What healthcare professionals need to know
‑ Written by Tam Truong Donnelly, Canada and Al-Anoud Mohammed Al-Thani, Qatar
Physical inactivity is a global health problem. Worldwide, close to one-third of people 15 years of age and older have insufficient levels of physical activity1. Being overweight or obese as the result of physical inactivity and an unhealthy diet can lead to metabolic changes and raise the risk of heart disease and cancer. It is estimated that physical inactivity causes 6 to 8% of the burden of coronary heart disease, 7% of type 2 diabetes, 10% of breast cancer and 10% of colon cancer2. It has been estimated that in the State of Qatar almost 50% of adults 18 to 19 years of age and 75% of adults 60 to 65 years of age have insufficient levels of physical activity3. It is also reported that more women than men over the age of 18 years had insufficient levels of physical activity in Qatar3. The World Health Organization recommends that to maintain health, adults 18 to 64 years of age should have a minimum of 150 minutes of moderate intensity aerobic activity per week4. However, only 40% of men and 27% of women reported they were physically active for at least 150 minutes per week in the Gulf Cooperation Council countries5. Therefore, the promotion of physical activity should be an important component of healthcare programmes and services for women. However, promotional strategies and intervention programmes will only be effective if healthcare professionals and policy makers know what prevents and what facilitates Arab women to be more physically active. As cultural and social processes shape the ways in which people think, act and use healthcare services6, Arab women’s decision to engage in routine physical activities and to live a healthy lifestyle are influenced not only by their cultural beliefs, values and practices, but also by their social positions within a particular society. Therefore, in promoting physical activity among Arab women, healthcare professionals need to consider the effect of social and cultural factors, economic status and gender relations on women’s healthcare behaviours.
CHALLENGES, OPPORTUNITIES AND SOCIO-CULTURAL INFLUENCES ON ARAB WOMEN’S PHYSICAL ACTIVITIES
An exploratory qualitative study was conducted recently in Qatar by Donnelly and colleagues examining socio-cultural factors that influenced healthy lifestyles (i.e. physical activity, healthy diet and non-smoking) of Arabic women with heart disease living in Qatar7,8. Although the majority of women participants believed that exercise is important to maintain health, reduce weight and prevent cardiovascular diseases, it was difficult for women to actively engage in daily physical activity. Barriers to physical activity reported by these women included health problems, traditional beliefs and women’s domestic responsibilities. Although social values and beliefs about women’s activities outside of the home have changed, traditional beliefs and practices that restrict women’s mobility continue to influence their participation in physical activity. It is important to note that, even though some individual women retain traditional beliefs that restrict their mobility, these cultural beliefs have minimal influence on women’s decision to engage in physical activities given the changes in attitude and values that have occurred in the present society.
As with many women worldwide, family roles, home responsibilities and time spent caring for family members were viewed as an important priority for the Arab women participating in the study by Donnelly et al. The environmental factor of a hot desert climate is another barrier for women to engage in exercise and participate in outdoor activities. Acknowledging that the cooler months of winter in Qatar are conducive to exercise but that hot summer months pose a challenge, participants suggested that public shopping malls, where air-conditioning is available, could include walking tracks and health centres for exercising.
Rapid changes in socio-demographic and economic conditions both positively and negatively influence the ability of these women to pursue a healthy lifestyle7,8. Factors that facilitated Arab women’s engagement in physical activity included accessible and affordable recreational facilities in Doha and encouragement from physicians and family members (e.g. daughters) to exercise. Qatar’s advancements in scientific knowledge and education – with many Western and European institutions and universities now being an important part of the country’s economic, educational and social fabric – were viewed as positive influences for a healthier lifestyle. The adoption of Western values, beliefs and practices (e.g. a preference to have a slimmer body) and an appreciation of female beauty and health has also been a motivation to exercise for many Arab women.
In addition to the above study, a review of the literature that focuses on the barriers and facilitators to physical activity among Arab adults living in the Middle East and abroad was conducted9. A total of 15 studies were included in this review. Similar to the exploratory qualitative study of Donnelly et al, barriers cited in the reviewed studies were lack of time, poor health status, traditional roles for women, lack of social support, lack of exercise facilities in some areas, excessive use of housemaids to complete active household tasks and hot weather. The facilitators of physical activity include a desire to have a slimmer body, good support from the government and social support systems9, and the positive influence of the Muslim religion. As religious principles and practices are very important in Middle Eastern societies, it is fortunate that the Islamic religion and culture promote physical health by encouraging a healthy diet and regular exercise8,10,11.
As a continuation of the abovementioned study, a group of researchers from Qatar Supreme Council of Health, Hamad Medical Corporation, Qatar University and University of Calgary – Qatar, with the support of Qatar National Research Fund (NPRP No. 6–049–3–009), are conducting another larger, more comprehensive study. The goals of this study, of Arabic-speaking adults 18 years of age and older in Qatar, are to:
determine their physical activity levels and food habits,
assess their attitudinal, normative and control beliefs regarding physical activity and healthy diet,
determine significant predictors of their intentions to engage in physical activity and healthy eating,
gain an in-depth understanding of factors (e.g. environmental, social, cultural and policy) that influence their physical activity and eating behaviours,
identify tailored health-promoting strategies to increase active living and healthy diets in the study population.
The study is in the first year of its 3-year duration. The findings from this study are expected to help clinicians and healthcare planners to develop appropriate health policies and awareness-raising and educational campaigns to promote active living and healthy diets in Qatar.
RECOMMENDATIONS FOR HEALTHCARE PROFESSIONALS
Healthcare providers, especially physicians, play a very important role in promoting, encouraging and assisting Arab women to be physically active. Similar to the rest of the world, in the Middle East, physicians are trusted healthcare providers and their advice is valued by members of society. Studies from Qatar7,8 indicated that the majority of women were satisfied with the healthcare that they received. Thus, physicians are in the best position to provide counselling and guidance to Arab women regarding weight loss, healthy diet and exercise. Therefore, physicians and other healthcare providers need to take a more proactive role in promoting physical activity in order to increase quality of life and prevent or reduce the heavy burden of chronic illness and lifestyle-related diseases.
Qatar has a multicultural society and many healthcare professionals come from different ethno-cultural backgrounds. Therefore, to understand Arab women’s healthcare behaviour (i.e. participation in a regular exercise regime and living a physically active lifestyle), healthcare professionals need to be reflective of their own biomedical knowledge and training background, while at the same time seeking to understand Arab women’s conceptualisation of health, illness and disease and how cultural knowledge and values shape these women’s expectations towards healthcare practices in the context of Middle Eastern society.
As traditional cultural beliefs, values and practices exert great influence on Middle Eastern women’s ability to engage in physical activity and exercise, to effectively promote active lifestyle to Arab women who also have different levels of socioeconomic status, healthcare professionals should be encouraged to be open minded and to consider how cultural, social and economic processes shape their clients’ healthcare practices. Professional advice provided to these women should be contextual, realistic and practical based on the woman’s abilities and capabilities. Although regular participation in exercise programmes would be a preferred mode for all women, increased physical activity by any means should be acknowledged and strongly encouraged. For example, with Middle Eastern countries’ economic growth, the use of domestic helpers in some ways represents a negative influence on women’s daily physical activity level. Thus, simple yet practical advice such as praying five times daily, participating in housework and not being overly dependent on housemaids could also be recommended to women.
Healthcare providers and policy makers need to recognise and acknowledge women’s strength and motivation and empower them to attain and maintain a healthy lifestyle. As Arab women have become more educated, more aware of their health and more orientated towards living a healthier lifestyle, they value physical exercise and want to be healthy and fit despite challenges and cultural restrictions. There is a very strong desire to be more physically active among Arab women. Many Arab women take responsibility for their own health and healthcare while acknowledging the significant influence of family and society on their healthcare decision-making and practice.
The Qatari government has provided many recreational facilities with affordable fees to its people: for example, the fee for entry into the Aspire Academy for Sports Excellence is 250 Qatar riyals (~US$70.00) per month. To many Arab women, the availability and accessibility of recreational facilities and an environment conducive to exercise have motivated women to become more physically active by either engaging in regular exercise programmes or by simply walking around the facilities. However, adding more facilities throughout Qatar that are free of charge would provide even more opportunity for all women to be more physically active. As the principles of Islamic morality and ethics are widely followed and practiced in Qatar, healthcare professionals’ recommendations of physical activities to women should be culturally appropriate and religiously compliant. Sensitivity to modesty, assertiveness and expected social norms and religious practices should be considered by decision-makers and planners when planning exercise regimes and designing facilities that maintain privacy for Arab women.
Creating an environment that is conducive to increased physical activity is another priority for healthcare planners and decision-makers. Planning for sidewalks and over- or under-passes on streets and more green places with play areas for children, developing walking tracks in public shopping malls where air-conditioning is available and building health and recreational centres for both women and children would encourage more exercise among Arab women. The availability and accessibility of healthcare programmes and services is an important consideration to ensure participation in healthy lifestyles by all Arab women. Further reducing or eliminating fees for the use of recreational facilities might help motivate and encourage women across different socioeconomic strata to exercise.
It is imperative for healthcare policy makers to support and strengthen collaborative relationships with healthcare providers, especially physicians, because Arab women often perceive physicians as their primary source of medical information. It is important to recognise that healthcare professionals in the Middle East are practicing in a unique setting. They are providing healthcare services based on Western biomedicine models, knowledge and values within the context of Middle Eastern economic, socio-cultural knowledge and values. Collaborative and trusting relationships between clients and healthcare providers require much more effort and sensitivity; therefore, more support for these healthcare providers is needed. It is recognised that physicians are often constrained by their limited time and heavy workloads; thus, other healthcare providers such as nurses, health educators, nutritionists and social workers should be encouraged, trained and legislated for their roles and scope of practice to be active promoters of a healthy lifestyle.
Media campaigns and health education should be considered as two important strategies to increase awareness of healthy lifestyles. Women participants of the study in Qatar suggested that television and radio programmes in both Arabic and English and public educational lectures are needed to increase health awareness in the general population. Public lectures about healthy diet, food choices and the negative health consequences of an unhealthy lifestyle should be incorporated as a component of available services in every primary healthcare centre. In addition, healthcare providers should be encouraged to actively distribute brochures that discuss a healthy lifestyle and physical activity to clients during their clinic visits. Importantly, the required information should be presented in a style that would motivate patients to read and enable them to understand what was being communicated. Family priorities often take precedence over women’s health needs and women are not likely to comply with suggested exercise routines if they are experiencing stress due to their multiple roles. Therefore, outreach material that explains why participation in healthy lifestyles can benefit both the individual and the family might be a more socially and culturally sensitive, and effective way of promoting healthy lifestyles among Arab women.
Finally, healthy practices and their positive consequences should be communicated to families and individuals of all ages, especially children. Promotion of physical activity, regular exercise and a healthy diet should start early in life to foster a life-long habit. Therefore, school- aged children should be taught how to live a healthy lifestyle; they should be educated about the benefits and harmful consequences of lifestyle choices, which importantly should be modelled by the healthy lifestyle of their parents and other family members. Collaboration between the State’s Health Council and Education Council and between healthcare institutions and school administration and staff should be strengthened for the purpose of health promotion and disease prevention among children of all ages.
This paper emphasises the importance of considering cultural, social and religious factors when developing strategies to promote healthy lifestyles in Qatar and other Middle Eastern countries. Any educational, health promotion and disease-prevention programmes developed without consideration of these factors are likely to be less effective.
Implementation of nationwide campaigning and legislation for active participation in physical activity has successfully increased population awareness and level of participation among people living in Qatar. Evidence shows that since His Highness the Emir Sheikh Tamin bin Hamad Al Thani in 2012 declared 14 February as National Sports Day, not only have the people of Qatar celebrated it as a national holiday with participation in sport programmes and activities, but more importantly, living an active lifestyle has been clearly communicated and supported by the government. Active living is now incorporated into people’s consciousness as a preferable way of life for men, women and children from every walk of life in Qatar.
There remains a paucity of evidence on the physical activity and dietary habits of Arab women. More systematic research to gain a deeper understanding of the challenges and the opportunities to engage in active living and healthy eating of Arab women is needed. Findings from such studies will build a solid foundation of knowledge that can be used to inform the development of tailored and culturally sensitive multiple-intervention programmes. Increasing active living and healthy diets will have a positive effect on pressing health problems such as cardiovascular diseases, diabetes, obesity and cancer, which will ultimately improve the health and well-being of Arabic women living in the Middle East region and possibly women of similar ethno-cultural backgrounds in other parts of the world.
The authors wish to express their deepest gratitude to the Qatar National Research Fund for providing funding for research programmes under its National Priority Research Programme and Undergraduate Research Experience Programme. The article’s contents are solely the responsibility of the authors and do not necessarily represent the official views of the Qatar National Research Fund.
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Tam Truong Donnelly Ph.D.
Full Professor - University of Calgary
Adjunct Professor - Community Health Sciences
Faculty of Medicine, University of Calgary
Al-Anoud Mohammed Al-Thani M.D. Manager, Health Promotion & NCD
Public Health Department
Supreme Council of Health, State of Qatar