Abstract
Background
The conflict that began in Sudan in April 2023 has displaced over 6.6 million individuals, with hundreds of thousands seeking refuge in Egypt. Displaced populations face significant post-migration stressors that elevate the risk of psychological distress.
Objectives
This pilot study aimed to provide a preliminary estimate of the prevalence of probable posttraumatic stress disorder (PTSD) among Sudanese refugees in Cairo and identify associated sociodemographic risk factors.
Methods
A pilot cross-sectional survey was conducted with 397 Sudanese refugees recruited via convenience snowball sampling. We utilized the Arabic version of the PTSD Checklist for DSM-5 (PCL-5) to estimate the frequency of probable PTSD and gathered data on displacement history.
Results
The prevalence of probable PTSD in this sample was 70.8%. Multivariate analysis indicated that a prior psychiatric history and caregiving responsibilities were significantly associated with meeting the threshold for probable PTSD. Younger adults reported higher symptom scores, though age was not a significant predictor in the adjusted model. No significant differences in prevalence were observed between refugees who entered Egypt through legal versus unauthorized routes.
Conclusions
These preliminary findings reveal a high psychological burden among Sudanese refugees in Egypt, underscoring the acute nature of the crisis. There is an urgent need for the integration of culturally sensitive mental health screenings and psychosocial interventions within refugee response frameworks. Further longitudinal research is required to explore the long-term effects of displacement on this population.
Keywords: Probable PTSD, Refugees, Displacement, Trauma, Prevalence, Sudan conflict, Egypt
Introduction
Background
Sudan’s history of political instability culminated on April 15, 2023, in a violent conflict between the Rapid Support Forces (RSF) and the Sudanese Armed Forces (SAF), triggering the largest displacement crisis of the year [2]. The capital, Khartoum, which historically served as a hub for infrastructure and security, became a primary focal point of the violence, forcing millions to flee their homes [3]. Egypt has emerged as a primary destination for those seeking security, food, and medical care, hosting over 500,000 Sudanese refugees as of early 2024 [4]. This sudden and traumatic displacement has exposed civilians to extreme trauma, including direct violence and the collapse of social structures, necessitating an urgent assessment of the psychological toll on this population.
To understand the psychological burden on this population, we adopted an interactional framework approach ([5] This model suggests that refugee mental health is not shaped solely by the initial trauma of war, but by the compounding effect of post-migration stressors—such as economic instability and legal limbo—interacting with those earlier experiences. War exposure is a primary driver of distress, and high prevalence rates of psychological morbidity have been consistently documented in other war-affected populations, such as those studied by Farhood [6] and Karam [7] While the clinical threshold for probable posttraumatic stress disorder (PTSD) involves symptoms of intrusion, avoidance, and hyperarousal, research suggests that symptom severity is positively correlated with the frequency and intensity of life-altering traumatic events experienced during migration [8].
Since the onset of the conflict, the number of Sudanese refugees in Egypt has increased significantly, with many individuals arriving after facing atrocities or resorting to difficult border crossings facilitated by smugglers [9]. These refugees face a complex host environment where the need for security is often met with the uncertainty of legal status and the loss of social networks, which further compounds the trauma of their initial experiences [10]. Current global estimates suggest that millions of war survivors living in postwar regions suffer from probable PTSD, highlighting the pervasive nature of war-related trauma on a global scale [11].
Despite the scale of this humanitarian crisis, there remains a significant gap in the literature regarding the mental health of Sudanese refugees specifically residing in Egypt. While a recent study by Haydar [12] examined the prevalence of probable PTSD among internally displaced persons (IDPs) within Sudan, the escalating violence has since forced hundreds of thousands of additional civilians to seek refuge abroad in a different socio-economic context. Given the distinct social support systems and stressors faced by refugees in Egypt compared to IDPs in Sudan, it is imperative to assess how these factors influence symptom prevalence. Therefore, the primary aim of this pilot study is to provide a preliminary estimate of probable PTSD prevalence and identify associated sociodemographic risk factors among Sudanese refugees in Cairo.
Literature review
Sudan’s ongoing conflict has entered its second year, yet the mental health outcomes of its displaced population remain under-researched. While exposure to war-related trauma is a known driver of psychological distress, the prevalence of probable posttraumatic stress disorder (PTSD) specifically among Sudanese refugees warrants urgent investigation. High prevalence rates of psychological morbidity have been consistently documented in other war-affected populations globally. Consistent with the high prevalence rates of psychological morbidity documented in other conflict-affected populations in the region [6]and [7], the trauma currently experienced by Sudanese refugees is expected to lead to severe mental health outcomes.
Egypt, which shares long-standing cultural and historical ties with Sudan, has become a primary destination for those seeking refuge. However, the host country’s distinct social support systems and economic conditions provide a contrasting context that may uniquely influence the resilience and vulnerability of these refugees [10], [13]. A significant gap exists in current psychiatric literature regarding this specific population. Most existing studies focus either on internally displaced persons (IDPs) within Sudan or on refugees who have resettled in high-income countries in Europe and North America. This overlooks the unique challenges faced by the hundreds of thousands of refugees residing in neighboring countries like Egypt, where post-migration stressors—such as legal uncertainty and limited access to formal mental health services—may exacerbate pre-existing trauma.
While a recent study by Haydar [12]examined probable PTSD among IDPs within Sudan, the subsequent escalation of violence has forced a large-scale migration into Egypt, creating an acute need for host-country-specific data. Therefore, this pilot study aims to address this gap by providing preliminary empirical evidence on the prevalence of symptoms exceeding the PTSD threshold among Sudanese refugees in Cairo. By identifying key sociodemographic risk factors, this research contributes to a more nuanced understanding of the mental health crisis facing this population and provides data necessary for developing targeted, culturally sensitive interventions.
Objectives
The primary aim of this pilot study was to estimate the prevalence of probable posttraumatic stress disorder (PTSD) among Sudanese refugees residing in Cairo, Egypt, following displacement caused by the April 2023 conflict. Additionally, the study sought to investigate the associations between symptom severity and key factors, including age, duration of stay in Egypt, and history of prior psychiatric conditions. By providing these preliminary data, the study aims to identify vulnerable subgroups within the refugee population to inform the development of targeted mental health support and intervention programs.
Materials and methods
Study design and area
A pilot cross-sectional descriptive study was conducted in Cairo, Egypt, to assess the prevalence of probable posttraumatic stress disorder (PTSD) among Sudanese refugees. Data collection took place over a 6-week period between August and September 2024. Cairo was selected as the study area due to its high concentration of Sudanese refugees and its role as a primary urban hub for displacement services.
Study population and sample
The study targeted Sudanese refugees residing in Cairo who were displaced following the onset of the conflict in April 2023.
| Inclusion criteria: | Exclusion criteria: |
|---|---|
|
• Aged 18 years and above • Sudanese nationality • Residing in Cairo at the time of the survey • Arrival in Egypt within 16 months following the April 2023 conflict |
• Refusal to provide informed consent |
Sample size and sampling technique
A convenience sampling method was employed to recruit participants. While a target sample size of 385 was determined using Cochran’s equation to provide an approximate guide for a 95% confidence level and 5% margin of error, this calculation was used as a preliminary benchmark rather than a strict requirement for representativeness, given the pilot nature of the study and the use of non-probability sampling.
Participants were recruited through the primary channel: snowball sampling initiated through trusted community leaders on social media platforms (primarily WhatsApp and Facebook groups used by the refugee community). A total of 447 individuals were invited to participate, of whom 402 responded. Following the application of inclusion and exclusion criteria, the final sample consisted of N = 397 participants, representing a response rate of 90%.
Data analysis
Quantitative data were analyzed using IBM SPSS Statistics (Version 25). Prior to analysis, the dataset was screened for missing values and outliers; listwise deletion was applied for cases with missing data, as the missingness rate was below 5%. Descriptive statistics, including means (M) and standard deviations (SD), were used to summarize participant characteristics.
Associations between categorical variables were assessed using Pearson’s chi-square (χ2) tests, while independent samples t-tests were used for continuous variables. Assumptions for parametric tests, including normality and homogeneity of variance, were verified. Variables with p < 0.05 in the univariate analysis were included in the subsequent multivariate binary logistic regression model to identify independent risk factors for probable PTSD. Although age showed borderline significance (p = 0.054), it was retained in the regression analysis due to its theoretical importance in the refugee mental health literature.
Multicollinearity among independent variables was assessed using Variance Inflation Factors (VIFs), with all VIFs below 5, indicating no significant collinearity. Statistical significance for all tests was set at p ≤ 0.05, and all p -values are reported as two-tailed.
PTSD measurement (PCL-5)
Symptoms of probable posttraumatic stress disorder (PTSD) were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) [14]The PCL-5 is a 20-item self-report instrument that evaluates the severity of symptoms across four clusters: re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal.
Each item is scored on a Likert scale ranging from 0 ("Not at all") to 4 ("Extremely"). In accordance with established scoring guidelines, a total score of ≥ 33 was used as the cutoff for a provisional diagnosis of probable PTSD. Additionally, the DSM-5 diagnostic rule was applied, requiring at least one symptom from category B (re-experiencing), one from category C (avoidance), two from category D (cognition/mood), and two from category E (hyperarousal) to be rated as at least "Moderately" (score of 2 or higher).
Justification for the arabic PCL-5 version
The study utilized the Arabic translation of the PCL-5 provided by the Los Angeles Department of Mental Health (LADMH). While other versions exist, such as the one validated by Ibrahim [15]and [16]. The LADMH version was selected due to its wide accessibility and its demonstrated clarity and cultural appropriateness in previous studies with diverse Arabic-speaking refugee populations. To ensure reliability within the current study context, the internal consistency of the scale was calculated. In this sample of Sudanese refugees, the PCL-5 demonstrated excellent internal consistency (Cronbach’s α = 0.918).
Interpretation of results
For the purposes of establishing the prevalence rate in this pilot study, a total severity score of ≥ 33 was used as the primary cutoff for probable PTSD. The DSM-5 symptom cluster criteria were utilized strictly for the secondary analysis of symptom profiles (e.g., re-experiencing vs. avoidance) presented in Table 2.
Table 2.
Number of participants for each response category of the PCL-5 questionnaire
| Characteristics: In the past month, have you experienced: |
Not at all | A little bit | Moderate | Quite a bit | Extremely |
|---|---|---|---|---|---|
| N = 397 | N = 397 | N = 397 | N = 397 | N = 397 | |
| n (%) | n (%) | n (%) | n (%) | n (%) | |
| Re-experiencing Questions | |||||
| Repeated, disturbing, and unwanted memories of the stressful experience? | 54 (13.6) | 53 (13.4) | 113 (28.5) | 92 (23.2) | 85 (21.4) |
| Repeated, disturbing dreams of the stressful experience? | 148 (37.3) | 85 (21.4) | 69 (17.4) | 53 (13.4) | 42 (10.6) |
| Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? | 111 (28) | 76 (19.1) | 74 (18.6) | 69 (17.4) | 67 (16.9) |
| Feeling very upset when something reminds you of a stressful experience? | 40 (10.1) | 58 (14.6) | 75 (18.9) | 80 (20.2) | 144 (36.3) |
| Having physical solid reactions when something reminds you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? | 164 (41.3) | 62 (15.6) | 73 (18.4) | 42 (10.6) | 56 (14.1) |
| Avoidance Questions | |||||
| Avoiding memories, thoughts, or feelings related to the stressful experience? | 56 (14.1) | 60 (15.1) | 63 (15.9) | 67 (16.9) | 151 (38.0) |
| Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? | 101 (25.4) | 41 (10.3) | 84 (21.2) | 61 (15.3) | 110 (27.7) |
| Negative alterations in cognition and mood: Questions | |||||
| Trouble remembering important parts of the stressful experience | 131 (33) | 62 (15.6) | 54 (13.6) | 69 (17.4) | 81 (20.4) |
| Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? | 113 (28.5) | 47 (11.8) | 51 (12.8) | 66 (16.6) | 120 (30.2) |
| Blaming yourself or someone else for the stressful experience or what happened after it? | 155 (39) | 57 (14.4) | 46 (11.6) | 47 (11.8) | 92 (23.2) |
| Having strong negative feelings such as fear, horror, anger, guilt, or shame? | 57 (14.4) | 51 (12.8) | 70 (17.6) | 64 (16.1) | 155 (39.0) |
| Loss of interest in activities that you used to enjoy? | 42 (10.6) | 40 (10.1) | 70 (17.6) | 57 (14.4) | 188 (47.4) |
| Feeling distant or cut off from other people? | 47 (11.8) | 53 (13.3) | 73 (18.4) | 67 (16.9) | 157 (39.5) |
| Are you having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? | 60 (15.1) | 62 (15.6) | 83 (20.9) | 75 (18.9) | 117 (29.5) |
| Hyperarousal Questions | |||||
| Irritable behavior, angry outbursts, or acting aggressively? | 116 (29.2) | 67 (16.9) | 64 (16.1) | 55 (13.9) | 94 (23.7) |
| Taking too many risks or doing things that could cause you harm? | 269 (67.8) | 55 (13.9) | 31 (7.8) | 17 (4.3) | 25 (6.3) |
| Being “super alert,” or watchful, or on guard? | 72 (18.1) | 56 (14.1) | 79 (19.9) | 71 (17.9) | 119 (30) |
| Feeling jumpy or easily startled? | 69 (17.4) | 60 (15.1) | 76 (19.1) | 68 (17.1) | 124 (31.2) |
| Having difficulty concentrating | 38 (9.6) | 52 (13.1) | 68 (17.2) | 90 (22.7) | 149 (37.5) |
| Trouble falling or staying asleep | 72 (18.1) | 46 (11.6) | 53 (13.4) | 65 (16.4) | 161 (40.6) |
It is important to note that the PCL-5 is a screening instrument and provides a provisional assessment of symptom severity. While the interpretation of scores follows clinical guidelines, these results indicate probable PTSD and do not constitute a formal clinical diagnosis, which would require a structured psychiatric interview conducted by a qualified clinician (e.g., the Clinician-Administered PTSD Scale for DSM-5, CAPS-5).
Results
Sociodemographic and probable PTSD prevalence
A total of 402 participants were initially recruited. After applying the inclusion and exclusion criteria, five individuals were excluded (three were under 18 years of age and two had resided in Egypt prior to April 2023), resulting in a final analytic sample of N = 397 Sudanese refugees. As shown in Table 1, the sample was relatively balanced by gender (52.4% female, n = 208). The mean age of participants was 29.3 years (SD = 12.7), with the vast majority of the sample (74.8%, n = 297) consisting of young adults aged 18–30.
Table 1.
Sociodemographic, displacement factors, and preexisting conditions and their associations with PTSD diagnosis via the chi-square test and Student’s t test*
| Variable | Categories | Total | PTSD Status | X2 / t | df | P value | |
|---|---|---|---|---|---|---|---|
| Positive PTSD | Negative PTSD | ||||||
| frequency (%)/Mean ± SD | frequency (%)/Mean ± SD | frequency (%)/Mean ± SD | |||||
| N = 397 | N = 281 | N = 116 | |||||
| Sex | Male | 189 (47.6) | 142 (75.1) | 47 (24.9) | 3.303 | 1 | 0.069 |
| Female | 208 (52.4) | 139 (66.8) | 69 (33.2) | ||||
| Age | - | 29.3 ± 12.7 | 28.5 ± 11.9 | 31.4 ± 14.3 | 1.935 | 183.5 | 0.054* |
| Age Groups | < 50 | 39 (9.8) | 24 (61.5) | 15 (38.5) | 3.979 | 2 | 0.137 |
| 18–30 | 297 (74.8) | 218 (73.4) | 79 (26.6) | ||||
| 30–50 | 61 (15.4) | 39 (63.9) | 22 (36.1) | ||||
| Caring for an ill individual | No | 225 (56.7) | 149 (66.2) | 76 (33.8) | 5.218 | 1 | 0.022 |
| Yes | 127 (43.3) | 132 (76.7) | 40 (23.3) | ||||
| Frequency of Displacement | Only Egypt | 134 (33.8) | 96 (71.6) | 38 (28.4) | 0.072 | 1 | 0.788 |
| Multiple Displacements | 263 (66.2) | 185 (70.3) | 78 (29.7) | ||||
| Legality of Entry | Legal Entry | 237 (59.7) | 186 (70.9) | 69 (29.1) | 0.003 | 1 | 0.955 |
| Illegal Entry | 160 (40.3) | 113 (70.6) | 47 (29.4) | ||||
| Duration of stay in Cairo | - | 8.9 ± 3.9 | 9 ± 4 | 8.5 ± 3.6 | -1.233 | 395 | 0.218* |
| Living Arrangement | Alone | 22 (5.5) | 19 (86.4) | 3 (13.6) | 3.180 | 2 | 0.204 |
| With Family | 343 (86.4) | 238 (69.4) | 105 (30.6) | ||||
| Friends or Relatives | 32 (8.1) | 24 (75) | 8 (25) | ||||
| Preexisting Conditions | No preexisting Condition | 250 (63) | 164 (65.6) | 86 (34.4) | 16.845 | 3 | 0.001 |
| Physiological | 56 (14.1) | 37 (66.1) | 19 (33.9) | ||||
| ○ Psychiatric | 70 (17.6) | 61 (87.1) | 9 (12.9) | ||||
| Both | 21 (5.3) | 19 (90.5) | 2 (9.5) | ||||
P values in bold indicate significance
Based on the PCL-5 cutoff score of ≥ 33, the prevalence of probable PTSD in this pilot sample was 70.8% (n = 281; see Fig. 1). Bivariate analyses (Table 1) indicated that providing care for an ill individual was significantly associated with meeting the threshold for probable PTSD, χ2 (1, N = 397) = 5.22, p = 0.022. While males reported a higher prevalence of probable PTSD (75.1%) than females (66.8%), this association only approached statistical significance, χ2 (1, N = 397) = 3.30, p = 0.069. Similarly, age showed a borderline significant association with symptom status; the mean age of those meeting the probable PTSD threshold (M = 28.5, SD = 11.9) was lower than that of those who did not (M = 31.4, SD = 14.3), t (183.5) = 1.94, p = 0.054.
Fig. 1.
PTSD probable diagnosis among participants
The specific symptom profile of the participants, categorized by the four DSM-5 symptom clusters, is detailed in Table 2. In the re-experiencing cluster, the most severe symptom reported was "feeling very upset when reminded of the stressful experience," with 36.3% (n = 144) of participants rating this as extreme. For the avoidance cluster, 38.0% of the sample (n = 151) reported an extreme tendency to "avoid memories, thoughts, or feelings" related to their trauma.
Within the cluster of negative alterations in cognition and mood, the most frequent extreme symptom was a "loss of interest in previously enjoyed activities" (47.4%, n = 188). Finally, in the hyperarousal cluster, 40.6% of participants (n = 161) reported extreme "difficulty falling or staying asleep." Collectively, these findings from Table 2 underscore a significant psychological burden, with symptoms related to cognitive disengagement and sleep disturbance being particularly pervasive in this refugee population.
Displacement factors and preexisting conditions
The mean duration of stay in Cairo for the study population was 8.9 months (SD = 3.9). There was no statistically significant difference in the duration of stay between those who met the threshold for probable PTSD (M = 9.0, SD = 4.0) and those who did not (M = 8.5, SD = 3.6), t (395) = -1.23, p = 0.218. As shown in Fig. 2, the arrival patterns of participants followed a bimodal distribution, with two distinct peaks observed at 14 months and 7 months prior to data collection. Notably, 51.0% of the participants arrived during the eight-month period following the attack on Medani in December 2023.
Fig. 2.
Frequency distribution of participants by duration of stay in Cairo (months)
Regarding displacement history, 66.2% (n = 263) of participants had experienced multiple displacements before reaching Cairo (Fig. 3). The prevalence of probable PTSD among those with multiple displacements (70.3%) was nearly identical to the prevalence among those who experienced a single displacement event to Egypt (71.6%), showing no significant association between the frequency of displacement and symptom status, χ2 (1, N = 397) = 0.07, p = 0.788 (Table 1). Similarly, the legality of entry into Egypt was not a significant determinant of probable PTSD; the prevalence among undocumented immigrants (70.6%) was nearly identical to that of authorized entrants (70.8%), χ2 (1, N = 397) = 0.003, p = 0.955. Most participants (86.4%, n = 343) resided with their families. Regarding health history, 17.6% (n = 70) of participants reported a prior psychiatric diagnosis, while 14.1% (n = 56) reported a physical illness. Preexisting health conditions were strongly associated with meeting the threshold for probable PTSD, χ2 (3, N = 397) = 16.85, p = 0.001. Specifically, participants with both psychiatric and physiological histories showed the highest prevalence of probable PTSD (90.5%), compared to 65.6% among those with no preexisting conditions (Table 1).
Fig. 3.
Number of participants by duration of stay in Cairo, comparing prior displacement and single displacement to Egypt
Association between risk factors and probable PTSD
To identify independent predictors of probable PTSD, variables that demonstrated a statistically significant association (p < 0.05) in the bivariate analysis—including age, caregiving status, and preexisting psychiatric history—were entered into a multivariate logistic regression model (Table 3). Prior to the analysis, multicollinearity diagnostics were performed; all Variance Inflation Factor (VIF) values were found to be below 1.4, confirming the suitability of the variables for the model.
Table 3.
Logistic regression predicting the risk factors for having PTSD
| variable | category | PTSD | |||
|---|---|---|---|---|---|
| Univariate Regression | Multivariate Regression | ||||
| OR (C.I) | p value | AOR (C.I) | P Value | ||
| Age | - | 0.983 (0.97–1) | 0.039 | 0.985 (0.97–1.00) | 0.106 |
| Caring for an ill individual | No | 1 | 1 | ||
| Yes | 1.683 | 0.023 | 1.6 (1.004–2.55) | 0.049 | |
| Preexisting Conditions | No preexisting Condition | 1 | 1 | ||
| Physiological | 1.021 (0.55–1.88) | 0.946 | 1.156 (0.59–2.24) | 0.670 | |
| Psychiatric | 3.55 (1.68–7.50) | 0.001 | 3.29 (1.55–6.97) | 0.002 | |
| Both | 4.98 (1.13–21.89) | 0.033 | 4.07 (0.91–18.16) | 0.066 | |
P values in bold indicate significance
In the univariate analysis, age was initially found to have a slight protective effect, with the odds of meeting the probable PTSD threshold decreasing by 1.7% for each additional year of age (OR = 0.98, 95% CI [0.97, 1.00], p = 0.039). However, after adjusting for confounding variables in the multivariate model, the association between age and probable PTSD was no longer statistically significant (p = 0.106).
The final multivariate model identified two independent predictors of probable PTSD: caregiving for an ill individual and a prior psychiatric diagnosis. Individuals who served as caregivers had 1.6 times greater odds of meeting the probable PTSD threshold compared to non-caregivers (AOR = 1.60, 95% CI [1.00, 2.55], p = 0.049). Additionally, a prior psychiatric history was the strongest predictor in the model; individuals with a pre-conflict psychiatric diagnosis had 3.29 times greater odds of reporting symptoms consistent with probable PTSD compared to those with no prior history (AOR = 3.29, 95% CI [1.55, 6.97], p = 0.002).
Discussion
This pilot study examined the prevalence of probable posttraumatic stress disorder (PTSD) among Sudanese refugees in Cairo shortly after the onset of the 2023 Sudan war. Our findings reveal an alarmingly high prevalence rate of 70.8%. This figure is significantly higher than the 29–37% prevalence typically reported in meta-analyses of war-refugee populations globally [11] and [5] This discrepancy likely reflects the acute phase of the displacement; our participants were surveyed within months of fleeing active combat, a period characterized by intense "event-related" distress.
When compared to the findings of Haydar [12]who reported a prevalence of approximately 50% among internally displaced persons (IDPs) within Sudan using a similar methodology, our higher rate suggests that the act of seeking refuge in a neighboring country introduces additional "post-migration" stressors. According to the interactional framework [5], the psychological state of a refugee is not only determined by the initial trauma of war but is exacerbated by the "daily stressors" of displacement, such as legal uncertainty, loss of social networks, and economic instability in the host country.
Regarding demographic vulnerabilities, our analysis revealed that although males reported a higher prevalence of probable PTSD (75.1%) than females (66.8%), this association only approached statistical significance. The literature on gender differences in trauma response is often complex and context-dependent. For example, a study by Ainamani et al. [17] among Congolese refugees in Uganda demonstrated distinct gender differences in response to war-related trauma, typically noting a higher symptom burden and vulnerability among females. The contrary trend observed in our Sudanese cohort—where men exhibited slightly higher rates of probable PTSD—may reflect the specific types of trauma and direct violence experienced by men during the acute phase of the Sudan conflict. Furthermore, it may highlight the intense post-migration pressures and role shifts faced by men struggling to secure employment and provide for their families in the Egyptian host environment. This underscores the need for gender-sensitive mental health interventions that account for the specific cultural and situational realities of this refugee population.
The high levels of distress found in this sample are consistent with findings from other conflict-affected populations in the region. Studies by Farhood and Noureddine (2013) [6] and Karam et al. (2006) [7], in war-affected Lebanon demonstrated that continuous exposure to violence and displacement creates a cumulative trauma effect, leading to high thresholds of probable PTSD. The pervasiveness of symptoms in our sample—particularly in the domains of sleep disturbance and cognitive disengagement (Table 2)—further underscores the profound psychological toll that the current Sudanese conflict is exerting on civilians.
The multivariate analysis identified prior psychiatric history and caregiving responsibilities as the strongest independent predictors of probable PTSD. The finding that individuals with a pre-conflict psychiatric diagnosis had 3.29 times greater odds of meeting the symptom threshold aligns with the "vulnerability-stress" model, suggesting that prior psychological fragility lowers the threshold for new war-related trauma to manifest as PTSD.
A striking finding in our analysis was the significant burden placed on those caring for ill family members. In a stable environment, caregiving is difficult; in the context of displacement, where formal healthcare is often inaccessible and extended family networks are shattered, this role becomes a profound source of secondary trauma. This identifies a specific, often invisible subgroup of refugees who are at high risk of burnout and require urgent, targeted psychosocial support.
Conversely, our study found no significant association between probable PTSD and legal status or age. The nearly identical prevalence rates between authorized (70.8%) and unauthorized (70.6%) entrants suggest that in the acute phase of a conflict, the "shock" of the primary trauma (war and flight) is so dominant that it overshadows the secondary stress of legal status. Similarly, while younger adults (18–30) reported higher raw scores, age was not a significant predictor in the final model. This "convergence" of symptom levels across different demographic groups suggests that the intensity of the current Sudan conflict is an "equalizer" of trauma, affecting all refugees regardless of their socio-economic or legal standing.
Ethical considerations
Participation in this study was entirely voluntary. The participants were educated on the objectives and methods of the study and freely chose to participate.
Written consent was obtained before the surveys were taken.
Ethical approval was granted by the Department of Community Medicine, Faculty of Medicine, University of Khartoum.
Implications and Future Directions.
The high prevalence of probable PTSD found in this pilot study suggests several critical pathways for policy and future research. First, it is recommended that governmental health facilities and international humanitarian agencies in Egypt prioritize the integration of mental health screening into primary care for newly arrived Sudanese refugees. Given the significant association between prior psychiatric history and current symptom severity, early identification of vulnerable individuals is essential to prevent the chronicization of trauma.
Second, future research should focus on the formal cultural validation of the Arabic PCL-5 specifically for Sudanese populations. While the tool is a robust screening instrument, its diagnostic accuracy in this unique cultural context warrants further investigation. Finally, it is recommended that future studies utilize longitudinal designs and qualitative methodologies to explore the long-term impact of post-migration stressors—such as legal status and social isolation—on the recovery trajectories of refugees.
Limitations
This pilot study has several limitations that must be considered when interpreting the findings. First, the use of convenience sampling and a cross-sectional design limits the generalizability of the results and precludes any definitive conclusions regarding causality. While the study identifies significant associations, it cannot confirm that the April 2023 conflict was the sole cause of the reported symptoms.
Second, the PCL-5 is a self-report screening tool and does not constitute a formal clinical diagnosis. A definitive PTSD diagnosis would require a structured clinical interview, such as the CAPS-5, conducted by a qualified mental health professional. Furthermore, this study did not inquire about specific traumatic events (Criterion A); while it is assumed that the war and subsequent displacement served as the primary stressors, the lack of data on specific events is a methodological constraint.
Third, several potential confounding variables were not measured, including participants’ education levels, employment status, and perceived social support, all of which are known mediators of mental health outcomes in refugee populations. Additionally, the study did not control for family clustering. Since multiple individuals from the same household may have participated, the independence of the data points may be compromised, as family members often share similar trauma exposures and post-migration living conditions. Finally, the study was limited to refugees residing in Cairo; therefore, the findings may not reflect the experiences of Sudanese refugees in other regions of Egypt or those in rural settings.
Conclusion
This pilot study was undertaken among Sudanese refugees residing in Egypt for up to sixteen months following the recent conflict. Our findings revealed that approximately 70% of the participants presented symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD). This high prevalence is highly concerning and underscores the profound psychological toll that prolonged displacement and exposure to conflict-related stressors can have on vulnerable populations.
These results compel us to consider broader implications for mental health policy and practice. The data suggest that cumulative exposures—ranging from repeated displacements to ongoing violence and uncertainty—significantly exacerbate PTSD symptoms. As corroborated by Ng et al. [18], and Yuval et al. [19]. it is not merely legal status or singular traumatic events but also the relentless accumulation of stressors that intensifies psychological distress. In light of these insights, targeted mental health interventions and comprehensive support programs are urgently needed to mitigate the adverse effects of trauma and to foster resilience among refugees.
Nevertheless, while this study provides important preliminary insights, it is not without limitations. The reliance on convenience sampling and the cross-sectional design limits the generalizability of our findings and precludes definitive conclusions regarding causality. Future research should strive to employ randomized sampling methods and longitudinal designs to capture the evolving nature of trauma exposure and recovery in this population. Moreover, further exploration of cultural factors and personal coping strategies will be essential in developing nuanced and effective mental health services [20].
In summary, our study contributes to a growing body of evidence that highlights the multifaceted and enduring impact of war-related trauma on refugee populations. By deepening our understanding of these dynamics, we hope to inform policymakers, humanitarian agencies, and mental health professionals, ultimately paving the way for interventions that are both evidence-based and culturally sensitive.
Acknowledgements
Department of Community Medicine University of Khartoum for Ethical Clearance
Author contributions
Aseel designed the research, wrote the manuscript, and did the data analysis. Shaza reviewed the manuscript and edited the discussion Ola reviewed the data analysis Galam, Mohamed and Muathal reviewed the manuscript.
Funding
The authors independently funded this research. No external funding was needed for this study.
Data availability
Research data supporting this publication are available upon request.
Declarations
Ethics approval
This research was approved by the Department of Community Medicine, Faculty of Medicine, University of Khartoum.
Ethical compliance
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards [1].
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Research data supporting this publication are available upon request.