Abstract
BACKGROUND: Informed consent is a cornerstone of ethical surgical practice, yet significant challenges persist in ensuring patients' comprehension, particularly in low-resource settings. Cultural norms, literacy barriers, and limited institutional support often hinder truly informed decision-making. METHODS: A hospital-based cross-sectional study was conducted from September to December 2024 at a rural surgical center in Omdurman, Sudan. A total of 422 adult patients undergoing elective surgery were interviewed postoperatively using a validated, culturally adapted questionnaire. Descriptive and inferential statistics were applied to assess patient demographics, perceptions of the informed consent process, and associated barriers. RESULTS: The mean age of participants was 42.0 ± 14.3 years, with a near-equal gender distribution. Only 17.1% of patients signed their own surgical consent forms, with 80.6% of these self-signers being male. Among those whose consent was signed by relatives (82.9%), females were overrepresented (56.6%). While 91.5% recognized the importance of informed consent, only 33.6% understood its medico-legal significance. Consent explanations were predominantly delivered by residents or house officers (62.1%), and just 20.1% of patients felt that the discussion influenced their surgical decision. Self-signers were more likely to recall discussion of surgical complications (75.0% vs. 51.4%; p < 0.001), less likely to recall expected benefits (61.1% vs. 78.9%; p = 0.001), and showed no significant difference for consequences if surgery was not performed (80.6% vs. 82.9%; p = 1.0). Overall satisfaction with the consent process was high (87.7%), though this did not correlate with comprehension. Educational status significantly influenced autonomy, with illiterate participants disproportionately less likely to sign their own forms and more likely to cite language barriers and lack of information (p < 0.05). CONCLUSION: Despite high reported satisfaction, substantial deficiencies exist in patients' comprehension and autonomy in the informed consent process in Sudan. Gender disparities, literacy limitations, and systemic reliance on junior staff compromise the ethical validity of consent. Interventions tailored to cultural and educational contexts-such as provider training, simplified materials, and patient-centered communication-are urgently needed to enhance informed surgical decision-making in low-resource environments.