Medical Education Amidst Conflict: A National Assessment of Sudanese Medical Students’ Perceptions Using the DREEM Tool

Medical Education Amidst Conflict: A National Assessment of Sudanese Medical Students’ Perceptions Using the DREEM Tool | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Medical Education Amidst Conflict: A National Assessment of Sudanese Medical Students’ Perceptions Using the DREEM Tool Nihal Elmubarak A. Hussein, Malaz M. Abdalmotalib, Muaiad Adil A. Abdelmotalab, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7329997/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background The ongoing conflict in Sudan has severely disrupted medical education, urging the need to assess the educational environment experienced by medical students across the country. Methods A cross-sectional study was conducted between December 2024 and February 2025, involving 2,714 medical students from 46 Sudanese universities. A convenience sampling method was implemented. Data were collected via a self-administered online questionnaire comprising demographic items and the Dundee Ready Education Environment Measure (DREEM) scale. The 50-item DREEM assesses five domains: perceptions of learning, teachers, academic self-perception, atmosphere, and social self-perception. Reliability was assessed using Cronbach’s alpha, and data were analyzed using SPSS v29. Independent t-tests and ANOVA were performed to explore associations between DREEM scores and demographic variables. Results The sample was predominantly female (70.1%), with a median age of 22 years. The overall mean DREEM score was 125.99, indicating an environment that was more positive than negative. Among the subdomains, perceptions of atmosphere (M = 30.23) and learning (M = 29.83) scored highest, while social self-perception was lowest (M = 17.36). Reliability analysis demonstrated good internal consistency for the total scale (α = 0.882), with acceptable reliability across most subscales except social self-perception (α = 0.495). Gender and academic level significantly influenced subscale scores. Clinical students and those residing in dormitories also reported more favorable perceptions (p < 0.05). Conclusion Despite the ongoing conflict, medical students in Sudan reported generally positive perceptions of their educational environment, but major concerns centered on academic stress, passive teaching, and weak institutional support were highlighted. These results point to urgent priorities for strengthening medical education during crises to maintain its quality and continuity. Clinical trial number: Not applicable Medical Education DREEM Educational Environment Sudan war Medical Students Students Perception Introduction Since April 2023, Sudan has faced an escalating humanitarian crisis triggered by armed conflict, resulting in the displacement of nearly 13 million people, including over 3.3 million who have fled across countries [ 1 ] [ 2 ]. Higher education in Sudan confronts profound structural and operational challenges, while simultaneously offering significant potential to contribute to national recovery. Numerous universities sustained physical damage or were forced to suspend operations, resulting in widespread disruption to academic progress. Additionally, both faculty and students experienced mass displacement, leading to a critical loss of human resources and a breakdown in institutional continuity [ 3 ] . Medical education, in particular, has borne a disproportionate share of this disruption. Even before the current conflict, Sudanese medical schools were grappling with longstanding challenges rooted in the political instability that followed the 2018 revolution [ 4 ]. Recent assessments indicate that nearly 60% of medical facilities located in conflict zones have been attacked, with approximately 70% repurposed as military installations [ 5 ]. Even Educational Institutions in comparatively safer regions have been converted into shelters for displaced populations [ 6 ], and as the conflict continues to expand, the damage also continues to intensify. The educational environment encompasses the social, organizational, and physical contexts that shape students' learning experiences, perceptions, and engagement [ 7 ] [ 8 ]. A growing body of evidence highlights the profound influence of the educational environment on students’ cognitive development, acquisition of skills, and academic performance [ 9 ][ 10 ]. Understanding students’ perceptions of the educational environment is essential, as positive perceptions have been linked to improved academic performance, while negative experiences may indicate critical gaps in mentorship, faculty engagement, and student support systems that warrant targeted interventions [ 9 ]. Furthermore, because the educational environment directly influences student engagement—a critical, modifiable determinant of learning—it represents a key area for development [ 7 ]. In light of the unprecedented disruption to Sudanese medical education, there is a pressing need to systematically assess how the current crisis has shaped students’ perceptions of their educational environment. This study seeks to provide an evidence-based understanding of these perceptions, identify critical areas for intervention, and contribute to broader efforts to safeguard and rebuild medical education in Sudan during and beyond the current conflict. Methodology Study design: A cross-sectional study was carried out between December 2024 and February 2025, during the Sudanese current conflict, to evaluate students' perceptions of various aspects of their educational environment. Study Setting and Population: The study included 2,714 medical students from 46 universities, encompassing both public and private institutions across various regions of Sudan. Participants were eligible for inclusion if they were medical students aged 18 years or older and enrolled in any academic year at the Sudanese Medical Students. Sampling A convenience sampling method was utilized in this study. Data Collection Tool and Procedure The questionnaire included demographic variables (age, gender, certificate type, admission type, academic year, and level) and assessed the educational environment using the 50-item DREEM scale. Items were rated on a five-point Likert scale, with negative statements reverse-scored; higher scores indicated a more favorable perception. The total DREEM score ranges from 0 (worst) to 200 (ideal), covering five subscales: Perceptions of Learning (12 items, max 48), Perceptions of Teachers (11 items, max 44), Academic Self-Perceptions (8 items, max 32), Perceptions of Atmosphere (12 items, max 48), and Social Self-Perceptions (7 items, max 28). [ 11 ]. Data collectors from various universities were assigned to collect responses from their respective institutions. The self-administered online questionnaire was distributed through official university channels, including Telegram, Whatsapp, and LinkedIn. Reliability analysis The internal consistency of the DREEM scale was assessed using Cronbach’s alpha. The total 50-item scale demonstrated excellent reliability (α = 0.882). Subscale reliability coefficients were as follows: Students’ Perceptions of Learning (SPoL) α = 0.738, Students’ Perceptions of Teachers (SPoT) α = 0.659, Students’ Academic Self-Perceptions (SPaSP) α = 0.778, Students’ Perceptions of Atmosphere (SPoA) α = 0.794, and Students’ Social Self-Perceptions (SSSP) α = 0.495. While most subscales showed acceptable to good internal consistency, the lower reliability of the SSSP subscale suggests potential variability in responses for that domain. Data Management and Analysis Data was initially organized in Microsoft Excel and then analyzed using SPSS version 29. Descriptive statistics were used to summarize demographic characteristics and continuous variables such as age and DREEM scores, reported as means and standard deviations. The internal consistency of the measurement instruments was assessed using Cronbach's alpha coefficients. Independent sample t-tests were employed to compare mean DREEM scores between two groups (e.g., males vs. females), while one-way ANOVA was used to assess differences across multiple groups (e.g., academic years). For significant ANOVA results, post-hoc comparisons were conducted using Tukey’s HSD test. A 95% confidence level was applied, with statistical significance set at P < 0.05. All findings were interpreted about the study objectives and relevant literature. Interpretation of the scores of the overall DREEM and the subclasses Score Mean Interpretation Overall DREEM Interpretation Total DREEM Score 0–50 very poor 51–100 many problems 101–150 more positive than negative 151–200 excellent DREEM subscales Interpretation Students’ Perception of Learning 0–12 Very poor 13–24 Teaching is viewed negatively 25–36 A more positive perception 37–48 Teaching is highly regarded Students’ Perceptions of Teachers 0–11 Abysmal 12–22 In need of retraining 23–33 Moving in the right direction 34–44 Model course organizers Students’ Academic Self-Perceptions 0–8 Feelings of total failure 9–16 Many negative aspects 17–24 Feeling more on the positive side 25–32 Confident Students’ Perceptions of Atmosphere 0–12 A terrible environment 13–24 Many issues that need changing 25–36 A more positive atmosphere 37–48 A good feeling overall Students’ Social Self-Perceptions 0–7 Miserable 8–14 Not a nice place 15–21 Not too bad 22–28 Very good socially single item Interpretation The individual item Scores ≥ 3 Indicated real positive points Scores ≤ 2 problem areas that required attention. between 2 and 3 areas that could be enhanced Results A total of 2,714 participants filled the survey, the majority were females (70.1%), and 29.9% were males. The median of their age was 22 years. ( IQR = 3) Participants represented various universities and academic levels, with the University of Khartoum being the most represented (13.6%). The majority were in clinical years (39.2%), held Sudanese high school certificates (86.6%), and were admitted through general admission (57.3%). For a detailed breakdown of university affiliation, academic year, classification, and educational background, refer to (Table 1). Reliability analysis The internal consistency of the DREEM scale was assessed using Cronbach’s alpha. The total 50-item scale demonstrated excellent reliability (α = 0.882). Subscale reliability coefficients were as follows: Students’ Perceptions of Learning (SPoL) α = 0.738, Students’ Perceptions of Teachers (SPoT) α = 0.659, Students’ Academic Self-Perceptions (SPaSP) α = 0.778, Students’ Perceptions of Atmosphere (SPoA) α = 0.794, and Students’ Social Self-Perceptions (SSSP) α = 0.495. While most subscales showed acceptable to good internal consistency, the lower reliability of the SSSP subscale suggests potential variability in responses for that domain, for details refer to table 2. DREEM total, subscale and single items analysis As presented in (Table 2) , students generally expressed positive perceptions of their educational environment, with the highest mean scores observed in the domains of Perception of Atmosphere (M = 30.23) and Perception of Learning (M = 29.83), suggesting favorable views of the academic environment and learning experiences. The lowest score was noted in Social Self-Perception (M = 17.36). The total DREEM score (M = 125.99) reflects an overall environment that is more positive than negative. Further insight from (Table 3) reveals consistent areas for improvement across individual items. Many teaching-related items (e.g., active learning encouragement, student-centered methods, and effective use of time) received moderate scores, typically around 2.6–2.8, indicating areas that could be enhanced. Problematic areas included an overemphasis on factual learning (M = 1.45) and teacher-centered approaches (M = 1.55). Students also raised concerns about teachers' authoritarian behavior and classroom anger, as well as the prevalence of ridicule and poor feedback practices. In terms of academic self-perception, while students felt relatively confident about passing the year (M = 2.91), scores for memorization ability (M = 2.33) and professional preparation (M = 2.55) highlight potential gaps. The perception of atmosphere was marked by issues such as cheating (M = 1.79) and disappointing experiences (M = 1.93), despite positive feelings about interpersonal skill development (M = 2.82). Social support emerged as a mixed domain. Students appreciated friendships (M = 3.13) but also reported fatigue (M = 1.60) and some degree of loneliness (M = 2.40). For detailed item-level responses, refer to (Table 3). Variation in Students’ Perceptions: Various demographic and academic factors were found to influence students' perception. In terms of gender differences, male students demonstrated slightly higher scores in academic self-perception (SASP) (p < 0.001), whereas female students scored higher in social perceptions (SPT) (p = 0.013). However, the overall perception scores did not differ significantly between genders. Similarly, students in Grade 1 and Grade 5 demonstrated higher scores in specific subscales compared to other academic years (p < 0.05). Differences were also observed between basic and clinical students, with clinical students generally reporting better perceptions in some aspects, though the differences reached statistical significance only in a few subscales (p < 0.05). Furthermore, students residing in university dormitories had significantly more positive perceptions of their educational environment compared to those living in private residences (p < 0.05). Regarding students' educational background, no significant differences were found between those admitted through general versus private admission pathways. However, students with non-Sudanese certificates exhibited higher scores in specific subscales (p < 0.05). Variables Categories N % Gender Males 812 29% Female 1902 70.10% Residancy Family house 1461 53.80% With relatives 293 10.80% University dormitories 372 13.70% Private dormitories 225 8.30% Private residence 253 9.30% Others 110 4.10% Academic year Grade 1 208 7.70% Grade 2 479 17.60% Grade 3 678 25.00% Grade 4 552 20.30% Grade 5 529 19.50% Grade 6 268 9.90% Curriculum Stage Basic science student 868 32.00% Pre-clinical student 783 28.90% Clinical student 1063 39.20% Type of certificate Sudanese 2349 86.60% Arabic countries certificate 271 10.00% Ig certificate 75 2.80% Others 19 0.70% Type of admission General 1555 57.30% Private 1052 38.80% Others 107 3.90% Table (1) Show Students Demographic Characteristics (N = 2,714) DREEM subscales and total score Min Max M ± SD Skewness* Kurtosis** Interpretation Number of items Cronbach's Alpha Perception of Learning 4 44 29.83 ± 5.78 -0.718 0.844 A more positive perception 12 0.738 Perception of Teachers 3 44 27.02 ± 4.92 0.022 1.326 Moving in the right direction 11 0.659 Academic Self Perception 0 32 21.55 ± 5.11 -0.471 0.679 Feeling more on the positive side 8 0.778 Perception Of Atmosphere 3 48 30.23 ± 6.68 -0.639 0.809 A more positive atmosphere 12 0.794 Social Self Perception 0 28 17.36 ± 3.96 -0.556 0.885 Not too bad 7 0.495 Total DREEM score 27 188 125.99 ± 19.76 -0.549 1.31 more positive than negative 50 0.882 * Standard Error = 0.047 ** Standard Error = 0.094 Table (2): Subscale and total DREEM Items Label M ± SD Interpretation 1. Perceptions of Teaching [12 item] 1. I'm encouraged to participate in class Class Participation Encouragement 2.70 ± 0.98 areas that could be enhanced 2. The teaching is often stimulating Teaching Stimulation 2.64 ± 0.95 areas that could be enhanced 3. The teaching is student-centered Student-Centered Approach 2.66 ± 0.90 areas that could be enhanced 4. The teaching is sufficiently concerned to develop my competence Competence Development 2.66 ± 0.96 areas that could be enhanced 5. The teaching is well focused Focus of Teaching 2.65 ± 0.91 areas that could be enhanced 6. The teaching is sufficiently concerned to develop my confidence Confidence Building 2.62 ± 1.01 areas that could be enhanced 7. The teaching time is put to good use Effective Use of Teaching Time 2.60 ± 0.97 areas that could be enhanced 8. The teaching over-emphasizes factual learning Emphasis on Factual Learning 1.45 ± 0.89 problem area 9. I'm clear about the learning objectives of the course Clarity of Learning Objectives 2.83 ± 0.87 areas that could be enhanced 10. The teaching encourages me to be an active learner Encouragement of Active Learning 2.81 ± 0.96 areas that could be enhanced 11. Long-term learning is emphasized over short-term learning Emphasis on Long-Term Learning 2.65 ± 0.91 areas that could be enhanced 12. The teaching is too teacher-centered Teacher-Centered Approach 1.55 ± 1.01 problem area 2. Perceptions of Teachers [11 item] 13. The teachers are knowledgeable Teacher Knowledge 3.16 ± 0.75 real positive points 14. The teachers are patient with patients Patience with Patients 2.83 ± 0.84 areas that could be enhanced 15. The teachers ridicule the students Ridiculing Students 1.83 ± 1.09 problem area 16. The teachers are authoritarian Authoritarian Teaching Style 1.68 ± 1.03 problem area 17. The teachers have good communication skills with patients Communication Skills with Patients 2.94 ± 0.83 areas that could be enhanced 18. The teachers are good at providing feedback to students Providing Feedback 2.74 ± 0.91 areas that could be enhanced 19. The teachers provide constructive criticism here Constructive Criticism 2.59 ± 0.90 areas that could be enhanced 20. The teachers give clear examples Clarity of Examples 2.88 ± 0.85 areas that could be enhanced 21. The teachers get angry in class Teachers' Anger in Class 1.82 ± 1.11 problem area 22. The teachers are well prepared for their class Preparation for Class 2.79 ± 0.91 areas that could be enhanced 23. The students irritate the teachers Students Irritating Teachers 1.74 ± 1.08 problem area 3. Academic Self-Perceptions [8 items] 24. Learning strategies which worked well for me before continue to work for me now Effectiveness of Learning Strategies 2.74 ± 0.92 areas that could be enhanced 25. I'm confident about my passing this year Confidence in Passing 2.91 ± 0.89 areas that could be enhanced 26. I feel I'm being well prepared for my profession Professional Preparation 2.55 ± 0.99 areas that could be enhanced 27. Last year's work has been a good preparation for this year's work Continuity in Preparation 2.58 ± 1.00 areas that could be enhanced 28. I'm able to memorize all I need Memorization Ability 2.33 ± 1.05 areas that could be enhanced 29. I have learned a lot about empathy in my profession Learning Empathy 2.76 ± 0.91 areas that could be enhanced 30. My problem-solving skills are being well developed here Problem-Solving Skills Development 2.76 ± 0.91 areas that could be enhanced 31. Much of what I have to learn seems relevant to a career in medicine Relevance of Learning to Medicine 2.92 ± 0.82 areas that could be enhanced 4. Perceptions of Atmosphere [12 items] 32. The atmosphere is relaxed during the ward teaching Ward Teaching Atmosphere 2.65 ± 0.97 areas that could be enhanced 33. This school is well time-tabled School Timetabling 2.39 ± 1.13 areas that could be enhanced 34. Cheating is a problem in this school Perception of Cheating 1.79 ± 1.21 problem area 35. The atmosphere is relaxed during the lectures Lecture Atmosphere 2.68 ± 0.95 areas that could be enhanced 36. There are opportunities for me to develop inter-personal skills Opportunities for Interpersonal Skills Development 2.82 ± 0.88 areas that could be enhanced 37. I feel comfortable in class socially Social Comfort in Class 2.76 ± 0.97 areas that could be enhanced 38. The atmosphere is relaxed during seminars/tutorials Seminars/Tutorials Atmosphere 2.70 ± 0.95 areas that could be enhanced 39. I find the experience disappointing Overall Experience Disappointment 1.93 ± 1.15 problem area 40. I’m able to concentrate well Concentration Ability 2.66 ± 0.93 areas that could be enhanced 41. The enjoyment outweighs the stress of studying medicine Enjoyment vs. Stress 2.55 ± 1.07 areas that could be enhanced 42. The atmosphere motivates me as a learner Motivational Atmosphere 2.63 ± 1.00 areas that could be enhanced 43. I feel able to ask the questions I want Comfort in Asking Questions 2.67 ± 1.03 areas that could be enhanced 5. Social Self-perception [7 items] 44. There is a good support system for students who get stressed Support System for Stress 2.36 ± 1.20 areas that could be enhanced 45. I am too tired to enjoy this course Course Enjoyment and Fatigue 1.60 ± 1.05 problem area 46. I am rarely bored on this course Course Engagement 2.24 ± 1.05 areas that could be enhanced 47. I have good friends in this school Social Support from Friends 3.13 ± 0.91 real positive points 48. My social life is good Social Life Satisfaction 2.87 ± 0.98 areas that could be enhanced 49. I seldom feel lonely Loneliness 2.40 ± 1.12 areas that could be enhanced 50. My accommodation is pleasant Accommodation Satisfaction 2.77 ± 0.93 areas that could be enhanced Table (3) Show DREEM individual items Scores N M ± SD t df p-value Mean Difference 95% CI SPL Male 812 29.86 ± 5.97 0.204 1470.5 0.839 0.05029 -0.434, 0.535 Female 1902 29.81 ± 5.70 SPT Male 812 26.66 ± 4.80 -2.48 1580.4 0.013 -0.50463 -0.904, -0.106 Female 1902 27.17 ± 4.97 SASP Male 812 22.06 ± 5.05 3.416 1551.8 < .001 0.72631 0.309, 1.143 Female 1902 21.33 ± 5.12 SPA Male 812 30.48 ± 6.89 1.255 1472.7 0.21 0.35763 -0.201, 0.917 Female 1902 30.13 ± 6.59 SSSP Male 812 17.57 ± 4.01 1.753 1509.1 0.08 0.29294 -0.035, 0.621 Female 1902 17.28 ± 3.94 Full score Male 812 126.64 ± 19.87 1.11 1521.2 0.267 0.92253 -0.707, 2.552 Female 1902 125.71 ± 19.71 DREEM Full score Yes 716 125.16 ± 20.32 Table (4): Variation in Students' Perceptions Based on Gender (t-test) Table (5): Factors affect Students' Perceptions (ANOVA) Variables SPL SPT SASP SPA SSSP DREEM Full Score F (p- value) F (p- value) F (p- value) F (p- value) F (p- value) F (p- value) η² Academic Year 1.657 (0.142) 0.708 (0.617) 5.53 (< .001) 3.981 (0.001) 1.75 (0.12) 1.138 (0.338) 0.002 Curriculum Stage 3.614 (0.027) 3.574 (0.028) 13.464 (< .001) 6.223 (0.002) 4.877 (0.008) 2.15 (0.117) 0.002 Admission 1.355 (0.258) 1.284 (0.277) 1.255 (0.285) 1.473 (0.229) 2.278 (0.103) 0.647 (0.524) 0 Certificate Type 3.725 (0.011) 0.255 (0.858) 1.488 (0.216) 3.875 (0.009) 3.201 (0.022) 3.306 (0.019) 0.004 Discussion This study was conducted during the ongoing conflict in Sudan, which has severely disrupted infrastructure and public services, including higher education [ 12 ]. Universities have experienced extensive damage, with the displacement of faculty and students further degrading the learning environment [ 13 ]. Assessing student perceptions during this period highlights key challenges and can inform efforts to improve medical education under crisis conditions. DREEM score (total and subscales, single items) 1/ Total DREEM Score : The overall DREEM score of 125.99/200 reflects a generally positive perception of the educational environment, notably higher than previous Sudanese studies (104–122), though still below one outlier (132). Despite ongoing conflict, economic hardship, and displacement, this score is similar to regional averages in Africa and Gulf countries (116–130), suggesting a degree of resilience in Sudan’s medical education system. However, scores remain lower than those reported in high-income countries like the UK (143) [ 14 ], Australia (141) [ 15 ], and Thailand (131.1) [ 16 ]. Likely due to differences in educational infrastructure, support systems, and stability. The findings highlight both the challenges and adaptability of students and institutions in conflict-affected settings. 2/ Perception of Learning : Amid wartime disruptions in Sudan, students' perceptions of teaching reveal a strained yet resilient educational environment. This domain was rated positively overall (29.83 ± 5.78), consistent with findings from earlier Sudanese studies conducted before the conflict [ 17 ] [ 18 ]. When examining individual item scores, we found that clarity of objectives (2.83 ± 0.87), encouragement of active learning (2.81 ± 0.96), and class participation (2.70 ± 0.98) received higher ratings, yet most items indicated areas needing enhancement. Alarmingly low scores for overemphasis on factual learning (1.45 ± 0.89) and teacher-centered methods (1.55 ± 1.01) may reflect a critical dissatisfaction with passive instructional strategies that fail to engage students meaningfully, particularly during crises. In a context of displacement and institutional breakdown, these findings highlight a compromised instructional quality and reduced engagement that may affect students’ academic performance [ 19 ] [ 20 ] [ 21 ]. The limited support for competence, confidence, and long-term learning points to the urgent need for adaptive, student-centered teaching strategies tailored to crisis settings.[ 22 ] . 3/ Perception of Teachers : In the context of the ongoing war in Sudan, teachers—particularly in medical and health education—are generally perceived as moving in the right direction. Their knowledge ability received a favorable mean score of 3.16 ± 0.75, reflecting the continued application of high standards by universities in selecting qualified educators, despite the disruption of war. However, this interpretation warrants caution, as it may be influenced by institutional resilience or limited access to a broader range of teaching environments. Educators also demonstrated strengths in their ability to provide feedback (2.74 ± 0.91) and communicate effectively with patients (2.94 ± 0.83), both of which are essential skills in conflict-affected health education. Several problematic behaviors among educators were also identified. These included authoritarianism (1.68 ± 1.03), ridiculing students (1.83 ± 1.09), expressions of anger in class (1.80 ± 1.11), and irritation toward students (1.74 ± 1.08). Such behaviors, especially in conflict zones, can severely compromise the learning environment and are often symptomatic of chronic stress, emotional fatigue, and burnout experienced by teachers working under persistent instability [ 23 ]. These findings highlight the urgent need for conflict-sensitive approaches and mental health support tailored for educators operating in war-affected regions. The war has intensified existing stressors such as shortages of teaching materials, administrative burdens, and the increasing diversity of students' psychosocial needs [ 24 ]. These challenges frequently overwhelm educators and may manifest as irritability, authoritarian responses, or emotional disengagement. Although many teachers receive training in instructional delivery and possess the necessary subject knowledge, they often lack preparation in areas such as crisis communication, emotional intelligence, and generational engagement skills that are critical in conflict-affected classrooms. [ 25 ] [ 26 ] [ 27 ] [ 28 ] [ 29 ]. This skills gap is particularly damaging in the context of war, where the role of educators extends beyond academic instruction to include psychological and emotional support. A Turkish study has underscored the importance of teacher attitudes in shaping students' development, reporting that educators are the second-most influential factor in individual growth after parents. Positive teacher attitudes were shown to enhance both academic performance and personality development, whereas negative attitudes had detrimental effects [ 30 ]. In conflict settings, especially among Sudanese medical students, respectful and supportive teacher–student relationships are vital. These relationships not only foster academic engagement and resilience but also provide emotional anchors during times of personal and collective trauma [ 19 ] [ 20 ] [ 21 ]. Ultimately, improving teacher capacity and well-being under conflict conditions directly translates into safer, more supportive learning environments for students who are already bearing the psychological burden of war. 4/ Perception of Atmosphere Amid the ongoing conflict in Sudan, students’ perceptions of the educational atmosphere reflect a learning environment under significant strain. The Perception of Atmosphere domain had a total mean score of 30.23 ± 6.68 out of a maximum of 48, indicating a slightly positive yet suboptimal perception. These modest scores in the Perception of Atmosphere domain have been reported in other Sudanese educational settings [ 18 ] and in international studies from stable environments such as Malaysia [ 31 ] and Kuwait [ 32 ], these comparisons are limited by vast contextual differences. Notably, none of the 12 items within this domain achieved a mean score above 3.0, suggesting the absence of perceived strengths and highlighting a broad need for improvement across multiple aspects of the educational climate. Among the most concerning findings was the low mean score for the item “Cheating is a problem in this school” (1.79 ± 1.21), a problem that is known to undermine the learning environment and demotivate students [ 33 ]. Similarly, the item “I find the experience disappointing” (1.93 ± 1.15) signals widespread dissatisfaction and disillusionment, potentially linked to systemic challenges such as conflict-related disruptions, displacement, and a lack of adequate student support systems. Several other items point to environmental and structural stressors. For example, school timetabling scored low (2.39 ± 1.13), reflecting inconsistencies and lack of coordination, which previous studies have shown to contribute significantly to student stress and reduced academic performance [ 34 ]. Additionally, the item “The enjoyment outweighs the stress of studying medicine” scored poorly (2.55 ± 1.07), indicating that for many students, the psychological burden of medical education outweighs its intrinsic rewards, particularly under crisis conditions. While moderate scores were observed in areas such as interpersonal skills development (2.82 ± 0.88), social comfort in class (2.76 ± 0.97), and comfort in asking questions (2.67 ± 1.03), they remain below desirable thresholds. These suggest that while students are not entirely alienated, they lack optimal levels of peer interaction and participatory engagement. The ability to concentrate well (2.66 ± 0.93) and the perceived motivational atmosphere (2.63 ± 1.00) also scored low, reflecting ongoing psychological fatigue, possible burnout, and limited institutional mechanisms to sustain academic motivation under duress [ 35 ] [ 36 ] . Interestingly, the highest-rated it was “The atmosphere is relaxed during lectures” (2.87 ± 1.12), which may reflect positive student-teacher rapport or a low-pressure teaching style. However, this finding is ambiguous. Without accompanying active learning strategies, such an atmosphere could also signal disengagement or a lack of academic rigor. In contrast, low agreement with the statement “I feel able to ask the questions I want” (2.14 ± 1.16) raises concerns about communication barriers, mostly aggravated by the ongoing conflict and educational disruption. Furthermore, the item “The atmosphere motivates me as a learner” scored poorly (2.28 ± 1.16), suggesting a misalignment between the current educational environments and students’ motivational needs—an issue compounded by the stress of displacement, unstable learning conditions, and limited psychosocial support. This aligns with literature emphasizing that motivation and learning are heavily influenced by the psychological safety and responsiveness of the academic environment [ 18 ] . In summary, the findings from this domain reveal a fragile and demotivating learning atmosphere, shaped by conflict-related instability and institutional shortcomings. To improve this domain, medical schools must focus on creating psychologically safe and inclusive classrooms, promoting student participation, addressing academic misconduct proactively, and ensuring structural stability through consistent timetabling and student support services. These steps are essential not only to enhance students’ educational experiences but also to sustain their academic engagement and resilience during times of crisis. 5/ Academic Self-Perception This domain had a moderately positive mean score of 20.59 ± 5.62 out of 28, indicating students generally feel competent in their academic abilities. This is consistent with a previous study in Sudan [ 18 ] [ 17 ] and studies from other countries such as Malaysia [ 31 ] and Kuwait [ 37 ]. However, lower scores were also seen in some settings. [ 38 ] . Students agreed they are learning strategies relevant to becoming doctors (2.80 ± 0.91), which aligns with studies linking curriculum relevance with increased student motivation and academic engagement [ 39 ] . Notably, the item “I have learned a lot about empathy in my profession” received a low mean score (2.10 ± 1.08), suggesting a persistent gap in the integration of emotional intelligence and empathy training within medical education. This concern aligns with global findings, particularly in conflict-affected and resource-constrained settings, where such competencies are often underemphasized despite their critical importance [ 40 ]. A significant concern was also the low confidence in passing exams (1.97 ± 1.12), which may indicate anxiety, poor formative assessment, or a lack of academic support services, which can affect their academic performance. This aligns with literature showing that fear of failure and lack of confidence are associated with increased stress and reduced academic performance [ 41 ] [ 42 ]. Improving feedback systems, providing accessible academic support, and integrating emotional skills training may help in enhancing students’ academic self-concept and reducing exam-related stress. This domain had a moderately positive mean score of 21.55 ± 5.11 out of 32, indicating students generally feel competent in their academic abilities. This is consistent with studies in Sudan [ 18 ] [ 37 ] and other countries such as Malaysia [ 31 ] and Kuwait [ 37 ] However, lower scores were seen in other settings [ 38 ]. Although students did not report it as a problematic area, a notable deficit that required improvement was observed in their preparedness for future professional roles (2.55 ± 0.99) and their ability to cope with the demands of memorization (2.33 ± 1.05). The low confidence in professional preparedness is concerning, as the ongoing conflict in Sudan has severely disrupted medical education and compromised clinical training environments. [ 43 ]. This may affect the students and can lead to doubts about their competencies. Additionally, the pervasive insecurity, risk of displacement, and the severe humanitarian consequences exacerbate these fears [ 44 ] [ 45 ]. Such psychological burdens also compromise cognitive performance and explain the memorization difficulties, as chronic stress is known to impair memory [ 46 ] [ 47 ] . On the other hand, students reported a relatively high perception of the relevance of their learning to their future medical careers (2.92 ± 0.82), indicating that, despite the conflict, the core educational content remains meaningful and aligned with professional goals. This perceived relevance underscores the resilience of Sudanese medical students and faculty in maintaining academic focus. Institutional efforts such as rapid transitions to online learning and collaborative initiatives with local and international partners have likely contributed to sustaining curricular continuity during the disruption [ 48 ], even though these collaborations primarily supported content delivery rather than influencing students' perceptions directly. In summary, while students show moderate academic self-confidence, gaps in professional preparedness and memory may reflect the toll of conflict and disrupted training. Still, the strong perceived relevance of their education underscores the resilience of Sudanese medical schools and the value of adaptive strategies in maintaining core learning amid crisis. 6/ Social Self-Perception This domain had a total possible score of 28, with students reporting a mean of 17.36 ± 3.96, out of 28 points for maximum score, reflecting a moderately low perception of their social well-being. It revealed a mixed picture, with limited strengths and several areas in need of improvement. The most positively rated item was the presence of peer support, with students agreeing that they have good friends within the school (3.13 ± 0.91). This suggests that, despite the instability caused by the ongoing conflict, interpersonal relationships among students remain a key source of resilience and psychological buffering. However, most other items in this domain reflected concerning areas. The item “I am too tired to enjoy this course” scored the lowest (1.60 ± 1.05), highlighting a significant problem with fatigue and academic burnout, which is possibly worsened by displacement, disrupted routines, and increased psychosocial stress [ 35 ] (link). Similarly, students reported low levels of perceived institutional support for managing stress (2.36 ± 1.20), pointing to a gap in mental health services and structured coping mechanisms provided by universities. Moderate but suboptimal scores were observed for items related to social life satisfaction (2.87 ± 0.98), course engagement (2.24 ± 1.05), and accommodation conditions (2.77 ± 0.93). These findings suggest that although some semblance of normalcy is retained, students are experiencing disruptions in their broader social environment and living conditions, which are known to impact mental well-being and academic success [ 49 ]. The score for loneliness also (2.40 ± 1.12) further underscores the need for stronger psychosocial support frameworks. Taken together, these results reveal that while peer relationships remain a valuable asset, the broader social and institutional environment is under strain. Addressing student fatigue, enhancing emotional support systems, and improving living conditions are essential to safeguarding the well-being of medical students during the ongoing conflict in Sudan. [ 18 ] . 7/ Gender Difference : There was no significant difference in the overall DREEM score between male and female students, indicating that both groups were similarly affected by the ongoing conflict. A study from Syria. Using the DREEM scale during conflict found no gender specific differences, indicating that subtle, context-specific factors may shape students' perceptions in different ways [ 50 ] . Beyond the context of war, this finding is consistent with results from several institutions worldwide, including the United Kingdom [ 51 ], India [ 52 ], Iran [ 53 ], and Saudi Arabia [ 54 ]. Conversely, some studies report significant gender-based differences [ 55 ] [ 56 ], likely influenced by cultural norms, coping styles, and learning preferences. [ 57 ] [ 58 ]. Nonetheless, it is important to recognize that this surface-level similarity between males and females in the overall DREEM score may mask more complex gender-specific perceptions. In our study, females expressed a more positive perception of their teachers, a finding that aligns with other studies [ 50 ] [ 59 ]. In the context of ongoing conflict, this may reflect females’ stronger perception of connection and support from teachers. Alternatively, it could be related to gender differences in learning styles [ 58 ]. Shifting to Academic self-perception, Male students exhibit significantly higher scores in the Academic Self-Perception subscale, indicating a greater sense of academic confidence compared to their female counterparts [ 60 ]. This finding suggests that male students tend to perceive themselves as more academically capable and self-assured. A similar finding was also reported in a Moroccan Medical University, which reinforces the possibility that gendered differences in academic confidence persist. ( [ 61 ] 8/ Admission Type : Regarding the admission type, our study indicates no statistically significant differences in the total DREEM score and across all the sub-scales, suggesting that students across different admission pathways perceive their learning environment similarly. This contrasts with a previous study at the University of Bahri, Sudan, which reported a more positive perception of learning among general admission students [ 9 ]. The lack of significant differences based on admission type might stem from unique contextual factors in Sudan, including war, political instability and COVID-19. This also may reflect a homogenized educational experience shaped by uniform institutional policies, curricular structures, and shared challenges such as disrupted learning and resource constraints during the conflict. The absence of significant differences in students' perceptions based on admission type may be attributed to Sudan's unique contextual challenges, including ongoing conflict, political instability, and the impacts of the COVID-19 pandemic. [ 62 ] [ 63 ]. These widespread disruptions likely created a shared educational experience across all student groups, shaped by uniform institutional policies, standardized curricula, and common obstacles such as interrupted learning and limited resources. In such a context, the influence of the admission route may be diminished, as broader systemic pressures take precedence. The relatively consistent DREEM scores reflect this homogenized experience, yet they also underscore the need for ongoing assessment of the learning environment to ensure that all students receive adequate support, especially during times of crisis. 9/ Type of certificate Our findings indicate significant differences in students’ perceptions of the educational environment across certificate types, particularly in perceptions of learning, atmosphere, and social self-perception. Students with certificates other than Sudanese and Arabic certificates had the highest ratings, followed by Sudanese students, while students with certificates from Arabic countries consistently reported the lowest scores. In our study, Arabic certificate holders had a mean perception of atmosphere score of 28.94 ± 7.26, which, while still within a positive range, was significantly lower than that of Sudanese students (30.23 ± 6.68). Their mean social self-perception score was 16.72 ± 3.99, also lower than the Sudanese students’ mean of 17.36 ± 3.96. A possible explanation for these findings is that Arabic certificate students may have already formed lower perceptions of their learning environment before entering medical school. Studies from Saudi Arabia suggest that students in similar educational settings have reported lower perceptions of atmosphere and social self-perception [ 20 ]. This may be attributed to the nature of pre-university learning conditions for students with Arabic certificates, which could shape their expectations and subsequently influence their perceptions in medical school. Additionally, differences in educational infrastructure, curriculum design might contribute to this result. Another possible factor is social integration, as these students may feel less connected to the local academic and social community, potentially impacting their overall experience. These scores suggest that Arabic certificate students in our study may be reflecting a broader pattern observed in similar educational environments. Further research is needed to explore whether these perceptions stem from prior educational experiences, difficulties in adaptation, or other contributing factors, and to identify interventions that could enhance their academic and social experience. 10/ Academic year Our study found no statistically significant differences in overall DREEM scores across academic years (F = 1.138, p = 0.338, η² = 0.002), indicating a generally stable perception of the educational environment. First-year students had the highest average score (128.86), while third-year students had the lowest (125.32), though the differences were not statistically meaningful. These findings contrast with studies from Saudi Arabia [ 54 ], Spain [ 64 ], Nigeria [ 65 ], and India [ 66 ], which reported a decline in student satisfaction as training progressed. Conversely, our results align with previous Sudanese data, which showed moderate but fluctuating DREEM scores across years, with some significant differences [ 67 ]. The slightly higher scores observed in our cohort may reflect institutional resilience and consistent support mechanisms despite external challenges such as conflict and displacement. Further investigation is needed to identify the specific protective factors contributing to this stability. Across several DREEM domains (SPL, SPT and SSP), no significant differences were found among academic years. For SPL, mean scores were closely clustered (F = 1.657, p = 0.142, η² = 0.003), suggesting homogenous learning experiences throughout the curriculum. This contrasts with South Indian and Saudi studies reporting higher satisfaction in early years and progressive declines in later semesters [ 68 ] [ 54 ]. Similarly, SPT scores remained stable (F = 0.708, p = 0.617, η² = 0.001), with minimal variation between Grade 3 (27.21) and Grade 5 (26.71). This contrasts with findings from Qadi Ayyad and Ankara universities, where senior students expressed more negative views of faculty [ 61 ] [96], and with a Sudanese study noting a peak in Grade 3 before decline [ 67 ]. SSP scores also showed no significant change (F = 1.75, p = 0.12, η² = 0.003), remaining fairly stable from Grade 1 (18.01) to Grade 5 (17.21). This suggests that students’ sense of social confidence and support is preserved despite increasing academic demands, a trend consistent with regional data [ 54 ] [ 67 ] . The overall consistency in these domains may indicate uniform teaching practices and early formation of student expectations. It could also reflect institutional policies that ensure a relatively stable academic and social environment across all stages of training. However, the absence of significant variation does not rule out subtle differences that may need further investigation. In contrast to the stability observed above, two domains ( academic self-perception and perception of the learning atmosphere) showed significant variation across academic years. ASP varied significantly (F = 5.53, p < 0.001, η² = 0.01), with Grades 1 and 5 reporting the highest confidence (22.16 and 22.19), and Grade 3 the lowest (20.94). A similar finding was documented in Sudanese students, where final-year learners demonstrated higher academic confidence compared to those in earlier years [ 67 ]. This mid-program dip may reflect the transitional stress associated with moving from pre-clinical to clinical education [ 70 ]. Perception of the atmosphere also significantly declined (F = 3.981, p = 0.001, η² = 0.007), with first-year students viewing it most positively (31.51) and fifth-year students the least (29.67). Post hoc analysis confirmed significantly better perceptions in Grade 1 compared to Grades 4 and 5. Similar declines were reported in Saudi and Sudanese studies, where senior students perceived the learning atmosphere less favorably [ 54 ] [ 67 ] [ 71 ]. This trend is likely driven by increased academic pressures, complex clinical duties, and limited structured time for feedback and peer interaction [ 72 ]. As students advance, they face heavier workloads, less direct supervision, and higher expectations, which may reduce their perception of a supportive and engaging academic environment. 11/ Basic and Preclinical vs. Clinical All five DREEM subscales showed significant variation across academic phases. The most notable difference was in academic self-perception (F = 13.464, p < 0.001, η² = 0.01), with preclinical students reporting significantly lower perception than both clinical (p < 0.001) and basic science students (p = 0.017). This is similar to a previous Sudanese study [ 21 ], and contrasts with a Spanish study that reported a decline in academic perception with the progression in academic phases [ 64 ]. The drop during preclinical years may reflect academic pressure and limited clinical exposure, while confidence appears to rebound in clinical stages due to real-world application. An Australian study also found a significant improvement in academic confidence throughout years of clinical training (p < 0.001) [ 73 ] . In the perception of learning, the pre-clinical students had significantly lower perceptions than clinical students (p = 0.022). While Basic Science and Clinical students had relatively similar ratings, in contrast, preclinical students rated their teachers more positively than clinical students ( p = 0.039), with basic science students' ratings similar to clinical students. This may reflect declining teacher-student interaction as clinical demands increase. Similar trends were seen in Spain and Pakistan [ 64 ][ 74 ]. The similar perception of teachers' scores between Basic Science and Clinical students may stem from limited personalized interaction in both phases, as Basic Sciences rely on large lectures, while Clinical training often suffers from inconsistent clinical teaching. In contrast, preclinical students benefit from more structured, small-group teaching, leading to more positive perceptions. This suggests that structured faculty engagement significantly influences students’ views of teaching quality. Perception of the atmosphere declined with academic progression, highest in basic and lowest in clinical students (F = 6.223, p = 0.002), echoing the Spanish study [ 64 ]. Social self-perception followed a similar pattern (F = 4.877, p = 0.008), likely due to academic load, reduced peer interaction, and clinical stress. Despite differences in subscales, total DREEM scores showed no significant variation (F = 2.15, p = 0.117). Basic and clinical students reported comparable scores, with preclinical slightly lower. Similar trends were reported in Pakistan [ 72 ], but the Spanish study found a significant overall decline [ 64 ]. This suggests that while students' experiences vary across specific domains, their overall perception of the educational environment remains relatively stable throughout the academic journey, emphasizing the need to tailor educational approaches to each academic phase to enhance the overall learning experience. Conclusion This study reports resilience among Sudanese medical students as despite the extreme challenges of conflict, these students still show moderately positive perceptions towards their educational environment. However, the impact of war on academic self-perception and emotional well-being across academic years can't be denied. Ongoing conflict increases existing challenges and creates new ones, like psychological stress and teaching infrastructure disruption. Differences in perceptions across academic years show an urgent need for specialized interventions such as an academic support system, a mental health guide program and resilience in the academic curriculum. To mitigate these risks, it is essential to implement targeted support programs that address students’ social and emotional needs. Interventions should be tailored to the different challenges faced by students at various academic levels. Regular assessment of the learning environment should be maintained to guide timely responses, especially during crises. Furthermore, strong collaboration between universities, stakeholders, and student representatives is crucial to ensure continuity and uphold the quality of medical education in Sudan. Ultimately, educational environment improvement during conflicts, not only focused on infrastructure, it is on hope, capacity and training of future health care providers. As Sudan faces this humanitarian crisis, perceived quality of medical education must remain a national priority. Strengths and limitations This study presents several notable strengths. It is the first to apply the DREEM scale to evaluate medical education during an active conflict in Sudan, providing novel insights into students’ experiences under crisis conditions. The large, diverse sample comprising 2,714 students from 46 universities across Sudan enhances the national relevance of the findings. The use of the validated DREEM instrument allowed for a robust, multidimensional assessment of the educational environment, supported by strong internal consistency (α = 0.882). The application of appropriate statistical tests further ensured reliable subgroup comparisons. Nonetheless, limitations must be acknowledged. The cross-sectional design restricts causal inferences and reflects only a single time point. The use of convenience sampling and online distribution may have introduced selection bias, likely excluding students in severely affected or low-connectivity areas. Self-reported data are also subject to response and social desirability biases. Moreover, variations in conflict severity and institutional response were not controlled for, which may limit the generalizability of results across all settings. Despite these limitations, the study establishes a critical foundation for future longitudinal research and targeted educational interventions during crises. Declarations Disclosure : Funding Sources: This Study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethical Considerations Ethical approval for this study was obtained from the national ethics committees at the Ministry of Higher Education. All procedures involving human participants were in accordance with the ethical standards of the Helsinki Declaration. Prior to participation, written informed consent was obtained from all students.. Confidentiality was maintained by ensuring that all collected data were anonymized, and no personally identifiable information was recorded or shared. Data was securely stored and accessible only for the research team. No incentives were provided to participants for their involvement in the study. Consent for publication All participants provided written informed consent for their data to be used in this study and for the publication of anonymized findings. Personal identifiers were not collected or published, ensuring participant confidentiality. Competing interests The authors declare no competing interests. Human ethics and consent to participate declarations : Not applicable. Data Availability The datasets generated and analyzed during this study are available from the corresponding author on reasonable request. Acknowledgments The authors would like to acknowledge the data collectors for their assistance distributing the questionnaire among universities : 1/ Munzir Faisal Suliman Eltahir - Omdurman Islamic University Faculty of Medicine and Health Sciences 2/ MIHAD OSMAN ZUMRAWI MOHAMED - University of khartoum , faculty of medicine 3/ Eman Almuez Ahmed Mohamed - University of Gezira , faculty of medicine and we sincerely appreciate the respondents for taking the time to complete the survey. Author Contributions N.E.A.H. and M.M.A conceptualized and designed the study, led the writing of the manuscript, and supervised the overall project. M.S.H.M and M.M.Y.S performed statistical analysis , data interpretation and prepared tables and figures. M.A.A.A supported data management and helped with methodological inputs .H.S.S and O.Y.M.Y conducted the literature search, participate in drafting the introduction and theoretical framework . M.A.B. and A.H.A.A.M. assisted in data management and contributed to reviewing and checking the final draft . All the authors participate in data collection and manuscript writing and reviewing and authors read and approved the final manuscript . References Sudan emergency [Internet]. UNHCR. Available from: https://www.unhcr.org/emergencies/sudan-emergency ‌Sudan: No respite for civilians amid unrelenting war and aid access barriers [Internet]. UN News. 2025. Available from: https://news.un.org/en/story/2025/04/1162386 ‌Eldin H, Rania M.H. Baleela. Preliminary investigation and analysis of the impact of the Sudan War on higher education and scientific research sectors. International Journal of Educational Development. 2024 Dec 17;112:103190–0. ‌Mohamed MS, Dibya Sundar Panda, Fatima Abubker Fadul, Awada Abdelmageed Saadeldin, Mona Timan Idriss, Khan YH, et al. Assessment of the impact of COVID-19 and political instability on mental health of university students in Sudan. Eastern Mediterranean Health Journal/Eastern Mediterranean health journal. 2024 May 13;30(4):272–82. ‌Babiker A. War and education: the attacks on medical schools amidst ongoing armed conflict, Sudan 2023. figshare [Internet]. 2024 Mar 29 [cited 2025 Jul 31]; Available from: https://springernature.figshare.com/collections/War_and_education_ the_attacks_on_medical_schools_ amidst_ongoing_armed_conflict_ Sudan_2023/7155818/1 ‌Eldin AG. Forgotten and Neglected, War-Torn Sudan Has Become the World’s Leading Displacement Crisis [Internet]. migrationpolicy.org. 2025. Available from: https://www.migrationpolicy.org/article/sudan-civil-war-displacement ‌Kassab SE, Ramya Rathan, Taylor D, Hamdy H. The impact of the educational environment on student engagement and academic performance in health professions education. BMC Medical Education. 2024 Nov 7;24(1). ‌Al-Saleh S, Al-Madi EM, AlMufleh B, Al-Degheishem AH. Educational environment as perceived by dental students at King Saud University. The Saudi Dental Journal. 2018 Jul;30(3):240–9. ‌Salih KM, Idris ME, Elfaki OA, Osman NM, Nour SM, Elsidig HA, et al. MBBS teaching program, according to DREEM in College of Medicine, University of Bahri, Khartoum, Sudan. Advances in Medical Education and Practice [Internet]. 2018 Sep 4 [cited 2021 Nov 10];9:617–22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129022/ ‌Jaffery AH, Kishwar M. Student’s perception of educational environment and their academic performance: Are they related? Pak Armed Forces Med J. 2019;69(6):1267–71 McAleer S, Roff S. Curriculum, environment, climate, quality and change in medical education: a unifying perspective. Med Teach. 2001;23(5):443–54 Elgadal M, Glade R. Research in displacement: The impact of war on Sudan’s higher education & academic research community. Oxford (UK): Rift Valley Institute; 2024 Abdellatif, S. M. F., Elmubarak, S. a. A., Suliman, H. A., Osman, M. E. M., Ahmed, A. a. M., Dawi, E. a. R., & Konozy, E. H. E. (2025). A nation in crisis: effects of Sudan’s armed conflict on university professors, research scientists, and students. Medicine Conflict & Survival, 1–21. https://doi.org/10.1080/13623699.2025.2511573 Monrouxe LV . Negotiating professional identities: dominant and contesting narratives in medical students’ longitudinal audio diaries. Med Educ. 2008;42(4):533–540. doi:10.1111/j.1365-2929.2007.02686.x Kassem A, Levin L. Periodontal health and orthodontic treatment. Eur J Oral Sci. 2018;126(Suppl 1):13–17. doi:10.1111/eje.13005 Hongkan W, Arora R, Muenpa R, Chamnan P. Perception of educational environment among medical students in Thailand. Int J Med Educ. 2018 Jan 26;9:18–23. doi:10.5116/ijme.5a4a.1eda Salih KMA, Idris MEA, Elfaki OA, Osman NMN, Nour SM, Elsiddig HA, et al. Measurement of the educational environment in MBBS teaching program, according to DREEM in College of Medicine, University of Bahri, Khartoum, Sudan. Adv Med Educ Pract. 2018;9:617–622. doi:10.2147/AMEP.S160218 Mohammed D, Yassen E, Mohamed M, Eltayeb R, Asmally R, Mohammed S, et al. Educational environment and its relation to academic performance as perceived by medical students in University of Khartoum. A cross Sectional Study, Sudan, 2020. MedEdPublish. 2021;10(1). Denz-Penhey H, Murdoch JC. A comparison between findings from the DREEM questionnaire and that from qualitative interviews. Medical Teacher. 2009 Jan;31(10):e449–53. ‌Essa M. Students Perceptions of Learning Environment in Jazan Medical School in Saudi Arabia. Research Square (Research Square). 2022 Apr 14; ‌Abdullahi H, Elshazali OH, Shaheen S. Medical students’ perception of the educational environment in the Faculty of Medicine, University of Khartoum, Sudan. 2019 Oct 27;12(3):1631–7. Available from: https://www.researchgate.net/publication/341049570 Challa KT, Sayed A, Acharya Y. Modern techniques of teaching and learning in medical education: a descriptive literature review. MedEdPublish. 2021;10(1). ‌Eldin H, Rania M.H. Baleela. Preliminary investigation and analysis of the impact of the Sudan War on higher education and scientific research sectors. International Journal of Educational Development. 2024 Dec 17;112:103190–0. ‌Omer AT, Ali EM, Elhassan ME, Ibrahim SA, Ahmed YS. Medical education challenges during the war crisis in Sudan: a cross-sectional study, 2023–2024. BMC Medical Education. 2024 Nov 23;24(1). ‌Monks J, Schmidt RM. The Impact of Class Size on Outcomes in Higher Education. The BE Journal of Economic Analysis & Policy [Internet]. 2011 Sep 29;11(1). Available from: https://www.ilr.cornell.edu/sites/ilr.cornell.edu/files/WP136.pdf Trigwell K. Relations between teachers’ emotions in teaching and their approaches to teaching in higher education. Instructional Science [Internet]. 2011 Oct 30;40(3):607–21. Available from: https://link.springer.com/article/10.1007/s11251-011-9192-3 ‌Khan AT, Ullah A, Ahmad I, Kazmi MZ. The Impact of Political Instability on Financial Anxiety, Career Orientation, Job Aspirations, Academic Performance, and Psychological Well-being among University Students. Physical Education, Health and Social Sciences [Internet]. 2025;3(1):161–71. Available from: http://journal-of-social-education.org/index.php/Jorunal/article/view/105 ‌Garcia P, Qin J. Identifying the generation gap in higher education. LearnTechLib. [Internet]. 2007 [cited 2025 Jul 31]; Available from: https://www.learntechlib.org/p/104229/ Josephine J, Jones L. Understanding the Impact of Generation Gap on Teaching and Learning in Medical Education: A Phenomenological Study. Advances in Medical Education and Practice. 2022 Sep;Volume 13:1071–9. ‌Ulug M, Ozden MS, Eryilmaz A. The Effects of Teachers’ Attitudes on Students’ Personality and Performance. Procedia - Social and Behavioral Sciences [Internet]. 2011;30(30):738–42. Available from: https://www.sciencedirect.com/science/article/pii/S1877042811019690 ‌Kaur V. Assessment of institutional educational environment using the DREEM inventory. Int J Appl Basic Med Res. 2020;1(1):?–? doi:10.4103/ijabmr.IJABMR_470_20 Marwan, Y., Karim, J., Al-Halabi, B., Sadeq, H., Dawas, A., & Al-Abdulrazzaq, D. (2015). The educational environment of the undergraduate medical curriculum at Kuwait University. Advances in Medical Education and Practice, 297. https://doi.org/10.2147/amep.s81729 Guruswami GK, Mumtaz S, Gopakumar A, Khan E, Abdullah F, Parahoo SK. Academic Integrity Perceptions Among Health-Professions’ Students: A Cross-Sectional Study in The Middle East. Journal of Academic Ethics. 2022 Jul 5;21(2). Jones PJ, Park SY, Lefevor GT. Contemporary College Student Anxiety: The Role of Academic Distress, Financial Stress, and Support. Journal of College Counseling. 2018 Oct;21(3):252–64. ‌Saeed AA, Mohammad A, Abass AA, Mohammed AA, Fidaaldeen Adil Abdallh, Ali HE, et al. Psychological impact and coping mechanisms among sudanese medical students: a study on anxiety, depression, behavioral, and cognitive changes post COVID-19 lockdown and ongoing conflict. BMC Psychology. 2025 Jan 14;13(1). Salih HS, Ibrahim SA, Gaded AA, Abdo L, Mahmoud MF, Elbadawi MH, et al. Depression, stress and anxiety among Khartoum University students who stay in war-afflicted regions in Sudan 2024. BMC Psychiatry. 2025 Feb 15;25(1). Al Fryan LH, Shomo MI, Bani IA. Assessment of the “students” perceptions of education using Dundee Ready Environment Educational Measure (DREEM) inventory at Princess Nourah bint Abdulrahman University, Saudi Arabia. BMC Medical Education. 2024 Aug 26;24(1). Ahmed Y, Taha MH, Al-Neel S, Gaffar AM. Students’ perception of the learning environment and its relation to their study year and performance in Sudan. International Journal of Medical Education [Internet]. 2018 May 24;9:145–50. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129164/ Adkins WA, Davidson MG. Ordinary Differential Equations. Undergraduate Texts in Mathematics. New York: Springer; 2012. DOI: 10.1007/978‑1‑4614‑3618‑8 Chen H, Xuan H, Cai J, Liu M, Shi L. The impact of empathy on medical students: an integrative review. BMC medical education. 2024 Apr 25;24(1). Nair PN, Sutar MD. Fear of Failure, Academic Self-Efficacy and Academic Performance among College Students. International Journal of Indian Psychology [Internet]. 2023 Jul 14;11(3). Available from: https://ijip.in/articles/fear-of-failure-academic-self-efficacy-and-academic-performance-among-college-students/ Bedewy D, Gabriel A. Examining Perceptions of Academic Stress and Its Sources among University Students: The Perception of Academic Stress Scale. Health Psychology Open [Internet]. 2015;2(2):1–9. Available from: https://journals.sagepub.com/doi/full/10.1177/2055102915596714 Abdallah E, Amna Khairy, Osman S, Musab Babiker Haga, Hashim S, Abbu M, et al. War and education: the attacks on medical schools amidst ongoing armed conflict, Sudan 2023. Conflict and health. 2024 Mar 29;18(1). Omer AT, Ali EM, Elhassan ME, Ibrahim SA, Ahmed YS. Medical education challenges during the war crisis in Sudan: a cross-sectional study, 2023–2024. BMC Medical Education. 2024 Nov 23;24(1). Abdulhamid SM, Almokdad FK, Ahmed RJQ, Elbashir RMAM, Suleiman YAA. Psychological status of medical students and interns in the wake of the armed conflict of April 2023 in Sudan: a cross‑sectional study [preprint]. medRxiv. 2024 Feb 27:2024.02.27.24303455. doi:10.1101/2024.02.27.24303455 Klier C, Buratto LG. Stress and long-term memory retrieval: a systematic review. Trends in Psychiatry and Psychotherapy [Internet]. 2020;42(3):284–91. Available from: https://www.scielo.br/j/trends/a/G9LbsdJggQx4wP85GvDxBNh/?lang=en Schwabe L. Memory under stress: from Adaptation to Disorder. Biological psychiatry. 2024 Jun 1;97(4). Ahmed, M. E. M., Tibin, E. I., Ibrahim, A., & Elimam, A. M. (2024a). Epigram from the Sudanese Medical School’s Resilience in Wartime. OALib, 11(10), 1–16. https://doi.org/10.4236/oalib.1112399. Kornbluh M, Wilking J, Roll S, Donatello R. Exploring housing insecurity in relation to student success. Journal of American College Health. 2022 Apr 26;72(3):1–5. Ghaith Alfakhry, Naeem A, M Bader AboHajar, Alfakhry A, Abdul Fattah Mohandes, Ali I, et al. Revealing the significant shortcomings in the learning environment at the three largest medical schools in Syria: what’s next? 2023 Jan 3;23(1). Miles S, Leinster SJ. Medical students’ perceptions of their educational environment: expected versus actual perceptions. Medical Education. 2007 Feb 2;41(3):265–72. Available from: https://pubmed.ncbi.nlm.nih.gov/17316211/ Abraham R, Ramnarayan K, Vinod P, Torke S. Students’ perceptions of learning environment in an Indian medical school. BMC Medical Education [Internet]. 2008 Apr 11;8(1). Available from: https://doi.org/10.1186/1472-6920-8-20 Behkam, S., Tavallaei, A., Maghbouli, N., Mafinejad, M. K., & Ali, J. H. (2022). Students’ perception of educational environment based on Dundee Ready Education Environment Measure and the role of peer mentoring: a cross-sectional study. BMC Medical Education, 22(1). https://doi.org/10.1186/s12909-022-03219-8 Awawdeh, M., Alosail, L. A., Alqahtani, M., Almotairi, A., Almikhem, R. N., Alahmadi, R. A., Aldughaither, A. A., & Alamoud, K. A. (2024). Students’ perception of the educational environment at King Saud bin Abdulaziz University for health sciences using DREEM tool. BMC Medical Education, 24(1). https://doi.org/10.1186/s12909-023-05004-7 Dunne, F., McAleer, S., & Roff, S. (2006). Assessment of the undergraduate medical education environment in a large UK medical school. Health Education Journal, 65(2), 149–158. https://doi.org/10.1177/001789690606500205 Al-Hazimi, A., Zaini, R., Al-Hyiani, A., Hassan, N., Gunaid, A., Ponnamperuma, G., Karunathilake, I., Roff, S., McAleer, S., & Davis, M. (2004). Educational environment in traditional and innovative medical schools: A study in four undergraduate medical schools. Education for Health, 17(2), 192–203. https://doi.org/10.1080/13576280410001711003 Legewie, J., & DiPrete, T. A. (2012). School context and the gender gap in educational achievement. American Sociological Review, 77(3), 463–485. https://doi.org/10.1177/0003122412440802 Sarabi-Asiabar, A., Jafari, M., Sadeghifar, J., Tofighi, S., Zaboli, R., Peyman, H., Salimi, M., & Shams, L. (2014). The relationship between learning style preferences and gender, educational major and status in first year medical Students: a survey study from Iran. Iranian Red Crescent Medical Journal, 17(1). https://doi.org/10.5812/ircmj.18250 Hongkan, W., Arora, R., Muenpa, R., & Chamnan, P. (2018). Perception of educational environment among medical students in Thailand. International Journal of Medical Education, 9, 18–23. https://doi.org/10.5116/ijme.5a4a.1eda Blanch, D. C., Hall, J. A., Roter, D. L., & Frankel, R. M. (2008). Medical student gender and issues of confidence. Patient Education and Counseling, 72(3), 374–381. https://doi.org/10.1016/j.pec.2008.05.021 A, B. (2020). Students Perceptions of the Educational Environment: A Cross-Sectional Study from a Moroccan Medical University. Psychology and Psychotherapy Research Study, 4(1). https://doi.org/10.31031/pprs.2020.03.000576 RESEARCH IN DISPLACEMENT: THE IMPACT OF WAR ON SUDAN’S HIGHER EDUCATION AND ACADEMIC RESEARCH – Rift Valley Institute. (2024). https://riftvalley.net/publication/research-in-displacement/ Suliman, N. H. E. E. N. K. A. (n.d.). The impact of COVID-19 on Sudanese higher education system. International Journal of Science and Research (IJSR). https://www.ijsr.net/getabstract.php?paperid=SR20629224804 Pales, J., Gual, A., Escaneroi, J., Tomás, I., De Castro, F. R., Elorudy, M., Virumbrales, M., Rodríguez, G., & Arce, V. (2015). Educational climate perception by preclinical and clinical medical students in five Spanish medical schools. International Journal of Medical Education, 6, 65–75. https://doi.org/10.5116/ijme.5557.25f9 Roff, S., McAleer, S., Ifere, O., & Bhattacharya, S. (2001). A global diagnostic tool for measuring educational environment: comparing Nigeria and Nepal. Medical Teacher, 23(4), 378–382. https://doi.org/10.1080/01421590120043080 Vishwanathan, K., Patel, G. M., & Patel, D. J. (2021). Impact and perception about distant online medical education (tele-education) on the educational environment during the COVID-19 pandemic. Journal of Family Medicine and Primary Care, 10(6), 2216–2224. https://doi.org/10.4103/jfmpc.jfmpc_2306_20 Ahmed, Y., Taha, M. H., Al-Neel, S., & Gaffar, A. M. (2018). Students’ perception of the learning environment and its relation to their study year and performance in Sudan. International Journal of Medical Education, 9, 145–150. https://doi.org/10.5116/ijme.5af0.1fee Pai, P. G., Menezes, V., Srikanth, Subramanian, A. M., & Shenoy, J. P. (2014). Medical students’ perception of their educational environment. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2014/5559.3944 Demirören, M. (2008). Perceptions of students in different phases of medical education of educational environment: Ankara University Faculty of Medicine. Medical Education Online, 13. https://doi.org/10.3885/meo.2008.res00267 Voltmer, E., Köslich-Strumann, S., Voltmer, J., & Kötter, T. (2021). Stress and behavior patterns throughout medical education – a six year longitudinal study. BMC Medical Education, 21(1). https://doi.org/10.1186/s12909-021-02862-x Kumar, V., Yeturu, S., Pentapati, K., Krishnan, N., Roy, S., & Babu, R. (2022). Students’ perceptions of their educational environment in a south Indian dental school—A cross-sectional study. Journal of International Oral Health, 14(5), 518. https://doi.org/10.4103/jioh.jioh_34_22 Kumar, B., Shah, M. a. A., Kumari, R., Kumar, A., Kumar, J., & Tahir, A. (2019). Depression, anxiety, and stress among final-year medical students. Cureus. https://doi.org/10.7759/cureus.4257 McNair, R., Griffiths, L., Reid, K., & Sloan, H. (2016). Medical students developing confidence and patient centredness in diverse clinical settings: a longitudinal survey study. BMC Medical Education, 16(1). https://doi.org/10.1186/s12909-016-0689-y Raza, A., & Khaliq, T. (2022). STUDENTS DREEM FROM PRE-CLINICAL TO CLINICAL YEARS - A CROSS SECTIONAL ANALYSIS FROM REHMAN MEDICAL COLLEGE, PESHAWAR. Journal of Ayub Medical College Abbottabad, 34(1), 145–153. https://doi.org/10.55519/jamc-01-9110 Additional Declarations No competing interests reported. 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Hussein","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIie3PsUrEQBCA4QkHe82qbSqfIRJYT1hyD2Kzy0Js9BrbK/awsLkXEAufQLBKPWHhquXSBq65e4OITQoLd2NhIUm0E9y/HOZjGIBQ6C82oQB7AAFAAJuWu1G0wlEiPklUPqxzT/QwgS8yMZSYbjZIzqdHZSOv+eLkcSOQ0ip7vjfuypJf9pGLu2MVyyK/jbc5YjzbqcJKRzb5je4hiaGJI0ZqO9WY0J1i6EikzRBJW0+ePBFkq1h1GCWsu/JiCSISzFg9foXN/C9nlohytVaC1e6KGPqlsmn9WvDFqSXp23ubzVl1ddg3S95LviW7TfHTdd/8N8uhUCj0P/oAKUFqvKW5Hz4AAAAASUVORK5CYII=","orcid":"","institution":"University of Khartoum","correspondingAuthor":true,"prefix":"","firstName":"Nihal","middleName":"Elmubarak A.","lastName":"Hussein","suffix":""},{"id":515476670,"identity":"369c5851-b8cc-4204-ba58-2ce3264545cb","order_by":1,"name":"Malaz M. Abdalmotalib","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Malaz","middleName":"M.","lastName":"Abdalmotalib","suffix":""},{"id":515476671,"identity":"f610603e-38bf-4611-8f93-ec89ada1b794","order_by":2,"name":"Muaiad Adil A. Abdelmotalab","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Muaiad","middleName":"Adil A.","lastName":"Abdelmotalab","suffix":""},{"id":515476672,"identity":"91c3b8f7-ee15-4797-9c55-a0ac1d050db5","order_by":3,"name":"Mona S. H. Mohammed","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Mona","middleName":"S. H.","lastName":"Mohammed","suffix":""},{"id":515476673,"identity":"1082fec5-cfa5-432f-81a9-cb0762f87a4e","order_by":4,"name":"Ola Yaser Mohammed Yassen","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Ola","middleName":"Yaser Mohammed","lastName":"Yassen","suffix":""},{"id":515476674,"identity":"80273de4-f244-473f-92d2-ca24e86acf81","order_by":5,"name":"Hajar Saad Salih","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Hajar","middleName":"Saad","lastName":"Salih","suffix":""},{"id":515476675,"identity":"2bfa9e60-9894-4730-9695-feb23fde81c4","order_by":6,"name":"Abdelmoula Hashim Abdelmagid Mohamed","email":"","orcid":"","institution":"University of Gezira","correspondingAuthor":false,"prefix":"","firstName":"Abdelmoula","middleName":"Hashim Abdelmagid","lastName":"Mohamed","suffix":""},{"id":515476676,"identity":"db8a8be4-1809-49de-907b-afb9c93b676d","order_by":7,"name":"Musab Mohammed Yassin Siddig","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Musab","middleName":"Mohammed Yassin","lastName":"Siddig","suffix":""},{"id":515476677,"identity":"c3b01bca-007c-401c-9b02-f88801b613db","order_by":8,"name":"Mohaned Ali Bala","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Mohaned","middleName":"Ali","lastName":"Bala","suffix":""}],"badges":[],"createdAt":"2025-08-08 20:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7329997/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7329997/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91567641,"identity":"3ac56c07-a6d3-44e1-9c09-5857a359c1f2","added_by":"auto","created_at":"2025-09-17 20:12:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1764672,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7329997/v1/87ca4147-f5a1-4373-86ce-8648f1321ca3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Medical Education Amidst Conflict: A National Assessment of Sudanese Medical Students’ Perceptions Using the DREEM Tool","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince April 2023, Sudan has faced an escalating humanitarian crisis triggered by armed conflict, resulting in the displacement of nearly 13\u0026nbsp;million people, including over 3.3\u0026nbsp;million who have fled across countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Higher education in Sudan confronts profound structural and operational challenges, while simultaneously offering significant potential to contribute to national recovery. Numerous universities sustained physical damage or were forced to suspend operations, resulting in widespread disruption to academic progress. Additionally, both faculty and students experienced mass displacement, leading to a critical loss of human resources and a breakdown in institutional continuity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eMedical education, in particular, has borne a disproportionate share of this disruption. Even before the current conflict, Sudanese medical schools were grappling with longstanding challenges rooted in the political instability that followed the 2018 revolution [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Recent assessments indicate that nearly 60% of medical facilities located in conflict zones have been attacked, with approximately 70% repurposed as military installations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Even Educational Institutions in comparatively safer regions have been converted into shelters for displaced populations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and as the conflict continues to expand, the damage also continues to intensify.\u003c/p\u003e\u003cp\u003eThe educational environment encompasses the social, organizational, and physical contexts that shape students' learning experiences, perceptions, and engagement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A growing body of evidence highlights the profound influence of the educational environment on students\u0026rsquo; cognitive development, acquisition of skills, and academic performance [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Understanding students\u0026rsquo; perceptions of the educational environment is essential, as positive perceptions have been linked to improved academic performance, while negative experiences may indicate critical gaps in mentorship, faculty engagement, and student support systems that warrant targeted interventions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, because the educational environment directly influences student engagement\u0026mdash;a critical, modifiable determinant of learning\u0026mdash;it represents a key area for development [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn light of the unprecedented disruption to Sudanese medical education, there is a pressing need to systematically assess how the current crisis has shaped students\u0026rsquo; perceptions of their educational environment. This study seeks to provide an evidence-based understanding of these perceptions, identify critical areas for intervention, and contribute to broader efforts to safeguard and rebuild medical education in Sudan during and beyond the current conflict.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design:\u003c/h2\u003e\u003cp\u003eA cross-sectional study was carried out between December 2024 and February 2025, during the Sudanese current conflict, to evaluate students' perceptions of various aspects of their educational environment.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting and Population:\u003c/h3\u003e\n\u003cp\u003eThe study included 2,714 medical students from 46 universities, encompassing both public and private institutions across various regions of Sudan. Participants were eligible for inclusion if they were medical students aged 18 years or older and enrolled in any academic year at the Sudanese Medical Students.\u003c/p\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eA convenience sampling method was utilized in this study.\u003c/p\u003e\n\u003ch3\u003eData Collection Tool and Procedure\u003c/h3\u003e\n\u003cp\u003eThe questionnaire included demographic variables (age, gender, certificate type, admission type, academic year, and level) and assessed the educational environment using the 50-item DREEM scale. Items were rated on a five-point Likert scale, with negative statements reverse-scored; higher scores indicated a more favorable perception. The total DREEM score ranges from 0 (worst) to 200 (ideal), covering five subscales: Perceptions of Learning (12 items, max 48), Perceptions of Teachers (11 items, max 44), Academic Self-Perceptions (8 items, max 32), Perceptions of Atmosphere (12 items, max 48), and Social Self-Perceptions (7 items, max 28). [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Data collectors from various universities were assigned to collect responses from their respective institutions. The self-administered online questionnaire was distributed through official university channels, including Telegram, Whatsapp, and LinkedIn.\u003c/p\u003e\n\u003ch3\u003eReliability analysis\u003c/h3\u003e\n\u003cp\u003eThe internal consistency of the DREEM scale was assessed using Cronbach\u0026rsquo;s alpha. The total 50-item scale demonstrated excellent reliability (α\u0026thinsp;=\u0026thinsp;0.882). Subscale reliability coefficients were as follows: Students\u0026rsquo; Perceptions of Learning (SPoL) α\u0026thinsp;=\u0026thinsp;0.738, Students\u0026rsquo; Perceptions of Teachers (SPoT) α\u0026thinsp;=\u0026thinsp;0.659, Students\u0026rsquo; Academic Self-Perceptions (SPaSP) α\u0026thinsp;=\u0026thinsp;0.778, Students\u0026rsquo; Perceptions of Atmosphere (SPoA) α\u0026thinsp;=\u0026thinsp;0.794, and Students\u0026rsquo; Social Self-Perceptions (SSSP) α\u0026thinsp;=\u0026thinsp;0.495. While most subscales showed acceptable to good internal consistency, the lower reliability of the SSSP subscale suggests potential variability in responses for that domain.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Management and Analysis\u003c/h2\u003e\u003cp\u003eData was initially organized in Microsoft Excel and then analyzed using SPSS version 29. Descriptive statistics were used to summarize demographic characteristics and continuous variables such as age and DREEM scores, reported as means and standard deviations. The internal consistency of the measurement instruments was assessed using Cronbach's alpha coefficients. Independent sample t-tests were employed to compare mean DREEM scores between two groups (e.g., males vs. females), while one-way ANOVA was used to assess differences across multiple groups (e.g., academic years). For significant ANOVA results, post-hoc comparisons were conducted using Tukey\u0026rsquo;s HSD test. A 95% confidence level was applied, with statistical significance set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All findings were interpreted about the study objectives and relevant literature.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInterpretation of the scores of the overall DREEM and the subclasses\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eOverall DREEM Interpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTotal DREEM Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003every poor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003emany problems\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101\u0026ndash;150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003emore positive than negative\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e151\u0026ndash;200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eexcellent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDREEM subscales Interpretation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eStudents\u0026rsquo; Perception of Learning\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVery poor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTeaching is viewed negatively\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA more positive perception\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u0026ndash;48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTeaching is highly regarded\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eStudents\u0026rsquo; Perceptions of Teachers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbysmal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u0026ndash;22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIn need of retraining\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u0026ndash;33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMoving in the right direction\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel course organizers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eStudents\u0026rsquo; Academic Self-Perceptions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFeelings of total failure\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u0026ndash;16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMany negative aspects\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFeeling more on the positive side\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConfident\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eStudents\u0026rsquo; Perceptions of Atmosphere\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA terrible environment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMany issues that need changing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA more positive atmosphere\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u0026ndash;48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA good feeling overall\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eStudents\u0026rsquo; Social Self-Perceptions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMiserable\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u0026ndash;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot a nice place\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u0026ndash;21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot too bad\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u0026ndash;28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVery good socially\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003esingle item Interpretation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eThe individual item\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScores\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIndicated real positive points\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScores\u0026thinsp;\u0026le;\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eproblem areas that required attention.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ebetween 2 and 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 2,714 participants filled the survey, the majority were females (70.1%), and 29.9% were males. The median of their age was 22 years. ( IQR\u0026thinsp;=\u0026thinsp;3) Participants represented various universities and academic levels, with the University of Khartoum being the most represented (13.6%). The majority were in clinical years (39.2%), held Sudanese high school certificates (86.6%), and were admitted through general admission (57.3%). For a detailed breakdown of university affiliation, academic year, classification, and educational background, refer to \u003cb\u003e(Table\u0026nbsp;1).\u003c/b\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eReliability analysis\u003c/h2\u003e\u003cp\u003eThe internal consistency of the DREEM scale was assessed using Cronbach\u0026rsquo;s alpha. The total 50-item scale demonstrated excellent reliability (α\u0026thinsp;=\u0026thinsp;0.882). Subscale reliability coefficients were as follows: Students\u0026rsquo; Perceptions of Learning (SPoL) α\u0026thinsp;=\u0026thinsp;0.738, Students\u0026rsquo; Perceptions of Teachers (SPoT) α\u0026thinsp;=\u0026thinsp;0.659, Students\u0026rsquo; Academic Self-Perceptions (SPaSP) α\u0026thinsp;=\u0026thinsp;0.778, Students\u0026rsquo; Perceptions of Atmosphere (SPoA) α\u0026thinsp;=\u0026thinsp;0.794, and Students\u0026rsquo; Social Self-Perceptions (SSSP) α\u0026thinsp;=\u0026thinsp;0.495. While most subscales showed acceptable to good internal consistency, the lower reliability of the SSSP subscale suggests potential variability in responses for that domain, for details refer to table 2.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDREEM total, subscale and single items analysis\u003c/h2\u003e\u003cp\u003eAs presented in \u003cb\u003e(Table\u0026nbsp;2)\u003c/b\u003e, students generally expressed positive perceptions of their educational environment, with the highest mean scores observed in the domains of Perception of Atmosphere (M\u0026thinsp;=\u0026thinsp;30.23) and Perception of Learning (M\u0026thinsp;=\u0026thinsp;29.83), suggesting favorable views of the academic environment and learning experiences. The lowest score was noted in Social Self-Perception (M\u0026thinsp;=\u0026thinsp;17.36). The total DREEM score (M\u0026thinsp;=\u0026thinsp;125.99) reflects an overall environment that is more positive than negative.\u003c/p\u003e\u003cp\u003eFurther insight from \u003cb\u003e(Table\u0026nbsp;3)\u003c/b\u003e reveals consistent areas for improvement across individual items. Many teaching-related items (e.g., active learning encouragement, student-centered methods, and effective use of time) received moderate scores, typically around 2.6\u0026ndash;2.8, indicating areas that could be enhanced. Problematic areas included an overemphasis on factual learning (M\u0026thinsp;=\u0026thinsp;1.45) and teacher-centered approaches (M\u0026thinsp;=\u0026thinsp;1.55). Students also raised concerns about teachers' authoritarian behavior and classroom anger, as well as the prevalence of ridicule and poor feedback practices.\u003c/p\u003e\u003cp\u003eIn terms of academic self-perception, while students felt relatively confident about passing the year (M\u0026thinsp;=\u0026thinsp;2.91), scores for memorization ability (M\u0026thinsp;=\u0026thinsp;2.33) and professional preparation (M\u0026thinsp;=\u0026thinsp;2.55) highlight potential gaps. The perception of atmosphere was marked by issues such as cheating (M\u0026thinsp;=\u0026thinsp;1.79) and disappointing experiences (M\u0026thinsp;=\u0026thinsp;1.93), despite positive feelings about interpersonal skill development (M\u0026thinsp;=\u0026thinsp;2.82). Social support emerged as a mixed domain. Students appreciated friendships (M\u0026thinsp;=\u0026thinsp;3.13) but also reported fatigue (M\u0026thinsp;=\u0026thinsp;1.60) and some degree of loneliness (M\u0026thinsp;=\u0026thinsp;2.40). For detailed item-level responses, refer to \u003cb\u003e(Table\u0026nbsp;3).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eVariation in Students\u0026rsquo; Perceptions:\u003c/h2\u003e\u003cp\u003eVarious demographic and academic factors were found to influence students' perception. In terms of gender differences, male students demonstrated slightly higher scores in academic self-perception (SASP) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas female students scored higher in social perceptions (SPT) (p\u0026thinsp;=\u0026thinsp;0.013). However, the overall perception scores did not differ significantly between genders. Similarly, students in Grade 1 and Grade 5 demonstrated higher scores in specific subscales compared to other academic years (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Differences were also observed between basic and clinical students, with clinical students generally reporting better perceptions in some aspects, though the differences reached statistical significance only in a few subscales (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, students residing in university dormitories had significantly more positive perceptions of their educational environment compared to those living in private residences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Regarding students' educational background, no significant differences were found between those admitted through general versus private admission pathways. However, students with non-Sudanese certificates exhibited higher scores in specific subscales (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1902\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.10%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eResidancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamily house\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1461\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.80%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWith relatives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e293\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.80%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity dormitories\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.70%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrivate dormitories\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e225\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.30%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrivate residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.30%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.10%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eAcademic year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.70%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e479\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.60%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e678\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.00%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e552\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.30%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e529\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.50%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.90%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCurriculum Stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBasic science student\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e868\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.00%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-clinical student\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e783\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.90%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical student\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.20%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eType of certificate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSudanese\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2349\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.60%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArabic countries certificate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e271\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.00%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIg certificate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.80%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.70%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eType of admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1555\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57.30%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.80%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.90%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTable\u0026nbsp;(1) Show Students Demographic Characteristics (N\u0026thinsp;=\u0026thinsp;2,714)\u003c/span\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDREEM subscales and total score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMax\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSkewness*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eKurtosis**\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNumber of items\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eCronbach's Alpha\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerception of Learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e29.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.718\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.844\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eA more positive perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.738\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerception of Teachers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e27.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.326\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMoving in the right direction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.659\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Self Perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e21.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.471\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.679\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eFeeling more on the positive side\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.778\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerception Of Atmosphere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e30.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.639\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.809\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eA more positive atmosphere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.794\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Self Perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e17.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.556\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.885\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot too bad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.495\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal DREEM score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e188\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e125.99\u0026thinsp;\u0026plusmn;\u0026thinsp;19.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.549\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003emore positive than negative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.882\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e* Standard Error\u0026thinsp;=\u0026thinsp;0.047\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e** Standard Error\u0026thinsp;=\u0026thinsp;0.094\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTable\u0026nbsp;(2): Subscale and total DREEM\u003c/span\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLabel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1. Perceptions of Teaching [12 item]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. I'm encouraged to participate in class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClass Participation Encouragement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. The teaching is often stimulating\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTeaching Stimulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3.\u0026nbsp; The teaching is student-centered\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent-Centered Approach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. The teaching is sufficiently concerned to develop my competence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCompetence Development\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. The teaching is well focused\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFocus of Teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. The teaching is sufficiently concerned to develop my confidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConfidence Building\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. The teaching time is put to good use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffective Use of Teaching Time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. The teaching over-emphasizes factual learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmphasis on Factual Learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. I'm clear about the learning objectives of the course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClarity of Learning Objectives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10. The teaching encourages me to be an active learner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEncouragement of Active Learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11. Long-term learning is emphasized over short-term learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmphasis on Long-Term Learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12. The teaching is too teacher-centered\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTeacher-Centered Approach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2. Perceptions of Teachers [11 item]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13. The teachers are knowledgeable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTeacher Knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ereal positive points\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14. The teachers are patient with patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatience with Patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15. The teachers ridicule the students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRidiculing Students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16. The teachers are authoritarian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAuthoritarian Teaching Style\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17. The teachers have good communication skills with patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunication Skills with Patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18. The teachers are good at providing feedback to students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProviding Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19. The teachers provide constructive criticism here\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConstructive Criticism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20. The teachers give clear examples\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClarity of Examples\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21. The teachers get angry in class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTeachers' Anger in Class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22. The teachers are well prepared for their class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreparation for Class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23. The students irritate the teachers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudents Irritating Teachers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3. Academic Self-Perceptions [8 items]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24. Learning strategies which worked well for me before continue to work for me now\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffectiveness of Learning Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25. I'm confident about my passing this year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConfidence in Passing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.91\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26. I feel I'm being well prepared for my profession\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProfessional Preparation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e27. Last year's work has been a good preparation for this year's work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContinuity in Preparation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e28. I'm able to memorize all I need\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMemorization Ability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e29. I have learned a lot about empathy in my profession\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLearning Empathy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30. My problem-solving skills are being well developed here\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProblem-Solving Skills Development\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31. Much of what I have to learn seems relevant to a career in medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRelevance of Learning to Medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e4. Perceptions of Atmosphere [12 items]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e32. The atmosphere is relaxed during the ward teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWard Teaching Atmosphere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e33. This school is well time-tabled\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSchool Timetabling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e34. Cheating is a problem in this school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerception of Cheating\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e35. The atmosphere is relaxed during the lectures\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLecture Atmosphere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36. There are opportunities for me to develop inter-personal skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOpportunities for Interpersonal Skills Development\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e37. I feel comfortable in class socially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial Comfort in Class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e38. The atmosphere is relaxed during seminars/tutorials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSeminars/Tutorials Atmosphere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e39. I find the experience disappointing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverall Experience Disappointment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40. I\u0026rsquo;m able to concentrate well\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConcentration Ability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e41. The enjoyment outweighs the stress of studying medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnjoyment vs. Stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e42. The atmosphere motivates me as a learner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMotivational Atmosphere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e43. I feel able to ask the questions I want\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComfort in Asking Questions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e5. Social Self-perception [7 items]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e44. There is a good support system for students who get stressed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupport System for Stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45. I am too tired to enjoy this course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCourse Enjoyment and Fatigue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eproblem area\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e46. I am rarely bored on this course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCourse Engagement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e47. I have good friends in this school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial Support from Friends\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ereal positive points\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e48. My social life is good\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial Life Satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e49. I seldom feel lonely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLoneliness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50. My accommodation is pleasant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAccommodation Satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eareas that could be enhanced\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(3) Show DREEM individual items Scores\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMean Difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSPL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e29.86\u0026thinsp;\u0026plusmn;\u0026thinsp;5.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1470.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.839\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.05029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e-0.434, 0.535\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1902\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e29.81\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSPT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e26.66\u0026thinsp;\u0026plusmn;\u0026thinsp;4.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-2.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1580.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e-0.50463\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e-0.904, -0.106\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1902\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e27.17\u0026thinsp;\u0026plusmn;\u0026thinsp;4.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSASP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e22.06\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1551.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.72631\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.309, 1.143\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1902\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e21.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSPA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e30.48\u0026thinsp;\u0026plusmn;\u0026thinsp;6.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.255\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1472.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.35763\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e-0.201, 0.917\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1902\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e30.13\u0026thinsp;\u0026plusmn;\u0026thinsp;6.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSSSP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e17.57\u0026thinsp;\u0026plusmn;\u0026thinsp;4.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.753\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1509.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.29294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e-0.035, 0.621\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1902\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e17.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFull score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e126.64\u0026thinsp;\u0026plusmn;\u0026thinsp;19.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1521.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.92253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e-0.707, 2.552\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1902\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e125.71\u0026thinsp;\u0026plusmn;\u0026thinsp;19.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDREEM Full score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e716\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e125.16\u0026thinsp;\u0026plusmn;\u0026thinsp;20.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(4): Variation in Students' Perceptions Based on Gender (t-test)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(5): Factors affect Students' Perceptions (ANOVA)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabf\" border=\"1\"\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSPL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSPT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSASP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSPA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSSSP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eDREEM Full Score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF (p- value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF (p- value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eF (p- value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF (p- value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eF (p- value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eF (p- value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eη\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.657 (0.142)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.708 (0.617)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5.53 (\u0026lt;\u0026thinsp;.001)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e3.981 (0.001)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.75 (0.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.138 (0.338)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurriculum Stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3.614 (0.027)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e3.574 (0.028)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e13.464 (\u0026lt;\u0026thinsp;.001)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e6.223 (0.002)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e4.877 (0.008)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.15 (0.117)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdmission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.355 (0.258)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.284 (0.277)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.255 (0.285)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.473 (0.229)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.278 (0.103)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.647 (0.524)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCertificate Type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3.725 (0.011)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.255 (0.858)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.488 (0.216)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e3.875 (0.009)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e3.201 (0.022)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3.306 (0.019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was conducted during the ongoing conflict in Sudan, which has severely disrupted infrastructure and public services, including higher education [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Universities have experienced extensive damage, with the displacement of faculty and students further degrading the learning environment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Assessing student perceptions during this period highlights key challenges and can inform efforts to improve medical education under crisis conditions.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eDREEM score (total and subscales, single items)\u003c/h2\u003e\u003cp\u003e\u003cb\u003e1/ Total DREEM Score\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe overall DREEM score of 125.99/200 reflects a generally positive perception of the educational environment, notably higher than previous Sudanese studies (104\u0026ndash;122), though still below one outlier (132). Despite ongoing conflict, economic hardship, and displacement, this score is similar to regional averages in Africa and Gulf countries (116\u0026ndash;130), suggesting a degree of resilience in Sudan\u0026rsquo;s medical education system. However, scores remain lower than those reported in high-income countries like the UK (143) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], Australia (141) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and Thailand (131.1) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Likely due to differences in educational infrastructure, support systems, and stability. The findings highlight both the challenges and adaptability of students and institutions in conflict-affected settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2/ Perception of Learning\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAmid wartime disruptions in Sudan, students' perceptions of teaching reveal a strained yet resilient educational environment. This domain was rated positively overall (29.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.78), consistent with findings from earlier Sudanese studies conducted before the conflict [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. When examining individual item scores, we found that clarity of objectives (2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87), encouragement of active learning (2.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96), and class participation (2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98) received higher ratings, yet most items indicated areas needing enhancement. Alarmingly low scores for overemphasis on factual learning (1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89) and teacher-centered methods (1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01) may reflect a critical dissatisfaction with passive instructional strategies that fail to engage students meaningfully, particularly during crises.\u003c/p\u003e\u003cp\u003eIn a context of displacement and institutional breakdown, these findings highlight a compromised instructional quality and reduced engagement that may affect students\u0026rsquo; academic performance [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The limited support for competence, confidence, and long-term learning points to the urgent need for adaptive, student-centered teaching strategies tailored to crisis settings.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003e\u003cb\u003e3/ Perception of Teachers\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eIn the context of the ongoing war in Sudan, teachers\u0026mdash;particularly in medical and health education\u0026mdash;are generally perceived as moving in the right direction. Their knowledge ability received a favorable mean score of 3.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75, reflecting the continued application of high standards by universities in selecting qualified educators, despite the disruption of war. However, this interpretation warrants caution, as it may be influenced by institutional resilience or limited access to a broader range of teaching environments.\u003c/p\u003e\u003cp\u003eEducators also demonstrated strengths in their ability to provide feedback (2.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91) and communicate effectively with patients (2.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83), both of which are essential skills in conflict-affected health education.\u003c/p\u003e\u003cp\u003eSeveral problematic behaviors among educators were also identified. These included authoritarianism (1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03), ridiculing students (1.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09), expressions of anger in class (1.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11), and irritation toward students (1.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08). Such behaviors, especially in conflict zones, can severely compromise the learning environment and are often symptomatic of chronic stress, emotional fatigue, and burnout experienced by teachers working under persistent instability [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These findings highlight the urgent need for conflict-sensitive approaches and mental health support tailored for educators operating in war-affected regions.\u003c/p\u003e\u003cp\u003eThe war has intensified existing stressors such as shortages of teaching materials, administrative burdens, and the increasing diversity of students' psychosocial needs [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These challenges frequently overwhelm educators and may manifest as irritability, authoritarian responses, or emotional disengagement. Although many teachers receive training in instructional delivery and possess the necessary subject knowledge, they often lack preparation in areas such as crisis communication, emotional intelligence, and generational engagement skills that are critical in conflict-affected classrooms. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis skills gap is particularly damaging in the context of war, where the role of educators extends beyond academic instruction to include psychological and emotional support. A Turkish study has underscored the importance of teacher attitudes in shaping students' development, reporting that educators are the second-most influential factor in individual growth after parents. Positive teacher attitudes were shown to enhance both academic performance and personality development, whereas negative attitudes had detrimental effects [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In conflict settings, especially among Sudanese medical students, respectful and supportive teacher\u0026ndash;student relationships are vital. These relationships not only foster academic engagement and resilience but also provide emotional anchors during times of personal and collective trauma [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Ultimately, improving teacher capacity and well-being under conflict conditions directly translates into safer, more supportive learning environments for students who are already bearing the psychological burden of war.\u003c/p\u003e\u003cp\u003e\u003cb\u003e4/ Perception of Atmosphere\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmid the ongoing conflict in Sudan, students\u0026rsquo; perceptions of the educational atmosphere reflect a learning environment under significant strain. The Perception of Atmosphere domain had a total mean score of 30.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.68 out of a maximum of 48, indicating a slightly positive yet suboptimal perception. These modest scores in the Perception of Atmosphere domain have been reported in other Sudanese educational settings [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and in international studies from stable environments such as Malaysia [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and Kuwait [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], these comparisons are limited by vast contextual differences.\u003c/p\u003e\u003cp\u003eNotably, none of the 12 items within this domain achieved a mean score above 3.0, suggesting the absence of perceived strengths and highlighting a broad need for improvement across multiple aspects of the educational climate.\u003c/p\u003e\u003cp\u003eAmong the most concerning findings was the low mean score for the item \u0026ldquo;Cheating is a problem in this school\u0026rdquo; (1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21), a problem that is known to undermine the learning environment and demotivate students [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Similarly, the item \u0026ldquo;I find the experience disappointing\u0026rdquo; (1.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15) signals widespread dissatisfaction and disillusionment, potentially linked to systemic challenges such as conflict-related disruptions, displacement, and a lack of adequate student support systems.\u003c/p\u003e\u003cp\u003eSeveral other items point to environmental and structural stressors. For example, school timetabling scored low (2.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13), reflecting inconsistencies and lack of coordination, which previous studies have shown to contribute significantly to student stress and reduced academic performance [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, the item \u0026ldquo;The enjoyment outweighs the stress of studying medicine\u0026rdquo; scored poorly (2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07), indicating that for many students, the psychological burden of medical education outweighs its intrinsic rewards, particularly under crisis conditions.\u003c/p\u003e\u003cp\u003eWhile moderate scores were observed in areas such as interpersonal skills development (2.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88), social comfort in class (2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97), and comfort in asking questions (2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03), they remain below desirable thresholds. These suggest that while students are not entirely alienated, they lack optimal levels of peer interaction and participatory engagement. The ability to concentrate well (2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93) and the perceived motivational atmosphere (2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00) also scored low, reflecting ongoing psychological fatigue, possible burnout, and limited institutional mechanisms to sustain academic motivation under duress [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eInterestingly, the highest-rated it was \u0026ldquo;The atmosphere is relaxed during lectures\u0026rdquo; (2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12), which may reflect positive student-teacher rapport or a low-pressure teaching style. However, this finding is ambiguous. Without accompanying active learning strategies, such an atmosphere could also signal disengagement or a lack of academic rigor. In contrast, low agreement with the statement \u0026ldquo;I feel able to ask the questions I want\u0026rdquo; (2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16) raises concerns about communication barriers, mostly aggravated by the ongoing conflict and educational disruption.\u003c/p\u003e\u003cp\u003eFurthermore, the item \u0026ldquo;The atmosphere motivates me as a learner\u0026rdquo; scored poorly (2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16), suggesting a misalignment between the current educational environments and students\u0026rsquo; motivational needs\u0026mdash;an issue compounded by the stress of displacement, unstable learning conditions, and limited psychosocial support. This aligns with literature emphasizing that motivation and learning are heavily influenced by the psychological safety and responsiveness of the academic environment [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eIn summary, the findings from this domain reveal a fragile and demotivating learning atmosphere, shaped by conflict-related instability and institutional shortcomings. To improve this domain, medical schools must focus on creating psychologically safe and inclusive classrooms, promoting student participation, addressing academic misconduct proactively, and ensuring structural stability through consistent timetabling and student support services. These steps are essential not only to enhance students\u0026rsquo; educational experiences but also to sustain their academic engagement and resilience during times of crisis.\u003c/p\u003e\u003cp\u003e\u003cb\u003e5/ Academic Self-Perception\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis domain had a moderately positive mean score of 20.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.62 out of 28, indicating students generally feel competent in their academic abilities. This is consistent with a previous study in Sudan [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and studies from other countries such as Malaysia [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and Kuwait [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, lower scores were also seen in some settings. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eStudents agreed they are learning strategies relevant to becoming doctors (2.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91), which aligns with studies linking curriculum relevance with increased student motivation and academic engagement [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eNotably, the item \u0026ldquo;I have learned a lot about empathy in my profession\u0026rdquo; received a low mean score (2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08), suggesting a persistent gap in the integration of emotional intelligence and empathy training within medical education. This concern aligns with global findings, particularly in conflict-affected and resource-constrained settings, where such competencies are often underemphasized despite their critical importance [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. A significant concern was also the low confidence in passing exams (1.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12), which may indicate anxiety, poor formative assessment, or a lack of academic support services, which can affect their academic performance. This aligns with literature showing that fear of failure and lack of confidence are associated with increased stress and reduced academic performance [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Improving feedback systems, providing accessible academic support, and integrating emotional skills training may help in enhancing students\u0026rsquo; academic self-concept and reducing exam-related stress.\u003c/p\u003e\u003cp\u003eThis domain had a moderately positive mean score of 21.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11 out of 32, indicating students generally feel competent in their academic abilities. This is consistent with studies in Sudan [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and other countries such as Malaysia [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and Kuwait [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] However, lower scores were seen in other settings [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Although students did not report it as a problematic area, a notable deficit that required improvement was observed in their preparedness for future professional roles (2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99) and their ability to cope with the demands of memorization (2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05).\u003c/p\u003e\u003cp\u003eThe low confidence in professional preparedness is concerning, as the ongoing conflict in Sudan has severely disrupted medical education and compromised clinical training environments. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. This may affect the students and can lead to doubts about their competencies. Additionally, the pervasive insecurity, risk of displacement, and the severe humanitarian consequences exacerbate these fears [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Such psychological burdens also compromise cognitive performance and explain the memorization difficulties, as chronic stress is known to impair memory [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eOn the other hand, students reported a relatively high perception of the relevance of their learning to their future medical careers (2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82), indicating that, despite the conflict, the core educational content remains meaningful and aligned with professional goals. This perceived relevance underscores the resilience of Sudanese medical students and faculty in maintaining academic focus. Institutional efforts such as rapid transitions to online learning and collaborative initiatives with local and international partners have likely contributed to sustaining curricular continuity during the disruption [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], even though these collaborations primarily supported content delivery rather than influencing students' perceptions directly.\u003c/p\u003e\u003cp\u003eIn summary, while students show moderate academic self-confidence, gaps in professional preparedness and memory may reflect the toll of conflict and disrupted training. Still, the strong perceived relevance of their education underscores the resilience of Sudanese medical schools and the value of adaptive strategies in maintaining core learning amid crisis.\u003c/p\u003e\u003cp\u003e\u003cb\u003e6/ Social Self-Perception\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis domain had a total possible score of 28, with students reporting a mean of 17.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96, out of 28 points for maximum score, reflecting a moderately low perception of their social well-being. It revealed a mixed picture, with limited strengths and several areas in need of improvement. The most positively rated item was the presence of peer support, with students agreeing that they have good friends within the school (3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91). This suggests that, despite the instability caused by the ongoing conflict, interpersonal relationships among students remain a key source of resilience and psychological buffering. However, most other items in this domain reflected concerning areas. The item \u0026ldquo;I am too tired to enjoy this course\u0026rdquo; scored the lowest (1.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05), highlighting a significant problem with fatigue and academic burnout, which is possibly worsened by displacement, disrupted routines, and increased psychosocial stress [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] (link). Similarly, students reported low levels of perceived institutional support for managing stress (2.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20), pointing to a gap in mental health services and structured coping mechanisms provided by universities.\u003c/p\u003e\u003cp\u003eModerate but suboptimal scores were observed for items related to social life satisfaction (2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98), course engagement (2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05), and accommodation conditions (2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93). These findings suggest that although some semblance of normalcy is retained, students are experiencing disruptions in their broader social environment and living conditions, which are known to impact mental well-being and academic success [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The score for loneliness also (2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12) further underscores the need for stronger psychosocial support frameworks.\u003c/p\u003e\u003cp\u003eTaken together, these results reveal that while peer relationships remain a valuable asset, the broader social and institutional environment is under strain. Addressing student fatigue, enhancing emotional support systems, and improving living conditions are essential to safeguarding the well-being of medical students during the ongoing conflict in Sudan. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003e\u003cb\u003e7/ Gender Difference\u003c/b\u003e :\u003c/p\u003e\u003cp\u003eThere was no significant difference in the overall DREEM score between male and female students, indicating that both groups were similarly affected by the ongoing conflict. A study from Syria. Using the DREEM scale during conflict found no gender specific differences, indicating that subtle, context-specific factors may shape students' perceptions in different ways [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eBeyond the context of war, this finding is consistent with results from several institutions worldwide, including the United Kingdom [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], India [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], Iran [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], and Saudi Arabia [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Conversely, some studies report significant gender-based differences [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], likely influenced by cultural norms, coping styles, and learning preferences. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Nonetheless, it is important to recognize that this surface-level similarity between males and females in the overall DREEM score may mask more complex gender-specific perceptions. In our study, females expressed a more positive perception of their teachers, a finding that aligns with other studies [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. In the context of ongoing conflict, this may reflect females\u0026rsquo; stronger perception of connection and support from teachers. Alternatively, it could be related to gender differences in learning styles [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eShifting to Academic self-perception, Male students exhibit significantly higher scores in the Academic Self-Perception subscale, indicating a greater sense of academic confidence compared to their female counterparts [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. This finding suggests that male students tend to perceive themselves as more academically capable and self-assured. A similar finding was also reported in a Moroccan Medical University, which reinforces the possibility that gendered differences in academic confidence persist. ( [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e\u003cb\u003e8/ Admission Type\u003c/b\u003e :\u003c/p\u003e\u003cp\u003eRegarding the admission type, our study indicates no statistically significant differences in the total DREEM score and across all the sub-scales, suggesting that students across different admission pathways perceive their learning environment similarly. This contrasts with a previous study at the University of Bahri, Sudan, which reported a more positive perception of learning among general admission students [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The lack of significant differences based on admission type might stem from unique contextual factors in Sudan, including war, political instability and COVID-19. This also may reflect a homogenized educational experience shaped by uniform institutional policies, curricular structures, and shared challenges such as disrupted learning and resource constraints during the conflict.\u003c/p\u003e\u003cp\u003eThe absence of significant differences in students' perceptions based on admission type may be attributed to Sudan's unique contextual challenges, including ongoing conflict, political instability, and the impacts of the COVID-19 pandemic. [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. These widespread disruptions likely created a shared educational experience across all student groups, shaped by uniform institutional policies, standardized curricula, and common obstacles such as interrupted learning and limited resources. In such a context, the influence of the admission route may be diminished, as broader systemic pressures take precedence. The relatively consistent DREEM scores reflect this homogenized experience, yet they also underscore the need for ongoing assessment of the learning environment to ensure that all students receive adequate support, especially during times of crisis.\u003c/p\u003e\u003cp\u003e\u003cb\u003e9/ Type of certificate\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOur findings indicate significant differences in students\u0026rsquo; perceptions of the educational environment across certificate types, particularly in perceptions of learning, atmosphere, and social self-perception. Students with certificates other than Sudanese and Arabic certificates had the highest ratings, followed by Sudanese students, while students with certificates from Arabic countries consistently reported the lowest scores. In our study, Arabic certificate holders had a mean perception of atmosphere score of 28.94\u0026thinsp;\u0026plusmn;\u0026thinsp;7.26, which, while still within a positive range, was significantly lower than that of Sudanese students (30.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.68). Their mean social self-perception score was 16.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99, also lower than the Sudanese students\u0026rsquo; mean of 17.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96.\u003c/p\u003e\u003cp\u003eA possible explanation for these findings is that Arabic certificate students may have already formed lower perceptions of their learning environment before entering medical school. Studies from Saudi Arabia suggest that students in similar educational settings have reported lower perceptions of atmosphere and social self-perception [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This may be attributed to the nature of pre-university learning conditions for students with Arabic certificates, which could shape their expectations and subsequently influence their perceptions in medical school. Additionally, differences in educational infrastructure, curriculum design might contribute to this result. Another possible factor is social integration, as these students may feel less connected to the local academic and social community, potentially impacting their overall experience.\u003c/p\u003e\u003cp\u003eThese scores suggest that Arabic certificate students in our study may be reflecting a broader pattern observed in similar educational environments. Further research is needed to explore whether these perceptions stem from prior educational experiences, difficulties in adaptation, or other contributing factors, and to identify interventions that could enhance their academic and social experience.\u003c/p\u003e\u003cp\u003e\u003cb\u003e10/ Academic year\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOur study found no statistically significant differences in overall DREEM scores across academic years (F\u0026thinsp;=\u0026thinsp;1.138, p\u0026thinsp;=\u0026thinsp;0.338, η\u0026sup2; = 0.002), indicating a generally stable perception of the educational environment. First-year students had the highest average score (128.86), while third-year students had the lowest (125.32), though the differences were not statistically meaningful. These findings contrast with studies from Saudi Arabia [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], Spain [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], Nigeria [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e], and India [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e], which reported a decline in student satisfaction as training progressed. Conversely, our results align with previous Sudanese data, which showed moderate but fluctuating DREEM scores across years, with some significant differences [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. The slightly higher scores observed in our cohort may reflect institutional resilience and consistent support mechanisms despite external challenges such as conflict and displacement. Further investigation is needed to identify the specific protective factors contributing to this stability.\u003c/p\u003e\u003cp\u003eAcross several DREEM domains (SPL, SPT and SSP), no significant differences were found among academic years. For SPL, mean scores were closely clustered (F\u0026thinsp;=\u0026thinsp;1.657, p\u0026thinsp;=\u0026thinsp;0.142, η\u0026sup2; = 0.003), suggesting homogenous learning experiences throughout the curriculum. This contrasts with South Indian and Saudi studies reporting higher satisfaction in early years and progressive declines in later semesters [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Similarly, SPT scores remained stable (F\u0026thinsp;=\u0026thinsp;0.708, p\u0026thinsp;=\u0026thinsp;0.617, η\u0026sup2; = 0.001), with minimal variation between Grade 3 (27.21) and Grade 5 (26.71). This contrasts with findings from Qadi Ayyad and Ankara universities, where senior students expressed more negative views of faculty [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] [96], and with a Sudanese study noting a peak in Grade 3 before decline [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. SSP scores also showed no significant change (F\u0026thinsp;=\u0026thinsp;1.75, p\u0026thinsp;=\u0026thinsp;0.12, η\u0026sup2; = 0.003), remaining fairly stable from Grade 1 (18.01) to Grade 5 (17.21). This suggests that students\u0026rsquo; sense of social confidence and support is preserved despite increasing academic demands, a trend consistent with regional data [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eThe overall consistency in these domains may indicate uniform teaching practices and early formation of student expectations. It could also reflect institutional policies that ensure a relatively stable academic and social environment across all stages of training. However, the absence of significant variation does not rule out subtle differences that may need further investigation.\u003c/p\u003e\u003cp\u003eIn contrast to the stability observed above, two domains ( academic self-perception and perception of the learning atmosphere) showed significant variation across academic years. ASP varied significantly (F\u0026thinsp;=\u0026thinsp;5.53, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.01), with Grades 1 and 5 reporting the highest confidence (22.16 and 22.19), and Grade 3 the lowest (20.94). A similar finding was documented in Sudanese students, where final-year learners demonstrated higher academic confidence compared to those in earlier years [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. This mid-program dip may reflect the transitional stress associated with moving from pre-clinical to clinical education [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePerception of the atmosphere also significantly declined (F\u0026thinsp;=\u0026thinsp;3.981, p\u0026thinsp;=\u0026thinsp;0.001, η\u0026sup2; = 0.007), with first-year students viewing it most positively (31.51) and fifth-year students the least (29.67). Post hoc analysis confirmed significantly better perceptions in Grade 1 compared to Grades 4 and 5. Similar declines were reported in Saudi and Sudanese studies, where senior students perceived the learning atmosphere less favorably [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. This trend is likely driven by increased academic pressures, complex clinical duties, and limited structured time for feedback and peer interaction [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. As students advance, they face heavier workloads, less direct supervision, and higher expectations, which may reduce their perception of a supportive and engaging academic environment.\u003c/p\u003e\u003cp\u003e\u003cb\u003e11/ Basic and Preclinical vs. Clinical\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll five DREEM subscales showed significant variation across academic phases. The most notable difference was in academic self-perception (F\u0026thinsp;=\u0026thinsp;13.464, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.01), with preclinical students reporting significantly lower perception than both clinical (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and basic science students (p\u0026thinsp;=\u0026thinsp;0.017). This is similar to a previous Sudanese study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and contrasts with a Spanish study that reported a decline in academic perception with the progression in academic phases [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. The drop during preclinical years may reflect academic pressure and limited clinical exposure, while confidence appears to rebound in clinical stages due to real-world application. An Australian study also found a significant improvement in academic confidence throughout years of clinical training (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eIn the perception of learning, the pre-clinical students had significantly lower perceptions than clinical students (p\u0026thinsp;=\u0026thinsp;0.022). While Basic Science and Clinical students had relatively similar ratings, in contrast, preclinical students rated their teachers more positively than clinical students ( p\u0026thinsp;=\u0026thinsp;0.039), with basic science students' ratings similar to clinical students. This may reflect declining teacher-student interaction as clinical demands increase. Similar trends were seen in Spain and Pakistan [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e][\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. The similar perception of teachers' scores between Basic Science and Clinical students may stem from limited personalized interaction in both phases, as Basic Sciences rely on large lectures, while Clinical training often suffers from inconsistent clinical teaching. In contrast, preclinical students benefit from more structured, small-group teaching, leading to more positive perceptions. This suggests that structured faculty engagement significantly influences students\u0026rsquo; views of teaching quality.\u003c/p\u003e\u003cp\u003ePerception of the atmosphere declined with academic progression, highest in basic and lowest in clinical students (F\u0026thinsp;=\u0026thinsp;6.223, p\u0026thinsp;=\u0026thinsp;0.002), echoing the Spanish study [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Social self-perception followed a similar pattern (F\u0026thinsp;=\u0026thinsp;4.877, p\u0026thinsp;=\u0026thinsp;0.008), likely due to academic load, reduced peer interaction, and clinical stress.\u003c/p\u003e\u003cp\u003eDespite differences in subscales, total DREEM scores showed no significant variation (F\u0026thinsp;=\u0026thinsp;2.15, p\u0026thinsp;=\u0026thinsp;0.117). Basic and clinical students reported comparable scores, with preclinical slightly lower. Similar trends were reported in Pakistan [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e], but the Spanish study found a significant overall decline [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. This suggests that while students' experiences vary across specific domains, their overall perception of the educational environment remains relatively stable throughout the academic journey, emphasizing the need to tailor educational approaches to each academic phase to enhance the overall learning experience.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reports resilience among Sudanese medical students as despite the extreme challenges of conflict, these students still show moderately positive perceptions towards their educational environment. However, the impact of war on academic self-perception and emotional well-being across academic years can't be denied.\u003c/p\u003e\u003cp\u003eOngoing conflict increases existing challenges and creates new ones, like psychological stress and teaching infrastructure disruption. Differences in perceptions across academic years show an urgent need for specialized interventions such as an academic support system, a mental health guide program and resilience in the academic curriculum.\u003c/p\u003e\u003cp\u003eTo mitigate these risks, it is essential to implement targeted support programs that address students\u0026rsquo; social and emotional needs. Interventions should be tailored to the different challenges faced by students at various academic levels. Regular assessment of the learning environment should be maintained to guide timely responses, especially during crises. Furthermore, strong collaboration between universities, stakeholders, and student representatives is crucial to ensure continuity and uphold the quality of medical education in Sudan.\u003c/p\u003e\u003cp\u003eUltimately, educational environment improvement during conflicts, not only focused on infrastructure, it is on hope, capacity and training of future health care providers. As Sudan faces this humanitarian crisis, perceived quality of medical education must remain a national priority.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis study presents several notable strengths. It is the first to apply the DREEM scale to evaluate medical education during an active conflict in Sudan, providing novel insights into students\u0026rsquo; experiences under crisis conditions. The large, diverse sample comprising 2,714 students from 46 universities across Sudan enhances the national relevance of the findings. The use of the validated DREEM instrument allowed for a robust, multidimensional assessment of the educational environment, supported by strong internal consistency (α\u0026thinsp;=\u0026thinsp;0.882). The application of appropriate statistical tests further ensured reliable subgroup comparisons.\u003c/p\u003e\u003cp\u003eNonetheless, limitations must be acknowledged. The cross-sectional design restricts causal inferences and reflects only a single time point. The use of convenience sampling and online distribution may have introduced selection bias, likely excluding students in severely affected or low-connectivity areas. Self-reported data are also subject to response and social desirability biases. Moreover, variations in conflict severity and institutional response were not controlled for, which may limit the generalizability of results across all settings.\u003c/p\u003e\u003cp\u003eDespite these limitations, the study establishes a critical foundation for future longitudinal research and targeted educational interventions during crises.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003cstrong\u003e\u003cu\u003eDisclosure :\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis Study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Conflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the national ethics committees at the Ministry of Higher Education. All procedures involving human participants were in accordance with the ethical standards of the Helsinki Declaration. Prior to participation, written informed consent was obtained from all students.. Confidentiality was maintained by ensuring that all collected data were anonymized, and no personally identifiable information was recorded or shared. Data was securely stored and accessible only for the research team. No incentives were provided to participants for their involvement in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided written informed consent for their data to be used in this study and for the publication of anonymized findings. Personal identifiers were not collected or published, ensuring participant confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman ethics and consent to participate declarations :\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Data Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the data collectors for their assistance distributing the questionnaire among universities :\u003c/p\u003e\n\u003cp\u003e1/ Munzir Faisal Suliman Eltahir - Omdurman Islamic University Faculty of Medicine and Health Sciences\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2/ MIHAD OSMAN ZUMRAWI MOHAMED - University of khartoum , faculty of medicine\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3/ Eman Almuez Ahmed Mohamed - University of Gezira , faculty of medicine\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eand we sincerely appreciate the respondents for taking the time to complete the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Author Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.E.A.H. and M.M.A conceptualized and designed the study, led the writing of the manuscript, and supervised the overall project. \u0026nbsp;M.S.H.M and \u0026nbsp;M.M.Y.S \u0026nbsp; \u0026nbsp;performed statistical analysis , \u0026nbsp; data interpretation and prepared tables and figures. M.A.A.A supported data management and helped with methodological inputs .H.S.S and O.Y.M.Y conducted the literature search, participate \u0026nbsp; in drafting the introduction and theoretical framework . M.A.B. \u0026nbsp;and \u0026nbsp; \u0026nbsp;A.H.A.A.M. assisted in data management and contributed to reviewing and checking the final draft . All the authors participate in data collection and manuscript writing and reviewing and \u0026nbsp; authors read and approved the final manuscript .\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSudan emergency [Internet]. UNHCR. Available from: https://www.unhcr.org/emergencies/sudan-emergency\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Sudan: No respite for civilians amid unrelenting war and aid access barriers [Internet]. UN News. 2025. Available from: https://news.un.org/en/story/2025/04/1162386\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Eldin H, Rania M.H. Baleela. Preliminary investigation and analysis of the impact of the Sudan War on higher education and scientific research sectors. International Journal of Educational Development. 2024 Dec 17;112:103190\u0026ndash;0.\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Mohamed MS, Dibya Sundar Panda, Fatima Abubker Fadul, Awada Abdelmageed Saadeldin, Mona Timan Idriss, Khan YH, et al. Assessment of the impact of COVID-19 and political instability on mental health of university students in Sudan. Eastern Mediterranean Health Journal/Eastern Mediterranean health journal. 2024 May 13;30(4):272\u0026ndash;82.\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Babiker A. War and education: the attacks on medical schools amidst ongoing armed conflict, Sudan 2023. figshare [Internet]. 2024 Mar 29 [cited 2025 Jul 31]; Available from: https://springernature.figshare.com/collections/War_and_education_\nthe_attacks_on_medical_schools_\namidst_ongoing_armed_conflict_\nSudan_2023/7155818/1\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Eldin AG. Forgotten and Neglected, War-Torn Sudan Has Become the World\u0026rsquo;s Leading Displacement Crisis [Internet]. migrationpolicy.org. 2025. Available from: https://www.migrationpolicy.org/article/sudan-civil-war-displacement\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Kassab SE, Ramya Rathan, Taylor D, Hamdy H. The impact of the educational environment on student engagement and academic performance in health professions education. BMC Medical Education. 2024 Nov 7;24(1).\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Al-Saleh S, Al-Madi EM, AlMufleh B, Al-Degheishem AH. Educational environment as perceived by dental students at King Saud University. The Saudi Dental Journal. 2018 Jul;30(3):240\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Salih KM, Idris ME, Elfaki OA, Osman NM, Nour SM, Elsidig HA, et al. MBBS teaching program, according to DREEM in College of Medicine, University of Bahri, Khartoum, Sudan. Advances in Medical Education and Practice [Internet]. 2018 Sep 4 [cited 2021 Nov 10];9:617\u0026ndash;22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129022/\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Jaffery AH, Kishwar M. Student\u0026rsquo;s perception of educational environment and their academic performance: Are they related? Pak Armed Forces Med J. 2019;69(6):1267\u0026ndash;71\u003c/li\u003e\n\u003cli\u003eMcAleer S, Roff S. Curriculum, environment, climate, quality and change in medical education: a unifying perspective. Med Teach. 2001;23(5):443\u0026ndash;54\u003c/li\u003e\n\u003cli\u003eElgadal M, Glade R. Research in displacement: The impact of war on Sudan\u0026rsquo;s higher education \u0026amp; academic research community. Oxford (UK): Rift Valley Institute; 2024\u003c/li\u003e\n\u003cli\u003eAbdellatif, S. M. F., Elmubarak, S. a. A., Suliman, H. A., Osman, M. E. M., Ahmed, A. a. M., Dawi, E. a. R., \u0026amp; Konozy, E. H. E. (2025). A nation in crisis: effects of Sudan\u0026rsquo;s armed conflict on university professors, research scientists, and students. Medicine Conflict \u0026amp; Survival, 1\u0026ndash;21. https://doi.org/10.1080/13623699.2025.2511573\u003c/li\u003e\n\u003cli\u003eMonrouxe LV\u003cstrong\u003e.\u003c/strong\u003e Negotiating professional identities: dominant and contesting narratives in medical students\u0026rsquo; longitudinal audio diaries. Med Educ. 2008;42(4):533\u0026ndash;540. doi:10.1111/j.1365-2929.2007.02686.x\u003c/li\u003e\n\u003cli\u003eKassem A, Levin L. Periodontal health and orthodontic treatment. Eur J Oral Sci. 2018;126(Suppl 1):13\u0026ndash;17. doi:10.1111/eje.13005\u003c/li\u003e\n\u003cli\u003eHongkan W, Arora R, Muenpa R, Chamnan P. Perception of educational environment among medical students in Thailand. Int J Med Educ. 2018 Jan 26;9:18\u0026ndash;23. doi:10.5116/ijme.5a4a.1eda\u003c/li\u003e\n\u003cli\u003eSalih KMA, Idris MEA, Elfaki OA, Osman NMN, Nour SM, Elsiddig HA, et al. Measurement of the educational environment in MBBS teaching program, according to DREEM in College of Medicine, University of Bahri, Khartoum, Sudan. Adv Med Educ Pract. 2018;9:617\u0026ndash;622. doi:10.2147/AMEP.S160218\u003c/li\u003e\n\u003cli\u003eMohammed D, Yassen E, Mohamed M, Eltayeb R, Asmally R, Mohammed S, et al. Educational environment and its relation to academic performance as perceived by medical students in University of Khartoum. A cross Sectional Study, Sudan, 2020. MedEdPublish. 2021;10(1).\u003c/li\u003e\n\u003cli\u003eDenz-Penhey H, Murdoch JC. A comparison between findings from the DREEM questionnaire and that from qualitative interviews. Medical Teacher. 2009 Jan;31(10):e449\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Essa M. Students Perceptions of Learning Environment in Jazan Medical School in Saudi Arabia. Research Square (Research Square). 2022 Apr 14;\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Abdullahi H, Elshazali OH, Shaheen S. Medical students\u0026rsquo; perception of the educational environment in the Faculty of Medicine, University of Khartoum, Sudan. 2019 Oct 27;12(3):1631\u0026ndash;7. Available from: https://www.researchgate.net/publication/341049570\u003c/li\u003e\n\u003cli\u003eChalla KT, Sayed A, Acharya Y. Modern techniques of teaching and learning in medical education: a descriptive literature review. MedEdPublish. 2021;10(1).\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Eldin H, Rania M.H. Baleela. Preliminary investigation and analysis of the impact of the Sudan War on higher education and scientific research sectors. International Journal of Educational Development. 2024 Dec 17;112:103190\u0026ndash;0.\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Omer AT, Ali EM, Elhassan ME, Ibrahim SA, Ahmed YS. Medical education challenges during the war crisis in Sudan: a cross-sectional study, 2023\u0026ndash;2024. BMC Medical Education. 2024 Nov 23;24(1).\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Monks J, Schmidt RM. The Impact of Class Size on Outcomes in Higher Education. The BE Journal of Economic Analysis \u0026amp; Policy [Internet]. 2011 Sep 29;11(1). Available from: https://www.ilr.cornell.edu/sites/ilr.cornell.edu/files/WP136.pdf\u003c/li\u003e\n\u003cli\u003eTrigwell K. Relations between teachers\u0026rsquo; emotions in teaching and their approaches to teaching in higher education. Instructional Science [Internet]. 2011 Oct 30;40(3):607\u0026ndash;21. Available from: https://link.springer.com/article/10.1007/s11251-011-9192-3\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Khan AT, Ullah A, Ahmad I, Kazmi MZ. The Impact of Political Instability on Financial Anxiety, Career Orientation, Job Aspirations, Academic Performance, and Psychological Well-being among University Students. Physical Education, Health and Social Sciences [Internet]. 2025;3(1):161\u0026ndash;71. Available from: http://journal-of-social-education.org/index.php/Jorunal/article/view/105\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Garcia P, Qin J. Identifying the generation gap in higher education. LearnTechLib. [Internet]. 2007 [cited 2025 Jul 31]; Available from: https://www.learntechlib.org/p/104229/\u003c/li\u003e\n\u003cli\u003eJosephine J, Jones L. Understanding the Impact of Generation Gap on Teaching and Learning in Medical Education: A Phenomenological Study. Advances in Medical Education and Practice. 2022 Sep;Volume 13:1071\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Ulug M, Ozden MS, Eryilmaz A. The Effects of Teachers\u0026rsquo; Attitudes on Students\u0026rsquo; Personality and Performance. Procedia - Social and Behavioral Sciences [Internet]. 2011;30(30):738\u0026ndash;42. Available from: https://www.sciencedirect.com/science/article/pii/S1877042811019690\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Kaur V. Assessment of institutional educational environment using the DREEM inventory. Int J Appl Basic Med Res. 2020;1(1):?\u0026ndash;? doi:10.4103/ijabmr.IJABMR_470_20\u003c/li\u003e\n\u003cli\u003eMarwan, Y., Karim, J., Al-Halabi, B., Sadeq, H., Dawas, A., \u0026amp; Al-Abdulrazzaq, D. (2015). The educational environment of the undergraduate medical curriculum at Kuwait University. Advances in Medical Education and Practice, 297. https://doi.org/10.2147/amep.s81729\u003c/li\u003e\n\u003cli\u003eGuruswami GK, Mumtaz S, Gopakumar A, Khan E, Abdullah F, Parahoo SK. Academic Integrity Perceptions Among Health-Professions\u0026rsquo; Students: A Cross-Sectional Study in The Middle East. Journal of Academic Ethics. 2022 Jul 5;21(2).\u003c/li\u003e\n\u003cli\u003eJones PJ, Park SY, Lefevor GT. Contemporary College Student Anxiety: The Role of Academic Distress, Financial Stress, and Support. Journal of College Counseling. 2018 Oct;21(3):252\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Saeed AA, Mohammad A, Abass AA, Mohammed AA, Fidaaldeen Adil Abdallh, Ali HE, et al. Psychological impact and coping mechanisms among sudanese medical students: a study on anxiety, depression, behavioral, and cognitive changes post COVID-19 lockdown and ongoing conflict. BMC Psychology. 2025 Jan 14;13(1).\u003c/li\u003e\n\u003cli\u003eSalih HS, Ibrahim SA, Gaded AA, Abdo L, Mahmoud MF, Elbadawi MH, et al. Depression, stress and anxiety among Khartoum University students who stay in war-afflicted regions in Sudan 2024. BMC Psychiatry. 2025 Feb 15;25(1).\u003c/li\u003e\n\u003cli\u003eAl Fryan LH, Shomo MI, Bani IA. Assessment of the \u0026ldquo;students\u0026rdquo; perceptions of education using Dundee Ready Environment Educational Measure (DREEM) inventory at Princess Nourah bint Abdulrahman University, Saudi Arabia. BMC Medical Education. 2024 Aug 26;24(1).\u003c/li\u003e\n\u003cli\u003eAhmed Y, Taha MH, Al-Neel S, Gaffar AM. Students\u0026rsquo; perception of the learning environment and its relation to their study year and performance in Sudan. International Journal of Medical Education [Internet]. 2018 May 24;9:145\u0026ndash;50. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129164/\u003c/li\u003e\n\u003cli\u003eAdkins WA, Davidson MG. Ordinary Differential Equations. Undergraduate Texts in Mathematics. New York: Springer; 2012. DOI: 10.1007/978‑1‑4614‑3618‑8\u003c/li\u003e\n\u003cli\u003eChen H, Xuan H, Cai J, Liu M, Shi L. The impact of empathy on medical students: an integrative review. BMC medical education. 2024 Apr 25;24(1).\u003c/li\u003e\n\u003cli\u003eNair PN, Sutar MD. Fear of Failure, Academic Self-Efficacy and Academic Performance among College Students. International Journal of Indian Psychology [Internet]. 2023 Jul 14;11(3). Available from: https://ijip.in/articles/fear-of-failure-academic-self-efficacy-and-academic-performance-among-college-students/\u003c/li\u003e\n\u003cli\u003eBedewy D, Gabriel A. Examining Perceptions of Academic Stress and Its Sources among University Students: The Perception of Academic Stress Scale. Health Psychology Open [Internet]. 2015;2(2):1\u0026ndash;9. Available from: https://journals.sagepub.com/doi/full/10.1177/2055102915596714\u003c/li\u003e\n\u003cli\u003eAbdallah E, Amna Khairy, Osman S, Musab Babiker Haga, Hashim S, Abbu M, et al. War and education: the attacks on medical schools amidst ongoing armed conflict, Sudan 2023. Conflict and health. 2024 Mar 29;18(1).\u003c/li\u003e\n\u003cli\u003eOmer AT, Ali EM, Elhassan ME, Ibrahim SA, Ahmed YS. Medical education challenges during the war crisis in Sudan: a cross-sectional study, 2023\u0026ndash;2024. BMC Medical Education. 2024 Nov 23;24(1).\u003c/li\u003e\n\u003cli\u003eAbdulhamid SM, Almokdad FK, Ahmed RJQ, Elbashir RMAM, Suleiman YAA. Psychological status of medical students and interns in the wake of the armed conflict of April 2023 in Sudan: a cross‑sectional study [preprint]. medRxiv. 2024 Feb 27:2024.02.27.24303455. doi:10.1101/2024.02.27.24303455\u003c/li\u003e\n\u003cli\u003eKlier C, Buratto LG. Stress and long-term memory retrieval: a systematic review. Trends in Psychiatry and Psychotherapy [Internet]. 2020;42(3):284\u0026ndash;91. Available from: https://www.scielo.br/j/trends/a/G9LbsdJggQx4wP85GvDxBNh/?lang=en\u003c/li\u003e\n\u003cli\u003eSchwabe L. Memory under stress: from Adaptation to Disorder. Biological psychiatry. 2024 Jun 1;97(4).\u003c/li\u003e\n\u003cli\u003eAhmed, M. E. M., Tibin, E. I., Ibrahim, A., \u0026amp; Elimam, A. M. (2024a). Epigram from the Sudanese Medical School\u0026rsquo;s Resilience in Wartime. OALib, 11(10), 1\u0026ndash;16. https://doi.org/10.4236/oalib.1112399.\u003c/li\u003e\n\u003cli\u003eKornbluh M, Wilking J, Roll S, Donatello R. Exploring housing insecurity in relation to student success. Journal of American College Health. 2022 Apr 26;72(3):1\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eGhaith Alfakhry, Naeem A, M Bader AboHajar, Alfakhry A, Abdul Fattah Mohandes, Ali I, et al. Revealing the significant shortcomings in the learning environment at the three largest medical schools in Syria: what\u0026rsquo;s next? 2023 Jan 3;23(1). \u003c/li\u003e\n\u003cli\u003eMiles S, Leinster SJ. Medical students\u0026rsquo; perceptions of their educational environment: expected versus actual perceptions. Medical Education. 2007 Feb 2;41(3):265\u0026ndash;72. Available from: https://pubmed.ncbi.nlm.nih.gov/17316211/\u003c/li\u003e\n\u003cli\u003eAbraham R, Ramnarayan K, Vinod P, Torke S. Students\u0026rsquo; perceptions of learning environment in an Indian medical school. BMC Medical Education [Internet]. 2008 Apr 11;8(1). Available from: https://doi.org/10.1186/1472-6920-8-20\u003c/li\u003e\n\u003cli\u003eBehkam, S., Tavallaei, A., Maghbouli, N., Mafinejad, M. K., \u0026amp; Ali, J. H. (2022). Students\u0026rsquo; perception of educational environment based on Dundee Ready Education Environment Measure and the role of peer mentoring: a cross-sectional study. BMC Medical Education, 22(1). https://doi.org/10.1186/s12909-022-03219-8\u003c/li\u003e\n\u003cli\u003eAwawdeh, M., Alosail, L. A., Alqahtani, M., Almotairi, A., Almikhem, R. N., Alahmadi, R. A., Aldughaither, A. A., \u0026amp; Alamoud, K. A. (2024). Students\u0026rsquo; perception of the educational environment at King Saud bin Abdulaziz University for health sciences using DREEM tool. BMC Medical Education, 24(1). https://doi.org/10.1186/s12909-023-05004-7\u003c/li\u003e\n\u003cli\u003eDunne, F., McAleer, S., \u0026amp; Roff, S. (2006). Assessment of the undergraduate medical education environment in a large UK medical school. Health Education Journal, 65(2), 149\u0026ndash;158. https://doi.org/10.1177/001789690606500205\u003c/li\u003e\n\u003cli\u003eAl-Hazimi, A., Zaini, R., Al-Hyiani, A., Hassan, N., Gunaid, A., Ponnamperuma, G., Karunathilake, I., Roff, S., McAleer, S., \u0026amp; Davis, M. (2004). Educational environment in traditional and innovative medical schools: A study in four undergraduate medical schools. Education for Health, 17(2), 192\u0026ndash;203. https://doi.org/10.1080/13576280410001711003\u003c/li\u003e\n\u003cli\u003eLegewie, J., \u0026amp; DiPrete, T. A. (2012). School context and the gender gap in educational achievement. American Sociological Review, 77(3), 463\u0026ndash;485. https://doi.org/10.1177/0003122412440802 \u003c/li\u003e\n\u003cli\u003eSarabi-Asiabar, A., Jafari, M., Sadeghifar, J., Tofighi, S., Zaboli, R., Peyman, H., Salimi, M., \u0026amp; Shams, L. (2014). The relationship between learning style preferences and gender, educational major and status in first year medical Students: a survey study from Iran. Iranian Red Crescent Medical Journal, 17(1). https://doi.org/10.5812/ircmj.18250\u003c/li\u003e\n\u003cli\u003eHongkan, W., Arora, R., Muenpa, R., \u0026amp; Chamnan, P. (2018). Perception of educational environment among medical students in Thailand. International Journal of Medical Education, 9, 18\u0026ndash;23. https://doi.org/10.5116/ijme.5a4a.1eda\u003c/li\u003e\n\u003cli\u003eBlanch, D. C., Hall, J. A., Roter, D. L., \u0026amp; Frankel, R. M. (2008). Medical student gender and issues of confidence. Patient Education and Counseling, 72(3), 374\u0026ndash;381. https://doi.org/10.1016/j.pec.2008.05.021\u003c/li\u003e\n\u003cli\u003eA, B. (2020). Students Perceptions of the Educational Environment: A Cross-Sectional Study from a Moroccan Medical University. Psychology and Psychotherapy Research Study, 4(1). https://doi.org/10.31031/pprs.2020.03.000576\u003c/li\u003e\n\u003cli\u003eRESEARCH IN DISPLACEMENT: THE IMPACT OF WAR ON SUDAN\u0026rsquo;S HIGHER EDUCATION AND ACADEMIC RESEARCH \u0026ndash; Rift Valley Institute. (2024). https://riftvalley.net/publication/research-in-displacement/\u003c/li\u003e\n\u003cli\u003eSuliman, N. H. E. E. N. K. A. (n.d.). The impact of COVID-19 on Sudanese higher education system. International Journal of Science and Research (IJSR). https://www.ijsr.net/getabstract.php?paperid=SR20629224804\u003c/li\u003e\n\u003cli\u003ePales, J., Gual, A., Escaneroi, J., Tom\u0026aacute;s, I., De Castro, F. R., Elorudy, M., Virumbrales, M., Rodr\u0026iacute;guez, G., \u0026amp; Arce, V. (2015). Educational climate perception by preclinical and clinical medical students in five Spanish medical schools. International Journal of Medical Education, 6, 65\u0026ndash;75. https://doi.org/10.5116/ijme.5557.25f9\u003c/li\u003e\n\u003cli\u003eRoff, S., McAleer, S., Ifere, O., \u0026amp; Bhattacharya, S. (2001). A global diagnostic tool for measuring educational environment: comparing Nigeria and Nepal. Medical Teacher, 23(4), 378\u0026ndash;382. https://doi.org/10.1080/01421590120043080\u003c/li\u003e\n\u003cli\u003eVishwanathan, K., Patel, G. M., \u0026amp; Patel, D. J. (2021). Impact and perception about distant online medical education (tele-education) on the educational environment during the COVID-19 pandemic. Journal of Family Medicine and Primary Care, 10(6), 2216\u0026ndash;2224. https://doi.org/10.4103/jfmpc.jfmpc_2306_20\u003c/li\u003e\n\u003cli\u003eAhmed, Y., Taha, M. H., Al-Neel, S., \u0026amp; Gaffar, A. M. (2018). Students\u0026rsquo; perception of the learning environment and its relation to their study year and performance in Sudan. International Journal of Medical Education, 9, 145\u0026ndash;150. https://doi.org/10.5116/ijme.5af0.1fee\u003c/li\u003e\n\u003cli\u003ePai, P. G., Menezes, V., Srikanth, Subramanian, A. M., \u0026amp; Shenoy, J. P. (2014). Medical students\u0026rsquo; perception of their educational environment. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2014/5559.3944\u003c/li\u003e\n\u003cli\u003eDemir\u0026ouml;ren, M. (2008). Perceptions of students in different phases of medical education of educational environment: Ankara University Faculty of Medicine. Medical Education Online, 13. https://doi.org/10.3885/meo.2008.res00267\u003c/li\u003e\n\u003cli\u003eVoltmer, E., K\u0026ouml;slich-Strumann, S., Voltmer, J., \u0026amp; K\u0026ouml;tter, T. (2021). Stress and behavior patterns throughout medical education \u0026ndash; a six year longitudinal study. BMC Medical Education, 21(1). https://doi.org/10.1186/s12909-021-02862-x\u003c/li\u003e\n\u003cli\u003eKumar, V., Yeturu, S., Pentapati, K., Krishnan, N., Roy, S., \u0026amp; Babu, R. (2022). Students\u0026rsquo; perceptions of their educational environment in a south Indian dental school\u0026mdash;A cross-sectional study. Journal of International Oral Health, 14(5), 518. https://doi.org/10.4103/jioh.jioh_34_22\u003c/li\u003e\n\u003cli\u003eKumar, B., Shah, M. a. A., Kumari, R., Kumar, A., Kumar, J., \u0026amp; Tahir, A. (2019). Depression, anxiety, and stress among final-year medical students. Cureus. https://doi.org/10.7759/cureus.4257\u003c/li\u003e\n\u003cli\u003eMcNair, R., Griffiths, L., Reid, K., \u0026amp; Sloan, H. (2016). Medical students developing confidence and patient centredness in diverse clinical settings: a longitudinal survey study. BMC Medical Education, 16(1). https://doi.org/10.1186/s12909-016-0689-y\u003c/li\u003e\n\u003cli\u003eRaza, A., \u0026amp; Khaliq, T. (2022). STUDENTS DREEM FROM PRE-CLINICAL TO CLINICAL YEARS - A CROSS SECTIONAL ANALYSIS FROM REHMAN MEDICAL COLLEGE, PESHAWAR. Journal of Ayub Medical College Abbottabad, 34(1), 145\u0026ndash;153. https://doi.org/10.55519/jamc-01-9110\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical Education, DREEM, Educational Environment, Sudan war, Medical Students, Students Perception","lastPublishedDoi":"10.21203/rs.3.rs-7329997/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7329997/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ongoing conflict in Sudan has severely disrupted medical education, urging the need to assess the educational environment experienced by medical students across the country.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted between December 2024 and February 2025, involving 2,714 medical students from 46 Sudanese universities. A convenience sampling method was implemented. Data were collected via a self-administered online questionnaire comprising demographic items and the Dundee Ready Education Environment Measure (DREEM) scale. The 50-item DREEM assesses five domains: perceptions of learning, teachers, academic self-perception, atmosphere, and social self-perception. Reliability was assessed using Cronbach’s alpha, and data were analyzed using SPSS v29. Independent t-tests and ANOVA were performed to explore associations between DREEM scores and demographic variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample was predominantly female (70.1%), with a median age of 22 years. The overall mean DREEM score was 125.99, indicating an environment that was more positive than negative. Among the subdomains, perceptions of atmosphere (M = 30.23) and learning (M = 29.83) scored highest, while social self-perception was lowest (M = 17.36). Reliability analysis demonstrated good internal consistency for the total scale (α = 0.882), with acceptable reliability across most subscales except social self-perception (α = 0.495). Gender and academic level significantly influenced subscale scores. Clinical students and those residing in dormitories also reported more favorable perceptions (p \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the ongoing conflict, medical students in Sudan reported generally positive perceptions of their educational environment, but major concerns centered on academic stress, passive teaching, and weak institutional support were highlighted. These results point to urgent priorities for strengthening medical education during crises to maintain its quality and continuity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Medical Education Amidst Conflict: A National Assessment of Sudanese Medical Students’ Perceptions Using the DREEM Tool","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-17 19:56:21","doi":"10.21203/rs.3.rs-7329997/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-21T20:26:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T17:39:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18912952201637274289327038934990286969","date":"2025-09-17T13:26:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177641568371217253911665604276226910284","date":"2025-09-17T09:43:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193503109523088053548478171494453151891","date":"2025-09-12T16:39:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-10T15:32:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T06:57:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-14T10:18:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T03:17:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-08-14T03:13:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae9ff54d-5e4f-4462-962d-30add0bba0bc","owner":[],"postedDate":"September 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-17T19:56:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-17 19:56:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7329997","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7329997","identity":"rs-7329997","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}