Self-care interventions among the Jordanians during the COVID-19 lockdown: A cross-sectional study of community pharmacists’ observations

INTRODUCTION

The COVID-19 virus was first detected in animals and then transmitted to humans in 2019 in Wuhan, China. According to the World Health Organization (WHO), the reported deaths reached more than 6 million and a half, with 651 million confirmed cases due to COVID-19 in over 180 countries (COVID-19, WHO). There is currently no cure for COVID-19 infection, although many therapies are being investigated to treat COVID-19; however, vaccination programs were applied in the second year of the pandemic (Alinia-Ahandani and Sheydaei, 2020), including antivirals such as remdesivir and ivermectin and immunomodulatory agents such as corticosteroids. Several medications, including antivirals like ritonavir/lopinavir and antimalarials like hydroxychloroquine, had been tried and discontinued. Remdesivir is currently the only antiviral agent approved by the Food and Drug Administration (FDA) for COVID-19, but only in some cases (Aslan and Akova, 2021). Moreover, suggested preventive methods against COVID-19 were created based on overcoming the manner of transmissions and include frequent hand washing, maintaining physical separation, disinfections, quarantine, avoiding face contact with dirty hands, and wearing a mask advised, especially for suspects and those caring for them (Girum et al., 2020).

The first case in Jordan was reported on March 2, 2020, and 15 days later, Jordan entered a comprehensive lockdown period (corona.moh.gov.jo). The lack of treatment or a vaccine at the time of the study prompted many people to consider new interventions to protect the health and safety of themselves and their families. It is well-established that chronic diseases, including hypertension, cancer, asthma, chronic obstructive pulmonary disease (COPD), and diabetes, are among the top comorbidities with COVID-19 (Fekadu et al., 2021). The pandemic’s spread was a great challenge to the healthcare system in Jordan and worldwide. Therefore, the International Pharmaceutical Federation declares new guidelines for pharmacists’ new roles throughout the pandemic, besides their traditional role of patient counseling and regular medication supply and dispensing (fip.org). Community pharmacists were the first healthcare providers to meet and answer the patients’ questions about COVID-19 treatment, educate patients about the spread and prevention of the coronavirus infection, provide medications for home delivery, and perform routine tasks such as refilling the patients’ prescriptions, detecting and referring early suspected cases of COVID-19, and playing a latent role in vaccinating the patients (fip.org, Pinto et al., 2021).

Almost half of the world’s population lacked access to the required healthcare; consequently, the WHO recommended self-care interventions (including counseling and medications) in the areas of disease prevention and self-medication to enable governments and communities to control the spread of the virus and promote health, with or without the support of health professionals for nearly half of the world’s population (WHO.int-self-care). In the pandemic curfews and lockdowns, pharmacists in community pharmacies and drug stores played a crucial role in the continuous supply of over-the-counter, chronic diseases, and COVID-19-related medications. Since they are knowledgeable about medications, they made significant contributions to financially and regionally marginalized communities (Hess et al., 2022; Strand et al., 2020). At the beginning of the COVID-19 pandemic, people were terrified of the rapidly spreading disease and the lack of vaccines to prevent or drugs to treat that virus infection worldwide. Therefore, people in different countries searched for alternative modalities for prevention and an attempt to treat COVID-19 disease. Community pharmacists played a crucial role in self-care interventions used by patients at the beginning of the pandemic (Cadogan and Hughes, 2021). One of the vital alternatives was dietary (nutritional) supplements that include herbs, vitamins, and minerals as potential substitutes to strengthen the immune system and decrease the risk of acquiring the COVID-19 infection (Elayeh et al., 2021; Jalil et al., 2020; Younis et al., 2021).

In Jordan, during the first 3 weeks of February 2020, a general lockdown was applied with limited access to community pharmacies and hospitals due to the COVID-19 pandemic. During the lockdown periods, Jordan’s primary care, specialized clinics, and health institutions were closed as a preventive measure for COVID-19. People were turning to community pharmacies to search for and ask about complementary alternatives that help them prevent COVID-19. As a result of limited access to hospitals and closed clinics, pharmacists were driven to meet the public needs by answering their queries about supplying self-protection demands. A limited number of studies explore public practices during the pandemic, for example, from a nutrition and diet perspective (Alhaj et al., 2021). Only a few published studies were found to explore the pharmacist’s perspective on the pandemic itself (Al-Daghastani et al., 2021). However, no published studies in Jordan were found evaluating the detailed pharmacists’ observations of self-care measures adopted by the public during the lockdowns (Abdel Jalil et al., 2020). Consequently, this study aims to explore the self-care interventions used by Jordanians to prevent or treat COVID-19 symptoms during the early applied lockdowns, based on the observations of community pharmacists and pharmacists working in drug stores, and to explore how community pharmacies sales of self-care medications and products have been affected by the COVID-19 lockdown. The information provided will assist decision-makers in dealing with future emergency health challenges since disease prevention could sustain health systems.

METHODOLOGY

Study design and data collection

This study is a cross-sectional study conducted during the repeated lockdowns in Jordan between February 2020 and October 2020. Key pharmaceutical sectors working within the pharmaceutical supply chain system, i.e., community pharmacies and medical representatives of drug stores in Jordan, were invited to participate in the study. Only registered pharmaceutical personnel (pharmacists) working within and conversant with Jordan’s pharmaceutical supply chain system were included in the study. The questionnaire was designed by a group of academic staff members from the School of Medicine, Al-Balqa Applied University, and the Faculty of Pharmaceutical Sciences, Hashemite University, Zarqa, Jordan. A separate panel of pharmacology and pharmacoeconomics experts reviewed the questionnaire draft and recommended modifications. Furthermore, a web-based pilot study was conducted (15 community pharmacists and medical representatives) on the most prescribed self-care products and medications during COVID-19 lockdowns, in addition to evaluating the questionnaire design and length and the questions’ clarity and appropriateness to reflect the current study objectives. The responses received from the pilot study were utilized to develop the final questionnaire but were not used for the final data analysis. We used the link to the final questionnaire form to invite pharmacists to participate in the current study using pharmacists’ Facebook and WhatsApp-restricted groups. A brief introduction on the first page of the questionnaire to inform the participants includes the following: the study aims to explore their observations of self-care interventions through the lockdowns, data used for scientific research purposes, a statement that confirms the confidentiality of the study results, and the time required to complete the questionnaire. A self-administered questionnaire was developed in English and translated into Arabic (Jordan’s mother tongue). It consisted of 25 closed-ended questions and multiple-choice questions generated using Microsoft Forms^®. This survey is divided into four sections: the first part contains the participants’ demographic data questions, such as gender, age, community pharmacy location, and educational level; in the second part, participants were asked general questions about the pandemic, available medications, and new findings regarding COVID-19 treatment and prevention; the third part contains specific questions regarding the sales of self-care interventions during partial lockdowns; the fourth part contains questions regarding the sources of information and training courses participants attended. Figure 1 illustrates a schematic representation of the various stages of the study.

Figure 1. Schematic diagram of the different stages of the study. [Click here to view]

RESULTS

Sociodemographic characteristics of participants

Data were analyzed from 138 respondents who completed the survey. The sociodemographic analysis showed that more than half of the participants were males (58.7%), while the rest were females (41.3%), as illustrated in Table 1. In addition, more than one-third (38.2%) were between the ages of 25 and 34 years, followed by the age groups 35–44 years (25.5%) and 45–55 years (22.7%). Interestingly, most respondents have a bachelor’s degree (91.3%), compared to the postgraduates (8.7%). Table 1 also shows that community pharmacists constituted 71.7% of the studied population, while the rest were medical representatives (28.3%). Approximately half of the participants were from the capital city Amman (42.7%), followed by workers in the southern region (26.4%). In comparison, the proportions of participants from the central and northern regions were 16.4% and 14.5%, respectively.

Table 1. Sociodemographic details of pharmacist participants (N = 138). [Click here to view]

Sales of self-care measures during the repeated lockdown

Most participants (94.2%) generally affirmed that they noticed a marked decrease in general sales during the repeated lockdowns. However, the most sold items of the self-care intervention were gloves and masks, as reported by 43.20% of the participants, followed by disinfectant solutions like alcohol and others (17.43%), and dietary supplements demanded items (17.01%), as shown in Figure 2B. Similarly, there was a noticeable interest in purchasing preventive items, like Air Doctor ^® (a Japanese technology hung on the chest with sanitizing effect) used as a preventive measure, aspirin, and antimalarials (10.58%, 4.17%, and 2.57%, respectively). At the same time, the least sold items concerning COVID-19 prevention or treatments were herbs, antiviral drugs, and normal saline (0.43%, 0.86%, and 0.96%, respectively). It should be pointed out that an increase in ordering dietary supplements was reported by 61.6% of the participants, compared to those who observed a decrease or no change in the percentage of demand for nutritional supplements (23.9% and 14.5%, respectively).

Figure 2. (A) Categories of patients interested in self-care interventions according to participants’ responses. (B) General categories of most sold items during the lockdown period of the COVID-19 pandemic. [Click here to view]

Additionally, around two-thirds of respondents (65.9%) found it easy to supply self-care measures to citizens during the lockdown, compared to 34.1% who found difficulty in their services.

Source of information about the study participants about COVID-19 and continuous education and training during the lockdown

Most of the respondents reported that the information published by the governmental sector [Ministry of Health (MOH) and the Jordan FDA (JFDA)] (64.50%) was the primary source of information regarding COVID-19, followed by lower percentages for WHO bulletins (48.20%), newspapers and self-education (41.80%), and Jordan Pharmacists Association (24.50%) as shown in Figure 4. The last source of information selected by the participants was social media and colleagues (12.7%).

Figure 3. (A) Types of dietary supplements that the customers most purchased during the lockdown periods of the COVID-19 pandemic. (B) The herbal preparations customers bought ordered or asked about their usefulness during the lockdown periods to prevent the COVID-19 virus. [Click here to view]

Figure 4. The source of information about COVID-19 used in sales and counseling patients to prevent the virus. [Click here to view]

Regarding attending training workshops on COVID-19 prevention and treatment, more than half of the participants (62.3%) did not attend any awareness workshops specialized in dealing with patients’ inquiries related to the pandemic, compared to 16.7% who attended only one workshop. Among those who attended two workshops, 44.9% of the participants reported attending the workshop in person, compared to 55.1% of those who attended remote workshops. Among the attendees, 21.0% attended more than five workshops.

Table 2 shows a significant difference (p < 0.05) in relation to participants’ gender about inquiries related to dietary supplements and vitamins, which were noted by male participants more than females. On the other hand, the age group of 24–35 years of the participants reported an increase in purchase or interest in the issue of dietary supplements and vitamins during the lockdown periods for economic reasons. Interestingly, pharmacists with bachelor’s degrees have noticed increased questions about antimalarial and antiviral drugs as a treatment or preventive measure for the COVID-19 virus.

DISCUSSION

This study was designed to explore pharmacists’ experience during the repeated lockdowns in Jordan regarding public self-care practices in response to COVID-19 infection. Despite the low infection rates in pediatrics and adolescents, half of the participants (50.9%) reported that children’s parents sought self-care interventions for their children. The infection of COVID-19 in children has shown a range of manifestations ranging from asymptomatic, mild respiratory tract symptoms to severe pneumonia with acute respiratory distress syndrome up to severe pneumonia in susceptible patients or those with underlying diseases (Malcangi et al., 2022). However, based on JFDA bulletins, Jordan’s pediatric population is prone to allergy-related illnesses, so parents may be concerned about COVID-19 prevention (Al-Iede et al., 2021).

By the end of the first month of the lockdown (March 17, 2020, till April 16, 2020), pharmacies in Jordan reported a drop in general sales similar to reported sales in many countries worldwide, which can be attributed to the decreased working hours after the brief allowances and shortages of drug supplies due to discontinued drug import (Romano et al., 2021). Since the WHO announced that the main route of the viral infection was through direct skin contact and respiratory droplets (during coughing, talking, or sneezing), it was evident that using gloves and masks was the primary method adopted for personal protection within the public (Hemmer et al., 2021). Consequently, an increase in the sales of self-care products (gloves, masks, and Air Doctor^®) related to COVID-19 prevention was reported in the current study. As affirmed by the study participants, the public fulfillment of restrictions enforced by the local government, including physical distancing through floor markings and wearing masks and gloves, was very high. On the other hand, disposable gloves (both nitrile medical gloves and latex with powder and powder-free) were also reported to be used by customers during the pandemic despite the absence of conclusive evidence of their benefits; however, they were recommended for healthcare professionals (Khubchandani et al., 2020; Schobere et al., 2022). Similarly, hand sanitizers were the second most reported sales of self-care measures since the WHO guideline recommended them to minimize disease transmission, which has been reported to reduce the burden on healthcare providers (Prajapati et al., 2022).

The widespread use of dietary supplements for preventing and treating COVID-19 was mainly guided by social media, with a marginal role for healthcare practitioners (Radwan et al., 2022). The US FDA did not authorize using any dietary supplement to prevent or manage COVID-19. In the present study, the most reported sales regarding dietary supplements were vitamins C, B, and D, zinc, and multivitamins. Before the pandemic’s spread, vitamin C was a typical alleviating therapy in respiratory tract infections (bacterial and viral origin) in Jordan. It has been proposed that vitamin C has immune-modulatory mechanisms that can help to alleviate or reduce COVID-19 symptoms, thus preventing worsening internal vascular endothelial injury (Ahmad, 2022). On the other hand, the increased use of vitamin B by pharmacy customers can be attributed to its role in the activation of innate and adaptive immune responses against COVID-19 through improving lung functions, protecting endothelial lining, preventing thrombosis, and reducing the length of hospital stay as reported in similar studies (Babar et al., 2021; Shakoor et al., 2021).

Similarly, the increased interest and use of zinc-containing supplements described by study participants can be explained by their ability to prevent the growth of coronavirus in cells grown in the lab by inhibiting RNA polymerase activity, which has also been investigated (te Velthuis et al., 2010). Zinc was proposed to help in the pathogenesis of COVID-19 infection due to its immune response modulation and anti-inflammatory properties, thus enhancing the recovery of patients with severe pneumonia. On the other hand, despite the elevated queries or sales regarding vitamin D during the lockdown, vitamin D supplementation was not associated with reducing the risk of all causes of acute respiratory tract infection or COVID-19 (Jolliffe et al., 2022). The reported use of folic acid in this study as a therapeutic agent to treat COVID-19 can be explained by its role in DNA and protein synthesis and, to a lesser extent, the adaptive immune response (Shakoor et al., 2021).

Other dietary supplements chosen by the Jordanians were similar to those previously published studies; these include iron (Bastin et al., 2022), magnesium (Trapani et al., 2022), cod live oil (Brunvoll et al., 2022), ginseng (Yi, 2022), and calcium (Crespi and Alcock, 2020). Fadiyah et al. (2022) reviewed the data from several studies showing that omega-3 plays a significant role in COVID-19 prevention, management, and treatment. In infected patients, omega-3 increased the survival rate in COVID-19 patients by reducing the duration of symptoms, with a potential role in overcoming renal and respiratory dysfunction (Doaei et al., 2021).

Table 2. Association between sociodemographic characteristics and participants’ observation regarding public concerns about self-care measures during the COVID-19 pandemic (N = 138). [Click here to view]

Similarly, study participants reported an increased interest in some prescribed medications that were associated with COVID-19 disease. For example, the choice of aspirin as a self-care intervention can be explained by the high incidences of venous thromboembolism and pulmonary embolism reported in diagnosed COVID-19 cases. Aspirin has been reported to significantly decrease mortality risk by 32% at 14 and 30 days after COVID-19 infection (Zareef et al., 2022). Likewise, acyclovir, an oral antiviral, was proposed as an adjuvant therapy since an acyclovir derivative was evaluated to form a stable complex with coronavirus (Heidary et al., 2021). However, according to JFDA instructions to the pharmacies during the pandemic, direct purchasing of acyclovir from pharmacies was prohibited as a strategy to enable tracking and control the spread of the infection. The participants also reported a low interest of the public (2.57%) in hydroxychloroquine (an antimalarial drug), which initially received emergency authorization from the US FDA for use against the virus. However, this authorization was later revoked due to nonsuccessful results in randomized controlled trials (fda.gov).

Likewise, nasal and mouth rinses were proposed by Jordanians, as observed in this study, since COVID-19 spreads by contact and respiratory droplets. In Jordan, normal saline (0.9% sodium chloride) is available as an over-the-counter medication in plastic bags or as sprays, nasal drops, and so forth. However, reports have demonstrated a higher efficacy of hypertonic solution (with a concentration of less than 5% sodium chloride) than regular saline rinses. The higher osmolarity of hypertonic solutions pulls water out of cells, resulting in enhanced hydration of the aqueous portion of the mucosal lining, followed by increased calcium efflux from nasal epithelial cells, improving mucociliary clearance and reducing epithelial edema (Farrell et al., 2020).

Similar to previous studies in Jordan, herbal medicine is considered a traditional remedy for various ailments (Al-Daghistani et al., 2021; Al-Hamaideh et al., 2017, 2020; Jaber et al., 2020). According to the study participants, many queries were received regarding herbs like anise, lemon, honey, and ginger. The following paragraphs discuss the most inquired herbs concerning their antiviral properties and the reported literature regarding their investigation in COVID-19 prevention and treatment. The most reported herbal remedy by the participants was star anise (Illicium verum) which contains shikimic acid. This intermediate is used to manufacture oseltamivir (Tamiflu^®), an antiviral influenza A and B medication. Moreover, molecular docking studies demonstrated that the star anise phytoconstituents, verimol G is considered a potential COVID-19 antivirus that inhibits Mpro, the main protease of the virus (Singh et al., 2021). Likewise, lemon (Citrus limon, family Rutaceae) is a commonly used remedy in colds and respiratory infections due to its antioxidant and anti-inflammatory properties (Thota et al., 2020). In a survey-based study involving more than 2,000 Jordanians in 2021, lemon consumption before infection was associated with a lower incidence of severe COVID-19 and hospitalization (Nimer et al., 2022). Studies investigating the effectiveness of lemon in COVID-19 have proposed that lemon oils (citronellol and geranium oil) displayed significant ACE2 inhibitory effects through significant downregulation of angiotensin-converting enzyme 2 (ACE2) expression in epithelial cells that affect ACE2 (Senthil Kumar et al., 2020).

To a lesser extent, Jordanians choose other herbal remedies that have been reported to have immune-supportive properties or have been investigated later on for their effectiveness in COVID-19, like chamomile (Moghaddam et al., 2021), cinnamon (Yakhchali et al., 2021), sesame oil (Allam et al., 2021), hot pepper (Gharaibeh et al., 2020; Sen et al., 2022), onion (Dorsch and Ring, 2020), and fenugreek and cumin (Sen et al., 2022). Interestingly, honey was reported as one of the self-interventions according to 35.50% of participants. Honey’s antioxidant and anti-inflammatory properties helped prevent lung, renal, and cardiovascular damage in COVID-19 infections (Rao et al., 2016). Two mechanisms were postulated for this action: the increased serum levels of interferon-gamma, which plays a significant role in the control of COVID-19 infection, and the substantial binding affinity to the main protease (Mpro) necessary for the virus replication (Abedi et al., 2021).

Garlic (Allium sativum) is a common plant in Jordan, with combined antiviral and immune system function-preserving properties, as observed in patients with COVID-19 infection (Sharanya et al., 2021). According to published studies, garlic prevents COVID-19 infection by enhancing immune system cells and suppressing the generation and secretion of proinflammatory cytokines and the proinflammatory hormone leptin, which is obtained from adipose tissue (Donma and Donma, 2020). On the other hand, ginger (Zingiber officinale) is available as dry and fresh rhizome in Jordan with antioxidant, antiviral, antibacterial, and antidiabetic properties (Jafarzadeh et al., 2021). Studies conducted in Saudi Arabia revealed that ginger users had a lower percentage of COVID-19 hospitalization compared to nonusers (28.0% and 38.0%, respectively). Studies conducted in Saudi Arabia revealed that ginger users infected with COVID-19 had a lower hospitalization percentage than nonusers (28.0% and 38.0%, respectively). Similar results were reported in studies conducted in Bangladesh, Iran, Tunisia, and some parts of Africa, which decreased the time for mechanical ventilation for patients suffering from COVID-19 pulmonary complications such as pneumonia and lung fibrosis (Jafarzadeh et al., 2021).

On the other hand, curcumin [the main ingredient of turmeric (Curcuma longa)] and a common condiment in Jordan have also been reported by study participants as a self-care intervention (Rattis et al., 2021). The antiviral effect of curcumin against the COVID-19 virus is mediated by inhibiting the binding of the viral S protein to the ACE2 receptor and the endosomal acidification required for processing the proteins. The anti-inflammatory, anticoagulant, and antithrombotic effects of curcumin proved their usefulness as adjunctive therapy in alleviating COVID-19 symptoms and have been reported in several studies (Vahedian-Azimi et al., 2022). Interestingly, it has been reported that a 1,000 mg turmeric supplement was successfully used to restore smell and taste after COVID-19 infection (Chabot and Huntwork, 2021). Despite the reported interest of pharmacy customers in herbal medicine, it should be pointed out that other studies showed a decrease in interest among Jordanians in using herbs for other ailments (Al-Hamaideh and Dmour, 2023; Al-Qudah et al., 2022).

Finally, study results emphasized the critical role of the health authorities (MOH/JFDA) and WHO bulletins in supplying the most recent information to the public, the participants’ confidence in this information, and the participant’s adherence to official sources to aid the public during the lockdown in the prevention and treatment of the infection. On the other hand, the decreased interest of participants in information published on social media (12.70%) shows its low influence on the pharmacists’ choice as a source of reliable information. Most importantly, the low number of participants who attended awareness sessions regarding COVID-19 demands the need to make these sessions mandatory in the future since pharmacists acted as frontline healthcare providers for the public in coping with similar diseases.

STUDY LIMITATIONS

One of the current study’s limitations is that cross-sectional studies cannot determine causality. In addition, young pharmacists are more accustomed to social media platforms and are more interactive with online surveys; however, anonymizing the participants (name, location, etc.) helps to decrease this bias. Even though the sample size in this study is limited, including participants from all Jordanian locations increases the representation of the study results. The results also explain the prevalence and consistency of the findings, which point to the necessity of applying the current study’s findings to all Jordanian community pharmacies. It should be pointed out that the authors of this article conducted a similar study to explore the self-care measures adopted by Jordanians (number of participants > 500) to gain more insights into public practices during the lockdown (data not shown).

CONCLUSION

Throughout COVID-19 intermittent lockdowns, self-care interventions were common among the elderly and patients suffering chronic diseases in Jordan. Despite the decreased pharmacy sales, self-care measures like gloves, masks, disinfectants, and dietary supplements (zinc, vitamins C, B, and D) increased. To a lesser extent, the sales of prescription drugs like aspirin, hydroxychloroquine, and acyclovir were reported. Additionally, the interest in herbal medicines (like anise, lemon, honey, ginger, turmeric, and garlic) increased. Although many participants did not attend training workshops during the lockdowns, they tracked information supplied by the official health authorities (MOH, JFDA, WHO, and Jordan Pharmacists Association) about the pandemic. These results emphasize the necessity of awareness campaigns and continuous learning programs to ensure community pharmacists appropriately counsel their customers in future emergency conditions as frontline healthcare providers.

AUTHOR CONTRIBUTIONS

ID and KH contributed to the conceptualization, questionnaire design, focus, and organization of the manuscript. ID, KH, SQ, and JS performed the literature review and drafted the initial version of the manuscript. SQ and JS performed the statistical analysis in addition to the graph generation. All authors revised the review for content and contributed revised text, and all authors approved the final version of the submitted manuscript.

FINANCIAL SUPPORT

There is no funding to report.

ETHICAL APPROVALS

All research activities were conducted under the study plan approved by the Ethics Committee of Al-Balqa Applied University (Approval number: 26/3/1/603). The electronic form of the questionnaire was entirely anonymous and did not allow identifying the participant’s name or location. Informed consent was included in the questionnaire interface and obtained from all subjects involved in the study.

DATA AVAILABILITY

All data generated and analyzed are included in this research article.

PUBLISHER’S NOTE

This journal remains neutral with regard to jurisdictional claims in published institutional affiliation.

REFERENCES

 Abedi F, Ghasemi S, Farkhondeh T, Azimi-Nezhad M, Shakibaei M, Samarghandian S. Possible potential effects of honey and its main components against Covid-19 infection. Dose Response, 2021; 19(1):1559325820982423; doi: 10.1177/1559325820982423. CrossRef

 Abdel Jalil M, Alsous MM, Abu Hammour K, Saleh MM, Mousa R, Hammad EA. Role of pharmacists in COVID-19 disease: a Jordanian perspective. Disaster Med Public Health Prep, 2020; 14(6):782–8; doi: 10.1017/dmp.2020.186. CrossRef

 Ahmad SR. Vitamin C for COVID-19 treatment: have we got enough evidence? Front Nutr, 2022; 9:892561; doi:10.3389/fnut.2022.892561. CrossRef

 Al-Daghastani T, Tadros O, Arabiyat S, Jaber D, AlSalamat H. Pharmacists’ perception of the coronavirus pandemic (COVID-19) in Jordan: a cross-sectional study. Int J Environ Res Public Health, 2021; 18(21):11541; doi:10.3390/ijerph182111541. CrossRef

 Al-Daghistani HI, Abu-Niaaj LF, Bustanji Y, Al-Hamaideh KD, Al-Salamat H, Nassar MN, Jaber HM, Amer NH, Abu-Irmaileh B, Al-Nuaimi AH. Antibacterial and cytotoxicity evaluation of Arum hygrophilum Bioss. Eur Rev Med Pharmacol Sci, 2021; 25(23):7306–16.

 Alhaj O, Al-Sayyed HF, AlRasheed MM, Jahrami H. Appraisal survey of the knowledge, attitudes, and behaviors of Jordanian society toward diet and nutrition during COVID-19 era. J Public Health Res, 2021; 10(4):2381; doi: 10.4081/jphr.2021.2381. CrossRef

 Al-Hamaideh KD, El-Elimat T, Afifi FU, Kasabri V. Phytochemical screening and pharmacological activities of Echium judaeum Lacaita extracts growing Wild in Jordan. Jordan J Pharm Sci, 2017; 10(3):153–64.

 Al-Hamaideh KD, Dmour IM. Diuretics misuse: a cross-sectional study to explore community pharmacist’s perceptions of diuretics use and misuse. J Appl Pharm Sci, 2023; doi:10.7324/JAPS.2023.104335. CrossRef

 Al-Hamaideh KD, Dmour I, El-Elimat T, Afifi FU. UPLC-MS profile and anti-proliferative activity of the berries of an aggressive wild-growing weed: Solanum elaeagnifolium Cav. (Solanaceae). Trop J Nat Prod Res, 2020; 4(12):1131–8; doi.org/10.26538/tjnpr/v4i12.16. CrossRef

 Al-Iede M, Waters K, Aleidi SM, Alqutawneh B, Alnawaiseh H, Alshraideh A, Almaaitah S, Mahmoud R, Abualsoud R, Kiswani A, Al-Zayadneh E, Yousef AM. Impact of COVID-19 lockdown on children with asthma in Jordan: a parental questionnaire. BMJ Paediatr Open, 2021; 5(1):e001136; doi: 10.1136/bmjpo-2021-001136. CrossRef

 Alinia-Ahandani E, Sheydaei M. Overview of the introduction to the new coronavirus (COVID19): a review. J Med Biol Sci Res, 2020; 6(2):14–20.

 Allam AE, Amen Y, Ashour A, Assaf HK, Hassan HA, Abdel-Rahman IM, Sayed AM, Shimizu K. In silico study of natural compounds from sesame against COVID-19 by targeting Mpro, PLpro and RdRp. RSC Adv, 2021; 11(36):22398–408; doi: 10.1039/d1ra03937g. CrossRef

 Al-Qudah SA, Al-Hamaideh KD, Dmour IM, Al Sbaihi SS. Overweight management: a cross-sectional study with special insight on metformin use in obesity control. J Appl Pharm Sci, 2022; 12(08):179–86.

 Aslan AT, Akova M. Current status of therapeutic alternatives for COVID-19: a narrative review. Le Infezioni Med, 2021; 29(3):312.

 Babar Q, Ali A, Saeed A, Tahir MF. Novel treatment strategy against COVID-19 through anti-inflammatory, antioxidant and immunostimulatory properties of the B vitamin complex. In B-complex vitamins—sources, intakes and novel applications. IntechOpen, 2021; doi:10.5772/intechopen.100251. CrossRef

 Bastin A, Shiri H, Zanganeh S, Fooladi S, Momeni Moghaddam MA, Mehrabani M, Nematollahi MH. Iron chelator or iron infection. Biol Trace Elem Res, 2022; 200(11):4571–81; doi: 10.1007/s12011-021-03048-8. CrossRef

 Brunvoll SH, Nygaard AB, Ellingjord-Dale M, Holland P, Istre MS, Kalleberg KT, Søraas CL, Holven KB, Ulven SM, Hjartåker A, Haider T, Lund-Johansen F, Dahl JA, Meyer HE, Søraas A. Prevention of COVID-19 and other acute respiratory infections with cod liver oil supplementation, a low dose vitamin D supplement: quadruple blinded, randomised placebo controlled trial. BMJ, 2022; 378:e071245; doi:10.1136/bmj-2022-071245. CrossRef

 Cadogan CA, Hughes CM. On the frontline against COVID-19: community pharmacists’ contribution during a public health crisis. Res. Social Adm Pharm, 2021; (1):2032–5; https://developmentgoals.fip.org/dg16/

 Chabot AB, Huntwork MP. Turmeric as a possible treatment for COVID-19-induced anosmia and ageusia. Cureus, 2021; 13(9):e17829; doi:10.7759/cureus.17829. CrossRef

 Crespi B, Alcock J. Conflicts over calcium and the treatment of COVID-19. Evol Med Public Health, 2020; 9(1):149–56; doi:10.1093/emph/eoaa046. CrossRef

 Doaei S, Gholami S, Rastgoo S, Gholamalizadeh M, Bourbour F, Bagheri SE, Samipoor F, Akbari ME, Shadnoush M, Ghorat F, Mosavi Jarrahi SA, Ashouri Mirsadeghi N, Hajipour A, Joola P, Moslem A, Goodarzi MO. The effect of omega-3 fatty acid supplementation on clinical and biochemical parameters of critically ill patients with COVID-19: a randomized clinical trial. J Transl Med, 2021; 19(1):128; doi:10.1186/s12967-021-02795-5. CrossRef

 Donma MM, Donma O. The effects of Allium sativum on immunity within the scope of COVID-19 infection. Med. Hypotheses, 2020; 144:109934; doi:10.1016/j.mehy.2020.109934. CrossRef

 Dorsch W, Ring J. Anti-inflammatory substances from onions could be an option for treatment of COVID-19—a hypothesis. Allergo J Int, 2020; 29(8):30–1; doi:10.1007/s15007-020-2644-9. CrossRef

 Farrell NF, Klatt-Cromwell C, Schneider JS. Benefits and safety of nasal saline irrigations in a pandemic—Washing COVID-19 away. JAMA Otolaryngol Head Neck Surg, 2020; 146(9):787–8; doi:10.1001/jamaoto.2020.1622. CrossRef

 Fekadu G, Bekele F, Tolossa T, Fetensa G, Turi E, Getachew M, Abdisa E, Assefa L, Afeta M, Demisew W, Dugassa D, Diriba DC, Labata BG. Impact of COVID-19 pandemic on chronic diseases) care follow-up and current perspectives in low resource settings: a narrative review. Int J Physiol Pathophysiol Pharmacol, 2021; 13(3):86–93.

 Elayeh E, Akour A, Haddadin RN. Prevalence and predictors of self-medication drugs to prevent or treat COVID-19: experience from a Middle Eastern country. Int J Clin Pract, 2021; 75(11):e14860.

 Fadiyah N, Megawati G, Erlangga Luftimas D. Potential of omega 3 supplementation for coronavirus disease 2019 (COVID-19): a scoping review. Int J Gen Med, 2022; 15:3915–22

 Gharaibeh A, Gharaibeh MM, Gharaibeh S. Relation between COVID-19 and high capsaicin diets. Magna Sci Adv Res Rev, 2020; 1(1):030–2; doi: 10.30574/msarr.2020.1.1.0029. CrossRef

 Girum T, Lentiro K, Geremew M, Migora B, Shewamare S. Global strategies and effectiveness for COVID-19 prevention through contact tracing, screening, quarantine, and isolation: a systematic review. Trop Med Health, 2020; 48(1):1–15.

 Heidary F, Madani S, Gharebaghi R, Asadi-amoli F. Acyclovir as a potential adjuvant therapy in COVID-19 treatment regimens. Pharm Sci, 2021; 10. Available via https://ps.tbzmed.ac.ir/Inpress/ps-34330; doi: 10.34172/PS.2021.38. CrossRef

 Hemmer CJ, Hufert F, Siewert S, Reisinger E. Protection from COVID-19—the efficacy of face masks. Dtsch Arztebl Int, 2021; 118(5):59–65; doi: 10.3238/arztebl.m2021.0119. CrossRef

 Hess K, Bach A, Won K, Seed SM. Community pharmacists’ roles during the COVID-19 pandemic. J Pharm Pract, 2022; 35(3):469–76.

 Jaber HM, Al-Hamaideh KD, Al-Daghistani HI, Amer NH, Nassar MN, Al-Latif A, Saleh MH, Al-Nuaimi AH. Antibacterial activity and chemical composition of Arum hygrophilum Boiss crude extracts. Jordan J Biol Sci 2020; 13(2):159–64.

 Jafarzadeh A, Jafarzadeh S, Nemati M. Therapeutic potential of ginger against COVID-19: is there enough evidence? J Tradit Chinese Med Sci, 2021; 8(4):267–79; doi: 10.1016/j.jtcms.2021.10.001. CrossRef

 Jalil MA, Alsous MM, Hammour KA., Saleh MM, Mousa R, Hammad EA. Role of pharmacists in COVID-19 disease: a Jordanian perspective. Disaster Med Public Health Prep, 2020; 14(6):782–8.

 Jolliffe DA, Holt H, Greenig M, Talaei M, Perdek N, Pfeffer P, Vivaldi G, Maltby S, Symons J, Barlow NL, Normandale A, Garcha R, Richter AG, Faustini SE, Orton C, Ford D, Lyons RA, Davies GA, Kee F, Griffiths CJ, Norrie J, Sheikh A, Shaheen SO, Relton C, Martineau AR. Effect of a test-and-treat approach to vitamin D supplementation on risk of all cause acute respiratory tract infection and COVID-19: phase 3 randomised controlled trial (CORONAVIT). BMJ, 2022; 378:e071230; doi:10.1136/bmj-2022-071230. CrossRef

 Khubchandani J, Saiki D, Kandiah J. Masks, gloves, and the COVID-19 pandemic: rapid assessment of public behaviors in the United States. Epidemiologia, 2020; 1(1):16–22; doi:10.3390/epidemiologia1010004. CrossRef

 Malcangi G, Inchingolo AD, Inchingolo AM, Piras F, Settanni V, Garofoli G, Palmieri G, Ceci S, Patano A, Mancini A, Vimercati L, Nemore D, Scardapane A, Rapone B, Semjonova A, D’Oria MT, Macchia L, Bordea IR, Migliore G, Scarano A, Lorusso F, Tartaglia GM, Giovanniello D, Nucci L, Maggialetti N, Parisi A, Domenico MD, Brienza N, Tafuri S, Stefanizzi P, Curatoli L, Corriero A, Contaldo M, Inchingolo F, Dipalma G. COVID-19 infection in children and infants: current status on therapies and vaccines. Children, 2022; 9(2):249; doi:10.3390/children9020249. CrossRef

 Moghaddam MS, Torabzadeh Khorasani N, Assaran Darban R, Rahimi HR. The effect of chamomile extract on coronavirus. Rev Clin Med, 2021; 8(2):92–5; doi: 10.22038/rcm.2021.58399.1370. CrossRef

 Nimer RM, Khabour OF, Swedan SF Kofahi HM. Effect of natural uses prior to infection with COVID-19 on disease severity and hospitalization: a self-reported cross-sectional survey study. F1000Res, 2022; 11:639; doi:10.12688/f1000research.121933.2. CrossRef

 Pinto GS, Hung M, Okoya F, Uzman N. FIP’s response to the COVID-19 pandemic: global pharmacy rises to the challenge. Res Social Adm. Pharm, 2021; 17(1):1929–33.

 Prajapati P, Desai H, Chandarana C. Hand sanitizers as a preventive measure in COVID-19 pandemic, its characteristics, and harmful effects: a review. J Egypt Public Health Assoc, 2022; 97(1):6; doi: 10.1186/s42506-021-00094-x. CrossRef

 Radwan H, Hasan H, Jaafar Z, Abbas N, Rashed Saif E, Al Kitbi M, Al Hilali M, Naja F. Diets and dietary supplements used during the COVID-19 pandemic in the united Arab emirates: a cross-sectional survey. Saudi Pharm J, 2022; 30(4):421–32; doi: 10.1016/j.jsps.2022.01.019. CrossRef

 Romano S, Galante H, Figueira D, Mendes Z, Rodrigues AT. Time-trend analysis of medicine sales and shortages during COVID-19 outbreak: data from community pharmacies. Res Social Adm Pharm, 2021; 17(1):1876–81; doi:10.1016/j.sapharm.2020.05.024. CrossRef

 Rattis BAC, Ramos SG, Celes MRN. Curcumin as a potential treatment for COVID-19. Front Pharmacol, 2021; 12:675287; doi: 10.3389/fphar.2021.675287. CrossRef

 Schobere D, Osmancevic S, Reiter L, Thonhofer N, Hoedl M. Rapid review and meta-analysis of the effectiveness of personal protective equipment for healthcare workers during the COVID-19 pandemic. Public Health Res Pract (Oxford, England), 2022; 4:100280; doi:10.1016/j.puhip.2022.100280. CrossRef

 Senthil Kumar KJ, Gokila Vani M, Wang CS, Chen CC, Chen YC, Lu LP, Huang CH, Lai CS, Wang SY. Geranium and lemon essential oils and their active compounds downregulate angiotensin-converting Enzyme 2 (ACE2), a SARS-CoV-2 spike receptor-binding domain, in epithelial cells. Plants (Basel), 2020; 9(6):770; doi: 10.3390/plants9060770. CrossRef

 Shakoor H, Feehan J, Mikkelsen K, Al Dhaheri AS, Ali HI., Platat C, Ismail LC, Stojanovska L, Apostolopoulos V. Be well: a potential role for vitamin B in COVID-19. Maturitas, 2021; 144:108–11; doi:10.1016/j.maturitas.2020.08.007. CrossRef

  Sharanya CS, Sabu A, Haridas M. Potent phytochemicals against COVID-19 infection from phyto-materials used as antivirals in complementary medicines: a review. Future J Pharm Sci, 2021:7(1):113; doi:10.1186/s43094-021-00259-7. CrossRef

 Singh N, Yarla NS., Siddiqi NJ, de Lourdes Pereira M, Sharma B. Features, harmacological chemistry, molecular mechanism and health benefits of lemon. Med Chem (Shariqah (United Arab Emirates)), 2021; 17(3):187–202; doi:10.2174/1573406416666200909104050. CrossRef

 Strand MA, Bratberg J, Eukel H, Hardy M, Williams C. Community pharmacists’ contributions to disease management during the COVID-19 pandemic. Prev Chronic Dis, 2020; 17:E69; doi: 10.5888/pcd17.200317. CrossRef

 te Velthuis AJW, van den Worm SHE, Sims AC, Baric RS, Snijder EJ, van Hemert MJ. Zn2+ inhibits coronavirus and arterivirus RNA polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture. PLoS Pathog, 2010: 6(11):e1001176; doi:10.1371/journal.ppat.1001176. CrossRef

 Trapani V, Rosanoff A, Baniasadi S, Barbagallo M, Castiglioni S, Guerrero-Romero F, Iotti S, Mazur A, Micke, O, Pourdowlat G, Scarpati G, Wolf FI, Maier JA. The relevance of magnesium homeostasis in COVID-19. Eur J Nutr, 2022; 61(2):625–36; doi:10.1007/s00394-021-02704-y. CrossRef

 Thota SM, Balan V, Sivaramakrishnan V. Natural products as home-based prophylactic and symptom management agents in the setting of COVID-19. Phytother Res, 2020; 34:3148–67; doi:10.1002/ptr.6794. CrossRef

 Sen D, Debnath P, Debnath B, Bhaumik S, Debnath S. Identification of potential inhibitors of SARS-CoV-2 main protease and spike receptor from 10 important spices through structure-based virtual screening and molecular dynamic study. J Biomol Struct Dyn, 2022; 40(2):941–62; doi:10.1080/07391102.2020.1819883. CrossRef

 Rao PV, Krishnan KT, Salleh N. Gan SH. Biological and therapeutic effects of honey produced by honey bees and stingless bees: a comparative review. Rev Bras Farmacogn, 2016; 26:657–64; doi:10.1016/j.bjp.2016.01.012. CrossRef

 Vahedian-Azimi A, Abbasifard M, Rahimi-Bashar F, Guest PC, Majeed M, Mohammadi A, Banach M, Jamialahmadi T, Sahebkar A. Effectiveness of curcumin on outcomes of hospitalized COVID-19 patients: a systematic review of clinical trials. Nutrients, 2022; 14(2):256; doi: 10.3390/nu14020256. CrossRef

 Yakhchali M, Taghipour Z, Mirabzadeh Ardakani M, Alizadeh Vaghasloo M, Vazirian M, Sadrai S. Cinnamon and its possible impact on COVID-19: the viewpoint of traditional and conventional medicine. Biomed Pharmacother, 2021; 143:112221; doi:10.1016/j.biopha.2021.112221. CrossRef

 Yi YS. Potential benefits of ginseng against COVID-19 by targeting inflammasomes. J Ginseng Res, 2022; 46(6):722–30; doi: 10.1016/j.jgr.2022.03.008. CrossRef

 Younis NAAY, Hamam RM, Mayyas A. Online survey: prevalence and attitude of Jordanians towards using herbal remedies in the pandemic COVID-19. Pharmacogn Mag, 2021; 13(6s):1632–8.

 Zareef R, Diab M, Al Saleh T, Makarem A, Younis NK, Bitar F, Arabi M. Aspirin in COVID-19: pros and cons. Front Pharmacol, 2022; 13:849628; doi: 10.3389/fphar.2022.849628. CrossRef

 https://www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or (Accessed 24 December 2022).

 https://covid19.who.int/#:~:text=Globally%2C%20as%20of%204%3A38pm,vaccine%20doses%20have%20been%20administered (Accessed 31 December 2022).

 Rasoft. 2022. Available via http://www.raosoft.com/samplesize.html (Accessed 10 December 2022).

 https://corona.moh.gov.jo/ar/ (Accessed 10 December 2022).

 https://www.fip.org (Accessed 10 December 2022).

 https://www.who.int/health-topics/self-care (Accessed 01January 2023).

 https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide (Accessed 12 December 2022).