Prevalence of Generalized Anxiety Disorder and Associated Risk Factors Among Medical Students in Sudan: A Cross-Sectional Study at Omdurman Islamic University

Background: Generalized Anxiety Disorder (GAD) is a mental illness that significantly affects various domains of daily functioning. Limited research has been conducted on GAD among medical students in Sudan, particularly during the socio-political and economic crises. This study aimed to assess the prevalence of GAD, identify risk factors, and evaluate its impact on academic performance and daily activities among Sudanese medical students. Methods: A cross-sectional study was conducted among undergraduate medical students at Omdurman Islamic University. Data were collected using a self-administered online questionnaire via Google Forms, consisting of two parts: socio-demographic information and the Generalized Anxiety Disorder Questionnaire (GAD-7), a validated tool for screening and measuring the severity of GAD. Results: A total of 374 medical students participated, with 64.7% being female. The GAD-7 scores were high (above 9), suggesting GAD among 33.7% of participants, with severity levels of 41.2% for mild anxiety, 21.4% for moderate anxiety, and 12.3% for severe anxiety. Comparison of means showed significant associations between GAD and female students (p<0.001) and students with chronic diseases (p=0.034). GAD significantly impacted daily activities (p<0.001). Multiple logistic regression analysis found that students in the final year had significantly higher GAD-7 scores (Adjusted Odds Ratio=4.25, 95% Confidence Interval=1.27-14.22). Conclusions: The higher scores on the GAD-7 measure among Sudanese medical students are concerning. This emphasizes the urgent need to raise awareness, normalize mental health discussions, and provide accessible counseling services tailored to the students' needs.


Introduction
Mental disorders are the leading cause of disability worldwide.Individuals with significant mental health issues tend to have a lifespan that is 10 to 20 years shorter than that of the average person. 1neralized Anxiety Disorder (GAD) is a mental condition characterized by persistent and excessive anxiety and worry about various events or activities, such as school or work performance.These symptoms occur on most days for at least six months and can hinder functioning in social, occupational, or other domains. 2e disease is highly prevalent; in the United States, it is estimated that 6.8 million adults have GAD, with only 43.2% receiving treatment. 3It is also estimated that 5.7% of U.S. adults experience generalized anxiety disorder at some point in their lives. 4udies have consistently shown that females are more likely than males to develop GAD, 5,6 with the prevalence being twice as high for them. 7There are other risk factors associated with GAD, such as genetic factors, 8 and chronic diseases like diabetes mellitus, 9 asthma, 10 and systemic lupus erythematosus. 11e demanding nature of medical school with challenging training programs, both academically and emotionally across all professions, places medical students at a higher risk for GAD compared to the general population.Studies have revealed that 29% to 38% of medical students experience GAD, in contrast to the 3% to 25% prevalence observed in the general population. 12he academic years in medical school are filled with numerous challenges, including demanding coursework, difficult exams, and extensive study hours.
Studies have shown that the prevalence of GAD among medical students varies between countries.A study conducted in the USA reported that 65.9% of medical students exhibited symptoms of anxiety. 13Meanwhile, in Saudi Arabia, 69% of medical students were found to have varying degrees of GAD, 14 and in Egypt, the rate was a bit higher at 77.1%. 15e effects of GAD on medical students are profound.A study conducted in Mexico aimed to assess the impact of GAD on university students during the COVID-19 pandemic on academic performance.The findings revealed a significant negative effect of anxiety on students' academic performance. 16Similarly, a study among medical students in Syria demonstrated a negative association between anxiety and academic performance. 17xiety not only affects academic performance but also impairs the ability to achieve work goals, manage household tasks, and interact with others.Several studies have reported that GAD is associated with a poor quality of life. 18,19ile the global prevalence rates are alarming, the situation in Sudan presents unique challenges; in 2020, a study among medical students revealed prevalence rates of depression at 75%, anxiety at 55.3%, and stress at 51.8%. 20In recent years, Sudan has faced political and environmental instability, significantly impacting the mental health of its population.Medical students in Sudan are particularly struggling to manage the requirements of their academic programs with the unstable socio-political environment, potentially exacerbating their mental health issues. 21ven the significant global and local implications of GAD among medical students, particularly amidst the critical socio-political challenges in Sudan, there is a pressing need for more comprehensive studies within the country.This study aimed to determine the prevalence of GAD, explore associated risk factors, and evaluate its impact on academic performance and daily activities among medical students at Omdurman Islamic University to contribute valuable insights that can guide more effective mental health support strategies for medical students in Sudan.

Ethical Considerations
This study received ethical approval on July 21, 2022, from the Ethics Committee of the Faculty of Medicine at Omdurman Islamic University (Ethical Approval No. 3/2022).All participants provided informed consent online.

Sampling Strategy
The sample size was calculated to be 379 using the following formula: n=Z 2 p[1-p]/d 2 , where n = calculated sample size, p is the prevalence of anxiety based on a previous study = 0.553, Z is the confidence level used = 1.96, and d = the level of precision (0.05). 20rticipants for the study were selected using a systematic random sampling technique.The student list was obtained from the faculty administration.To determine the sampling interval, we divided the total number of medical students by the calculated sample size, resulting in an interval of five.A random number generator was used to select the first study participant from the first five students on the list.Subsequently, every fifth student from this initial point was selected to participate in the study.The inclusion criteria included medical students actively enrolled at the university.There were no exclusion criteria.At the start of the questionnaire, participants were informed about the purpose of the study, and assured that their involvement was entirely voluntary and that their anonymity would be preserved.Only those who gave their consent were able to fill out the questionnaire.

Data Collection Tools
Data were collected using a self-administered online questionnaire via Google Forms.The selected participants received the questionnaire link through WhatsApp.The questionnaire consisted of two sections: The first part was sociodemographic information, specific risk factors, and academic performance data: (gender, age, marital status, academic year, residence, living situation, grade point average (GPA), and medical history).The second part assessed GAD severity using the Generalized Anxiety Disorder Questionnaire (GAD-7).

Academic Performance
The academic performance of students was evaluated using their GPA, as per the system of the faculty of Medicine at Omdurman Islamic University administration.GPAs were categorized on a scale from 0 to 4, with the following classifications: Distinction (3.5-4), Very Good (3-3.49),Good (2.50-2.99),Pass (2-2.49), and Fail (<2).

Statistical Analysis
Data were analyzed using SPSS version 28.Descriptive statistics, such as frequencies, means, standard deviations, and percentages, were employed to describe the dataset.A GAD-7 score of 10 or more was considered indicative of high anxiety levels.The relationship between risk factors and GAD was analyzed using t-tests and one-way ANOVA.Statistical significance was set at P = 0.05 or less.To measure the effect size, Cohen's d was used for t-tests, and eta-squared was used for oneway ANOVA tests.Simple and multiple logistic regression were performed to predict Generalized Anxiety Disorder from various independent variables.

Sociodemographic and Risk Factor Profiles
A total of 374 medical students participated in this study.Most of them were female (64.7%).Their mean age was 21.07 ± 2.18, ranging from 16 to 29 years.Socio-demographic data are presented in Table 1.Out of the 374 medical students who participated in the study, 101 of them reported engaging in regular exercise.It was found that nearly 50% of these students reported engaging in regular cardio exercises, while approximately 40% stated that they regularly engage in walking exercises, as depicted in Figure 1.

Prevalence and Severity of Generalized Anxiety Disorder among Medical Students at Omdurman Islamic University
According to the GAD-7 scale, 33.7% of the medical students exhibited high GAD scores, indicating scores of 10 or more.The severity of these anxiety levels is detailed in Figure 2.

Assessment of the Risk Factors for GAD among Medical Students at Omdurman Islamic University
A comparison of means was conducted to examine variable differences in GAD-7 scores.The results indicated that Female medical students (M = 7.80) had significantly higher GAD-7 scores than male medical students (M = 6.06) (p < 0.001).Additionally, no significant differences were found between age, academic year, residence city, marital status, residence situation, smoking status, and GAD-7 scores (all p-values > 0.05).However, medical students with chronic diseases had significantly higher GAD-7 scores (M = 8.64) than those without (M = 7.03) (p = 0.034).Furthermore, there was a significant difference in the GAD-7 scores between medical students who reported performing regular exercise (M = 7.41) and those who did not (M = 6.29, p = 0.05.A multiple logistic regression analysis was conducted to investigate the relationship between several predictor variables and the presence of Generalized anxiety disorder.The results show that being female (p < 0.001, AOR = 2.399) and being in the 5th academic year (p = 0.019, AOR = 4.246) were associated with higher odds of anxiety (Table 3).

Impact of GAD on academic performance among medical students at Omdurman Islamic University
The mean GPA of the medical students is 3.25 ± 0.525 SD.To evaluate the impact of Generalized Anxiety Disorder on students' academic performance, we compared the means of the GPA across various GAD severity levels using an ANOVA test.The findings, detailed in Table 4, show no significant differences in the GPAs across the different levels of anxiety among the students.

Impact of GAD on daily life activities among medical students at Omdurman Islamic University
A comparison of the means was conducted to study the impact of GAD on daily activities among students.Significantly higher mean GAD-7 scores were found among students who reported extremely difficult (11.80) and very difficult (11.95) daily activities, and lower mean GAD-7 scores were found among students who reported not difficult (4.10) and somewhat difficult (6.86) daily activities (p < 0.001, Table 5).

Discussion
Our study found that 33.7% of medical students had significantly high GAD-7 scores (scores > 9), suggesting the possibility of GAD.This rate is slightly higher than the 29% recently reported among medical students at the University of Khartoum, Sudan. 24Another study, conducted during the COVID-19 lockdown in Sudan reported a prevalence rate of 55.3%; however, this study employed the DASS-21 scale, a different assessment tool, potentially explaining the variance in rates. 20rticipants in our study were exposed to a complex social and political environment characterized by political unrest and economic hardship.Even following the COVID-19 pandemic, colleges often faced closures due to the unstable political situation.These factors could heighten anxiety and uncertainty about future careers among students, thereby impacting their mental well-being.
Comparatively, studies in Saudi Arabia and the USA reported prevalence rates of 31.2% and 30.6%, respectively. 13,25In contrast, studies in Egypt reported higher anxiety rates of 77.1% and 56%; however, these studies utilized the DASS-42 tool, which might account for the higher rates. 26,27high level of stress often accompanies medical school.A comparative study assessed stress levels among students from various disciplines.The findings revealed that 54.3% of medical students reported experiencing significant stress, compared to 36.6% of arts students, 32% of business students, and 15.3% of engineering students. 28 our study, a significant association was observed between female medical students and GAD (p < 0.001).This finding is consistent with studies conducted among medical students in several countries, including Saudi Arabia, 29 Turkey, 30 Egypt, 31 and the United States. 13Some studies suggest that specific biological factors, such as abnormalities in female hormones, might contribute to increased anxiety in women, potentially leading to a higher risk of GAD compared to men. 32,33Another study indicated that female students may be more susceptible to GAD due to their perception of patient contacts and autopsy-related duties as stressful, with exams also being a significant source of stress. 34Moreover, multiple studies have reported that female medical students are more likely to experience of imposter syndrome, which is strongly associated with anxiety and other psychological conditions. 35,36e study revealed that final-year medical students were more likely to experience generalized anxiety disorder (GAD) than students in earlier academic years (AOR= 4.25) (p=0.019).This can be explained by the increase in academic and practical workloads, as well as the stress associated with final exams, during the last year.This aligns with previous research indicating a progressive increase in stress throughout medical education. 37xisting studies suggest that mental health often declines upon entering medical school and remains challenging throughout the program. 38garding academic performance, our study did not find a significant difference in GPA scores across different GAD severities.This finding contradicts the results of many studies, including a meta-analysis of 238 studies, which found a significant association between increased GAD severity and poorer academic performance. 39However, our results align with other research that found no association between academic performance and GAD. 40Some studies have even suggested that anxiety levels might increase with higher GPA scores, as students may become more concerned about maintaining their grades. 25hese variations could be attributed to the different tools used, which can lead to varied results.It is worth noting that our study relied on self-reported GPA, rather than obtaining the data directly from faculty administration.
In our study, students who reported extreme difficulty in achieving their work, managing household tasks, or interacting with others had significantly higher mean GAD scores.This finding is similar to previous studies that have reported a positive correlation between higher levels of anxiety severity and poorer quality of life, 18,19 and lower health-related quality of life. 41dical students with chronic diseases in our study exhibited higher mean GAD scores, consistent with earlier research that found significantly higher GAD scores among patients with conditions such as asthma, 10 type 2 diabetes, 9 and systemic lupus erythematosus (SLE). 11These findings suggest that medical students with chronic diseases may be more susceptible to developing symptoms of GAD, which could have important implications for their mental health and overall well-being.
Surprisingly, our study demonstrates that medical students who engaged in regular exercise scored higher on the GAD-7 scale.This is contradictory to the existing literature, which suggests that physical activity plays an essential role in anxiety treatment 42 , particularly high-intensity exercise. 43,44However, this finding could be attributed to several factors.First, students with higher levels of anxiety might be more inclined to use regular exercise as a coping mechanism, leading to a correlation where those with higher anxiety levels are also those who exercise more.Second, medical students may engage in exercise to manage the high stress of their academic environment, which could contribute to higher anxiety levels despite regular physical activity.Additionally, it is noteworthy that the number of students who reported engaging in regular exercise was relatively small (n=101), which could influence the study's findings.

Strengths and Limitations
Our study provided significant insights into the mental health challenges faced by medical students in Sudan during a critical period.It was conducted at one of the largest and most prominent public universities in the country.However, the study had certain limitations.While the GAD-7 tool was reliable, it's important to acknowledge that it functioned as a screening tool rather than a diagnostic instrument; a clinical assessment was necessary for a definitive diagnosis.The study was conducted at the Faculty of Medicine at Omdurman Islamic University.Although this is a large institution, this specific setting might have limited the ability to generalize our findings to medical students in other regions or countries.This suggested the need for multicenter studies.Furthermore, most of our study participants were female, which might have influenced the applicability of our findings across different genders.Moreover, the small sample size might have reduced the study's statistical power to detect significant effects.

Conclusion
This study revealed high GAD scores among Sudanese medical students, with significant associations found between GAD and female medical students as well as students with chronic diseases.GAD was found to negatively impact the ability of affected students to manage household tasks.The high prevalence of anxiety among medical students raises concerns, emphasizing the need for increased awareness, mainly focusing on recognizing and managing anxiety disorders.It is crucial to normalize discussions about mental health and provide easy access to counseling and psychotherapy services tailored to student needs.Additionally, fostering a culture of wellness within medical schools should be prioritized, with an emphasis on promoting healthy habits such as exercise, adequate sleep, and stress management.Furthermore, establishing peer support systems, including mentorship programs where senior students can guide and support juniors, can significantly contribute to a supportive environment.Additionally, training should be provided to faculty and administrative staff on how to identify and respond to students who experience anxiety, ensuring they can offer appropriate support or referrals.Future research should focus on evaluating the barriers to conducting and assessing the effectiveness of mental health services targeted at medical students and intervention programs aimed at reducing anxiety.

Summary -Accelerating Translation Title: Understanding Anxiety among Medical Students in Sudan: A Study from Omdurman Islamic University
Main Problem: Anxiety, specifically Generalized Anxiety Disorder (GAD), was identified as a significant challenge globally, notably affecting the academic performance and overall quality of life of medical students.This problem was particularly pronounced in regions experiencing sociopolitical unrest, such as Sudan, where medical students were under increased stress due to the demanding nature of their studies compounded by external instability.

Aim:
The study aimed to assess the prevalence of GAD among medical students at Omdurman Islamic University, identify the key factors that contributed to its development, and evaluate its impact on students' academic achievements and daily functioning.The goal was to provide insights that could aid in developing better support systems for medical students' mental health, particularly in challenging environments like Sudan.
Methodology: This study was conducted among medical students at Omdurman Islamic University, a public university in Omdurman City, Sudan.The university was established in 1912 and has 22 faculties.In 2022, there were around 26,000 students.We used a method called systematic sampling to select participants for the study.
To collect data, we used an online questionnaire with two parts.The first part asked about things like age, gender, marital status, academic year, where the students lived, their grade point average, and medical history.
The second part focused on generalized anxiety disorder (GAD) and used a questionnaire called the Generalized Anxiety Disorder Questionnaire (GAD-7) to measure its severity.
The study followed ethical guidelines and received approval from the Omdurman Islamic University Ethics Committee of the Faculty of Medicine.
All participants gave their consent to participate in the study electronically.

Results:
In this study, we looked at a total of 374 medical students who participated.It's interesting to note that most of them were female, making up 64.7% of the participants.Out of all the medical students in the study, 35 of them mentioned having a chronic disease.What's even more interesting is that more than one-third of these students, specifically 35.7%, reported having asthma.
Out of the 364 medical students who took part, 101 of them said they regularly exercise.It's worth mentioning that nearly half of these students, about 50%, mentioned doing cardio exercises on a regular basis.Additionally, around 40% of them said they regularly engage in walking exercises.
We found that about one-third of the medical students, specifically 33.7%, had high possibility of Generalized Anxiety Disorder (GAD).When we looked at the severity of anxiety, we found that 41.2% had mild anxiety, 21.4% had moderate anxiety, and 12.3% had severe anxiety.
To understand the differences in anxiety levels, we compared the average scores.It turned out that female medical students had significantly higher anxiety scores (average score of 7.80) compared to male medical students (average score of 6.06).However, we didn't find any significant differences in anxiety scores based on factors like age, city of residence, marital status, or living situation.
We found that fifth-year medical students are significantly more likely to experience anxiety than students in other academic years Interestingly, medical students with chronic diseases had significantly higher anxiety scores (average score of 8.64) compared to those without chronic diseases (average score of 7.03).Moreover, we found a significant difference in anxiety scores between students who reported regular exercise (average score of 7.41) and those who didn't (average score of 6.29).
We also looked at the impact of anxiety on academic performance.however, we didn't find any significant association between anxiety and academic performance.
To understand how anxiety affects daily activities, we compared the average scores again.Students who reported extremely difficult daily activities had significantly higher anxiety scores (average score of 11.80), as did those who reported very difficult daily activities (average score of

Figure 2 :
Figure 2: Prevalence and Severity of Generalized Anxiety Disorder (GAD) among Participants at Omdurman Islamic University, n=374.
This descriptive cross-sectional institution-based study was conducted among medical students at Omdurman Islamic University from October to December 2022.The university, located in Omdurman City, Khartoum State, Sudan, had approximately 26,000 students in 2022.