Educational interventions modestly reduce average drugs per prescription in MENA region hospitals

INTRODUCTION: Rational prescribing is challenging due to global antibiotic resistance and widespread polypharmacy. Evidence on effective interventions to improve prescribing practices in MENA is limited. AIM: This systematic review and meta-analysis evaluated the effectiveness of multifaceted and educational interventions in improving WHO/INRUD prescribing indicators in the Middle East and North Africa (MENA). METHOD: We searched PubMed, Scopus, and CINHAL up to June 10, 2025, for experimental studies evaluating the effectiveness of multifaceted interventions on WHO/INRUD prescribing indicators. Searches were supplemented by screening reference lists of relevant reviews, first 20 pages of Google Scholar results, and ResearchRabbit.ai for citation-chaining to identify additional records. Primary outcomes included WHO/INRUD prescribing indicators: average number of drugs per prescription, percentage of encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed, percentage of drugs prescribed by generics, and percentage of drugs prescribed from the essential medicines list. Methodological quality was assessed with the MASTER scale. Meta-analysis used a bias-adjusted inverse-variance heterogeneity model adjusted with quality score. Heterogeneity and publication bias were assessed using I, the Doi plot, and LFK index. RESULTS: Sixteen studies (seven RCTs, six pre-post, three quasi-experimental) from Iran, UAE, Egypt, Sudan, Lebanon, Saudi Arabia, and Palestine were included. Multifaceted interventions modestly reduced the average number of drugs per prescription (weighted mean difference WMD - 0.10, (95% CI - 0.18 to -0.02; I = 99.8%). There was a downward trend in the odds of prescriptions with antibiotics (OR 0.65; 95% CI 0.41 to 1.03, I = 93.5%) and injections (OR 0.93, 95% CI 0.82 to 1.04, I = 25.3%), though these did not reach statistical significance and confidence intervals included the possibility of no effect. Meta-analysis revealed extreme statistical heterogeneity (I up to 99.8%), and the GRADE certainty of evidence was low to very low for all outcomes. CONCLUSION: Multifaceted interventions in the MENA region demonstrate potential for modest improvements in prescribing indicators, though evidence certainty remains low to very low. With non-significant pooled effects for antibiotics and injections, these exploratory findings suggest that context-specific stewardship and prescribing quality programs can achieve targeted improvements, but also highlight the need for more locally led, rigorous research with longer follow-up to inform policy decisions.