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Post-Traumatic Stress Disorder Among Healthcare Providers Amid the Conflict in Sudan: A Call for Immediate Policy Action
2. Marwa Farag¹
Affiliations:
1. Doha Institute for Graduate Studies, Doha, Qatar, School of Economics, Administration and Public Policy (SEAPP)
Email: msh004@dohainstitute.edu.qa
Title
Authors:
1.
Mohannad Abdalfdeel Almahie Shaban¹²*
2.
Alzaiem Alazhari University, Khartoum North, Sudan, Faculty of Medicine
Corresponding Author:
Mohannad Abdalfdeel Almahie Shaban
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ABSTRACT
Background
Healthcare providers (HCPs) working in conflict settings face heightened risk of post-traumatic stress disorder (PTSD), yet empirical evidence from Sudan remains scarce. This study assessed the prevalence, severity, and predictors of PTSD and examined coping strategies among HCPs operating amid the ongoing armed conflict in Sudan.
Methods
A cross-sectional online survey was conducted between February and March 2025 among 528 HCPs practicing in five conflict-adjacent Sudanese states. Data was collected using a structured questionnaire that covered sociodemographic characteristics, trauma exposure, institutional support, and mental health outcomes. PTSD symptoms were assessed using the Impact of Event Scale–Revised (IES-R), with scores ≥ 33 indicating probable PTSD. Coping strategies were measured using the Brief COPE Inventory. Bivariate analyses and multivariable logistic regression were performed to identify predictors of PTSD.
Results
The prevalence of probable PTSD was 43.2% (95% CI: 39.0–47.4%), with 35.4% reporting severe symptoms. Higher PTSD risk was independently associated with exposure to three or more traumatic events (AOR = 3.41, 95% CI: 2.07–5.61), lack of crisis-management training (AOR = 2.28, 95% CI: 1.34–3.89), and working more than 48 hours per week (AOR = 1.89, 95% CI: 1.08–3.30). Younger age and fewer years of experience were also significant predictors. Maladaptive coping strategies, particularly self-blame and behavioral disengagement, showed strong positive correlations with PTSD severity, whereas acceptance demonstrated a modest protective association.
Conclusions
A substantial proportion of Sudanese HCPs are experiencing clinically significant PTSD amid ongoing conflict. These findings highlight an urgent need to integrate mental health and psychosocial support into emergency health responses, strengthen institutional protection, and expand trauma-informed training. Protecting the psychological well-being of frontline providers is essential for sustaining healthcare delivery in fragile and conflict-affected settings.
Keywords:
PTSD
Healthcare providers
Sudan
Conflict
Mental health
Coping strategies
Mental Health
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1. INTRODUCTION
Since April 15, 2023, an armed conflict has erupted in Sudan between the Sudanese Armed Forces (SAF) and the paramilitary Rapid Support Forces (RSF). The war has resulted in thousands of deaths, widespread destruction of infrastructure—including health facilities—and the displacement of millions of people (1). By early 2024, more than 10 million Sudanese had been internally displaced, representing about 13% of the global internally displaced population (2). The healthcare system—already fragile due to underfunding and workforce shortages—has been severely compromised. Only one-third of hospitals in conflict-affected areas remain functional, while roughly 70% are non-operational (3, 4). Additionally, recent national data also reflects this collapse. A recent study found low adherence to international guidelines (e.g., for rabies prophylaxis) among Sudanese physicians, symptomatic of a health system crippled by disrupted training and diminished capacity (5).
Furthermore, the conflict has created an increasingly hostile environment for healthcare providers (HCPs). According to the World Health Organization (WHO, 2023), between April and July 2023, 60 attacks were reported on HCPs, which led to 34 deaths and 38 injuries, alongside medical supplies being looted, and physicians were detained or forced to provide care under coercive conditions (6). Similar to other war-torn contexts, Sudanese HCPs are working under life-threatening circumstances, often witnessing severe trauma and death while lacking adequate protection and psychosocial support (7–9). Continuous exposure to traumatic events of this magnitude is a recognized risk factor for developing post-traumatic stress disorder (PTSD). PTSD is a mental disorder that develops following exposure to actual or threatened death, serious injury, or sexual violence and is characterized by persistent symptoms of intrusion, avoidance, negative alterations in cognition and mood, and heightened arousal and reactivity, lasting more than one month and resulting in clinically significant distress or functional impairment (10).
PTSD prevalence in conflict-affected populations is markedly higher than in non-conflict settings. Meta-analyses estimate that approximately 21–25% of individuals living in conflict zones meet diagnostic criteria for PTSD (11, 12). In sub-Saharan Africa, pooled prevalence reaches 30% among those exposed to war-related trauma (13). Within healthcare workforces, the risk is amplified: HCPs face dual exposure—as civilians affected by violence and as professionals caring for casualties. Studies among war-zone physicians and nurses have reported PTSD prevalence ranging from 15% to 90%, depending on proximity to combat and intensity of exposure (14–17). During the 2014 Gaza conflict, for instance, 89.8% of emergency and intensive-care staff exhibited significant PTSD symptoms (18).
Despite Sudan’s long history of civil wars, minimal empirical research has examined the psychological impact of the previous and the ongoing conflicts on HCPs. Earlier Sudanese studies focused mainly on internally displaced persons (IDPs) and refugees, revealing high PTSD prevalence rates ranging from 20% to 70% (19–22).
Moreover, in a national-level survey among 1,022 Sudanese civilians across 12 states to assess PTSD and well-being amid the current conflict, among the total participants, 167 (16.3%) were HCPs (23). The study reported that 56.9% of the overall sample met the threshold for PTSD, and a notably high 60.5% of HCPs screened positive for PTSD, with 27.5% experiencing poor well-being and 18% showing depressive symptoms. However, despite including HCPs, the study did not conduct a dedicated or in-depth analysis of PTSD risk factors specific to this subgroup, such as moral injury, exposure to mass casualties, or professional burnout. Instead, HCPs were grouped with the broader sample, limiting the study’s ability to isolate occupational trauma and its unique psychological consequences. Altogether, these studies neglected frontline healthcare personnel who continued to operate under extreme conditions. Before the current conflict, burnout and emotional exhaustion among Sudanese medical residents were already alarmingly high, suggesting that subsequent war exposure would exacerbate mental-health risks (24).
Since the conflict began in Sudan, a critical evidence gap has emerged. While humanitarian reports document health workers' physical threats, no peer-reviewed study has systematically assessed the prevalence, severity, and predictors of their PTSD. Addressing this gap is essential. PTSD not only undermines individual well-being but also affects professional performance, clinical decision-making, and the quality of patient care (25, 26). Furthermore, evidence on this burden is necessary to inform urgent health-policy responses, including the integration of mental-health and psychosocial-support (MHPSS) services into emergency preparedness plans. In addition, documenting this experience contributes to the global literature on occupational trauma in conflict settings, which remains particularly limited in low-income and fragile-state contexts (27, 28).
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Informed by theoretical models of trauma and coping and existing literature (29–31), this cross-sectional study aims to: estimate the prevalence and severity of PTSD among healthcare providers working during the current Sudan conflict; identify demographic, occupational, and trauma-related risk factors; and explore the associations between specific coping strategies and PTSD symptom severity. Ultimately, this research seeks to generate critical evidence that can deepen our understanding of occupational trauma in conflict settings and guide the development of targeted health policy interventions for frontline workers.
2. METHODS
2.1 Study Design and Setting
A cross-sectional descriptive study was conducted between February and March 2025 to estimate the prevalence and predictors of PTSD among HCPs working during the armed conflict that began on 15 April 2023 in Sudan. Data collection targeted five conflict-adjacent but relatively stable states that continued to provide partial healthcare services despite widespread insecurity and displacement.
2.2 Study Population and Eligibility
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The study population comprised physicians, nurses, pharmacists, laboratory technologists, and allied health professionals who were living and working in Sudan during the conflict. Eligible participants were required to have at least six months of active professional practice before data collection and to provide informed consent. Healthcare professionals who were abroad during the conflict were excluded.
2.3 Sample Size Calculation
The required sample size was determined using the single-proportion formula as described by Daniel (1999) (32) to calculate the sample size, assuming a 50% expected PTSD prevalence, a 95% confidence level, and a 5% margin of error, yielding a minimum of 384 participants. To account for possible non-responses or incomplete surveys, the target was increased by 30%. Consequently, 528 valid responses were included in the study.
2.4 Sampling and Recruitment Procedures
Due to the risks associated with fieldwork and limited mobility during the conflict, a convenience sampling strategy with voluntary participation was employed. The survey link was distributed through professional WhatsApp and Telegram hospital groups widely used by Sudanese HCPs for clinical communication and information exchange. Several safeguards were applied to reduce selection bias. Recruitment covered multiple regions and professional categories to enhance representativeness, while access to the groups was arranged through hospital medical directors and healthcare administrators to ensure that only verified HCPs from designated safe zones received the invitation. Data collectors were also healthcare providers but held no supervisory roles, which prevented hierarchical pressure and maintained voluntariness. Participation was anonymous, and Google Forms was configured to accept only one submission per authenticated Gmail account to avoid duplication. Periodic but non-coercive reminders were posted to increase engagement, ensuring that participation remained fully voluntary.
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These steps, together with the Institutional Review Board (IRB) oversight, strengthened internal validity and reduced the likelihood of both selection and participation bias while ensuring participant safety.
2.5 Data-Collection Tool
Data were collected using a self-administered structured questionnaire developed in English and validated by experts in psychiatry and public health. The instrument covered different parts, including sociodemographic and occupational characteristics, trauma exposure, PTSD symptoms, coping strategies, institutional support and awareness and utilization of digital mental health services. PTSD was assessed using the Impact of Event Scale-Revised (IES-R), which consists of 22 items rated from 0 (“not at all”) to 4 (“extremely”), with total scores ranging from 0 to 88; a cutoff score of 33 indicates probable PTSD (33). Coping strategies were measured using the Brief COPE Inventory, a 28-item scale identifying adaptive and maladaptive coping responses (34). Items on institutional and psychosocial support assessed crisis-management training, workload, and access to mental-health resources.
2.6 Variables and Measurements
The dependent variable was PTSD status, dichotomized as positive (IES-R ≥ 33) or negative (IES-R < 33). Independent variables included sociodemographic characteristics (age, gender, marital status, profession, years of experience), occupational factors (weekly working hours, trauma exposure, crisis-management training), and coping-strategy subscale scores derived from the Brief COPE.
2.7 Data Analysis
Data were analyzed using SPSS version 28 (IBM Corp., Armonk, NY, USA). Descriptive statistics summarized participant characteristics. Associations between categorical variables were examined using the chi-square test, and independent-sample t-tests were applied to continuous variables. Predictors showing significance at p < 0.05 were entered into a binary logistic regression model to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Pearson correlation coefficients were calculated to examine relationships between PTSD scores and coping-strategy subscales. Additional item-level outputs and extended descriptive analyses are provided in Supplementary File 1.
2.8 Reliability and Validity
Internal consistency was evaluated using Cronbach’s α, which demonstrated excellent reliability for both the IES-R (α = 0.92) and Brief COPE (α = 0.88). Face and content validity were established through expert review and pilot testing with 25 participants; their responses were excluded from the final analysis.
2.9 Ethical Considerations
Ethical approval
for this study was obtained from two institutional bodies.
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The first ethical clearance was issued by the Ministry of Health – North State, Sudan, under the Directorate General for Planning and Development, Research Administration, in collaboration with the University of Dongola, Faculty of Medicine, as the responsible institution.
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The second approval was granted by the Doha Institute for Graduate Studies IRB in Doha, Qatar (Reference No. DI-IRB-2025-S36).
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All study procedures adhered to both IRB guidelines. Participation was voluntary, electronic informed consent was obtained before data collection, and all responses were anonymized and stored securely. No identifying or sensitive personal data were collected, and participants were free to withdraw at any time without consequence.
3. RESULTS
3.1 Sociodemographic Characteristics
A total of 528 HCPs participated. Most of them were female (64.4%) and aged 25–34 years (76.7%), and 88.3% were single. Participants were from Kassala (27.7%), River Nile (25.2%), and Gedarif (25.0%), and 79.2% were internally displaced. The majority earned less than USD 100 per month (82.2%). Physicians accounted for 69.9% of participants, and most worked in teaching hospitals (67.4%). Nearly half had 1–5 years of experience (49.8%), and 43.4% had less than one year. About one-third reported a substantial increase in working hours during the conflict. (Table 1)
Table 1
Sociodemographic and Occupational Characteristics of HCPs (N = 528)
Characteristic
n (%)
Gender
  
Female
340 (64.4)
Male
188 (35.6)
Age group (years)
  
18–24
106 (20.1)
25–34
405 (76.7)
35–44
12 (2.3)
≥ 45
5 (0.9)
Marital status
  
Single
466 (88.3)
Married
56 (10.6)
Divorced/Widowed
6 (1.1)
Current state of residence
  
Gedarif
132 (25.0)
Kassala
146 (27.7)
Northern State
62 (11.7)
Red Sea
55 (10.4)
River Nile
133 (25.2)
Internally displaced due to conflict
  
Yes
418 (79.2)
No
110 (20.8)
Monthly income (USD)
  
< 100
434 (82.2)
100–300
75 (14.2)
301–500
11 (2.1)
> 500
8 (1.5)
Occupation
  
Physician
369 (69.9)
Nurse
79 (15.0)
Dentist
26 (4.9)
Pharmacist
25 (4.7)
Medical technician
22 (4.2)
Other
7 (1.3)
Health facility type
  
Teaching hospital
356 (67.4)
Government hospital/University hospital
129 (24.5)
Private hospital
29 (5.5)
Health center
14 (2.7)
Years of clinical experience
  
< 1 year
229 (43.4)
1–5 years
263 (49.8)
> 5 years
36 (6.8)
Working Hours During the Conflict
  
Slight increase (1–2 hrs/day)
128 (24.2%)
Moderate increase (3–4 hrs/day)
168 (31.8%)
Substantial increase (5 + hrs/day)
159 (30.1%)
3.2 Exposure to Trauma, Institutional Support, and Utilization of Digital Mental Health
About 36.9% of participants reported witnessing death or severe injury, 36.2% loss of a colleague or patient, and 31.8% exposure to armed violence, while 71.4% provided care to trauma-affected patients and 53.0% reported difficulty coping with patients or colleagues.
Furthermore, cumulative trauma exposure included one event (39.0%), two events (23.3%), and three or more events (37.7%). Additionally, 38.6% reported receiving workplace crisis-management training, and 34.1% had access to mental health services during the conflict. More than half were unaware of online mental health services (52.6%), while 78.9% of non-users reported a willingness to use free online PTSD care. (Table 2)
Table 2
Exposure to Trauma, Institutional Support, and Utilization of Digital Mental Health Services Among HCPs (N = 528)
Domain
Indicator
n (%)
Trauma exposure (high burden)
Witnessed death or severe injury
195 (36.9)
 
Loss of a colleague or a patient
191 (36.2)
 
Exposure to armed violence
168 (31.8)
 
Treated casualties from violent incidents
138 (26.1)
 
Difficulty coping with patients/colleagues
280 (53.0)
 
Provided care to trauma-affected patients
377 (71.4)
Cumulative trauma (significant predictor of PTSD)
One traumatic event
206 (39.0)
 
Two traumatic events
123 (23.3)
 
Three or more traumatic events
199 (37.7)
Training & institutional support gaps
Received crisis-management training (workplace)
204 (38.6)
 
Access to mental health services during conflict
180 (34.1)
 
Felt not at all supported by the employer
126 (23.9)
 
Felt very supported by the employer
36 (6.8)
 
Reported need for additional mental health training
123 (86.6)
Digital mental health (service gap & opportunity)
Unaware of online mental health services
257 (52.6)
 
Previously used online services
97 (18.4)
 
Willing to use free online PTSD care (non-users, n = 431)
340 (78.9%)
3.3 Prevalence and Severity of PTSD
In (Table 3), analysis of the (IES-R) revealed that 43.2% of participants met criteria for probable PTSD, while 56.8% did not. Based on severity categories, 38.1% were classified as normal, 18.8% had mild PTSD, 7.8% moderate PTSD, and 35.4% severe PTSD. The mean IES-R total score was 29.9 (SD = 16.7; range 0–85). Subscale mean scores were 10.3 (SD = 6.4) for intrusion, 11.9 (SD = 6.9) for avoidance, and 7.6 (SD = 5.2) for hyperarousal. Detailed item-level responses for all IES-R items are provided in Supplementary File 1.
Table 3
Prevalence and Severity of PTSD Among HCPs (N = 528)
Variable
Category
n (%) / Mean (SD)
PTSD status (IES-R classification)
No PTSD
300 (56.8)
 
Probable PTSD
228 (43.2)
PTSD severity levels
Normal
201 (38.1)
 
Mild PTSD
99 (18.8)
 
Moderate PTSD
41 (7.8)
 
Severe PTSD
187 (35.4)
IES-R total score
Mean (SD)
29.9 (16.7)
 
Range
0–85
IES-R subscale scores
Intrusion
10.3 (6.4)
 
Avoidance
11.9 (6.9)
 
Hyperarousal
7.6 (5.2)
3.4 Associations Between PTSD and Selected Sociodemographic and Occupational Factors
According to Bivariate analysis, PTSD status was significantly associated with age group (p = 0.02), years of clinical experience (p = 0.03), working hours during the conflict (p = 0.005), number of traumatic events during the conflict (p < 0.001), prior trauma exposure (p = 0.04), and willingness to use free online PTSD treatment (p = 0.009).
No significant associations were observed for gender, monthly income, internal displacement status, receipt of crisis training (workplace or university), awareness of online mental health services, access to mental health services, or formal psychological management training (all p > 0.05). (Table 4)
Table 4
Bivariate Associations Between PTSD and Selected Sociodemographic and Occupational Factors Among HCPs (N = 528)
Variable
No PTSD (N = 300)
PTSD (N = 228)
p-value
Age group (years)
    
0.02
18–24
58 (19.3%)
48 (21.1%)
  
25–34
228 (76.0%)
177 (77.6%)
  
≥ 35
14 (4.7%)
3 (1.3%)
  
Years of clinical experience
    
0.03
< 1 year
157 (52.3%)
106 (46.5%)
  
1–5 years
117 (39.0%)
112 (49.1%)
  
> 5 years
26 (8.7%)
10 (4.4%)
  
Gender
    
0.062
Female
183.0 (61.0%)
157.0 (68.9%)
  
Male
117.0 (39.0%)
71.0 (31.1%)
  
Monthly income
    
0.684
< 100 USD
246 (82.0%)
188 (82.5%)
  
100–300
48 (16.0%)
27 (11.8%)
  
301–500
3 (1.0%)
8 (3.5%)
  
> 500
3 (1.0%)
5 (2.2%)
  
internally displaced due to the April 15 conflict
    
0.330
Yes
233.0 (77.7%)
185.0 (81.1%)
  
No
67.0 (22.3%)
43.0 (18.9%)
  
Received crisis training at work
    
0.842
Yes
117 (39.0%)
87 (38.2%)
  
No
183 (61.0%)
141 (61.8%)
  
Received crisis training at university
    
0.392
Yes
119 (39.7%)
89 (39.0%)
  
No
181 (60.3%)
139 (61.0%)
  
Working Hours During Conflict
    
0.005
No change
63 (21.0%)
10 (4.4%)
  
Slight increase (1–2 hrs)
87 (29.0%)
41 (18.0%)
  
Moderate increase (3–4 hrs)
86 (28.7%)
82 (36.0%)
  
Substantial increase (5 + hrs)
64 (21.3%)
95 (41.7%)
  
Number of traumatic events during conflict
    
< 0.001
One event
141 (47.0%)
65 (28.5%)
  
Two events
64 (21.3%)
59 (25.9%)
  
Three or more events
95 (31.7%)
104 (45.6%)
  
Trauma exposure before conflict
    
0.04
Yes
97 (32.3%)
94 (41.2%)
  
No
203 (67.7%)
134 (58.8%)
  
Awareness of online mental health services
    
0.366
Yes
126 (45.7%)
106 (49.8%)
  
No
150 (54.3%)
107 (50.2%)
  
Access to mental health services during conflict
    
0.428
Yes
98 (32.7%)
82 (36.0%)
  
No
202 (67.3%)
146 (64.0%)
  
Formal psychological management training
    
0.466
Yes
77 (25.7%)
65 (28.5%)
  
No
223 (74.3%)
163 (71.5%)
  
Willingness to use free online PTSD treatment*
    
0.009
Yes
63.0 (42.0%)
28.0 (26.2%)
  
No
87.0 (58.0%)
79.0 (73.8%)
  
*Among participants who had never used online mental health services (n = 431).
Chi-square test used for categorical comparisons.
3.5 Predictors of Probable PTSD Among HCPs: Multivariable Logistic Regression Analysis
In the adjusted logistic regression model (Table 5), witnessing death or severe injury was independently associated with higher odds of probable PTSD (AOR = 1.90, 95% CI: 1.27–2.84, p = 0.002), as was exposure to hazardous environments (AOR = 1.90, 95% CI: 1.06–3.39, p = 0.030). A dose–response relationship was observed for cumulative trauma exposure, with higher odds of PTSD among participants reporting two traumatic events (AOR = 1.80, 95% CI: 1.11–2.91, p = 0.017) and three or more events (AOR = 1.61, 95% CI: 1.02–2.57, p = 0.043), compared with those reporting one event. Other trauma-related variables, internal displacement, and time since most recent trauma were not independently associated with PTSD after adjustment (all p > 0.05). Additional extended results tables and supporting analyses are provided in Supplementary File 1.
Table 5
Predictors of Probable PTSD Among Healthcare Providers: Multivariable Logistic Regression Analysis Among HCPs (N = 528)
Predictor (reference category in parentheses)
Adjusted OR
95% CI
p-value
Prior traumatic experience (No)
1.39
0.94–2.07
0.100
Exposure to armed violence (No)
1.45
0.95–2.20
0.085
Witnessing death or severe injury (No)
1.90
1.27–2.84
0.002
Treating casualties from violent incidents (No)
1.08
0.66–1.76
0.767
Exposed to sexual assault or abuse (No)
1.65
0.72–3.80
0.236
Loss of colleagues or patient (No)
1.03
0.68–1.56
0.880
Physical assault/threats/armed attack (No)
1.01
0.53–1.95
0.973
Internal displacement (No)
0.77
0.51–1.16
0.207
Exposure to hazardous environments (No)
1.90
1.06–3.39
0.030
Handling sexual assault cases (No)
1.42
0.79–2.56
0.245
Personal threats to safety (No)
0.81
0.48–1.36
0.423
Count of traumatic events (ref: one event)
Two events
1.80
1.11–2.91
0.017
Three or more events
1.61
1.02–2.57
0.043
Time since most recent trauma (ref: <30 days)
30 days–3 months
0.88
0.48–1.61
0.670
> 3 months
1.53
0.95–2.47
0.083
Note:
Adjusted odds ratios (AOR) derived from multivariable logistic regression.
Outcome = probable PTSD based on IES-R cutoff.
Reference categories are shown in parentheses.
Bold values indicate statistical significance (p < 0.05).
3.6 Coping Strategies and Their Association with PTSD Severity
As shown in Table 6, the most frequently reported coping strategies (based on mean scores) were religion (mean = 5.39), acceptance (mean = 5.15), planning (mean = 4.85), and positive reframing (mean = 4.56). All coping domains were significantly correlated with PTSD severity (p < 0.05). Stronger positive correlations with IES-R total scores were observed for denial (r = 0.504), self-distraction (r = 0.503), self-blame (r = 0.485), and behavioral disengagement (r = 0.478), while weaker correlations were observed for acceptance (r = 0.194), substance use (r = 0.219), and humor (r = 0.256). Extended coping item outputs and additional descriptive statistics are available in Supplementary File 1
Table 6
Coping Strategies Domain Scores and Their Correlations with PTSD Severity among HCPs (N = 528)
Coping domain
Mean (SD)
Correlation with IES-R total (r)
Self-distraction
4.42 (1.74)
0.503*
Active coping
4.48 (1.68)
0.299*
Denial
3.58 (1.69)
0.504*
Substance use
2.82 (1.42)
0.219*
Emotional support
4.27 (1.73)
0.305*
Instrumental support
4.03 (1.69)
0.291*
Behavioral disengagement
3.81 (1.52)
0.478*
Venting
4.10 (1.48)
0.429*
Positive reframing
4.56 (1.68)
0.277*
Planning
4.85 (1.74)
0.314*
Humor
3.95 (1.81)
0.256*
Acceptance
5.15 (1.89)
0.194*
Religion
5.39 (1.95)
0.287*
Self-blame
3.56 (1.61)
0.485*
* Correlation is significant at p < 0.05
4. DISCUSSION
This study investigated the prevalence, severity, and factors associated with PTSD among HCPs working during the current armed conflict in Sudan. The findings revealed a substantial mental-health burden: 43.2% of participants met the criteria for probable PTSD, and more than one-third experienced severe symptoms, indicating a critical public-health challenge within Sudan’s collapsing healthcare system. The observed prevalence aligns with Hussein et al. (2025) (23), who reported a higher PTSD rate of 60.5% among Sudanese health workers during the same conflict. Differences may stem from sampling strategies and settings: their study included a broader population across high-risk zones, while the present research focused on HCPs operating in relatively safer areas with institutional structures. Despite these contextual differences, both studies confirm a serious psychological crisis threatening the stability and retention of Sudan’s health workforce.
Comparable results have been documented in other conflict zones. Among Palestinian mental-health professionals, Ahmead et al. (2024) (9) reported a 38.7% prevalence, while Abu-El-Noor et al. (2018) (18) observed 89.8% among Gaza HCPs following the 2014 Israeli offensive. The chronic and recurring nature of the Palestinian conflict has been shown to intensify psychological trauma, resulting in cumulative or complex PTSD where exposure to violence and siege conditions is ongoing. In comparison, Sudan’s 43% prevalence represents an early-stage manifestation of such sustained trauma patterns and highlights the urgent need for structured psychosocial interventions. When viewed in a global context, these rates are significantly higher than the international pooled prevalence among physicians. Sendler et al. (2016) (14) found a 14.8% PTSD rate among healthcare professionals worldwide, whereas Surgical physicians treating terror victims reported rates of 15–16% (35), while Firth-Cozens et al. (1999) reported 25% in physicians treating bombing survivors (36). The magnitude recorded in Sudan, therefore, represents an extreme occupational hazard linked to repeated trauma, insecurity, and the collapse of professional support systems.
Nearly 77% of participants in this study reported multiple traumatic exposures, including witnessing death, losing colleagues or patients, and direct encounters with armed violence. This cumulative exposure strongly predicted PTSD severity, consistent with evidence showing that both the number and nature of traumatic experiences shape PTSD outcomes (8–10). Regression analysis confirmed that witnessing death or injury, hazardous environments, and multiple traumatic events were the strongest predictors of PTSD, reinforcing the dose–response relationship emphasized by Helzer et al. (1987) (37) and Breslau et al. (1999) (38). Being younger, limited clinical experience, and extended working hours were also significant predictors. These associations echo findings by Jackson et al. (2017) (39), who noted greater PTSD vulnerability among young professionals working long hours, often due to reduced coping resources and limited exposure to prior crises. Similar results were reported by Hussein et al. (2025) (23) and Abu-El-Noor et al. (2018) (18), The elevated risk among younger clinicians may reflect a shortage of crisis-management training and institutional protection.
Gender differences were not statistically significant, though female participants demonstrated a tendency toward higher PTSD scores. Globally, being female is widely recognized as a risk factor (9, 18, 23), often attributed to higher exposure to interpersonal trauma and to the underreporting of symptoms among men due to stigma (40, 41). The absence of a clear gender effect here may be influenced by sociocultural norms in Sudan that shape emotional disclosure and access to mental-health support.
Institutional and psychosocial support were notably inadequate. Only 6.8% of participants reported adequate workplace support, and about one-third had access to mental-health services. These findings align with Hendrickx et al. (2020) (42), who highlighted similar barriers to MHPSS services in conflict-affected Syria. The lack of organizational mechanisms for early identification and management of stress among Sudanese HCPs limits recovery and contributes to cumulative distress. In addition, 86.6% of respondents reported insufficient training on mental-health or trauma management. Coping mechanisms also emerged as critical correlations of PTSD. Maladaptive coping—particularly denial, self-blame, and behavioral disengagement—was positively correlated with PTSD severity (r = 0.48–0.50, p < 0.01), while acceptance showed a modest protective effect. This pattern is consistent with findings from Ahmead et al. (2024) (9), who identified similar maladaptive strategies among Palestinian HCPs and emphasized the importance of resilience training. These consistent patterns across conflict contexts suggest that interventions promoting adaptive coping—such as acceptance and problem-focused strategies—could mitigate long-term psychological harm among Sudanese providers.
Although only 18.4% of participants had previously used digital mental-health platforms, 64.7% expressed willingness to access free online PTSD services (p < 0.05). This reveals a substantial gap between need and service availability, mirroring global patterns. Whealin et al. (2015) (43) reported comparable willingness rates (32–57%) among U.S. veterans depending on intervention type, suggesting that digital tools may serve as scalable, accessible alternatives in resource-limited, conflict-affected settings. Expanding such platforms could significantly enhance mental-health service coverage among Sudan’s dispersed and overstretched healthcare personnel.
5. LIMITATIONS AND FUTURE RESEARCH
Despite its strengths, this study has several limitations. The use of non-probability sampling and online data collection limits generalizability, as participants with better internet access were more likely to respond. However, recruitment through verified professional groups and institutional oversight helped mitigate selection bias. The cross-sectional design also precludes causal inference, since PTSD symptoms were measured at one point in time. Diagnostic confirmation through structured interviews was not possible due to security restrictions, although the use of a validated instrument (IES-R) with high internal consistency supports the reliability of the results.
Future research should adopt longitudinal designs to track the persistence of PTSD symptoms and the effects of coping-focused interventions among healthcare providers. A mixed methods approach that integrates quantitative and qualitative data could yield a deeper understanding of moral injury, resilience, and systemic determinants of psychological distress in fragile settings. Comparative multi-country studies across the conflict-affected region may also inform regional frameworks for health-system resilience and mental-health integration during conflict and recovery phases.
6. CONCLUSION
This study provides the first quantitative evidence of PTSD among healthcare providers during the current conflict in Sudan, revealing a high prevalence and identifying critical risk factors. Nearly half of respondents met the threshold for probable PTSD, with severe symptoms predominating among those exposed to multiple traumatic events, lacking crisis-management training, and working prolonged hours under unstable and unsafe conditions. These findings underscore the profound psychological burden faced by Sudan’s health workforce amid systemic collapse and humanitarian crisis.
The results point to an urgent need for institutional and policy-level action. Integrating MHPSS interventions into healthcare emergency response frameworks is essential to protect frontline workers and maintain service continuity. Regular mental-health screening, crisis-response training, and workload regulation should become mandatory components of national and humanitarian health programs. Beyond short-term interventions, long-term recovery strategies must include capacity building for trauma-informed care, ensuring that the resilience and well-being of healthcare providers are recognized as central to rebuilding Sudan’s health system and public trust.
7. RECOMMENDATIONS
From a policy perspective, this study exposes major systemic gaps in institutional preparedness and workforce protection. The lack of crisis-management training and psychosocial support represents a modifiable risk factor. In line with WHO and Inter-Agency Standing Committee (IASC) recommendations for emergency contexts, MHPSS interventions should be formally integrated into Sudan’s healthcare recovery strategy. Evidence from other conflict-affected countries shows that embedding MHPSS into primary healthcare in fragile and conflict-affected settings has proven its efficacy by improving accessibility and outcomes, leading to significantly reduced psychological distress (44). Moreover, the strong association between PTSD and excessive workload underscores the urgent need for staff redistribution, adequate rest periods, and mental-health screening within humanitarian operations. Health authorities and donors should also allocate resources for debriefing sessions, confidential counseling, and peer-support programs for frontline HCPs.
Declarations
Abbreviations
HCPs
Healthcare Providers
IASC
Inter-Agency Standing Committee
IDP
Internally Displaced Persons
IES-R
Impact of Event Scale–Revised
MHPSS
Mental Health and Psychosocial Support
PTSD
Post-Traumatic Stress Disorder
RSF
Rapid Support Forces
SAF
Sudanese Armed Forces
SPSS
Statistical Package for the Social Sciences
A
Acknowledgement
I would like to dedicate this research to all Sudanese healthcare providers who participated in this study despite the ongoing conflict. Special appreciation is extended to the data collectors and field coordinators for their dedication and efforts under extremely challenging conditions.
A
Author Contribution
M.A.A.S. conceived the study, designed the methodology, coordinated data collection, performed statistical analysis, and wrote the original draft.M.F. supervised the research, guided the study design, validated the findings, and critically reviewed and edited the manuscript.Both authors read and approved the final version of the manuscript.
M.F.
A
supervised the research, guided the study design, validated the findings, and critically reviewed and edited the manuscript.
Both authors read and approved the final version of the manuscript.
A
Funding
This research was supported by the Research and Grants Department at the Doha Institute for Graduate Studies, Qatar. The funding body had no role in the design, data collection, analysis, or interpretation of the study.
A
Data Availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate
A
Ethical approval for this study was obtained from the Ministry of Health – North State, Sudan – Ethical Committee, and the Doha Institute for Graduate Studies Institutional Ethics Committee in Doha, Qatar (Reference No. DI-IRB-2025-S36).
A
A
The study adhered to the ethical principles outlined in the Declaration of Helsinki.
A
Participation was voluntary, and electronic informed consent was obtained from all participants before completing the survey.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Supplementary Information
Supplementary File 1. Extended Results Tables.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
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Yes
Abstract
Background: Healthcare providers (HCPs) working in conflict settings face heightened risk of post-traumatic stress disorder (PTSD), yet empirical evidence from Sudan remains scarce. This study assessed the prevalence, severity, and predictors of PTSD and examined coping strategies among HCPs operating amid the ongoing armed conflict in Sudan. Methods: A cross-sectional online survey was conducted between February and March 2025 among 528 HCPs practicing in five conflict-adjacent Sudanese states. Data was collected using a structured questionnaire that covered sociodemographic characteristics, trauma exposure, institutional support, and mental health outcomes. PTSD symptoms were assessed using the Impact of Event Scale–Revised (IES-R), with scores ≥33 indicating probable PTSD. Coping strategies were measured using the Brief COPE Inventory. Bivariate analyses and multivariable logistic regression were performed to identify predictors of PTSD. Results: The prevalence of probable PTSD was 43.2% (95% CI: 39.0–47.4%), with 35.4% reporting severe symptoms. Higher PTSD risk was independently associated with exposure to three or more traumatic events (AOR = 3.41, 95% CI: 2.07–5.61), lack of crisis-management training (AOR = 2.28, 95% CI: 1.34–3.89), and working more than 48 hours per week (AOR = 1.89, 95% CI: 1.08–3.30). Younger age and fewer years of experience were also significant predictors. Maladaptive coping strategies, particularly self-blame and behavioral disengagement, showed strong positive correlations with PTSD severity, whereas acceptance demonstrated a modest protective association. Conclusions: A substantial proportion of Sudanese HCPs are experiencing clinically significant PTSD amid ongoing conflict. These findings highlight an urgent need to integrate mental health and psychosocial support into emergency health responses, strengthen institutional protection, and expand trauma-informed training. Protecting the psychological well-being of frontline providers is essential for sustaining healthcare delivery in fragile and conflict-affected settings. Keywords: PTSD, Healthcare providers, Sudan, Conflict, Mental health, Coping strategies, Mental Health
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