Use of Medications in Arab Countries

Sanah Hasan, Muaed J Al-Omar, Hamzah AlZubaidy, andYaser Mohammed Al-Worafi

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Pharmacy and Pharmacist Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Pharmacy Personnel and Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Pharmacy Hours of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Pharmaceutical Market, Procurement, and Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Medicine Availability and Affordability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Medication Waste and Disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pharmacovigilance in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Medication Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Health Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Patient Assessment, Counseling, and Sources of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Adherence to Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Medication Misuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Self-Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Use of Traditional and Complimentary Therapies in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . 22Areas of Public Health Concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Use of Contraceptives in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

S. Hasan (*)Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University,Ajman, United Arab Emiratese-mail: sanahenayah@gmail.com; S.hasan@ajman.ac.ae

M. J. Al-OmarCollege of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emiratese-mail: muayyad74@yahoo.com; m.alomar@ajman.ac.ae

H. AlZubaidyCollege of Pharmacy, University of Sharjah, Sharjah, United Arab Emiratese-mail: halzubaidi@sharjah.ac.ae

Y. M. Al-WorafiCollege of Pharmacy and Health Sciences, Ajman University, Fujairah, United Arab Emiratese-mail: yworafi@yahoo.com; y.alworafi@ajman.ac.ae

© Springer Nature Switzerland AG 2019I. Laher (ed.), Handbook of Healthcare in the Arab World,https://doi.org/10.1007/978-3-319-74365-3_91-1

1

Contraception Methods in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Over-the-Counter Access to Oral Contraceptives in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . 25Tolerability of Oral Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Availability of Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Immunization in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Smoking Cessation in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Weight Management in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Factors Contributing to Increased Obesity in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Obesity in Arab Women (Sociocultural Context) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Weight Management Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

AbstractUse of medications in Arab countries is complex; although it follows strict lawsand regulations, there seems to be many forces that push and pull implementationof these in several directions. Pharmacy practice in the Arab countries is predom-inantly similar, with a few country-specific factors that are affected by regulation,policy, and education in that country. Medications are mostly imported, but localmanufacturing (mostly generic substitutes to imported brand name medications)still occurs and is encouraged by governments in the region. Medications areusually sold in pharmacies, that are hospital or community-based, by mostly alicensed pharmacist and often by other personnel such as pharmacy assistants andtechnicians. Medications classified as prescription medications are convenientlyavailable to consumers without prescription as long as they are able to pay. Thiscreates a situation where medication adverse drug reactions monitoring andfollow-up to outcomes of medication therapy are suboptimal. Medication misuse,intentional or unintentional, is on the rise in Arab countries. This chapter coversbriefly overall medication and pharmacy regulation in Arab countries, extent ofmedication performance monitoring, adherence to medications, and factors thataffect patients’ adherence to their therapy including issues related to medicationliteracy. Key areas of medication use and misuse, including self-medicatingpractices, are covered in detail in this chapter. Major healthcare areas of concernaffecting general public health in Arab countries that are managed with pharma-ceuticals including contraception, immunization, smoking cessation, and weightmanagement are also discussed.

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

2 S. Hasan et al.

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 andenforcement to these regulations. All countries have at least two drug classificationsof prescription and nonprescription (over-the-counter, OTC) medications, whileothers have a third category of pharmacist-only medications; the characteristics ofthe classifications may differ by country. In general, more drugs are availablewithout prescription in Arab than in Western countries. This puts greater responsi-bility on the shoulder of the pharmacist to provide safe and effective therapy and torefer patients to medical management when necessary. Unfortunately, the level ofpractice 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 manycommunity pharmacies, dispensing and counseling are predominantly carried out bypharmacy technicians while pharmacist–patient interaction occurs infrequently (Al-Wazaify and Albsoul-Younes 2005).

Understanding how medications are regulated, dispensed, and discussed bypharmacists and used by consumers in Arab countries is important as medicationsconstitute a key intervention in the prevention and management of disease. However,their use may be associated with adverse drug reactions, errors, misuse, abuse, lowliteracy, and improper adherence, all of which lead to negative patient medicationexperiences, possibly leading to suboptimal patient outcomes. Pharmacy is practicedin different ways, e.g., dispensing, compounding and preparation, marketing,counseling, etc., and pharmacists play a significant role in the provision of pharma-ceutical care, an important component of overall health care. This chapter on the useof medications in Arab countries aims to provide a general overview of pharmacy asa healthcare discipline, its control over medications and their safe use and theservices offered in pharmacies. The chapter also aims to shed some light on thebehavior 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. Discuss general regulations related to pharmacy licensing and ownership, phar-macist training requirements, pharmaceutical market, procurement, and costs inArab countries

2. Explore Arab country capacity for pharmacovigilance and adverse drugreporting systems and resources

3. Highlight common prescribing and medication administration errors includingcommonly involved medications in Arab countries

4. Describe the health literacy and medication knowledge of the general public inArab countries and emphasize local culture and language dimensions to healthliteracy in the region

5. Describe patient assessment, counseling, and advice giving practices of phar-macists, by discussing areas of strength and weakness

Use of Medications in Arab Countries 3

6. Describe medication taking behavior and adherence patterns of patients in Arabcountries, and the reasons and beliefs behind nonadherent behavior

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

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

9. Differentiate the types of traditional and complementary therapies consumersuse to enhance health and treat disease in Arab countries

10. Assess social and cultural issues associated with contraception in Arab coun-tries, the products available, patterns of use, and tolerability of these products

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

12. Investigate quit behaviors and pharmacological interventions to help quitsmoking in Arab countries

13. Discuss weight management modalities commonly used by consumers in Arabcountries

Pharmacy and Pharmacist Regulation

National drug authorities and/or ministries of health are responsible for the regula-tion of pharmacy practice, and drug registration and procurement policies in Arabcountries (Fathelrahman et al. 2016). For a pharmacy to be in operation in Arabcountries, a pharmacy license must be obtained from the authorities. Pharmacyownership is allowed for non-nationals in some Arab countries, but the majoritylimit it to country nationals (Fathelrahman et al. 2016). In many countries, only apharmacist who has at least a bachelor’s degree in pharmacy or pharmaceuticalscience can legally open a pharmacy, but adherence to pharmacy regulation is notstrict. In Yemen, for example, pharmacies are routinely owned and managed by non-pharmacists (Al-Worafi 2014b). The regulations in Saudi Arabia allow non-pharma-cists 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 interms of degree qualifications, required training, and licensing examinations. Train-ing after graduation is not required for pharmacist licensing and no licensingexamination is required for registration in Yemen (Al-Worafi 2014b). Licensingpharmacists in Saudi Arabia requires them to undergo training after graduation andto pass an examination for those graduating from Saudi private universities; theserequirements are not compulsory for those graduating from public universities(Almeman and Al-jedai 2016). Pharmacists’ employment and remuneration are

4 S. Hasan et al.

classified into various categories in Arab countries. In Yemen, pharmacist employ-ment is classified into three categories: pharmacist, specialist, and consultantaccording to the pharmacist qualifications. A pharmacist with an undergraduatedegree in pharmacy is classified as pharmacist, a pharmacist with a master’s degreein pharmaceutical sciences is classified as specialist, and a pharmacist with a PhDdegree 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 qualificationand experience (Almeman and Al-jedai 2016). A pharmacist with a bachelor’sdegree is classified as pharmacist, a pharmacist with a master’s degree in pharma-ceutical sciences or PharmD (Doctor of Pharmacy) degree and with 3 years ofexperience is classified as pharmacist I, and a pharmacist with a PhD degree or itsequivalent in pharmaceutical sciences with 3 years of experience is classified asconsultant pharmacist. Generally, licensing pharmacy technicians in Arab countriesdoes 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 differsfrom one country to another, and it ranges between 1.7 and 17.5. The highest numberof pharmacists per 10,000 population was reported in Jordan at 17.5 followed byEgypt at 17.3 pharmacists. Table 1 lists available information about the number oflicensed pharmacists per 10,000 population in Arab countries (Alefan and Halboup2016; Elsayed et al. 2016; Almeman and Al-jedai 2016; Al-Worafi 2016; Kheir2016; Ibrahim and Wayyes 2016; Alfadl et al. 2016; WHO 2008).

Pharmacy Hours of Service

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

Use of Medications in Arab Countries 5

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). Thelocal drug production varies and ranges from 0% to more than 90% of the nationaldrug market. On average, the local drug industry covers 50% of the total drugmarket. The Arab drug market was estimated at US$ 10 billion in 2007 with SaudiArabia and Egypt occupying the largest market sizes with more than US$ 1.2 billioneach (Khoja and Bawazir 2005). Many Arab countries encourage and support theirnational medication manufacturing by reducing the prices of the locallymanufactured medications by 20% or more in comparison to the original brandedmedications. There are more than 245 pharmaceutical manufacturing plants in Arabcountries, with a consistent increase in their numbers. However, manufacture isusually limited to the production of generic or company-branded generic pharma-ceuticals already under license. (Kandil 2004)

Naturally, there are differences between various Arab countries in demographicand economic indicators. They also have different health systems which maypredominantly be dependent on the private sector such as in Lebanon (Karam2005) or on the public health sector with general health insurance coverage suchas 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 fromthe 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 medi-cines for their public health sector; the price is usually three times higher for the

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

6 S. Hasan et al.

original drug (WHO 2008). Medicines’ prices in private retail pharmacies areusually high for all original and generic medicines, with the differences in the pricesbetween original and generic medicines too small to be noted in some countries. Thisis usually attributed to individual country pricing policies and added price mark ups,which eliminate the differences in the prices of the generic medicines compared tooriginal brands. This ultimately means that patients in these countries are not trulybenefiting from the use of generic medicines (WHO 2008). Table 2 shows examplesof the cumulative effects of different price components that are applied to the pricesof medicines in some Arab countries. Lebanon and Sudan include charges forprofessional pharmaceutical associations. Mark-ups in Kuwait do not include pro-fessional pharmacist fee but are markedly higher than other countries. Countries likeMorocco (Table 2) and Syria commonly procure generic medicines at a higher pricethan other countries, hence careful review of procurement policies are due in thesecountries (Sallouta et al. 2004). Other suboptimal procurement practices in somecountries is the procurement of old branded medicines instead of their substitutablecheaper generics, as is the case with diazepam and amitriptyline, which are preferredmedicines used in several conditions. This ultimately increases costs to both thegovernments and patients who pay for these medicines (WHO 2008). Nationalpolicy and medicines regulators should review their pharmaceutical pricing regula-tions and possibly remove taxes and import duties to optimize availability of, andaccess to, medicines, especially for those who have difficulty affording them (WHO2008).

Medicine Availability and Affordability

Medicines available in the public sector are usually generics. Many countries do notcharge patients for medicines in the public health sector; however, in some countriessuch as Jordan, Sudan, and Yemen, they do. Patients mostly could afford to pay forstandard treatments of common conditions with medicines obtained from the publicsector, when the medicines are available (WHO 2007b). However, when the med-icines are unavailable, patients resort to the private sector which usually stocks moreof 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 patientsresort to the private sector to obtain their medicines (WHO 2008). The balancebetween availability of brand and generic medicines in the private sector variesbetween countries.

To estimate affordability, the median price ratio (MPR) obtained by dividing thelocal unit price of a medicine by the international reference price of that samemedicine, giving an indication of how many times more expensive (or cheaper)the medicine is than the reference price. This also facilitates national and interna-tional comparison of medicines’ prices. An MPR of public sector procurement pricesshould usually be �1 as this price would be considered equivalent to the priceoffered by bulk suppliers. A standard MPR for medicines in the private sector isdependent on the medicine itself and the country pharmaceutical market (WHO

Use of Medications in Arab Countries 7

Table 2 Examples of the cumulative effects of price components for medicines in Arab countriesa

Medicine Type of chargeAmount ofcharge

Price ofdispensedquantity

Cumulative %mark-up

Jordan: Private sector, originator brand (imported)

Amoxicillin250 mg � 20cap

Insurance fees 1.0% 4.08 1.00%

Bank fees 1.0% 4.12 2.01%

Transport andclearance

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)

Amoxicillin250 mg � 20cap

Insurance fees 1.0% 2.08 1.00%

Bank fees 1.0% 2.10 2.01%

Transport andclearance

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)

Beclometasone0.05 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

Atenolol30 � 50 mg tabs

Customs clearingand 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)

Atenolol60 � 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)

Amitriptyline100 � 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)

8 S. Hasan et al.

2008). The Affordability of certain standard treatments for common conditions istypically estimated by comparing their costs to the daily wage of the lowest paidunskilled government worker. Table 3 shows examples of the affordability ofstandard treatments based on the wage of the lowest paid unskilled governmentworker and local prices of the medicine in private retail pharmacies in some Arabcountries.

In a field study to measure the price, availability, and affordability of selectedmedicines in Jordan in 2004 using a standardized methodology developed by theWorld Health Organization (WHO 2007a), it was shown that in the public sector, theprocurement of medicines is effective as the procurement prices were close tointernational reference prices. Patients were able to obtain generic medicines atsimilar prices to the procurement prices in the public sector. Nevertheless, availabil-ity of generic medicines in the public sector was poor (median 28%); half of themedicines were found in only 5.1–61.1% of the surveyed public facilities. This againconcluded that these patients were purchasing their medicines from the privatesector, which stocked more of the originator medicines in Jordan. Additionally, thegovernment in some instances was purchasing originator brands where lower-pricedgenerics were available. In these cases, patients were paying a lot more to purchaseoriginator products as compared to the lowest priced generics. They were alsopaying about 10 times more for generics in the private sector than in the publicsector. In this survey, affordability of medicines was also estimated based on thenumber of days the lowest paid government worker would need to cover costsneeded to treat common conditions. For example, they would need less than1 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 fluox-etine from the private sector, and up to 21.6 days’ wages to purchase originatorbrands from the private sector (Table 3).

In Egypt, the public health system scheme provides medicines free of charge forparticular conditions such as those in the Essential Medicines List, medicines formalaria, tuberculosis, hepatitis C, and immunizations (WHO 2011). Additionally,certain population groups receive medicines free of charge such as people who couldnot afford to buy them, children under the age of five, and the elderly. When theMPR was used to compare prices of medicines to international reference prices, itwas found for generics to be 0.95, no originators were found in the governmentalsector. 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 treatmentwith co-trimoxazole (reference medicine) for a child respiratory infection; thepurchase of the generic medicine necessitated 0.3 days’ wage in the public sectorand 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 govern-ment, through the SFDA, set the prices of pharmaceutical products. As the popula-tion enjoyed free health care in addition to the recent introduction of compulsoryhealth insurance, the impact of price variation between generics and originatormedicines was not felt. Generally, the Saudi population preferred to use originatorbranded medicines (Khan et al. 2015).

Use of Medications in Arab Countries 9

Table

3Affordabilityof

standard

treatm

entsbasedon

thewageof

thelowestpaid

unskilled

governmentworkerandlocalprices

ofthemedicinein

private

retailph

armaciesa

Stand

ardtreatm

ent

type

Affordability(no.

ofdays’wages)

Jordan

Kuw

ait

Lebanon

Morocco

Sud

anSyria

Tun

isia

Yem

en

Acuterespiratoryinfection

Amoxicillin

250mg1capsule3tim

es/day

for7days

OB

2.3

2.4

–1.0

––

––

LPG

0.9

––

0.8

0.4

0.6

–0.2

Acuterespiratoryinfection(child)

Co-trim

oxazolesuspension5ml2tim

es/day

for7days

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

Diclofenac25

mg1tablet2tim

esadayfor30

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

Beclometasoneinhaler(1

inhalerov

er30

days)

OB

2.4

2.7

1.6

––

––

–

LPG

1.6

–0.7

1.0

–1.6

0.4

1.8

Depression

Fluox

etine20

0mg2capsules

once

adayfor30

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

Metform

in500mg1tablet3tim

esdaily

for30

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

Carbamazepine200mg1tablet2tim

esdaily

for30

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

NifedipineRetard20

mg1tabletdaily

for30

days

OB

–4.2

2.1

2.9

––

1.3

8.6

LPG

1.7

–0.9

1.2

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10 S. Hasan et al.

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

Medication Waste and Disposal

Lack of appropriate medication disposal programs has been reported in Arabcountries (Al-Shareef et al. 2016). Several studies were conducted to exploremedication disposal behavior among the general public. In a study from Kuwait in2007, 97% of study participants disposed unused and expired medications in thehousehold waste while the rest (3%) reported that they either flushed their unusedand/or expired medications down the toilet or gave them to other individuals such asfriends (Abahussain and Ball 2007). Similar findings were reported from SaudiArabia. A study that explored the behavior of 300 patients in two university tertiarycare hospitals regarding their disposal practices of unused and expired medicationsfound that awareness among members of the general public toward medicationdisposal was very low. Seventy-nine percent of patients reported that they disposedtheir unused and expired medications through household waste, 7% disposed themin the toilet or sink, and others reported keeping them for future use, returning themto physicians or pharmacists, or giving them to other individuals such as family orfriends (Al-Shareef et al. 2016). Data from Qatar confirmed the same findings as77% 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 expiredmedications 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 thepractice of pharmacists toward the disposal of unwanted medications in Kuwait,reported that the practice among pharmacists toward disposal of medications was notoptimal as 77% of them reported that they disposed their unused medicationsthrough the waste disposal system (Abahussain et al. 2012).

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

Use of Medications in Arab Countries 11

Pharmacovigilance in Arab Countries

Pharmacovigilance is the “science and activities relating to the detection, assess-ment, understanding and prevention of adverse effects and all other problems relatedto medicines” (WHO 2009). It seems there are wide disparities in pharmacovigilancesystems and national capacities to monitor and ensure safe use of medications inArab countries. According to WHO revelations, only six Arab countries have theminimal requirements for a functional national pharmacovigilance system. Thesecountries are Jordan, Egypt, Morocco, Saudi Arabia, Sudan, and Tunisia (Qato2017). One of the few reports on pharmacovigilance in the region noted thatamong 10 national bodies responsible for drug safety that were interviewed, onlysix described a formal drug monitoring program at the national level (Wilbur 2013).

In 2015, Arab and Eastern Mediterranean countries contributed with 0.6% of the2.1 million suspected Individual Case Safety Reports (ICSRs) in VigiBase (WHO2017b), the global database for Adverse Drug Reaction (ADR) reports, reflecting thelow participation in adverse drug reporting from the region. Another study foundthat 11 Arab and Eastern Mediterranean countries received less than five ADRreports per million inhabitants per year, an insufficient number to be able to identifydrug-related problems (Qato 2017). Reports from Saudi Arabia have revealed thatpharmacists do not have good knowledge of ADR reporting; only a few pharmacistshave ever reported ADRs, and they declared they are largely unaware of the processof ADR reporting (Mahmoud et al. 2013). A study from the UAE, mirroring thatfrom Saudi Arabia, found that identification and reporting of medication errors andadverse drug reactions was only carried out by one third of community pharmacies(Hasan et al. 2012). Reasons for not reporting ADRs, principally, included lack ofawareness about the method of reporting, disclaiming responsibility for ADRreporting, and the belief that most ADRs in community pharmacy are minor anddo not need to be reported (Mahmoud et al. 2013). Others also cited lack of healthprofessional education and public awareness about the importance of reportingadverse events, and the presence of counterfeit medications (Al-Worafi 2014a).

This state of affairs reflects the challenges of inadequate resources devoted todrug safety agenda at the national level, as well as the low prioritization ofpharmacovigilance as a drug monitoring scheme in most countries in the Arabregion. Understanding the value of incorporating pharmacovigilance as a key com-ponent of regulatory budgets by policymakers is of great importance. One importantissue for the development of a strong pharmacovigilance system is the presence oftrained health professionals. In many countries in the region, unfortunately, there isshortage of highly qualified professionals, which is core to the problem. Hence, anyefforts to build pharmacovigilance capacity whether at the national or regional levelsshould focus on consolidating data and enhancing personnel resources (Ahmad2014; Bham 2015). Moreover, enhanced collaboration with qualified local andinternational pharmaceutical policy researchers can help support building and sus-taining the capacity for pharmacovigilance. More organized utilization of the Inter-net and possibly social media for the reporting and collection of ADRs are also worthexploring (Qato 2017; Wilbur 2013).

12 S. Hasan et al.

Medication Errors

Prescribing errors have been defined as errors initiated during the prescribingprocess. These include the incorrect selection of medication, dose, strength, fre-quency, 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 tomedication dosing, frequency, and strength (Alsulami et al. 2013). The rate of dosingerrors during medication prescribing reported from the region ranged between0.15% and 34.8% of prescriptions (Al Khaja et al. 2007; Khoja et al. 2011). Across-sectional study analyzed all medication prescriptions from five public and fiveprivate primary health clinics in Riyadh city, Saudi Arabia. Prescriptions from thepublic and private clinics for 2463 and 2836 respectively were analyzed for errorsusing the Neville et al.’s classification of prescription errors. In this classification,errors were classified into one of four categories based on their potential clinicaloutcomes (Al Khoja et al. 2011): Type A = potentially serious to patient; typeB=major nuisance and so pharmacist/doctor contact was required); type C=minornuisance and so pharmacist must use professional judgment; and type D = trivial.Prescribing errors were found in 990/5299 (18.7%) prescriptions. Both type B andtype C errors (major and minor nuisance) were more often associated with pre-scriptions from public than private clinics. Type D errors (trivial) were significantlymore likely to occur with private health sector prescriptions. Type A errors (poten-tially serious) were rare (8/5299 drugs; 0.15%) and the rate did not differ signifi-cantly between the two health sectors. Potentially life-threatening type A errors inboth sectors were mainly related to overdosage. These errors were most commonlyassociated with medicines for diabetes or hypertension.

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

Administration errors have been defined as “inconsistency between treatment thatis either prescribed or recommended according to standard hospital policies andprocedures and the drug therapy received by the patient” (Greengold et al. 2003).Administration errors may be health professional-related or patient-related. Thereported administration error rates varied from low to high in a given setting inArab countries (Sadat-Ali et al. 2010; Saab et al. 2006). A study was carried out atKing Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia during theperiod from January 2008 to December 2009. Incident reports were collectedretrospectively from the medical records of patients. There were only 38 medication

Use of Medications in Arab Countries 13

incidents reported for the study period with the most common reported error beingmissed 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 wereconducted with elderly patients between November 2004 and May 2005 by qualifiedpharmacists. Based on a literature review describing guidelines for the inappropriateuse of medications in the elderly, patient therapies were assessed and classified aseither appropriate or inappropriate. More than half (59.6%) of the patients wereconsidered taking at least one inappropriate medication. Inappropriate medicationuse was most identified based on Beers’ criteria classifications (22.4%), missingdoses (18.8%), or incorrect frequency of administration (13.0%) (Saab et al. 2006).

Most medication errors reported in the studies from Arab countries were relatedto antihistamines (Al Khaja et al. 2007), antibiotics (Alagha et al. 2011), andanticoagulants (Alagha et al. 2011). In pediatric patients, the most common medi-cations associated with errors include antihistamines, paracetamol, electrolytes, andbronchodilators (Al Khaja et al. 2007). Poor knowledge of medicine prescribing andadministration was reported as key factor leading to medication errors in Arabcountries (Al Khaja et al. 2007). Other factors cited included lack of pharmacologybackground on the part of physicians and nurses, poor adherence with drug pre-scribing and administration procedures, lack of reporting of medication errors, heavyworkload and untrained staff, and inefficient communication between healthcareprofessionals (Alsulami et al. 2013).

The development of preventive strategies for avoiding prescription errors iscrucial, including training initiatives to improve physicians’ prescribing skills andstrict 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 incounseling and informing patients about the importance of appropriate drug use andadministration. Improved communication and collaborations between health pro-fessionals have a paramount effect in improving patient experiences withmedications.

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 andpamphlets” (Tkacz et al. 2008). Health literacy is connected to health outcomes (vonWagner et al. 2009). Low health literacy is associated with lower rates of adherenceand use of preventive measures, higher healthcare expenses, more hospitalizations,poorer health status, and higher mortality rates (Ickes and Cottrell 2010; MacLeod etal. 2017).

People’s knowledge of and attitude toward medications are important factorsaffecting the use of these medications. In a study from Jordan, 67.1% of the publicbelieved that antibiotics treat common cold and cough. Many patients in this region

14 S. Hasan et al.

also thought antibiotics were used for viral infections (Alzoubi et al. 2013; Darwishet al. 2014), and about 28% misused antibiotics as analgesics (Shehadeh et al. 2012).

Many traditional patient education programs rely on written material aboutdisease processes, medical management, and self-care behaviors such as eatinghealthy, exercising regularly, adhering to medical treatments, and self-monitoringof disease outcomes (Yamashita and Kart 2011). Findings about health informationpresented to patients show that the information is developed at a higher level thanwhat patients could understand, which could affect the effectiveness of such infor-mation (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) back-grounds (such as Arabic backgrounds), it may be exaggerated by language barriers(Mohammad et al. 2015). Multilingual health information materials were founduseful in enhancing understanding of patients, many of whom preferred writtenhealth information in their native language. Similarly, multilingual labels on medi-cines bottles were found to ease comprehension of the label; some patients statedthey were writing the name of the medicine in their native language on the label toallow easier reference. Additionally, patients relied heavily on listening to the doctoror pharmacist who could speak their first language. Most patients emphasized theneed to overcome the communication barrier that existed between them and phar-macists who did not speak their language of origin, especially in situations where thephysician 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 designof interventional programs and development of educational material that suits theirhealth literacy level. Consequently, it is pivotal to develop valid and reliable tools inArabic language to assess health literacy among Arab populations. Tools to testhealth literacy have mostly been developed in the English language in English-speaking countries. A limited number of studies have focused on translating andculturally adapting health literacy tools that were suitable for the Arabic language orcontext. Hence, it is important that researchers and clinicians are inspired andsupported 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 theymay be in a community or institutional setting. In Arab countries, patient counselingis provided by pharmacists at varying levels in different countries and in varioussettings. In a study from Saudi Arabia exploring the counseling of communitypharmacists to simulated patients (SPs), the types of questions asked, counselingrate, and information provided were assessed (Alaqeel and Abanmy 2015). Pharma-cists asked the SP questions during 10.0% of the visits, provided information during4.6% 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 71visits (47.3%), provided counseling during 150 visits (100%), and both asked

Use of Medications in Arab Countries 15

questions and provided counseling, during 65 (43.3%) of the visits. Most pharma-cists did not ask about history of drug allergy or any use of other medications. Themost common type of information (97.3%) provided during the visits was informa-tion on dose. Reported barriers to counseling included being too busy (59.6%) andnot having the patient medical history (61.9%) (Alaqeel and Abanmy 2015).

A study sought to determine the prevalence of prescription medication sales andexplore how pharmacists assessed and counseled patients with acute cardiac condi-tions: acute coronary syndrome (ACS) and acute heart failure (AHF) showed thatpatient assessment and counseling on disease state by pharmacists needed to beimproved. Of 600 pharmacists, 63.2% sold several prescription medications withoutprescription, about a quarter did not ask any questions; 52% asked one or twoquestions; 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 largelyprovided. Less than one third of the pharmacists always provided printed medicationinformation or regularly provided counseling to patients, and only 11% regularlyprovided counseling in a private area in the pharmacy.

Another study was set to determine the effectiveness of a home medicationmanagement program in Jordan that included pharmacist counseling to identify,prevent, and resolve treatment-related problems. Participants were distributed intoeither control or intervention groups. Participants in the intervention group werevisited at home by the pharmacist who gave information about medication adher-ence, and educated the participants on frequency of monitoring of their conditionand on pharmacological and non-pharmacological therapies (Basheti et al. 2016). At3 month follow-up in the intervention group, the number of treatment-relatedproblems decreased, and their adherence to medications and self-care behaviorsimproved.

In a study from Palestine assessing patients’ self-medication practices and possi-ble role of community pharmacists (Al-Ramahi 2013), 19.3% of respondents saidthat 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 primaryreason for visiting a pharmacy was to obtain prescription medicines as reported by57.1% of participants, 19.3% to purchase OTC medicines, while 23.6% to purchaseother items. About 23% strongly agreed and 61.5% agreed that the communitypharmacist played an important role in providing advice to patients.

The laws governing practice in many Arab countries do not give clear guidelineson what the expectations of community pharmacists are on information giving, andwhat pharmacists could or could not provide. These guidelines are timely andurgently 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, druginteractions, and adverse drug reactions is increasing in Arab countries (Abanmy etal. 2012), many people are consulting Arabic drug information websites. However,in a study from Saudi Arabia, 54% of respondents did not depend on informationavailable on Arabic websites when making decisions on drug use. Although the

16 S. Hasan et al.

information was available and easily understood, the quality and credibility of theinformation were questionable. The need for dependable Arabic drug informationwebsites was considered important to meet population needs for information espe-cially that inadequate English language skills were considered barriers to accessingdependable foreign websites (Abanmy et al. 2012).

Adherence to Medications

Adherence is defined by the World Health Organization (WHO) as “the extent towhich a person’s behavior – taking a medication, following a diet, and/or executinglifestyle changes – corresponds with agreed recommendations from a health careprovider” (WHO 2003). In developed countries, medication adherence rates forchronic disease were reported at 50% by the WHO, and were expected to be lowerin developing countries with less access to health care. (WHO 2003) Overall, theestimated 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 hyperten-sion, 1.4% and 27.1% for diabetes, and 24–88% for depression.

Reasons reported by patients for nonadherence included forgetfulness, medica-tion side-effects, wanting a “drug holiday” (Youssef and Moubarak 2002), concernsabout drug dependency, feeling well, medication not helping to improve feeling (Al-Saffar et al. 2005), infrequent follow-up visits, lack of health education, shortage ofdrugs, ignorance of the chronicity of the disease, patient not knowing to continuetreatment (Al-Jahdali et al. 2007), disbelief about the value and need for adherence,social stigma (Jeragh-Alhaddad et al. 2015), complicated treatment regimen, patientunable to see usual doctor (Al-Saffar et al. 2005), patient feeling better withtreatment, cost of medications, and finally, patient-reported laziness (Al-Jahdali etal. 2007). Avery important reason reported for nonadherence was related to patients’concerns, beliefs, and attitudes. In Arab countries, beliefs of patients about medica-tions 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 arevulnerable to these adverse effects” were noted (Al-Qasem et al. 2011). Patientswith reservations about the efficacy of the medications, and those who wereconcerned about negative side effects of the medications, were less likely to beadherent (Ajlouni et al. 2008).

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

Use of Medications in Arab Countries 17

Medication Misuse

The term abuse is used to describe the use of drugs for non-medical purposes whilemisuse is used to describe the use of a drug for medical purposes, but in aninappropriate 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. Itis not only common in adult individuals but also in children and pregnant women(Khalifeh et al. 2017). With increased self-medication comes increased misuse ofmedications. The reported prevalence of self-medication misuse in Arab countries ishigh, making it a health challenge in these countries (Khalifeh et al. 2017). Medi-cines implicated in self-medication misuse belong to different pharmacologic groupssuch as codeine-based products, tramadol, topical ocular anesthetics, topical corti-costeroids, antibiotics, and antimalarials (Khalifeh et al. 2017). In a study fromPalestine, antitussives, antihistamines, laxatives, analgesics, decongestants, andsedatives were the most to be misused in the community (Sweileh et al. 2004). Itwas estimated that (52.6%) antitussive users were misusing them. The most misusedantitussives were: (codeine phosphate/pseudoephedrine/triprolidine) and/or (ephed-rine/ammonium chloride/codeine phosphate/pheniramine maleate). Another class ofdrugs believed to be misused was antihistamines including chlorpheniramine,loratadine, cyproheptadine, or dimethindene. Laxative misuse mostly amongfemales attempting to control their weight were most widely misused includingthose containing bisacodyl, senna, or both. Combination products of analgesicsand decongestants or antihistamines in cold and flu preparations were also consid-ered drugs of misuse. Simple analgesics including nonsteroidal anti-inflammatorydrugs, paracetamol and paracetamol-containing products were also implicated(Sweileh et al. 2004).

Corticosteroids including clobetasole and betamethasone were commonly mis-used at the dermatological center in Arab countries for lightening the skin or mildacne. Unfortunately, the medical staff including pharmacists were sometimesresponsible for recommending the inappropriate use of medicines (Al-Dhalimi andAljawahiry 2006).

Inappropriateness of antibiotic use is defined as inappropriate use of antibiotics totreat responsive infections, including use of too broad-spectrum agents, incorrectdrug dose or duration, and poor adherence (Sabry et al. 2014). Overuse of antibioticsis common in Arab countries; self-medication rates range from 32% to 42% asreported 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 treatmentof respiratory tract symptoms such as sore throat, cough, and flu and other reasonsincluding urinary tract infections or gastrointestinal symptoms. Patterns of antibioticmisuse were largely related to not completing the full course of treatment whichranged from 29% to 86% (Mohanna 2010; Ghaieth et al. 2015; Jose et al. 2013).Reasons for self-medicating with antibiotics included: the antibiotics were foundeffective on previous use, the medicines were available at home as leftovers from

18 S. Hasan et al.

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 preventingindiscriminate access and availability of these medications to the public, and bycounseling patients on their appropriate use. Adequate enforcement of the lawsprohibiting non-prescription sale of prescription medications without prescriptionis due. This is especially crucial for antibiotics to prevent antimicrobial resistance.

Drug Abuse

Drug abuse is increasingly becoming a problem in many Arab countries despitestrong condemnations that may be religious, cultural, or legal. This increase could berecognized due to various factors including the geographic position of countries inthe region, putting them on the route between the countries that produce illegalsubstances and the world market at large (AlMarri and Oei 2009). Commonly usedagents 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 studiedwere poly-substance users (84.4%) with various combinations of agents being usedat different age levels. The majority of the poly-substance users took three or moresubstances (89%) consisting of recreational, illicit and prescribed substances. Thesecombinations of substances had either similar or differing effects on the centralnervous system (CNS), which could cause major effects on health including increas-ing the risk of overdosing and/or fatality. The most commonly used substances wereopioids and alcohol. Tramadol use constituted 67.2% of opioid users and its use washighest among the youngest age group (<30 years old). Other prescribed misusedmedications included pregabalin, procyclidin, and carisoprodol whose use was againhighest 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 combina-tion with each other with Pregabalin taking the largest share of consumption of over68% (27% as single use and 41% in mixture). Procylidin is the second most commonwhile the least common was the Carisoprodol (31%). The use of prescription drugsfor recreational use points to the appearance of a new form of misuse with a changefrom usual illicit substances toward legally prescribed drugs. The competition toexperiment with new substances among the young with the perception that thesewere less dangerous than illicit substances resulted in this shift. Additionally,combinations of these substances were used to enhance and maintain the effect ofthe drugs for a longer time as perceived by the users. Unfortunately, the use of thesemedications as mixtures is a major health concern due to the potential risk of toxicitythat can lead to overdose and death. Poly-substance use disorder is clinicallychallenging to diagnose, because the criteria for diagnosis are not well-established.Poly-substance users have been shown to be at higher risk of psychological

Use of Medications in Arab Countries 19

comorbidities, and impaired cognitive functioning that unpredictably affect treat-ment outcomes (Connor et al. 2014).

Development of effective public awareness strategies about drug use and misuseis required such as using mass media to promote awareness of prevention programsand highlighting the risks of both illicit and pharmaceutical substance abuse. Addi-tionally, challenges to control pharmaceuticals’ availability as recreational drugsneed to be addressed at the national levels in Arab countries.

Self-Medication

Self-medication is common practice in the medical field in which medicines areconsidered safe and effective when used by consumers for a particular purposewithout prescription. Consumers usually use these products to manage commonailments, at their own risk. The dosage and indication of these products play anessential role in their classification as prescription or non-prescription medications.Ibuprofen, for instance, is a prescription medication at high doses when used for thetreatment of different types of arthritis but considered a non-prescription medicationwhen 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.), eco-nomic value and an acceptable risk if used frequently, and convenience (WHO2000).

Despite the safety profile of medications used in self-medication, there are risksassociated with using medications without consulting a medical professional, whichmay include serious medical consequences. For products sold online, there isconcern about the safety of the medications since no clear policies are in place tomonitor the quality of medications sold through the internet; additionally, internetsites tend to advertise prescription medications as non-prescription. In most cases,self-medication occurs in the absence of medical supervision and when compared tothe use of prescription medications, their use is unexplored in relation to: interactionswith other medications, alcohol or food, and their safety in certain populations suchas pregnant, lactating, pediatric, or geriatric groups has not been established(McLaughlin et al. 1998). Uncontrolled use of medications leads to serious medicalconsequences and waste of public income and resources with no guaranteed properhealth outcomes. Antibiotics, for instance, may increase the risk of bacterial resis-tance and serious medical consequences like pseudomembranous colitis (Abasaeedet al. 2009). Chronic use of analgesics in high doses may have a negative effect onthe kidney and liver and could lead to tolerance (Barakat-Haddad and Siddiqua2015). The use of antihistamines could lead to serious hazards if used before runningheavy machinery or driving vehicles. In general, adopting self-medication practicedoes not guarantee the safety and efficacy of the products and should only be usedwhen necessary according to product recommendation.

The incidence of self-medication in Arab countries is high. In a community-basedstudy on the prevalence of self-medication involving 1100 adults in Egypt, it was

20 S. Hasan et al.

found that the majority self-medicated (86.4%), mainly utilizing both medicationsand Complementary and Alternative Medicine (CAM) therapies. Of the medicationsused, analgesics were the most common (96.7%), followed by cough and coldpreparations (81.9%); however, a further 53.9% also claimed to self-medicate withantibiotics (El-Nimr et al. 2015).

Likewise, in Saudi Arabia, the rate of self-medication is alarmingly high. Acommunity pharmacy-based study involving 538 customers in Riyadh (Aljadheyet al. 2015) reported that 285 medications were bought without a prescription despitethat about 49% of the medications were classified as prescription medications. Themost frequently purchased prescription medications were antibiotics (22%) andanalgesics/antipyretics (19%). The main reasons given for purchasing medicationswithout a prescription were that the ailment was too insignificant to warrant adoctor’s visit (54%), time saving (40%), and the participant regarding the ailmentas minor (40%). Worryingly, over 68% of participants were unaware the medicationspurchased were prescription-only (Aljadhey et al. 2015). Another cross-sectionalstudy from Saudi Arabia on self-medicating with antibiotics revealed that 34% ofparticipants used antibiotics without prescription, despite that 81% of participantswere aware that this was potentially harmful. The most frequently used antibioticwas amoxicillin/clavulanic acid (41.5%), followed by amoxicillin as a plain ingre-dient (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 ishigh at 97.8%, mainly to treat headaches (90.1%), dysmenorrhea (84.7%), andconstipation (60.3%). Appropriately, pharmacists supplied 80.1% of the studentswith information regarding doses, duration of treatments, and side effects (Al-Hussaini et al. 2014). The high prevalence of self-medication is particularly worri-some among school-aged children in Jordan. In another study from Jordan, the rateof self-medication was reported to be approximately 40% and treatment was gener-ally used for sore throat, common cold, and dental infections. The most frequentlyused antibiotic was amoxicillin, but only 37.6% of patients were following thecorrect dosing guidelines. The main reason given for self-medication was claimingto have had a similar infection in the past (Sawair et al. 2009).

The most commonly used antibiotics for self-medication were amoxicillin orampicillin among various Arab countries including Libya, Tunisia, Egypt (Sciclunaet 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 forurinary tract infections (Al-Ghamdi 2001); Metronidazole and TMP/SMX werecommonly 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 pharmacistsdispensed POMs without a prescription were that pharmacists did not know thestatus of the medications (i.e., POM or OTC), patients requested the specific

Use of Medications in Arab Countries 21

medication, and that some patients could only pay for a pharmacy visit. The attitudeof “if we did not sell it, somebody else will” also prevailed.

It was evident that patient education and awareness campaigns were needed toenhance patients’ knowledge and possibly behavior concerning the use of medica-tions for self-treatment. Emphasis should be on the hazards of self-medication thatcould be encountered when the patient takes responsibility for their health decisionswithout consulting a health professional, and on following the recommendationsaccompanying these medications to ensure their appropriate use. Strict enforcementof the regulations on dispensing POMmedications by pharmacists only at the receiptof 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 inter-vention other than conventional medicines (Falkenberg et al. 2012). The CAMapproach supports the idea of helping the body to heal itself with minimum helpusing natural resources (Falkenberg et al. 2012). CAM uses the mind, body, andspirit as a base in implementing holistic medicine such as aromatherapy andreflexology.

The incidence of CAM use in Arab countries varies according to country. A studyfrom the UAE involving 135 participants showed that people from different culturalbackgrounds had different experiences using CAM. Participants from the Far Eastwere 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, theoverall satisfaction with CAM was 71.8%; however, only 10% would recommend itto others. Another study from the UAE showed that the most common form of CAMused in the UAE was herbal medicine. Of the surveyed participants, 52.9% preferredto use CAM rather than conventional medications to prevent illness (Sridhar et al.2017). A positive previous experience and a lower incidence of adverse reactionswere 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, accountingfor 75% of all CAM use according to a national survey. As many as 40% ofrespondents claimed to use CAM as an alternative to conventional medications,but only 28% informed their physicians of their use. The use of CAM was largelyassociated with chronic illness, lack of access to adequate health care, and higherincome households (Naja et al. 2015).

In Palestine, the use of CAM is often advocated by community pharmacists totheir clients. This was reported in a cross-sectional study from Palestine of patientsbeing 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 theirdiabetes. The herbs were used primarily as decoctions and included: Trigonellaberythea, Olea europaea, Teucrium capitatum, and Cinnamomum zeylanicum. Themajority of CAM users were over 40, female and lived in refugee camps. The mainreason cited for using CAM was based on a recommendation from a friend or

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relative. The majority of CAM users (71.7%) were happy with its use (Ali-Shtayeh etal. 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, thosewho had diabetes for a long time, or had complications associated with diabetes weremore likely to use CAM. About 64% of the CAM users reportedly used CAM tocontrol their diabetes (Khalaf and Whitford 2010).

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

The use of CAM among pregnant women seemed to be quite common in Arabcountries. 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 medicinewas most frequently reported (53.7%) followed by multivitamins (36.3%). Interest-ingly, only 0.5% of participants informed their physicians that they used CAMduring pregnancy (Hwang et al. 2016). The anti-hemorrhoidal product “NeoHealar”a Jordanian product which included oil extracts from lupin, Vateria indica, pepper-mint (Mentha piperita), and Aloe vera was a commonly used product in pregnancy(Abramowitz et al. 2010). Sumac (R. coriaria), an abundant Mediterranean herbavailable in Syria, Palestine, Jordan, and Lebanon, was proven to have someastringent effect in the anal area and for the treatment of hemorrhoids (Kossah etal. 2010).

Other commonly treated conditions with CAM therapy in Arab countries includeheadache and pediculosis capitis infestations. In addition to the use of traditionalanalgesics, people in Arab countries tended to utilize folk medicines for the treat-ment of different types of headache: aniseed tea, ginger tea, black tea, green tea,topical “Abu fas,” chamomile tea (babunaj) for tension headaches, and thyme (allforms; fresh, dry, or tea) and coriander seed for sinus and migraine headaches(Sawalha et al. 2008). In Arab countries, many traditional remedies are used tocure 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 alsoused in Arab folk medicine as repellants for pediculosis capitis. Other products usedto 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 justifythe widespread use of these alternative treatments in Arab countries. Though the useof many products might be seen as advantageous, their common use could be a causefor concern as the potential risks associated with their use have not been adequatelyexplored, especially in certain group such as pregnant women and pediatricpopulations.

Use of Medications in Arab Countries 23

Areas of Public Health Concern

Four areas of major public health and healthcare concerns that involve the use ofmedicines and may be unique in their own ways in the Arab countries include birthcontrol and use of contraceptives, immunizations, smoking cessation, and weightmanagement. Hence, the rest of the Chapter will discuss these healthcare needs anddrug 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’sefforts to reduce poverty, and to help in achieving development goals. The use ofeffective contraceptive methods is important in the Arab countries, as clinicaltermination for unwanted pregnancies is not acceptable culturally and religiously.

It is estimated that, yearly, more than 45 million induced abortions are carried outworldwide in unsafe conditions, and as a result, there is a high risk of maternalmorbidity and mortality. Somalia, Sudan, and Yemen have the lowest use of con-traceptive methods and the highest percentage of maternal deaths (77%). In Somaliaspecifically, women usually give birth to more than six children on average and onlya low percentage use modern contraception. Out of every 16 women, one is at a riskof dying due to complications of pregnancy or childbirth. In addition, complicationsduring pregnancy and delivery result in many disorders and injuries such as damageto the reproductive organs (UNFPA 2012). Improving education about the use ofcontraceptive methods is essential to minimize the risks and create more efficientfamily planning.

Contraception Methods in Arab Countries

Today, 4 out of 10 married women living in Arab countries at reproductive age usemodern contraception (UNFPA 2012), highlighting the need for family planningservices. Contraceptive use is higher in couples who live in urban cities and belongto traditional backgrounds (i.e., non-Bedouin). These couples are usually moreeducated and the wife is employed (Elgharabway et al. 2015). In Arab countries,about a quarter of all pregnancies are unintended. Emergency contraceptives areused as a preventative measure in the case of unprotected sexual activity to avoidunplanned 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 accom-modates the needs and inquiries of Arab women about reproductive health. ThisArabic-language web site was adapted from Not-2-Late.com, its English counter-part, which was operated by both the OPR and the Association of ReproductiveHealth Professionals (ARHP) (Foster et al. 2005).

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In all Arab countries except Egypt, oral contraceptives are the usual form ofmodern contraceptive methods used. The older age group in Egypt usually dependson intrauterine devices (IUD), while in Syria, Jordan, Palestine, and Iraq onlyslightly more than 2% of women depend on the IUD. Algeria and Morocco have avery high percentage use of pills compared to the other modern methods (Howse2014). In Kuwait, the use of oral contraceptives remains the leading contraceptionmethod. 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 head-aches, dizziness, water retention, and weakness. On the other hand, there was anincrease 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% ofyoung couples depend on the male condom. Permanent methods of contraception arenot used among young or old age groups (Howse 2014). The use of traditionalmethods of contraception, such as lactation amenorrhea, is high and exceeds thelevels 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 wasrequired) 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 regardedas one of the most convenient and reliable methods of preventing pregnancy. Theconcentration of both estrogen and progestin has been reduced over the years tominimize side effects and cardiovascular complications giving oral contraceptives ahigh level of user tolerability and satisfaction. To measure tolerability and satisfac-tion with OC among women in Arab countries, a study was conducted in severalcountries including Syria, Lebanon, and Jordan to ascertain the pattern of bleeding,tolerance, and patient satisfaction with OC consisting of 3 mg of drospirenone and30 mcg of ethinyl estradiol in a real-life setting. The study concluded that the producthad positive results in regard to patterns of bleeding, signs of fluid retention, andpatient satisfaction (Endrikat et al. 2009).

Use of Medications in Arab Countries 25

Availability of Contraceptives

Contraceptive use among Arabs is more widely accepted nowadays because of therelaxation of laws restricting women’s rights, the increase in girls’ education andsocial changes (modernization and urbanization). Governments in the Arab countriesdo 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 reportissued by the United Nations in 2015, the unmet need for family planning in Arabcountries ranged from 12% in Jordan to 28.3% in Oman (UN 2015). In many Arabcountries, modern methods of contraception are readily available through govern-ment 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 infectiousdisease. Immunity can be acquired naturally (when a person develops an infection orwhen a newborn or a fetus receives antibodies from its mother), or artificially(through vaccination or the administration of preformed antibodies) (Levinson2017). Vaccination is the most effective and cost-efficient method for preventinginfectious diseases. The active ingredient in a vaccine can be an inactivated bacte-rium or virus; live, attenuated bacterium or virus; or a component of the bacterium orvirus. It stimulates the body’s cell- and antibody-mediated immunities, providinglong-lasting protection against the infectious agent (Levinson 2017). The WorldHealth Organization recommends that the following vaccines be part of all immu-nization 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, rotavirusvaccine, measles vaccine, rubella vaccine, and human papillomavirus (HPV) vac-cine. Country-specific WHO recommendations relevant to some Arab countriesinclude vaccination for the following diseases: yellow fever, typhoid fever,mumps, hepatitis A, and meningococcal disease (WHO 2017c). The immunizationschedules of all Arab countries are based on WHO recommendations. Table 4highlights key points pertaining to the vaccination programs in Arab countries(WHO 2017d).

The WHO and United Nations Children’s Fund (UNICEF) estimates indicate thatmost Arab countries have maintained consistently high immunization coveragelevels (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 somecountries to have suboptimal coverage levels.

Syria has maintained immunization coverage levels around 80–90% throughoutthe years 2000–2010 (WHO-UNICEF 2016). The Syrian Civil War, which started in2011, has led to a serious decline in access to vaccines for children in contested areasof 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

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serious consequence of this has been a poliomyelitis outbreak in 2013 that led to theparalysis of 17 children. The WHO and UNICEF responded by organizing a polioeradication campaign to vaccinate all children under the age of 5 years, whether theystill lived at home or were displaced within the country or to the neighboringcountries (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 vaccinationefforts in the country have been challenged by the lack of security, lack of funding,power shortages, and ineffective communication between the Ministry of Health andthe other directorates. Iraq has seen polio, measles, and mumps outbreaks in therecent years. The Iraqi government has been working in coordination with the WHOand UNICEF to achieve high immunization coverage, with emphasis on refugeesand internally displaced people (WHO 2016).

Somalia is classified by the United Nations as a “least-developed country.” It hassuffered 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 risingabove 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 vacci-nation campaigns against these diseases. The 2015 measles vaccination campaignaimed to reach four million Somali children under 10 years of age through a networkof fixed, temporary, and mobile posts. The 2013 polio outbreak was the first inSomalia in 6 years. An emergency vaccination campaign was conducted and volun-teers were recruited to help administer the vaccines.

Sudan had low immunization coverage in the past years, and around one third ofchildren did not have access to several essential vaccines. The Sudanese Ministry ofHealth, in association with the WHO, UNICEF, and Gavi, implemented a plan toprovide vaccinations to hard-to-reach groups such as nomads and people in conflictareas. Interventions included choosing a focal person in each nomadic tribe andtracking them and training volunteer vaccinators in the tribes. The government alsoworked with nongovernmental organizations and cooperated with armed groups toreach people in conflict zones. The plan resulted in more than 90% of Sudanesechildren being vaccinated against diphtheria, tetanus, pertussis, and polio (WHO2013b). Meningitis A vaccination has been added to the routine immunizationschedule in Sudan, and plans are underway to conduct a measles immunizationcampaign (WHO 2013b).

Smoking Cessation in Arab Countries

Globally, smoking is the main preventable cause of death. Smoking cessation hasimmediate and long-term health benefits, including reduction in blood pressure,heart rate, and carbon monoxide levels. It also improves circulatory and lungfunctions and decreases the risk of coronary heart disease, stroke, and cancer.

Use of Medications in Arab Countries 27

Several methods are available for smoking cessation. They include unassistedquitting, behavioral therapy, and the use of medications. Pharmacotherapy insmoking cessation aims to reduce nicotine withdrawal symptoms, facilitating absti-nence (Rigotti 2017).

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

In the Arab region, the scarcity of smoking cessation services is a major chal-lenge, and where such services are available they typically mirror western treatmentprograms without careful adaptation to local healthcare delivery and cultural con-texts (Fiore et al. 2008). Within this context, results of a randomized clinical trial inSyria that compared behavioral counseling vs counseling plus NRT showed noadvantage for NRT over counseling alone. This suggested that NRT might not beuseful if implemented in other cultures and healthcare settings than western cultureswhere it was first proved useful (Ward et al. 2013). Within this context also, a recentstudy demonstrated that when a smoking cessation intervention was culturallytailored it led to positive effects; this was the case in a one group pre/post studythat was conducted in Florida, USA. which assessed the effectiveness of Sehatack –

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 programschedules

Egypt, Jordan, Somalia, Syria, andTunisia

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 allchildren, while UAE provides it to high riskindividuals and travelers

All Gulf countries Provide varicella vaccination to children. In Kuwait,varicella vaccine is only given to healthcare workerswho are at risk

All countries Offer influenza vaccination to at-risk groups (such aschildren, the elderly, healthcare workers, and travelers)

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a culturally tailored smoking cessation intervention for Arab American men (Haddadet al. 2017).

Till now, the alarming tobacco epidemic in Arab communities provokes sub-optimal response at the public health and policy levels. However, the adoption of theFramework Convention on Tobacco Control (FCTC) and the implementation ofvarious serious tobacco control measures in most Arab countries turned around thegrim perspective of the tobacco control situation (Maziak et al. 2014). The success ofsome of these initiatives to limit tobacco use in this region relied on multi-sectorpartnership, governmental and civil society involvement, and the engagement andleadership of academia (Maziak et al. 2014). For example, in Palestine, the ministryof health partnered with the legislative council, academia, and various health-relatednongovernmental organizations (NGOs) to sponsor a comprehensive tobacco con-trol program in 2005. Similarly, in Lebanon, the American University of Beirut’sTobacco Control Research Group worked closely with civil society groups (IndyActand Tobacco Free Initiative) to advocate for the adoption of a comprehensivetobacco control law. Their campaign targeted three main groups: policy makers,the media, and NGOs. This collective multi-sectorial effort concluded with thepassage of a comprehensive and strong tobacco control law (law 174) (Maziak etal. 2014).

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

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

Bupropion is an antidepressant that is effective for smoking cessation. It isthought to act by increasing the release of norepinephrine and dopamine in thecentral nervous system. It is recommended to be started one week before the plannedquit day, and to be continued for at least 11 weeks after quitting (12-week course atleast). Bupropion has been associated with an increased risk of depression andsuicidal or self-harming behavior, but a randomized controlled trial compared this

Use of Medications in Arab Countries 29

risk in bupropion to placebo and found no significant difference. This led the Foodand Drug Administration to withdraw the black-box warning about the seriousneuropsychiatric side effects of bupropion (Rigotti 2017). Bupropion is legallysold in nine Arab countries: Libya, Morocco, the West Bank and Gaza, Lebanon,Iraq, Qatar, Bahrain, Saudi Arabia, and the UAE. A prescription is required topurchase it in most of these countries. Bupropion is partially covered by the nationalinsurance in Iraq and the UAE and fully covered in Qatar and Saudi Arabia (WHO2017a).

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

Very little data exists on the extent and success of the use of pharmacotherapy insmoking cessation in Arab countries. The Global Adult Tobacco Survey (GATS) wasconducted in two Arab countries only: Egypt and Qatar. In Egypt, 19.4% of adultssmoked tobacco; of current smokers, 95% were daily smokers, and men smoked onaverage 19.4 cigarettes per day. On tobacco use pattern, cigarettes were the mostpopular 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 quitsmoking, 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 onstrengthening smoking cessation support services in Egypt. Although there weresome cessation clinics available, they were not easily accessible or as effective ashoped for, as no nicotine replacement therapy was offered (Emam et al. 2009; GATS2013).

In Qatar, 21.3% of men and 0.6% of women currently smoked tobacco. Theprevalence of shisha smoking among Qatari men was 5.3% compared to 0.4% forQatari women. Alarmingly, it was reported that above 10% of current shishasmokers started shisha smoking before the age of 18 (Emam et al. 2009; GATS2013). About 67% of current tobacco smokers were interested in quitting; 41.3% ofwomen and 37.7% of men tried to quit smoking on their own, whereas 71.9% of menand 61.6% of women received advice by a healthcare provider on quitting. Only21.9% of men and 19.6% of women attempted to quit smoking using pharmaco-therapy. Tobacco users who wanted to quit were not adequately supported toovercome their dependence. Healthcare system should increase and strengthensmoking cessation services and create structured programs using proper counselingalone or in combination with pharmacotherapy.

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

A high proportion of smokers in Arab countries reported trying to quit smoking orthinking about quitting. In a study in Jordan, 62.8% of the surveyed sample reportedtrying to quit in the previous year (Jaghbir et al. 2014). Similar numbers werereported in Qatar (66.8%) (GATS 2013), Egypt (41.1%), (Emam et al. 2009), andSyria (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) inArab countries is low: 8.7% in Jordan (Jaghbir et al. 2014), 24.2% in Qatar (GATS2013), 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 Arabcountries could be attributed to the failure to respond to the tobacco epidemic atpolicy and public health levels. Nineteen of the 22 Arab countries have joined theWorld Health Organization Framework Convention on Tobacco Control (WHOFCTC), which aimed to provide member states with a coordinated roadmap towardthe implementation of tobacco control policies. These countries have adoptedcomprehensive national tobacco control laws, but the new legislation had not beenimplemented or enforced in many member Arab countries (Maziak et al. 2014).Policies mandated by the FTCT and adopted in member Arab countries includedrestricting smoking in public places, large and pictorial warnings on tobacco prod-ucts, 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), andonly 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 Arabcountries, the low utilization of medications in smoking cessation could be explainedby the fact that most quitting attempts were done without consultation with ahealthcare provider. This could be indicative of the poor awareness and healthcareseeking behavior in Arab societies and/or the lack of systematic smoking cessationinterventions by healthcare providers in Arab countries. It must be taken intoconsideration, however, that smoking cessation interventions developed for Westernsocieties and healthcare systems may not be as effective if implemented in the Arabic

Use of Medications in Arab Countries 31

context. Research findings showed that interventions needed to be locally fitted toshow effectiveness. Future research is necessary to develop smoking cessationinterventions that are tailored to the Arabic communities, accounting for the vari-ability in income between different Arab countries (Ward et al. 2013).

Weight Management in Arab Countries

TheWHO defines obesity as an abnormal or excessive fat accumulation that presentsa risk to health, or a BMI of 30 kg/m2 or more. Excess weight has been associatedwith an increased burden of noncommunicable diseases worldwide, which mayinclude elevating the risk for hypertension, diabetes mellitus, cerebral and cardio-vascular disease, disordered sleep breathing, and various cancers.

Obesity in Arab countries has increased at an alarming rate in the past threedecades and is more pronounced in women compared to men. According to theWHO estimates in 2010, Kuwait had the highest prevalence of obesity in Arabcountries with 30% of males and 55% of females over the age of 15 being classifiedas 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 startedabout four decades ago, which had a marked effect on the youth particularly. Thehigh availability of calorie-dense food and sweetened beverages and lack of physicalactivity resulted in an increase in the rates of obesity. Easy access to private cars andthe 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 partof social gatherings in the Arab culture, and traditional meals usually contain riceand meat, which are high in carbohydrates and fat. In addition, westernization inArab countries led to an increase in the popularity of fast food. These unhealthyeating habits in many Arab countries contributed to the rise in obesity. Studiesshowed 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 torapid urbanization and improved living conditions (Badran and Laher 2011). Forexample, high-income families in Kuwait consume more meats and eggs as com-pared to low-income families. In Egypt, poor people have lower rates of obesitycompared to richer people. Marital status could also contribute to obesity. In Jordan,the rate of obesity was higher in married compared to unmarried adults. Similarfindings were reported in several Arabian Gulf countries (Badran and Laher 2011).

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According to the STEPwise survey done by the WHO in 2003–2007, sedentarylifestyles were very common in Arab countries, ranging from 31.15% in Syria to86.8% in Sudan (WHO 2007b).

A study conducted in 34 countries worldwide to assess physical activity andsedentary lifestyle in schoolchildren reported that in some Arab countries like Egypt,UAE, and Oman, schoolchildren had the lowest rates of physical activity andwalking or riding a bicycle to school (Guthold et al. 2010). The low rates of physicalactivity could be attributed to very high temperatures in most Arab countries thatforce 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 andLaher 2011; Naweed and Asem 2016).

Obesity in Arab Women (Sociocultural Context)

Traditions in Arab countries restrict the lifestyle choices of women, resulting inwomen having an increased prevalence of obesity (Naweed and Asem 2016). Manywomen have limited access to exercise facilities. Moreover, almost all families inSaudi Arabia and Kuwait employ housemaids and cooks; hence, housewives havefewer chores to do. About half the women in Syria and Palestine lead a sedentarylifestyle. Multiple pregnancies contribute to obesity in Arab women. Around 30% ofSyrian women with one child are obese, and the prevalence increases to 75% withseven children (Badran and Laher 2011). A study conducted on Emirati womenclassified barriers to weight control as: personal barriers (lack of motivation, highappetite), social/environmental barriers (housemaids, social gatherings, outdooractivity restrictions), and physical activity barriers (lack of exercise facilities, hotweather) (Ali et al. 2010).

To combat increasing obesity rates in the Arab countries, there is an urgent needto develop effective measures to prevention and control of this major public healthproblem. Hence, an Arab strategy was developed by the Arab Taskforce for Obesityand Physical Activity aiming to control and reduce the incidence of overweight andobesity by promoting healthy dietary habits and increased physical activity. It waspostulated that governmental and nongovernmental organizations should be moti-vated to set policies and implement sets of programs that were targeted to encourageactive living among all age groups (Musaiger et al. 2011). This strategy provided aroadmap and guidelines for each Arab country to prepare its own action plan toprevent and control obesity. The strategy had specific objectives and specific indi-cators to assess achievement of the objectives in nine areas including: child-carecenters for preschool children, schools, primary health care, secondary care, andfood companies among others (Musaiger et al. 2011). For example, for preschool agechildren the strategy aimed at using these child care centers to improve the aware-ness, skills, and capacity of staff and parents to adopt healthy nutrition, healthyweight, and active play.

Use of Medications in Arab Countries 33

Weight Management Modalities

In the long-term management of obesity, pharmacotherapy can be a useful adjunct tolifestyle modification in selected patients. Weight loss medications may be consid-ered for those with a BMI � 30 or those with a BMI � 27 and have obesity-relatedcomorbid conditions.

Sibutramine is a serotonin-norepinephrine reuptake inhibitor that is indicated forthe treatment of obesity by reducing appetite, and inducing feeling of satiety andpossibly thermogenesis (Luque and Rey 2002). Recently and due to adverse effects,it has been banned from most markets; however, studies of this agent are stillrelevant as it is often a hidden ingredient in herbal and over the counter slimmingproducts (Oberholzer et al. 2015). Rimonabant is an inverse agonist to the cannabi-noid receptor CB1 that, on average, reduces weight by 4–5 kg (Padwal andMajumdar 2007). Sibutramine has been associated with increased cardiovascularevents and Rimonabant has been linked to increased suicidality, which led to theirremoval from the market, so their use is very limited in Arab countries (Naweed andAsem 2016). Orlistat is a pancreatic lipase inhibitor that prevents the digestion andabsorption of dietary triacylglycerol in the small intestine. Its side effects includecramping and severe diarrhea (Badran and Laher 2011). No research has beenpublished on the extent or success of orlistat in the management of obesity in Arabcountries.

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 pharma-cies like medications for chronic diseases. Frequently, untested and unregisteredweight loss products were marketed as nutrients or vitamins in Arab countries.Published data on the use of pharmaceutical therapy of obesity in Arabic countriesis very scarce. Weight loss products show limited efficacy and have many sideeffects. This has caused a rise in the popularity of weight loss surgeries and lifestylemodification, over pharmaceutical therapy, as the cornerstone of obesity manage-ment in many Arab countries (Naweed and Asem 2016).

Urbanization in Arabic countries have led to greater consumption of unhealthyfood and decreased physical activity, which has led to an increase in the prevalenceof obesity in children, adolescents, and adults, especially women in Arab countries.Cultural factors and lack of awareness about obesity-related risk factors are alsocontributory to the rise of the alarming obesity phenomenon. Generally, medicalmanagement of obesity has shown limited progress due to the modesty of theassociated weight loss in relation to numerous side effects. Weight-loss surgerieshave thus been the cornerstone of obesity management in Arab countries. Obesity isa major public health problem that requires much strategy by government andnational authorities, private healthcare systems, and the individual populations inArab countries.

34 S. Hasan et al.

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 druginformation, advice, and counseling. However, several factors contribute to short-comings in the practice of pharmacy in the Arab countries and so several methodsare required to correct them. The laws governing the practice of pharmacy in manyArab countries do not give clear guidelines on what the expectations of communitypharmacists are, and what pharmacists could or could not provide as it relates topatient assessment, information giving, and labeling of sold medications. Strictenforcement of regulations in Arab countries is warranted; legislation does notallow pharmacists to dispense POM medications without prescription and yet thepractice continues to allow public access to a wide range of medications withoutprescription at the expense of safety and effectiveness.

It seems there are wide disparities in pharmacovigilance systems and nationalcapacities to monitor and ensure safe use of medications in Arab countries.According to WHO revelations, only six Arab countries have the minimal require-ments for a functional national pharmacovigilance system. Reports from Arabcountries revealed that pharmacists and other health professionals do not havegood knowledge of ADR reporting, which compromises monitoring of medicationsafety 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 maybe as high as 88%. Within specific disease states, patients reported nonadherence forhypertension, diabetes, and depression. Reasons reported for nonadherence includeforgetfulness, medication side effects, wanting a “drug holiday,” concerns aboutdrug dependency, feeling well, treatment regimen that is complicated, patient feelingbetter with treatment, cost of medications, and patient-reported laziness. A veryimportant reason reported for nonadherence was related to patients’ concerns,beliefs, and attitudes. Beliefs of patients about medications play a significant rolein determining their adherence to taking medications and need to be explored as partof interventions targeting improving adherence.

Notably, the incidence of self-medication in Arab countries is high. It is clear thatawareness campaigns and patient education are needed to enhance patients’ knowl-edge about the appropriateness and potential hazards of medication use withoutconsulting a healthcare professional. Medicines implicated in self-medication mis-use 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 fortreatment of respiratory tract symptoms such as sore throat, cough, and flu.

Unfortunately, the use of prescription medications for recreational use is a newtrend of misuse with a change from usual illicit substances toward legally prescribedmedications, 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

Use of Medications in Arab Countries 35

medicines include contraception, immunization, smoking cessation, and weightmanagement. Evidence on medicines use to enhance health promotion and diseaseprevention modalities is limited, but there are indications it may suboptimal in Arabcountries. These may be due to individual, social, cultural, or government andregulatory-related factors.

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