A cross-sectional study on the perceived barriers to physical exercise among women in Iraqi Kurdistan Region

This study showed that the built environment factors were the most frequently reported barriers, followed by interpersonal and social environment factors. The most prevalent interpersonal barriers were lack of time (47.4%), fatigue (24%), and cost (22.4%). The most important social environment barriers included work (30.6%), harassment outside (22.2%), not having a friend or family member accompanying (19%), and not being allowed by family (15.4%). The most prevalent built environment barriers included the lack of footpaths (34.4%), limited accessibility of exercise facilities (25.8%), and environmental pollution (21%).

In the current study, lack of time was the most prevalent interpersonal barrier to physical exercise among women. Other important interpersonal barriers included fatigue and cost. Another study from Singapore also identified time and fatigue as the top barriers to physical activity in the general adult population [15]. Another study from Saudi Arabia also recognized fatigue and lack of time as the main interpersonal barriers among a sample of women with diabetes mellitus [22]. Affordability or cost was also an important barrier in a study on the disadvantaged women population in Canada [14].

Most women, whether single or married, young or old, have many responsibilities, such as taking care of children, cooking, and cleaning at home, besides working or studying. Therefore, they usually feel fatigued and lack time for leisure activities such as physical exercise. Lack of time was significantly higher among employed women and students.

The cost is also an important barrier since participation in physical exercise programs in health/fitness clubs or gyms is relatively expensive in Erbil (minimum of USD100 per month). Women have limited choices, as the culture does not encourage them to practice physical exercise in parks and open spaces. In the current study, the cost factor was particularly important for women from rural areas and those with lower economic status.

In our study, only care for children and family and age interpersonal barriers were significantly associated with the age of the participants. Care for children and the family barrier was more prevalent in women aged 36–45. The age barrier was more prevalent among those 46 and older. A Brazil study showed that older adults and older adults reported intrapersonal barriers to physical exercise more frequently than younger women [23].

This study determined work as the most prevalent social environment barrier to physical exercise, followed by harassment outside, not having a friend or family member accompanying, and not being allowed by family. Nonsupportive cultural and social norms were also important social environment barriers among disadvantaged women in Canada [14]. A systematic review also identified similar social environment barriers to physical exercise among young women, including social support, religious and cultural norms, and safety issues related to sexual harassment and other forms of sexual violence in public spaces [24]. Despite good progress with women’s political and social participation in Kurdistan, many social and cultural factors still restrict women from their rights and freedom. The relatively high prevalence of harassment and not being allowed by family indicates such restriction [19, 20].

Women at a younger age, with lower education, singles, students, non-employed, and lower economic status were more likely not to be allowed by the family to practice physical exercise. Many other social environment barriers were significantly higher among women with lower education levels, employment, and economic status. This finding indicates that women with less empowerment are at higher risk of controlling behavior by their families and husbands. These women might not be at risk of deprivation of physical exercise only. However, they may be vulnerable to other human rights abuses and suffer poor health outcomes [25]. Research has shown that women empowerment programs have contributed to women’s increased motivation to change physical activity behavior [26].

Research has shown a positive relationship between the support for physical exercise from partners and family and engagement in physical exercise [27]. Sometimes partners or families prevent or discourage women from physical exercise for disapproving exercise outfits, thinking that sport is only for men, restricting women from leaving home, fear or worry of neighborhood safety, or even thinking that exercise is harmful for reproduction [28‐32].

In this study, the most prevalent built environment barrier was the lack of footpaths, cycle lanes, or parks. This was followed by limited accessibility of gyms or other exercise facilities and environmental pollution. Another study on the adult population in Singapore also identified a lack of footpaths, cycle lanes, or parks, and pollution as the top three barriers to physical activity [15]. Lack of footpaths, cycle lanes, or parks was a significant factor for transport-related physical activity. The study from Canada on disadvantaged women similarly identified lack of accessibility as a key barrier to leisure-time physical activity [14].

Erbil has no special cycle lanes, and the footpaths are generally not in good shape. While walking along roads and streets, people frequently require going on roads and being at risk of road traffic accidents. On the other hand, the number of parks is also limited, and many are not in good condition. Most small parks and gardens near the residential quarters include big generators that provide electricity to the surrounding houses. The noise and pollution from these generators make these gardens and parks inappropriate for physical exercise.

Most built environment barriers were more prevalent among older women, women with higher education, and employed. This might indicate a higher awareness of these groups of women of these barriers. However, employed women and those with limited time and fatigue might find such excuses not to carry out physical exercise.

This study has assessed the main barriers to physical exercise among women in a majority Kurdish and Muslim setting. Other studies have shown high levels of interest but low levels of activity in participating in physical exercise among Muslim women. Muslim women face many barriers and challenges to physical exercise, and progress has been slow. Barriers preventing Muslim women’s participation include religious and cultural barriers, the lack of women-only spaces or facilities, the lack of modest sports attire, and the potential to encounter discrimination [33, 34]. Interventions to encourage the engagement of Muslim women in physical exercise should address the multiple layers of the socioecological model to redress the main barriers at different levels. These different levels of barriers include intrapersonal barriers, such as lack of self-efficacy, motivation, and knowledge; interpersonal barriers, such as lack of social support; and environmental barriers, such as lack of affordable facilities appropriate for the cultural and religious beliefs regarding the participation of women with gender-sensitive and modest dress [35].

This study is the first from Iraq and Iraqi Kurdistan region to investigate the barriers to physical exercise among women. Similar studies from the neighboring countries and other Middle Eastern and Arab countries are also very limited. This study shows the main types and details of the barriers to physical exercise among women in these settings. While recent interest and engagement in physical exercise has increased in the region, women, especially those from conservative and deprived societies, have limited engagement in physical exercise, which could be due to different types of barriers. Determining these barriers can help in taking appropriate actions to overcome these barriers to increase the level of participation of women in physical exercise.

This study has some limitations. The type of the study and sampling method affect the generalizability of the findings. The convenience sampling method is usually used when it is difficult to obtain the list of the population to choose a random sample. The snowball sampling method is more useful when it is difficult to identify respondents and there are stigma issues in the research topic. In the ideal situation, the random sampling method should have been used for this study. However, convenience and snowball sampling methods were used due to the difficulty of obtaining a detailed list of the study population with their contact and directly contacting women in this society based on a random selection. A longitudinal study that applies random sampling and considers confounding variables is needed to provide generalizable findings. This study mixed girls and women for the same barriers. Married and unmarried women have different barriers to physical exercise in the Kurdish and Muslim community contexts. Several valid and reliable questionnaires exist for assessing physical activity barriers, such as the Exercise Benefits/Barriers Scale [36]. However, we decided to use a new tool since the existing tools do not cover all the potential barriers relevant to the Kurdish and Muslim contexts.