REC), National University - Sudan (Approval No.: NU-REC/014–024/14). Participants were informed about the study’s purposes and gathered data will be confidential and used only for research purposes. Informed consent was obtained from all participants prior to filling out the questionnaire, in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.