The effects of positive psychology interventions in Arab countries: A systematic review (2025)

PPIs beyond Western countries

The applicability and validity of PPIs outside of Western culture (Hendriks & Graafsma,2019; Ng & Lim,2019; Smith et al.,2019) have also been explored. This signifies a move away from PPIs being primarily examined within Western countries dominated by WEIRD populations (Hendriks et al.,2019). For instance, in Hendriks et al.'s.(2018) systematic review from non-Western countries (n= 28), a moderate effect of PPIs on well-being and a large effect on depression and anxiety was found; yet, their review included only English language studies published until 2017, thus potentially missing out on a wealth of research published in other languages. Recently, Carr et al.'s.(2021) meta-analysis included studies published in peer-reviewed journals or grey literature in any language. Reviewing 347 studies, they found a small to medium effect of PPIs on well-being and distress. However Arabic language databases were not searched, and too few results from Arab countries limit our knowledge on their regional efficacy in the Arab world.

Across the Middle East and North Africa (MENA) region, positive psychology has sparked the interest of scholars. Warren et al.(2015) published a regional systematic review looking at the characteristics of positive psychological research. The number of publications had risen since 2011 to include 53 studies that were focused on developing positive states as much as dealing with adversity.

Considering cultural fit when implementing PPIs is vital (Hendriks et al.,2019; Kubokawa & Ottaway,2009; Lambert & Pasha-Zaidi,2019b), including differences between Western ‘individualist’ and Eastern ‘collectivist’ cultures (Ng & Lim,2019), as well as religion and spirituality, especially as these influence subjective well-being (Abdel-Khalek,2019). Research evaluating the effects of PPIs among Arab populations suggests they are being tailored to fit aspects of culture (e.g. Al-Ghalib & Salim,2018; Basurrah et al.,2020). In a recent research paper (Basurrah et al.,2022) on positive psychology in Arab countries, we highlighted the importance of cultural factors that must be considered when evaluating PPIs in Arab countries. It has been suggested that differences exist between individual Western culture and collective Arab culture in terms of self-concept, emotions, values, and religion (Basurrah et al.,2022), which may lead to different effects of PPIs compared with those reported in Western culture. For instance, the construction of self-concept varies between Western and Arab cultures. While people from the West focus on the self-directed and autonomous individual (Realo et al.,2002), those of Arab culture, who value their family, friendship, and community, emphasise their relationships with others to build their self-concept (Markus & Kitayama,1991). Hence, a more prosocial (group-oriented) PPIs practice such as the act of kindness or the gratitude letter may enhance the well-being of the Arab population more than self-oriented PPIs (e.g. identifying character strengths; Basurrah et al.,2022).

It is now well established that considering culture when applying PPIs is vital as various cultures have distinct ways of defining the self, experiencing emotions, and expressing values (Kubokawa & Ottaway,2009). Still, an understanding of the effects of PPIs in the Arab region is lacking as no systematic review exists. This information would help to disseminate PPI research, enrich the field of positive psychology and mental health, and offer the basis for a culturally responsive indigenous positive psychology (Kim et al.,2018; Lambert & Pasha-Zaidi,2019b). Therefore, the primary aim of this review was to synthesise the up-to-date evidence about the use and the effects of PPIs on well-being and mental health in both the general public and in clinical populations in the Arab region. The secondary aims were to determine the quality of the studies and examine if PPIs were adapted for the local Arab context.

Search strategy

We searched PsycINFO, PubMed, Scopus, and ProQuest Dissertation and Thesis as well as Arabic databases, including Dar Al Mandumah and Al Manhal. Results were limited to peer-reviewed articles and dissertations published in English or Arabic from 1998—the inception of positive psychology—to 28 February 2022. We also checked the reference lists of included studies and previous reviews (Bolier et al.,2013; Carr et al.,2021; Hendriks et al.,2018, 2019, 2020; Sin & Lyubomirsky,2009; Warren et al.,2015). We manually searched the Middle East Journal of Positive Psychology, the recent book, Positive Psychology in the Middle East/North Africa (Lambert & Pasha-Zaidi,2019b), and contacted regional experts. Keywords related to ‘positive psychology interventions’ and ‘Arab countries’ were searched. To develop equivalent search terms in Arabic, AB, a native Arabic speaker, translated English search terms in consultation with MA.

Study selection

After the removal of duplicates, AB screened the titles and abstracts and two reviewers (MA and TS) independently screened 10% of these for interrater reliability (Cohen's Kappa statistic =0.87 and 0.97 in Arabic and English studies respectively indicating near perfect agreement). Next, full articles were screened by three reviewers (AB, MA, and TS). There was a near perfect interrater agreement for screening full texts with a Cohen's kappa of 0.90 and 0.97 in Arabic and English studies, respectively.

In accordance with the study protocol (Basurrah et al.,2021), articles were excluded if they examined physical activity interventions or more traditional psychotherapy interventions such as cognitive behavioural therapy (CBT). When a study included Arab and non-Arab participants, the study was included if the results of Arab participants were presented separately.

Data extraction and study quality assessment

An Excel data extraction form was developed and piloted in four randomly selected studies. Data from the included studies were extracted by three independent reviewers (AB, MA, and TS). There was a high level of interrater agreement across the three raters. For data extraction 15 items, an interrater agreement was 0.98 and 0.96 in Arabic and English studies, respectively. The extracted information included author(s), year of publication, country, study design, details of the intervention, delivery form, session duration, control group, number of participants, mean age and standard deviation, female percentage, retention rate (post), follow-up assessment, and main findings. In the case of missing data, we contacted 11 authors, seven of whom provided additional information. Data were reviewed as reported where author contact was not possible. Because a meta-analysis was deemed inappropriate due to the heterogeneity of study designs, varying interventions and outcome measures employed, a narrative synthesis was undertaken.

Study quality was evaluated using the Cochrane risk-of-bias tools. The Rob2 tool (Sterne et al.,2019) assesses RCTs across five domains: (1) Randomisation process; (2) deviations from intended intervention; (3) missing data; (4) outcome measurement; (5) selection of the reported result. The quality of a study was assessed as ‘Low’, ‘Some concerns’, or ‘High’ risk of bias, as determined by a validated a priori algorithm. The ROBINS-I tool (Sterne et al.,2016) assessed quasi-experimental studies based on seven domains: (1) Confounding; (2) selection of participants; (3) classification of interventions; (4) deviations from intended intervention; (5) missing data; (6) outcome measurement; (7) selection of the reported result. The quality of a study was assessed as ‘Low’, ‘Moderate’, ‘Serious’, ‘Critical’ risk of bias, or ‘No information’. This was conducted independently by three reviewers (AB, MA, and TS). Interrater agreement was 0.89 and 0.85 in Arabic and English studies, respectively. Any disagreement was resolved through discussion with the review team. In the case of insufficient information, we contacted the study authors.

Participant characteristics

The studies contained a total of 3598 participants at post-assessment, of whom 2127 participants were in the PPI groups. Twenty-eight studies reported the mean age of participants, which was 21.6years (SD=2.46). The sex distribution was skewed towards females (75%), with 16 studies reporting only female participants and five omitting such information. Most studies (n= 32, 73%) were conducted on adults and 12 (27%) were conducted on youth up to 17 years. Further, 38 studies (86%) were conducted among healthy populations (with more than half [66%] being conducted among university or school students) and six (14%) on clinical populations, including children with diabetes mellitus, injured military, drug addicts, learning disabled, deaf samples, and depressed cancer patients. Intervention group sample sizes ranged from five to 833 participants, with 26 studies (59%) having fewer than 30 participants. Only three studies included sample sizes of more than 100 participants.

Intervention characteristics

Just over half (n= 23, 52%) of the studies were MPPIs, with the other half using single PPIs, including mindfulness, positive thinking, character strengths, hope, optimism, self-compassion, and psychological support for positive traits. Almost all studies (92%) adapted PPIs for the local context. Delivery was mostly group-based in 39 studies (89%), self-help/online in three studies (7%) or delivered individually in two studies (5%). Almost all studies (91%, n= 40), compared a PPI with a no-intervention control group, two studies compared a PPI with an active control group and two studies with a waiting list.

Outcomes

Forty studies measured well-being, nine measured depression, and 13 and 11 studies measured anxiety and stress, respectively. Further, 25 studies measured a follow-up, ranging from four to 20 weeks, with 12 studies measuring less than 8weeks follow-up and (n= 13) studies measuring eight to 20 weeks. Of the Arabic studies, most of the measures were developed by the authors themselves (Abu Ghali,2017; Al-Eroud,2018; Al-Hattab,2017; Al-khatatneh,2019; Al-Khateeb & Ma'ali,2019; Al–Menshawi,2021; Al-Salmouni,2016; Al-Sanabani & Al-Sabwa,2014; Alzoghby,2017; Elaiwah,2017; Eldabee,2021; Haddad,2014; Issa,2019; Khlef et al.,2021; Mansour et al.,2016; A. Ramadan & Al-Dars,2017; Soud & Al-Rashid,2018; Zahran,2015) with validity and reliability noted. Therefore, in TableS1, we decided to present the main findings rather than list the instruments used. Because of the level of heterogeneity between studies in terms of outcomes and interventions, the data are summarised qualitatively.

The effects of PPIs on well-being and mental health

Risk of bias assessment

Overall, 12 RCTs were assessed using the Rob2 tool: Four were at low risk of bias, another three were at high risk, and five had some concerns (Figure2). Three studies were ranked as having a ‘high risk of bias’ around the measurement of the outcomes and three were ranked as having ‘some concerns’ in the randomisation process. All Arabic RCTs (n= 5) mentioned that participants were randomised, but only two (Abu Ghali,2017; Al-Rashidi,2018) noted the randomisation sequence.

The remaining quasi-experimental (QE) studies (n= 32) were evaluated using the ROBINS-I tool (Figure3). All of the included studies, except one study (Lambert et al.,2021) was at ‘some concern’, were at ‘serious risk of bias’ according to the ROBINS-I criteria, which considers a study to be at serious risk if it scores ‘serious’ in at least one domain. The most frequently noted domains causing ‘serious’ risk of bias included measurement of outcomes (n= 31) and confounding (n= 9). In terms of outcome measures, the variables of interest in this review rely on self-reports, and thus all included QE studies are at serious risk as the assessment was not performed under blinded circumstances given the nature of PPIs (i.e. measurement of outcomes is self-reported, participants are aware of the intervention as are the outcome assessors themselves). All studies used a ‘no intervention’ control group and nearly all studies were at low risk of bias, as there was complete data for all participants and only two studies were at serious risk, given a large number of missing data and one at some concern.

Limitations and strengths

Our review is limited by the small number of RCTs and the high level of heterogeneity of PPIs and the outcome measures that precluded a comprehensive meta-analysis being conducted. The low quality of included studies, small sample sizes, and incomplete data in some were additional limitations. Our review has several strengths. Our search strategy and analysis included both Arabic and English databases published in peer-reviewed journals and dissertations. This meant that we were able to identify a significant number of relevant studies (n= 34) in the Arabic language, identifying what PPIs have been examined in these countries, the gaps in the research, and to examine the methodological quality of these studies.

Future research

As Arab countries produce only 1% of the global output of peer-reviewed publications in psychology (Alzahrani,2020; Maalouf et al.,2019), building greater awareness of, and research capacity in positive psychology to generate culturally appropriate adaptations, novel PPIs (Lambert & Pasha-Zaidi,2019a), and a database on issues of well-being to support overall health efforts, is critical. We recommend that researchers follow protocol guidelines and include active control groups rather than have no treatment group. Well-designed RCTs that use power analysis to determine sample size, as well as increase sample diversity (for example, by including internally displaced people (IDPs), low socioeconomic groups, or conflict victims), are also recommended. This can help to generalise results and determine real life applications and efficacy. Research into questions of cultural specificity, user preference, and PPI ‘fit’ to determine which PPIs are most effective in cultural, religious, and/or social contexts where values differ from those for which the PPIs were originally developed (Lambert & Pasha-Zaidi,2019b) must continue.