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Erschienen in: BMC Public Health 1/2018

Open Access 01.12.2018 | Research article

Physical inactivity, gender and culture in Arab countries: a systematic assessment of the literature

verfasst von: Eman Sharara, Chaza Akik, Hala Ghattas, Carla Makhlouf Obermeyer

Erschienen in: BMC Public Health | Ausgabe 1/2018

Abstract

Background

Physical inactivity is associated with excess weight and adverse health outcomes. We synthesize the evidence on physical inactivity and its social determinants in Arab countries, with special attention to gender and cultural context.

Methods

We searched MEDLINE, Popline, and SSCI for articles published between 2000 and 2016, assessing the prevalence of physical inactivity and its social determinants. We also included national survey reports on physical activity, and searched for analyses of the social context of physical activity.

Results

We found 172 articles meeting inclusion criteria. Standardized data are available from surveys by the World Health Organization for almost all countries, but journal articles show great variability in definitions, measurements and methodology. Prevalence of inactivity among adults and children/adolescents is high across countries, and is higher among women. Some determinants of physical inactivity in the region (age, gender, low education) are shared with other regions, but specific aspects of the cultural context of the region seem particularly discouraging of physical activity. We draw on social science studies to gain insights into why this is so.

Conclusions

Physical inactivity among Arab adults and children/adolescents is high. Studies using harmonized approaches, rigorous analytic techniques and a deeper examination of context are needed to design appropriate interventions.
Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s12889-018-5472-z) contains supplementary material, which is available to authorized users.
Abkürzungen
ATLS
Arab Teens Lifestyle Study
DALYs
Disability Adjusted Life Years
GPAQ
Global Physical Activity Questionnaire
GSHS
Global School-based Student Health Surveys
IPAQ
International Physical Activity Questionnaire
KPAS
Kaiser Physical Activity Survey
KSA
Kingdom of Saudi Arabia
LASA
Longitudinal Aging Study Amsterdam
MESA
Multi-Ethnic Study of Atherosclerosis questionnaire
ODK
Open Data Kit
PACE+
Patient-Centered Assessment and Counseling for Exercise Plus Nutrition
PRISMA
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
SSCI
Social Sciences Citation Index
UAE
United Arab Emirates
WHO STEPS
World Health Organization STEPwise approach to Surveillance
WHO
World Health Organization
WHS
World Health Surveys
YRBSS
The Youth Risk Behavior Surveillance System

Background

Global increases in body mass index, raised blood pressure and cardiovascular disease have been attributed in part to the reduction in physical activity resulting from changes in the organization of labor and transportation, and to increases in sedentary behavior. The evidence on the magnitude of these changes and their consequences for health is well recognized. The World Health Organization (WHO) ranks physical inactivity as the fourth leading cause of global mortality, estimating that it results in 3.2 million deaths globally, mainly due to cardiovascular disease, diabetes, hypertension, and some cancers [16]. Analyses of the Global Burden of Disease estimate that insufficient physical activity accounts for an estimated 13.4 million disability adjusted life years (DALYs) related to ischemic heart disease, diabetes and stroke [7].
There are major variations in the prevalence of physical inactivity across regions and among countries. In the Arab region, alarming predictions have been made in light of very unfavorable combinations of risk factors related to body mass index, its determinants including physical activity, and its health consequences [810]. Some studies have compared indicators across countries [1115], but there have not been comprehensive assessments of the prevalence and determinants of physical inactivity across the Arab region. Yet, such regionally specific assessments are key to identify patterns and formulate interventions, and would be especially timely, given mounting evidence on the health effects of sedentary behaviour and physical inactivity, the growing awareness of the need for population interventions, and the urgency of scaling up policies and programs to increase physical activity in low and middle income countries [16]. In addition, there is a need to go beyond simplistic explanations of observed patterns in terms of religion or education.
Hence, this study was designed to review research on the subject, assess levels and variability in physical inactivity across countries and social groups, and gain insights into the extent to which social determinants, in particular those related to gender, could explain such unfavorable indicators. The diversity of indicators and measures in the region, and the difficulty of obtaining original survey data precluded the possibility of conducting a systematic review or meta-analysis. But we thought it was important to take stock of what was known about physical inactivity in the region and to review the explanations that are offered for observed levels, in order to identify patterns and to inform policies designed to increase physical activity.
The review proceeds as follows. We first present a summary of the evidence from studies published in peer-reviewed journals, including the availability and comparability of studies and the instruments used. Secondly, we provide a synthesis of prevalence levels based on the reports of surveys that have used standardized definitions and measurements. We then bring together the results of studies that examined the social determinants of physical activity, with special attention to those related to gender and cultural factors. Lastly we draw the implications of these results for research and policies.

Methods

Search strategy and inclusion criteria

We sought to retrieve research published in refereed journals and reports of surveys, and our approach was three-pronged. First, we searched for articles in refereed journals investigating physical inactivity in countries of the Arab region, published between January 2000 and January 2016, in MEDLINE, Popline and Social Sciences Citation Index (SSCI) databases. Various combinations of MeSH terms and key words were used, related to physical activity/ inactivity, sedentary lifestyle, exercise, sports, its prevalence, incidence, epidemiology, the burden it represents, and social or cultural factors. Details are shown in Additional file 1. Studies published in any language were retrieved. Two researchers conducted title and abstract screening, followed by full-text screening, checking to harmonize results regarding inclusion or exclusion; disagreements were discussed by the team as a whole and resolved. This was done according to the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) appraisal tool for systematic reviews [17]. In addition to the electronic search, we searched reference lists of the articles identified.
Sources were included if they fulfilled the following criteria: assessed physical activity or inactivity as an outcome or a determinant; were conducted among residents of Arab countries (the 22 countries of the Arab League: Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kingdom of Saudi Arabia (KSA), Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Somalia, Sudan, Syria, Tunisia, United Arab Emirates (UAE), and Yemen); described the design and methods; reported on sample size; described how physical activity/inactivity was measured; reported on the prevalence of physical activity/inactivity. Multi-country studies were included if they presented data on at least one Arab country. Studies conducted exclusively on patients with a particular disease diagnosis, and studies conducted on Arabs residing outside the Arab region were excluded. To be included, articles needed to fulfill quality criteria informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [18], including clear eligibility criteria for study selection, description of information sources, data and variables; we excluded studies that did not report on sample size, age range of study population, and those that presented unclear or inconsistent numbers.
Secondly, we retrieved the reports of surveys on physical activity conducted by international organizations in collaboration with country partners; these surveys generally use standardized instruments and the two main sources are the World Health Organization (WHO) surveys on non-communicable disease risk factors (STEPS) which include modules on physical activity among adults; and the Global School-based Student Health Surveys (GSHS) which measure activity among adolescents. We present results separately for studies based on national surveys using standardized definitions and measures, and whose results represent comparable and higher-quality estimates.
A third part of the review was to retrieve data from sources that considered physical inactivity in relation to social factors such as age, marriage, education, employment, residence, and those that examined cultural and social barriers to physical activity. We sought to gain insights into the socio-cultural context of physical activity, and to explain the patterns that emerged from the analysis of the quantifiable data. We extracted notes and themes from those sources that included qualitative information, and provide a critical synthesis of main findings. Thus, this review draws both on rigorous quantitative analyses and a narrative synthesis of qualitative studies.

Data extraction and analysis

Citations from search results of databases were imported into the reference manager EndNote and duplicates removed. We used the open-source Open Data Kit (ODK) (https://​ona.​io/​) to create the data entry protocol. The data extracted for each study included: (1) article identification (title, author/s, publication year, journal, country/ies of study); (2) research design, setting, sample size, study population, gender, and age; (3) definition of physical activity/inactivity, instrument used, reported prevalence; and, (4) demographic, economic, lifestyle and social correlates of physical inactivity. In addition, we retrieved themes from those studies that examined the social context of physical activity and provided information about gender and cultural differences.
We retrieved the most recent data from STEPS and GSHS surveys. For countries where no published reports were available, we retrieved any data available from the WHO website.
Regarding the outcome variable, because of the diversity of definitions and measures of physical activity, we found that the most consistent way to report the results was to use physical inactivity, which refers to not engaging in any physical activity and/or being in the lowest category of physical activity, however physical activity was defined in the study. This is consistent with other studies that have reviewed physical activity across the world [13].
We present results separately for adults and for children/adolescents. We defined as adults those respondents aged 18 or older, or those who were categorized as adults in the articles; younger respondents were categorized as children/adolescents. In the discussion, we build on the narrative synthesis of qualitative studies.

Results

The evidence on physical inactivity

Sources and quality of data

Our search retrieved 1,228 articles, of which 172 met the inclusion criteria. Figure 1 provides a flow chart of the review’s inclusion and exclusion process. The included articles referred to a total of 157 datasets: 149 from studies conducted in a single country and 8 conducted as part of multi-country studies; the results of multi-country studies are counted once for each individual country. Some articles were based on the same datasets, including six articles based on STEPS and GSHS surveys. Only 16/143 journal articles reported on surveys using nationally representative samples; qualitative data were retrieved from five qualitative studies and from four mixed methods studies.
All STEPS and GSHS, and 125/157 journal articles include both men/boys and women/girls. GSHS surveys (usually on adolescents 13-15) have been conducted in all but four countries of the region (Bahrain, Comoros, KSA, and Somalia). STEPS surveys usually include adults aged 25-64. Age categories in journal articles are more diverse. 12 countries had both STEPS and GSHS surveys. Unlike GSHS, not all STEPS were based on nationally representative samples (exceptions were Algeria, Mauritania, Oman and Sudan). Additional results about the prevalence of physical inactivity and its determinants are available from journal articles that used the World Health Surveys (WHS) as data sources. STEPS are based on household surveys and GSHS on school populations, while the settings in journal articles included schools (28%), health facilities (27%), households (16%), and universities (15%).
Table 1 shows disparities in the available evidence: for some countries there are very few studies (Algeria, Comoros, Djibouti, Iraq, Somalia, Sudan and Yemen), while for others many more sources are available (for example 40 for Saudi Arabia). There is also a variability in sample size, with most studies in the range of 200-2000 and a few large studies including several thousand respondents.
Table 1
The evidence on physical activity in Arab Countries: studies, sample sizes and instruments
Country
Total number of studies
Data from Reports/Factsheetsa
Data from Journal Articles
Studies (#)
Sample size/range
Single country studies (#)
Multi-country studies (#)
Sample size/range
Nationally representative studies (#)
Instruments usedb,c
Algeria
4
2 [116, 117]
4102 – 4532
1 [118]
1 [15]
293 – 4698d
-
Locally Validated Questionnaire [15]
Bahrain
4
1 [119]
1769
4 [82, 120122]
0
142 – 2013
1 [122]
WHO Heart and Health Questionnaire [120]
Comoros
3
1 [123]
5556
0
2 [12, 13]
1492 – 212021d
-
IPAQ [12, 13]
Djibouti
1e
1 [124]
1777
0
1 [11, 58]
829 – 882
1 [58]
PACE+ [11, 58]
Egypt
12e
2 [125, 126]
2568 – 5300
7 [34, 46, 74, 127130]
4 [11, 21, 58, 131, 132]
188 – 3271
1 [58]
IPAQ [131] PACE+ [11, 58]
Iraq
3
2 [133, 134]
2038 – 4120
1 [135]
0
200
-
-
Jordan
15e
2 [136, 137]
2197 – 3654
12 [61, 64, 70, 72, 80, 81, 138143]
2 [11, 15, 58]
209 – 8791
3 [58, 138, 141]
PACE+ [11, 58] ATLS [140]
Locally Validated Questionnaire [15]
KSA
48
1 [144]
3547
46 [19, 20, 2427, 36, 38, 41, 42, 44, 48, 5154, 65, 66, 68, 69, 73, 93, 96, 98, 99, 103, 107, 145167]
1 [12]
30 – 197681
3 [38, 157, 167]
ATLS [24, 42, 66, 98, 99, 167]
Barriers to Being Active Quiz: CDC website [44]
CDC Adolescent Health Survey [27]
Electronic Pedometer [19, 20]
GPAQ [36, 54, 107, 150]
IPAQ [12, 26, 69, 93, 157] KPAS [25]
WHO stepwise questionnaire [166]
YRBSS and GSHS Questionnaires [167]
Kuwait
15
2 [94, 168]
2280 – 3637
12 [37, 49, 79, 97, 169177]
1 [15]
224 – 38611
3 [169171]
The Exercise Pattern Questionnaire [172]
Locally Validated Questionnaire [15]
Lebanon
13e
2 [178, 179]
1982 – 2286
13 [22, 29, 30, 35, 57, 59, 63, 114, 180186]
0
83 – 2608
5 [35, 181, 182, 185, 186]
IPAQ: 2 used a shorter version [35, 181, 182]
Self-reported Weekly Activity Checklist [59]
Libya
5e
2 [187, 188]
2242 – 3590
2 [56, 189]
2 [11, 15, 58]
383 – 1300
1 [58]
Locally Validated Questionnaire [15]
Mauritania
4
2 [190, 191]
2063 – 2600
0
2 [12, 13]
2726 – 212021f
-
IPAQ [12, 13]
Morocco
6e
1 [192]
2924
5 [38, 61, 62, 75, 84, 85, 105, 193]
1 [11, 58]
239 – 2891
1 [58]
IPAQ [39]
PACE+ [11, 58]
Oman
7e
2 [94, 194]
1373 –3468
5 [33, 71, 195197]
2 [11, 58, 198]
10 – 5409
2 [58, 195]
GPAQ [33] GSHS Questionnaire [197]
IPAQ [196] LASA Physical Activity Questionnaire [197]
PACE+ [11, 58]
WHO Health Behavior in School Children [196]
Palestine
11
2 [126, 199, 200]
1908 – 6957
8 [55, 77, 86, 100, 201204]
1 [15]
16 – 8885
1 [202]
MESA [204]
Locally Validated Questionnaire [15]
Qatar
10e
2 [205, 206]
2021 – 2496
9 [23, 40, 207214]
0
340 – 2467
1 [214]
GPAQ [214]
Somalia
1
0
-
1 [215]
0
173
-
-
Sudan
3
2 [216, 217]
1573 – 2211
1 [218]
0
1200
-
-
Syria
4
1 [219]
3102
2 [92, 220, 221]
1 [15]
1168-2037
-
Locally Validated Questionnaire [15]
Tunisia
12e
1 [222]
2870
9 [31, 32, 43, 76, 223228]
4 [1113, 58, 131]
10 – 17789
2 [43, 223]
IPAQ [12, 13, 228], (including 1 short version) PACE+ [11]
Locally Validated questionnaire [31, 43, 223, 224]
UAE
15e
1 [229]
2581
11 [28, 45, 47, 67, 78, 83, 96, 230233]
4 [1113, 15, 58]
20 – 9918
1 [58]
Health Promoting Lifestyle Profile [47]
IPAQ: 3 used shorter version [12, 13, 78, 83]
PACE+ [11, 58]
Locally Validated Questionnaire [15]
Yemen
1e
1 [234]
1175
0
1 [11]
568
1 [11]
PACE+ [11]
aWHO-STEPS and GSHS used GPAQ and PACE+ respectively to assess physical inactivity
bThis column indicates whether some studies used internationally or locally standardized/validated instruments, with the reference number in brackets; where not indicated, the assessment of physical activity was either not specified or based on a single question
cATLS: Arab Teens Lifestyle Study – GSHS: Global School-based Student Health survey – IPAQ: International Physical Activity Questionnaire – KPAS: Kaiser Physical Activity Survey –LASA: Longitudinal Aging Study Amsterdam – MESA: Multi-Ethnic Study of Atherosclerosis questionnaire – PACE+: Patient-Centered Assessment and Counseling for Exercise Plus Nutrition – YRBSS: The Youth Risk Behavior Surveillance System
dFor multi-country studies where the information on sample size was not available for each country, we included the pooled sample size.
eA number of journal articles are based on WHO surveys (STEPS and GSHS)
STEPS and GSHS use standardized instruments, namely the Global Physical Activity Questionnaire (GPAQ) and the Patient-Centered Assessment and Counseling for Exercise Plus Nutrition (PACE+) respectively, but only 38/143 journal articles referred to studies that used validated instruments. About half of these used internationally validated tools, such as the International Physical Activity Questionnaire (IPAQ), the GPAQ or the PACE+; others used regionally or nationally validated questionnaires. Two studies used electronic pedometers [19, 20]. The majority of studies (112/157) simply used respondents’ reports. Only five studies followed the WHO’s recommendations regarding the multi-dimensional categorization of physical activity into work, active transportation, household and family, and leisure-time activities; the questionnaires that follow this recommendation include the long version of IPAQ, the GPAQ, and the Kaiser Physical Activity Survey (KPAS).

Prevalence of physical inactivity

Tables 2 and 3 present the prevalence of physical inactivity among adults; Table 2 summarizes data from WHO-STEPS surveys and Table 3 presents results of journal articles. Among adults, the prevalence of physical inactivity defined as performing less than 600 MET-minute per week, exceeded 40% in all Arab countries except for Comoros (21%), Egypt (32%) Jordan (5%); it reached 68% in KSA (national) and 87% in Sudan (subnational).
Table 2
Prevalence of physical inactivity among adults based on data from WHO-STEPS surveys
Countrya
Year of study
Age range
Sample size
Prevalence of Physical inactivity
National samples
 Comoros
2011
25-64
5556
20.1
 Egypt
2011-2012
15-64
5300
32.1
 Jordan
2007
18+
3654
5.2
 Iraq
2015
18+
4120
47.0
 Kuwait
2014
18-69
4391
62.6
 Libya
2009
25-64
3590
43.9
 Lebanon
2008
25-64
1982
45.8
 Palestine
2010-2011
15-64
6957
46.5
 Qatar
2012
18-64
2496
45.9
 Saudi Arabia
2005
25-64
3547
67.6
Subnational samples
 Algeria
2003
25-64
4102
40.7
 Mauritania
2006
25-64
1971b
51.3
 Sudan
2005-2006
25-64
1573
86.8
aFor Bahrain and Oman, surveys were available but no total physical inactivity prevalence could be retrieved; specific prevalence of work, transportation, and leisure time were 71.9%, 63.9%, and 57.1%., respectively for Bahrain and 6.4%, 30.1%, and 53.8% for Oman
bSample size was calculated for age group (25-64) from numbers provided in the report
Table 3
Prevalence of physical inactivity among adults based on findings from published literature
Country
First author, year (year of study)
Source
Definition
Instrument
Prevalence (%)
Age range
Sample size
National samples
 Comoros
Guthold, 2008 (2002-2003)
World Health Survey
<600 MET-minutes/week
IPAQ
2.7
18-69
1492
 Jordan
Zindah, 2008 (2004)
Behavioral Risk Factor Surveillance System
Not engaging in moderate activity (resulting in light sweating, small increases in breathing or heart rate.
NA
51.8
18+
710
 Kuwait
Ahmed, 2013 (2002-2009)
National Nutrition Surveillance Data
No deliberate non-work related exercise outside the home such as walking, running or cycling
NA
68.4
20+
32811
Al-Zenki, 2012 (2008-2009)
NA
Neither moderately nor very activea
NA
77.1
20+
765
Alarouj, 2013 (NA)
NA
Neither moderate nor vigorous physical activitya
NA
63.0
20-65
1970
 KSA
Al-Baghli, 2008 (2004-2005)
NA
No physical activity or mild physical activity (ordinary housework, walking)
NA
79.2
30+
197681
Al-Nozha, 2007 (1995-2000)
Coronary Artery Disease in Saudis Study (CADISS)
<600 MET-minutes/week
NA
96.1
30-70
17395
Memish, 2014 (2013)
Saudi Health Information Survey
Neither moderate nor vigorous physical activitya
IPAQ
69.1
15+
10735
 Lebanon
Farah, 2015 (2013-2014)
NA
Neither moderate-intensity physical activity for at least 150 min per week or vigorous intensity physical activity for 75 min at least per week
NA
76.0
40+
1515
Tohme, 2005 (2003-2004)
NA
Less than 30 min of physical exercise
NA
40.3
30+
954
 Mauritania
Guthold, 2008 (2002-2003)
World Health Survey
<600 MET-minutes/week
IPAQ
61.9
18-49
1492
 Morocco
El Rhazi, 2011 (2008)
NA
Less than 30 min per day
 
38.7
18+
2620
Najdi, 2011 (2008)
NA
<3METs
IPAQ
16.5
18-99
2613
 Palestine
Baron-Epel, 2005 (2002-2003)
KAP and EUROCHIS&
Exercising less than once per week for at least 20 consecutive minutesb
NA
62.8
21+
1826c
 Tunisia
Guthold, 2008 (2002-2003)
World Health Survey
<600 MET-minutes/week
IPAQ
14.6
18-69
4332
 UAE
Guthold, 2008 (2002-2003)
World Health Survey
<600 MET-minutes/week
IPAQ
43.2
18-69
1104
Subnational samplesd
 Bahrain
Al-Mahroos, 2001 (NA)
NA
<1 km walking
WHO Heart and Health Questionnaire
77.5
40-69
2013
Hamadeh, 2000 (NA)
NA
No exercise
NA
89.1
30-79
516
 Egypt
Abolfotouh, 2007 (2002-2003)
NA
No non-vigorous physical activity for at least 20 minutes or 3 times per week
NA
33.8
17-25
600
Kamel, 2013 (2010-2011)
NA
NA
NA
63.8
60+
340
Mahfouz, 2014 (2011)
NA
No exercise
NA
78.3
NA
300
 Jordan
Centers for Disease, Control, Prevention, 2003 (2002)
Jordan Behavioral Risk Factor Survey
Less than having moderate: activity that caused light sweating and small increases in heart rate or breathing for 30 minutes
NA
47.4
18+
8791
Mohannad, 2008 (2002)
NA
No activity that caused light sweating and small increases in heart rate or breathing
NA
58.7
40+
3083
Kulwicki, 2001 (NA)
NA
No exercise
NA
22.5
17-93
209
Madanat, 2006 (2003)
NA
<30 mins of physical activity/week
NA
81.5
Mean: 21.1
431
 KSA
Almurshed, 2009 (2003-2004)
NA
No exercise
NA
52.0
30+
50
Al-Quaiz, 2009 (2007)
NA
Not practicing in any regular sport and leisure time physical activity
CDC web site questionnaire
82.4
15-80
450
Al-Senany, 2015 (NA)
NA
Less than one hour weekly activity
NA
69.0
60-90
55
Amin, 2011 (NA)
NA
<600 MET-minutes/week
GPAQ
48.0
18-64
2176
Amin, 2014 (NA)
NA
<30 minutes /≥ 5 days/week
GPAQe
80.0
18-78
2127
Awadalla, 2004 (2012-2013)
NA
Neither vigorous: >6 METs nor moderate: 3-6 METs
IPAQ (short form)
58.0
17-25
1257
Garawi, 2015 (2004-2005)
NA
<600 MET-minutes/week
GPAQ
67.0
15-64
4758
 Kuwait
Naser Al-Isa, 2011 (NA)f
NA
Not engaging in regular physical activity
NA
45.0
NA
787
 Lebanon
Al-Tannir, 2008 (2007)
NA
Less than 3 days/week
NA
44.5
18+
346
Musharrafieh, 2008 (2001)
NA
Physical exercise for <0.5 h/week
NA
73.6
Mean: 21.0
2013
Tamim, 2003 (2000-2001)
NA
<3 hours/week
NA
64.3
Mean: 21.0
1964
 Mauritania
Guthold, 2008 (2002-2003)
World Health Survey
<600 MET-minutes/week
IPAQ
61.9
18-49
2726
 Palestine
Abdul-Rahim, 2003 (NA)
NA
Occupation-related sedentary-light PA for men AND no exercise for women
NA
56.2
30-65
936
Abu-Mourad, 2008 (2005)
NA
No home exercise or sports
NA
78.0
18+
956
 Qatar
Al-Nakeeb, 2015 (NA)
NA
<840 MET-min/week
NA
50. 8g
Mean= 21.2
732
Bener, 2004 (2003)
NA
Not walking, cycling at least 30 minutes/day
NA
55.3
25-65
1208
 Somalia
Ali, 2015 (2013)
NA
<2 hours/week
NA
33.5
18-29
173
 Syria
Al Ali, 2011 (2006)
2nd Aleppo Household Survey
Less than 15 mins/ week of sport or brisk walking
NA
82.3
25+
1168
 Tunisia
Maatoug, 2009 (2009)
NA
<150 mins/week of moderate level of physical activity
Oxford Health Alliance Community Intervention for Health Project
44.4
Mean: 37.9
1880
 UAE
Abdulle, 2006 (2001-2005)
NA
Less than one hour, <3 times per week
NA
39.4
20-75
424h
McIlvenny, 2000 (NA)
NA
No regular exercise
NA
54.0
18-94
254
Sabri, 2004 (2001-2002)
NA
< 1 hour/week) of sport
NA
47.5
20-65
436
aDefinition of physical activity not specified
bIt includes: walking, running, swimming playing ball games or any other sports activities (combined every day and nearly every day with once or twice a week)
cPrevalence rate for Arabs only
dOne study conducted in Libya by Salam (2012) was excluded from the prevalence table; it includes adolescents and youth (17-24 years) and the prevalence was 65.0%
eCombined Global Physical Activity Questionnaire (GPAQ) version 2.0 with a modified show card based on World Health Organization STEPs survey
fKuwaiti college students
gOnly Qatari students
hOnly normotensives
Among the 102 journal articles on adults, 48 reported on prevalence among both men and women. In most countries, inactivity exceeded 40%; a few studies found lower inactivity, including nationally representative studies in Comoros (3%), Morocco (17%), and Tunisia (15%), and subnational studies in Egypt and Somalia (34%) and Jordan (23%).
Physical inactivity among children/adolescents is presented in Tables 4 and 5, based on GSHS reports (Table 4) and journal articles (Table 5). Prevalence of physical inactivity, defined in GSHS as <60 minutes per day on 5 or more days during the past seven days, is very high, with a low of 65% in Lebanon and a high of 91% in Egypt. Journal articles report similarly high levels of inactivity (>60%) except in KSA (45%) and Tunisia (29%), with smaller studies showing a wide variation within and among countries.
Table 4
Prevalence of physical inactivity among children/adolescents using data from Global School-based Student Health Surveys (GSHS)a
Country
Year of study
Age range
Sample size
Total prevalence of physical inactivity
Definition: < 60 mins per day on five or more days during the past seven days
 Iraq
2012
13-15
2038
80.0
 Lebanon
2011
13-15
2286
65.4
 Mauritania
2010
13-15
2063
83.7
 Morocco
2010
13-15
2924
82.6
 Palestine (Gaza Strip)
2010
13-15
2677
75.8
 Palestine (West Bank)
2010
13-15
1908
81.7
 Qatar
2011
13-15
2021
85.0
 Sudan
2012
13-15
2211
89.0
 Syria
2010
13-15
3102
84.9
 UAE
2010
13-15
2581
72.5
Definition: < 60 mins per day on all 7 days during the past 7 days
 Djibouti
2007
13-15
1777
85.1
 Egypt
2006
13-15
5249
90.6
 Jordan
2007
13-15
2197
85.6
 Kuwait
2015
13-17
3637
84.4
 Libya
2007
13-15
2242
83.9
 Oman
2015
13-17
3468
88.3
 Tunisia
2008
13-15
2870
81.5
 Yemen
2008
13-15
1175
84.8
aAll based on nationally representative samples
Table 5
Prevalence of physical inactivity among children/adolescents using data from journal articles
Country
First author, year
Source
Definition
Questionnaire used
Prevalence (%)
Age range
Sample size
National samples
 Bahrain
Musaiger, 2014 (2006–2007)
NA
<5days/week of playing sport
NA
72.1
15-18
735
 Egypt
Salazar-Martinez, 2006 (1997)
NA
Not engaged in sports
NA
62.3
11-19
1502
 KSA
AlBuhairan, 2015 (NA)
NA
Complete absence of exercise
YRBSS and the GSHS Questionnairesa
45.2
Mean: 15.8
12575
 Oman
Afifi, 2006 (2004)
NA
Engaging in physical activities <once per week, apart from school physical education
27-item Child Depression Inventory
66.3
14-20
5409
 Palestine
Al Sabbah, 2007 (2003–2004)
Health Behavior in School-aged Children Survey
< 60 minutes/day, <5/7 days per week
WHO international HBSC questionnaire
80.0
12-18
8885
 Tunisia
Nouira, 2014 (2009-2010)
NA
NA
Oxford Health Alliance for community intervention for health
88.1
12-14
3987
Aounallah-Skhiri, 2012 2005
NA
< 3 Mets
Locally validated questionnaire
29.4
15-19
2870
Subnational sampleb
 Algeria
Abbes, 2016 (2010-2011)
NA
Not engaged in sports
NA
92.8
6-11
293
 Egypt
Shady, 2015 (NS)
NA
< 4 hours/week
NA
65.5
9-11
200
 Jordan
Haddad, 2009 (NA)
NA
Not very physically nor moderately active
modified Adolescent Wellness Appraisal (AWA)
4.0
12-17
530
 KSA
Al-Hazzaa, 2011 (2009-2010)
Arab Teens Lifestyle Study
<1680 METs-min/week
ATLS
61.9
15-19
2908
Al-Muhaimeed, 2015 (2012)
NA
Not engaging in sports
NA
27.3
6-10
601
Al-Mutairi, 2015 (2013)
NA
No regular exercise
NA
31.9
15-22
426
Al-Othman, 2012 (2010)
NA
NAc
NA
15.7
6-17
331
Mahfouz, 2011 (2008)
NA
Less than 30 mins of physical exercise during the previous week
CDC Adolescent Health Survey Questionnaire
34.3
11-19
1869
 Kuwait
Shehab, 2005 (NA)
NA
Only performing normal daily routine with some recreational activities or walking slowly and doing no structured exercise
NA
71.3
10-18
400
 Lebanon
Nasreddine, 2014 (2009)
NA
Based on weekly frequency: Neverd
NA
32.6
Mean: 13.06
868
 Palestine
Jildeh, 2011 (2002-2003)
The Health Behavior for School-Aged Children Project (HBSC)
<5 days a week
First Palestinian National Health and Nutrition Survey Questionnaire (2000)
77.6
11-16
314
Arar, 2009 (NA)
NA
No extra-curricular (EC) physical activities
NA
43.3
9-11
180
 Sudan
Moukhyer, 2008 (2001)
NA
Not engaging in sports activities
NA
33.4
10-19
1200
aGSHS: Global School-based Student Health survey – YRBSS: The Youth Risk Behavior Surveillance System
bOne study conducted in Lebanon by Shediac-Riskallah (2001) was excluded from the prevalence table as it includes youth (16+ years)
cModerate intensity activities included: playground activities, brisk walking, dancing, and bicycle riding. Higher intensity activities included: ball games, jumping rope, active games involving running and chasing, and swimming
dFrequency and type of activities performed along with duration (number of minutes per week)

Gender differences in physical inactivity

Where physical activity was reported among men/boys and women/girls, we calculated the M/F ratio of the prevalence of physical inactivity. Figures 2 and 3 show gender ratios among adults and children/adolescents respectively. Overall, the prevalence of inactivity was higher among women/girls in all but 9 studies (8 adults and 1 children/adolescents).

Socio-demographic and lifestyle determinants

Data from 41 articles about sociodemographic determinants of inactivity were analyzed and results are summarized in Table 6. Inactivity increased with age (18/24 studies), being married (7/10 studies), and urban residence (5/5 studies); it decreased with increased education (14/20 studies) and employment (6/8 studies); parity was positively associated with inactivity in one study. For other sociodemographic determinants, reported associations were inconsistent.
Table 6
Factors associated with physical inactivity in Arab countries
 
Statistical association with physical inactivity
Positive
Negative
Other associations
Agea
[13, 29, 35, 36, 38, 39, 69, 73, 83, 92, 100, 135, 143, 153, 176, 218, 221, 231]
[44, 71, 142]
U shape [63, 202]
Curvilinear [41]
Marital status
[29, 37, 38, 41, 105, 181, 232]
[42, 79, 221]
 
Educational levela,b
[35, 54]
[30, 33, 38, 41, 42, 46, 92, 100, 148, 150, 171, 218, 231, 232]
No effect [34, 69, 93]
Employmenta
[54, 150]
[30, 33, 36, 92, 183, 232]
 
SESa,c
[12, 35, 46, 75, 105, 232]
[42, 44, 54, 92, 181]
U shape [83]
Urban residence
[35, 36, 43, 77, 150]
  
Consuming fruits/vegetables
 
[33]
 
Smokinga
[2932]
[225]
 
Alcohol
[30]
  
Screen timed
[2128]
  
Overweight/ Obesitye
[22, 24, 29, 33, 35, 3739]
[30, 4042]
No effect [43]
Chronic medical conditionsa
[29, 3436]
  
Parity
[107]
  
aThe direction of the association between physical inactivity and some variables was not specified in other studies: age [15, 93, 140, 147, 161], educational level [39, 151], employment [29, 37], SES [26, 31, 34, 39, 140], smoking [30], overweight/obesity [15], and chronic medical conditions [28]
bEducation categorized as iliterate, primary, intermediate, secondary,and university
cSocio-economic status (SES): SES score, resources, income, housing type, wealth, Human Development Index, schooling type, domestic help, car ownership
dScreen time: Television viewing, computer using, video gaming
eThe association between underweight and physical inactivity was mentioned in one study and showed a positive association
Several studies found associations between physical inactivity and lifestyle factors. Predictably, screen time was positively associated with physical inactivity in all eight studies that examined this factor [2128]. Smoking and alcohol were positively associated with physical inactivity [2932], while consuming fruits and vegetables was negatively correlated [33]. Four studies found a positive association between physical inactivity and chronic medical conditions [29, 3436].
The studies we reviewed did not report consistent associations between obesity and physical inactivity: 8/13 found a positive association [22, 24, 29, 33, 35, 3739], four reported the reverse [30, 4042] and one showed no effect [43].

Barriers to Physical activity

We examined the subset of studies that investigated barriers to exercise. Some reported reasons were shared with other parts of the world, while others were specific to the Arab region. It is clear that the hot climate of the Arabian Peninsula and Gulf countries limits outdoor physical activity to relatively short seasons and requires special indoor facilities [13, 38, 4452]. In addition in most countries, the built environment, inadequate public transportation systems, and lack of spaces for walkers or joggers discourage exercise [15, 20, 26, 31, 38, 42, 46, 47, 5368]. As in other studies, time constraints were mentioned as barriers [15, 26, 28, 30, 31, 4042, 46, 52, 54, 67, 6973], in addition to insufficient motivation or interest [25, 26, 34, 44, 46, 54, 71, 73], other priorities [26], and lack of skills [26, 44].
A particularity of the region is the lack of encouragement for physical activity by many parents, who appear to favor educational and spiritual activities over physical activities for their children. Lack of support for physical activity is also noted among friends, peers, and even teachers, in studies conducted in Saudi Arabia, Egypt, and Jordan [15, 20, 2426, 30, 42, 46, 5355, 64, 66, 68, 71, 74]. Another regionally specific factor relates to gender constraints: even where fitness facilities are available, as is the case in the more affluent countries of the region, accessibility is a problem, particularly for women.
Lower physical activity among women has been attributed to gender norms, including conservative dress that is not suitable for physical activity, the need for women to be chaperoned in public spaces, and the paucity of gender-segregated fitness facilities [15, 28, 62, 64, 67, 71, 75, 76]. In addition, cultural values put a premium on comfort for both genders, physical exertion is avoided, and public spaces such as streets are not considered appropriate for physical activity. Thus, both general norms and gender norms converge to discourage physical activity [15, 27, 31, 41, 4547, 54, 60, 6264, 67, 74, 75, 7786].

Discussion

The diversity of definitions and methods among studies published in journals and the fact that only 43/157 studies used validated instruments hampers comparisons of the prevalence and correlates of physical activity, and it is possible that some of the differences we found are artifactual. Using inactivity instead of activity improves the comparability, but it is clear that harmonizing definitions and measurements and considering the multi-dimensional aspects of physical activity would improve the evidence for the region.
Despite these limitations, it is possible to discern some patterns. The results of this review indicate that throughout the region, levels of physical inactivity are very high. Inactivity among adults is 40% or higher in all but five of the fifteen countries with nationally representative surveys; studies with smaller samples suggest even higher levels of inactivity (>60%). Among children and adolescents, inactivity is alarmingly high, around 80% in all national surveys except Tunisia.
High inactivity among children and adolescents is documented in other regions [87, 88] and is a worldwide problem, but the levels of adult inactivity we found in this review compare very unfavorably with those of other regions. Inactivity levels in Europe, the western Pacific, Africa, and southeast Asia are considerably lower (25%, 34%, 28% and 17% respectively [8890]); they are even lower in South-East Asia and Africa (15% and 21% respectively); the Americas have lower or similar inactivity levels [8890]. These high levels of inactivity indicate that social circumstances in many countries of the region do not seem to encourage physical activity. Some comparative analyses across countries in the Arab region and outside it have reported that Muslim countries were more likely to be physically inactive, and seemed to suggest that religion constitutes an obstacle to physical activity [91]. This however is not consistent with the diverse interpretations of religious doctrine in the region, and the fact that there are no grounds for arguing that Islamic doctrine is antithetical to exercise. In addition, there is no evidence linking religious observance to lower activity. The one study that compared Muslims and non-Muslims, conducted in Syria, found no significant differences in physical activity between Muslim Syrians and Syrians belonging to other religious groups [92]. Such research highlights the complex interplay among the multiple factors that hinder physical activity.
Physical and social barriers to exercise have been amply documented in multiple Arab countries: the hot weather discourages walking and exertion outdoors; an unfriendly built environment hinders exercise and promotes a car culture; physical exertion is associated with lower status occupations; a premium is placed on comfort; all these contribute to devaluing and discouraging exercise. That parental preferences favor spiritual and educational, over physical activities, and social gatherings are the main leisure activity further contributes to reducing physical activity and encouraging sedentarity [93, 94].
The combination of physical obstacles and low valuations translates into insufficient interest and motivation to exercise, which are documented in multiple countries [20, 46, 52, 68, 90]. A number of studies [24, 40, 71, 74, 95101] bring out the clustering of health risks within the studied populations, whereby physical activity is one among a set of lifestyle factors that may include energy dense foods, sweet drinks, sedentariness, and unsafe driving. This suggests that lack of knowledge about healthy behaviors in general contributes to inactivity, and emphasizes the role of social activities that are focused on sedentarity and unhealthy snacking. Interestingly, studies [72] that have probed into perceptions of health behaviors have found these to be limited to hygiene, rest and diet, but not physical activity. Thus a combination of material and cultural factors translates into barriers to physical activity at multiple levels and to a lack of awareness and motivation among the population.
A striking result of this analysis is the consistency of gender differences in physical inactivity: in nearly all (45/53) studies conducted among adults and (31/32) among children/adolescents, prevalence of inactivity was higher among women/girls. While traditional religious norms have been reported to potentially define acceptable behaviors for women and preclude exercising, careful qualitative research [76, 102] shows that these are not insurmountable obstacles. Studies show that some women athletes negotiate their involvement in sports even as they continue to wear Islamic clothing, and that decisions to exercise are influenced by new ideas about healthy lifestyles disseminated by professionals. In addition, some studies [103] suggest that ideas about physical activity can become more positive, and that cultural barriers can be overcome when adequate facilities are available.
Studies on ideas about the body report preferences for heavier shapes, especially for men [104] and ethnographic research indicates that there is a normalization of weight gain with increasing age and with maternal status among women [105, 106]. Such notions of the body likely translate into a lack of motivation to exercise and maintain optimal weight across the life cycle for both sexes, and women are vulnerable to weight gain with successive pregnancies. Women's marginalization in segregated societies [107] further pushes them towards a lifestyle centered on hospitality, excessive food consumption and sedentariness. But research also indicates that ideal body shapes can change as a result of exposure to media, as younger women in several countries of the region seem to have adopted thinner body shape preferences [108]. Ideas about exercise can also be transformed by initiatives that provide information about the link between health and exercise, activities that involve women in sports, and efforts to change societal valuations of exertion—and of women [109].
Some initiatives, inspired by those in other regions [110] are underway: policies have been formulated in Oman and Qatar; healthy lifestyles including exercise have been promoted in Morocco, Bahrain and Palestine [111]; some have reported success in improving physical activity in Dubai [89], and Oman [112], while others, such as school-based interventions [113, 114] in Lebanon and Tunisia did not report improvements in physical activity or reductions in screen time. A closer examination of these interventions’ successes and failures can provide useful lessons for future efforts.

Conclusions

The high levels of inactivity in the region call for considerable efforts to tackle the material and socio-cultural aspects of the cultural context that discourage physical activity. Multi-sectoral efforts are needed, including collaborations among ministries of health, sports, youth and education, as well as wider collaborations that involve sectors such as transport, environment and urban planning [16, 111, 115].

Acknowledgements

This work was funded in part by a grant (106981–001) from the International Development Research Centre (IDRC) in Canada. The funder had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
We would like to thank Dr. Regina Guthold of the World Health Organization, for her constructive comments on a previous draft of the manuscript, and Zeina Jamaluddine for assisting with the preparation of the data extraction protocol.

Funding

This work was funded by a grant (106981–001) from the International Development Research Centre (IDRC) in Canada. The funder had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Availability of data and materials

Data were extracted from published sources. Data sharing not applicable.
Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
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Metadaten
Titel
Physical inactivity, gender and culture in Arab countries: a systematic assessment of the literature
verfasst von
Eman Sharara
Chaza Akik
Hala Ghattas
Carla Makhlouf Obermeyer
Publikationsdatum
01.12.2018
Verlag
BioMed Central
Erschienen in
BMC Public Health / Ausgabe 1/2018
Elektronische ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-018-5472-z

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