p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4

Available online at www.sciencedirect.com

Public Health

journal homepage: www.elsevier.com/puhe

Review Paper

Toward patient-centered care and inclusive health-

care governance: a review of patient empowerment
in the UAE

V. Bodolica a,*, M. Spraggon b,1

a
American University of Sharjah, School of Business Administration, P.O. Box 26666, Sharjah, United Arab Emirates
b
Mohammed Bin Rashid School of Government (MBRSG), Convention Tower, Level 7, P.O. Box 72229, Dubai, United
Arab Emirates

article info abstract

Article history: Objectives: The purpose of this article was twofold. We aimed to both clarify the multidi-
Received 10 May 2018 mensional notion of patient empowerment (PE) and conduct a comprehensive survey of
Received in revised form PE-related literature in the specific context of the United Arab Emirates (UAE).
14 January 2019 Study design: The study objectives were achieved by means of a two-phased systematic
Accepted 31 January 2019 review of the literature on PE and associated dimensions.
Methods: The first phase consisted in the database search for recent review articles on the
construct of PE that were published in the past five years. The second phase focused on the
Keywords: identification of extant empirical research on PE and related concepts in UAE settings. In
Patient empowerment total, 13 review articles and 17 empirical studies were eligible and included in our analysis.
Patient-centered care Results: The retained PE review articles pointed to two major themes and four topics on
Health-care governance ‘conceptual clarification’ and ‘contextual embeddedness’, where PE was tackled in relation
Policy making to national health-care system, health-care governance, information technology, and
United Arab Emirates therapeutic continuum. Our analysis of UAE-based PE studies unveiled three themes on
‘chronic disease care’ (with three topics of ‘general inquiries’, ‘diabetes management’, and
‘diabetic complications’), ‘self-medication with drugs’, and ‘non-therapeutic in-
terventions’. By juxtaposing the identified PE themes and topics, we derived three prom-
ising opportunities for researchers, practitioners, and policymakers to consolidate, expand,
and initiate relevant PE interventions in the UAE.
Conclusion: This review article found that PE represents an emergent and underexplored
notion in the UAE health-care system. As UAE ambitions to become a sought-after medical
hub in the global arena, the design and implementation of adequate PE strategies and
reforms play a critical role in the development of a world-class patient-centered health
care in the country.
© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ(971) 56 1018688.

E-mail addresses: virginia.bodolica@hec.ca (V. Bodolica), martin.spraggon-hernandez@hec.ca (M. Spraggon).
1
Tel.: þ(971) 56 6069447.
https://doi.org/10.1016/j.puhe.2019.01.017
0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4 115

Complete, PubMed Central, and PsycInfo databases. To

Introduction generate review-only PE articles, we used the keyword
technique searching for ‘PE’ and ‘review’ words simulta-
Giving patients a greater voice and more power in their neously in ’ title/abstract. After screening the generated
interaction with suppliers of health care is a national priority records, we removed duplicates and excluded non-reviews
in many countries around the globe.1e4 Patient empower- and non-PE papers. Five articles were identified by holding
ment (PE) emerged as a focal element in governmental ef- discussions with colleagues, but only two were retained as
forts to achieve patient-centeredness for inducing enhanced the other three were conceptual papers.
self-care efficacy, increased medication adherence, opti- The assessment of articles’ full texts for securing
mized resource usage, and improved citizens’ well-being.5e7 compliance with eligibility criteria was performed by two
This trend was accompanied by a growth in studies on PE peers in parallel to increase confidence and eliminate bias.
along the therapeutic continuum,8,9 resulting in many con- The eligibility considerations were as follows: articles had to
ceptualizations and measurements to operationalize this review PE and related literature; be published in peer-
notion.10,11 PE is defined as the perceived ability of the pa- reviewed English-language journals; and appear in press
tient to self-manage own health by getting involved in de- from 2013 onwards. Empirical and conceptual articles, tech-
cisions and assuming responsibility for choices affecting nical papers/doctoral theses, books/reports, policy briefings,
personal health.12 and non-refereed contributions were excluded. The individ-
Recognizing the challenges of applying the multidimen- ual results of each peer were compared, and one discrepancy
sional PE concept in empirical settings, scholars synthesized emerged regarding a review on patient involvement.4 This
extant knowledge on PE and related dimensions to generate a discrepancy was addressed in a meeting, where the decision
unified measurement scale.13 Although much research was to drop this paper was made because of its lack of conceptual
conducted on PE in Western nations, little is known about PE PE focus.
initiatives in the emerging market context of the United Arab A final check for sample comprehensiveness was per-
Emirates (UAE). The UAE government pursues continuous formed using the ancestry approach of articles’ identifica-
improvement across an integrated health-care system, tion.25,26 It allows examining the reference lists of the most
including institutional and service quality, resource usage and recent articles to determine whether new entries could be
cost control, and actual health outcomes for its pop- generated that were missed through database searching. We
ulation.14e16 To achieve this strategic priority, while adapting screened the references of the six retained articles published
to the needs of a changing demographic profile and account- in 2016e2017 in search for non-identified reviews. Because
ing for the surge of several chronic diseases, the UAE this procedure did not yield additional eligible articles, our
embarked on a program of medical reforms and renova- final sample of 13 PE-related reviews remained unchanged.
tions.15 Determined to secure a leading position in interna- These review articles were examined to derive an accurate
tional rankings, the country aspires to develop a world-class definition and understanding of PE and associated dimensions.
health-care system and transform itself into a sought-after Islamic scholars highlighted ethical concerns regarding the
medical hub in the global arena.17e20 relevance/timeliness of the principle of individual autonomy
The notable progress that has been achieved in the UAE and right to self-determination in local settings on the basis of
health-care sector has been well documented in academic/ historic, religious, and sociocultural considerations of the
practitioner publications.21e23 Yet, the extent to which Muslim population.22,27 These concerns could have delayed the
members of the public have been empowered to take control widespread acceptance of PE in the UAE, affecting the amount
of their health and participate in the design, delivery, and of scholarly production on this topic. Because by focusing on PE
governance of health care remains unclear. No systematic exclusively, without considering closely related terms, we
effort has been deployed to analyze the UAE-based evidence could have missed relevant literature, we kept our search as
on PE, and we bridge this gap via a two-phased literature re- open/comprehensive as possible.
view. This article offers a critical assessment of the current Our analysis revealed that patient autonomy/self-
state of empirical PE research and related constructs in the determination, patient choice/voice, patient engagement/
cultural/regulatory framework of the UAE. participation, patient involvement/activism, patients’ rights,
self-care/self-management, coping with disease, patient
knowledge/information empowerment, and shared decision-
Methods making are used interchangeably to infer PE. These terms,
separated by the Boolean operator ‘or’, were entered as key-
All the review procedures were conducted in accordance words when performing the database search. We used the
with Preferred Reporting Items for Systematic Reviews and operator ‘and’ to limit the search to only UAE-based PE
Meta-Analyses (PRISMA) guidelines13,15,24 (Fig. 1). The pur- studies. To capture locally oriented articles, we alternated
pose of the first phase was to clarify the notion of PE and between the country name and its three-letter acronym and
related dimensions. A thorough database search was made used the names of Abu Dhabi, Dubai, and Sharjah emirates.
to detect refereed articles published in the past five years Because PE topicality is a recent occurrence in the Arab region,
that reviewed PE research. We focused deliberately on we focused on articles published over the past decade to
recent review articles as they offer a holistic analysis of the generate an updated account of PE in the UAE.
diversified PE-related literature cumulated over the years. To complete the second phase of our survey, we followed
Our search was made using ProQuest Health and Medical the aforementioned procedures. To decide about the retention
116 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4

Fig. 1 e Methods of the two-phased systematic review of the literature on PE in the UAE. PE, patient empowerment; UAE, the
United Arab Emirates.

of papers, we defined a slightly different set of eligibility

criteria. The following conditions for inclusion should have Results
been met: empirical articles on PE and associated constructs
in the UAE, published in refereed English-language journals PE-related review articles
from 2008 onwards. Non-academic literature, conceptual pa-
pers, and empirical studies that offered an aggregated anal- Two themes emerged from the content analysis of 13 PE re-
ysis of PE-related issues in several Arab states were excluded. views: ‘conceptual clarification’ and ‘contextual embedded-
This was the case of a breast cancer control strategies’ study ness’ (Table 1). Four first-theme articles are dedicated
in four geographical regions, where PE emerged as a consti- exclusively to elucidating the notion of PE and associated di-
tutive dimension of ‘promoting advocacy’ theme.28 This mensions. Each survey advances a different conceptual model
article was excluded because its findings were presented to map PE-related constructs, highlighting the difficulty of
indiscriminately for a group of 12 Arab nations, without making sense of this complex literature. Some authors focus
separating the effects for each included country. on PE indicators and behaviors,29 whereas others uncover the
The full texts of 75 generated articles were thoroughly antecedents, attributes, and consequences of PE.30 The
examined to verify their eligibility. Because most of them did concept is interpreted through the lens of an enabling process
not pertain to any dimension of PE, only 16 papers were that leads to various outcomes10 or presented as a combina-
retained. By screening the references of a recently published tion of ability, motivation, and power.11
survey on diabetes self-management in the Gulf,24 we iden- Among the most cited PE elements are patient's medical
tified one pertinent entry. Each researcher from our team knowledge, coping skills, health literacy/education,
analyzed the contents of the retrieved studies and confirmed information-seeking behavior, gaining control, sense of
their inclusion in the review. The second phase of the pro- meaning, shared decision-making, self-care/self-manage-
cess yielded a sample of 17 empirical articles on UAE-based ment, and self-efficacy. PE is mapped in relationship with
PE issues. patient activation, enablement, engagement, involvement,
Table 1 e Recent literature review articles related to the concept of PE.
Reference Context Emphasis PE elements and associated dimensions Findings and contribution
Theme 1: conceptual clarification (4 articles)
Bravo et al.29 Acontextual(concept Conceptual model of PE (at Indicators (self-efficacy, knowledge, skills, personal PE is a state ranging from low to high level;
focused) patient, professional, and control, health literacy, sense of meaning, feeling responsibilities of patients, providers and health-care
system level) respected); behaviors (self-management, shared system to use PE interventions to enhance clinical
decision making, take part in groups, use Internet to outcomes
search/share info)
Cerezo et al.10 Acontextual(concept Analysis of dimensions and PE as enabling process (knowledge acquisition, coping challenge of incorporating PE in health-care practice
focused) measures of PE concept skills); PE as outcome (participation in decision making, through motivational strategies to induce behavioral
gaining control); other PE dimensions (self-care, capacity change
building, trust, motivation, sense of meaning, positive
attitude)
Fumagalli et al.11 Acontextual(concept Conceptual map for PE and PE as a process, emergent state, and behavior PE mapped in close relationship with patient activation,
focused) 5 related concepts (participation and involvement); PE as a combination of enablement, engagement, involvement, and

p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4
ability (enablement), motivation (engagement), and participation
power (activation)
Castro et al.30 Acontextual(concept Conceptual analysis of PE, Antecedents (patient education, knowledge, control, process model in health care to improve quality of care/
focused) patient participation, and participation); attributes (enablement, activation); life: strategy of patient participation facilitates patient-
patient-centeredness consequences (self-efficacy, control, self-management); centeredness, which leads to PE
is a much broader concept than patient participation
and patient-centeredness
Theme 2: contextual embeddedness (9 articles):
Topic 2.1: PE and national health-care system
Boudioni et al.31 National health-care Role of citizenship, culture, Patient/social/community participation; public PE shaped by stronger (weaker) citizenship and longer
system voluntary community involvement; patient informed choice and voice; (shorter) tradition of voluntary action in England
organization in PE in Greece patients’ rights; expert patients; patient ability to control (Greece)
and England own care
Boudioni et al.32 Health-care policies Comparison of national legislation-driven; patients’ rights (access to health care, policies emphasize: patient-centered services, public
policies, systems, structures quality of care, approval of treatment, respect, consent, involvement and PE, in England; patient rights,
of PE in Greece and England confidentiality, information, informed choice, responsibilities, and quality of services, in Greece
involvement in own health care, right of redress);
patient-focused services
Topic 2.2: PE and health-care governance
Bodolica and Health-care Divide between PE (patient choice, autonomy, medical literacy) as a advocate the integration of macro and micro governance
Spraggon33 governance macrogovernance and component of micro-level governance (in the patient devices in health-care settings
microgovernance ephysician relationship)
Tofan et al.34 Relational PE as governance PE as distrust-based governance tool (patient autonomy, conceptual framework integrating both trust- (doctor-
governance mechanism in physiciane assertive control, info empowerment, choice, focused) and distrust-based (patient-led) governance
epatient relationship involvement, decision-making authority, eHealth,
system distrust, use of Internet for info)
(continued on next page)

117
118 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4

participation,11 and patient-centeredness, indicating that PE is

measure of PE to assess its association with the uptake of

huge variety in conceptual operationalization of PE; need

focus on pain treatment given by clinician, involvement

a broad concept that embraces multiple components.30 To

PE promotes adherence; need for joint empowerment

IT (educational, electronic, patient-to-patient, portal
services and multicomponent) contributes to PE by
improve clinical outcomes and quality of life, PE interventions

IT contributes to PE (more proactive behavior) and

to attain definitional consensus and standardized should be integrated into medical practice through jointly
deployed efforts of patients, physicians, and health-care or-

enhancing autonomy, knowledge and skills

Findings and contribution

(patients who share control with doctors)

ganizations to induce a long-lasting behavioral change.10,29

allows citizens to act as info providers

Nine ‘contextual embeddedness’ articles conceptualize PE
in relation to ‘health-care system’, ‘health-care governance’,

of patient and interaction of both

‘information technology’ (IT), and ‘therapeutic continuum’.
Citizenship, culture, and tradition of voluntary action play a
critical role in shaping PE at the national level,31 giving rise to
health-care reforms and PE policies and systems.32 PE is
eHealth solutions

viewed as a distrust-based (patient-driven) governance attri-

bute in the physicianepatient relationship34 and a microlevel
governance component.33 Acknowledging the macroemicro
divide in health-care governance, scholars promote the inte-
gration of macrolevel (policy-making) and microlevel (doc-
torepatient interaction) governance initiatives in medical
settings. IT-based studies conclude that patients’ utilization
PE components: internal health locus of control (belief of
health services; access control; self-care; patient as info

self-efficacy; increasing abilities; locus of control; active

knowledge, confidence for self-care); use of eHealth tech

being in control of own health) and self-efficacy (disease

support from community, family and friends; perceiving
provider instructions; patient engagement (self-control,

of eHealth tools contributes to their empowerment35 through

being autonomous and respected; having knowledge;
having psychosocial and behavioral skills; perceiving
self-management, self-efficacy) and activation (skill,

source; decision making; privacy and confidentiality

patient education; health literacy; remote access to

coping; participation in decision making; resources

enhanced autonomy, knowledge, proactive behavior, and

PE elements and associated dimensions

involvement in decisions; ability to find mistakes;

preparedness; personal control; understanding of

self-management,36 allowing people to act as seekers and

suppliers of medical information.37 To achieve better out-
comes in cancer pain management38 and medication adher-
ence,39 ‘therapeutic continuum’ researchers advocate the
principle of shared control and joint empowerment of pa-
tients and physicians.
(induced by caregiver, skills)

PE is a complex multidimensional construct, which in-

corporates many tightly intertwined elements (autonomy, self-
management, general)

efficacy, health literacy, information search/use, personal

oneself to be useful

control, coping with illness), is relevant at multiple levels

(micro, meso, macro), is analyzed from the standpoint of
several stakeholders (patient, clinician, health-care system), is
interpreted in many ways (process, state, behavior, feeling,
intervention, outcome), emerges at different stages (anteced-
ents, attributes, consequences), is seen as a intrapersonal
disposition (patient power/control) or relational concept (power
Effect of 2 PE dimensions on
analysis of PE in controlling
Conceptual components of

Analysis of how various IT

in clinicianepatient relationship), is linked to many disciplines

and eHealth portal usage
Analysis of PE construct;

empowerment of cancer
relationship between PE

PE; contribution of IT to

(IT, governance, public policy/administration), oscillates along

Conceptual model and
tools contribute to PE

a continuum (low to high), and is influenced by various mod-

Emphasis

erators (culture, citizenship, legislation, socio-economic con-

ditions, professional goals, health status, education).
adherence
survivors

PE-related issues in the UAE

pain

Our analysis suggests that most of the 17 UAE-based PE in-

quiries represent the outcome of repeated efforts of the same
Topic 2.3: PE and information technology

Topic 2.4: PE and therapeutic continuum

researcher teams from local medical colleges/institutions

Electronic health

(Table 2). The majority uses cross-sectional surveys and sta-

technology (IT)
Context

management
Information

Information

Cancer pain

tistical analyses, with only three articles making use of qual-

Medication
technology

adherence

itative methodologies to analyze specific case/interview

data.40e42 While adult patients represent the common study
PE, patient empowerment.
Table 1 e (continued )

subjects, one paper uses clinical professionals43 and four use

college students,41,44 of which two focus on expatriate ado-
lescents.45,46 Only one investigation has explicitly mentioned
te Boveldt et al.38
Calvillo et al.37

Nafradi et al.39

PE (as a perception of being knowledgeable47), with most ar-

Risling et al.35

Groen et al.36
Reference

ticles referring to various PE dimensions. The two closely

related PE constructs that were tackled in UAE studies are
patient involvement48 and local community engagement.41
Eleven papers concentrate on patient capacity for self-care/
Table 2 e Reviewed empirical studies related to PE in the UAE health-care settings.
Reference Method Subjects Field PE/related constructs use Main findings and implications
Theme 1: chronic disease care (11 studies):
Topic 1.1: general inquiries
Hashim et al.43 Cross-sectional 38 nurses and Chronic disease care n/a/patient self-management clinicians’ non-use of proactive patient self-management tools;
survey, regression physicians attending support services’ usage by outreach programs and patient education needed to improve
a workshop clinicians self-care and make chronic disease care systematic (not
episodic)
Sayiner et al.49 Cross-sectional 27 subjects (out of Chronic obstructive n/a/knowledge/being informed feeling of being informed about respiratory condition is
survey, comparison 1392 across 11 MENA pulmonary disease about disease, info seeking suboptimal (higher in the UAE than MENA); info obtained from
states) behavior from various sources doctors, TV and Internet; need for more patient education
Topic 1.2: diabetes management
Baynouna et al.47 Surveys, regressions 442 patients, 7 Hypertension, PE as perception of being behavior assessment needed to design effective interventions
centers in Al Ain diabetes mellitus knowledgeable; ability for self- to increase PE and adherence to healthy lifestyle behavior (via
management self-management)
Hashim et al.50 Cross-sectional 165 patients, 2 clinics Type 2 diabetes n/a/disease-related knowledge of patients’ knowledge about diabetes remained low over the 2001

p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4
survey, regression in Al Ain mellitus patients, self-management e2014 period; education efforts need to focus on behavioral
strategies to enable and encourage patients to adopt self-care
Abduelkarem and Before-after study, 59 patients, 3 Type 2 diabetes n/a/self-care and self- poor disease knowledge, diet and exercise; info programs
Sackville51 24 months pharmacies in mellitus management (achieved via improve self-management; continuous long-term info/
Sharjah information reminders sent education initiatives needed to induce behavioral change to
through pharmacists) adopt self-care
Sulaiman et al.40 Qualitative, 41 patients, Sharjah Diabetes n/a/patients’ disease-related knowledge varied; disease attributed to lifestyle, contextual and
interviews knowledge cultural factors; need for culturally-sensitive strategies to
educate about illness
Al-Maskari et al.73 Cross-sectional 575 patients, 2 Diabetes mellitus n/a/patient self-management of low patient awareness; poor knowledge/skills to self-manage
survey hospitals in Al Ain their chronic disease the condition; awareness programs critical to improve coping,
adherence and self-care
Topic 1.3: diabetic complications
Al-Kaabi et al.58 Cross-sectional 409 patients, clinics Diabetes and dietary n/a/self-monitoring or self- poor self-monitoring and dietary practice; patient-tailored
study in Al Ain practice management of disease dietary counseling needed to empower patients to self-manage
their chronic disease
Al-Kaabi et al.52 Cross-sectional 390 patients, 6 clinics Diabetes and n/a/self-monitoring or self- low level of self-monitoring and physical activity; patient-
survey in Al Ain physical activity management of disease tailored counseling needed to empower patients to self-manage
their chronic disease
Al-Kaabi et al.53 Experimental design, 221 illiterate patients Diabetic foot n/a/illiteracy of patients as illiteracy induces poor knowledge of diabetes and its foot
survey in Al Ain problems predictor of poor foot-related self- complications; education programs for illiterate patients
care needed to enhance self-care
Sulaiman et al.59 Cross-sectional 347 patients, clinics Diabetes, n/a/patient self-care (as correlate depressed diabetic patients have poor self-care and adherence;
survey in Sharjah depression, anxiety of depression) need for self-management initiatives to improve coping with
chronic illness
Theme 2: self-medication with drugs (3 studies)
Shehnaz et al.45 Cross sectional 324 expatriate Self-medication with n/a/self-care attitude or high prevalence of self-medication as evidence of taking
survey students, 4 schools drugs autonomous health behavior responsibility for own health but also risk of misuse; education
programs needed for making the transition to self-care
successful

119
(continued on next page)
120 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4

self-management/self-monitoring, with patient’s disease-

medication; parents, pharmacists and media as sources of info;

source of info; pharmacist plays a key role in patient education

to reduce risk of obesity, need to design multifaceted education

Adolescents’ lack of knowledge of healthy eating and nutrition;
Refusal of cross-gender examination (obstetrics and stomach);

patients of their religious duty to contribute towards doctors’

related knowledge and information-seeking behavior being

self-medication is common; pharmacists and family as main

consanguinity); higher awareness and life expectancy, lower

incidence of disease and cost, better health; need to address
examined on six and three occasions, respectively.

project benefits: law for premarital screening (due to high

cultural sensitivities and build partnerships across levels

need to account for religious and cultural issues; remind

We identified three themes on PE-related issues in the UAE:

programs to increase knowledge of healthy nutrition

low drug knowledge scores, high inclination for self-

‘chronic disease care’, ‘self-medication with drugs’, and ‘non-

Main findings and implications

therapeutic interventions’. The contents of 11 first-theme ar-

ticles point to three topics: ‘general inquiries’, ‘diabetes
management’, and ‘diabetic complications’. Because public
awareness about chronic conditions is suboptimal, the adop-
tion of patient education programs and system interventions
is recommended to depart from episodic to more systematic
need of education campaigns

chronic disease care.43,49 The five ‘diabetes management’

studies suggest that educational initiatives in the UAE should
be deployed continuously to induce sustainable behavioral
change for patient espousal of self-care attitudes.50,51 Because
about self-care

diabetic complications are associated with poor dietary prac-

tice, foot problems, low physical activity, depression, and
training

anxiety, diabetes counseling should be tailored to patients’

needs to improve their coping with chronic illness.52,53
The second theme includes three studies on self-
medication, treated as an aspect of patient self-care. Self-
self-care and sources of drugs’ info
n/a/self-medication as an aspect of

in students’ medical education (for

n/a/knowledge of healthy nutrition

n/a/patient involvement (consent)
n/a/drug knowledge; info seeking

n/a/patient and local community

medication, which refers to situations when people admin-

PE/related constructs use

behavior from various sources

ister drugs to treat self-recognized symptoms/sicknesses

engagement (to educate and

examination by a student)

without professional consultation, represents a means for

empowering patients to take control of their health.54 Yet, the
PE, patient empowerment; UAE, the United Arab Emirates; n/a, not applicable; MENA, Middle East and North Africa.

high inclination for self-medication by UAE adults and ado-

spread awareness)

lescents42 is accompanied by low levels of public knowledge

and understanding of medicines and antibiotics.46 The prac-
tice of self-medication raises ethical concerns and risks of
and diet

drugs’ misuse, indicating that the population might not be

well equipped to take higher responsibility for personal
health. To make the transition to self-care a successful un-
Self-medication with

Self-medication with

Nutrition and dietary

Obstetrics, stomach,
face, child scenarios

dertaking in the UAE, patient education programs are needed

with the active participation of clinicians, pharmacists, par-
Genetic disease
Field

ents, media, and other stakeholders.42,45

screening

The three ‘non-therapeutic interventions’ articles address

habits

well-being issues that consider UAE's cultural/religious spec-

drugs

drugs

ificities and cut across many stakeholder groups (adolescents,

female Muslims, young Emirati couples). Given the prevalence
adolescent students

218 female Emiratis

21 college students,

of obesity in the UAE, researchers promote multifaceted

(Muslims) in Al Ain

schools in Sharjah
300 adolescents, 4
purposive sample

educational interventions to enhance adolescents’ knowledge

Subjects
324 expatriate

of healthy nutrition and encourage adopting beneficial dietary

30 subjects,

community

habits.44 Because consanguineous marriages are practiced by

clinics

Muslim couples, local community engagement is critical for

Theme 3: non-therapeutic interventions (3 studies)

overcoming culturally induced resistance and spreading

awareness about genetic disease screening to drive the
implementation of a premarital screening law.41 In a study of
Qualitative, content

Case study, project

Interviews, clinical

patient involvement in students’ medical education, Emirati

Cross-sectional

Cross-sectional
Method

women with gynecological problems refused to submit to

regressions

cross-gender examinations.48 While addressing cultural sen-

scenarios,
analysis
survey

survey

sitivities is important, female patients need to be reminded of

their social/religious duty to contribute towards doctors’
Table 2 e (continued )

training in the country.

Laurance et al.41
Shehnaz et al.46

Al-Yateem and
McLean et al.48

Discussion
Hasan et al.42

Rossiter44
Reference

By juxtaposing themes and topics from PE reviews and UAE-

based studies, we delineate three opportunities for future in-
quiry and policy intervention on PE in the UAE (Fig. 2).
 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4 121

Fig. 2 e Opportunities derived from juxtaposing themes/topics from Tables 1 and 2. PE, patient empowerment; UAE, the
United Arab Emirates.

Opportunity (1)dconsolidate Opportunity (2)dexpand

Most UAE studies connect PE with therapeutic continuum The sporadic and inconsistent use of PE suggests that the topic
aspects of chronic disease care and self-medication. This requires deeper exploration in the UAE. The propensity of
provides opportunities for consolidation by conducting decision-makers, clinical professionals, and patient advocates
confirmatory research on larger samples across different to discuss PE is the lowest in Arab countries, compared with
Emirates to build a foundation for making generalizations. the CanadaeAustralia cluster and even Latin American and
Unsurprisingly, most sampled studies relate to diabetes and Asian nations.28 Given the embryonic stage of development
its complications, because 20% of the total UAE population is and scarcity of relevant UAE-based studies, many opportu-
battling this chronic condition.55 PE plays a critical role in the nities for expanding inquiry exist by combining insights from
successful management of chronic illness, where the onus is ‘conceptual clarification’ and ‘non-therapeutic interventions’
on the patient to embrace the logic of active coping with dis- themes. To design viable interventions,41,48 we recommend
ease through disciplined self-monitoring.49,56,57 Yet, the delving deeper into PE and its contextual application by
diabetes-related knowledge, information-seeking behavior, considering social, cultural, and religious characteristics of
and self-management attitudes of UAE patients remain the UAE.62
weak.40,52,58,59 The UAE Government ambitions to reduce the The difficulty of achieving definitional consensus on PE10,30
percentage of diabetes by 2021, but the attainment of this goal is acknowledged because of the variability of national settings
depends on the effectiveness of PE programs to encourage where the concept is used, inferring asymmetric levels of lit-
optimal levels of patient self-care.60 eracy and access to information, concerns about digital divide
In an analysis of health status in the UAE, cardiovascular and availability of Internet, and confidentiality issues.35 We
diseases, injury, cancers, and respiratory disorders were call for contextualizing conceptual clarity efforts through a
identified as public health priorities to be addressed at the measurement scale that would allow operationalizing PE
national level.61 Further assessments are needed on the within the locally relevant value sets of the UAE. A hindrance
contribution of PE strategies to the enhancement of health for PE interventions may be the low literacy rates among older
outcomes of patients with these chronic conditions through Emiratis and unskilled expatriate workers who lack formal
higher self-efficacy, pain management,38 and medication education.15 Developing a reliable health-literacy screening
adherence.39 Extant studies on self-medication in the UAE instrument that would be culturally specific to target idio-
focus on its risks and negative health implications due to the syncrasies of the UAE socio-economic fabric represents a step
gap between patients’ state of ‘feeling’ and ‘being’ informed forward.63 There is more scope for expanding research/prac-
about drugs and medical principles.45,46 Authors noted that the tice on the effectiveness of PE methods directed to the youth
prevalence of antibiotics’ self-medication in Abu Dhabi may to inculcate a mentality of healthy nutrition,44 as obesity
reflect both the lack of punitive legislation for pharmacies reduction among children represents another target of the
dispensing drugs without prescription and the demographic 2021 UAE National Agenda.60
aspect of the Emirate where its expatriate majority relies on Although PE is gaining traction in global markets, some
home country sources of medicines.54 Regulatory in- cultures might not be ready to embrace the trend toward
terventions and educational programs aimed at reducing the increased autonomy and self-determination. In Muslim
incidence of drugs’ misuse will help refocusing researchers’ countries, patients may prefer to rely on professionals’ expert
attention on the study of beneficial aspects of self-medication opinions or concede their individual decision-making power
as a manifestation of autonomous health behavior. to their (male) family members.27 From the perspective of
122 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4

Islam, although people enjoy the freedom of self-governance, with other Arab states, but no associations were made with
the principles of beneficence and non-maleficence are given PE-related consequences.69 In technology-savvy nations, a
priority in medical decision-making, especially when patients tighter integration of IT into the medical sector may offer
are uninformed and possess limited understanding of their benefits in terms of health outcomes and general well-
disease.64 To decide about a treatment while accounting for being.22 In the 2016 Global IT Report, UAE is ranked 26th
patients’ lack of competence, Islamic teachings reserve a worldwide and 1st in the Middle East on the Networked
central place to physicians, due to their professional and Readiness Index, unveiling a high level of government usage
religious duty to do good and ward off harm.65 Faith-based, and social impact of IT.70 Considering the ever-expanding
community-empowered, and family-centered participatory role of digital technologies and electronic portals in the
approaches may be appealing to the Muslim UAE majority, UAE medical landscape, more research is needed on how e-
where Islamic principles and religious obligations form part of health contributes to PE.
daily life. The role that community leaders, places of worship, UAE residents are becoming increasingly active on social
and the family can play in spreading awareness about healthy media, rely on cellphone apps to make decisions, participate
lifestyles and empowering the UAE population to self-manage in online forums and support groups, and use media channels
their health is worthy of further exploration.22 to access health-related data.22 Although social media usage
for health information is an indicator of PE, this technology is
Opportunity (3)dinitiate associated with data inaccuracies, limited usability, misin-
formation, and privacy/security issues.68 If information-
Our analysis unveils a major decoupling between PE topics in seeking behavior is deployed as a tool for ‘empowering’
review articles and those examined in the UAE context. The rather than ‘misleading’ patients,71 health-care organizations
dearth of UAE-embedded inquiries on PE in relation to ‘na- have to ensure the readability of data available online to
tional health-care system’, ‘health-care governance’, and ‘IT’ improve people's health literacy. Clinicians should fulfill their
provides opportunities for initiating research, reforms, and moral obligation of facilitating PE by directing patients to
practice in these areas. Because PE is viewed as a fundamental health websites that are reliable and trustworthy.72 Studies on
pillar in the development of a sustainable health-care the role of social, educational and economic factors in the
ecosystem,5 decision-makers ought to craft initiatives that information-seeking behavior of empowered patients could
would boost patient participation across levels of an inte- be insightful for disseminating digitally the medical infor-
grated health-care system. The future makeup of medical mation that people can comprehend and act upon to solve
practice and the implementation of a patient-centered their health-related concerns.
approach to care depend on PE strategies that are formu-
lated today.30e32 UAE legislators and practitioners should
revisit institutional/clinical arrangements in health service Author statements
provision to offer more room for residents to get involved in
the design and delivery of care and play a heightened role in Ethical approval
health-care governance.33
A greater sense of health ownership could be developed None sought. Ethical approval was not required as this is a
through educational policies and supporting infrastructures review article that relies on publicly available published work.
that would empower patients in medical encounters. People
should engage in health-related initiatives in their community Funding
and voice their opinions regarding national priorities for pol-
icymaking. Scholars could assess the effectiveness of patient- None declared.
directed interventions in transforming people into value cre-
ators and active participants in health-care markets.3 Federal Competing interests
public health frameworks should be revised periodically to
secure compliance with international best practices and None declared.
alignment with dominant health concerns. The diversity of
the UAE population (age/gender distribution, educational/
references
economic backgrounds, social/cultural characteristics) poses
challenges for the design of adequate public health reforms.61
PE education and intervention methods should be culturally
1. Moretta Tartaglione A, Cavacece Y, Cassia F, Russo G. The
sensitive, embedded in the nation's social fabric,66 and excellence of patient-centered healthcare: investigating the
tailored to the needs of a specific group.41 links between empowerment, co-creation and satisfaction.
Digital era technologies represent valuable platforms for TQM J 2018;30(2):153e67.
drawing on citizens’ insights to transform public institutions 2. Tofan G, Spraggon M, Bodolica V. Agency problems, ethical
and policymaking.35 Although health websites allow challenges and governance attributes in different models of
physicianepatient interaction within the assisted
empowering Saudi Arabia patients,67,68 studies on how the
reproduction setting. Publ Health 2013a;127(6):597e600.
adoption of electronic health systems drive PE in the UAE are
3. Dent M, Pahor M. Patient involvement in Europe e a
lacking. Only one inquiry examined clinicians’ viewpoints comparative framework. J Health Organisat Manag
about e-health development challenges in the UAE compared 2015;29(5):546e55.
 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4 123

4. Snyder H, Engstrom J. The antecedents, forms and 25. Bodolica V, Spraggon M. Mergers and acquisitions and executive
consequences of patient involvement: a narrative review of compensation. Series: routledge studies in corporate governance.
the literature. Int J Nurs Stud 2016;53:351e8. New York: Routledge; 2015.
5. Palumbo R, Cosimato S, Tommasetti A. Dream or reality? A 26. Bodolica V, Spraggon M. Merger and acquisition transactions
recipe for sustainable and innovative health care ecosystems. and executive compensation: a review of the empirical
TQM J 2017;29(6):847e62. evidence. Acad Manag Ann 2009;3(1):109e81.
6. Bodolica V, Spraggon M, Tofan G. A structuration framework 27. Malek MM, Abdul Rahman NN, Hasan MS, Abdullah LH.
for bridging the macro-micro divide in healthcare Islamic considerations on the application of patient's
governance. Health Expect 2016;19(4):790e804. autonomy in end-of-life decision. J Relig Health 2018. https://
7. Scholl I, Zill JM, Harter M, Dirmaier J. An integrative model of doi.org/10.1007/s10943-018-0575-5.
patient-centeredness e a systematic review and concept 28. Bridges JFP, Anderson BO, Buzaid AC, Jazieh AR,
analysis. PLoS One 2014;9(9). e107828. Niessen LW, Blauvelt BM, Buchanan DR. Identifying
8. Chang AK, Fritschi C, Kim MJ. Nurse-led empowerment important breast cancer control strategies in Asia, Latin
strategies for hypertensive patients with metabolic America and the Middle East/North Africa. BMC Health Serv
syndrome. Contemp Nurse 2012;42:118e28. Res 2011;11:227.
9. Nafradi L, Nakamoto K, Csabai M, Papp-Zipernovszky O, 29. Bravo P, Edwards A, Barr PJ, Scholl I, Elwyn G, McAllister M.
Schulz PJ. An empirical test of the Health Empowerment Conceptualizing patient empowerment: a mixed methods
Model: does patient empowerment moderate the effect of study. BMC Health Serv Res 2015;15:252.
health literacy on health status? Patient Educ Counsel 30. Castro EA, Regenmortel TV, Vanhaecht K, Sermeus W,
2018;101:511e7. Hecke AV. Patient empowerment, patient participation and
10. Cerezo PG, Juve-Udina ME, Delgado-Hito P. Concepts and patient-centeredness in hospital care: a concept analysis
measures of patient empowerment: a comprehensive review. based on a literature review. Patient Educ Counsel
Rev Esc Enferm USP 2016;50(4):664e71. 2016;99:1923e39.
11. Fumagalli LP, Radaelli G, Lettieri E, Bertele P, Masella C. 31. Boudioni M, McLaren S, Lister G. The role of citizenship,
Patient empowerment and its neighbors: clarifying the culture and voluntary community organizations towards
boundaries and their mutual relationships. Health Policy patient empowerment in England and Greece. Int J Caring Sci
2015;119:384e94. 2017a;10(1):303e12.
12. Schulz PJ, Nakamoto K. Health literacy and patient 32. Boudioni M, McLaren S, Lister G. A critical analysis of national
empowerment in health communication: the importance of policies, systems, and structures of patient empowerment in
separating conjoined twins. Patient Educ Counsel 2013;90:4e11. England and Greece. Patient Prefer Adherence
13. Barr PJ, Scholl I, Bravo P, Faber MJ, Elwyn G, McAllister M. 2017b;11:1657e69.
Assessment of patient empowerment - a systematic review of 33. Bodolica V, Spraggon M. Clinical governance infrastructures
measures. PLoS One 2015;10(5):1e24. and relational mechanisms of control in healthcare
14. Spraggon M, Bodolica V. Managing organizations in the United organizations. J Health Manag 2014;16(2):183e98.
Arab Emirates: dynamic characteristics and key economic 34. Tofan G, Bodolica V, Spraggon M. Governance mechanisms in
developments. New York: Palgrave Macmillan; 2014. the physician-patient relationship: a literature review and
15. Koornneef E, Robben P, Blair I. Progress and outcomes of conceptual framework. Health Expect 2013b;16(1):14e31.
health systems reform in the United Arab Emirates: a 35. Risling T, Martinez J, Young J, Thorp-Froslie N. Evaluating
systematic review. BMC Health Serv Res 2017;17:672. patient empowerment in association with eHealth
16. Bodolica V, Spraggon M, Shahid A. Strategic adaptation to technology: scoping review. J Med Internet Res 2017;19(9):e329.
environmental jolts: an analysis of corporate resilience in the 36. Groen WG, Kuijpers W, Oldenburg HS, Wouters MW,
property development sector in Dubai. Middle East J Manag Aaronson NK, van Harten WH. Empowerment of cancer
2018;5(1):1e20. survivors through information technology: an integrative
17. UAE Government. Good health and wellbeing. 2018. Retrieved review. J Med Internet Res 2015;17(11). e270.
from: https://government.ae/en/about-the-uae/leaving-no- 37. Calvillo J, Roman I, Roa LM. How technology is
one-behind/3goodhealthandwellbeing. empowering patients? A literature review. Health Expect
18. Federal Competitiveness and Statistics Authority. Government and 2013;18(5):643e52.
private sector health services statistics. 2018. Retrieved from, 38. te Boveldt N, Vernooij-Dassen M, Leppink I, Samwel H,
http://fcsa.gov.ae/en-us. Vissers K, Engels Y. Patient empowerment in cancer pain
19. Legatum Institute. The legatum prosperity Index 2017. management: an integrative literature review. Psycho Oncol
Retrieved from www.properity.com. 2014;23:1203e11.
20. World Economic Forum. The global competitiveness report 39. Nafradi L, Nakamoto K, Schulz PJ. Is patient empowerment
2017e2018. Retrieved from https://www.weforum.org. the key to promote adherence? A systematic review of the
21. Abuhejleh A, Dulaimi M, Ellahham S. Using Lean relationship between self-efficacy, health locus of control and
management to leverage innovation in healthcare projects: medication adherence. PLoS One 2017;12(10). e0186458.
case study of a public hospital in the UAE. BMJ Innov 40. Sulaiman N, Hamdan A, Al-Bedri DAM, Young D. Diabetes
2016;2:22e32. knowledge and attitudes towards prevention and health
22. Gachiri W. A gradient analysis of economic development and promotion: qualitative study in Sharjah, United Arab
chronic diseases. Case of diabetes and life expectancy in Emirates. Int J Food Saf Nutr Public Health 2009;2(1):78e88.
United Arab Emirates. J App Bus Econ 2017;19(1):35e43. 41. Laurance J, Henderson S, Howitt PJ, Matar M, Al Kuwari H,
23. Weber AS, Turjoman R, Shaheen Y, Al Sayyed F, Hwang MJ, Edgman-Levitan S, Darzi A. Patient engagement: four case
Malick F. Systematic thematic review of e-health research in studies that highlight the potential for improved health
the Gulf Cooperation Council (Arabian Gulf): Bahrain, Kuwait, outcomes and reduced costs. Health Aff 2014;33(9):1627e34.
Oman, Qatar, Saudi Arabia and United Arab Emirates. J 42. Hasan S, Farghadani G, Al Haideri SK, Fathy MA. Pharmacist
Telemed Telecare 2017;23(4):452e9. opportunities to improve public self-medicating practices in
24. Al Slamah T, Nicholl BI, Alslail FY, Melville CA. Self- the UAE. Pharmacol Pharm 2016;7:459e71.
management of type 2 diabetes in gulf cooperation council 43. Hashim MJ, Prinsloo A, Mirza DM. Quality improvement tools
countries: a systematic review. PLoS One 2017;12(12). e0189160. for chronic disease care e more effective processes are less
124 p u b l i c h e a l t h 1 6 9 ( 2 0 1 9 ) 1 1 4 e1 2 4

likely to be implemented in developing countries. Int J Health patients in the United Arab Emirates. Rev Diabet Stud
Care Qual Assur 2013;26(1):14e9. 2008;5(2):110e5.
44. Al-Yateem N, Rossiter R. Nutritional knowledge and habits of 59. Sulaiman N, Hamdan A, Tamim H, Mahmood DA, Young D.
adolescents aged 9 to 13 years in Sharjah, United Arab The prevalence and correlates of depression and anxiety in a
Emirates: a cross-sectional study. East Mediterr Health J sample of diabetic patients in Sharjah, United Arab Emirates.
2017;23(8):551e8. BMC Fam Pract 2010;11:80.
45. Shehnaz SI, Khan N, Sreedharan J, Issa KJ, Arifulla M. Self- 60. UAE Government. Health and fitness. 2018. Retrieved from:
medication and related health complaints among expatriate https://government.ae/en/information-and-services/health-
high school students in the United Arab Emirates. Pharm Pract and-fitness.
2013;11(4):211e8. 61. Loney T, Aw T-C, Handysides DG, Ali R, Blair I, Grivna M, et al.
46. Shehnaz SI, Khan N, Sreedharan J, Arifulla M. Drug An analysis of the health status of the United Arab Emirates:
knowledge of expatriate adolescents in the United Arab the ‘Big 4’ public health issues. Glob Health Action
Emirates and their attitudes towards self-medication. Int J 2013;6:20100.
Adolesc Med Health 2014;26(3):423e31. 62. Bodolica V, Spraggon M. Life on heels and making deals: a
47. Baynouna LM, Neglekerke NJD, Ali HE, ZeinAlDeen SM, Al narrative approach to female entrepreneurial experiences in
Ameri TA. Audit of healthy lifestyle behaviors among patients the UAE. Manag Decis 2015;53(5):984e1004.
with diabetes and hypertension attending ambulatory health 63. Nair SC, Satish KP, Sreedharan J, Ibrahim H. Assessing health
care services in the United Arab Emirates. Glob Health Promot literacy in the Eastern and Middle-Eastern cultures. BMC
2014;21(4):44e51. Public Health 2016;16:831.
48. McLean M, Al Ahbabi S, Al Ameri M, Al Mansoori M, Al 64. Rathor MY, Rani MF, Shah AS, Leman WI, Akter SF,
Yahyaei F, Bernsen R. Muslim women and medical students Omar AM. The principle of autonomy as related to personal
in the clinical encounter. Med Educ 2010;44:306e15. decision-making concerning health and research from an
49. Sayiner A, Alzaabi A, Obeidatc NM, Nejjari C, Beji M, ‘Islamic viewpoint’. J Islamic Med Assoc North America
Uzaslan E. Attitudes and beliefs about COPD: data from the 2011;43(1):27e34.
BREATHE study. Respir Med 2012;106(S2):S60e74. 65. Elbarazi I, Devlin NJ, Katsaiti M-S, Papadimitropoulos EA,
50. Hashim MJ, Mustafa H, Ali H. Knowledge of diabetes among Shah KK, Blair I. The effect of religion on the perception of
patients in the United Arab Emirates and trends since 2001: a health states among adults in the United Arab Emirates: a
study using the Michigan Diabetes Knowledge Test. East qualitative study. BMJ Open 2017;7. e016969.
Mediterr Health J 2016;22(10):742e8. 66. Bodolica V, Spraggon M, Zaidi S. Boundary management
51. Abdulelkarem AR, Sackville MA. Changes of some health strategies for governing family firms: a UAE-based case study.
indicators in patients with type 2 diabetes: a prospective J Bus Res 2015;68(3):684e93.
study in three community pharmacies in Sharjah, United 67. Househ M, Alsughayar A, Al-Mutairi M. Empowering Saudi
Arab Emirates. Libyan J Med 2009;4(1):31e6. patients: how do Saudi health websites compare to
52. Al-Kaabi J, Al-Maskari F, Saadi H, Afandi B, Parkar H, international health websites? Stud Health Technol Inf
Nagelkerke N. Physical activity and reported barriers to 2013;183:296e301.
activity among type 2 diabetic patients in the United Arab 68. Househ M, Borycki E, Kushniruk A. Empowering patients
Emirates. Rev Diabet Stud 2009;6(4):271e8. through social media: the benefits and challenges. Health Inf J
53. Al-Kaabi JM, Al Maskari F, Cragg P, Afandi B, Souid A-K. 2014;20(1):50e8.
Illiteracy and diabetic foot complications. Prim Care Diabetes 69. Uluc NCI, Ferman M. A comparative analysis of user insights
2015;9:465e72. for e-health development challenges in Turkey, Kingdom of
54. Abasaeed A, Vlcek J, Abuelkhair M, Kubena A. Self-medication Saudi Arabia, Egypt and United Arab Emirates. J Manag Market
with antibiotics by the community of Abu Dhabi Emirate, Logis 2016;3(2):176e89.
United Arab Emirates. J Infect Dev Ctries 2009;3(7):491e7. 70. World Economic Forum. The global information technology
55. Alhyas L, McKay A, Balasanthiran A, Majeed A. Quality of type report. 2016. https://www.weforum.org.
2 diabetes management in the states of the Co-operation 71. Dahl S, Eagle L. Empowering or misleading? Online health
Council for the Arab states of the Gulf: a systematic review. information provision challenges. Market Intell Plann
PLoS One 2011;6(8). e22186. 2016;34(7):1000e20.
56. Lorig KR, Holman H. Self-management education: history, 72. Spraggon M, Bodolica V. Trust, authentic pride and moral
definition, outcomes, and mechanisms. Ann Behav Med reasoning: a unified framework of relational governance and
2003;26(1):1e7. emotional self-regulation. Bus Ethics Eur Rev
57. Zimbudzi E, Lo C, Misso M, Ranasinha S, Zoungas S. 2015;24(3):297e314.
Effectiveness of management models for facilitating self- 73. Al-Maskari F, El-Sadig M, Al-Kaabi JM, Afandi B, Nagelkerke N,
management and patient outcomes in adults with diabetes Yeatts KB. Knowledge, attitude and practices of diabetic
and chronic kidney disease. Syst Rev 2015;4:81. patients in the United Arab Emirates. PLoS One 2013;8(1).
58. Al-Kaabi J, Al-Maskari F, Saadi H, Afandi B, Parkar H, e52857.
Nagelkerke N. Assessment of dietary practice among diabetic