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Health & Place

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Giving young Emirati women a voice: Participatory action research on physical activity
Gabriella Berger a,, Anita Peerson b,1
a b

Fujairah College, Fujairah, United Arab Emirates Statewide Emergency Program, Department of Human Services, 18/50 Lonsdale Street, Melbourne 3000, Victoria, Australia

a r t i c l e in fo
Article history: Received 23 July 2007 Received in revised form 6 March 2008 Accepted 10 March 2008 Keywords: Physical activity Social and cultural factors Qualitative health promotion research Young women United Arab Emirates

abstract
International evidence on health promotion indicates the importance of regular physical activity for preventing and reducing the incidence of obesity and chronic diseases. This study investigated the relationship between physical activity and the social milieu of young Muslim women in the United Arab Emirates. This participatory action research project included semi-structured in-depth interviews and focus groups and yielded qualitative data. Set within a context of rapid social change, perceived barriers to daily exercise inuenced participants physical activity levels and overall well-being. Results indicated a lack of physical exercise and strategies were proposed for implementation by college staff and students. & 2008 Elsevier Ltd. All rights reserved.

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:

 a multi-country strategy developed to counteract obesity

(WHO Regional Ofce for Europe, 2006);

 the Countrywide Integrated Noncommunicable Diseases Inter     

vention (CINDI) involving 29 participating countries (WHO, 2003, 2007); systematic reviews by the Cochrane Collaboration (Renders et al., 2000; Jackson et al., 2005), best practice guidelines for various chronic diseases and surveillance (Public Health Agency of Canada, 2007); a proposal for re-orienting the primary care system for improved prevention and management of diabetes (Health Council Canada, 2007); reporting on peoples behaviour for unhealthy weight gain, as well as enablers and barriers to overcoming obesity (Department of Health, 2007); development of a National Chronic Disease Strategy (Australian Health Ministers Conference, 2005); implementation of the Australian Better Health Initiative, focussing on various health promotion interventions to improve health and well-being (Council of Australian Governments, 2006); 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 comorbidities) through better management and care coordination (Department of Human Services, 2006);

 by the World Health Organization (WHO) (1986, 2004) and the

WHO Regional Ofce for the Eastern Mediterranean (2003);
Corresponding author. Tel.: +971 9 2244499; fax: +971 9 2244488.

E-mail addresses: gabyberger@gmx.net (G. Berger), anita.peerson@dhs.vic.gov.au (A. Peerson). 1 Tel.: +61 3 90967773. 1353-8292/$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2008.03.003

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 implementation of a framework for health sector action on 

physical activity (National Public Health Partnership, 2005); and a growing interest in the benets of healthy built environments to encourage physical activity (National Heart Foundation, 2004).

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). Middle Eastern studies 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 nding (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 (1545 years) concluded that to meet womens 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 dees Gods will. The WHO Regional Ofce 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 2565 years, the range of prevalence of selected risk factors is: smoking (1645%), hypertension (2030%), overweightobesity (4070%), and hyperlipidaemia (2045%) (p.6). United Arab Emirates studies 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 inuenced 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 signicant 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 (3039 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 (1018 years) conrmed that at age 14, obesity was 23 times higher than the international standard (Al-Haddad et al., 2005).

Pharmacological and non-pharmacological interventions can be implemented to prevent, treat, and manage an individuals 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 modication programs (addressing specic 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 signicant 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 moderateintensity 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 benets 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, nding 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). Identied barriers included lack of awareness of benets, 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 tness assessment by a general practitioner, clients were prescribed a recommended physical activity

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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 (1116 years). Data analysis of their activity diaries revealed that physical activity was ranked low, whilst cultural and weather restrictions profoundly affected the insignicant role exercise plays in everyday life. Aims 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 womens participation in physical activity, this paper focuses on a sample of young Emirati womens attitudes towards physical activity.

Research method Participatory action research (PAR) was selected as the preferred method for conducting this qualitative study (using semi-structured, in-depth interviews and focus groups) given constraints of the research setting and the project focus (Israel et al., 2003). Originating from elds such as sociology, psychology, management, and marketing (Baum et al., 2006), PAR has gained recognition as a contemporary, inclusive way of bringing participation into action research (Elden and Levin, 1991; Stringer and Genat, 2004). It can include combined data-gathering methods and is often selected to conduct cross-cultural, community-based, participatory research and includes qualitative methods. This approach, now increasingly used in public health research, addresses health disparities and is particularly recommended in cyclical, non-linear, longitudinal research designs because it produces knowledge both as a means and an end (Israel et al., 2003; Khanlou and Peter, 2005). Meyer (2000) also agrees that the PAR approach is well-suited to identifying problems in health care and developing solutions that contribute to social change, with both tools informing each other, thereby increasing reliability and validity (Khanlou and Peter, 2005). Ethical approval The college ethics committee acknowledged the importance of physical activity and granted ethical approval for this small project with a limit on the sample size. A large-scale study was not permissible due to concerns over class disruptions during the data collection phase. Once approval was granted, the health committee provided its support. Informed consent was obtained from all participants prior to the study. The critical reference group A critical reference group was formally established to facilitate the research process. The group comprised 11 members; 8 expatriate staff members from Western countries (Australia, United States, England, Canada) and 3 UAE nationals (2 of them students). Of note, while most were English teachers, four had a background in health: psychology, health promotion, and nursing. The rst author of this paper and the critical reference group members perceived that increasing female students physical activity levels would lead to health benets as described in the international literature. The critical reference group assisted with a statement of support for the project, together with a 100-word research description. The PAR project was discussed at monthly health committee meetings, following electronic distribution of the agenda and minutes. The critical reference group provided the rst author of this paper with expert advice and local knowledge. Participants involvement in the research process has meant that culturally appropriate models based on local beliefs and values would be respected and incorporated into any proposed solutions. The social milieu and its relationship between health inequalities would also be considered. The members agreed the students themselves would need to value physical activity if behavioural and lifestyle changes were to be successful and sustainable. Nonetheless, the critical reference group has pledged continuing support of ongoing health promotion efforts with the commencement of the new academic year (200607). Sample The recruitment of participants and data collection by the rst author of this paper was facilitated with the assistance of a class

Methodology College This study on physical activity levels of young Emirati women was undertaken at a womens college, Fujairah, UAE, from September 2005 to April 2006. According to ofcial college reports, around 600 female students were enrolled during the 200506 academic year. The majority were rst-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 personnel are Arabic speakers with high-level English skills. The college curricula (including business, information technology, and banking) are taught in English to young Emirati women whose rst language is Arabic and who study all subjects through ESL (English as a second language). Prior to college enrolment, all students ESL knowledge was assessed and students with a minimum of low-intermediate-level English were accepted as students. The students had been previously engaged in ESL for 68 years in local government and private schools, and their familiarity with topics of a personal nature are considered well within the range of communicative possibility. The rst author of this paper had been teaching English at the college for over 3 years at the time of the research and was familiar with students oral communication ability, which usually ranked much higher than their writing and reading skills. English language competency varied. The third-year students were competent speakers, and were expected to achieve a TOEFL (Test of English as a Foreign Language) or IELTS (International English Language Testing System) band 56 (higher intermediate level competency) at the end of the academic year. First-year students English would approximate a band 3 and this of course limited their linguistic discourse and uency. Physical exercise is considered an optional social activity rather than a mandatory component of the college curricula. A female mathematics teacher offered weekly 1-hour handball or football sessions during the semester to 20 interested students. Findings from the literature review combined with local evidence gathered from informal discussions with staff and students (200205) suggested that physical inactivity was widespread among female students at the college. Since the published literature conrmed that no study of this kind had previously been undertaken, this project was perceived as urgent and timely.

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teacher (member of the critical reference group) who supported the research project. Of the recruited sample of female students from two rst-year classes (n 20), 15 were rst-year college students and ve were third-year college students (1827 years), unmarried, of Islamic faith, with Arabic as a rst language. Sample selection was guided by (1) ethical clearance advice that only a small-scale study would be permitted, (2) students could be approached only if their class teacher agreed to cooperate, and (3) regular teaching was not disrupted. As this class teacher was interested in health promotion and provided the students with the opportunity to exercise in a female sports centre swimming pool, the trips to the pool provided the unique opportunity for data collection. Data collection Interviews and focus groups were conducted to shed light on the relationship between young Emirati womens relationship of physical activity within the broader social context. To overcome potential communication problems, the interview guide was bilingual (English/Arabic) so that comments could be made in either language, and also translated from Arabic into English. The instrument was pre-tested on three rst-year students to ensure wording and expression were understood and culturally appropriate. Bilingual college staff members were also available as translators. These measures reduced language barriers and facilitated communication. Interviews afford considerable exibility to the data collection process, both in terms of areas explored and the direction of the discussion (Darlington and Scott, 2002, p. 49). Initially, ve participants were asked a series of 25 questions in individual semi-structured interviews, addressing their perceptions, habits, and experiences of physical activity within the social context of their culture. Interviews assumed the appearance of a natural, interesting conversation, which was guided to focus on the research topic by encouraging women to contribute their views without attempting to convert the data into numbers (Lupton et al., 1992). The same questions explored during interviews were also discussed with 15 Emirati female students who participated in two focus group sessions (seven and eight students, respectively). The women were interviewed at college either during a break between classes or at the swimming pool; the small numbers facilitated good interaction and focussed at the micro-level. [A] cross-ow of communication sparks ideas that would not emerge as easily in a one-to-one interview. Groups also take the pressure off participants to respond to every question y and enables exploration of a range of subjective responses in relation to one or more topics in a relatively short space of time and relatively economically (Darlington and Scott, 2002, p. 62). The rst author of this paper conducted both interviews and focus group discussions (5060 min), which were manually recorded where participants granted permission, with the interview guide serving as a basis for asking questions. All notes were subsequently transcribed within 24 hours of data collection (Darlington and Scott, 2002). Questions were regularly re-phrased as participants were prompted and probed to determine their views on physical activity; meanings, barriers, and facilitators. In particular, information was sought on their preferences and habits over time, how they have progressed from childhood through to adolescence and adulthood, and what they had planned for their futures. Data analysis The resulting qualitative data were de-identied and independently analysed by both authors for content analysis of key

themes (Darlington and Scott, 2002). Content analysis of the qualitative data revealed the following themes: female students understanding of the benets of physical activity; preferred forms of physical activity; barriers, and facilitators of physical activity; and suggested future initiatives. Interview data were treated separately from focus group discussion data: both were seen as two distinct forms of data collection (Darlington and Scott, 2002). The use of software for qualitative data analysis, such as NVIVO or NUD*IST, was not employed given the modest sample size. All direct quotes obtained from interviews and focus groups discussions are reported in italics.

Results Students physical activity patterns Data about Emirati students physical activity patterns at college were obtained principally from the critical reference groups reections 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 with few willing students participating in the different disciplines (i.e. basketball, handball, obstacle races, running, table tennis). For example, of the total college population (N 620 students) in 2005, only 20 students participated in each event (3.2%). To increase participation, 15 female college staff rst demonstrated the activities, and then students performed the activity for which most of them were given prizes. The sports day coordinator, a teacher and former athlete, commented on the many hours spanning several months regarding the donation of equipment, prizes, and sponsorship. Given students disappointing participation gures, she stated that she would probably not bother to organise another such event for 2006. She therefore sought feedback from all students in early 2006 to gauge the level of support of another sports event. Only 27 students replied in the afrmative (4.3%), therefore the annual sports event 200607 was cancelled. As a health promotion initiative, this teacher also offered swimming instruction to all rst-year students by organising a bus to take consecutive classes to a nearby ladies-only indoor swimming pool. She observed that while initially students were excited about being able to swim for the rst time in their lives, they then began to panic when it all became real. Five out of six classes went as a group at different times, where the venue had been made available after-hours. The sixth class of students agreed to go swimming but when two students pulled out because they were feeling unwell due to that time of the month (menstruation), the rest of the students refused to go. Their swimming class was cancelled and students from other classes were taken for the second time. This swimming project was ongoing for the semester until June 2006 and is planned to continue in 2007. Results from interviews and focus groups Key themes arising from the qualitative data were: the young womens understanding of the benets of physical activity; the relationship between weight, diet, and physical activity; preferred forms of physical activity; factors inuencing restricted physical activity; and suggestions for future physical activity initiatives.

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None of the students engaged in regular physical exercise at the time of the research and they were unclear and unconcerned about any benets. Occasional attempts at walking were infrequent and no individual had ever engaged in moderate or vigorous leisure beyond a few weeks. Similarly, the range of sports engaged in was extremely limited, with walking mentioned most frequently. Physical activity, weight, and diet During interviews and focus groups, participants monosyllabic answers proved to be telltale signs: most comments were focussed on their social situation and they were unable to articulate the benets of physical activity. Some participants considered it important, good and healthy and relaxed. Others did not readily understand why physical activity was benecial. One participant suggested that exercise is good because it circulates the blood, prevents sickness and admitted that I am not sure why. Others commented: I think it will help to prevent diseases like heart disease and exercise is good if you want to get slim and when you want to prepare for marriage. Three participants indicated the lack of information they had received at school about exercise. I think that walking doesnt give that much benet, but I dont know as we never got much information from school about health. Participants perceived a sketchy relationship between weight, diet, and physical activity. For the most part, whilst they did not know their exact or approximate weight, they expressed the need for weight control: three students perceived they were unhealthy and overweight whilst two students described themselves as healthy but underweight. Some students mentioned eating less in the evening and staying away from rice and chips, I am not used to exercising and so I try to eat less, and being unhealthy because I always eat heavy food like Arabic food. One participant indicated she ate more food for emotional reasons: I eat a lot when I am angry, I eat away at my anger, but did not state the source of her anger. Comparisons were also made to their friends who are not fat like me but thin. They just dont eat much. Overall, students did not subscribe to the idea of exercise: walking, dancing, basketball, and football were most often mentioned. Physical activity sessions were variable, sporadic, and usually short-lived. One student had tried aerobics and a few tried swimming but did not continue due to cultural reasons. Swimming did appeal because it doesnt make you sweat. Walking is the easiest exercise and anyone can do it, there is nothing to learn. Another student would walk a few laps in the park at a slow pace. Transport to and from the sports venue proved to be a barrier: I joined a gym last semester and I stopped going after a few weeks because no one is taking me there in a car. In addition, exercise was not generally considered a social activity accompanied by friends or relatives. I mostly walk alone.

Factors inuencing physical activity As the results demonstrated that the participants were physically inactive, the factors inuencing their desire to exercise require detailed analysis. These factors included: gender and age; role models; culture; climate; clothing and make-up; personal motivation, time and opportunity; and school and government policies. Gender and age issues, a lack of role models, and peer support embedded in UAE culture need to be considered foremost for some participants. A positive attitude to exercise, accessibility, and affordability, in the company of friends, are enablers that foster the uptake of physical activity. For other participants, however, a lack of motivation, a dislike for exercise, tiredness, non-participation of friends, and a preference for watching rather than playing a sport pose barriers. The following transcribed notes from a trip to the local ladies-only swimming pool illustrate the role of culture: A teacher decided to take each of the ve rst-year classes swimming to a ladies-only pool. On this day, a group of 10 students were excited about going swimming after lunch but none of them had a swimming costume. The pool manager, a local woman, mentioned this to the teachers and also brought swimming caps that the young women were required to wear. None of them wanted to wear the caps and none of them wanted to wear a swimming costume. Twenty minutes later the rst student entered the water fully clothed, followed by four more. Some of them had to be almost dragged in and there was much screaming, laughing and excitement. They remained at the shallow end of the pool and held onto kickboards to remain aoat. The remaining ve students watched the action in the water. They indicated that they liked swimming and wanted to try it, but none could actually swim or brought a swimming costume. Interestingly, only the very slim students were in the water. All other students who were overweight stayed out. Miss, I am fat said one of them, giving an explanation why exercise is therefore not advisable. The UAE climate can be both an enabler and an obstacle to physical activity levels of young Emirati women. I exercise anytime, summer and winter y but I do less walking in the summer and my girlfriends complain that in the summer they sweat. They dont like to sweat. The intense heat of the summer months from June to August means profuse sweating, resulting in either a preference for the hot weather because you lose more weight (perceived as a positive benet) or you cant exercise if its too hot, but you can go to the gym which is likely to be air-conditioned and therefore a cooler and more comfortable environment for exercise. Clothing, make-up, and a lack of motivation and time also presented barriers to participation in exercise. Most girls dont like to wear sports clothes under their abaya [black national dress] and shaylah [black head scarf]. Older and married ladies dont like it as much either, they refer to sports wear under their abayas. In addition, the sports outt is not allowed in school and the school could conscate make-up and perfume. Further explanation revealed the students are not allowed to put on make-up and perfume in school, so they apply these at home. The women felt negative about exercise because their grooming efforts might be ruined by exercise. Moreover, being personally motivated to participate in any physical activity requires not only commitment

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but also opportunity and time because Im busy at home after college. Students older female relatives, too, appeared not to engage in regular exercise, due to lack of motivation and limited opportunity. Reliance on transport was a constant and signicant barrier as only certain trusted persons would be accepted as a suitable driver. Few students drive to college in their own car, the overwhelming majority are either picked up by family members or board the college bus. High school policies appear not to encourage physical activity and girls are readily excused from sport sessions, an attitude often shared by teachers lack of enthusiasm. Few sports are offered to girls on a regular basis. Most students mentioned there were no female-only exercise venues in the vicinity. Many respondents stated that they used to disappear from exercise classes without penalty. In my family only the men exercise, my brothers are the only ones exercising in my family, my sisters dont exercise and none of the ladies exercise. When girls reach adolescence, from about age 12 onwards, they are discouraged from exercise: when the girls breasts started to show they say halas [nished]. Follow-up strategies It was recognised that, in order to achieve long-term success, behavioural changes needed to be initiated and welcomed by the Emirati students themselves. The colleges health committee pledged to support these ongoing health promotion efforts at the local level. Suggestions for future initiatives included health promotion information posters, health information days, a student-governed health information group as well as continued provision and increase in exercise classes (e.g. yoga, Pilates, amenco dancing, ball games). The results of this PAR study have inuenced health promotion activities at the college. A funding proposal for a health display case was submitted and approved in 2005. Health promotion posters displayed various topics (e.g. health, workplace stress, blood donation, nutrition and exercise, dental health, child health, reproductive health, etc.). Health seminars were scheduled and health information was distributed to students via their class advisors. Announcements such as exercise classes (e.g. Pilates, karate) were prominently displayed and a healthy canteen food initiative promoted healthy food options (together with nutritional information). The heavily advertised Pilates classes were received with much enthusiasm, especially when the rst author of this paper mentioned them to students during the interviews. To this date, none of the students have opted to participate since classes commenced in early February 2006. GB recalls: None of the students have ever approached me or asked me serious questions about joining Pilates. They joke about it. There has been one expression of interest but there are no students participating in Pilates. The Pilates class was advertised as women only to enable local women to participate; otherwise they would never join. The door from the college gym to the hallway was always locked and screened off to provide the women with privacy. Initially, I received 12 expressions of interest in the Pilates class. Ten female (Western) college staff members participated. However, by April 2006, only a group of six women were left and continued until the end of June. I am now teaching Pilates at an advanced level (May 2007) and have advertised in the local paper. The class is bigger than ever and has up to 15 participants. The lack of local women has opened the doors to men, the class is now mixed.

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 rst study of this nature to report on UAE womens physical activity preferences within their social environment. The project ndings specically apply to young Muslim women attending college, UAE, and indicate they had not developed a healthy adult lifestyle including regular exercise. The overwhelming ndings, supported by other UAE studies (cf. Musaiger, 1998; Carter et al., 2004; Henry et al., 2004), revealed that none of the study participants: (1) were exercising at the time of the research; (2) had been exercising regularly since primary school; and (3) exhibited noteworthy interest in the topic. The mentioned restricted exercise choices and the scarcity of data further conrm this. Techniques to evade physical activity were developed to an art form throughout high school and became common behavioural norms in young adulthood. The low value of exercise was not only prevalent among physical education teachers at school, but also found within a social environment of family, friends, and peers. In UAE culture, women are affected by signicant barriers to physical activity. Whilst it is generally supported and encouraged among men, women usually abstained from any forms of exercise that might risk the appearance of unfeminine pearls of sweat because girls were meant to look clean. Swimming, a refreshing sport in a hot climate, was made possible by the provision of a ladies-only indoor swimming pool attached to a gym and basketball court, but these facilities were mostly unused. Conversations with the female director of an all-female tness centre conrmed that cultural/religious restrictions on presenting the female body in a full-length swimsuit, or even in a tracksuit, operated well beyond the male gaze. Barriers also included lack of: (1) female role models among peers and families, (2) social support, (3) transportation, (4) nancial means, (5) time and opportunity, (6) information on the benets of exercise, and (7) school support. The students in this study conrmed that physical activity is not valued. No one encourages us. The teachers dont seem to care and we didnt have any exercise clubs until now. We never got any information about exercises. We dont really know about the benet of exercise, not exactly. A lack of physical activity affects morbidity in adolescence and adulthood, and mortality in adulthood (Hallal et al., 2006a, b). The resulting high levels of obesity found among the UAE female population (Henry et al., 2004) indicate that health promotion initiatives are urgently needed. All relevant parties critically reected on the historical, cultural, and geographic context inuencing young womens levels of physical activity, shared insights into their worldviews, and proposed action for change. The critical reference group improved the inquirys relevance by assisting in the study design and supporting Emirati students in their efforts to bring about changes. An often-heard comment during meetings was that we can only make baby steps at a time. The complexity of this task meant that some barriers to physical activity could be identied through PAR and addressed through health promotion measures at the college.

Study limitations A small sample size (due to ethics approval) and participants reluctance to discuss physical activity resulted in limited data. Cross-cultural communication in English and Arabic may also have inuenced data collection. Nonetheless, some gender, social,

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and cultural barriers to physical activity were identied, and could be further explored in a larger study. The qualitative data also provide some insights into how college staff provides health information for its female students, and offers opportunities for physical activity as part of the curricula. Additionally, future research could consider a larger sample of young women and also include men (of a similar age cohort) attending college, with ethics committee approval. Attention to womens and mens perceptions of the risks of physical inactivity for the incidence of chronic disease in the UAE population could be considered. Further studies could address: two comparable groups of women: attendance and non-attendance at college to determine any signicant differences in physical activity levels, or alternatively, address the physical activity levels of female students of different age cohorts (i.e. school entry, completion of primary school, late secondary education, and college attendance). In addition, subjective selfreports of health could be linked with objective biometric measures (e.g. height, weight, body mass index). Identifying the various sources of health information (including physical activity) for young women (and men) could also provide insights into gaps in knowledge, and how health promotion messages could be better targeted.

anonymous reviewers provided insightful comments on the paper. Lesley Ellis, David Lloyd, and Nia Thompson kindly assisted with published papers. Disclaimer: This paper reects the authors views and not of the Department of Human Services, Victoria, Australia. References
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Conclusion Using critical reection 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 difcult to implement physical activities at the college from an organisational perspective. Any proposed health promotion initiatives are channelled via the health committee to the college director who then determines if and how much funding is approved for various requests. Women who hold a high-prole position or are elite athletes in the UAE may offer alternative female role models for young women. They could be involved in health promotion campaigns as advocates of healthy lifestyles, by eating nutritious food and engaging in moderate physical activity. Womens participation in sports could be further encouraged through government policies and programs, with the provision of resources and skilled personnel accessible to communities at the local level. In addition, the World Health Organizations concept of Health Promoting Schools was informed by the Ottawa Charter for Health Promotion (1986), and the Global School Health Initiative was launched in 1995, as a setting for health promotion activities, including fostering the physical activity of children and adolescents (Booth and Okley, 2005; Mitchell et al., 2005). Many countries have implemented this initiative, including Australia (National Health and Medical Research Council, 1996; Booth and Okley, 2005), Scotland (Inchley et al., 2006), Nigeria, Pakistan, and the United States, whereby families, communities, and schools can work together (Birdthistle and Health and Human Development Programs, 1999).

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

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