Cultural Sensitivity and Global Pharmacy Engagement in the Arab World

Language.

Arabic is the official language of all countries in the Arab world and the Arab league and is one of the six official languages of the United Nations. Arabic is a Semitic language and, depending on the source, ranks between third and sixth in the world in number of native speakers.⁴¹ There are four main regional dialects of Arabic: Egyptian, Iraqi/Gulf, Levantine (Jordan, Lebanon, Palestine, Syria), and Magreb (North Africa). Numerous variations in these dialects exist.⁴² In addition, several other languages such as Kurdish and Berber are spoken in small areas throughout the Arab world.⁴² Arabic text is written in the Arabic alphabet, from right to left. This alphabet contains 28 consonants and three vowels, although only long vowels are written.⁴³ This can lead to many translations, with the same word spelled several ways in English based on its pronunciation (eg, Koran, Quran, and Qu’ran; Mohammed, Muhamad, and Mohamad; Muslim and Mozlem). Through the Quran, over 1.5 billion Muslims throughout the world learn at least basic Arabic for worship. Calligraphy in Arabic is considered an art form. Despite the official status of Arabic, English, and, to a lesser extent, French remain the languages of higher education (including in pharmacy education) and health care documentation in most countries.

Transportation.

The types of available transportation within and between the different countries of the Arab world is variable. For the most part, transportation within major cities is well established. However, urban planning is difficult in some ancient cities such as Amman, Beirut, Cairo, and Damascus, because of the age of the infrastructure. Modern streets and highways, including cross-country highways, exist in the majority of Arab countries. Some countries such as Egypt have extensive railroad systems, and Cairo has an underground metro system.⁴⁴ The newly established GCC States have a more organized and advanced transportation system with spacious highways, smart city plans, and traffic apps.^45,46 While transportation network companies and taxi services are available in many countries, bus services vary. Because of heavy traffic in urban areas, driving can be very challenging in countries such as Egypt, Jordan, Lebanon, and Syria, and is not recommended for first-time visitors.^47,48 Speeding and aggressive driving is a problem in most Arab countries, with some countries having the highest traffic death rates in the world. However, in recent years, local rules against speeding and aggressive driving are becoming more stringent.^49,50

Diet.

The Arab diet consists of a healthy Mediterranean diet. Breakfast includes local and imported cheeses, olives, olive oil and thyme, humus, Ful medames (ie, Vicia faba), falafel, and boiled eggs. Rice, lamb meat, pita bread, and cooked vegetables are also common.^51,52 Many traditional dishes are available in most Arab countries such as kebab, Jordanian and gulf states mansaf; Palestinian musakhan, Lebanese tabouli, Moroccan couscous, and stuffed cabbage and eggplant.^51-53 Fruits as well as sweets such as baklava and kenafeh are also commonly served after meals. Offering food to guests is a common practice, as is insisting they have second and third servings. Visitors to Arab countries should be aware and sensitive of such traditional hospitality practices. In addition to local cuisine, most Arab countries have restaurant franchises from many Western European countries as well as those from the United States. Indian, Chinese, Italian, and, to a lesser extent, Mexican and French restaurants are also present in most countries. Pork products are not available in most Arab countries because of Islamic teachings. While sale of alcohol is permitted in some countries such as Jordan, Lebanon, and the UAE, it is prohibited in other countries such as Saudi Arabia. Visitors should be aware of local rules and regulations regarding alcohol and follow them.

Safety.

Safety in all global engagements is imperative, and that is no different for the Arab world.^54-56 However, the sensationalist way in which some Western media outlets portray the Arab world makes many in the West reluctant to engage in outreach activities in the region because of safety concerns. For the majority of the countries in the Arab world, it is safe to travel, and visitors usually have pleasant and fulfilling experiences.⁵⁷ However, caution should be exercised when engaged with countries where there is conflict and increased political tension, such as is currently the case in Iraq, Libya, Palestine, Syria, and Yemen. Prospective visitors should access the US State Department website to check on travel advisories before making any travel plans.⁵⁸

Status of Women.

Arab women in general and Muslim women in particular are portrayed in a negative way in Western media including in the United States. However, in many Arab countries, especially in Egypt, Jordan, Lebanon, Palestine, and Tunisia, women have historically been well integrated into the fabric of society and all its sectors.⁵⁹ Many hold higher professional and leadership positions such as deans and directors of pharmacy.^60,61 However, women’s rights remain as much of an issue as in many other parts of the world.^59,60 While Islam is blamed for some of the restrictions on women in the Arab world, since its inception, Islam has recognized the full personhood of women. Islam also established a woman’s right to choose a husband, have an inheritance, own property, and pursue an education. Islam recognizes that marriage is a contract between a man and a woman, and as such, the woman’s consent to marry is required.²¹ The restrictions and discrimination that women often face emanate from cultural and political factors. For example, in Saudi Arabia a woman is required to cover her entire body, and there is a separation of men and women in education and in many aspects of the public domain. However, most Arab countries do not impose these limitations.⁶² Overall, modesty for both Muslim and Christian men and women is a virtue that is promoted in most Arab countries based on religion and tradition.

Health Care System.

Health care systems in the Arab world have advanced in a number of countries in the last 20 years, with increased access to all sectors of health care including governmental and private hospitals, ambulatory care clinics, pharmacies, and dental clinics.⁶³ In Abu Dhabi, Dubai, and Qatar, state of the art hospitals were recently completed.⁶⁴ In July 2017, the Dubai Health Authority announced that it will open 12 new private hospitals by 2020.⁶⁵ This expansion of health care has increased the region’s attractiveness for medical tourism. Egypt, Jordan, and Lebanon have been destinations for health tourism for many years, with some of the Gulf States now working to increase their share of the health tourism market.^66-69 In 2016, Dubai launched the world’s first medical tourism portal with a goal of attracting over 500,000 international medical tourists.⁷⁰ The wars in Libya, Syria, and Yemen have created an influx of patients seeking medical care. The medical expertise, desirable weather, and somewhat conservative societies made countries such as Egypt, Jordan, and Lebanon a perfect destination for many patients from these countries and the GCC in general.

Bahrain has a universal health care system that is free of charge to Bahraini citizens and subsidized for non-Bahrainis.⁷¹ Health care expenditure accounted for 4.5% of Bahrain's gross domestic product (GDP), according to the World Health Organization.⁷² Similar to all GCC countries, the Kuwaiti government offers its citizens free medical treatment at government facilities. The Ministry of Health (MoH) strictly controls the price of medications in pharmacies, which eliminates the need to go from pharmacy to pharmacy to find lower prices.⁷³ The health care in Oman has significantly improved after the MoH was established in 1976. Most of the country's medical staff are foreigners; however, this is changing rapidly as the government is employing new policies to encourage its own citizens to work in the medical field.⁷⁴ Health care in Qatar is regarded as being one of the highest quality in the region.^75,76 Health care is free for nationals, but expatriates (an expatriate is a person who resides outside their native country) have the option of obtaining a state insurance card. Recently the government has made treatment of cancer for expatriates 100% free of charge, which is considered unprecedented in the rich gulf region.^75-77 The health care system in Saudi Arabia is also considered of high quality.^78-80 Private health insurance is essential as most private hospitals and clinics with high standards are expensive. In contrast, public hospitals are usually free.^78-80 In the UAE, over 50% of the 2017 budget allocation went toward social services, of which 8.6% was allocated to health care.⁸¹ The country is rolling out a compulsory health insurance program for expatriates, particularly in Dubai.⁸² For citizens, medical care is free of charge.^81-83 The private health care sector has risen significantly in recent years and will continue to drive growth in the country. Currently, only GCC nationals are permitted to use governmental pharmacies which offer drugs at lower prices than privately owned pharmacies.^81,82

Jordan has one of the most modern health care infrastructures in the Arab world, with almost 63% of Jordanians being insured.^84,85 Jordan hospitals are mainly those of the MoH and the Royal Medical Services.⁸⁴ Other smaller public hospitals include several university-based programs, such as Jordan University Hospital in Amman and King Abdullah Hospital in Irbid. The advanced health care services in Jordan have led to its ranking as the number one medical tourism provider in the Arab region and among the top five in the world, as well as the top medical tourism destination in the Middle East and North Africa.⁶⁶ In Lebanon, the quality of health care varies between the public and the private sectors with the latter (eg, American University of Beirut Medical Center⁸⁶ and the Hotel Dieu de France⁸⁷) providing better quality health care at a higher cost.

Drug Regulations.

The majority of the health sectors in the Arab world are overseen by a MoH. However, with the exception of the UAE, all the countries examined have their own regulatory authority which monitors and controls the pharmaceutical and food industry (Table 2),^88,89 similar to the US Food and Drug Administration. The health care industry in the UAE is regulated by a MoH with further oversight in the Emirate of Dubai by its respective agency.⁹⁰ In Kuwait, the Kuwait Drug and Food Control Administration is the main regulator of quality and safety of medications, herbal products, dietary supplements, and medicated cosmetics.⁹¹ The Directorate General of Pharmaceutical Affairs and Drug Control is the regulative authority of Oman.⁹² It is accountable to ensure the drugs in Oman are safe, effective, and of high quality, whether manufactured for local use or exportation. The Saudi Food and Drug Authority (SFDA) is responsible for regulating medications, food, cosmetics, and electronic products in Saudi Arabia. Like the other administrations, its main mission is to ensure the safety, quality, efficacy, and accessibility of these products to the public.⁹³ Finally, in the UAE, pharmacy and supplies are regulated by several departments within the MoH, and medications must be registered before they can legally be imported into the country.⁹⁰

In general, the regulations referring to drug dispensing are comparable to those of the West; however, the laws are not strictly enforced in community pharmacies. For example, in many countries in the Arab world, despite efforts by the MoH to curb this behavior, patients can still procure medications without a prescription, with the exception of narcotics and major tranquilizers.

Orientalist View.

The Orientalist view of the Arab world persists both in public attitudes and in academic literature. The landmark work on Orientalism was a book published by Edward W. Said in 1978¹³⁰ in which he examines the representations of Eastern peoples and cultures by the West and the definition of orientalism. His ideas permeate the literature on Arab stereotypes, with his description of the orientalist representation of Muslim societies as negative and more backward than modern European societies in aspects of culture, politics, and social interaction.¹³⁰ He contends that this depiction has created an inferiority complex among Arabs when interacting with the West. Based on his study of the media, J. G. Shaheen proposed four major misconceptions regarding Muslims and Arabs: they are astoundingly wealthy, they are barbarians and uncultured, they are sex maniacs with a penchant for white slavery, and they revel in acts of terrorism.¹³¹ He and others have documented that the region is also portrayed as an oil-rich desert run by dictators, the people are seen as uncivilized and all thought to be Muslim; the women are oppressed, veiled, and uneducated; and the men are dominating and terrorists.^131-137

A study of the effects of the Orientalist view on biomedical literature published in 2007 by L.D. Laird and associates found several latent themes related to Islam.¹³⁸ The first theme was that being Muslim meant one was in particular need of intervention because strict adherence to Islam posed health risks, and that maintaining traditions adversely affected Muslims so they should modernize. Negative perceptions of Muslims as uneducated, oppressed, fatalistic, and traditional contribute to this theme. The next theme was that Islam itself creates obstacles to health care, with conflicts between religious practices and medical treatment seen as noncompliance or obstructivism. The examples given are of fasting during Ramadan and strict adherence to gender roles. The study does offer one positive theme: that practicing Islam could promote good health if a person was truly adherent, leading to less substance abuse; fewer penile, cervical and breast cancers; and other positive health effects resulting from Islamic dietary and spiritual practices. The conclusions drawn were that the scientific literature often sees Muslims as a homogeneous group who are different, inferior, and in need of intervention. Although some literature attempts to move beyond these stereotypes, the views are far from balanced.^138,139

Even the nomenclature of the region is subject to the Orientalist view. The question arises as to the difference between the Middle East and the Arab world, but the Middle East is a Eurocentric appellation solely geographically defined. Instead, as previously mentioned, Arab signifies a pan-ethnic group that share a common language, culture, and history. Depending on the geographical boundaries used to define the Middle East, between 50% to 80% of Middle Easterners are Arab.^134,135,137

Purposeful Engagement.

One of the most critical aspects of global engagement is to ensure that it is purposeful. Thus, engagements should be needs based. In unpublished data from several pharmacy deans of Arab universities, clinical training and expertise in teaching therapeutics, social, and behavioral sciences, and pharmaceutics were identified as their main areas of need. Thus, collaborative efforts should address these identified needs. Other countries with lack of resources would benefit from more outreach activities in education and research to promote clinical pharmacy practice.¹⁴⁰ Respect for the local culture is important in all patient interactions; thus, cultural sensitivity in the continuum of cultural competency is required.¹⁴¹ For example, in areas where traditional medicine is used, listening to the patient about why he/she thinks traditional medicine is the right therapy, explaining to him/her how modern medicine helps in treating disease, acknowledging the patient’s input regarding traditional medicine and his/her experience with it, recommending a course of treatment based on evidence, and negotiating an action plan are critical to achieving optimal outcomes.¹⁴²

Religion.

Religion plays a major role for both Muslims and Christians in the Arab world.^134,135 In the case of Islam, respect for religious practices such as the need to pray five times per day and fasting during the month of Ramadan is vital.^139,143-145 While this practice varies among countries, in Saudi Arabia, people stop everything at the time of prayer. Similarly, eating food in public during the month of Ramadan is strongly discouraged. In general, understanding the impact of religion on health and healing beliefs is an important aspect of practice in the Arab world.^143-145 The Arab Christian communities have become accustomed to the common culture, although religious practices do vary between the Coptic Orthodox Church of Alexandria in Egypt, the Greek Orthodox Church of Antioch in Syria, and the Maronite Catholic Church in Lebanon.¹⁴⁶

Family Role.

The importance of family in the Arab culture cannot be overstated.^134,135,147 Family has always been viewed as a source of security and empowerment because of the extended support it provides. Greetings almost always include asking about family members, and it is not uncommon for extended family members to live together.^134,135,147 This culture holds on to its patriarchal roots, especially in rural areas, with the oldest male having responsibility for the entire family. Whether this happens to be the father or the eldest son, he must provide for and protect his family.^134,135,147 In most countries, younger women depend on their grandmothers and mothers during childbirth and for childcare. Unlike in modern Western societies, in the Arab world, young adults stay at home until they are married, and the family cares for the elderly instead of placing them in a health care facility. Resources for long-term care are minimal to nonexistent in most Arab countries.^148,149 However, there have been increased efforts in some countries to provide these resources.^148,149

A patient’s family members are extensively involved in all health care decisions, including whether to tell the patient about their diagnosis or prognosis. Advanced directives are often foreign concepts for Muslims, as death is seen as God’s will and not their place to interfere with His plan.^144,145,150 Thus, depending on religious convictions, some families may be reluctant to withdraw care or provide extreme measures. In some countries and especially in rural areas, a woman may believe that her family, husband, or physician knows best, so she often lets them make health care management decisions on her behalf. Al-Amoudi emphasizes how Saudi health rules and regulations do allow for women with the mental capacity to make their own health decisions and that all stakeholders should be educated about these rules so that delay in therapy does not occur and patients are not harmed.¹⁵¹

Historically, mental health care was confined to the immediate and extended family. People with mental illness and their families were often looked down upon, rejected, and secluded; therefore, these illnesses were kept secret from nonfamily members, including physicians and mental health professionals.¹⁵² However, this culture is changing, and families, especially those in urban areas, will seek medical support for mental illness. While more recently some improvements in services and efforts to increase awareness have occurred, most countries still do not allocate enough expenditures and lack the professional human resources to meet the needs of patients with mental health issues.¹⁵² Thus, mental health is an important potential area to target in global engagement activities.

Gender Issues.

Arab Muslim women are diverse in their adherence to religious and cultural traditions, with the vast majority adhering based on personal convictions but in some countries based on family pressure and governmental rules. However, many Arab women, especially in major cities in Egypt, Lebanon, and other countries, are more secular in their actions, behaviors, beliefs, and dress.¹⁵³ Over the last several years, women’s education has flourished, with women majoring in all fields^154-156 as well as with women gaining the right to vote and run for office.^157-159 However, further efforts are needed to ensure equal opportunities between men and women.^154-156

Generally, in terms of health, modesty and privacy are valued by Arab women. Some Arab women, like their counterparts in many parts of the world, would prefer same sex care providers if possible, especially in obstetrics and gynecology. Also, they may avoid unnecessary touching of the opposite sex, eg, patting, hugging or handshaking, especially those women who are religiously inclined.^144,145,160 For health care professionals, it is critical to avoid misconceptions and stereotyping of Arab women based on an orientalist view that depicts them as fragile, sexually and socially oppressed, and lacking the ability to represent themselves.

Health and Healing Practices.

For many people in the Arab world, health beliefs may come down to: “medicine only goes so far, then comes God,” and when it comes to health and healing, “prevention is the best cure.”^{144,145,161-164} Such beliefs are influenced by Islam.^161-163 A holistic approach to health is prevalent where physical, emotional, and spiritual health cannot be separated. Thus, prayers and spiritual leaders play an important role.¹⁶¹ AlRawi and colleagues proposed a conceptual model which combines traditional Arabic and Islamic Medicine and consists of three elements: spiritual healing, herbal medicine, and dietary practices.¹⁶⁵ Muslim-Arabs believe that their bodies are a trust from God and as such they are accountable for how they look after their health. Therefore, the preservation and maintenance of health (eg, personal hygiene and nutrition) rather than the treatment of disease or restoration of health when it is lost is the goal.^161,163,164 However, in case of illness, in addition to medications and surgery, prayers, visitations, seeking help from God, and rehabilitative psychospiritual healing interventions are pursued.¹⁶¹ The Qur’an is considered the source of direction for healing, guidance, and mercy in case of physical and psychological inflictions.¹⁶² Another important aspect of health and healing is the belief that God gave the knowledge and wisdom to health care professionals and thus they have the responsibility to improve health. Thus, the Arab culture based on Islamic teachings is not always fatalistic. There is the belief that God created a cure for every disease. However, other beliefs do exist such as that disease and human suffering are tests or punishments from God, and sickness is a source of purification from sin and an acceptance of fate at the end of life.^164,165 Depending on their religious inclinations, some patients will not consume medicines that contain alcohol or pork products or any medicine during the fasting hours of Ramadan. Others will resort to reciting the Qur’an, visiting the mosque, and seeking a religious leader to help in their healing.^144,161,162

Over the last century, religious scholars in the Arab world have strived to address ethical issues surrounding many modern medical discoveries such as organ donation and transplantation, artificial support to prolong life, assisted suicide and euthanasia, abortion, assisted reproductive technology, genetic engineering, and cloning. While rulings on these issues may be similar in many countries, it is important to know any specifics that are unique to each country.^166,167

Beyond religion, cultural and mystical practices do exist in the Arab world, especially in rural areas. For example, cupping and cautery may still be seen in in Jordan, Saudi Arabia, and Yemen, as well as countries in North Africa.¹⁶⁸ Amulets are also used in some countries to prevent “evil eye.”¹⁶⁹ Evil eye is invoked in health and healing especially when a child becomes sick or dies, or a woman is not able to carry a child.¹⁷⁰

Life expectancy is improving in the Arab world. The disease burden in the region has shifted to more chronic than communicable diseases, similar to that in Western countries.¹⁷¹ Most of these diseases are caused by diet and lifestyle choices. However, in the poorer areas of the region, infectious diseases remain common.

Western Culture vs Arab Culture.

Western culture is considered individualistic, personal goals are emphasized, self-identity is viewed apart from the group, the person is in control of his environment, time dominates interactions, interactions are informal, time is precise, and directness and openness characterize communication.^147,172-175 Arab culture, on the other hand, is oriented toward collectivism, where group goals override self, self-identity is part of a group, the environment is controlled by fate, human interaction dominates, time is loose and informal, and a hierarchy of individuals and indirectness in interactions is emphasized.^172-175 While it is important to keep all these aspects of the Arab culture in mind, it is important to recognize that not all interactions with people in the Arab world will follow such a collectivism orientation. Other aspects of the culture may favor taking time to establish a social relationship before the transaction of a business or health care encounter as compared to the “let’s get down to business” mentality in the West. Also, while science is considered important, religion, traditions, and mysticism still play a role in explaining the physical world.^147,172-175

Patriarchal Attitudes of Health Care Professionals and Educators.

Based on the authors’ experience, in the Arab world, the physician usually lies at the top of the professional hierarchy, as is true in many countries. The physician has a monopoly on decision-making in many aspects of health care. In general, the Arab culture is formal and patriarchal, which lends itself to this hierarchy.^147,174,175 This hierarchy is also reflected in how professionals at universities and health care facilities act in a formal way in their interactions with other health care professionals and students. Some find it difficult to say, “I do not know,” and do not accept being questioned or challenged by their students and subordinates. While educators and professionals are respectful to visitors from other countries, especially those from Western countries, at times their actions may be influenced by the “inferiority complex” referenced earlier¹³⁰ or by what natives term the “Khawaja complex”¹⁷⁶ (discussed later). So, visitors, especially those from Western countries, can help (without disturbing the existing culture) by exhibiting their informal way of interacting with colleagues and students and by showing humility, eg, stating when they do not know an answer, seeking the opinion of the host professionals, and giving their hosts opportunities to take the lead.

Verbal and Nonverbal Communication.

In the Arab culture, body language is a very important aspect of communication. Thus, it is important for guests to be familiar with these unique aspects in order to effectively communicate a message and not insult anyone unintentionally. At the beginning and end of each visit, a handshake with the right hand is usually given while the left hand grasps the other person’s elbow. The handshake usually lasts longer than it does in Western culture but tends to be less firm.^147,173,177 When greeting close friends and family members, it is appropriate for a person to welcome them with a hug or two kisses on the cheek. During the greeting, it is usually a sign of respect to place your hand on your heart and give a slight bow.^147,173,177 Conservative and veiled women may not choose to shake hands with men and will instead acknowledge them by either bowing their head or placing the right hand on the heart area.^147,173

There are also certain ways for a person to position their body to avoid offending people. For example, they should not point the toe or heel or any part of their foot at a person and should not show the soles of their feet or use their foot to move an object. This is considered rude and disrespectful in the Arab culture as the foot is viewed as the lowest part of one’s body and is forbidden to be seen or exposed. The feet should never be put on a coffee table, footstool, or desk.^147,178 In addition, it is common courtesy in many countries for guests to remove their shoes before entering private homes. It is also important for a guest to know that when passing or receiving an object or food to do so with their right hand, as the left hand is sometimes viewed as “unclean” in certain parts of the Arab world.^147,178

When it comes to verbal communication with Arabs, a guest must keep in mind that they believe that words hold power.¹⁴⁷ Arab people do not enjoy talking in negative ways because of their belief that this is associated with negative results. Arabs love poetry and creative speech. They are also fond of flowery blessings.^147,174 When discussing the unfortunate events of someone else, they tend to use euphemisms to describe how they are doing. Overall, these are general communication skills that translate from one Arab country to the next. However, as with any culture, guests should follow nonverbal cues from their host and treat each person as an individual.

The Inferiority Complex of the Khawaja/Ajnabi vs Distrust of Westerners.

Because of the Western colonization of many Arab countries and the subjugation of natives that occurred over many years, there are still remnants of an inferiority complex among Arabs. This has led some people in the Arab world to emulate the West in many aspects of life and to value Westerners (Khawaja or Ajnabi) and their knowledge over that of natives of their own country and other Arabs.^130,176 As a result, many Westerners who come to Arab countries to work are provided with incentives and benefits far beyond what is given to other nationalities.¹⁷⁹ For example, North American and Western European citizens are paid much higher than those from countries such as the Philippines and India. However, these incentives have declined in recent years with the drop in oil prices and the focus on training their own citizens.¹⁸⁰

Conversely, there is some element of mistrust of the West in many countries because of the colonial era, Western military action in the Arab and Muslim worlds, and the support of Israel (especially by the United States). There is also suspicion about the intentions of some Westerners when they engage with the Arab world. Therefore, clear intentions and transparency are recommended to build trust and alleviate any suspicisons.^147,181

Work Hours and Work Habits.

The concept of time is different in most of the Arab world compared to that in Western countries where “time is money.” The concept of time in the Arab world revolves around events and time of the day.^147,182 While it is important to be on time, visitors should not be offended if their guest is late.¹⁸² A typical work week is five days with Friday and Saturday off in most countries, except Lebanon where Saturdays and Sundays are off. Businesses are usually open from 9:30 a.m. to 1:30 p.m. and reopen from 3:30 p.m. to 6 p.m. During the month of Ramadan, businesses offer employees more flexible and/or fewer working hours.

In Saudi Arabia, the salary packages, including incentives, for Westerners are usually greater than or equal to those offered in their countries and other Arab countries.¹⁸⁰ This is because there is no personal taxation, making net income much greater, which is one of the major benefits of working in Saudi Arabia. Office hours range from 8 a.m. until noon, then from 4 to 7 p.m. However, hospital staff work schedules similar to those of their Western counterparts. Friday is considered the Muslim day of rest, with work days usually being Sunday through Thursday. However, in Oman weekends are usually on Thursday and Friday.

The UAE also does not tax salaries; however, the cost of living there is increasing.¹⁸³ Some companies offer attractive benefits to their employees such as 30 calendar days off per year and free annual flights back to their home country. Salaries in Kuwait are usually similar or higher than salaries in most Western countries, and there is no income tax.¹⁸⁰ Friday is the official day off in Kuwait, with Thursday or Saturday off depending on the business.