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A systematic review of qualitative studiesexploring the factors influencing thephysical activity levels of Arab migrantsAymen El Masri1, Gregory S. Kolt1 and Emma S. George1,2*
Abstract
Background: Evidence suggests that Arab migrant populations engage in low levels of physical activity. To ourknowledge, there are no reviews that explore the perspectives of Arab migrant populations on the factorsinfluencing physical activity. The aim of this systematic review was to thematically synthesise qualitative literatureon the factors influencing physical activity among Arab migrant populations.
Methods: Five electronic databases (CINAHL, SPORTDiscus, PsychoInfo, MEDLINE, Embase) were searched in July2018 and searched again in April 2020. A manual search in Google Scholar was also performed using keywords andthe reference lists of included studies were also screened to identify further articles. The eligibility criteria forinclusion were studies that sampled adult (≥18 years) Arab migrant populations, used qualitative methodology,explored the factors influencing physical activity as a primary aim, and were published in English. The 10-itemCritical Appraisal Skills Programme (CASP) checklist was used to assess methodological quality of individual studies.The results of the studies were thematically synthesised using the qualitative software Quirkos v1.6.
Results: A total of 15 studies were included, with the largest proportion of studies conducted in Australia, followedby the United States, Netherlands, Sweden, and then Canada. Five studies exclusively sampled Arab migrantpopulations in their study. A total of 7 major themes influencing physical activity among Arab migrants emergedfrom the synthesis: culture and religion, competing commitments and time, social factors, health-related influences,accessibility issues, outdoor environment, and the migratory experience.
Conclusions: The findings of this review highlighted the various factors influencing the physical activity levels ofArab migrant adults. While many of the factors influencing physical activity are shared with those experienced byother populations (e.g., time constraints), for Arab migrant populations there are other more unique factors closelyassociated with culture and religion that appear to influence their levels of physical activity. The findings of thisreview could be used to inform the design of physical activity interventions targeting Arab migrant populations.
Keywords: Physical activity, Migrant, Immigrant, Arab
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: [email protected] of Health Sciences, Western Sydney University, Penrith, NSW 2751,Australia2Translational Health Research Institute, Western Sydney University, Penrith,Australia
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 https://doi.org/10.1186/s12966-020-01056-w
BackgroundParticipation in regular physical activity has many healthbenefits, including a reduced risk of all-cause mortalityand various chronic diseases [1], improving bone andmuscle strength, improving mental and cognitive health,and also reducing the risk of falls [2]. It is recommendedthat adults accumulate 150 min of moderate physical ac-tivity or more per week, spread across most, or prefera-bly all, days of the week to obtain such health benefits[3, 4]. Globally, however, it has been reported that morethan a quarter of adults aged 18 years and older are notmeeting physical activity guidelines [5].Evidence suggests that physical activity levels tend to
be lower among culturally and linguistically diverse(CALD) populations. For example, an Australian studyreported that migrants from non-English speaking back-grounds had lower levels of physical activity in compari-son to those born in Australia [6]. Additionally, it hasbeen reported that more newly arrived migrants toCanada have lower levels of leisure-time physical activityin comparison to established migrants [7]. There aremany factors that influence the physical activity levels ofCALD populations. While many of these factors areshared with the general population (e.g., time, motiv-ation), there are other factors that are more specific toCALD populations. Common factors that have been re-ported to influence physical activity levels among CALDpopulations include a lack of culturally tailored healthpromotion initiatives, limited knowledge on preventativehealth benefits of physical activity, the migratory experi-ence, language, culture and religion, and socioeconomicstatus [8, 9]. Factors influencing physical activity thatmay be specific to CALD populations include the uniqueexperience of acculturation (i.e., convergence of behav-iours towards those of the host country), citizenship sta-tus, and English language proficiency [10]. It isimportant to note, however, that the physical activity ex-periences differ between CALD groups and can be influ-enced by a range of factors such as the reasons formigration, time spent in host country, and cultural andreligious practices [10]. It is therefore important to ex-plore the factors that influence physical activity partici-pation in specific CALD groups, to ensure culturally-tailored physical activity programs meet the needs andpreferences of the target population [10].The available evidence on the health of Arab migrant
populations suggests that rates of diabetes are higheramong Arab migrants than the majority population ofhost countries including Australia [11], Denmark [12],Sweden [13], and the United States (US) [14]. Further,higher rates of weight-related issues have also been re-ported among Arab migrants in Australia [15] andSweden [13]. Despite this, Arab migrant populations invarious migratory contexts are more likely to display
lower levels of physical activity in comparison to the ma-jority population of the host country [13, 16, 17].Acculturation appears to be an influential factor on the
physical activity levels of Arab migrant populations. Manystudies among Arab-Americans have reported that higherlevels of acculturation is associated with higher levels ofphysical activity [18–21]. Similarly, other studies in thecontext of Australia [16] and the US [22] have shown thatbeing born outside the host country was a predictor forlower levels of physical activity among Arab migrant pop-ulations. Furthermore, a study among Tunisian migrantmen to France reported that those who had distant socialties to their origin country were engaging in lower levelsof physical activity in comparison to those who had mod-erate and closer ties to their country of origin [23]. AmongArab-Americans, other factors that are reported to influ-ence levels of physical activity include self-efficacy [18, 20,22, 24], social support [18, 20], age, education [20], stresslevels [20, 24], lack of motivation, familial responsibilities,and competing priorities [24].Despite the widely reported health benefits of regular
physical activity, the literature published to date demon-strates low levels of physical activity among Arab mi-grants in various migratory contexts. Yet to ourknowledge, there are no reviews which explore the per-spectives of Arab migrant populations on factors influ-encing physical activity. The information obtained fromsuch a review could be beneficial in gaining an in-depthunderstanding of the important factors that need to beconsidered when developing culturally-tailored programsor initiatives for Arab migrant populations. This may beespecially important given the large Arab populationsoutside their country of origin. The aim of this study istherefore to systematically review qualitative literatureexploring the factors that influence physical activityamong Arab migrant adults.
MethodsThis qualitative review was guided by the PreferredReporting Items for Systematic Reviews and Meta-Analyses [25] and the Enhancing Transparency inReporting Synthesis of Qualitative Research statement[26]. The protocol for this review was not registered.
Inclusion criteriaTo be included in this review, studies needed to meetthe following criteria: (1) include Arab migrants as apopulation of interest (i.e., includes first generation mi-grants or those with Arab ancestry); (2) qualitative meth-odology (e.g., data-collection, method of analysis); (3)explore factors influencing physical activity participationas a primary aim; (4) focus on adults (i.e., ≥18 years); and(5) published in English. For the purposes of this review,Arab migrant populations were those who were defined
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 2 of 16
as ‘Arab’ or ‘Arabic speakers’ in studies, or migrantsfrom Arab countries as defined in the Australian Stand-ard Classification of Cultural and Ethnic Groups (i.e., Al-gerian, Egyptian, Iraqi, Jordanian, Kuwaiti, Lebanese,Libyan, Moroccan, Palestinian, Saudi Arabian, Syrian,Tunisian, Yemeni, Bahraini, Emirati, Omani, Qatari)[27]. Studies that included Arab migrants with othernon-Arab migrant populations were eligible for inclusionin this review provided that Arab migrants were notedas a targeted population of interest, and that the findingsattributable to Arab migrant participants could be distin-guished from those of other CALD participants.
Literature searchA systematic search of CINAHL (EBSCO), SPORTDis-cus (EBSCO), PsycInfo (EBSCO), MEDLINE (Ovid), andEmbase (Ovid) was performed in July 2018 and updatedin April 2020 to identify articles that met the inclusioncriteria. Manual searching was also conducted in GoogleScholar. The search terms included a combination ofterms related to Arab populations, physical activity, andqualitative methodology. All searches included the useof subject headings where available (see Additional file 1for example search strategy). The reference lists of eli-gible articles were also screened to identify further arti-cles for inclusion in the review. Further, a manual searchwas conducted to locate full-text articles for conferencesabstracts that were identified in the initial databasesearch. The first author (AE) developed the search strat-egy with input from the third author (ESG). The first au-thor (AE) conducted the initial database searches andscreened the titles and abstracts of the search results.The first (AE) and third author (ESG) independentlyscreened the articles that made it through to the full-text screening stage. For any uncertainty regarding theeligibility of a study, discussions were had with all threeauthors (AE, GSK, ESG) until a consensus was reached.The first author (AE) screened the reference lists of arti-cles deemed eligible to identify further studies, with theeligibility of potential studies discussed by all authors(AE, GSK, ESG).
Data extraction and analysisThe following data were extracted from each study:(1) author and year of publication; (2) study setting;(3) aims of the research; (4) characteristics of thesample; (5) qualitative methods used; (6) type of ana-lysis; and (7) study results or findings. The resultsfrom each study were considered the text under the‘results’, ‘findings’ or similar titled sections of the arti-cles. For studies that did not exclusively focus onArab migrant populations, the results that were ex-tracted and used in this review included: (1) resultsthat were identified as specific to the Arab migrant
subsample; (2) results in which the authors reportedapplying to all or the majority of participants; or (3)instances where the authors have made general state-ments referring to ‘the participants’ of the study with-out specifying a particular subgroup. Further, forstudies that explored physical activity in addition toother lifestyle factors, only the physical activity rele-vant data were extracted.Thematic synthesis was employed to inductively
analyse the extracted data from each study [28]. Thisprocess comprised three steps, which included line-by-line coding of the extracted data, categorisation ofdescriptive themes, and the development of analyticalthemes that went ‘beyond’ the results that were re-ported from the original studies. The first author(AE) independently coded the results of all includedstudies, and the third author (ESG) independentlycoded the results of 20% of the articles chosen at ran-dom. The independent coding was cross-checked toensure the comprehensiveness of the codes beingassigned. Codes were then grouped into descriptivethemes, followed by the creation of analytical themesby the first author (AE), which were reviewed anddiscussed with the third author (ESG) until a consen-sus was reached on the final analytical themes. It isimportant to note that two studies included in thesynthesis were studies including authors of thecurrent review. The first author (AE) performed themajority of the analysis in the current review as wellas for one of the included studies [29]. The secondauthor (GSK) was a co-author in another includedstudy [30], however was not involved in the analysisof the current review. Data analysis was performedusing Quirkos v1.6 (https://www.quirkos.com/index.html).The methodological quality for individual studies was
assessed using the 10-item Critical Appraisal SkillsProgramme (CASP) checklist [31]. Items 1–9 werescored as ‘Yes’ or ‘Unclear/No’. Item 10 was rated as ei-ther ‘valuable’ or ‘not valuable’ based on the contributionof the study to the literature and discussion on potentialimplications of the study findings. The relevant textfrom each study related to each CASP item was enteredverbatim into a spreadsheet and scored by the first au-thor (AE), and then cross-checked for consistency by thethird author (ESG).
ResultsStudy selectionA total of 1810 records were retrieved from the databasesearch and 15 additional results through other sources,of which 1166 unique records were obtained. Afterscreening titles and abstracts, 41 articles remained forfull-text screening. Fifteen of these studies met the
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 3 of 16
eligibility criteria. Figure 1 presents the screeningprocess of studies included in this review.
Study characteristicsTable 1 presents the characteristics of the includedstudies.The studies were published between 1998 [43] and
2020 [29, 39]. Five studies were conducted in Australia[29, 30, 36, 41, 43], three in the US [33, 38, 42], three inthe Netherlands [34, 37, 44], three in Sweden [32, 35,40], and one in Canada [39]. The target population ofthe 15 studies included Arab migrant groups from theMiddle East and North Africa, with a total of five studiesexclusively focusing on Arab migrant samples [29, 33,35, 38, 42]. A total of six studies focused on physical ac-tivity as the primary behaviour of interest [29, 30, 32, 38,40, 43], while the remaining studies focused on physicalactivity in addition to other lifestyle behaviours (e.g.,physical activity and diet).A commonly used approach to recruitment was to tar-
get community [29, 30, 34, 37–40, 43, 44] and religiouscentres and organisations [29, 34, 37, 39, 42, 44]. Thesample sizes of Arabs in the included studies rangedfrom 11 [32] to 45 [43]. A total of seven studies includedboth men and women [29, 33, 35, 37, 39, 41, 44], sevenstudies focused exclusively on women [30, 32, 34, 36, 40,42, 43], and one study focused on men [38].
Ten studies employed focus groups for data collection[29, 30, 32–35, 37, 40, 41, 44], two studies used interviews[36, 38], and three studies used a combination of bothfocus groups and interviews [39, 42, 43]. The interviewsand focus group duration ranged from 30 [38] to 180min[44]. Five studies reported that monetary incentives wereprovided for participation [30, 33, 34, 37, 44].
Methodological quality of included studiesThe methodological quality of studies as assessed againstthe CASP checklist (see Additional file 2). For all studies,there was a clear aim, the qualitative methodology wasdeemed appropriate, they were deemed to have used ap-propriate research designs with justification, ethical issueshad been considered, and there were clear statements re-garding the findings. Most studies used appropriate re-cruitment methods (87%) [29, 30, 32–34, 36–41, 43, 44],and had rigorous methods of data analysis (87%) [29, 30,32–41, 44]. Only seven studies (47%) reported on orprovided sufficient detail in order to determine if therelationship between the researcher and participants hadbeen considered [29, 32 ,34, 35, 37, 39, 40].
SynthesisSeven major themes were identified through the qualita-tive synthesis. The themes were culture and religion,competing commitments and time, social factors,
Fig. 1 Study Selection
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 4 of 16
Table
1Stud
ycharacteristics
Autho
ran
dco
untry
Aim
s(verbatim
)ExclusivelyArabmigrant
pop
ulation
Cha
racteristics
ofsample
Dataco
llectionmetho
dAna
lysis
Caperchione
etal.(2011)[30]
Australia
Toexam
inesocio-cultu
ral
influen
cesof
physical
activity
behaviou
rsam
ongcultu
rally
and
lingu
isticallydiverse
wom
enin
Australiaby
iden
tifying
enablersand
barriersto
physical
activity.
No
Totalsam
ple:110wom
enfro
mBo
snian,
Arabic
speaking
,Filipino
,and
Sudane
sebackgrou
nds.
Age
d46.2±11.6years.
Arabsubsam
ple:29
Arabic-speaking
wom
enof
Egyptian,
Iraqi,Syrian,
Jordanian,
Palestinian,
andLebane
seethn
icity
(Firstge
neratio
n).
Age
d39.1±10.4years.
Focusgrou
psThem
atic
indu
ction
ElMasriet
al.(2020)[29]
Australia
Toexplorethe
percep
tions,b
arriers,
anden
ablersto
physical
activity
andminim
ising
sede
ntarybe
haviou
ram
ongArab-Australians
aged
35–64years.
Yes
28Arab-Australianadults(20
wom
en,8
men
).Majority
(78.6%
)Lebane
se,firstandlaterge
neratio
n.Age
d45.0±7.8years.
Focusgrou
psIndu
ctivethem
atic
analysis
Jörgen
sdotterWeg
nelius
etal.(2018)[32]
Swed
en
Theaim
ofthestud
ywas
toexam
ineho
wim
migrant
wom
enwith
prolon
ged
illne
ssexpe
riencethe
cond
ition
sforph
ysical
activity
from
anintersectio
nalp
erspective.
No
22im
migrant
wom
enwith
prolon
gedillne
ss.
Age
d35–60years.
Arabsubsam
ple:11
Arab
immigrant
wom
enfro
mSyria,Leb
anon
,Morocco,
andIraq.
Focusgrou
psSystem
atictext
cond
ensatio
n,intersectio
nality
used
asanalytical
framew
ork
Kahan(2011)
[33]
UnitedStates
Toexploretheirbe
liefs
andattitud
estoward
socioe
cologicalfactors
that
facilitated
and
hind
ered
theirindividu
alph
ysicalactivity
andbo
dycompo
sitio
n.
Yes
Arab-American
(Arab-league
natio
ns)college
stud
ents(12
wom
en,9
men
).Age
d22.3±3.0years.
Focusgrou
psThem
aticconten
tand
framew
orkanalysis
Nicolaouet
al.(2012)[34]
Nethe
rland
sTo
gain
insigh
tinto
the
influen
ceson
Moroccan
migrant
wom
en’sweigh
tandweigh
t-related
behaviou
rby
enriching
theirpe
rspe
ctives
with
thoseof
theirno
n-migrant
compatriots
livingin
Morocco.
No
Totalsam
ple:53
wom
enwho
were
Dutch-M
oroccanor
Moroccanliving
inMorocco.
Age
d16–59years.
Arabsubsam
ple:22
Dutch-
Moroccanwom
en,firstand
laterge
neratio
n.Age
d20–59years.
Focusgrou
psThem
aticanalysis
Olaya-Con
treras
etal.(2019)[35]
Swed
en
Toexplorepe
rcep
tions,
expe
riences
andbarriers
concerning
lifestyle
mod
ificatio
nsin
Iraqi
immigrantsto
Swed
enat
riskforType
2Diabe
tes.
Yes
33Iraqi
immigrants(19wom
en,14men
).Wom
enaged
50.7years,Men
aged
42.6years(m
ean).
Mostparticipantsdidno
tcompletesecond
aryscho
ol(86%
).
Focusgrou
psIndu
ctivethem
atic
analysis
Razeeet
al.(2010)[36]
Australia
Toexplorethebe
liefs,
attitud
es,socialsup
port,
barriersand
environm
entalinfluen
ces
No
Totalsam
ple:57
wom
enwith
ahistoryof
gestationald
iabe
tesand
who
spokeArabic,Cantone
se/
Mandarin
,orEnglishat
home.
Interviews
Them
aticanalysis
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 5 of 16
Table
1Stud
ycharacteristics(Con
tinued)
Autho
ran
dco
untry
Aim
s(verbatim
)ExclusivelyArabmigrant
pop
ulation
Cha
racteristics
ofsample
Dataco
llectionmetho
dAna
lysis
relatedto
diabetes
risk
behaviou
rsam
ongthree
grou
psof
wom
enof
different
cultu
ral
backgrou
ndswith
ahistoryof
gestational
diabetes.
Arabsubsam
ple:20
Arabwom
enof
MiddleEasternbackgrou
nds(m
ostly
Lebane
seandIraqi)with
ahistoryof
gestationald
iabe
tes.
Age
d36.0±5.0years.
Romeike
etal.(2016)[37]
Nethe
rland
sTo
gain
insigh
tinto
the
specificbe
liefsthat
unde
rliethesocio-
cogn
itive
constructs
relatedto
healthyeatin
gandph
ysicalactivity
amon
glower-edu
cated
Dutch,Turkish,and
Moroccanadults.
No
Totalsam
ple:90
adults(54wom
en,36
men
)of
Dutch,Turkish,and
Moroccan
backgrou
ndswith
low
levelsof
education.
Age
d46.2±12.6years.
Arabsubsam
ple:32
Moroccanadults
(19wom
en,13men
)with
low
levels
ofed
ucation.
Age
d47.9years,rang
e31–73.
Focusgrou
psCon
tent
analysis
(Framew
orkapproach)
Salehet
al.(2018)[38]
UnitedStates
Tode
scrib
ethedaily
physicalactivity
ofArab
men
livingin
theUnited
States
andto
explore
how
percep
tions
ofcardiovascular
diseaserisk
influen
cetheirinclusion
ofph
ysicalactivity
into
their
daily
routine.
Yes
20Arabmalecollege
stud
ents.
Age
d26
±4years.
Interviews
Indu
ctiveconten
tanalysis
Salm
aet
al.(2020)[39]
Canada
Todiscussexpe
riences
ofandbarriersto
physical
activity
from
the
perspe
ctiveof
SouthAsian,
Arab,
andAfricanMuslim
immigrant
commun
ities
inan
urbanCanadiancenter
inAlberta.
No
Totalsam
ple:68
olde
rMuslim
adults
(50wom
en,18men
)fro
mSouthAsian,
Arab,
andAfricanbackgrou
nds
Age
dbe
tween55
and85
years.
Sampleinclud
edolde
radults(n=52)
andstakeh
olde
rs(n=16).
Arabsubsam
ple:Arab-Muslim
sfro
mMiddleEast(Leb
anon
,Palestin
e,and
Syria;26%
),andAfrica
(Algeria,
Egypt;un
ableto
determ
inen).
Focusgrou
psandinterviews
Them
aticanalysis,
with
intersectio
nal
approach
Söde
rgrenet
al.(2008)
[40]
Swed
en
Toexploreim
migrant
wom
en’s
attitud
estowardand
expe
riences
ofph
ysical
activity
andexercise.
No
Totalsam
ple:63
immigrant
wom
enfro
mChile,Iraq,
andTurkey.
Age
d26–65years.
Arabsubsam
ple:23
Iraqi
wom
en.
Age
d26–65years.
Focusgrou
psGroun
dedtheo
ry
Sulaim
anet
al.(2007)
[41]
Australia
Theaim
ofthestud
ywas
toiden
tifypsycho
social
andcultu
ralfactorsthat
couldinform
thede
sign
ofahe
althylifestyle
interven
tionprog
ram
aimed
atprom
oting
physicalactivity
and
healthyeatin
g.
No
Totalsam
ple:52
Turkishand
Arabic-speaking
Australians
(41wom
en,11men
).Age
d58.8years,rang
e41–73.
Arabsubsam
ple:Arabic-speaking
adults
born
inLebano
n,Egypt,Iraq,
andSyria
(firstge
neratio
n).
Focusgrou
psThem
aticanalysis
Tamietal.(2012)[42]
Tocollect
exploratory
Yes
22Arabmothe
rsof
MiddleEastern
Interviewsand
Them
aticanalysis
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 6 of 16
Table
1Stud
ycharacteristics(Con
tinued)
Autho
ran
dco
untry
Aim
s(verbatim
)ExclusivelyArabmigrant
pop
ulation
Cha
racteristics
ofsample
Dataco
llectionmetho
dAna
lysis
UnitedStates
data
onArabmothe
rslivingin
Lubb
ock,Texas
regardingtheirdietary
andph
ysicalactivity
behaviors;andassess
the
relatio
nshipof
accultu
ratio
nto
thesedietaryand
physicalactivity
behaviors.
origin.
Age
d<45
years.
focusgrou
ps
Taylor
etal.(1998)[43]
Australia
Toexplorethevoices,
expe
riences
and
percep
tions
ofwom
enfro
mno
n-Englishspeaking
backgrou
ndsregarding
sportparticipation.
No
Totalsam
ple:186wom
enfro
mno
n-Englishspeaking
backgrou
nds.
Arabsubsam
ple:45
firstandsecond
-ge
neratio
nLebane
sewom
enin
Australia.
Interviewsandfocus
grou
psFram
eworkfor
nexusof
sport,ge
nder,and
ethn
icity,
andalso
used
theo
retical
analyses.
Teuscher
etal.(2015)[44]
Nethe
rland
sTo
unde
rstand
how
low
socioe
cono
micstatus
grou
pswith
different
ethn
icoriginspe
rceive
(health
)be
haviou
rssuch
ashe
althy
eatin
gandph
ysicalactivity
intheircontext.
No
99sociallydisadvantage
dadultsof
Turkish,
Moroccan,
andDutch
backgrou
nds.
Meanagebe
tween42
and66
years.
Arabsubsam
ple:Moroccanmen
and
wom
enwith
low
levelo
fed
ucation.
Focusgrou
psThem
aticanalysis
Note.So
mestud
iesthat
includ
edArabmigrantswith
othe
rno
n-Arabmigrant
popu
latio
nsdidno
trepo
rtthesamplesize
fortheArabmigrant
popu
latio
nspecifically.The
meanag
ean
dstan
dard
deviationwererepo
rted
ifavailable(Participan
tor
targeted
agerang
ewas
includ
edifmeanno
tavailable)
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 7 of 16
health-related influences, accessibility issues, outdoorenvironment, and the migratory experience. The themes,supporting quotes, and the contributing studies for eachtheme are presented in Table 2.
Culture and religionThe theme of culture and religion included three sub-themes: differing gender roles, requirement for appropri-ate settings and activities, and religion is influentialtowards physical activity.
Differing gender rolesThe role of women in taking on domestic responsibilitieswas reported in 8/15 studies [29, 30, 32, 33, 35, 36, 41, 43].For many Arab migrant populations, there is a cultural ex-pectation that women are tasked with carrying out domes-tic chores and responsibilities, such as cooking, cleaning,and looking after the family. For some Arab migrantwomen in the included studies, these roles were expectedto be performed despite their employment status. As aconsequence of these cultural norms and responsibilities,Arab migrant women had little time to engage in physicalactivity or look after their own health. Additionally, thepermissibility of physical activity for women may also actas a potential barrier for some women, as some may per-ceive it as not being ‘feminine’ (Taylor et al., 1998, p.7).Conversely, such roles and responsibilities were not ex-pected of Arab migrant men. The cultural expectation ofwomen not going outside the home environment bythemselves was noted among 3/15 studies [32, 33, 40].Some Arab migrants hold views that it is more acceptablefor men to be outside the home in comparison to women.
Requirement for appropriate settings and activitiesIssues surrounding gender-exclusive settings as a factorinfluencing physical activity was noted in 10/15 studies[29, 30, 32–35, 37, 39, 40, 43]. The requirement forgender-exclusive settings was a more prominent concernfor women as opposed to men, with less restrictions be-ing placed on men to adhere to such requirements.There is a strong need for women-only settings for phys-ical activity with female instructors, as some Arab mi-grant women are not comfortable in mixed-genderedsettings, however such settings (i.e., women-only) are re-portedly limited. Some Arab migrants hold the view thatArab men and women should not mix in public settingsor be involved in physical activities together. Some par-ticipants in the included studies described the ideal set-tings for physical activity that include gender-exclusivesettings or settings with areas where families can attendwith separate sections for men and women. Others havediscussed that there are certain conditions for the per-missibility of activities in mixed-gendered settings, forexample, in group physical activity classes the men are
at the front of the class with the women at the back toensure a sense of privacy for the women.The influence of issues concerning public modesty and
culturally appropriate forms of physical activity wasnoted among 8/15 studies [29, 30, 32, 33, 39–41, 43].Arab migrant women in particular raised concerns re-garding maintaining modesty in public settings, as someactivities performed in public were inappropriate forMuslim women. With respect to dress codes, some Arabmigrants were embarrassed or feared judgement whenwearing certain types of clothing for physical activity, orother nontraditional dress codes were deemed inappro-priate. In order to maintain modesty and privacy, indoorsettings were preferred. Additionally, cultural and reli-gious beliefs influenced the types of activities that weredeemed appropriate or preferred, with some stating thatthey wanted ‘pleasant and proper’ (i.e., appropriate)types of activities (Södergren et al., 2008, p.418). If noappropriate activities were available, many would avoidthese activities or wait for appropriate arrangements tobe made available.
Religion is influential towards physical activityA total of 6/15 studies reported on the influence of reli-gion on physical activity [29, 33, 34, 37, 39, 43]. ManyArab migrants perceived religion to encourage physicalactivity. For example, the Islamic prayer, which involvesprostrations and movements, may be considered to be aform of physical activity, and some have also noted howit is prescribed in religious texts to be physically activeas Muslims. However, religion influenced the types ofphysical activity that could be performed. For example,Islam prohibits mixed-gendered settings, thereforegender-exclusive settings are required for some. Physicalactivity programs or classes offered through religiouscentres can also act as a motivator for physical activity.
Competing commitments and timeCompeting commitments and a lack of time as a barriertowards leisure-time physical activity was noted among13/15 studies [29, 30, 32, 33, 35–41, 43, 44]. The respon-sibilities of domestic duties and family commitments,such as looking after children and family, was one of themost commonly cited reasons for a lack of time, particu-larly for Arab migrant women. Other commitments thatinfluenced the amount of physical activity one could en-gage in included work and school commitments. Col-lectively, these factors were given precedence overphysical activity, with Arab migrant participants in theincluded studies reporting limited time for themselves asa consequence. Sharing responsibilities among familymembers allowed extra time for some Arab migrants,however some did not receive this level of support fromfamily.
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 8 of 16
Table
2Selected
Quo
tesfro
mStud
ies
Them
esan
dsub-the
mes
Supporting
quo
tes
Con
tributingstud
ies
Culture
andreligion
Differingge
nder
roles
“Inou
rcultu
remen
usually
dono
thingat
home.Wom
endo
thecookingandthecleaning
,evenifthey
work.Ifthey
want
todo
something
they
don’thave
thechance.”(Caperchione
etal.,2011,p
.5).
“Wom
enhave
moreho
useh
oldob
ligations
whilemen
have
more[free]tim
e.”(Kahan
2011,p
.122)
[29,30,32,33,35,36,40,41,43]
Requ
iremen
tforapprop
riate
settings
andactivities
“Ifwewou
ldliketo
goto
thegym
then
wehave
tomen
tionthepe
rson
there,thereisno
men
togo
inside
.That’s
abit
ofprob
lem
forus.You
have
totrustthepe
oplethere,be
causeit’sou
rreligion.It’svery
hard.”(Caperchione
etal.,2011,p.5).
“Wewou
ldliketo
goto
places
onlyforwom
enwhe
rewecanexercise
anddo
sports.The
sefacilitiesne
edto
belocatedne
arwhe
rewelive;othe
rwise,itisno
tpo
ssibleforus
togo
there.”(Olaya-Con
treras
etal.,2019,p
.6).
“Ihave
told
theteache
rthat
itis‘haram
’,themen
muststandfirstandwestandbe
hind
,and
then
itwas
allright”(Söd
ergren
etal.,2008,p
.417).
[29,30,32–35,37,39–41,43].
Religionisinfluen
tialtow
ards
physicalactivity
“The
fivedaily
prayersactas
exercise,itiswrittenin
theQuran
aswell”(ElM
asriet
al.,2020,p
.6).
“Religiously,ifyouarego
ingto
goto
thebe
achto
swim
,willIb
eableto
goto
Bond
ibeach
andsw
imwhe
rethereisnaked
peop
le?No,religiously,Iwon
’tbe
allowed
,evenifmyhu
sbanddo
esn’tstop
me”
(ElM
asriet
al.,2020,p
.6).
[29,33,34,37,39,43]
Com
petin
gcommitm
ents
andtim
e“Usuallyitisho
usew
ork,forexam
ple,tid
ying
theho
use,cookingmeals,w
ashing
thedishes
inthekitche
n.IfIh
aveclothe
sto
wash,washtheclothe
s,hang
them
out,bringthem
in,allthis[in
additio
nto]caringforthechildren.Forexam
ple,ifmy
daug
hter
hasscho
olto
goto
Iwou
ldge
tup
with
them
inthemorning
.Prepare
breakfastforhe
randdresshe
randgive
her
alunchbo
xto
take
with
herto
scho
ol.Iwou
ldtake
care
ofhe
rfood
andhe
rne
edsthat
isothe
rthan
myhu
sband’sne
eds,of
course.Som
etim
esId
ono
trestdu
ringtheday.Sometim
esits
continuo
usactivity,con
tinuo
usactivity
until
Iam
reallytired
.”(Razee
etal.,2010,p
.134).
[29,30,32,33,35–41,43,44]
Socialfactors
Impo
rtance
ofsocialsupp
ort
andbe
long
ing
“Doyouremem
berforho
wlong
weused
towalktoge
ther
everymorning
,at6o’clockin
themorning
Iusedto
walkto
her
(other
participant’s)ho
useand...you
don’tfeelthetim
e,yeah,you
don’tfeelthetim
e”(ElM
asriet
al.,2020,p.5).
“...Iandmyfamily
hang
outandge
ttoge
ther
with
frien
dsfortheweekend
plan
includ
inggo
ingto
parksforbarbeq
ues
before/after
which
wemay
play
soccer,volleyballo
reven
basketball...theweeklyplan
isto
gettoge
ther
with
frien
dsfora
fun”
(Saleh
etal.,2018,p
.348).
“Iliketo
exercise
butit’shard
tofindtim
ewhe
nIh
avechildren;in
myfamily,m
ychildrenandmyhu
sbandareno
ten
gage
din
exercise
andthus,Iwillbe
alon
ein
myeffortto
exercise.”(Olaya-Con
treras
etal.,2019,p
.5).
“...it’s
alwayshard,likeifyoujoin
thegym,it’s
hard
likethefirsttim
eyouwalkin,everyon
e’slikeno
tyour
frien
d,youdo
n’t
know
anyone
”(ElM
asriet
al.,2020,p
.5).
[29,30,32,33,35–41,43,44].
Preferen
ceforgrou
p-based
settings
“Ican’tdo
it[exercise]
alon
e;alon
eisdifficult.Ifitiswith
inagrou
p,it’seasier,tog
ethe
rwith
thewom
en.”(Rom
eike
etal.,
2010,p
.10).
[29,30,32,37,39–41,43,44]
Respectedfig
ures
“Non
eof
uscando
anything
sensibleou
rselves,wene
edto
beorganizedandhave
someo
neto
lead
thisorganizedgrou
p...,thede
sire
totake
exercise
willincrease
inthat
way.”(Söd
ergren
etal.,2008,p
.417).
[32,40,41,43]
Health
-related
influen
ces
Existin
ghe
alth
cond
ition
sas
abarrier
“Ihave
prob
lemsin
mycervix,soIfeelrestrictedto
thekind
ofexercise
Ican
hand
le...Iu
sedto
love
tosw
imbu
tIstarted
toge
tcram
psso
now
Ipanicwhe
nIam
swim
ming.”(Caperchione
etal.,2011,p
.5).
“Myback
pain,m
yback
pain,Iwalkandwhatdo
youcallit,Ican’tmanageto
dothat.”(ElM
asriet
al.,2020,p.5).
[29,30,35–40,44]
Preven
tinghe
alth
issues
asamotivator
“I’m
morepreven
tionisbe
tter
than
acure,Iliketo
keep
fitandhe
althybe
fore
something
happ
ens,Id
on’twaitforsomething
togo
wrong
”(ElM
asriet
al.,2020,p
.5).
“The
reason
why
Ihavebe
enph
ysicallyactiveisto
lose
weigh
t;Id
ono
twantastroke
ordiabetes;M
anyin
myfamily
suffer
from
diabetes,so,Id
ono
twantto
sufferfro
mit.”(Olaya-Con
treras
etal.,2019,p
.5).
[29,30,33–36,38,39,42]
Accessibilityissues
Costs
“Oh!
Thereisno
nearby
placeto
perfo
rmaregu
larph
ysicalactivity,and
tohave
amem
bershipin
such
physicalprog
ram
as[29,32,37–43]
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 9 of 16
Table
2Selected
Quo
tesfro
mStud
ies(Con
tinued)
Them
esan
dsub-the
mes
Supporting
quo
tes
Con
tributingstud
ies
agym
isfinanciallybu
rden
someforme.”(Saleh
etal.,2018,p
.348).
“Inmycoun
try,sportscentersarecostly.H
ere,myhu
sbandandIg
oto
theRecCen
teranddo
physicalactivities
toge
ther.”
(Tam
ietal.,2012,p
.195).
Locatio
n“W
ewou
ldliketo
goto
places
onlyforwom
enwhe
rewecanexercise
anddo
sports.The
sefacilitiesne
edto
belocated
near
whe
rewelive;othe
rwise,itisno
tpo
ssibleforus
togo
there.”(Olaya-Con
treras
etal.,2019,p
.6).
[29,35,38,40,43].
Organised
physicalactivity
“Non
eof
uscando
anything
sensibleou
rselves,wene
edto
beorganizedandhave
someo
neto
lead
thisorganizedgrou
p...,thede
sire
totake
exercise
willincrease
inthat
way.”(Söd
ergren
etal.,2008,p
.417).
[29,32,33,39,40]
Awaren
essof
prog
rams
“...forus,as,likeas
mothe
rsin
that
age,Id
on’t[think]thereisalotof
things
availableforus...”
(ElM
asriet
al.,2020,p
.5).
[29,30,39,43]
Lang
uage
barriers
“Everyon
espeaking
Englishmakes
itdifficultat
first.Som
etim
esthey
comeup
toyouandtellyouwhatto
dobu
tyou
don’tun
derstand
whatthey’re
saying
.It’s
hard
even
ifthey
show
you.”(Tayloret
al.,1998,p
.7).
[29,32,39,41,43]
Outdo
oren
vironm
ent
Safety
concerns
“You
wou
ldfindmostof
theMuslim
ladies,the
y’ve
gotascarfin
thecar.I’vego
ton
ein
thecarbe
causeum
therewas
astagewhe
rethey
werejustrip
ping
them
off,so
everybod
y’sgo
tan
extrascarfin
thecar.”
(ElM
asriet
al.,2020,p.6).
[29,30,39,41,43]
Weather
barriers
“InMorocco,p
eoplearehe
althierthan
here,and
they
eateverything
.The
differenceisthereyouhave
thesun,you’re
busy
thewho
letim
eandyoubu
rnfat.Heretheweather
isalwaysbad,
andwehave
little
oppo
rtun
ityformovem
ent.”
(Nicolaou
etal.,2012,p
.888).
[32,34,35,39].
Migratory
expe
rience
“Whe
nIw
entto
Syria
Ilosteigh
tkilosIw
alkedalotand[yet]d
idn’tdo
anyexercise
bike,and
Iate
alot....Hereyouge
tinto
thecarandyoujustdrivein
thecar.”
(Sulaiman
etal.,2007,p.66).
“InMorocco
youlivedifferently,the
retheho
uses
arebigg
er,justwalking
from
room
toroom
issport.Hereyour
room
is2×2.”(Nicolaouet
al.,2012,p
.887).
[29,30,33,34,39–42]
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 10 of 16
Social factorsThe theme social factors included three subthemes: Im-portance of social support and belonging, preference forgroup-based settings, and respected figures.
Importance of social support and belongingThe importance of social support and belonging wasnoted in 12/15 studies [29, 32, 33, 35–41, 43, 44]. ManyArab migrants in the included studies reported that co-participation and receiving encouragement from familyand friends were motivators for physical activity partici-pation. In contrast, some lacked support from familymembers which was a barrier to physical activity partici-pation. Without social support, some Arab migrants feltalone, were not comfortable, or reported issues with be-longing, which negatively influenced their participationin physical activity. Some also preferred settings withwomen of the same culture. The socialising aspect ofphysical activity was an important motivating factor. In3/15 studies, children were specifically mentioned as adriver of physical activity participation [30, 32, 36]. SomeArab migrant women reported being motivated to en-gage in physical activity by their children or to set apositive example for the health of their children.
Preference for group-based settingsAnother factor was the importance of group-based settingsfor Arab migrants, which was reported among 9/15 studies[29, 30, 32, 37, 39–41, 43, 44]. Physical activity in group set-tings was preferred, as it was perceived to be easier, deemedmore enjoyable, and was seen as a motivator for participa-tion. Arab migrants were not motivated to engage in phys-ical activity without a group or when by themselves.
Respected figuresThe influence of respected figures on physical activityparticipation was noted among 4/15 studies [32, 40, 41,43]. Respected figures or those with qualifications, suchas instructors, sporting role models of the same ethni-city, community leaders, and health professionals arebeneficial towards motivating, encouraging, and facilitat-ing physical activity participation for Arab migrants.
Health-related influencesThe theme of health-related influences included twosubthemes: existing health conditions as a barrier andpreventing health issues as a motivator.
Existing health conditions as a barrierHealth-related influences as a barrier to physical activityparticipation was noted among 9/15 studies [29, 30, 35–40, 44]. Existing illnesses or health conditions (e.g., pain,chronic disease, mental health) were a commonly reportedfactor limiting or preventing engagement in physical
activity for many Arab migrants. Other barriers includedthe limitations associated with ageing. Similarly, the per-ceived risk of injury, pain, and the associated physiologicalresponses of physical activity, such as muscle soreness andincreased heart rate, deterred Arab migrants from en-gaging in physical activity. Additionally, a lack of energy,motivation, and tiredness were also reported factors influ-encing their level of activity. Returning to physical activityafter long periods of inactivity can also be a barrier forsome Arab migrants due to low levels of motivation.
Preventing health issues as a motivatorPreventive health issues as a motivator for physical activ-ity was reported in 9/15 studies [29, 30, 33–36, 38, 39,42]. Motivating factors for physical activity among Arabmigrants included preventive health, health scares, closefamily members’ experience with chronic disease, gen-eral health, and also to manage pain and age-related dis-abilities. Additionally, many Arab migrants also reportedengaging in physical activity for weight management, orfor both health-related and aesthetic reasons.
Accessibility issuesThe theme of accessibility issues included five sub-themes: costs, location, organised physical activity,awareness of programs, and language barriers.
CostsCosts associated with physical activity participation wasnoted as a factor influencing physical activity engagementin 9/15 studies [29, 32, 37–43]. Specifically, the cost ofphysical activity programs or facilities, such as gyms, werea common barrier for Arab migrants. Some Arab migrantsprefer walking, due to costs associated with other forms ofphysical activity in the host country. As noted in onestudy, however, some find the cost of physical activity inthe host country more affordable than in comparison tothat offered in their country of origin.
LocationAnother important factor related to accessibility was lo-cation which was noted in 5/15 studies [29, 35, 38, 40,43]. Arab migrants require settings that are close tohome for convenience, however a lack of local facilitieswere noted by some Arab migrants. The absence of lo-cally available facilitates that were deemed suitable was abarrier to physical activity.
Organised physical activityThe importance of organised or arranged physical activ-ity was noted in 5/15 studies [29, 32, 33, 39, 40]. Formany Arab migrants, formally organised physical activitywas a motivator, with many wanting physical activity tobe arranged for them as physical activity participation
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 11 of 16
was perceived as more acceptable if arranged. Some alsoviewed that organisations can help with the commence-ment of physical activity as they provide a sense of as-surance. Additionally, the socialising aspect is anotherreason for wanting organised or arranged physical activ-ity. Further, some Arab migrants were reportedly in-volved in physical activity programs offered throughreligious or ethnic community centres.
Awareness of programsIssues surrounding awareness of programs was noted in4/15 studies [29, 30, 39, 43]. Many Arab migrants werenot aware of physical activity programs in their localarea, which may be due to a lack of suitable locally avail-able programs or due to programs being offered only ona short-term basis. A lack of knowledge or awarenessabout where to access information regarding programsor activities or a lack of facilities providing such infor-mation were also a barrier. Additionally, if they wereaware of such programs, some did not know how to ac-cess them.
Language barriersThe impact of language barriers on physical activity par-ticipation was noted among 5/15 studies [29, 32, 39, 41,43]. Not being proficient in the language of the hostcountry prevented Arab migrants from being aware ofprograms, from obtaining information related to physicalactivity, and this limited their level of independence.Language barriers also made it difficult to understandphysical activity instructors or facilitators, with Arab mi-grants preferring Arabic speaking instructors or facilita-tors, as well as translated health promotion material.
Outdoor environmentThe theme of outdoor environment included two sub-themes: safety concerns and weather barriers.
Safety concernsConcerns for safety in public settings were noted as abarrier to physical activity participation in 5/15 studies[29, 30, 39, 41, 43]. Safety concerns were centred aroundfear of racism, fear of attacks (e.g., from other people ordogs), and residing in areas with high crime rates. Forsome Arab migrants, engaging in physical activity indaylight hours or with a partner ensured a sense ofsafety.
Weather barriersThe negative influence of weather conditions on outdoorphysical activity was noted in 4/15 studies [32, 34, 35,39]. Some Arab migrants were not accustomed to thecold winter weather in their host country. Additionally,some feared the risk of falling in the snow (where
present) or were embarrassed to wear wet weatherclothing.
The migratory experienceThe influence of the migratory experience and accul-turation was discussed in 8/15 studies [29, 30, 33, 34,39–42]. Many Arab migrants were reportedly moreactive in their country of origin in comparison totheir perceived level of physical activity in the hostcountry, and this was often attributed to a lifestylethat required higher rates of incidental physical activ-ity which were no longer performed in the host coun-try. For example, in their country of origin there wasless reliance on cars or poor infrastructure preventedtravelling by vehicle, consequently walking was usedas a common form of transport, whereas the lifestylein the host country heavily involved the use of vehi-cles for transport. Additionally, Arab migrants per-ceived that there was more opportunity for formalisedphysical activity in the host country which was notcommon in their country of origin. There was also areported lack of experience in certain types of activ-ities, such as hiking and cycling, as they did not ex-perience such activities, or they did not have theopportunity for leisure-time physical activity in theircountry of origin. Smaller homes in the host countrywere identified as barriers to physical activity, as theyrequired minimal exertion to maintain and did notallow for exercise equipment indoors due to limitedspace.
DiscussionThis systematic review highlighted various factors influ-encing physical activity participation among Arab mi-grant populations, which were grouped as themesincluding culture and religion, competing commitmentsand time, social factors, health-related influences, acces-sibility issues, outdoor environment and the migratoryexperience.Culture and religion were major factors influencing
the physical activity levels of Arab migrants. The re-quirement for appropriate settings and activities forphysical activity was a commonly cited reason influen-cing physical activity participation, more often cited bywomen. This requirement may not be specific to Arabpopulations, but rather it may stem from the fact that asignificant proportion of the samples of the includedstudies were of the Islamic faith, in which participationof males and females in the same activities is not permit-ted [45, 46]. When looking to develop interventions forArab migrants of the Islamic faith, it is important thatgender-exclusive settings are considered and adopted.As identified in the synthesis, public modesty and priv-acy were also a concern for Arab migrants, as there are
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 12 of 16
certain activities that cannot be performed in public(e.g., swimming). As such, offering gender-exclusive set-tings for physical activity may help address this issueand promote participation.Muslim Arab migrants perceived that the Islamic faith
encourages physical activity, through Islamic teachingsand also prayer, which is consistent with Arab popula-tions in their country of origin [47]. Benefits of Islamicprayer, which involves repetitive movements and pros-trations, include improved balance [48] as well as mentalhealth outcomes [49] among Muslims who regularlyprayed in comparison to those who do not. Further, anenabler to promoting levels of activity or participationamong Arab migrants is to conduct programs or offerphysical activity at the centres of religious or culturalgroups as identified in this systematic review. It has beenreported that offering lifestyle programs at centres of re-ligious or cultural organisations aids with recruitmentand interest in the programs for CALD participants [50].As Arab migrants prefer organised physical activity andculturally appropriate settings, organising physical activ-ity through religious organisations may be an importantstrategy to overcome these barriers. Additionally, it maypresent an opportunity to schedule moderate-vigorousintensity physical activity that some may be lacking.Those looking to develop health promotion initiativesfor Arab migrant populations should carefully considerthe role of religion on the lifestyle of potential partici-pants, and how programs might incorporate aspects ofreligion in order to facilitate and encourage healthylifestyles.Another important factor related to culture, was the
influence of gender roles among Arab migrants. Thefindings from this review suggest that in the Arab cul-ture it is expected that the women are responsible fortaking care of domestic roles, such as looking after thefamily, cooking, and cleaning. As a consequence, Arabmigrant women have little time for leisure-time physicalactivity or to look after their own health, which is con-sistent among Arab populations in their country of ori-gin [47]. Further, a recent study among Arab-Americanmothers reported that familial responsibilities were asso-ciated with lower levels of physical activity [24]. ForArab migrants, physical activity is viewed in terms of in-cidental physical activity associated with tasks of dailyliving [19, 34], as opposed to leisure-time physical activ-ity. As self-efficacy is an important factor influencing thephysical activity levels of Arab migrants [18, 20, 22], apotential strategy to increase levels of physical activity isto emphasise and encourage the incidental physical ac-tivity that is associated with tasks of daily living [19, 51].Social support for physical activity participation was
also identified as important for the promotion of phys-ical activity among Arab migrants [18, 20]. It has been
reported that a common source of support for less ac-culturated Arab-Americans is from friends and family,and from friends for Arab-Americans with a higher levelof acculturation [20]. To encourage participation inregular physical activity, it is recommended that physicalactivity interventions and community programs embedan element of social support to provide a sense of be-longing and encouragement. As identified in the synthe-sis, many Arab migrants do not feel comfortableengaging in physical activity alone due to issues with iso-lation, belonging, and safety. An ideal setting for physicalactivity for Arab migrants is one that is group-based [22]and also led by respected figures who can guide and en-courage Arab migrants in physical activity. Another im-portant factor is that Arab migrants prefer physicalactivity programs with others of the same culture, andthis should be considered when designing group-basedhealth promotion programs for Arab populations.Health-related factors were identified as both a barrier
and a motivating factor to physical activity participation.This is not unique to Arab migrants, and has been re-ported among other populations [52]. Arab migrants areaware of the health benefits associated with physical ac-tivity, yet for some, health limitations were seen as a bar-rier to physical activity. Accordingly, physical activityprescription may need to be modified or tailored to suitthose with medical issues, however physical activity isrecommended not only for prevention, but also for themanagement of chronic conditions [53]. When develop-ing physical activity programs for Arab migrants, andmore specifically those with health limitations, it is im-portant that this type of messaging should be incorpo-rated in the recruitment stages of interventions for Arabmigrant women who might be hesitant to engage due tomedical concerns, and also incorporated in the educa-tional component of interventions to change perceptionsrelating to physical activity and health.Another important factor identified from the synthesis
was the migratory experience of Arab populations. ManyArab migrants reported being more physically active intheir country of origin, which was attributable to thehigher levels of incidental physical activities of daily liv-ing in their origin country (e.g., walking to the store),which were no longer performed to the same degree inthe host country. This decline in physical activity follow-ing migration may be explained by the process of accul-turation, whereby the lifestyle and health behaviours ofmigrant populations tends to converge to those of thehost population with increased duration of residence inthe host country. However, evidence from quantitativeresearch suggests that acculturation was associated withhigher levels of physical activity in studies conductedamong Arab-Americans [18–21]. It is important to note,that the decline in physical activity following migration
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 13 of 16
that Arab migrants are referring to is most likely phys-ical activities associated with daily living that were nolonger performed to the same degree in the host coun-try. While there may be an initial decline in physical ac-tivity associated with tasks of daily living, over time,Arab migrants may have increased their levels of leisure-time physical activity or exercise, as the findings fromthis review suggested that Arab migrants had more op-portunity to experience various types of leisure-timephysical activity that they may not have previously beenexposed to in their country of origin. Based on this, it isimportant to consider the role of acculturation whenaiming to promote physical activity among Arabmigrants.It is important to consider the limitations of this sys-
tematic review and the available evidence. Firstly, only 5/15 studies exclusively focused on Arab migrants as theirtarget population, so the level of detail that each of theremaining studies reported regarding the factors influen-cing physical activity among the Arab migrant subsam-ples is limited. Another limitation is the classification ofresults that applied to Arab migrants among studies thatalso included other non-Arab migrant populations. Thisincluded results where the authors reported a findingapplied to all or the majority of participants, or moregenerally as ‘the participants’. A limitation of this is thatthe level of influence of Arab migrants on these findingscannot be determined. Based on the available informa-tion, the proportion of Arab migrants among 8/10 stud-ies that did not exclusively focus on Arab migrantsranged from 24 to 50% (the sample size of Arab mi-grants in the remaining two studies was not reported).Additionally, a greater proportion of studies focused onArab migrant women in comparison to men, or womenmade up the majority of the sample for studies that in-cluded both men and women. Consequently, the per-spectives of men may be underrepresented. Theclassification of Arab migrants used in this review is an-other potential limitation. All those under the ‘Arab’ cat-egory in the ABS Australian Standard Classification ofCultural and Ethnic Groups [27] were included in thisreview, which resulted in the exclusion of migrants fromother countries with a significant proportion of peoplewho may identify as Arab (e.g., those of Sudanese ethni-city). While steps were taken to ensure the rigour of theanalysis, it cannot be ruled out that a different team ofresearchers may analyse and interpret the data differ-ently due to the subjectivity associated with qualitativemethods. Another important limitation to note was thattwo studies included in the synthesis were publicationsby the authors of the current review, which could havepotentially biased the interpretation or organisation ofthe findings in the current synthesis. The second author(GSK) was a co-author on one of the included studies
[30], however, was not involved in the analysis of thecurrent review. The first author (AE) performed the ma-jority of the analysis for the current review as well as forone of the included studies [29]. Despite taking steps toreduce possible bias, there is potential for unintentionalbias or similarities in the thematic structure of thecurrent review and these published studies. A final limi-tation was that the first author performed the CASP rat-ing for the studies in question [29].
ConclusionIn conclusion, this systematic review synthesised qualita-tive literature exploring the factors influencing physicalactivity among Arab migrant populations. The findingshighlighted a range of factors that could be used to in-form the development of culturally tailored health pro-motion initiatives targeting Arab migrant populations.Future studies aiming to explore the factors influencingphysical activity among CALD populations should focuson specific ethnic groups or those with highly similarcultures in order to provide in-depth and detailed infor-mation on the factors influencing physical activity forsuch populations.
Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s12966-020-01056-w.
Additional file 1 Example search strategy.
Additional file 2 Critical Appraisal Skills Programme Checklist.
AbbreviationsCALD: Culturally and linguistically diverse; CASP: Critical Appraisal SkillsProgramme; US: United States
AcknowledgementsAE was supported by was supported by an Australian Government ResearchTraining Program (RTP) scholarship. The funding provider had no role in anyaspects of this research.
Authors’ contributionsAE, GSK, ESG conceptualised and designed the study. The literature searchand screening of titles and abstracts was performed by AE. Full-text screen-ing was performed by AE and ESG, with discussion with GSK to reach con-sensus. Data extraction was performed by AE and cross-checked by ESG.Initial data analysis coding performed by AE and ESG. AE performed the the-matic synthesis, and discussed with ESG and GSK. AE drafted the manuscript.All authors read and approved of the manuscript.
FundingThe first author was supported by an Australian Government ResearchTraining Program (RTP) scholarship between 2016 and 2019. The fundingprovider had no role in any aspects of this research.
Availability of data and materialsNot applicable.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
El Masri et al. International Journal of Behavioral Nutrition and Physical Activity (2021) 18:2 Page 14 of 16
Competing interestsThe authors would like to declare that a total of 2 studies that were includedin this review were published works of the authors of this systematic review.There are no other competing interests to declare.
Received: 28 August 2020 Accepted: 9 November 2020
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