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

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. Electronic supplementary material The online version of this article (10.1186/s12889-018-5472-z) contains supplementary material, which is available to authorized users.


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 [1][2][3][4][5][6]. 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 [8][9][10]. Some studies have compared indicators across countries [11][12][13][14][15], 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 peerreviewed 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.

Search strategy and inclusion criteria
We sought to retrieve research published in refereed journals and reports of surveys, and our approach was threepronged. 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.

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). 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.

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).
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 gendersegregated 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, 45-47, 54, 60, 62-64, 67, 74, 75, 77-86].

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 multidimensional 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%,  [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 Urban residence [35,36,43,77,150] Consuming fruits/ vegetables [33] Smoking a [29][30][31][32] [ 225] Alcohol [30] Screen time d [21][22][23][24][25][26][27][28] Overweight/ Obesity e [22,24,29,33,35,[37][38][39] [ 30, [40][41][42] No effect [43] Chronic medical conditions a [29,[34][35][36] Parity [107] a The 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] b The association between underweight and physical inactivity was mentioned in one study and showed a positive association 34%, 28% and 17% respectively [88][89][90]); they are even lower in South-East Asia and Africa (15% and 21% respectively); the Americas have lower or similar inactivity levels [88][89][90]. 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,[95][96][97][98][99][100][101] 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].