To the best of our knowledge, this is the first qualitative study to examine facilitators and barriers to physical activity in the Arab population either in Israel or the Middle East. A number of cross-sectional studies have examined levels of adherence to physical activity in Arab or Muslim populations (1
), but cultural and environmental impediments to physical activity have not been investigated (13
). We attempt to bridge this gap by illuminating cultural, environmental, and religious facilitators and barriers to physical activity among Arab Israelis.
Although participants recognized the importance of physical activity in health promotion and chronic disease prevention, most admitted to being not regularly active, which is consistent with findings in a multiethnic sample of older adults (14
). The contradiction between awareness of the importance of physical activity and lack of exercise could be explained by the role social norms play as a barrier to physical activity. Intracommunal consensus influences the minority to conform to norms of the majority, particularly when living in an extended-family structure (15
). Thus, living in an extended-family setting, which deemphasizes the importance of physical activity, prevented participants from leading a physically active lifestyle. The local community had been on occasion verbally disruptive or abusive of individuals or groups attempting to be physically active. Women, in particular, had to abide by cultural standards and often found themselves exercising in adjacent Jewish towns or at odd hours so that they would not be noticed by neighbors. A social environment conducive to physical activity (e.g., seeing people being physically active in your neighborhood) increases the likelihood of achieving recommended levels of physical activity (16
Participants perceived religion to be a facilitating factor because the Muslim scriptures justified physical activity. However, quantitative data from a parallel survey revealed no significant difference in physical activity levels between religious and nonreligious Arab students. Furthermore, some religious participants expressed fatalistic views of health, which impede health-promoting behaviors by reducing self-efficacy and increasing external locus of control (17
). Fatalism has also been found to act as a barrier to preventive health behavior among other minority populations (e.g., African Americans) and other cultures worldwide (18
The Social Ecological Model (22
), which acknowledges many factors that influence health behavior, could be used to examine the results of our study. Interpersonal factors, such as social environment and level of social support, had a greater effect on the behavior of study participants than did intrapersonal factors (e.g., attitude, self-efficacy). Female participants, for instance, reported that group camaraderie, rather than self-efficacy, encouraged them to become or stay physically active. Additionally, the Social Ecological Model's emphasis on environment and policy as facilitators of physical activity is consistent with the findings of the study. An urban environment was an enabling factor by providing facilities, sidewalks, and a socially acceptable venue for exercise. In contrast, the rural environment was primarily regarded as an impediment, not only because of the need to conform to social norms but also because appropriate facilities were lacking. Participants felt resources were not allocated by the government or local municipality to accommodate physical activity. Providing access to safe and culturally appropriate exercise facilities has been found to promote physical activity (25
To promote physical activity in the Arab Israeli population, program planners should consider using multiple health promotion strategies, such as social marketing and personal feedback (27
). Increasing the population's awareness, along with supporting positive physical activity trends (e.g., walking groups in Arab communities) might lead to a change in social norms, which, in turn, might encourage behavioral change. Moreover, environmental factors must be considered when designing physical activity promotion programs, including culturally appropriate facilities (e.g., separate facilities for women, with female instructors). A community-based approach involving religious leaders might facilitate change, and policy changes in allocating appropriate funds to promote physical activity of the minority population in Israel must be considered as well.
As is the case with other qualitative studies, the primary limitation of this study is the inability to generalize its findings (28
). However, focus group participants were demographically similar to the general Arab Israeli population in several ways. For example, 49% of focus group participants were female compared with 53% in the general Arab population. Other comparable variables included living environment (27% urban in focus group participants vs 21% in the general Arab population); physical activity levels of female participants (21% in participants vs 23% in 21- to 24-year-old Arab women); and physical activity levels of male participants (33% vs 25% in 21- to 24-year-old Arab men). The study sample was, however, different from the general Arab population in several ways. Christians were overrepresented in the study sample, and Muslims were underrepresented. Additionally, this sample of future health professionals might be more educated and cognizant of physical activity guidelines and health promotion strategies than the general Arab Israeli population, though this supposition has not been substantiated in national surveys.