Gender equality in education and community pharmacy practice in the Middle East: A systematic review of literature

Abstract

Background:

Most of the world has made progress towards attaining gender equality in education and practice of healthcare. Nevertheless, in the Middle East, noting restrictive social and religious norms, there are questions as to whether such equality witnessed in other parts of the world is a reality in this region.

Methods:

A comprehensive search of 4 electronic databases was carried out for literature on gender equality on education and community pharmacy practice in the Middle East. A total of 9 articles directly addressing issues on the study topic within the Middle East were included in the systematic review.

Results:

The findings showed good progress in educational attainments across most of the Middle Eastern region. Women and men alike have almost equal chances in education, with some nations like Saudi Arabia having more women than men graduating from universities. However, there are high-level disparities in community pharmacy practice, where despite many of the workers in pharmacy within the region being women, their representation in top positions in pharmacy is very low. They also earn less than their male counterparts, and at times they are forced to engage in unpaid healthcare work like it recently emerged in Lebanon following the financial crisis within the nation. Barriers such as restricted mobility, gendered social roles, and discrimination at work present as the key factors fueling the inequality levels witnessed in the region in pharmacy practice.

Conclusions:

The Middle East is a region that like other parts of the world, is making good progress towards equality in education. However, such equality in education appears not to translate to equal job opportunities in the practice of community pharmacy, pointing to a need for relevant stakeholders to engage in measures for addressing the identified barriers that prevent women from fully equaling men in healthcare practice for the benefit of the larger society.

1. Introduction

Gender equality has been a central issue in various sectors throughout the. Across different carriers, current literature shows that there has been an increasing attention being paid to the implications that gender equality has professional and educational domains.^[1,2] In the Middle East, the pursuit of gender equality remains a complex and evolving challenge, shaped by cultural, religious, as well as socio-political factors.^[3–5] Community pharmacy and education are both critical areas where gender dynamics significantly influence outcomes and opportunities and for this purpose, an understanding of the state of gender equality in these 2 areas is paramount.^[6,7] In line with this observation, this systematic review had the goal of exploring the state of gender equality within community pharmacy and education for the purpose of providing a comprehensive analysis regarding how gender roles, biases, and policies do impact the participation and advancement of women in community pharmacy and education across the Middle East.^[8–10] Upfront, it is vital to note that the Middle East presents a unique context for examining gender equality given that it is characterized by a diverse range of cultural norms and legal frameworks, alongside critical religious guidelines and practices.^[3,11] Countries in this region have made varying degrees of progress in addressing gender disparities, with some such as the Kingdom of Saudi Arabia adopting more progressive approaches and others maintaining traditional gender roles that limit women’s access to education and professional opportunities.^[12–14] The healthcare sector, including community pharmacy, is 1 area where these disparities are particularly evident. Pharmacy, as a profession, does require a high level of education and is often viewed as a more accessible healthcare career for women.^[15] However, the extent to which gender equality is realized in this field varies across the Middle East, influenced by factors such as educational access, employment policies, and societal attitudes toward women in the workforce.^[16,17]

Education plays a crucial role in shaping the professional growth not just within the Middle East but across the world.^[18,19] This role is particularly notable in the practice of community pharmacy, essentially because community pharmacy professionals have to be highly educated to ensure safety of patients and professionalism in their mandates.^[16] Access to education and the quality of educational experiences, for this reason, turn out to be pivotal in determining career trajectories and opportunities for advancement within the community pharmacy line of healthcare practice. In many Middle Eastern countries, current literature points that educational institutions have been criticized for perpetuating gender biases, both in their curricula and in the opportunities that they do provide to students in pursuit of relevant knowledge and qualifications to engage fully and professionally in community pharmacy.^[20,21] Gender segregation in schools and universities, disparities in enrollment and graduation rates between men and women, and the underrepresentation of women in leadership positions within educational institutions are all issues that reflect broader societal challenges regarding gender equality, and without a doubt, these educational inequalities easily translate into professional barriers that have a significant towards limiting women’s ability to enter and succeed in fields like community pharmacy.^[22]

Moreover, the current literature points to the fact that the broader socio-economic and cultural contexts are vital aspects that further influence gender equality in community pharmacy within the Middle East. The intersection of gender with factors such as socio-economic status, rural-urban divides, and legal restrictions have a critical role in complicating the overall outlook of gender equality and how it is attained across different nations within the Middle East region. In some countries, women do face legal or cultural restrictions on their ability to work in certain settings, travel without male guardianship, or engage in professional networks, all of which can hinder their participation in community pharmacy.^[23] Additionally, societal expectations and family responsibilities have consistently placed additional burdens on women seeking to fully engage in pursuit of education necessary to place them as qualified individuals within community pharmacy, making it difficult for them to pursue full-time careers or advance to leadership positions within the community pharmacy sector.^[23]

Despite these complex issues that are highly influential to women within the Middle East region when evaluated in the context of pursuing successful education and career in the pharmaceutical area, there is a notable gap in current literature exploring this topic. Much of the available research in the region has previously focused on either a particular nation or regions within the particular region, but there is an apparent major gap on research studies that expound on the issues and challenges faced by women across the Middle East in light educational and career paths in pharmacy. Accordingly, the current study fills this gap by bringing together perspectives from across different nations in the region for the purpose of giving an overall picture of the issues affecting women in this region within framework of successful attainment of education and career in the pharmaceutical industry. Ultimately and noting these perspectives from the background of the study topic, in this systematic review the authors purposed to explore and elaborate on these complex and interrelated issues around gender equality in education and community pharmacy through the synthesizing of existing research on gender equality in community pharmacy and education within the Middle East. The goals was to identify the key challenges and opportunities for promoting gender equality in these fields, allowing for the provision of the most suitable recommendations for policy and practice for the purpose of supporting more equitable outcomes, as well as contribute to a deeper understanding of the ways in which gender shapes professional and educational experiences in the Middle East and offer insights that are relevant not only to the region but to global discussions on gender equality in healthcare and education.

2. Methods and materials

2.1. Design

The complete study design was based on the guidelines of the preferred reporting items for systematic reviews and meta-analysis (PRISMA). Such a design ensured inclusion of the most relevant items for a comprehensive and meaningful review of existing literature on the study topic as guided by the PRISMA principles and guidelines for developing effective systematic literature review.

2.2. Search strategy

Four electronic databases namely the PubMed, Embase, cumulative index to nursing and allied literature (CINAHL), and Scopus were searched in August 2024 using a combination of keywords and MeSH (medical subject headings) to gather relevant articles for inclusion in the current literature review. The search strategy terms and MeSH phrases used to yield the included studies in this review are captured in Appendix S1, Supplemental Digital Content, http://links.lww.com/MD/O366. The lead researcher designed the search strategy and did the search across PubMed, Embase, CINAHL, and Scopus.

2.3. Screening for inclusion and exclusion

Two assistant researchers helped with the screening of the emerging studies for inclusion or exclusion from this review. The selection for inclusion was for studies published within the Middle East and countries within north Africa which predominantly have social, cultural, and religious practices that are strongly a match to those of nations within the Middle Eastern region. The justification for the inclusion of studies from these nations was that it would help ensure that the findings were reflective of the studies purpose and help in providing useful knowledge that could be helpful to policy makers and other relevant stakeholders in the healthcare sector in the pursuit of promoting a level playground for all genders.

Two reviewers engaged in the screening of all 2457 results that emerged from the initial search. The first step in the screening was to screen the titles and abstracts of the studies for their inclusion suitability in this study. After the first phase of screening, the reviewers screened the studies for location of publication to ensure that they were meeting the geographical location for the current study, and then the entire documents for the selected studies were read in complete to further ascertain their suitability for inclusion.

The exclusion criteria was for studies not done in English, not published or focusing their outcomes on the Middle East region, and for studies whose full articles could not be obtained.

2.4. Assessment of risk of bias in included studies

The assessment of bias in the included studies was carried out by 2 assistants to the researcher, employing the Risk of Bias in Non-randomized studies of Interventions (ROBINS-I) tool. The evaluation for risk of bias was based on 5 domains across all the included studies, these domains being risk of bias due to confounding factors, risk of bias due to selection of participants, risk of bias due to missing data, bias in measurement of outcomes, and bias due to selection of the reported results. Across all studies, the risk of bias was low, indicating that the used studies were appropriate for providing the data for guiding the conclusions arrived at in the current study.

3. Results

3.1. Study selection

The flow chart diagram shows the study selection process that the authors utilized for this systematic review, and it is demonstrated in Figure 1. As the diagram shows, the entire process from selection to screening and ultimately the included studies are captured, alongside with the reasons for exclusion at each level of the selection process.

Figure 1.

PRISMA 2020 flow diagram of searching, screening, and selecting the records. PRISMA = preferred reporting items for systematic reviews and meta-analysis.

3.2. Study characteristics

All the 9 studies included in this review covered concepts that are incredibly relevant for informing policy and decision making in healthcare for achieving optimal gender equality in education and community pharmacy practice within the Middle East, and by extension across the entire globe.

3.3. Assessment of bias in the studies

According to the PRISMA guidelines, 1 of the essential elements for credible and ethical research work is that the entire study is carried out without bias. In this regard and beyond the application of the ROBINS-I tool on 5 key domains as covered in the methodology, the researcher engaged in a detailed review of the studies for potential bias and to ensure that their inclusion for informing the current systematic review was not yielding misleading information. The assessment for bias included scrutinizing the foundations of each individual studies and whether it was carried out in line with provisions for professional research work, verifying of the authorship credentials to confirm that the authors were experts in the area of study, and confirming that the conclusions of each individual study were drawing from the reported research findings in that research article.

3.4. Results of the individual studies

The results of the individual included studies in this systematic review are captured in Table 1.

Table 1.

The results of the individual included studies in this systematic review.

Author(s)	Country/region	Area of focus in gender equality in education and community pharmacy practice	Key findings
Alsheri et al (2024)	Saudi Arabia	Perceptions and intentions among female pharmacy students to work in community pharmacy settings	Despite a conducive environment for female students to work in community pharmacy, factors such as training and individual attitudes hinder many of these students to work in community pharmacy after graduation, resulting in low rates of female professional working in community pharmacy within Saudi Arabia.
El Haji et al (2019)	Middle East	Perceptions of the public towards community pharmacy and the effect it has in promoting gender equality in community practice	The authors established that there is a low (about 33%) to average (about 67%) level of satisfaction with provision of community pharmacy services, and that gender differences did not play a critical role in influencing this satisfaction.
Halat et al (2023)	Lebanon	Gender experiences in pharmacy education as informed by the financial crisis in Lebanon	Recent years have seen advances in women education within Lebanon and the larger Middle Eastern region, but there is high level discrimination in pharmacy practice as women, despite being the majority in pharmacy, are the fewest in high pharmacy positions, and have been forced by the recent financial crisis in the nation to engage in homecare and unpaid community pharmacy work.
Tlaiss (2023)	Middle East	Barriers and enablers to education and community pharmacy practice	A wide range of barriers including discriminatory cultural values, gendered social roles, and patriarchal social settings are major barriers to women in healthcare within many developing Middle Eastern nations
Al-Asfour et al (2017)	Saudi Arabia	Barriers to women advance in the workplace environment	Lack of mobility, gender stereotypes, gender based discrimination in the workplace, limited and in some cases total lack of family and work balance, and excessive workload are key barriers that hinder Saudi women from effective progress in their career at the same pace as their male counter parts.
Baliamoune-Lutz and McGillivray (2015)	Middle East	Impact of gender inequality in education on income	Gender inequality impacts women negatively in their career, positioning them as lower earners even when engaging in same job positions as men within the Middle East.
Mobaraki and Soderfeldt (1995)	Saudi Arabia	Education inequality and its role in public health	As of 1995, there were great efforts towards education equality in Saudi Arabia, with findings showing that there were more women graduates in the nation than men as at the time of the study by Mobaraki & Solderfeldt.
Razzak et al (2024)	Oman	Attitudes of community pharmacists towards extending their professional role	The findings showed no gaps in relation to the perceptions of community pharmacists in extending their professional roles, alluding to an empowerment from education where both male and female community pharmacists are happy to engage more in their roles to promote better health outcomes and fully functional societies.
Al-Subeh and Alzoubi (2020)	Jordan	Barriers to women education in healthcare research	Restricted movement emerged as a major barrier for women to engage in constructive research work that could help bring about important improvements in healthcare.

4. Summary of the results

4.1. Unequal and biased representation in pharmacy professional positions

In Lebanon, current literature points to a critical issues around gender equality in the practice of community pharmacy and general pharmaceutical practices. According to Halat et al, the recent past has seen more women join pharmacy in Lebanon, promoted by calls and commitments towards gender equality and education in the nation.^[24] Nevertheless and despite women being the majority of the professionals in pharmacy, they are significantly underrepresented in high positions in the pharmacy academia. The recent crisis in the nation, apparently, impacted women negatively as it forced many of them to improvise their jobs as well as household responsibilities, the result being increase in unpaid care and household work.^[25]

4.2. Discriminatory cultural values

Similar findings were by Tlaiss who focusing on the barriers and enablers for women in healthcare practice within the Middle East, established that a wide range of barriers including discriminatory cultural values, gendered social roles, and patriarchal social settings are major barriers to women in healthcare within many developing Middle Eastern nations.^[26] Such barriers are a major hindrance on the way of community pharmacy as a core service that is valued by many members of society across the Middle Eastern region.^[27] Al-Asfour et al (2017) had also unearthed that of mobility, gender stereotypes, gender based discrimination in the workplace, limited and in some cases total lack of family and work balance, and excessive workload are key barriers that hinder Saudi women from effective progress in their career at the same rate with which men in their nation climb up the career ladder.^[28]

4.3. Willingness to develop professional skills through education

Women, like men, feel encouraged to extend their professional roles in community service, and this can be alluded to equality in educational outcomes according to Razzak et al (2024).^[29] In nations such as the Saudi Arabia, equality in education among healthcare workers appears to be strong, with the findings of this study showing that as of 1995, there were slightly more women in Saudi Universities than men according to Mobaraki and Soderfeldt (1995).^[30] Restricted movement, an attribute of the restrictive social practices in Saudi Arabia, emerges as a major barrier to women from participating in healthcare research as they may not freely engage in studies that call for their movement from 1 place to another. According to Baliamoune-Lutz and McGillivray (2015), women are still challenged when it comes to how much they earn from their careers doing the same work as men, even with same educational qualifications.^[31]

5. Discussion

5.1. Cultural and religious barriers to career advancement

The reviewed literature points to a pressing need for some nations within the Middle East to establish further measures to ensure optimal gender equality in community practice within the region.^[31] Lebanon is 1 such nations, the findings showing that the recent financial crisis had a major negative impact on women engaged in community pharmacy and other pharmaceutical practices. Most of the female pharmacists in the nation had to engage in activities that resulted in them being underpaid or completely unpaid for their community services, and indication that there is still a challenge of gender differences in relation to pharmacy opportunities and practice within the Middle Eastern region. A further surprising finding was that very few women are in high positions within the pharmacy sector in Lebanon, contrary to the fact that the largest number of pharmacists in the nation are women. Such an outcome points to a pressing issue where despite women having all credentials and qualifications to hold high positions in pharmacy, that still remains an unattained goal, potentially due to issues around religious and cultural restrictions.^[32] Such findings are amplified by Asi (2024) who notes that while women are extremely underrepresented in paid workforce within the region, within nations such as Jordan having women employment rate of 17.47 percent as of 2020.^[33] On the contrary, in the unpaid work, women are the majority, performing care giving tasks that promote a health and functional societies.

5.2. Societal setting barriers

Most of the world has moved from social settings that restrict women to particular gender roles and carriers, but for most developing nations in the Middle East this appears not to be the case. A recent report by the Human Rights Watch Organization found that across many Middle Eastern nations, from Yemen, Oman, United Arab Emirates, Syria, Lebanon, Iran, Iraq, Israel, Jordan, and even the North African Egypt, women cannot leave their homes without permissions from a male guardian, either their father or husband, as doing so places them in a situation where they can face possible sanction.^[23] This perspective is heavily supportive of the finding by Tlaiss who notes that factors such as discriminatory cultural values, gendered social roles, and patriarchal social settings are major obstacles to women in healthcare within many developing Middle Eastern nations.^[26] These barriers, originating from household settings and influenced and powered by cultural and social norms, even reach into organizational settings, hindering women’s progress in the career of pharmacy and other specialties.^[31] Such barriers point to the a situation where even for women to engage effectively in their pharmacy duties when they have attained working status, they may find it difficult to move freely to attend to their pharmacy duties as societal barriers hinder them from such free movement. According to Al-Asfour et al, women in Saudi Arabia find it difficult to move up the career ladder owing to factors such as restricted mobility, gender stereotypes as well as gender based discrimination in the workplace, limited family and work balance, and excessive workload.^[28]

5.3. Unequal representation in employment within the pharmacy industry

Apparently, education is an area where many nations have made positive strides to attain equality within the Middle East, but it is unfortunate that after equipping women with the relevant knowledge they end up finding it difficult to fully utilize this knowledge in pharmacy and other areas in ways that could promote better health and functional society within the region and the world at large. Considering that globalization has brought with it mobility of labor among other benefits, it is unfortunate that due to social and patriarchal settings women from the Middle East cannot have the motivation to look for work beyond their nations as even if they find such employment opportunities, they will be restricted from moving away unless they have supportive male figure who can welcome such moves.

According to Razzak et al (2024), both men and women in the healthcare sector feel encouraged to extend their professional roles in community service, which can be attributed to equal educational opportunities.^[29] This suggests that, at least in terms of educational outcomes, there is a level of gender equality that empowers women to pursue similar career paths as their male counterparts. However, the situation in Saudi Arabia presents a more complex picture. While Mobaraki and Soderfeldt (1995) indicate that by 1995, women slightly outnumbered men in Saudi universities, reflecting a strong presence of women in higher education, this does not necessarily translate into equal professional opportunities because restrictive social practices in Saudi Arabia, such as limitations on women’s movement do pose significant barriers to their participation in healthcare research and other professional activities that require mobility.^[30] This restriction hinders women’s ability to fully engage in their careers, despite their educational qualifications. Moreover, despite equal educational attainment, women in Saudi Arabia continue to face challenges in achieving economic equality. As noted by Baliamoune-Lutz and McGillivray (2015), women often earn less than men for doing the same work, even when they possess the same educational qualifications.^[31] This wage disparity underscores the persistent gender inequality in the workplace, where educational achievements do not necessarily translate into equitable economic outcomes.

5.4. Recommendations

The resolving of the challenges faced by women in the Middle East, challenges that according to this study revolve around the domestic environment, employment discrimination and traditional oppressive practices, calls for a mix of solutions. It is recommended that first avenue that can be adopted is legal changes to regulate equality in the context of employment and in general society are needed. Governments within the region should encourage and enhance the legislation on women employment, equality of wage between male and female employees as well as right to promotion to any position. Such changes need to be supported by punitive measures and by raising public and employers’ awareness of women’s rights.^[34] Also, some company policies like flex- time, parental leave, and office childcare services enable women to fulfill their careers and duties at home in other places around the world, and they could be of significant help if implemented within the workplace environment within this region.

In addition, education and capacity-building interventions can help to reduce culture norms and practices that serve to only limit women’s mobility and opportunities. To challenge the tradition for women, it is recommended that funds should be spent on education and vocational training for girls, essentially so that women could go to work having necessary skills and eliminate the pressure from the men in this region who appear to perceive women as not able to freely move and perform duties without the supervision of a male figure.^[35,36] Further, community campaigns to willingly discuss gender issues with males and females can go a long way towards bringing changes to the society and decreasing the prejudices against the independent women. Notably, education and participation around traditional stereotypes which have for decades hampered the advancement of women in the region is recommended as it can bring about the necessary awareness for better society and propel the Middle East region towards better equality for women and men alike.

6. Conclusion

The findings of this study point to a situation where much of the Middle East has made great progress towards attaining health education equality for healthcare professionals. In nations like Saudi Arabia, the findings show that more women are graduating from universities than men, and this is quite encouraging from the perspective of pursuit of gender equality in society. In addition, more women engage in community pharmacy practice, practical examples being the case of Jordan where the largest proportion of pharmacy professionals are women. Despite this positive trend towards attainment of gender equality in education within the Middle East, there are major disparities when looking at workplace outcomes particularly within the healthcare sector. In Jordan where more pharmacists are women, their numbers in high ranking pharmacy positions are minimal. Women face many other restrictions such as mobility, discrimination at work, and social gendered roles that prevent them from fully equaling their male counterparts in delivering healthcare services for healthy society. Accordingly, an the collaboration of all relevant stakeholders to implement the recommendations above is appropriate from nations within this region to further better the results so far attained towards gender equality both in education and career progress in the pharmaceutical industry.

Acknowledgments

The author extend their appreciation on Taif University, Saudi Arabia, for supporting this work through project number (TU-DSPP-2024-256).

Author contributions

Conceptualization: Ali Alshahrani.

Data curation: Ali Alshahrani.

Formal analysis: Ali Alshahrani.

Funding acquisition: Ali Alshahrani.

Investigation: Ali Alshahrani.

Methodology: Ali Alshahrani.

Project administration: Ali Alshahrani.

Resources: Ali Alshahrani.

Software: Ali Alshahrani.

Supervision: Ali Alshahrani.

Visualization: Ali Alshahrani.

Writing – original draft: Ali Alshahrani.