Assessment of physical activity and its facilitators and barriers among Syrian refugees living in Amman City, Jordan: a cross-sectional study

The growing influx of vulnerable populations poses many challenges to host countries [1]. Jordan, which has hosted refugees from various countries and areas for a long time, is no exception. Since 2011, millions of people have fled from Syria to Jordan and other neighbouring countries, and the influx of refugees has overstretched Jordan’s health system [2].

Non-communicable diseases (NCDs) kill 41 million people worldwide each year, and 77% of all NCD deaths occur in low- and middle-income countries [3]. The burden of NCDs such as cardiovascular disease, cancer, chronic lung diseases, and diabetes in the Arab world has increased, with variations between countries of different income levels [4]. Jordan is categorized as a lower-middle-income country, whereas Syria is categorized as a low-income country [5, 6]. Prior to the Syrian conflict that dates back to 2011, NCDs accounted for 77% of the total mortality in Syria in 2008 [7], whereas the mortality rate in Jordan due to NCDs was 76% in 2014 [8]. In addition, as the World Health Organization (WHO) explains that people of all regions and countries are affected by NCDs [3], the risks of developing NCDs among both Syrians and refugees are similar as well. Therefore, Syrian refugees in Jordan are likely to face a continuous high risk of death caused by NCDs.

The results of a survey conducted in 2014 reported that more than half of Syrian refugee households had a member with an NCD [9] and that the impending burden could incur substantial medical costs to the Government of Jordan. Until November 2014, primary and secondary care for Syrian refugees was free at public facilities in Jordan [10]. Since then, government policy has required refugees registered with the Ministry of Interior to pay a subsidized rate for care (similar to that for uninsured Jordanians) [11]. A previous study predicted that NCD diagnoses in Syrian refugees would become an increasing burden on health services in Jordan [9]; therefore, the health system is likely to be overwhelmed if the risk of NCDs among refugees continues to increase. Thus, it is critical to take primary preventive actions to reduce risk factors for NCDs before they even occur and to take appropriate measures for NCD control at an early stage.

Mental health issues remain a major public health challenge [12]. The WHO reports that “people living with mental health conditions are more likely to face other physical health problems”, such as NCDs [12]. In fact, for refugees, mental disorders become the high burden [12, 13]. Many of them suffer from trauma, depression, anxiety, and post-traumatic stress disorder, caused by their experience of the escape and evacuation from their homeland and fear of persecution [13, 14]. Even after arriving in host countries, refugees continue to be exposed to stressful situations [15‐17]. Therefore, there is an urgent need to take some measures to improve and control mental health among refugees.

Tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets are the four major modifiable behavioural risk factors for NCDs [18]. According to the WHO, physical inactivity has a wide range of negative impacts on such as the health system, economic development, and quality of life [12]. On the other hand, regular physical activity (PA) not only helps prevent and manage NCDs but also helps prevent diseases and improve mental health and quality of life [13, 18]. PA and physical inactivity affect both mental and physical health [19‐21], and regular PA is essential for everyone; refugees are no exception. To collect, analyze, and disseminate data on PA/physical inactivity, many studies have been conducted worldwide using the WHO STEPwise Approach to Chronic Disease Risk Factor Surveillance (STEPS) or the International Physical Activity Questionnaire (IPAQ). However, only a few studies have focused on PA of refugees living in neighbouring countries.

A few previous studies have reported that refugees have a high prevalence of physical inactivity: 50% among Palestine refugees diagnosed with diabetes mellitus living in Jordan [9] and 43% among the Sahrawi people living in refugee camps in Algeria [22].

Updating the prevalence of physical inactivity is significant, particularly for Syrians, because the country’s situation has changed dramatically. Literature review has found that only two studies had reported PA in Syrian refugees living in countries neighbouring Syria: a health status survey of Syrian refugees conducted in Turkey in 2015 [23] and the WHO STEPS survey conducted in Lebanon in 2017 [24]. The STEPS survey conducted in Jordan in 2007 targeted only Jordanians, and refugees were not included. The STEP survey in 2019 was the first one to include Syrian refugees living in Jordan [25]. The results revealed for the first time that the prevalence of physical inactivity among Syrian refugees in Jordan was 21.2%. The survey also showed that 25.7% of Jordanians were physically inactive [25].

Although previous reports have identified various facilitators of and barriers to PA, only a few studies about PA have been conducted among refugees in Arab countries. The present study aimed to determine the prevalence of PA and to identify the facilitators of and barriers to PA among Syrian refugees in Jordan. The findings will enable health policy developers to identify the root causes of some individual and structural risks factors for NCDs and to support strategic planning for multisectoral intervention for better health outcomes for both the host and refugee communities.

Our hypothesis is that the prevalence of physical inactivity among Syrian refugees living in an urban setting is high. We undertook the study in 2017, ahead of the Jordan National STEPS survey for NCD Risk Factors 2019, to determine the prevalence of physical inactivity in Syrian refugees and to assist in solving possible future problems related to NCDs. The 2019 STEPS survey did not include facilitators of and barriers to PA but noted that barriers to PA must be assessed and identified [25]. Therefore, additional studies are valuable for clarifying the facilitators of and barriers to PA, especially among refugees, to make the most of the findings in policy making and project creation.

This study provides valuable insights into the level of PA and the facilitators and barriers to PA among Syrian refugees living in Amman. Regarding the first key results, the study revealed that most Syrian refugees had a high level of PA; only 8.1% were physically inactive. This finding is lower than the result of the STEPS survey conducted in Jordan in 2019: the prevalence of insufficient PA among Syrian respondents was 21.2%, and that of Jordanians was 25.7% [25]. The STEPS survey in Syria in 2003 reported 32.9% of the Syrian did not meet these recommendations [38]. Other previous studies also reported refugees to be physically inactive in their host countries [23, 39]. This insufficiency could be attributed to several reasons: 1) the duration of refuge in Jordan spent by the Syrian. More than 79% of the participants had lived in Jordan for more than 4 years, and only few participants had lived in Jordan for a shorter period. According to a recent study reported that newly arrived refugees consider PA as a lesser priority [40], the PA level may depend on the length of stay in the host country. Therefore, fewer participants might have been classified as physically inactive in this study; 2) the difference in the target areas. The STEPS survey in Jordan in 2019 was a national survey that included Zarqa, Irbid, and Mafraq governorates in addition to Amman, whereas the present survey was only conducted in the Amman governorate; 3) Amman is a hilly city, making physical movement demanding. The WHO and other studies have reported geography as a critical factor influencing PA [41, 42]; Future regular studies including a broader sample and region are necessary to better compare the differences in PA levels across different lengths of stay and areas of residence in Jordan or any other host countries [25]; 4) the living environment of a refugee. A 2014 study that measured PA level across 5 refugee camps for Sahrawi people in Algeria showed that 43% of the participants were physically inactive [22]. Compared to living in a refugee camp, where movement is restricted to within the camp, urban refugees have fewer restrictions on movement. In addition, although the participants in this study live in a city, they are located far from the urban centre or in inconvenient places, which requires them to walk long distances to go shopping or visit administrative organizations such as the UNHCR office. However, no previous studies have compared the PA level between urban refugees and refugees in camp settings. Thus, we believe further studies are necessary to validate this finding; 5) potential motivation for participants to engage in PA [40]. The previous study reported that intrinsic motivation has been positively linked with PA [43]. Nearly half of the participants reported “promote and maintain health”(41.6%), “psychological wellbeing”(49.7%), and “relieve tension”(43.4%) as perceived facilitators, suggesting that spontaneous factors such as walking for a change of mood may have increased their PA level. Furthermore, although the participants in this study were not asked in detail about PA, some of the homes we visited for the survey had equipment for strength training and/or sports. To precisely identify the facilitators of PA, future study determining the facilitators by the level of PA is required.

Our results show that the PA level varied significantly by sex when considered in terms of METs. The levels of vigorous and moderate activity were higher among women than among men. These results are not consistent with those reported in most previous studies, which found that men were more likely to engage in vigorous activity because of social pressure and cultural norms [44]. The occupation status of the refugees can partially explain this finding. More than half of males did not work while almost all the females were housewives. Women, particularly mothers, believed that household chores were a type of exercise that could substitute for practicing sport [45]. The present study showed that men spent more time walking and sitting than did women, which is consistent with the finding reported in the international study by Bauman et al. (2009). That study noted that according to cultural norms, men had more opportunities to walk, either to the mosque to pray or to accompany women when they went out [46].

With regard to the predictors of PA, our analysis revealed that the self-perceived amount of PA was a significant indicator. In addition, those who did not report a change in their PA after arrival in Jordan were more physically inactive than those who did. This is likely associated with the finding reported by Morrison et al. (2017) that a negative mood (manifested here as indifference to PA status and amount of PA) is related to low PA levels [47].

We did not find a significant association between age and obesity and PA in this study. However, previous studies have reported that PA decreases with increasing age of a generation as their physical strength declines with age, making it more difficult for them to achieve normal PA levels [23, 48, 49]. The unique circumstance of the refugees requires the older adults to engage in labour work to support their families. The proportion of physically inactive refugees was higher among those with obesity than among those without. Several studies have reported higher levels of physical inactivity among obese participants [50, 51]. One plausible explanation of our result is the underestimation of the prevalence of obesity in this study at 15.0%, which is lower than the Syrian national representative (26.0%) [52]. This could be attributed to the use of self-report data instead of medical data [53].

The answers to questions about the facilitators of PA focused on physical and mental wellbeing. Almost half of the participants perceived that “psychological wellbeing” and “prevent diseases” could facilitate PA. “Relieve tension”, “self-dependence”, and “promote and maintain health” were mainly perceived as facilitators by physically active participants. Although a previous study supported our finding of “promote and maintain health” as a frequently reported facilitator among Egyptian University students, “relieve tension” was not a popular facilitator among them [32]. The difference between the main facilitators in our study and those among Egyptian students might be because of the refugees experiencing stress after arriving in Amman that makes them choose psychological factors as major facilitators of PA. This is in line with previous studies that found that positive beliefs, negative mood, and belief change had an association with change in PA level [32, 54, 55]. Given that psychological factors can effect a change in PA, they should be fully utilized in promotional programs to guarantee their success. More participants will engage in PA if they associate it with experiencing positive feelings and removing negative ones. Furthermore, our study found an association between a perceived facilitator “psychological wellbeing” and PA level. This result is consistent with that of previous studies that PA also plays an important role in improving the mental health of refugees [20, 21, 56]. Although no significant association between the PA level and the perceived facilitator “relieve tension” that was chosen by 43.4% of all participants was seen, PA plays an important role in improving mental health.

Regarding the barriers to PA, “high cost” and “time limitation” were the most significant barriers, consistent with previous reports [32, 44, 57]. As most refugees are in an economically difficult situation, “high cost” is the most common barrier [58]. “Time limitation”, which is likely the most common reason worldwide, was associated with other barriers such as having other priorities and being the sole source of care for the family [59]. Apart from other previously identified barriers such as a lack of knowledge of facilities in the local area, of the recommended levels of PA and of its health benefits (which could be addressed through awareness campaigns), time management skills, and reduction of PA-associated costs such as promotion of on-line based PA and distribution of coupons for using gyms should be considered by any program promoting PA [40]. Although no significant association between the PA level and the perceived barrier “Have other important priorities” was identified in this study, a similar barrier is reported as “competing priorities” by previous studies on identifying barriers and facilitators of PA among asylum seekers [40]. Future studies on determining the exact time limitations and costs that hinder PA and identifying factors taking higher priority over PA, among refugees in the host country, are required to devise strategies to promote PA among refugees according to its facilitators and barriers.

In this survey, we asked the participants to choose facilitators and barriers from a limited set of choices. However, other facilitators and barriers exist. In particular, regarding barriers, previous research reported that differences in language, culture, and religious beliefs could also be barriers [59‐61]. Guerin et al. (2003) reported that even when refugees have the opportunity to participate in PA programs in the host country, lack of understanding of the local language and poor literacy make following instruction challenging for them [39]. Experiences of discrimination and stigmatization may also affect PA [16, 62]. Gele A. et al. (2015) found that Somali women in Norway felt shame and stigma when they wanted to access health facilities such as the gym and swimming pool. Therefore, conducting additional research among urban refugees in the host country exploring more barriers and facilitators such as the aforementioned ones will aid in better understanding. Qualitative research is also essential to identifying potential facilitators and barriers. For the participants of this study and the refugees in Amman city, “high cost” and “time limitation” could be solved by setting up a place to provide opportunities for refugees to engage in PA in or near institutions such as the UNHCR where refugees visit for procedures. Offering different PA programs depending on the level of PA with free smartphone applications could be a practical solution [63].

This study had several limitations. First, the participants did not represent the entire population of interest as they were selected using a snowballing method, which might have introduced selection bias. Thus, our results cannot be generalized. Second, the results obtained could be underestimated or overestimated because some questions, such as amount of PA and diagnosis of hypertension and obesity, were answered through self-report measures. In addition, the question in IPAQ about PA in the last 7 days may have introduced recall bias. Furthermore, cross-sectional studies have the inherent disadvantage of being unable of establishing cause and effect. Moreover, the participants were not enquired about the details of PA, family size, cost, and the use of facilities that require fees, such as gyms. Such detailed information may have been useful in exploring the association with the PA level. With regard to family size, having family members requiring care, such as infants or elderly people, could have influenced the activity levels. Finally, we did not consider the effect size. Despite these limitations, our study adds to the body of literature on refugees’ PA and its distinctive facilitators and barriers, which can aid future studies that plan to promote PA among refugee populations.

In this study, we determined the PA level among Syrian refugees living in Amman, Jordan. This study also identified the most common facilitators of PA were “psychological wellbeing” and “prevent diseases”, and the most common barriers were “time limitation” and “high cost”. Our findings provide a valuable baseline for future studies to examine PA level and to verify its possible facilitators and barriers among refugees. Flexible PA programs promoted according to the PA level of refugees through free smartphone applications could improve their PA level and mental health, which would contribute to the prevention of NCDs among them. Furthermore, a mainstreaming of refugees into national interventions that aims to improve PA could apply for local people as well. Urgent action to developing strategies to support both physical and mental health among refugees by promoting PA is critical. Refugees should be surveyed more frequently, given their vulnerable and the changing environment.