War exposure and mental health in Sudanese medical students: the roles of psychological flexibility and self-esteem

Abstract

INTRODUCTION: The ongoing conflict in Sudan has disrupted medical education and affected the mental well-being of students. This study aimed to evaluate the effects of war exposure on psychological inflexibility (the inability to adaptively respond to distressing internal experiences), self-esteem, and mental health outcomes, specifically depression and anxiety. METHODS: A cross-sectional study was conducted in March 2025 among 148 medical students at Gadarif University, categorized as war-exposed (42.6%) or non-exposed (57.4%). Validated Arabic questionnaires assessed psychological inflexibility (AAQ-II), self-esteem (RSE), depression (PHQ-9), and anxiety (GAD-7). Mann-Whitney U tests and linear regression were used to assess group differences and predictors. RESULTS: No significant differences were found between groups in psychological inflexibility (p = 0.451) or self-esteem (p = 0.327). However, war-exposed students had higher depression (p = 0.031) and anxiety (p = 0.025). In regression models, war exposure was associated with increased depression (β = -2.371, p = 0.011) and anxiety (β = -2.529, p = 0.005). Furthermore, in both groups, higher psychological inflexibility predicted worse depression (β = 0.126, p < 0.001) and anxiety (β = 0.150, p < 0.001), while lower self-esteem predicted higher depression (β = -0.295, p = 0.009). A 1-point increase in inflexibility corresponded to a 0.13-point increase in depression symptoms. CONCLUSION: War exposure was associated with increased depression and anxiety, though it did not significantly alter psychological inflexibility or self-esteem. These psychological traits were independently associated with mental health outcomes, suggesting their role as key vulnerability factors. Strengthening resilience and self-worth-through interventions that enhance emotional regulation and coping-may reduce the psychological burden of conflict. Limitations include the cross-sectional design and sampling from a single institution.