Giving young Emirati women a voice: Participatory action research on physical activity
Introduction
Much has been written in recent years about chronic diseases and risk factors, and their impact on individuals, families, communities, and countries (Queensland Health, 2006; Catford, 2007). Given international evidence on the increasing incidence and prevalence of obesity and chronic disease (Murray and Lopez, 1996; Mathers et al., 1999; Al-Mahroos and Al-Roomi, 2001), it is vital for policy makers and public health professionals to develop and implement health promotion initiatives addressing risk factors for chronic disease, that are socially, culturally and gender-sensitive. The Australian Institute of Health and Welfare (2002) provides an evidence-based approach on chronic diseases and associated risk factors (i.e. physical inactivity, poor diet and nutrition, tobacco smoking, alcohol misuse, high blood pressure, high blood cholesterol, excess weight).
International initiatives taking a population health focus and evidence-based approach are underway, including, for example, the following:
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by the World Health Organization, 1986, World Health Organization, 2004 and the WHO Regional Office for the Eastern Mediterranean (2003);
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a multi-country strategy developed to counteract obesity (WHO Regional Office for Europe, 2006);
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the Countrywide Integrated Noncommunicable Diseases Intervention (CINDI) involving 29 participating countries (World Health Organization, 2003, World Health Organization and http://www.euro.who.int/cindi, 2007);
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systematic reviews by the Cochrane Collaboration (Renders et al., 2000; Jackson et al., 2005),
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best practice guidelines for various chronic diseases and surveillance (Public Health Agency of Canada, 2007);
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a proposal for re-orienting the primary care system for improved prevention and management of diabetes (Health Council Canada, 2007);
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reporting on people's behaviour for unhealthy weight gain, as well as enablers and barriers to overcoming obesity (Department of Health, 2007);
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development of a National Chronic Disease Strategy (Australian Health Ministers’ Conference, 2005);
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implementation of the Australian Better Health Initiative, focussing on various health promotion interventions to improve health and well-being (Council of Australian Governments, 2006);
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introduction of a Hospital Admission Risk Program to decrease emergency department presentation and admission of persons with a chronic disease who are ‘frequent attenders’, and also to reduce the acuity and severity of their condition (and co-morbidities) through better management and care coordination (Department of Human Services, 2006);
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implementation of a framework for health sector action on physical activity (National Public Health Partnership, 2005); and
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a growing interest in the benefits of healthy built environments to encourage physical activity (National Heart Foundation, 2004).
Pharmacological and non-pharmacological interventions can be implemented to prevent, treat, and manage an individual's chronic disease (and/or co-morbidities). Pharmacological interventions generally involve the prescription and use of medication (e.g. statin drugs to reduce blood cholesterol levels). Non-pharmacological interventions entail patients (and their families) receiving health information from health professionals and enrolment in lifestyle modification programs (addressing specific chronic diseases or risk factors). In some instances, health professionals may recommend (or general practitioners in Australia prescribe LifeScripts) (Department of Health and Ageing, 2007b; Australian Divisions of General Practice, 2007) that patients receive a combination of interventions.
The World Health Organization (2007) has published fact sheets addressing physical activity. Peer-reviewed epidemiological research (since 2000) continues to document the significant health gains of physical activity in areas such as cardiovascular disease, diabetes, stroke, mental health, falls prevention, and obesity (Brown and Bauman, 2000; McElduff et al., 2001; Tobias and Roberts, 2001; Cass and Price, 2003; Bull et al., 2004). A summary of epidemiological studies (Lee and Skerrett, 2001) indicates that there is a consistent risk reduction of about 30% for those persons achieving recommended levels of moderate-intensity physical activity on most days of the week. The relationship between physical activity and all-cause mortality has been described as ‘inverse’; those who were more active had lower rates of death. A milestone Danish study of 31,896 adults in Copenhagen demonstrated that cycling to work reduces the all-cause mortality risk, providing clear evidence on the benefits of active commuting (Andersen et al., 2000). Crespo et al. (2002) undertook a longitudinal study on the Puerto Rico Heart Health Cohort of 9136 middle-aged men, finding a 45% reduction in all-cause mortality in the most active group compared to the least active group. A reduction in all-cause mortality was also found in a study of 7553 elder American women (65+ years) (Gregg et al., 2003), a British cohort of 7735 older men (Wannamethee et al., 2000), and the prospective cohort study of 11,130 male Harvard University Alumni with a mean age of 58 (Lee and Pfaffenbarger, 2000). Following a systematic review, Hallal et al. (2006b, p. 1028) found that ‘there is consistent evidence that adolescent PA [physical activity] is positively associated with adult PA levels.’
Health promotion is moving forward with large-scale prevention trials in China, Finland and the United States (Bull et al., 2004). A host of health promotion activities in schools, workplaces, and the community have already been undertaken (Jones, 2004; McLean et al., 2005). An Australian study addressed the declining physical activity levels from puberty onwards in a high school population of 800 girls from mainly non-English speaking backgrounds, by providing curriculum interventions and a supportive physical, social, and organisational environment (Cass and Price, 2003). A survey of 30 worksites and 13 work insurance providers explored barriers to physical activity initiatives for Australian manufacturing workers (Veitch et al., 1999). Identified barriers included lack of awareness of benefits, program cost, and reluctance by workers to participate. Exercise on prescription schemes have existed in England and Wales since the 1990s whereby, after an initial fitness assessment by a general practitioner, clients were ‘prescribed’ a recommended physical activity program. This health promotion initiative also included South Asian Muslim women who faced additional barriers such as cost, lack of child care facilities, and cultural codes of conduct and language (Carroll et al., 2002).
Database searches yielded comparatively few results on physical exercise among Middle Eastern populations. Notably, a prevalence pattern of physical inactivity among Muslim women was a key finding (Al-Mahroos and Al-Roomi, 2001; Al Hazzaa, 2004; Carter et al., 2004). A qualitative study on the health perceptions and health behaviours of 267 poor urban Jordanian women (15–45 years) concluded that to meet women's health needs, a health promotion focus on regular exercise, preventive health checks, and healthy food were required (Mahasneh, 2001). A study entitled ‘Health Beliefs and Practices among Arab Women’ (Kridli, 2002) mentions that recent Arab-American immigrants do not usually engage in preventive health practices. Zurayk et al. (1997) indicate that prenatal care (to improve maternal health) is not highly valued among Arab women because it is believed that (1) women are proud to be healthy during pregnancy; (2) preventive medical practices are unnecessary, (3) excessive planning negatively affects their future, and (4) it defies God's will.
The WHO Regional Office for the Eastern Mediterranean (2003) reports on a follow-up of non-communicable diseases and the need for an integrated approach to addressing risk factors. ‘Chronic conditions are increasing dramatically such that by 2020, these conditions are expected to contribute to 60% of the disease burden in [the] Gulf area’ (2003, p.5). Furthermore, data on ‘risk factors provided by Gulf member states’ show that among people aged 25–65 years, the range of prevalence of selected risk factors is: smoking (16–45%), hypertension (20–30%), overweight–obesity (40–70%), and hyperlipidaemia (20–45%)’ (p.6).
Few studies examine the health and well-being of residents in the United Arab Emirates (UAE) (Eapen et al., 1998; Musaiger, 1998; Pritchard, 2000; Winslow et al., 2002; Carter et al., 2004; Musaiger, 2004). The UAE, a rapidly developing Islamic nation, has encountered marked social and economic change, and progressed from a nomadic culture to a high-technology oil-rich nation within the past 40 years (Kandela, 1999). An exploratory study of mothers and their daughters regarding generational and cultural changes revealed that the latter have had access to better education and medical care than the former. Both generations agreed that faith in Islam protects their children from future problems and the role of the family remains the cornerstone of society (Schvaneveldt et al., 2005). Socio-economic and health care changes in the UAE have influenced food consumption (i.e. less fruit and vegetables, more meat, poultry, sugar, and fat), whilst an increase in chronic diseases (e.g. cardiovascular disease, cancer, diabetes, hypertension, obesity) poses major health problems (Musaiger, 1998).
A significant lack of physical activity among the UAE population was widely documented (Musaiger, 1998; Carter et al., 2004; Henry et al., 2004; Sabri et al., 2004). Evidence that physical inactivity was a factor linked to the high increase of obesity in UAE women (30–39 years) resulted in recommendations for developing and implementing health promotion programs in the region (Musaiger et al., 2000). A study of 16,391 UAE school children (10–18 years) confirmed that at age 14, obesity was 2–3 times higher than the international standard (Al-Haddad et al., 2005). Findings from the Emirates National Diabetes study indicate an ‘alarming number of children in the UAE [suffer] from obesity’ due to ‘fundamental health practices’ in the UAE, including the ‘complete collapse of physical activity’ (Wattad, 2002, p. 38). Henry et al. (2004) investigated patterns of physical activity of 58 adolescent UAE girls (11–16 years). Data analysis of their activity diaries revealed that physical activity was ranked low, whilst cultural and weather restrictions profoundly affected the insignificant role exercise plays in everyday life.
This paper reports on a qualitative study with the aims to: (1) assess physical activity levels among young Emirati women attending college, (2) identify social and cultural barriers preventing them from engaging in physical activity, and (3) recommend strategies to increase physical activity. Given the scant-published evidence on young Emirati women's participation in physical activity, this paper focuses on a sample of young Emirati women's attitudes towards physical activity.
Section snippets
College
This study on physical activity levels of young Emirati women was undertaken at a women's college, Fujairah, UAE, from September 2005 to April 2006. According to official college reports, around 600 female students were enrolled during the 2005–06 academic year. The majority were first-year students, with a small percentage being newly married with children.
At the college, all communication is in English as teaching personnel are predominantly native English speakers but administrative
Students’ physical activity patterns
Data about Emirati students’ physical activity patterns at college were obtained principally from the critical reference group's reflections on three sports events at the college (in the winter of 2003, 2004, and 2005). The members indicated that despite sustained promotion of sports activities through class advisors and general health information sessions, these events were deemed unsuccessful due to low participation rates. Annual sports days had been well attended by the student audience but
Discussion
As demonstrated in the literature review, few studies on physical exercise and UAE women were available (Henry et al., 2004). As far as could be ascertained, this is the first study of this nature to report on UAE women's physical activity preferences within their social environment. The project findings specifically apply to young Muslim women attending college, UAE, and indicate they had not developed a healthy adult lifestyle including regular exercise. The overwhelming findings, supported
Conclusion
Using critical reflection during the data collection process, all participants in the study recognised the almost complete state of physical inactivity of young Emirati women at the college. A desire to improve the status quo was a common goal. Only a small sample of students participated in interviews and focus group discussions. However, a critical reference group was vital in providing key insights into the reasons why it is so difficult to implement physical activities at the college from
Acknowledgements
The college management and health committee supported this study. Ethical clearance was granted prior to the study and all participants gave verbal consent. Margo Saunders and two anonymous reviewers provided insightful comments on the paper. Lesley Ellis, David Lloyd, and Nia Thompson kindly assisted with published papers. Disclaimer: This paper reflects the authors’ views and not of the Department of Human Services, Victoria, Australia.
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