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Use of Medications in Arab Countries

  • Sanah HasanEmail author
  • Muaed J Al-Omar
  • Hamzah AlZubaidy
  • Yaser Mohammed Al-Worafi
Living reference work entry

Abstract

Use of medications in Arab countries is complex; although it follows strict laws and regulations, there seems to be many forces that push and pull implementation of these in several directions. Pharmacy practice in the Arab countries is predominantly similar, with a few country-specific factors that are affected by regulation, policy, and education in that country. Medications are mostly imported, but local manufacturing (mostly generic substitutes to imported brand name medications) still occurs and is encouraged by governments in the region. Medications are usually sold in pharmacies, that are hospital or community-based, by mostly a licensed pharmacist and often by other personnel such as pharmacy assistants and technicians. Medications classified as prescription medications are conveniently available to consumers without prescription as long as they are able to pay. This creates a situation where medication adverse drug reactions monitoring and follow-up to outcomes of medication therapy are suboptimal. Medication misuse, intentional or unintentional, is on the rise in Arab countries. This chapter covers briefly overall medication and pharmacy regulation in Arab countries, extent of medication performance monitoring, adherence to medications, and factors that affect patients’ adherence to their therapy including issues related to medication literacy. Key areas of medication use and misuse, including self-medicating practices, are covered in detail in this chapter. Major healthcare areas of concern affecting general public health in Arab countries that are managed with pharmaceuticals including contraception, immunization, smoking cessation, and weight management are also discussed.

Keywords

Arab countries Regulation Self-medication Community pharmacy Complimentary therapy Drug misuse Health literacy Contraception Smoking cessation Immunization Weight management 

Introduction

The overall level of pharmacy practice appears to be similar across Arab countries, although some differences exist in drug regulations and the degree of adherence and enforcement to these regulations. All countries have at least two drug classifications of prescription and nonprescription (over-the-counter, OTC) medications, while others have a third category of pharmacist-only medications; the characteristics of the classifications may differ by country. In general, more drugs are available without prescription in Arab than in Western countries. This puts greater responsibility on the shoulder of the pharmacist to provide safe and effective therapy and to refer patients to medical management when necessary. Unfortunately, the level of practice continues to be low despite advances in pharmacy education in the region; this is especially true in the community setting (Kheir et al. 2008) where in many community pharmacies, dispensing and counseling are predominantly carried out by pharmacy technicians while pharmacist–patient interaction occurs infrequently (Al-Wazaify and Albsoul-Younes 2005).

Understanding how medications are regulated, dispensed, and discussed by pharmacists and used by consumers in Arab countries is important as medications constitute a key intervention in the prevention and management of disease. However, their use may be associated with adverse drug reactions, errors, misuse, abuse, low literacy, and improper adherence, all of which lead to negative patient medication experiences, possibly leading to suboptimal patient outcomes. Pharmacy is practiced in different ways, e.g., dispensing, compounding and preparation, marketing, counseling, etc., and pharmacists play a significant role in the provision of pharmaceutical care, an important component of overall health care. This chapter on the use of medications in Arab countries aims to provide a general overview of pharmacy as a healthcare discipline, its control over medications and their safe use and the services offered in pharmacies. The chapter also aims to shed some light on the behavior of consumers regarding safe, appropriate use of medications in the self-management of disease and in health promotion and disease prevention activities. Specifically, the objectives that will be met in this chapter are:
  1. 1.

    Discuss general regulations related to pharmacy licensing and ownership, pharmacist training requirements, pharmaceutical market, procurement, and costs in Arab countries

     
  2. 2.

    Explore Arab country capacity for pharmacovigilance and adverse drug reporting systems and resources

     
  3. 3.

    Highlight common prescribing and medication administration errors including commonly involved medications in Arab countries

     
  4. 4.

    Describe the health literacy and medication knowledge of the general public in Arab countries and emphasize local culture and language dimensions to health literacy in the region

     
  5. 5.

    Describe patient assessment, counseling, and advice giving practices of pharmacists, by discussing areas of strength and weakness

     
  6. 6.

    Describe medication taking behavior and adherence patterns of patients in Arab countries, and the reasons and beliefs behind nonadherent behavior

     
  7. 7.

    Report on commonly abused medications, patterns of use, and combinations of products evolving as “street favorites”

     
  8. 8.

    Discuss self-medicating practices, types of medications used in self-medication, and risks associated with self-medication in the Arab countries

     
  9. 9.

    Differentiate the types of traditional and complementary therapies consumers use to enhance health and treat disease in Arab countries

     
  10. 10.

    Assess social and cultural issues associated with contraception in Arab countries, the products available, patterns of use, and tolerability of these products

     
  11. 11.

    Assess the status of immunization schedules in Arab countries, and the role of conflict and war in affecting immunization of immigrants and the people in areas of conflict.

     
  12. 12.

    Investigate quit behaviors and pharmacological interventions to help quit smoking in Arab countries

     
  13. 13.

    Discuss weight management modalities commonly used by consumers in Arab countries

     

Pharmacy and Pharmacist Regulation

National drug authorities and/or ministries of health are responsible for the regulation of pharmacy practice, and drug registration and procurement policies in Arab countries (Fathelrahman et al. 2016). For a pharmacy to be in operation in Arab countries, a pharmacy license must be obtained from the authorities. Pharmacy ownership is allowed for non-nationals in some Arab countries, but the majority limit it to country nationals (Fathelrahman et al. 2016). In many countries, only a pharmacist who has at least a bachelor’s degree in pharmacy or pharmaceutical science can legally open a pharmacy, but adherence to pharmacy regulation is not strict. In Yemen, for example, pharmacies are routinely owned and managed by non-pharmacists (Al-Worafi 2014b). The regulations in Saudi Arabia allow non-pharmacists to own pharmacies but the manager should be a registered pharmacist (Almeman and Al-jedai 2016). Similarly, pharmacies in the United Arab Emirate (UAE) may be owned by non-pharmacists but they must be managed by pharmacists (Hasan et al. 2011).

Licensing pharmacists in Arab countries differs from one country to another in terms of degree qualifications, required training, and licensing examinations. Training after graduation is not required for pharmacist licensing and no licensing examination is required for registration in Yemen (Al-Worafi 2014b). Licensing pharmacists in Saudi Arabia requires them to undergo training after graduation and to pass an examination for those graduating from Saudi private universities; these requirements are not compulsory for those graduating from public universities (Almeman and Al-jedai 2016). Pharmacists’ employment and remuneration are classified into various categories in Arab countries. In Yemen, pharmacist employment is classified into three categories: pharmacist, specialist, and consultant according to the pharmacist qualifications. A pharmacist with an undergraduate degree in pharmacy is classified as pharmacist, a pharmacist with a master’s degree in pharmaceutical sciences is classified as specialist, and a pharmacist with a PhD degree or its equivalent in pharmaceutical sciences is classified as consultant (Al-Worafi 2016).

In Saudi Arabia, pharmacist employment is classified into three categories: pharmacist, pharmacist I, and consultant pharmacist according to their qualification and experience (Almeman and Al-jedai 2016). A pharmacist with a bachelor’s degree is classified as pharmacist, a pharmacist with a master’s degree in pharmaceutical sciences or PharmD (Doctor of Pharmacy) degree and with 3 years of experience is classified as pharmacist I, and a pharmacist with a PhD degree or its equivalent in pharmaceutical sciences with 3 years of experience is classified as consultant pharmacist. Generally, licensing pharmacy technicians in Arab countries does not require training or passing an examination (Fathelrahman et al. 2016).

Pharmacy Personnel and Staff

The number of licensed pharmacists in Arab countries per 10,000 population differs from one country to another, and it ranges between 1.7 and 17.5. The highest number of pharmacists per 10,000 population was reported in Jordan at 17.5 followed by Egypt at 17.3 pharmacists. Table 1 lists available information about the number of licensed pharmacists per 10,000 population in Arab countries (Alefan and Halboup 2016; Elsayed et al. 2016; Almeman and Al-jedai 2016; Al-Worafi 2016; Kheir 2016; Ibrahim and Wayyes 2016; Alfadl et al. 2016; WHO 2008).
Table 1

Number of pharmacists/10,000 population in Arab countries

Country

Number of pharmacists per 10,000 population

Jordan

17.5

Egypt

17.3

Lebanon

13.8

Palestine

8.9

Syria

6.5

Saudi Arabia

5.5

Oman

5

Qatar

4.7

UAE

4

Iraq

3.6

Morocco

2.3

Sudan

2.2

Tunisia

2

Kuwait

2

Yemen

1.7

Pharmacy Hours of Service

The public has good access to pharmacy services in terms of opening hours and availability of the pharmacy services. These are similar in most Arab countries. In the UAE, community pharmacies are generally open every day; many pharmacies provide 24 h per day service, permission for which is granted by the licensing authorities upon an official application (Hasan et al. 2011; DHA 2013). These pharmacies are required to have a licensed pharmacist on duty for 24 h per day, all days of the week. A display sign indicating 24-h operating is required on the physical door of eligible pharmacies. A list of 24-h service pharmacies is available to the public in local newspapers or online on the health authorities= websites (Hasan et al. 2011; DHA 2013). Services in hospital pharmacies in Arab countries are generally available for 24 h per day (Alefan and Halboup 2016; Elsayed et al. 2016; Almeman and Al-jedai 2016; Al-Worafi 2016; Kheir 2016; Ibrahim and Wayyes 2016; Alfadl et al. 2016).

Pharmaceutical Market, Procurement, and Costs

Total health expenditure in Arab countries ranges from US$ 6 to 862 per capita, while medicines expenditure ranges from US$ 1 to 80 per capita (Kandil 2004). The local drug production varies and ranges from 0% to more than 90% of the national drug market. On average, the local drug industry covers 50% of the total drug market. The Arab drug market was estimated at US$ 10 billion in 2007 with Saudi Arabia and Egypt occupying the largest market sizes with more than US$ 1.2 billion each (Khoja and Bawazir 2005). Many Arab countries encourage and support their national medication manufacturing by reducing the prices of the locally manufactured medications by 20% or more in comparison to the original branded medications. There are more than 245 pharmaceutical manufacturing plants in Arab countries, with a consistent increase in their numbers. However, manufacture is usually limited to the production of generic or company-branded generic pharmaceuticals already under license. (Kandil 2004)

Naturally, there are differences between various Arab countries in demographic and economic indicators. They also have different health systems which may predominantly be dependent on the private sector such as in Lebanon (Karam 2005) or on the public health sector with general health insurance coverage such as in Kuwait (Ball et al. 2005). People in some Arab countries such as Saudi Arabia (Almalki et al. 2011) and Qatar (Kheir 2016) receive their medications for free from the public health sector, while people in many other countries such as Yemen, Sudan, and Jordan pay for their medications in both the private and public sectors (Al-Worafi 2014b, Alfadl et al. 2016; Alefan and Halboup 2016).

Most countries procure a mix of original (originator, brand) and generic medicines for their public health sector; the price is usually three times higher for the original drug (WHO 2008). Medicines’ prices in private retail pharmacies are usually high for all original and generic medicines, with the differences in the prices between original and generic medicines too small to be noted in some countries. This is usually attributed to individual country pricing policies and added price mark ups, which eliminate the differences in the prices of the generic medicines compared to original brands. This ultimately means that patients in these countries are not truly benefiting from the use of generic medicines (WHO 2008). Table 2 shows examples of the cumulative effects of different price components that are applied to the prices of medicines in some Arab countries. Lebanon and Sudan include charges for professional pharmaceutical associations. Mark-ups in Kuwait do not include professional pharmacist fee but are markedly higher than other countries. Countries like Morocco (Table 2) and Syria commonly procure generic medicines at a higher price than other countries, hence careful review of procurement policies are due in these countries (Sallouta et al. 2004). Other suboptimal procurement practices in some countries is the procurement of old branded medicines instead of their substitutable cheaper generics, as is the case with diazepam and amitriptyline, which are preferred medicines used in several conditions. This ultimately increases costs to both the governments and patients who pay for these medicines (WHO 2008). National policy and medicines regulators should review their pharmaceutical pricing regulations and possibly remove taxes and import duties to optimize availability of, and access to, medicines, especially for those who have difficulty affording them (WHO 2008).
Table 2

Examples of the cumulative effects of price components for medicines in Arab countriesa

Medicine

Type of charge

Amount of charge

Price of dispensed quantity

Cumulative % mark-up

Jordan: Private sector, originator brand (imported)

Amoxicillin 250 mg × 20cap

Insurance fees

1.0%

4.08

1.00%

Bank fees

1.0%

4.12

2.01%

Transport and clearance

1.5%

4.18

3.54%

Added fees

0.2%

4.19

3.75%

Wholesale mark-up

19.0%

4.99

23.46%

Retail mark-up

26.0%

6.28

55.56%

VAT

4.0%

6.54

61.78%

Jordan: Private sector, generic (imported)

Amoxicillin 250 mg × 20cap

Insurance fees

1.0%

2.08

1.00%

Bank fees

1.0%

2.10

2.01%

Transport and clearance

1.5%

2.13

3.54%

Added fees

0.2%

2.14

3.75%

Wholesale mark-up

19.0%

2.54

23.46%

Retail mark-up

26.0%

3.20

55.56%

VAT

4.0%

3.33

61.78%

Kuwait: Private sector, originator brand/lowest priced generic (imported)

Beclometasone 0.05 mg inhaler

Agent profit

35.0%

2.82

35.00%

Pharmacy profit

26.0%

3.55

70.10%

Lebanon: Private sector, originator brand/lowest priced generic (imported)a

Atenolol 30 × 50 mg tabs

Customs clearing and commission

11.5%

2474.63

11.50%

Importer profit

10.0%

2722.09

22.65%

Pharmacist profit

30.0%

3538.72

59.45%

Morocco: Private sector, most sold generic (local manufacture)

Atenolol 60 × 100 mg tab

Port/fee packaging

10.83

84.28

14.74%

Royalties

5.0%

88.49

20.48%

Packaging

5.0%

92.91

26.50%

Wholesale mark-up

10.0%

102.20

39.15%

Retail mark-up

30.0%

132.87

80.89%

Morocco: Private sector, originator brand (imported)

Amitriptyline 100 × 25 mg tab

File preparation fee

0.054

22.58

0.24%

Custom fee

0.0%

22.58

0.24%

VAT

7.0%

24.16

7.26%

Wholesale mark-up

10.0%

26.58

17.98%

Retail mark-up

30.0%

34.56

53.38%

aAdapted from WHO (2008)

Medicine Availability and Affordability

Medicines available in the public sector are usually generics. Many countries do not charge patients for medicines in the public health sector; however, in some countries such as Jordan, Sudan, and Yemen, they do. Patients mostly could afford to pay for standard treatments of common conditions with medicines obtained from the public sector, when the medicines are available (WHO 2007b). However, when the medicines are unavailable, patients resort to the private sector which usually stocks more of the originator brands. For example, in Yemen, although prices are moderately low, their availability is very poor (5%) in the public sector, which means that patients resort to the private sector to obtain their medicines (WHO 2008). The balance between availability of brand and generic medicines in the private sector varies between countries.

To estimate affordability, the median price ratio (MPR) obtained by dividing the local unit price of a medicine by the international reference price of that same medicine, giving an indication of how many times more expensive (or cheaper) the medicine is than the reference price. This also facilitates national and international comparison of medicines’ prices. An MPR of public sector procurement prices should usually be ≤1 as this price would be considered equivalent to the price offered by bulk suppliers. A standard MPR for medicines in the private sector is dependent on the medicine itself and the country pharmaceutical market (WHO 2008). The Affordability of certain standard treatments for common conditions is typically estimated by comparing their costs to the daily wage of the lowest paid unskilled government worker. Table 3 shows examples of the affordability of standard treatments based on the wage of the lowest paid unskilled government worker and local prices of the medicine in private retail pharmacies in some Arab countries.
Table 3

Affordability of standard treatments based on the wage of the lowest paid unskilled government worker and local prices of the medicine in private retail pharmaciesa

Standard treatment

type

Affordability (no. of days’ wages)

Jordan

Kuwait

Lebanon

Morocco

Sudan

Syria

Tunisia

Yemen

Acute respiratory infection

Amoxicillin 250 mg 1 capsule 3 times/day for 7 days

OB

2.3

2.4

1.0

LPG

0.9

0.8

0.4

0.6

0.2

Acute respiratory infection (child)

Co-trimoxazolesuspension 5 ml 2 times/day for 7 days

OB

0.9

0.6

0.3

1.4

0.5

0.3

0.8

LPG

0.3

1.0

0.4

0.2

0.3

0.2

0.3

0.2

Arthritis

Diclofenac 25 mg 1 tablet 2 times a day for 30 days

OB

4.6

5.2

2.0

1.1

5.4

3.2

1.3

5.0

LPG

2.1

3.5

1.7

0.8

0.9

0.8

0.7

0.6

Beclometasone inhaler (1 inhaler over 30 days)

OB

2.4

2.7

1.6

LPG

1.6

0.7

1.0

1.6

0.4

1.8

Depression

Fluoxetine 200 mg 2 capsules once a day for 30 days

OB

21.6

34.3

15.9

14.6

13.5

LPG

8.6

7.2

5.9

2.0

1.6

9.8

1.6

Diabetes

Metformin 500 mg 1 tablet 3 times daily for 30 days

OB

2.5

1.8

0.6

6.4

1.1

3.6

LPG

1.2

1.6

2.9

0.6

2.7

1.6

0.8

1.4

Epilepsy

Carbamazepine 200 mg 1 tablet 2 times daily for 30 days

OB

3.3

4.0

1.8

1.6

6.7

4.2

3.7

LPG

1.6

0.9

1.8

1.7

0.4

1.1

Hypertension

Nifedipine Retard 20 mg 1 tablet daily for 30 days

OB

4.2

2.1

2.9

1.3

8.6

LPG

1.7

0.9

1.2

1.7

0.2

1.0

Peptic ulcer

Omeprazole 20 mg 1 capsule daily for 30 days

OB

19.9

22.0

14.6

10.6

13.5

LPG

7.7

19.3

4.5

2.3

2.9

4.3

7.0

1.1

aAdapted from WHO (2008)

In a field study to measure the price, availability, and affordability of selected medicines in Jordan in 2004 using a standardized methodology developed by the World Health Organization (WHO 2007a), it was shown that in the public sector, the procurement of medicines is effective as the procurement prices were close to international reference prices. Patients were able to obtain generic medicines at similar prices to the procurement prices in the public sector. Nevertheless, availability of generic medicines in the public sector was poor (median 28%); half of the medicines were found in only 5.1–61.1% of the surveyed public facilities. This again concluded that these patients were purchasing their medicines from the private sector, which stocked more of the originator medicines in Jordan. Additionally, the government in some instances was purchasing originator brands where lower-priced generics were available. In these cases, patients were paying a lot more to purchase originator products as compared to the lowest priced generics. They were also paying about 10 times more for generics in the private sector than in the public sector. In this survey, affordability of medicines was also estimated based on the number of days the lowest paid government worker would need to cover costs needed to treat common conditions. For example, they would need less than 1 days’ wage to purchase generic fluoxetine from the public sector in Jordan (WHO 2007a), up to 8.6 days’ wages to purchase the lowest priced generic fluoxetine from the private sector, and up to 21.6 days’ wages to purchase originator brands from the private sector (Table 3).

In Egypt, the public health system scheme provides medicines free of charge for particular conditions such as those in the Essential Medicines List, medicines for malaria, tuberculosis, hepatitis C, and immunizations (WHO 2011). Additionally, certain population groups receive medicines free of charge such as people who could not afford to buy them, children under the age of five, and the elderly. When the MPR was used to compare prices of medicines to international reference prices, it was found for generics to be 0.95, no originators were found in the governmental sector. It was higher in the private sector at 1.69 for generics and 2.73 for originators. To assess affordability, the number of days’ wages required to purchase treatment with co-trimoxazole (reference medicine) for a child respiratory infection; the purchase of the generic medicine necessitated 0.3 days’ wage in the public sector and 0.5 days’ wage in the private sector (WHO 2011).

In Saudi Arabia, a review of government and Saudi Food and Drug Authority (SFDA) policy documents, guidelines, and published articles showed the government, through the SFDA, set the prices of pharmaceutical products. As the population enjoyed free health care in addition to the recent introduction of compulsory health insurance, the impact of price variation between generics and originator medicines was not felt. Generally, the Saudi population preferred to use originator branded medicines (Khan et al. 2015).

In Arab countries, most standard treatments with core medicines would be free or affordable from public health facilities when the medicines were available. However, the medicines were not always available in the public sector leading to patients obtaining their medicines from the private sector which stocked more of the higher-priced originator brands. There was wide variability in the affordability of medicines in private retail pharmacies to low-wage government workers across Arab countries and, in some cases, medicines were particularly unaffordable. Much effort would be needed to ensure that affordable low price generics were made available and prescribed for the low wage population in the Arab countries.

Medication Waste and Disposal

Lack of appropriate medication disposal programs has been reported in Arab countries (Al-Shareef et al. 2016). Several studies were conducted to explore medication disposal behavior among the general public. In a study from Kuwait in 2007, 97% of study participants disposed unused and expired medications in the household waste while the rest (3%) reported that they either flushed their unused and/or expired medications down the toilet or gave them to other individuals such as friends (Abahussain and Ball 2007). Similar findings were reported from Saudi Arabia. A study that explored the behavior of 300 patients in two university tertiary care hospitals regarding their disposal practices of unused and expired medications found that awareness among members of the general public toward medication disposal was very low. Seventy-nine percent of patients reported that they disposed their unused and expired medications through household waste, 7% disposed them in the toilet or sink, and others reported keeping them for future use, returning them to physicians or pharmacists, or giving them to other individuals such as family or friends (Al-Shareef et al. 2016). Data from Qatar confirmed the same findings as 77% of the public disposed their unused medications in the household waste, 6% reported disposing them in the toilet, while 4% reported keeping them (Kheir et al. 2011). In a study from Oman, 45% of patients disposed their unused and expired medications through household waste, 41% kept them for future use, and 12% returned them to the pharmacies or healthcare facilities (Abdo-Rabbo et al. 2009).

In a study conducted by Abahussain et al. in 2012, which sought to explore the practice of pharmacists toward the disposal of unwanted medications in Kuwait, reported that the practice among pharmacists toward disposal of medications was not optimal as 77% of them reported that they disposed their unused medications through the waste disposal system (Abahussain et al. 2012).

Improper medicine disposal could have a great environmental, economic, and public safety concerns in Arab countries. These require efforts to increase public health awareness of safe disposal of unused and expired medicines. Additionally, Arab countries could develop drug collection programs for redistribution of unused medicines to patients who cannot afford them, or for donation to humanitarian agencies provided that collected drugs meet storage standards for product integrity (Abou-Auda 2003).

Pharmacovigilance in Arab Countries

Pharmacovigilance is the “science and activities relating to the detection, assessment, understanding and prevention of adverse effects and all other problems related to medicines” (WHO 2009). It seems there are wide disparities in pharmacovigilance systems and national capacities to monitor and ensure safe use of medications in Arab countries. According to WHO revelations, only six Arab countries have the minimal requirements for a functional national pharmacovigilance system. These countries are Jordan, Egypt, Morocco, Saudi Arabia, Sudan, and Tunisia (Qato 2017). One of the few reports on pharmacovigilance in the region noted that among 10 national bodies responsible for drug safety that were interviewed, only six described a formal drug monitoring program at the national level (Wilbur 2013).

In 2015, Arab and Eastern Mediterranean countries contributed with 0.6% of the 2.1 million suspected Individual Case Safety Reports (ICSRs) in VigiBase (WHO 2017b), the global database for Adverse Drug Reaction (ADR) reports, reflecting the low participation in adverse drug reporting from the region. Another study found that 11 Arab and Eastern Mediterranean countries received less than five ADR reports per million inhabitants per year, an insufficient number to be able to identify drug-related problems (Qato 2017). Reports from Saudi Arabia have revealed that pharmacists do not have good knowledge of ADR reporting; only a few pharmacists have ever reported ADRs, and they declared they are largely unaware of the process of ADR reporting (Mahmoud et al. 2013). A study from the UAE, mirroring that from Saudi Arabia, found that identification and reporting of medication errors and adverse drug reactions was only carried out by one third of community pharmacies (Hasan et al. 2012). Reasons for not reporting ADRs, principally, included lack of awareness about the method of reporting, disclaiming responsibility for ADR reporting, and the belief that most ADRs in community pharmacy are minor and do not need to be reported (Mahmoud et al. 2013). Others also cited lack of health professional education and public awareness about the importance of reporting adverse events, and the presence of counterfeit medications (Al-Worafi 2014a).

This state of affairs reflects the challenges of inadequate resources devoted to drug safety agenda at the national level, as well as the low prioritization of pharmacovigilance as a drug monitoring scheme in most countries in the Arab region. Understanding the value of incorporating pharmacovigilance as a key component of regulatory budgets by policymakers is of great importance. One important issue for the development of a strong pharmacovigilance system is the presence of trained health professionals. In many countries in the region, unfortunately, there is shortage of highly qualified professionals, which is core to the problem. Hence, any efforts to build pharmacovigilance capacity whether at the national or regional levels should focus on consolidating data and enhancing personnel resources (Ahmad 2014; Bham 2015). Moreover, enhanced collaboration with qualified local and international pharmaceutical policy researchers can help support building and sustaining the capacity for pharmacovigilance. More organized utilization of the Internet and possibly social media for the reporting and collection of ADRs are also worth exploring (Qato 2017; Wilbur 2013).

Medication Errors

Prescribing errors have been defined as errors initiated during the prescribing process. These include the incorrect selection of medication, dose, strength, frequency, route of administration, dosage form, or instruction for use of a medication” (Lesar et al. 1997). Prescribing errors reported mostly in Arab countries are related to medication dosing, frequency, and strength (Alsulami et al. 2013). The rate of dosing errors during medication prescribing reported from the region ranged between 0.15% and 34.8% of prescriptions (Al Khaja et al. 2007; Khoja et al. 2011). A cross-sectional study analyzed all medication prescriptions from five public and five private primary health clinics in Riyadh city, Saudi Arabia. Prescriptions from the public and private clinics for 2463 and 2836 respectively were analyzed for errors using the Neville et al.’s classification of prescription errors. In this classification, errors were classified into one of four categories based on their potential clinical outcomes (Al Khoja et al. 2011): Type A = potentially serious to patient; type B = major nuisance and so pharmacist/doctor contact was required); type C = minor nuisance and so pharmacist must use professional judgment; and type D = trivial. Prescribing errors were found in 990/5299 (18.7%) prescriptions. Both type B and type C errors (major and minor nuisance) were more often associated with prescriptions from public than private clinics. Type D errors (trivial) were significantly more likely to occur with private health sector prescriptions. Type A errors (potentially serious) were rare (8/5299 drugs; 0.15%) and the rate did not differ significantly between the two health sectors. Potentially life-threatening type A errors in both sectors were mainly related to overdosage. These errors were most commonly associated with medicines for diabetes or hypertension.

In a study to evaluate drug utilization trends and to describe the prevalence and type of medication-related prescribing errors in infants treated at primary care health centers in Bahrain, prescribing errors were classified as “omission” (minor and major), “commission” (incorrect information) and “integration errors.” In 2282 prescriptions, 2066 (90.5%) were classified as omission (major), commission, and integration errors. In 54.1% of prescriptions with omission errors, the length of therapy and the required dosage form were not specified in 27.7% and 12.8% of prescriptions, respectively. In 43.5% of prescriptions with errors of commission, dosing frequency (20.8%) and dose/strength (17.7%) were most common. Errors of integration such as potential drug–drug interaction comprised 2.4% of all prescribing errors (Al Khaja et al. 2007).

Administration errors have been defined as “inconsistency between treatment that is either prescribed or recommended according to standard hospital policies and procedures and the drug therapy received by the patient” (Greengold et al. 2003). Administration errors may be health professional-related or patient-related. The reported administration error rates varied from low to high in a given setting in Arab countries (Sadat-Ali et al. 2010; Saab et al. 2006). A study was carried out at King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia during the period from January 2008 to December 2009. Incident reports were collected retrospectively from the medical records of patients. There were only 38 medication incidents reported for the study period with the most common reported error being missed medications, which was seen in 15 (39.5%) of cases.

In another study from Lebanon focusing on patient-related administration errors, records of elderly patients were retrieved from different community pharmacies. Patient profile review in combination with in-person patient interviews were conducted with elderly patients between November 2004 and May 2005 by qualified pharmacists. Based on a literature review describing guidelines for the inappropriate use of medications in the elderly, patient therapies were assessed and classified as either appropriate or inappropriate. More than half (59.6%) of the patients were considered taking at least one inappropriate medication. Inappropriate medication use was most identified based on Beers’ criteria classifications (22.4%), missing doses (18.8%), or incorrect frequency of administration (13.0%) (Saab et al. 2006).

Most medication errors reported in the studies from Arab countries were related to antihistamines (Al Khaja et al. 2007), antibiotics (Alagha et al. 2011), and anticoagulants (Alagha et al. 2011). In pediatric patients, the most common medications associated with errors include antihistamines, paracetamol, electrolytes, and bronchodilators (Al Khaja et al. 2007). Poor knowledge of medicine prescribing and administration was reported as key factor leading to medication errors in Arab countries (Al Khaja et al. 2007). Other factors cited included lack of pharmacology background on the part of physicians and nurses, poor adherence with drug prescribing and administration procedures, lack of reporting of medication errors, heavy workload and untrained staff, and inefficient communication between healthcare professionals (Alsulami et al. 2013).

The development of preventive strategies for avoiding prescription errors is crucial, including training initiatives to improve physicians’ prescribing skills and strict adherence to the use of national drug formularies (Al Khaja et al. 2005). Additionally, heath professionals such as pharmacists have a major role to play in counseling and informing patients about the importance of appropriate drug use and administration. Improved communication and collaborations between health professionals have a paramount effect in improving patient experiences with medications.

Health Literacy

Health literacy is the “ability of a person to read, compute and understand health-related information such as in a physician appointment slip, medication labels and pamphlets” (Tkacz et al. 2008). Health literacy is connected to health outcomes (von Wagner et al. 2009). Low health literacy is associated with lower rates of adherence and use of preventive measures, higher healthcare expenses, more hospitalizations, poorer health status, and higher mortality rates (Ickes and Cottrell 2010; MacLeod et al. 2017).

People’s knowledge of and attitude toward medications are important factors affecting the use of these medications. In a study from Jordan, 67.1% of the public believed that antibiotics treat common cold and cough. Many patients in this region also thought antibiotics were used for viral infections (Alzoubi et al. 2013; Darwish et al. 2014), and about 28% misused antibiotics as analgesics (Shehadeh et al. 2012).

Many traditional patient education programs rely on written material about disease processes, medical management, and self-care behaviors such as eating healthy, exercising regularly, adhering to medical treatments, and self-monitoring of disease outcomes (Yamashita and Kart 2011). Findings about health information presented to patients show that the information is developed at a higher level than what patients could understand, which could affect the effectiveness of such information (Murphy et al. 1993).

Low health literacy seems to be a problem in all communities (Emmerton et al. 2012), but for patients from culturally and linguistically diverse (CALD) backgrounds (such as Arabic backgrounds), it may be exaggerated by language barriers (Mohammad et al. 2015). Multilingual health information materials were found useful in enhancing understanding of patients, many of whom preferred written health information in their native language. Similarly, multilingual labels on medicines bottles were found to ease comprehension of the label; some patients stated they were writing the name of the medicine in their native language on the label to allow easier reference. Additionally, patients relied heavily on listening to the doctor or pharmacist who could speak their first language. Most patients emphasized the need to overcome the communication barrier that existed between them and pharmacists who did not speak their language of origin, especially in situations where the physician did not supply the information (Mohammad et al. 2015).

It is essential to assess the health literacy of patients, as this will help in the design of interventional programs and development of educational material that suits their health literacy level. Consequently, it is pivotal to develop valid and reliable tools in Arabic language to assess health literacy among Arab populations. Tools to test health literacy have mostly been developed in the English language in English-speaking countries. A limited number of studies have focused on translating and culturally adapting health literacy tools that were suitable for the Arabic language or context. Hence, it is important that researchers and clinicians are inspired and supported to develop these tools and make them available for use in clinical practice.

Patient Assessment, Counseling, and Sources of Information

Patient counseling is an important service provided by pharmacists whether they may be in a community or institutional setting. In Arab countries, patient counseling is provided by pharmacists at varying levels in different countries and in various settings. In a study from Saudi Arabia exploring the counseling of community pharmacists to simulated patients (SPs), the types of questions asked, counseling rate, and information provided were assessed (Alaqeel and Abanmy 2015). Pharmacists asked the SP questions during 10.0% of the visits, provided information during 4.6% of the visits, and both asked questions and provided counseling during (2.6%) of the visits. Upon the prompt of the SPs, the pharmacists asked questions during 71 visits (47.3%), provided counseling during 150 visits (100%), and both asked questions and provided counseling, during 65 (43.3%) of the visits. Most pharmacists did not ask about history of drug allergy or any use of other medications. The most common type of information (97.3%) provided during the visits was information on dose. Reported barriers to counseling included being too busy (59.6%) and not having the patient medical history (61.9%) (Alaqeel and Abanmy 2015).

A study sought to determine the prevalence of prescription medication sales and explore how pharmacists assessed and counseled patients with acute cardiac conditions: acute coronary syndrome (ACS) and acute heart failure (AHF) showed that patient assessment and counseling on disease state by pharmacists needed to be improved. Of 600 pharmacists, 63.2% sold several prescription medications without prescription, about a quarter did not ask any questions; 52% asked one or two questions; and 24% asked three or more questions (Kashour et al. 2016).

In a study of services provided in community pharmacies in the UAE (Hasan et al. 2012), the provision of print information and oral counseling were not largely provided. Less than one third of the pharmacists always provided printed medication information or regularly provided counseling to patients, and only 11% regularly provided counseling in a private area in the pharmacy.

Another study was set to determine the effectiveness of a home medication management program in Jordan that included pharmacist counseling to identify, prevent, and resolve treatment-related problems. Participants were distributed into either control or intervention groups. Participants in the intervention group were visited at home by the pharmacist who gave information about medication adherence, and educated the participants on frequency of monitoring of their condition and on pharmacological and non-pharmacological therapies (Basheti et al. 2016). At 3 month follow-up in the intervention group, the number of treatment-related problems decreased, and their adherence to medications and self-care behaviors improved.

In a study from Palestine assessing patients’ self-medication practices and possible role of community pharmacists (Al-Ramahi 2013), 19.3% of respondents said that they always asked for a pharmacist’s advice when requesting a product for self-care, while 29.3% said that they asked the pharmacist most of the time. The primary reason for visiting a pharmacy was to obtain prescription medicines as reported by 57.1% of participants, 19.3% to purchase OTC medicines, while 23.6% to purchase other items. About 23% strongly agreed and 61.5% agreed that the community pharmacist played an important role in providing advice to patients.

The laws governing practice in many Arab countries do not give clear guidelines on what the expectations of community pharmacists are on information giving, and what pharmacists could or could not provide. These guidelines are timely and urgently needed in a practice that is rapidly changing and demanding pharmacists’ involvement and skill development to meet the pressing needs of the community.

The use of the World Wide Web to access information about medication use, drug interactions, and adverse drug reactions is increasing in Arab countries (Abanmy et al. 2012), many people are consulting Arabic drug information websites. However, in a study from Saudi Arabia, 54% of respondents did not depend on information available on Arabic websites when making decisions on drug use. Although the information was available and easily understood, the quality and credibility of the information were questionable. The need for dependable Arabic drug information websites was considered important to meet population needs for information especially that inadequate English language skills were considered barriers to accessing dependable foreign websites (Abanmy et al. 2012).

Adherence to Medications

Adherence is defined by the World Health Organization (WHO) as “the extent to which a person’s behavior – taking a medication, following a diet, and/or executing lifestyle changes – corresponds with agreed recommendations from a health care provider” (WHO 2003). In developed countries, medication adherence rates for chronic disease were reported at 50% by the WHO, and were expected to be lower in developing countries with less access to health care. (WHO 2003) Overall, the estimated rates of nonadherence to medications in Arab countries range from 1.4% to 88% in the different studies (Al-Qasem et al. 2011). Within specific disease states, patient-reported nonadherence rates ranged between 23% and 49.5% for hypertension, 1.4% and 27.1% for diabetes, and 24–88% for depression.

Reasons reported by patients for nonadherence included forgetfulness, medication side-effects, wanting a “drug holiday” (Youssef and Moubarak 2002), concerns about drug dependency, feeling well, medication not helping to improve feeling (Al-Saffar et al. 2005), infrequent follow-up visits, lack of health education, shortage of drugs, ignorance of the chronicity of the disease, patient not knowing to continue treatment (Al-Jahdali et al. 2007), disbelief about the value and need for adherence, social stigma (Jeragh-Alhaddad et al. 2015), complicated treatment regimen, patient unable to see usual doctor (Al-Saffar et al. 2005), patient feeling better with treatment, cost of medications, and finally, patient-reported laziness (Al-Jahdali et al. 2007). A very important reason reported for nonadherence was related to patients’ concerns, beliefs, and attitudes. In Arab countries, beliefs of patients about medications play a significant role in determining their adherence to taking the medications. Negative beliefs among Arab patients such as “The medication is harmful,” or “Medications are overused by healthcare professionals,” and that “patients are vulnerable to these adverse effects” were noted (Al-Qasem et al. 2011). Patients with reservations about the efficacy of the medications, and those who were concerned about negative side effects of the medications, were less likely to be adherent (Ajlouni et al. 2008).

Research has emphasized the importance of measuring adherence among patients and exploring patients’ attitudes and beliefs about disease and its treatment. This will help to better understand patient nonadherence (Alhalaiqa et al. 2013), and hence aid in devising mechanisms to enhance adherence. Scales developed in the Arabic language to measure patient adherence to medications are much needed; these may be newly designed or adapted for Arabic culture and language from existing tools currently in use in other languages in research or clinical practice.

Medication Misuse

The term abuse is used to describe the use of drugs for non-medical purposes while misuse is used to describe the use of a drug for medical purposes, but in an inappropriate manner including wrong indication, dose, duration, or adherence (Sweileh et al. 2004; Sabry et al. 2014).

Self-medication in Arab countries for a wide variety of conditions is on the rise. It is not only common in adult individuals but also in children and pregnant women (Khalifeh et al. 2017). With increased self-medication comes increased misuse of medications. The reported prevalence of self-medication misuse in Arab countries is high, making it a health challenge in these countries (Khalifeh et al. 2017). Medicines implicated in self-medication misuse belong to different pharmacologic groups such as codeine-based products, tramadol, topical ocular anesthetics, topical corticosteroids, antibiotics, and antimalarials (Khalifeh et al. 2017). In a study from Palestine, antitussives, antihistamines, laxatives, analgesics, decongestants, and sedatives were the most to be misused in the community (Sweileh et al. 2004). It was estimated that (52.6%) antitussive users were misusing them. The most misused antitussives were: (codeine phosphate/pseudoephedrine/triprolidine) and/or (ephedrine/ammonium chloride/codeine phosphate/pheniramine maleate). Another class of drugs believed to be misused was antihistamines including chlorpheniramine, loratadine, cyproheptadine, or dimethindene. Laxative misuse mostly among females attempting to control their weight were most widely misused including those containing bisacodyl, senna, or both. Combination products of analgesics and decongestants or antihistamines in cold and flu preparations were also considered drugs of misuse. Simple analgesics including nonsteroidal anti-inflammatory drugs, paracetamol and paracetamol-containing products were also implicated (Sweileh et al. 2004).

Corticosteroids including clobetasole and betamethasone were commonly misused at the dermatological center in Arab countries for lightening the skin or mild acne. Unfortunately, the medical staff including pharmacists were sometimes responsible for recommending the inappropriate use of medicines (Al-Dhalimi and Aljawahiry 2006).

Inappropriateness of antibiotic use is defined as inappropriate use of antibiotics to treat responsive infections, including use of too broad-spectrum agents, incorrect drug dose or duration, and poor adherence (Sabry et al. 2014). Overuse of antibiotics is common in Arab countries; self-medication rates range from 32% to 42% as reported in Lebanon (Cheaito et al. 2014) and from 32% to 62%% in Jordan (Darwish et al. 2014). Antibiotics as self-medication were mainly used for treatment of respiratory tract symptoms such as sore throat, cough, and flu and other reasons including urinary tract infections or gastrointestinal symptoms. Patterns of antibiotic misuse were largely related to not completing the full course of treatment which ranged from 29% to 86% (Mohanna 2010; Ghaieth et al. 2015; Jose et al. 2013). Reasons for self-medicating with antibiotics included: the antibiotics were found effective on previous use, the medicines were available at home as leftovers from previous use, and as a recommendation from family and/or friends (Hasan et al. 2016).

Pharmacists are in an optimum position to optimize medication use by preventing indiscriminate access and availability of these medications to the public, and by counseling patients on their appropriate use. Adequate enforcement of the laws prohibiting non-prescription sale of prescription medications without prescription is due. This is especially crucial for antibiotics to prevent antimicrobial resistance.

Drug Abuse

Drug abuse is increasingly becoming a problem in many Arab countries despite strong condemnations that may be religious, cultural, or legal. This increase could be recognized due to various factors including the geographic position of countries in the region, putting them on the route between the countries that produce illegal substances and the world market at large (AlMarri and Oei 2009). Commonly used agents were psychotropic drugs, e.g., barbiturates (Phenobarbital), benzodiazepines (diazepam, nordiazepam, chlordiazepoxide), carbamazepine, and phenytoin (AL-Abdallat et al. 2016).

In a study from the UAE (Alblooshi et al. 2016), the majority of the group studied were poly-substance users (84.4%) with various combinations of agents being used at different age levels. The majority of the poly-substance users took three or more substances (89%) consisting of recreational, illicit and prescribed substances. These combinations of substances had either similar or differing effects on the central nervous system (CNS), which could cause major effects on health including increasing the risk of overdosing and/or fatality. The most commonly used substances were opioids and alcohol. Tramadol use constituted 67.2% of opioid users and its use was highest among the youngest age group (<30 years old). Other prescribed misused medications included pregabalin, procyclidin, and carisoprodol whose use was again highest among the youngest age group; the mean age of first use was 20 years (Alblooshi et al. 2016). The three drugs were consumed either alone or in combination with each other with Pregabalin taking the largest share of consumption of over 68% (27% as single use and 41% in mixture). Procylidin is the second most common while the least common was the Carisoprodol (31%). The use of prescription drugs for recreational use points to the appearance of a new form of misuse with a change from usual illicit substances toward legally prescribed drugs. The competition to experiment with new substances among the young with the perception that these were less dangerous than illicit substances resulted in this shift. Additionally, combinations of these substances were used to enhance and maintain the effect of the drugs for a longer time as perceived by the users. Unfortunately, the use of these medications as mixtures is a major health concern due to the potential risk of toxicity that can lead to overdose and death. Poly-substance use disorder is clinically challenging to diagnose, because the criteria for diagnosis are not well-established. Poly-substance users have been shown to be at higher risk of psychological comorbidities, and impaired cognitive functioning that unpredictably affect treatment outcomes (Connor et al. 2014).

Development of effective public awareness strategies about drug use and misuse is required such as using mass media to promote awareness of prevention programs and highlighting the risks of both illicit and pharmaceutical substance abuse. Additionally, challenges to control pharmaceuticals’ availability as recreational drugs need to be addressed at the national levels in Arab countries.

Self-Medication

Self-medication is common practice in the medical field in which medicines are considered safe and effective when used by consumers for a particular purpose without prescription. Consumers usually use these products to manage common ailments, at their own risk. The dosage and indication of these products play an essential role in their classification as prescription or non-prescription medications. Ibuprofen, for instance, is a prescription medication at high doses when used for the treatment of different types of arthritis but considered a non-prescription medication when used in the treatment of minor pain and headaches (WHO 2000). Self-medication provides many benefits to consumers such as effectiveness, reliability, availability, educational opportunities (heartburn, smoking cessation, etc.), economic value and an acceptable risk if used frequently, and convenience (WHO 2000).

Despite the safety profile of medications used in self-medication, there are risks associated with using medications without consulting a medical professional, which may include serious medical consequences. For products sold online, there is concern about the safety of the medications since no clear policies are in place to monitor the quality of medications sold through the internet; additionally, internet sites tend to advertise prescription medications as non-prescription. In most cases, self-medication occurs in the absence of medical supervision and when compared to the use of prescription medications, their use is unexplored in relation to: interactions with other medications, alcohol or food, and their safety in certain populations such as pregnant, lactating, pediatric, or geriatric groups has not been established (McLaughlin et al. 1998). Uncontrolled use of medications leads to serious medical consequences and waste of public income and resources with no guaranteed proper health outcomes. Antibiotics, for instance, may increase the risk of bacterial resistance and serious medical consequences like pseudomembranous colitis (Abasaeed et al. 2009). Chronic use of analgesics in high doses may have a negative effect on the kidney and liver and could lead to tolerance (Barakat-Haddad and Siddiqua 2015). The use of antihistamines could lead to serious hazards if used before running heavy machinery or driving vehicles. In general, adopting self-medication practice does not guarantee the safety and efficacy of the products and should only be used when necessary according to product recommendation.

The incidence of self-medication in Arab countries is high. In a community-based study on the prevalence of self-medication involving 1100 adults in Egypt, it was found that the majority self-medicated (86.4%), mainly utilizing both medications and Complementary and Alternative Medicine (CAM) therapies. Of the medications used, analgesics were the most common (96.7%), followed by cough and cold preparations (81.9%); however, a further 53.9% also claimed to self-medicate with antibiotics (El-Nimr et al. 2015).

Likewise, in Saudi Arabia, the rate of self-medication is alarmingly high. A community pharmacy-based study involving 538 customers in Riyadh (Aljadhey et al. 2015) reported that 285 medications were bought without a prescription despite that about 49% of the medications were classified as prescription medications. The most frequently purchased prescription medications were antibiotics (22%) and analgesics/antipyretics (19%). The main reasons given for purchasing medications without a prescription were that the ailment was too insignificant to warrant a doctor’s visit (54%), time saving (40%), and the participant regarding the ailment as minor (40%). Worryingly, over 68% of participants were unaware the medications purchased were prescription-only (Aljadhey et al. 2015). Another cross-sectional study from Saudi Arabia on self-medicating with antibiotics revealed that 34% of participants used antibiotics without prescription, despite that 81% of participants were aware that this was potentially harmful. The most frequently used antibiotic was amoxicillin/clavulanic acid (41.5%), followed by amoxicillin as a plain ingredient (39.9%). The main reason given for self-medicating with antibiotics was “previously having been prescribed the antibiotic by a physician” (36.6%) (Alghadeer et al. 2018).

In Jordan, the general prevalence of self-medication among university students is high at 97.8%, mainly to treat headaches (90.1%), dysmenorrhea (84.7%), and constipation (60.3%). Appropriately, pharmacists supplied 80.1% of the students with information regarding doses, duration of treatments, and side effects (Al-Hussaini et al. 2014). The high prevalence of self-medication is particularly worrisome among school-aged children in Jordan. In another study from Jordan, the rate of self-medication was reported to be approximately 40% and treatment was generally used for sore throat, common cold, and dental infections. The most frequently used antibiotic was amoxicillin, but only 37.6% of patients were following the correct dosing guidelines. The main reason given for self-medication was claiming to have had a similar infection in the past (Sawair et al. 2009).

The most commonly used antibiotics for self-medication were amoxicillin or ampicillin among various Arab countries including Libya, Tunisia, Egypt (Scicluna et al. 2009), the UAE (Abasaeed et al. 2009), Saudi Arabia (Alghadeer et al. 2018), Lebanon (Cheaito et al. 2014), and Jordan (Sawair et al. 2009). In Saudi Arabia, fluoroquinolones were the most commonly sold antibiotics as self-medication for urinary tract infections (Al-Ghamdi 2001); Metronidazole and TMP/SMX were commonly used in Yemen (Mohanna 2010).

Research findings confirmed that POMs, such as antibiotics, antihypertensives, and antipsychotics, were dispensed without a prescription in Arab countries (Al-Mohamadi et al. 2013; Bin Abdulhak et al. 2011). Common reasons pharmacists dispensed POMs without a prescription were that pharmacists did not know the status of the medications (i.e., POM or OTC), patients requested the specific medication, and that some patients could only pay for a pharmacy visit. The attitude of “if we did not sell it, somebody else will” also prevailed.

It was evident that patient education and awareness campaigns were needed to enhance patients’ knowledge and possibly behavior concerning the use of medications for self-treatment. Emphasis should be on the hazards of self-medication that could be encountered when the patient takes responsibility for their health decisions without consulting a health professional, and on following the recommendations accompanying these medications to ensure their appropriate use. Strict enforcement of the regulations on dispensing POM medications by pharmacists only at the receipt of a prescription should be imposed in Arab countries.

Use of Traditional and Complimentary Therapies in Arab Countries

Complementary and alternative medicine (CAM) is defined as any medical intervention other than conventional medicines (Falkenberg et al. 2012). The CAM approach supports the idea of helping the body to heal itself with minimum help using natural resources (Falkenberg et al. 2012). CAM uses the mind, body, and spirit as a base in implementing holistic medicine such as aromatherapy and reflexology.

The incidence of CAM use in Arab countries varies according to country. A study from the UAE involving 135 participants showed that people from different cultural backgrounds had different experiences using CAM. Participants from the Far East were more likely to use CAM (85.7%) than those from Pakistan (38.5%) or India (23%). Homeopathy was the most common form of CAM used. In general, the overall satisfaction with CAM was 71.8%; however, only 10% would recommend it to others. Another study from the UAE showed that the most common form of CAM used in the UAE was herbal medicine. Of the surveyed participants, 52.9% preferred to use CAM rather than conventional medications to prevent illness (Sridhar et al. 2017). A positive previous experience and a lower incidence of adverse reactions were reported from the UAE as main reasons for using CAM (Mathew et al. 2013).

Herbal therapies were also the main form of CAM used in Lebanon, accounting for 75% of all CAM use according to a national survey. As many as 40% of respondents claimed to use CAM as an alternative to conventional medications, but only 28% informed their physicians of their use. The use of CAM was largely associated with chronic illness, lack of access to adequate health care, and higher income households (Naja et al. 2015).

In Palestine, the use of CAM is often advocated by community pharmacists to their clients. This was reported in a cross-sectional study from Palestine of patients being treated at outpatient diabetes clinics. The study showed that more than half (51.9%) of patients reported using herbal treatments in an attempt to control their diabetes. The herbs were used primarily as decoctions and included: Trigonella berythea, Olea europaea, Teucrium capitatum, and Cinnamomum zeylanicum. The majority of CAM users were over 40, female and lived in refugee camps. The main reason cited for using CAM was based on a recommendation from a friend or relative. The majority of CAM users (71.7%) were happy with its use (Ali-Shtayeh et al. 2012).

In Bahrain, the use of CAM was a popular choice for diabetic patients, with 63% of respondents using CAM in the past 12 months. Patients who were female, those who had diabetes for a long time, or had complications associated with diabetes were more likely to use CAM. About 64% of the CAM users reportedly used CAM to control their diabetes (Khalaf and Whitford 2010).

In a study from Saudi Arabia, it was reported that 68% of participants had used CAM in the previous year. One of the most widespread types of CAM was of a spiritual type, with 50.3% of participants using methods such as reading Quran and praying. This was followed by the use of honey (40.1%), black seed (39.2%), and myrrh (35.4%). A less commonly practiced form of CAM was cupping, which was reportedly used by 45% of respondents (Al-Faris et al. 2008).

The use of CAM among pregnant women seemed to be quite common in Arab countries. In Iraq, out of 335 women who took part in a cross-sectional study, 56.7% claimed to have used at least one type of CAM during pregnancy. Herbal medicine was most frequently reported (53.7%) followed by multivitamins (36.3%). Interestingly, only 0.5% of participants informed their physicians that they used CAM during pregnancy (Hwang et al. 2016). The anti-hemorrhoidal product “NeoHealar” a Jordanian product which included oil extracts from lupin, Vateria indica, peppermint (Mentha piperita), and Aloe vera was a commonly used product in pregnancy (Abramowitz et al. 2010). Sumac (R. coriaria), an abundant Mediterranean herb available in Syria, Palestine, Jordan, and Lebanon, was proven to have some astringent effect in the anal area and for the treatment of hemorrhoids (Kossah et al. 2010).

Other commonly treated conditions with CAM therapy in Arab countries include headache and pediculosis capitis infestations. In addition to the use of traditional analgesics, people in Arab countries tended to utilize folk medicines for the treatment of different types of headache: aniseed tea, ginger tea, black tea, green tea, topical “Abu fas,” chamomile tea (babunaj) for tension headaches, and thyme (all forms; fresh, dry, or tea) and coriander seed for sinus and migraine headaches (Sawalha et al. 2008). In Arab countries, many traditional remedies are used to cure head lice. Some of these herbal medicines include Hemp (Cannabis sativa) (Lozano 1997). Honey, anise, and tea tree oil in combination with lemon oil are also used in Arab folk medicine as repellants for pediculosis capitis. Other products used to repel lice include apple cider vinegar, olive oil, mayonnaise suffocation, garlic, and egg yolk with lemon juice therapies.

The use of CAM therapy in Arab countries is mostly anecdotal. However, people’s beliefs that the therapies were safe and might be effective seemed to justify the widespread use of these alternative treatments in Arab countries. Though the use of many products might be seen as advantageous, their common use could be a cause for concern as the potential risks associated with their use have not been adequately explored, especially in certain group such as pregnant women and pediatric populations.

Areas of Public Health Concern

Four areas of major public health and healthcare concerns that involve the use of medicines and may be unique in their own ways in the Arab countries include birth control and use of contraceptives, immunizations, smoking cessation, and weight management. Hence, the rest of the Chapter will discuss these healthcare needs and drug use in their management.

Use of Contraceptives in Arab Countries

Islam, the major religion in the region, allows and encourages family planning. Family planning is important for improving women’s health, supporting a country’s efforts to reduce poverty, and to help in achieving development goals. The use of effective contraceptive methods is important in the Arab countries, as clinical termination for unwanted pregnancies is not acceptable culturally and religiously.

It is estimated that, yearly, more than 45 million induced abortions are carried out worldwide in unsafe conditions, and as a result, there is a high risk of maternal morbidity and mortality. Somalia, Sudan, and Yemen have the lowest use of contraceptive methods and the highest percentage of maternal deaths (77%). In Somalia specifically, women usually give birth to more than six children on average and only a low percentage use modern contraception. Out of every 16 women, one is at a risk of dying due to complications of pregnancy or childbirth. In addition, complications during pregnancy and delivery result in many disorders and injuries such as damage to the reproductive organs (UNFPA 2012). Improving education about the use of contraceptive methods is essential to minimize the risks and create more efficient family planning.

Contraception Methods in Arab Countries

Today, 4 out of 10 married women living in Arab countries at reproductive age use modern contraception (UNFPA 2012), highlighting the need for family planning services. Contraceptive use is higher in couples who live in urban cities and belong to traditional backgrounds (i.e., non-Bedouin). These couples are usually more educated and the wife is employed (Elgharabway et al. 2015). In Arab countries, about a quarter of all pregnancies are unintended. Emergency contraceptives are used as a preventative measure in the case of unprotected sexual activity to avoid unplanned pregnancy (Foster et al. 2005).

In May 2003, Ibis Reproductive Health and the Office of Population Research (OPR) at Princeton University co-developed the first Arabic web site that accommodates the needs and inquiries of Arab women about reproductive health. This Arabic-language web site was adapted from Not-2-Late.com, its English counterpart, which was operated by both the OPR and the Association of Reproductive Health Professionals (ARHP) (Foster et al. 2005).

In all Arab countries except Egypt, oral contraceptives are the usual form of modern contraceptive methods used. The older age group in Egypt usually depends on intrauterine devices (IUD), while in Syria, Jordan, Palestine, and Iraq only slightly more than 2% of women depend on the IUD. Algeria and Morocco have a very high percentage use of pills compared to the other modern methods (Howse 2014). In Kuwait, the use of oral contraceptives remains the leading contraception method. However, there was a decline in their use from 79% in 1984 to 45% in 1999. This decline was attributed to concerns about possible side effects such as headaches, dizziness, water retention, and weakness. On the other hand, there was an increase in the use of IUDs from 13% to 17% (Shah et al. 2001).

Contraceptive injections are not popular in Arab countries, with only about 1% use in Jordan and Djibouti. Djibouti is the only country where more than 2% of young couples depend on the male condom. Permanent methods of contraception are not used among young or old age groups (Howse 2014). The use of traditional methods of contraception, such as lactation amenorrhea, is high and exceeds the levels of modern methods used in Syria, Iraq, and Palestine (Howse 2014).

Over-the-Counter Access to Oral Contraceptives in Arab Countries

The following oral contraception (OC) patterns were noted (Grindlay et al. 2013):
  • OC was obtainable without prescription in Algeria, Bahrain, Lebanon, Morocco, Palestine, United Arab Emirates, and Yemen.

  • OC was legally obtainable without prescription (and no screening was required) in Djibouti, Egypt, Kuwait, Sudan, and Syria.

  • OC was legally obtainable without prescription (however, screening was required) in Tunisia.

  • OC was only sold on prescription in Jordan and Saudi Arabia.

Tolerability of Oral Contraceptives

A combination of synthetic estrogen and progestin in oral contraceptives is regarded as one of the most convenient and reliable methods of preventing pregnancy. The concentration of both estrogen and progestin has been reduced over the years to minimize side effects and cardiovascular complications giving oral contraceptives a high level of user tolerability and satisfaction. To measure tolerability and satisfaction with OC among women in Arab countries, a study was conducted in several countries including Syria, Lebanon, and Jordan to ascertain the pattern of bleeding, tolerance, and patient satisfaction with OC consisting of 3 mg of drospirenone and 30 mcg of ethinyl estradiol in a real-life setting. The study concluded that the product had positive results in regard to patterns of bleeding, signs of fluid retention, and patient satisfaction (Endrikat et al. 2009).

Availability of Contraceptives

Contraceptive use among Arabs is more widely accepted nowadays because of the relaxation of laws restricting women’s rights, the increase in girls’ education and social changes (modernization and urbanization). Governments in the Arab countries do not limit the access of married couples to family planning information or services, and every country has a national family planning program. According to a report issued by the United Nations in 2015, the unmet need for family planning in Arab countries ranged from 12% in Jordan to 28.3% in Oman (UN 2015). In many Arab countries, modern methods of contraception are readily available through government and private health services, or commercial pharmacies (Shah et al. 2001).

Immunization in Arab Countries

Immunization is the process of imparting immunity to a person against an infectious disease. Immunity can be acquired naturally (when a person develops an infection or when a newborn or a fetus receives antibodies from its mother), or artificially (through vaccination or the administration of preformed antibodies) (Levinson 2017). Vaccination is the most effective and cost-efficient method for preventing infectious diseases. The active ingredient in a vaccine can be an inactivated bacterium or virus; live, attenuated bacterium or virus; or a component of the bacterium or virus. It stimulates the body’s cell- and antibody-mediated immunities, providing long-lasting protection against the infectious agent (Levinson 2017). The World Health Organization recommends that the following vaccines be part of all immunization programs: Bacillus Calmette-Guérin (BCG) vaccine, hepatitis B vaccine, polio vaccine, diphtheria, tetanus, and pertussis (DTP)-containing vaccine, Haemophilus influenzae type b (Hib) vaccine, pneumococcal vaccine, rotavirus vaccine, measles vaccine, rubella vaccine, and human papillomavirus (HPV) vaccine. Country-specific WHO recommendations relevant to some Arab countries include vaccination for the following diseases: yellow fever, typhoid fever, mumps, hepatitis A, and meningococcal disease (WHO 2017c). The immunization schedules of all Arab countries are based on WHO recommendations. Table 4 highlights key points pertaining to the vaccination programs in Arab countries (WHO 2017d).
Table 4

Key highlights of vaccination programs in Arab countries

Country

Key highlight

Egypt, Lebanon, Kuwait, Oman, Somalia, Syria, Algeria, and Tunisia

Rotavirus vaccination not included in program schedules

Egypt, Jordan, Somalia, Syria, and Tunisia

Do not offer pneumococcal vaccination

Libya and Bahrain

Only countries to offer HPV vaccination

Morocco, Somalia, Sudan, Djibouti, Tunisia, and Yemen

Do not offer mumps vaccination

Djibouti, Iraq, Jordan, Morocco, Oman, Somalia, Tunisia, and Yemen

Do not offer meningococcal vaccination

Bahrain, Qatar, Saudi Arabia, and UAE

Provide hepatitis A vaccination routinely to all children, while UAE provides it to high risk individuals and travelers

All Gulf countries

Provide varicella vaccination to children. In Kuwait, varicella vaccine is only given to healthcare workers who are at risk

All countries

Offer influenza vaccination to at-risk groups (such as children, the elderly, healthcare workers, and travelers)

The WHO and United Nations Children’s Fund (UNICEF) estimates indicate that most Arab countries have maintained consistently high immunization coverage levels (90–100% for the vaccines offered in each country) in the past 10 years (WHO-UNICEF 2016). Political unrest and lack of resources have caused some countries to have suboptimal coverage levels.

Syria has maintained immunization coverage levels around 80–90% throughout the years 2000–2010 (WHO-UNICEF 2016). The Syrian Civil War, which started in 2011, has led to a serious decline in access to vaccines for children in contested areas of the country (500,000–700,000 children did not receive vaccinations as of 2013) (WHO 2013a). Immunization coverage fell below 60% for all vaccines. The most serious consequence of this has been a poliomyelitis outbreak in 2013 that led to the paralysis of 17 children. The WHO and UNICEF responded by organizing a polio eradication campaign to vaccinate all children under the age of 5 years, whether they still lived at home or were displaced within the country or to the neighboring countries (WHO 2013a). The reported coverage of the initiative was 77–102%, depending on the areas reached, and it halted the transmission of the disease. However, the virus reemerged in 2017, with 33 reported cases.

Immunization coverage in Iraq has been inadequate since 2003. The vaccination efforts in the country have been challenged by the lack of security, lack of funding, power shortages, and ineffective communication between the Ministry of Health and the other directorates. Iraq has seen polio, measles, and mumps outbreaks in the recent years. The Iraqi government has been working in coordination with the WHO and UNICEF to achieve high immunization coverage, with emphasis on refugees and internally displaced people (WHO 2016).

Somalia is classified by the United Nations as a “least-developed country.” It has suffered two famines in the past 6 years, and it has been in a civil war since 1991. Immunization coverage in Somalia is one of the lowest in the world – never rising above 60%. There have been cholera, measles, and polio outbreaks in recent years, and their effects were made worse by the prevalence of malnutrition among children (UN 2017). The WHO, UNICEF, and their partners have organized several vaccination campaigns against these diseases. The 2015 measles vaccination campaign aimed to reach four million Somali children under 10 years of age through a network of fixed, temporary, and mobile posts. The 2013 polio outbreak was the first in Somalia in 6 years. An emergency vaccination campaign was conducted and volunteers were recruited to help administer the vaccines.

Sudan had low immunization coverage in the past years, and around one third of children did not have access to several essential vaccines. The Sudanese Ministry of Health, in association with the WHO, UNICEF, and Gavi, implemented a plan to provide vaccinations to hard-to-reach groups such as nomads and people in conflict areas. Interventions included choosing a focal person in each nomadic tribe and tracking them and training volunteer vaccinators in the tribes. The government also worked with nongovernmental organizations and cooperated with armed groups to reach people in conflict zones. The plan resulted in more than 90% of Sudanese children being vaccinated against diphtheria, tetanus, pertussis, and polio (WHO 2013b). Meningitis A vaccination has been added to the routine immunization schedule in Sudan, and plans are underway to conduct a measles immunization campaign (WHO 2013b).

Smoking Cessation in Arab Countries

Globally, smoking is the main preventable cause of death. Smoking cessation has immediate and long-term health benefits, including reduction in blood pressure, heart rate, and carbon monoxide levels. It also improves circulatory and lung functions and decreases the risk of coronary heart disease, stroke, and cancer. Several methods are available for smoking cessation. They include unassisted quitting, behavioral therapy, and the use of medications. Pharmacotherapy in smoking cessation aims to reduce nicotine withdrawal symptoms, facilitating abstinence (Rigotti 2017).

The escalating tobacco epidemic in many Arab countries draws a worrisome picture. It is estimated that about half of the male population smokes cigarettes, and most of those are heavy smokers (i.e., average 20 cigarettes/day). In contrast, women smoking rates are lower than those of men in the Arabic region, but under-reporting is a key factor that should be considered as smoking by women is still socially unacceptable. Data from Tobacco Atlas revealed that most Arab countries have a 10 to 1 male:female ratio in cigarette smoking (GTSS 2005). However, and as described by Maziak et al., the relative insusceptibility of Arab women to cigarette smoking is challenged by the more culturally acceptable waterpipe tobacco smoking. Waterpipe smoking has recently risen in popularity as a tobacco use method particularly among the youth (Maziak et al. 2014).

In the Arab region, the scarcity of smoking cessation services is a major challenge, and where such services are available they typically mirror western treatment programs without careful adaptation to local healthcare delivery and cultural contexts (Fiore et al. 2008). Within this context, results of a randomized clinical trial in Syria that compared behavioral counseling vs counseling plus NRT showed no advantage for NRT over counseling alone. This suggested that NRT might not be useful if implemented in other cultures and healthcare settings than western cultures where it was first proved useful (Ward et al. 2013). Within this context also, a recent study demonstrated that when a smoking cessation intervention was culturally tailored it led to positive effects; this was the case in a one group pre/post study that was conducted in Florida, USA. which assessed the effectiveness of Sehatack – a culturally tailored smoking cessation intervention for Arab American men (Haddad et al. 2017).

Till now, the alarming tobacco epidemic in Arab communities provokes suboptimal response at the public health and policy levels. However, the adoption of the Framework Convention on Tobacco Control (FCTC) and the implementation of various serious tobacco control measures in most Arab countries turned around the grim perspective of the tobacco control situation (Maziak et al. 2014). The success of some of these initiatives to limit tobacco use in this region relied on multi-sector partnership, governmental and civil society involvement, and the engagement and leadership of academia (Maziak et al. 2014). For example, in Palestine, the ministry of health partnered with the legislative council, academia, and various health-related nongovernmental organizations (NGOs) to sponsor a comprehensive tobacco control program in 2005. Similarly, in Lebanon, the American University of Beirut’s Tobacco Control Research Group worked closely with civil society groups (IndyAct and Tobacco Free Initiative) to advocate for the adoption of a comprehensive tobacco control law. Their campaign targeted three main groups: policy makers, the media, and NGOs. This collective multi-sectorial effort concluded with the passage of a comprehensive and strong tobacco control law (law 174) (Maziak et al. 2014).

Nicotine replacement therapy (NRT) provides the smoker with nicotine instead of tobacco, and the dose of nicotine is gradually reduced as symptoms subside until complete abstinence is achieved. NRTs are almost twice as effective as placebo in achieving smoking cessation. They are available in many dosage forms such as transdermal patches, gums, lozenges, inhalers, and sprays. Patches are the easiest to use, they provide the most continuous nicotine delivery over a 24-h period, and have the highest adherence rate. The shorter-acting forms (like gums and lozenges) could be used in combination with the transdermal patches to further control craving and withdrawal symptoms, as it takes several hours for the patch to produce the peak nicotine blood level (Rigotti 2017).

The various dosage forms of NRT can be purchased in community pharmacies in most Arab countries without a prescription. Prescriptions for the sale of NRTs are required in Qatar, Morocco, and Tunisia. NRTs are not legally sold in Syria, Sudan, Mauritania, Comoros, and Somalia. Arab countries are equally divided in terms of insurance coverage of the cost of NRTs. NRTs are fully covered by the national insurance schemes in Tunisia, Bahrain, Kuwait, Qatar, and Saudi Arabia, and partially covered in Jordan, Iraq, and the United Arab Emirates. They are not covered by national insurance in the nine remaining Arab countries. NRTs are on the essential medicines list of Algeria, Iraq, Bahrain, Qatar, Kuwait, and Saudi Arabia (WHO 2017a).

Bupropion is an antidepressant that is effective for smoking cessation. It is thought to act by increasing the release of norepinephrine and dopamine in the central nervous system. It is recommended to be started one week before the planned quit day, and to be continued for at least 11 weeks after quitting (12-week course at least). Bupropion has been associated with an increased risk of depression and suicidal or self-harming behavior, but a randomized controlled trial compared this risk in bupropion to placebo and found no significant difference. This led the Food and Drug Administration to withdraw the black-box warning about the serious neuropsychiatric side effects of bupropion (Rigotti 2017). Bupropion is legally sold in nine Arab countries: Libya, Morocco, the West Bank and Gaza, Lebanon, Iraq, Qatar, Bahrain, Saudi Arabia, and the UAE. A prescription is required to purchase it in most of these countries. Bupropion is partially covered by the national insurance in Iraq and the UAE and fully covered in Qatar and Saudi Arabia (WHO 2017a).

Varenicline is a partial agonist of the nicotinic acetylcholine receptor, to which it binds weakly and reduces withdrawal symptoms. It also prevents the nicotine in tobacco smoke from biding to the receptor, decreasing the rewarding effect of smoking. Varenicline is effective in smoking cessation. The use of varenicline is associated with two safety issues: neuropsychiatric side effects and increased risk of cardiovascular events in patients with known cardiovascular disease. Varenicline is available in 11 Arab countries (Libya, Morocco, Lebanon, Jordan, the West Bank and Gaza, Syria, Bahrain, Kuwait, Qatar, Saudi Arabia, and the UAE). It is partially covered by national insurance in Jordan and the UAE and is fully covered in Saudi Arabia and Qatar (WHO 2017a).

Very little data exists on the extent and success of the use of pharmacotherapy in smoking cessation in Arab countries. The Global Adult Tobacco Survey (GATS) was conducted in two Arab countries only: Egypt and Qatar. In Egypt, 19.4% of adults smoked tobacco; of current smokers, 95% were daily smokers, and men smoked on average 19.4 cigarettes per day. On tobacco use pattern, cigarettes were the most popular type of product by men (31.7%), which was followed by shisha (6.2%), while among women smokers, 0.3% smoked shisha and 0.2% smoked cigarettes. Cessation data showed that among daily cigarette smokers, only 16.6% had quit smoking, whereas 42.8% stated they intended to quit. It was reported that only 2.0% of smokers used pharmacotherapy and 4.0% used cessation counseling (Emam et al. 2009; GATS 2013). The survey concluded that more effort should be placed on strengthening smoking cessation support services in Egypt. Although there were some cessation clinics available, they were not easily accessible or as effective as hoped for, as no nicotine replacement therapy was offered (Emam et al. 2009; GATS 2013).

In Qatar, 21.3% of men and 0.6% of women currently smoked tobacco. The prevalence of shisha smoking among Qatari men was 5.3% compared to 0.4% for Qatari women. Alarmingly, it was reported that above 10% of current shisha smokers started shisha smoking before the age of 18 (Emam et al. 2009; GATS 2013). About 67% of current tobacco smokers were interested in quitting; 41.3% of women and 37.7% of men tried to quit smoking on their own, whereas 71.9% of men and 61.6% of women received advice by a healthcare provider on quitting. Only 21.9% of men and 19.6% of women attempted to quit smoking using pharmacotherapy. Tobacco users who wanted to quit were not adequately supported to overcome their dependence. Healthcare system should increase and strengthen smoking cessation services and create structured programs using proper counseling alone or in combination with pharmacotherapy.

Smoking cessation services are uncommon in most Arab countries, which complicates cessation efforts. The WHO Tobacco Control Country Profiles indicated that smoking cessation services could be found in some hospitals and public health clinics in the UAE, Qatar, Syria, Saudi Arabia, and Morocco (WHO 2017a). Smoking cessation interventions in the UAE have had encouraging results, as quit rates increased with time as the service was delivered (Awad et al. 2010). A survey done in the UAE indicated that physicians held positive views regarding smoking cessation counseling, but required additional training to effectively deliver cessation support (Awad et al. 2010). Community pharmacists also were shown to have a role to play in smoking cessation in a randomized controlled trial in Qatar. Both trial groups (unstructured counseling and structured patient-specific counseling) had higher quit rates than usual care (El Hajj et al. 2017).

A high proportion of smokers in Arab countries reported trying to quit smoking or thinking about quitting. In a study in Jordan, 62.8% of the surveyed sample reported trying to quit in the previous year (Jaghbir et al. 2014). Similar numbers were reported in Qatar (66.8%) (GATS 2013), Egypt (41.1%), (Emam et al. 2009), and Syria (62%) (Maziak 2002). Despite this apparent high interest of smokers to quit, the proportion of former smokers (i.e., those who have successfully quit smoking) in Arab countries is low: 8.7% in Jordan (Jaghbir et al. 2014), 24.2% in Qatar (GATS 2013), and 12–15% in Syria (Maziak 2002) compared to the United States (55%).

The low smoking cessation rates and the increase in numbers of smokers in Arab countries could be attributed to the failure to respond to the tobacco epidemic at policy and public health levels. Nineteen of the 22 Arab countries have joined the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), which aimed to provide member states with a coordinated roadmap toward the implementation of tobacco control policies. These countries have adopted comprehensive national tobacco control laws, but the new legislation had not been implemented or enforced in many member Arab countries (Maziak et al. 2014). Policies mandated by the FTCT and adopted in member Arab countries included restricting smoking in public places, large and pictorial warnings on tobacco products, banning tobacco advertisement, and increasing the prices of tobacco products. Commitment to enforce these laws is poor in most Arab countries (Maziak et al. 2014), with only Qatar allocating funding for their enforcement (WHO 2017a), and only Jordan, the UAE, and Egypt requiring picture warnings on tobacco products. Unluckily, tobacco prices were the lowest in the Eastern Mediterranean Region (where most Arab countries are) compared to the other WHO regions (Emam et al. 2009; Maziak et al. 2014).

While the lack of data precludes generalizability of the findings to all Arab countries, the low utilization of medications in smoking cessation could be explained by the fact that most quitting attempts were done without consultation with a healthcare provider. This could be indicative of the poor awareness and healthcare seeking behavior in Arab societies and/or the lack of systematic smoking cessation interventions by healthcare providers in Arab countries. It must be taken into consideration, however, that smoking cessation interventions developed for Western societies and healthcare systems may not be as effective if implemented in the Arabic context. Research findings showed that interventions needed to be locally fitted to show effectiveness. Future research is necessary to develop smoking cessation interventions that are tailored to the Arabic communities, accounting for the variability in income between different Arab countries (Ward et al. 2013).

Weight Management in Arab Countries

The WHO defines obesity as an abnormal or excessive fat accumulation that presents a risk to health, or a BMI of 30 kg/m2 or more. Excess weight has been associated with an increased burden of noncommunicable diseases worldwide, which may include elevating the risk for hypertension, diabetes mellitus, cerebral and cardiovascular disease, disordered sleep breathing, and various cancers.

Obesity in Arab countries has increased at an alarming rate in the past three decades and is more pronounced in women compared to men. According to the WHO estimates in 2010, Kuwait had the highest prevalence of obesity in Arab countries with 30% of males and 55% of females over the age of 15 being classified as obese (Badran and Laher 2011).

Factors Contributing to Increased Obesity in Arab Countries

The Arab countries have experienced an enormous alteration in life style that started about four decades ago, which had a marked effect on the youth particularly. The high availability of calorie-dense food and sweetened beverages and lack of physical activity resulted in an increase in the rates of obesity. Easy access to private cars and the employment of housemaids may have also contributed to the rise in obesity (Al-Hazzaa et al. 2011; Naweed and Asem 2016). Food consumption is an integral part of social gatherings in the Arab culture, and traditional meals usually contain rice and meat, which are high in carbohydrates and fat. In addition, westernization in Arab countries led to an increase in the popularity of fast food. These unhealthy eating habits in many Arab countries contributed to the rise in obesity. Studies showed that in Lebanon, children were abandoning the Mediterranean-style diet (cereals, vegetables, and fruits) in favor of fast food (Naweed and Asem 2016).

Other factors have contributed to a change in eating habits in Arab countries. Growth in income in the Arabian Gulf countries due to rich oil deposits has led to rapid urbanization and improved living conditions (Badran and Laher 2011). For example, high-income families in Kuwait consume more meats and eggs as compared to low-income families. In Egypt, poor people have lower rates of obesity compared to richer people. Marital status could also contribute to obesity. In Jordan, the rate of obesity was higher in married compared to unmarried adults. Similar findings were reported in several Arabian Gulf countries (Badran and Laher 2011).

According to the STEPwise survey done by the WHO in 2003–2007, sedentary lifestyles were very common in Arab countries, ranging from 31.15% in Syria to 86.8% in Sudan (WHO 2007b).

A study conducted in 34 countries worldwide to assess physical activity and sedentary lifestyle in schoolchildren reported that in some Arab countries like Egypt, UAE, and Oman, schoolchildren had the lowest rates of physical activity and walking or riding a bicycle to school (Guthold et al. 2010). The low rates of physical activity could be attributed to very high temperatures in most Arab countries that force people to stay indoors and use cars to travel short distances. In addition, exercise is not a defining part of the culture within the Arab region (Badran and Laher 2011; Naweed and Asem 2016).

Obesity in Arab Women (Sociocultural Context)

Traditions in Arab countries restrict the lifestyle choices of women, resulting in women having an increased prevalence of obesity (Naweed and Asem 2016). Many women have limited access to exercise facilities. Moreover, almost all families in Saudi Arabia and Kuwait employ housemaids and cooks; hence, housewives have fewer chores to do. About half the women in Syria and Palestine lead a sedentary lifestyle. Multiple pregnancies contribute to obesity in Arab women. Around 30% of Syrian women with one child are obese, and the prevalence increases to 75% with seven children (Badran and Laher 2011). A study conducted on Emirati women classified barriers to weight control as: personal barriers (lack of motivation, high appetite), social/environmental barriers (housemaids, social gatherings, outdoor activity restrictions), and physical activity barriers (lack of exercise facilities, hot weather) (Ali et al. 2010).

To combat increasing obesity rates in the Arab countries, there is an urgent need to develop effective measures to prevention and control of this major public health problem. Hence, an Arab strategy was developed by the Arab Taskforce for Obesity and Physical Activity aiming to control and reduce the incidence of overweight and obesity by promoting healthy dietary habits and increased physical activity. It was postulated that governmental and nongovernmental organizations should be motivated to set policies and implement sets of programs that were targeted to encourage active living among all age groups (Musaiger et al. 2011). This strategy provided a roadmap and guidelines for each Arab country to prepare its own action plan to prevent and control obesity. The strategy had specific objectives and specific indicators to assess achievement of the objectives in nine areas including: child-care centers for preschool children, schools, primary health care, secondary care, and food companies among others (Musaiger et al. 2011). For example, for preschool age children the strategy aimed at using these child care centers to improve the awareness, skills, and capacity of staff and parents to adopt healthy nutrition, healthy weight, and active play.

Weight Management Modalities

In the long-term management of obesity, pharmacotherapy can be a useful adjunct to lifestyle modification in selected patients. Weight loss medications may be considered for those with a BMI ≥ 30 or those with a BMI ≥ 27 and have obesity-related comorbid conditions.

Sibutramine is a serotonin-norepinephrine reuptake inhibitor that is indicated for the treatment of obesity by reducing appetite, and inducing feeling of satiety and possibly thermogenesis (Luque and Rey 2002). Recently and due to adverse effects, it has been banned from most markets; however, studies of this agent are still relevant as it is often a hidden ingredient in herbal and over the counter slimming products (Oberholzer et al. 2015). Rimonabant is an inverse agonist to the cannabinoid receptor CB1 that, on average, reduces weight by 4–5 kg (Padwal and Majumdar 2007). Sibutramine has been associated with increased cardiovascular events and Rimonabant has been linked to increased suicidality, which led to their removal from the market, so their use is very limited in Arab countries (Naweed and Asem 2016). Orlistat is a pancreatic lipase inhibitor that prevents the digestion and absorption of dietary triacylglycerol in the small intestine. Its side effects include cramping and severe diarrhea (Badran and Laher 2011). No research has been published on the extent or success of orlistat in the management of obesity in Arab countries.

The sale of weight loss products is poorly regulated in many Arab countries. Slimming pills could be bought at gyms and beauty salons and are sold in pharmacies like medications for chronic diseases. Frequently, untested and unregistered weight loss products were marketed as nutrients or vitamins in Arab countries. Published data on the use of pharmaceutical therapy of obesity in Arabic countries is very scarce. Weight loss products show limited efficacy and have many side effects. This has caused a rise in the popularity of weight loss surgeries and lifestyle modification, over pharmaceutical therapy, as the cornerstone of obesity management in many Arab countries (Naweed and Asem 2016).

Urbanization in Arabic countries have led to greater consumption of unhealthy food and decreased physical activity, which has led to an increase in the prevalence of obesity in children, adolescents, and adults, especially women in Arab countries. Cultural factors and lack of awareness about obesity-related risk factors are also contributory to the rise of the alarming obesity phenomenon. Generally, medical management of obesity has shown limited progress due to the modesty of the associated weight loss in relation to numerous side effects. Weight-loss surgeries have thus been the cornerstone of obesity management in Arab countries. Obesity is a major public health problem that requires much strategy by government and national authorities, private healthcare systems, and the individual populations in Arab countries.

Conclusions

Overall, the general public in Arab countries has good access to pharmacy services. These include access to products such as medications and services such as drug information, advice, and counseling. However, several factors contribute to shortcomings in the practice of pharmacy in the Arab countries and so several methods are required to correct them. The laws governing the practice of pharmacy in many Arab countries do not give clear guidelines on what the expectations of community pharmacists are, and what pharmacists could or could not provide as it relates to patient assessment, information giving, and labeling of sold medications. Strict enforcement of regulations in Arab countries is warranted; legislation does not allow pharmacists to dispense POM medications without prescription and yet the practice continues to allow public access to a wide range of medications without prescription at the expense of safety and effectiveness.

It seems there are wide disparities in pharmacovigilance systems and national capacities to monitor and ensure safe use of medications in Arab countries. According to WHO revelations, only six Arab countries have the minimal requirements for a functional national pharmacovigilance system. Reports from Arab countries revealed that pharmacists and other health professionals do not have good knowledge of ADR reporting, which compromises monitoring of medication safety and use in the region.

Public use behaviors of medications are also associated with shortcomings. Overall, the estimated rates of nonadherence to medications in Arab countries may be as high as 88%. Within specific disease states, patients reported nonadherence for hypertension, diabetes, and depression. Reasons reported for nonadherence include forgetfulness, medication side effects, wanting a “drug holiday,” concerns about drug dependency, feeling well, treatment regimen that is complicated, patient feeling better with treatment, cost of medications, and patient-reported laziness. A very important reason reported for nonadherence was related to patients’ concerns, beliefs, and attitudes. Beliefs of patients about medications play a significant role in determining their adherence to taking medications and need to be explored as part of interventions targeting improving adherence.

Notably, the incidence of self-medication in Arab countries is high. It is clear that awareness campaigns and patient education are needed to enhance patients’ knowledge about the appropriateness and potential hazards of medication use without consulting a healthcare professional. Medicines implicated in self-medication misuse in Arab countries belong to different pharmacologic groups such as codeine-based products, tramadol, topical anesthetics, topical corticosteroids, and antibiotics. Overuse of antibiotics is common in Arab countries; antibiotics are mainly used for treatment of respiratory tract symptoms such as sore throat, cough, and flu.

Unfortunately, the use of prescription medications for recreational use is a new trend of misuse with a change from usual illicit substances toward legally prescribed medications, with the perception that these were less dangerous.

Crucial areas of public health interest in Arab countries that involve public well-being, health promotion, and disease prevention activities and encompass the use of medicines include contraception, immunization, smoking cessation, and weight management. Evidence on medicines use to enhance health promotion and disease prevention modalities is limited, but there are indications it may suboptimal in Arab countries. These may be due to individual, social, cultural, or government and regulatory-related factors.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Sanah Hasan
    • 1
    Email author
  • Muaed J Al-Omar
    • 2
  • Hamzah AlZubaidy
    • 3
  • Yaser Mohammed Al-Worafi
    • 4
  1. 1.Department of Clinical Sciences, College of Pharmacy and Health SciencesAjman UniversityAjmanUnited Arab Emirates
  2. 2.College of Pharmacy and Health SciencesAjman UniversityAjmanUnited Arab Emirates
  3. 3.College of PharmacyUniversity of SharjahSharjahUnited Arab Emirates
  4. 4.College of Pharmacy and Health SciencesAjman UniversityFujairahUnited Arab Emirates

Section editors and affiliations

  • Yusuf S. Khader
    • 1
  1. 1.Department of Community Medicine, Public Health and Family MedicineJordan University of Science & TechnologyIrbidJordan

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