Patterns of herbal medicine utilization for hypertension during the Sudanese crisis of 2025

Abstract

Sudan’s healthcare system has been severely disrupted by the ongoing humanitarian crisis, limiting access to essential services and medications. Understanding health-seeking behaviors during such disruptions is critical to informing culturally appropriate public health responses, particularly regarding traditional medicine use. This study aimed to assessPatterns of Herbal Medicine Utilization for Hypertension During the Sudanese Crisis of 2025. This cross-sectional study was conducted from February to June 2025 among adults with physician-diagnosed hypertension who were prescribed antihypertensive medication at diagnosis. Data were collected using a structured validated questionnaire administered face-to-face using Kobo Toolbox. Convenience sampling yielded 749 valid responses. Data were analyzed using SPSS v27, with statistical significance set at p < 0.05. The mean age was(56.8 ± 11.9) years; (54.1%) were female, (29.8%) were displaced and (50.5%) reported difficulty accessing antihypertensive medications. Herbal medicine use was reported by (91.2%); 65.2% used herbs before and during the crisis, and (19.8%) initiated use after the crisis began. Concurrent use of herb-drug use was reported by (71.7%), while adverse effects were uncommon(5.7%), and mostly mild. Lower income and rural residence were significantly associated with herbal use (p < 0.05). Herbal medicine use was wide spread among hypertensive Sudanese adults during the crisis, largely driven by affordability, accessibility challenges, and cultural familiarity. Given the high rate of concurrent use, public health messaging and clinician training on herb–drug safety should be prioritized.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-026-37696-4.

Introduction

Data from the World Health Organization (WHO), Global Burden of Disease (GBD) study, and the Non-Communicable Disease Risk Factor Collaboration (NCD-RisC) indicate that hypertension prevalence continues to rise globally, making it a major cause of heart disease, stroke, and early death^1,2. Currently, one billion individuals meet the standard diagnostic criteria (systolic ≥ 140 mmHg and/or diastolic ≥ 90 mmHg), yet only 54% are diagnosed, 42% receive treatment, and 21% achieve blood pressure control, highlighting significant gaps in prevention and management^1–5. In Africa and the Arab region, prevalence ranges from 26% to over 45%, with urban-rural disparities reflecting differences in lifestyle, socioeconomic status, and healthcare access^6–14.In Sudan, located in Northeast Africa, hypertension prevalence is approximately 30% in urban northern areas, 15–38% in rural regions, and reaches 50% among Nubian populations in the south^9–12.

Furthermore, Sudan’s healthcare system faces severe challenges due to limited infrastructure, socioeconomic constraints, political instability, and an ongoing humanitarian crisis, all of which hinder effective diagnosis, treatment, and control of diseases In conflict-affected regions, over half of patients with chronic illnesses experience significant barriers to care, including unaffordable medications, disrupted drug supplies, and displacement, often resulting in worsened symptoms, psychological distress, and increased hospitalization¹⁵.

Traditional or complementary medicine (TMC)refers to knowledge and practices aimed at preventing or treating illness, passed down through generations based on experience and observation, whether orally or in writing¹⁶. According to WHO, herbal medicine is composed of herbs, herbal materials, herbal preparations, and herbal products with active components from plants or plant parts or mixtures¹⁷.

Globally, 75–80% of the population, particularly in developing countries, uses herbal medicine due to its perceived safety, accessibility, affordability, and socio-cultural relevance^18–20.Herbal medicine is increasingly applied to manage hypertension, either alongside or as an alternative to conventional treatments^18,21,22. Several herbs, including doum (Hyphaene thebaica) or Gingerbread palm, garlic, ginger, fenugreek, cinnamon, and lemon, have been scientifically validated for their hypotensive effects over the past 30 years^18,21. In Sudan, herbal medicine is deeply rooted in cultural practices and has long provided an accessible, affordable health option, especially in regions where formal healthcare is limited or disrupted during crises^16,23.

Although widely used for hypertension in Africa and the Middle East, recent evidence on the use of herbal remedies in conflict-affected areas of Sudan remains limited^7,22,24–26. Evidence is particularly scarce regarding prevalence, types of products, preparation methods, patterns of concurrent use with antihypertensives, and associated safety concerns.

Understanding recent use patterns is crucial for developing effective culturally sensitive health interventions, highlighting how traditional practices adapt to systemic healthcare gaps, and informing public health strategies that mitigate risks such as herb–drug interactions, and support integrative care during the dual burden of hypertension and healthcare disruption in the Sudanese humanitarian crisis.

Therefore, this study aimed to assess the prevalence and patterns of herbal medicine use for hypertension management during the crisis, comparing usage before and during the crisis and exploring factors influencing these practices. We hypothesized that herbal medicine use increased due to reduced access to conventional antihypertensive. By documenting usage trends, preparation methods, and perceived safety, this study provides evidence to guide clinical counseling, public health policy, and culturally sensitive integrative approaches to hypertension care in conflict-affected settings.

Methods and materials

Sampling and study population

We conducted a descriptive cross-sectional study between February and June 2025. The target population was adults (≥ 18 years) with physician-diagnosed hypertension who were prescribed antihypertensive medication at diagnosis and who had lived in Sudan for ≥ 6 months during the crisis. The sample size formula for a single proportion [n = z² x (p) x (1 – p) ÷ e²] was used to estimate a minimum sample size of 385 (95% CI, margin of error 5%, assumed prevalence 50%). A convenience (non-probability) sampling approach was used because ongoing insecurity and restricted access prevented probabilistic household or clinic sampling in many areas. We recruited 749 participants to increase the descriptive power and sociodemographic diversity of the sample; however, this does not remove the potential for selection bias and limits generalizability (see Limitations).

Research area

The study aimed to include participants from all 18 states of Sudan. However, due to the ongoing armed conflict and intermittent internet access during the data collection period, complete nationwide coverage was not achieved. Most responses were obtained from Al-Gadarif, Khartoum, Kassala, Red Sea, River Nile, and Northern State, with smaller numbers from White Nile, Al-Gezira, and Kordofan. Participant distribution across states was unequal, reflecting the varying levels of accessibility and safety during the crisis. Figures (1).

Fig. 1.

Map illustrating security and stability levels across Sudanese states during the study period (February–June 2025). Generated by Google Gemini (December 2025) using data sourced from Vista Maps (vistamaps.xyz). This figure displays the classification of Sudanese states based on security status relevant to field accessibility during the study period. Each state is represented using three predefined categories: secure areas (green), unstable or recently recovered areas (yellow), and insecure conflict areas (red).Information on state stability levels was sourced from VistaMaps (https://www.google.com/url? sa=t&source=web&rct=j&opi=89978449&url=https://vistamaps.xyz/&ved=2ahUKEwjz6qvOwcaRAxVD3wIHHdn6NYkQFnoECCUQAQ&usg=AOvVaw0ywHQvP7BEXyng3MDcJRIJ).

Map illustrating security and stability levels across Sudanese states during the study period (February–June 2025). Generated by Google Gemini (December 2025) using data sourced from Vista Maps (vistamaps.xyz).

Data collection methods and tools

Data collection

Data were collected using a structured Arabic questionnaire administered through face-to-face interviews by trained data collectors using Kobo Toolbox. The platform allowed data entry in both online and offline modes, enabling uninterrupted collection in areas with stable or limited internet connectivity. Data collected offline were synchronized once internet access was available, ensuring standardized and continuous data collection despite conflict-related connectivity challenges.

Questionnaire development, piloting and translation

The questionnaire was developed in Arabic. It was reviewed and revised by three content experts (see Acknowledgements) and pilot tested with 80 participants (not included in the final sample) to assess comprehension and internal consistency. Cronbach’s α for the piloted questionnaire was 0.691. The Arabic-English translation for reporting and supplementary materials was checked by a bilingual expert to ensure semantic equivalence(see Acknowledgements).Supplementary materials [S1, S2] are the arabic and the translated english versions of the questionnaire.

Income reporting and classification

Income was collected in Sudanese pounds (SDG) and recorded as monthly household income categories used in the questionnaire. To aid international readers, these categories were grouped into broader descriptive classifications: low income (< 100,000 SDG), lower-middle income (100,000–300,000 SDG), middle income (300,000–600,000 SDG), upper-middle income (600,000–1,000,000 SDG), and high income (> 1,000,000 SDG).

Data management and analysis

749 responses remained after applying the response selection criteria, and removing the duplications.

Statistical analysis was done by SPSS version 27 (IBM Co., Armonk, NY, USA). Categorical variables were presented as frequencies and percentages and analyzed using chi-square and exact tests. Numerical variables were presented as mean and standard deviation and analyzed using independent t-test. P-value < 0.05 is considered statistically significant.

Ethics

Ethical approval was obtained from the Ministry of Health Research Ethics Committee, Northern State (supplementary materials [S3]). Informed consent was obtained from all participants. Data were collected anonymously and stored securely.

Results

A total of 749 participants participated in this study. The mean age of the participants was 56.81 years. The majority of participants were female, comprising 405 (54.1%). Additionally, most participants were married, comprising 584 (78.0%). Approximately one-third of the participants, 254 (33.9%), were secondary school graduates. Regarding income level, 228 (30.4%) of the participants earn a low monthly income. However, most participants, 328 (43.8%), were not employed. The highest percentage of the participants, 518 (69.2%), lived in an urban area (Table 1).

Table 1.

Characteristics of the participants (N = 749).

Age		Mean	SD
		56.81	11.92
		N	%
Gender	Male	343	45.8
	Female	405	54.1
	Prefer not to say	1	0.1
Marital status	Single	22	2.9
	Married	584	78.0
	Divorced	28	3.7
	Widowed	114	15.2
	Prefer not to say	1	0.1
Level of education	Uneducated/Non-Formal education	193	25.8
	Primary School graduate	166	22.2
	Secondary School graduate	254	33.9
	University graduate	112	15.0
	Higher Education	24	3.2
Income Level	Low income	228	30.4
	Lower – middle income	200	26.7
	Middle income	159	21.2
	Upper – middle income	73	9.7
	High income	89	11.9
Occupation	Unemployed	328	43.8
	Employer	141	18.8
	Farmer/Trader	147	19.6
	Labor Jobs	57	7.6
	Other	76	10.1
Current place of residence	Rural area	221	29.5
	Urban area	518	69.2
	Camp	10	1.3

SD: Standard deviation, N: Frequency, %: Percentage.

Regarding displacement status, 223 (29.8%) of the participants were displaced, including 163 (73.1%) participants, were displaced from Khartoum. Furthermore, most of the displaced participants, 182 (81.6%), had been displaced for more than one year (Table 2).

Table 2.

Displacement status of the participants.

		N	%
Current displacement status	No	526	70.2
	Yes	223	29.8
Areas of displacement (N = 223)	Al Jazeera	40	17.9
	Darfur	6	2.7
	Khartoum	163	73.1
	Kordofan	3	1.3
	Other	11	4.9
Duration of their displacement (N = 223)	Less than 6 months	8	3.6
	6_12 months	33	14.8
	More than 12 months	182	81.6

N: Frequency, %: Percentage.

Most participants, 275 (36.7%), had been diagnosed with hypertension 1 to 5 years ago, while 41 (5.5%) had been diagnosed with hypertension 20 years ago. The majority of the participants, 636 (84.9%), took prescribed anti-hypertensive medications. Furthermore, 378 (50.5%) of the participants found it difficult to access prescribed antihypertensive medications due to the current crisis (Table 3).

Table 3.

Duration since hypertension diagnosis and its medications, and their accessibility during the current crisis.

		N	%
Duration since hypertension diagnosis	Less than 1 year	45	6.0
	1_5 years	275	36.7
	6_10 years	242	32.3
	11_20 years	146	19.5
	More than 20 years	41	5.5
Current use of prescribed anti-hypertensive medications	No	113	15.1
	Yes	636	84.9
Difficulty in accessing prescribed antihypertensive medications due to the current crisis	No	371	49.5
	Yes	378	50.5

N: Frequency, %: Percentage.

Most participants, 488 (65.2%), had used herbal medicine both before and during the crisis/war, while 148 (19.8%) of them used herbal medicine during the crisis/war only. Of the 683 participants who used herbal medicine, 320 (46.9%) changed herbal use during the Sudanese crisis/war(Table 4).

Table 4.

Herbal medicine use and change of herbal medicine during the Sudanese crisis.

		N	%
Herbal medicine use to manage hypertension before or during the Sudanese crisis/war	No, I have never used herbal medicine to manage my hypertension	66	8.8
	Yes, I used herbal medicine before the crisis/war	47	6.3
	Yes, I used herbal medicine during the crisis/war	148	19.8
	I have used herbal medicine both before and during the crisis/war	488	65.2
Change of herbal medicine during the Sudanese crisis/war (N = 683)	No	363	53.1
	Yes	320	46.9

N: Frequency, %: Percentage.

Most participants, 526 (77.0%), used hibiscus as aherbal medicine for hypertension, while only 49 (7.2%) and 50 (7.3%) of them used Black seedsand moringa, respectively, as herbal medicines for hypertension (Table 5).

Table 5.

Herbal medicine used for hypertension treatment.

Herbal medicine (N = 683)	Scientific Name	N	%
Hibiscus (Karkadeh)	Hibiscus sabdariffa	526	77
Doum	Hyphaene thebaica	125	18.3
Garlic	Allium sativum	123	18
Ginger	Zingiber officinale	106	15.5
Fenugreek	Trigonellafoenum-graecum	103	15.1
Cinnamon	Cinnamomum spp.	93	13.6
Lemon	Citrus limon	92	13.5
Mint	Mentha spp.	55	8.1
Moringa	Moringa oleifera	50	7.3
Black seeds	Nigella sativa	49	7.2

N: Frequency, %: Percentage.

Of the 683 herbal medicine users, the plant parts utilized varied by herb (Table 6). Hibiscus flowers were most common (67.3% of hibiscus users), while roots were predominant for ginger (89.6%) and garlic (61.0%). Seeds were mainly used for fenugreek (88.3%) and black seeds (91.8%), and fruits for doum (92.0%). Multiple plant parts were often reported for the same herb.

Table 6.

Part of the plant used as herbal remedy for hypertension.

Herbal medicine	Leaves N (%)	Roots N (%)	Fruits N (%)	Flowers N (%)	Seeds N (%)	Other N (%)	Total
Hibiscus (Karkadeh)	137 (26.0%)	110 (20.9%)	53 (10.1%)	354 (67.3%)	24 (4.6%)	1 (0.2%)	526
Garlic	14 (11.4%)	75 (61.0%)	45 (36.6%)	15 (12.2%)	12 (9.8%)	1 (0.8%)	123
Ginger	7 (6.6%)	95 (89.6%)	14 (13.2%)	11 (10.4%)	10 (9.4%)	0 (0.0%)	106
Black seeds	2 (4.1%)	4 (8.2%)	8 (16.3%)	7 (14.3%)	45 (91.8%)	0 (0.0%)	49
Moringa	45 (90.0%)	0 (0.0%)	1 (2.0%)	3 (6.0%)	1 (2.0%)	0 (0.0%)	50
Fenugreek	5 (4.9%)	13 (12.6%)	17 (16.5%)	15 (14.6%)	91 (88.3%)	0 (0.0%)	103
Lemon	4 (4.3%)	6 (6.5%)	88 (95.7%)	12 (13.0%)	4 (4.3%)	0 (0.0%)	92
Cinnamon	6 (6.5%)	72 (77.4%)	14 (15.1%)	10 (10.8%)	6 (6.5%)	13 (14.0%)	93
Mint	37 (67.3%)	8 (14.5%)	14 (25.5%)	20 (36.4%)	9 (16.4%)	0 (0.0%)	55
Doum	11 (8.8%)	22 (17.6%)	115 (92.0%)	20 (16.0%)	11 (8.8%)	0 (0.0%)	125

Of the 526 participants who used hibiscus, 423 (80.41%) of them consumed hibiscus by steeping (soaking). Of the 123 participants who used garlic, 104 (84.55%) of them consumed garlic as raw herbs (e.g., eating directly). Of the 106 participants who used ginger, 97 (91.5%) of them consumed ginger by steeping (soaking). Of the 103 participants who used fenugreek, 79 (76.69%) of them consumed fenugreek by boiling. Of the 125 participants who used doum, 75 (60%) of them consumed doum, by steeping (soaking)(Table 7).

Table 7.

Methods of Preparing and consuming herbal remedies for hypertension.

Methods of preparing and consuming herbals	As raw herbs (e.g., eating directly) N (%)	As powdered herbs mixed with water N (%)	Steeping (Soaking) N (%)	Boiling N (%)	Other N (%)
Hibiscus (Karkadeh)	39(7.41%)	82(15.58%)	423(80.41%)	271(51.52%)	3(0.57%)
Garlic	104(84.55%)	26(21.13%)	7(5.69%)	12(9.75%)	0(0%)
Ginger	15(14.15%)	11(10.37%)	97(91.5%)	29(27.35%)	0(0%)
Black seeds (Nigella Sativa)	43(87.75%)	2(4.08%)	5(10.2%)	8(16.32%)	1(2.04%)
Moringa	2(4%)	2(4%)	3(6%)	42(84%)	2(4%)
Fenugreek	30(29.12%)	19(18.44%)	20(19.41%)	79(76.69%)	1(0.97%)
Lemon	23(25%)	24(26.08%)	43(46.73%)	19(20.65%)	11(11.95%)
Cinnamon	11(11.82%)	21(22.58%)	14(15.05%)	79(84.94%)	0(0%)
Mint	14(25.45%)	9(16.36%)	6(10.9%)	48(87.27%)	1(1.81%)
Doum	59(47.2%)	55(44%)	75(60%)	19(15.2%)	0(0%)

Most participants reported not using additional herbs beyond their main remedy (600; 87.8%), yet herbal remedies were commonly used alongside prescribed antihypertensive medications (490; 71.7%). Regular use varied, with the highest proportion using herbs a few times per week (266; 38.9%). Long-term use was common, as 464 participants (67.9%) had used herbal treatments for more than one year. Adverse events were uncommon (39; 5.7%), mostly mild such as nausea or dizziness (25; 64.1%). Herbal medicine was often viewed as more affordable than conventional drugs, with 211 (30.9%) reporting it as much more affordable. Among the small group commenting on accessibility (N = 47), most found herbs very accessible (42; 89.4%), and nearly all participants (673; 98.5%) said they would recommend herbal remedies to other hypertensive patients during the crisis(Table 8).

Table 8.

Use of herbal remedies, their side effects, and affordability.

		N	%
Use of any other herb	No	600	87.8
	Yes	83	12.2
Frequency of herbal remedies usage for blood pressure management	Daily	103	15.1
	A few times a week	266	38.9
	A few times a month	111	16.3
	Only when I have Symptoms	161	23.6
	Only when I cannot access conventional medicine	42	6.1
Concurrent use of herbal remedies and prescribed hypertension medications	No	193	28.3
	Yes	490	71.7
Duration of herbal treatment use	Less than 6 months	33	4.8
	6–12 months	55	8.1
	1–2 years	131	19.2
	3–5 years	209	30.6
	More than 5 years	255	37.3
Adverse events attributed to herbal treatments	No	644	94.3
	Yes	39	5.7
If yes, please describe the side effects (N = 39)	I am not sure if the side effects are due to the herbal treatments	5	12.8
	I have experienced mild side effects (e.g., nausea, dizziness)	25	64.1
	I have experienced significant side effects (e.g., allergic reactions, severe stomach issues)	9	23.1
Affordability of herbal medicines compared to conventional medications	Less affordable	196	28.7
	About the same	88	12.9
	Slightly more affordable	188	27.5
	Much more affordable	211	30.9
Accessibility of herbal medicines (N = 47)	Somewhat accessible	5	10.6
	Very accessible	42	89.4
Likelihood of recommending herbal medicine to other hypertensive patients during the crisis	No	10	1.5
	Yes	673	98.5

Participants who used herbs before the crisis were slightly older (59.9 ± 14.3 years) than those who began after the crisis (56.7 ± 11.6 years), though the difference was not significant (p = 0.132). Herbal use before the crisis was significantly associated with marital status, with a higher proportion of widowed individuals using herbs before the crisis (10; 21.3%) compared to after (103; 16.2%) (p = 0.026). Education also showed a strong association (p < 0.001), as those with higher education represented a larger proportion of pre-crisis users (6; 12.8%) than post-crisis users (16; 2.5%), while secondary education was more common among post-crisis users (228; 35.8%). Income level was also significant (p = 0.043), with fewer low-income participants using herbs before the crisis (7; 14.9%) compared to after (197; 31.0%). Residence was associated with timing of use (p = 0.039), as most pre-crisis users lived in urban areas (39; 83.0%), whereas rural residents were more represented among post-crisis users (208; 32.7%). No significant associations were found for gender (p = 0.278) or occupation (p = 0.073)(Table 9).

Table 9.

Association of herbal usage before and after crisis with patients’ characteristics.

	Herbal Usage	N	Mean ± SD	P Value
Age	Before crisis	47	59.94 ± 14.30	0.132
	After crisis	636	56.67 ± 11.63
		Herbal Usage		P Value
		Before crisis N (%)	After crisis N (%)
Gender	Male	25 (53.19%)	277 (43.55%)	0.278
	Female	22 (46.8%)	358 (56.28%)
	Prefer not to say	0 (0%)	1 (0.15%)
Marital status	Single	5 (10.63%)	11 (1.72%)	0.026*
	Married	31 (65.95%)	498 (78.3%)
	Divorced	1 (2.12%)	23 (3.61%)
	Widowed	10 (21.27%)	103 (16.19%)
	Prefer not to say	0 (0%)	1 (0.15%)
Level of education	Uneducated/Non-Formal education	13 (27.65%)	164 (25.78%)	< 0.001*
	Primary School graduate	13 (27.65%)	144 (22.64%)
	Secondary School graduate	7 (14.89%)	228 (35.84%)
	University graduate	8 (17.02%)	84 (13.2%)
	Higher Education	6 (12.76%)	16 (2.51%)
Income Level	Low income	7 (14.89%)	197 (30.97%)	0.043*
	Low – middle income	18 (38.29%)	165 (25.94%)
	Middle income	13 (27.65%)	143 (22.48%)
	Upper -middle income	7 (14.89%)	62 (9.74%)
	High income	2 (4.25%)	69 (10.84%)
Occupation	Unemployed	18 (38.29%)	275 (43.23%)	0.073
	Employer	9 (19.14%)	109 (17.13%)
	Farmer/Trader	16 (34.04%)	125 (19.65%)
	Labor Jobs	3 (6.38%)	53 (8.33%)
	Other	1 (2.12%)	74 (11.63%)
Current place of residence	Rural area	7 (14.89%)	208 (32.7%)	0.039*
	Urban area	39 (82.97%)	419 (65.88%)
	Camp	1 (2.12%)	9 (1.41%)

There was a statistically significant association between herbal usage before and after crisis and method of preparing and consuming hibiscus for hypertension, as, percentage of participants who consumed hibiscus by steeping (soaking) before crisis 35 (94.59%) was higher than the percentage of participants who consumed hibiscus by steeping (soaking) after crisis 388 (79.34%) (P = 0.024) (Table 10).

Table 10.

Association of herbal usage before and after crisis with methods of Preparing and consuming herbal remedies for hypertension.

Methods of preparing and consuming herbals	Herbal Usage		P Value
	Before crisis N (%)	After crisis N (%)
Karkadeh by steeping (Soaking)	35 (94.59%)	388 (79.34%)	0.024*
Garlic as raw herbs (e.g., eating directly)	10 (83.33%)	94 (84.68%)	> 0.999
Ginger by steeping (Soaking)	2 (28.57%)	9 (9.09%)	0.154
Black seeds (Nigella Sativa) as raw herbs (e.g., eating directly)	3 (100%)	40 (86.95%)	> 0.999
Moringa by boiling	1 (100%)	41 (83.67%)	> 0.999
Fenugreek by boiling	2 (66.66%)	77 (77%)	> 0.999
Lemon by steeping (Soaking)	2 (50%)	41 (46.59%)	> 0.999
Cinnamon by boiling	6 (85.71%)	73 (84.88%)	> 0.999
Mint by boiling	6 (100%)	42 (85.71%)	0.59
Doum by steeping (Soaking)	5 (83.33%)	70 (58.82%)	0.400

The logistic regression revealed that marital status was a strong significant predictor of herbal medicine use. Married individuals were over 11 times more likely to use herbal remedies (OR = 11.56, p = 0.001), while divorced and widowed individuals also showed significantly increased odds (OR = 14.81, p = 0.039 and OR = 9.93, p = 0.010, respectively). Furthermore, compared to participants earning a low monthly income those earning a low-middle and middle income being 73% (OR = 0.27, p = 0.015) and 70% (OR = 0.30, p = 0.039) less likely to use herbal medicine after crisis. Residing in an urban area was also associated with 60% lower odds of usage after crisis compared to rural areas (OR = 0.40, p = 0.043). (Table 11)

Table 11.

Multiple logistic regression for the factors associated with herbal usage before and after crisis.

Age	OR	P value	95% C.I.for OR
	0.97	0.069	0.94	1.00
Gender
Male		Ref.
Female	1.02	0.950	0.48	2.21
Prefer not to say	32484640.14	> 0.999	0.00
Marital status
Single		Ref.
Married	11.56	0.001*	2.69	49.76
Divorced	14.81	0.039*	1.15	191.41
Widowed	9.93	0.010*	1.74	56.78
Prefer not to say	536980899.28	> 0.999	0.00
Level of education
Uneducated/Non-Formal education		Ref.
Primary School graduate	1.70	0.287	0.64	4.55
Secondary School graduate	3.67	0.023*	1.20	11.29
University graduate	0.90	0.875	0.24	3.42
Higher Education	0.22	0.057	0.05	1.05
Income Level
Low income		Ref.
Low-middle income	0.27	0.015*	0.09	0.78
Middle income	0.30	0.039*	0.09	0.94
Upper-middle income	0.29	0.059	0.08	1.05
High income	2.27	0.407	0.33	15.78
Occupation
Unemployed		Ref.
Employer	1.35	0.617	0.42	4.33
Farmer/Trader	0.47	0.097	0.19	1.15
Labor Jobs	1.22	0.780	0.30	4.89
Other	3.76	0.248	0.40	35.48
Current place of residence
Rural area		Ref.
Urban area	0.40	0.043*	0.16	0.97
Camp	0.23	0.229	0.02	2.52

*: Significant as P value < 0.05.

Discussion

This study examined the prevalence, patterns, and cultural and socioeconomic determinants of herbal-medicine use for hypertension management among Sudanese patients. We compared use before and during the national crisis and identified the most commonly used remedies as well as patients’ perceptions of their safety. Overall, 91.2% of participants reported using herbal medicine, with 65.2% continuing its use through the crisis and 19.8% initiating use during the crisis, indicating that herbal medicine is well established in this population and that the crisis further prompted adoption among specific subgroups.

Several socio-cultural and economic factors contributed to the marked increase in herbal-medicine use for hypertension management, rising from 47 users before the crisis to 636 afterward. Age, gender, and occupation showed no significant associations with herbal-medicine use, whereas marital status, education level, income, and place of residence were all significantly associated. Participants with moderate education levels were more likely to use herbal remedies alongside conventional treatments, while those with higher education relied less on them. Similarly, low-income and rural participants reported higher usage, likely reflecting limited access to conventional healthcare and the relative affordability and accessibility of herbal remedies. During the crisis, over half of participants experienced difficulty accessing prescription medications, with 30.9% reporting cost and 89.4% reporting accessibility as key reasons for using herbal treatments.

A recent descriptive cross-sectional community-based study on chronic disease medication accessibility in Sudan’s conflict-affected districts found that over half of patients faced severe challenges due to damaged healthcare infrastructure, economic burden (76.3% earned < $100/month), and insecurity (42.5%). Major obstacles were medication unaffordability (34%), low income (26.7%), disruption in drug supplies (23%), and displacement (35.7% displaced > 6 months). Therefore, only 16.7% accessed medications through government facilities, while many relied on private pharmacies and healthcare facilities (51.5% and 35% respectively), or herbal remedies (22.2%). The most frequent conditions were hypertension (33.3%) and diabetes (48.5%). Treatment inaccessibility led to reduced doses (12%), worsened symptoms (32%), psychological distress (19.9%), reduced work capacity (24.8%), and increased hospitalization (16.3%)¹⁵.

Previous studies examining the use of Complementary and Alternative Medicine (CAM), particularly traditional herbal medicine, among hypertensive patients in various conflict-affected countries have revealed consistent patterns in demographic factors. For instance, CAM use was reported by 29% of 440 hypertensive patients in Idikan, Nigeria, and by 85.7% of 4,575 patients in Palestine, where herbal medicine was the most common^22,25. Furthermore, a systematic analysis of traditional herbal medicine use among hypertension patients in Sub-Saharan Africa found an average CAM prevalence of 38.6% (range from 25% to 65%), where traditional herbal medicine dominated CAM use in 86.7% to 96.6%, due to the perceived failure of conventional drugs (31.7%), high cost of allopathic medications (23.1%), cultural practices and indigenous herbal knowledge (20.2%), limited access to formal healthcare services (19.2%), safety concerns about pharmaceutical products (9.6%), and negative past experiences with healthcare providers (6.7%)²⁶.

Hibiscus (Karkadeh), particularly the flower part, remained the most commonly used herbal remedy, reported by 77%of herbal users probably due to its well-documented anti-hypertensive properties, including vasodilatory and diuretic effects supported by several studies^27–29. Other frequently used herbs included Doum (Hyphaene thebaica) (18.3%), garlic (18%) ginger (15.5%), fenugreek (15.1%), cinnamon (13.6%), and lemon (13.5%).The commonly used plant parts, consistent with traditional practices, were doum(Hyphaene thebaica)fruits, ginger roots, and fenugreek seeds. These results are in line with a previous cross-sectional study by Mohamed et al. that reported that 85.9% of Sudanese adults used herbal remedies, mostly as teas, such as hibiscus (79.9%), peppermint (73.8%), Acacia nilotica (71.4%), ginger (69.8%), and fenugreek (66.9%), primarily for coughs, colds, gastrointestinal issues, and joint pain³⁰.

Steeping was the preferred preparation method, particularly for hibiscus, ginger, and doum(Hyphaene thebaica), while garlic and black seeds were often consumed raw. However, following the Sudanese crisis, hibiscus was steeped less often (P = 0.024), presumably because of resource constraints, availability, or herbal knowledge changes. Interestingly, mint leaves were used significantly more during the crisis (P = 0.035) due to their accessibility, affordability, and association with relaxation, calming effects, and digestive benefits^31–33. Thus, our data indicate that shifts in usage patterns were influenced by availability and accessibility, rather than cultural preference alone.

A Ukrainian study investigating strategies to combat hidden hunger, particularly after the COVID-19 pandemic and the Russian-Ukrainian war, highlights that phytonutrient retention can be maximized by targeting specific native mint species (peppermint and spearmint for drying; horsemint for freezing) and optimizing processing methods, which would support efforts to fortify food and improve nutritional sustainability³². This suggests that during national hardship, such herbs may provide physical and emotional relief, including the management of stress-induced hypertension.

Although clinical outcomes were not objectively measured, most participants (98.5%) reported perceived benefits from herbal remedies and expressed willingness to recommend them to other hypertensive patients. Long-term use was also common, with 37.3% reporting use for more than five years, suggesting sustained adherence and trust in these remedies.

Herbal remedies are often perceived as safe due to their natural origin³⁴; however, our study identified several safety concerns that were likely exacerbated by increased use during the crisis. Overall, 5.7% of users experiencing adverse effects with 64.1% mild (e.g., nausea, dizziness), and 23.1%significant (e.g., allergic reactions, severe gastrointestinal issues).Notably, 71.7% of herbal users concurrently took prescribed antihypertensives, raising the risk of herb-drug interactions that could alter absorption, metabolism, and excretion, potentially compromising treatment safety and efficacy^35–37.This risk is elevated by poor patient-health care provider communication, as patients rarely report herbal use and providers rarely ask, leading to missed interactions and possible harmful side effects from commonly used herbs like garlic, ginger, fenugreek, peppers, green tea, and hawthorn^38–41. Therefore, proper documentation and education on herbal use are essential, particularly for older patients with comorbidities or on multiple medications^38,41.

Furthermore, a cross-sectional study of 100 hypertensive patients at primary health centers in Khartoum, Sudan (2022–2023) raised concerns about the use of herbal remedies and adherence to prescribed medical treatment and found that 49% of hypertensive patients used herbal remedies, mainly hibiscus (31%).Despite, 90% being on prescribed medications, 51% demonstrated low adherence, which was even lower among herbal users (67.3%). Low adherence was significantly associated with polypharmacy (p = 0.001) and lack of confidence in treatment (p = 0.012),indicating that herbal remedy use negatively affects adherence to hypertension treatment²³.

Taken together, these findings suggest that herbal medicine use is highly prevalent among hypertensive patients in Sudan, influenced by accessibility, affordability, and cultural trust. The recent crisis appears to have prompted increased adoption of herbal remedies, particularly among rural, low-income, and moderately educated individuals, and led to changes in usage patterns, including preparation methods. While this study does not directly assess healthcare system performance, limited access and high costs during the crisis may have reinforced reliance on local remedies. These factors likely contribute to the persistence and adaptation of herbal practices during socio-political, financial, and health-system disruptions, reflecting patterns observed in other crisis-affected settings where CAM often serves as a primary or substitute source of care^15,42.

To the best of our knowledge, this is among the first studies examining herbal medicine usage in HTN management during a national crisis, presenting up-to-date knowledge on health practices and patient behavior under compromised healthcare systems. A major strength of our study is the large and diverse sample, including urban, rural, and displaced populations across multiple Sudanese states, which enhances representativeness and supports transferability to similar conflict-affected settings. The study also provides comprehensive evidence comparing both pre-crisis and during-crisis practices regarding prevalence, usage patterns, cultural drivers, and perceived safety of herbal medicine in HTN management. Additionally, the inclusion of socioeconomic, demographic, and displacement data allowed detailed understanding of the cultural, economic, and accessibility factors influencing herbal medicine use.

Several limitations must be acknowledged. The prevailing insecurity and logistical constraints, which prevented a probabilistic sampling approach and objective clinical measurements, resulted in a reliance on self-reported data for hypertension diagnosis and herbal use, which may be affected by recall and social-desirability biases. Given the strong traditional significance of herbal medicine, participants may have overstated perceived benefits and understated adverse effects, potentially influencing reports of herbal use, adherence, and safety. Of note, hypertension status and symptoms were also self-reported, creating the possibility of exposure misclassification.

Additionally, many participants concurrently used prescribed antihypertensives, yet the study did not systematically assess herb-drug interaction factors such as exposure level, dosage, or timing. The absence of clinical blood pressure measurements further limited assessment of the real-world effectiveness or safety of this self-managed combination therapy. Moreover, the wide diversity of herbs, preparation methods, and dosages complicates both standardization and the evaluation of safety profiles.

Notably, the ongoing national crisis may plausibly explain many of the observed patterns; however, the cross-sectional design restricts causal inference, and other influences, such as economic constraints or widespread cultural practices, may also play a role. Finally, despite the large and diverse sample, logistical and security challenges restricted access to several conflict-affected regions, preventing probabilistic sampling and resulting in a non-representative and uneven distribution of participants across states. For example, most responses came from Al-Gadarif, Khartoum, Kassala, Red Sea, River Nile, and Northern State, with fewer from White Nile, Al-Gezira, and Kordofan, reflecting unequal accessibility and safety across regions during the crisis. In addition, urban residents (69.2%) and individuals with higher education (over 50%) were overrepresented, likely under-capturing the experiences of rural populations and those in other regions, thereby limiting the generalizability of the findings.

Given these findings, targeted policy and public-health actions are warranted. For instance, Incorporating CAM literacy into frontline health-worker training would improve providers’ ability to identify common herbal practices, communicate appropriately with patients, and detect potential interaction⁴³. Besides, establishing monitoring mechanisms for herb–drug interactions within emergency health programs would enhance pharmaco vigilance and help mitigate safety risks in fragile settings^44,45. Additionally, developing culturally appropriate patient-education materials (e.g., brief, language-specific leaflets, pictorial aids, and short scripts) could further support safe and informed herbal use, particularly during periods of health-care disruption^46,47. Furthermore, our findings highlight the urgency of resilient pharmaceutical supply chains and emergency medication distribution systems to reduce reliance on unregulated alternatives during conflict^48–50.

Future research should use objective clinical measures and detailed documentation of herbal use to better assess the safety and effectiveness of herbal remedies, especially alongside antihypertensive medications. In addition to evaluating the quality, safety, and regulation of commonly used herbs is essential for evidence-based integration into primary care and emergency settings. Longitudinal or cohort studies are needed to clarify causal relationships and explore how factors like displacement, income, and medication access influence hypertension management over time. Moreover, expanding research to underrepresented and hard-to-reach populations, alongside qualitative methods, would highlight socio-cultural determinants of herbal use.

Conclusion

In conclusion, this study confirms high prevalence of herbal medicine use among patients with HTN in Sudan, a pattern present even before the ongoing crisis. Importantly, our findings suggest that the current socio-political and economic challenges have sustained and potentially exacerbated reliance on these remedies, due to healthcare inaccessibility, financial constraints, and persistent cultural traditions. Despite the remedies’ having perceived beneficial therapeutic effects, there are safety, quality, and concurrent drug interaction concerns. There is an urgent need for an integrative public health intervention that considers traditional knowledge while ensuring patient safety, especially in fragile health systems affected by ongoing conflict.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

BP

Blood Pressure

CAM

Complementary and Alternative Medicine

GBD

Global Burden of Disease

HTN

Hypertension

NCD-RisC

Non-Communicable Disease Risk Factor Collaboration

SDG

Sudanese Pound (Currency)

SPSS

Statistical Package for the Social Sciences

TMC

Traditional or Complementary Medicine

WHO

World Health Organization

Author contributions

All authors participated in the conceptualization and design of the study. Abdelfatah AEH contributed to writing and supervision. Al-Romaysa MOKE contributed to writing and supervision. Nereen AA contributed to writing. Thoraya SMS contributed to supervision and data analysis and manuscript editing. Sarah ASM contributed to data analysis. Maal OOM, Abdelrahman EOA, Fatima AOH, Watfaa SMI, Manar MHA, Mohamed AOA, Waad SAA, and Osman AAA contributed to data collection. Khalid MAH trained the data collectors, and Kamal A. A. Mohammed supervised the research process and provided critical guidance and revisions. All authors revised and approved the final draft of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ministry of Health Research Ethics Committee, Northern State. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki, ensuring respect for participants’ rights and dignity. Participation was entirely voluntary, and no identifying personal information was collected. Informed consent was obtained from all participants prior to their inclusion in the study.

Disclosure

The interpretation of results was supported by the use of artificial intelligence assistance provided by OpenAI’s language model, which aided in drafting and refining the results text. The final interpretations and conclusions presented in this study are the result of the authors’ independent analysis.