Participation in physical activity extends life expectancy, reduces premature mortality related to CVD, diabetes and cancer, and promotes mental health( Reference Haskell, Lee and Pate 1 , 2 ). Sedentary behaviour (any waking behaviour involving very low energy expenditure while sitting or reclining( 3 )) is a newly identified risk for diabetes, obesity and biomarkers of chronic disease risk like abnormal glucose metabolism and dyslipidaemia( Reference Owen, Healy and Matthews 4 , Reference Thorp, Owen and Neuhaus 5 ). Recent extensive secondary analyses of an Omani population-based survey established the association of physical inactivity and sitting time with the metabolic syndrome and identified population subgroups who were the most inactive and who sat the longest( Reference Mabry, Winkler and Eakin 6 , Reference Mabry, Winkler and Reeves 7 ). Promoting physical activity and reducing prolonged sitting have the potential to be key strategies that could address the high prevalence of type 2 diabetes, CVD and other chronic diseases in Oman and other countries of the Gulf Cooperation Council (GCC; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates)( Reference Ng, Zaghloul and Ali 8 – 10 ).
Ecological models of physical activity and sedentary behaviour identify multilevel influences including intrapersonal, social, physical environment and public policy( Reference Sallis, Owen and Fisher 11 – Reference Owen, Sugiyama and Eakin 13 ). Key public health documents addressing physical activity – particularly the Centers for Disease Control and Prevention's Guide to Strategies for Increasing Physical Activity in the Community ( 14 ), the WHO guide to increasing physical activity( 15 ) and The Toronto Charter for Physical Activity: A Global Call for Action ( 16 ) – identify the importance of such broadly based perspectives that can guide environmental and policy initiatives.
Public health professionals can have an influential role in advocating and shaping evidence-based health policy and programmes( Reference Allender, Gleeson and Crammond 17 ). However, in the GCC, where limited evidence is available on the determinants of physical inactivity and prolonged sitting( Reference Ali, Baynouna and Bernsen 18 – Reference Amin, Suleman and Ali 20 ), an understanding of public health professionals’ perceptions of the influences on these health risk behaviours is required in order to inform relevant public health initiatives. The present qualitative study, guided by an ecological model of physical activity and sedentary behaviour( Reference Sallis, Owen and Fisher 11 , Reference Owen, Sugiyama and Eakin 13 ), aimed to identify policy and programme options to address physical inactivity and prolonged sitting in the adult population of Oman.
Methods
As part of a series of studies on physical inactivity and sitting time in Oman( Reference Mabry, Winkler and Eakin 6 , Reference Mabry, Winkler and Reeves 7 ), the current paper presents the results of a semi-structured interview survey, guided by an ecological model of health behaviour, undertaken to explore public health managers’ perceptions about addressing these health risk behaviours in Oman. Since prolonged sitting is an emerging risk factor about which little is known in the GCC, this issue was included in the study to examine if it was viewed as a risk factor within the broader context of addressing physical inactivity, and whether barriers and solutions would differ from those put forward for physical inactivity. The study was approved by the Research and Ethical Review Committee, Ministry of Health, Oman and the Behavioural and Social Sciences Ethical Review Committee, the University of Queensland, Australia.
Data collection
Semi-structured interviews were conducted by R.M.M. between the months of October 2011 and January 2012 with ten mid-level national public health managers in the Ministry of Health, Oman recruited by purposive sampling( Reference Dicicco-Bloom and Crabtree 21 ). An Information Note describing the study and summarizing the available evidence from Oman( Reference Mabry, Winkler and Eakin 6 , Reference Mabry, Winkler and Reeves 7 ) was shared with the participants as part of their invitation letter. Follow-up telephone calls were made to arrange a time and place for the interview. Although Arabic was the mother tongue for all participants, all interviews were conducted in English, since it is the common working language in the health sector in Oman.
The interview guide contained open-ended questions eliciting participants’ feedback on the barriers to reducing physical inactivity and prolonged sitting, and their suggestions on possible programmes and policies to address these behaviours (see Table 1). Interviews began with a brief overview of the study. Participants’ verbal consent to be interviewed and to be audio-recorded was obtained. Each participant described his/her role within the Ministry of Health. Participants’ perceptions of barriers and possible solutions were explored based on the evidence generated from a series of studies of these behaviours in Oman( Reference Mabry, Winkler and Eakin 6 , Reference Mabry, Winkler and Reeves 7 ). The duration of interviews ranged from 31 to 69 min (average time: 50 min). Interviews were digitally audio-recorded, transcribed verbatim and numbered to ensure anonymity of participants’ responses. Once initial transcripts were drafted, R.M.M. compared them with the original recordings and hand-written notes to ensure accurate transcription.
Interview schedule
Data analysis
Data analysis followed a hybrid of thematic content analysis and a framework approach( Reference Bradley, Curry and Devers 22 , Reference Pope, Ziebland and Mays 23 ) in line with the key aims of the study (identifying the barriers and solutions to physical inactivity and sedentary behaviour in Oman) and from the perspective of an ecological approach to understanding the determinants of health behaviours. Initial transcripts were read several times by authors R.M.M. and Z.Q.A. followed by open coding, grouping and categorizing data according to emerging themes. A coding scheme was then developed based on the major recurrent themes. All transcripts were then reviewed and segments of text coded by R.M.M. (and a sub-sample by Z.Q.A.) based on the coding scheme. Where differing interpretations of themes occurred, transcripts were re-reviewed until consensus was reached. Although an ecological model was used as a guide, the researchers followed the themes that emerged from the data.
Data collection and analysis was an iterative process, whereby later interviews allowed the exploration of themes and perceptions generated from early interviews as well as the generation of new themes. Interviews continued until data saturation, when interviews no longer brought new themes( Reference Dicicco-Bloom and Crabtree 21 , Reference Mays and Pope 24 ). To enhance rigour, analyses included searching for negative cases in code and theme development( Reference Mays and Pope 24 , Reference Mays and Pope 25 ). Analysis was done manually rather than using qualitative analysis software, since the sample size made this feasible. The common themes are presented in the Results section according to level of influence (intrapersonal, social, physical environmental and public policy) identified by ecological models( Reference Sallis, Owen and Fisher 11 , Reference Owen, Sugiyama and Eakin 13 ) and using extracts of participants’ responses as headings and as primary data.
Results
A total of ten interviews were conducted. All participants had a postgraduate degree in a field related to public health (including six with a medical background) and extensive public health experience (mean years in public health: 15 years). Except for one person, participants were Omani; half were women.
The participants identified numerous barriers to physical activity across the four main levels of influence described in ecological models (intrapersonal, social, physical environment and public policy) and proposed a wide range of public health solutions. Table 2 provides a summary of the emergent themes and sub-themes; sub-themes are ordered according to how often they were mentioned by participants. Although the findings presented below and in Table 2 are according to discrete themes, many participants’ responses were multi-factorial; for example, combining the social and physical environment (i.e. the cultural perception that sports clubs are for young people) or intrapersonal and social influences (i.e. not having time because of family and social responsibilities).
Public health managers’ perceptions on barriers and solutions to address physical inactivity and prolonged sitting in Oman
Perceptions about physical inactivity
Intrapersonal – ‘They have hundred … excuse[s]’
The most common personal-level barrier to Omanis engaging in physical activity mentioned by the interview participants was lack of motivation. In addition, several participants mentioned lack of awareness of the importance of physical activity and lack of time due to conflicting work and family responsibilities:
‘I mean, you look at the people you know before they get married and after they get married, even men, you become tied up with social barriers, you get tied up with the social engagement of your family to the extent that you cannot have control over your own life.’ (Participant 2)
Social – ‘It's a stigma if you run’
One of the most frequently mentioned barriers from the interviews was the socio-cultural norms that restrict women's participation in outdoor physical activity, including their conservative dress:
‘In our culture, if I was a woman interested in walking, and I walk by myself in the middle of the street, you know, it doesn't look good. You know, it looks bad. Still people will look at it in a negative way.’ (Participant 1)
A few participants mentioned social restrictions due to a person's age, particularly for women; however, one person noted that older people may be more active than their younger counterparts.
The other common barrier mentioned was the low value placed on physical activity in Oman:
‘The definition of physical activity is incorrect. In the West, physical activity is seen as an important part of life, like prayer and going to the mosque. But not so in Oman. It is not seen as important.’ (Participant 4)
Other issues mentioned by the participants were linked to modernization and urbanization, such as the cultural norm of employing domestic workers, using private vehicles rather than public transport which is known to promote physical activity( 26 ), and the limited availability, and a culturally negative perception of, public transportation:
‘…and the lack of [public] transportation, and the taboo associated. If you use a bus, everybody will question you. It is not considered normal.’ (Participant 2)
Physical environment – ‘Where will you go?’
The physical environment was the most frequently mentioned barrier for physical activity. Several participants spoke more generally about the limited availability of places to be physically active or about the inadequate built environment for physical activity:
‘Walking, you have to have a pleasant place. You can't walk everywhere. And you know that, if there's no pavement, a lot of cars, it's not a place for walking.’ (Participant 9)
Several participants also talked about the inaccessibility of government sports clubs due to distance and lack of transportation and their limited focus, and of private exercise facilities because of their cost or low quality:
‘Y'know, I feel the facilities are not well equipped, I mean, [particularly] for females… If it is there, it is not fully equipped. For example, the sports clubs in the wilayats [districts], it is only meant for males. Yes, we saw in the news that females are welcome to go there but I don't think … it is easy.’ (Participant 10)
Several participants mentioned the hot desert climate as a barrier to being physically active; however, one noted that in some areas, the relatively cold winter months may prevent some people from being active.
Public policy – ‘Our programme mostly just concentrate[s] on awareness’
The concerns with public policy were largely related to current interventions by the Ministry of Health. Many participants spoke of the inadequacy of health communication (including both mass media and printed educational materials):
‘As you know, we are delivering health messages in terms of TV programmes or in terms of leaflet, posters… Is this the correct kind of way to reach those people who are the new generation, who know about the internet, who have other methods, attractive methods, to reach them? So, we need to change the health message delivery. We need to study this group … how they can digest the health message.’ (Participant 6)
Several also noted the limited resources available at both the national and institutional level to address physical inactivity:
‘But most of the programme[s] in the government are not set up to do this type of intervention because we don't have the staff, the human resources to follow-up, to implement these things. That's why we only do awareness. It's the easy way because that's the only way we can educate people. But to change behaviour, you really need to build interventions that we really support people … to continue.’ (Participant 1)
Also, two participants mentioned that the focus in the Ministry of Health is on curative medicine rather than prevention, and that health is not considered in all government policies, due to the limited engagement by non-health stakeholders in public health issues.
Participants’ solutions to address physical inactivity
Participants provided a wide range of solutions to address physical inactivity, which can be grouped into two main areas: (i) building a supportive physical environment and (ii) building a supportive policy environment within the health sector as well as within other sectors.
Supportive physical environment – ‘We need … good pavements’
Many participants stressed the importance of having a supportive physical infrastructure (including transport to available sports facilities) to encourage people to be active:
‘If we encourage walking to schools, okay … this, of course, means to have good infrastructure, places, streets, or places which you should be safe because you're expecting the child may cross the road. For example, there should be facilities to make this easier… So it needs also, some … improvement in the infrastructure, streets.’ (Participant 3)
Several participants emphasized that the infrastructure should be culturally appropriate such as having separate spaces for women. In fact, one participant, in advocating for gender-segregated spaces, reported of communities in Oman that built gender-segregated walkways:
‘As I told you, in the beginning we thought this [segregated] walking pathway nobody would utilize. But I was surprised and amazed. So, maybe when we make things available for the people, [they] will go for it.’ (Participant 8)
Supportive health policy environment – ‘You really need to build interventions’
The participants had numerous policy solutions, most of them related to the Ministry of Health. The most commonly mentioned issue was the need to strengthen health communication:
‘We should have … some type of repeated campaigns on this just to increase the awareness. For example, it will happen here in Muscat but when you go into the regions it will rarely happen, these campaigns. It is just … haphazard activities.’ (Participant 5)
However, two participants felt that it would be better to focus on policy to support active living, such as development and transport policies that would make regular walking the easy choice.
Many participants also suggested strengthening the school health programme and conducting research to evaluate current interventions. Although only one participant mentioned using the workplace as a setting to promote physical activity, several focused specifically on how the Ministry of Health should promote physical activity among its own staff:
‘Actually before just going to anybody and asking them to do physical activity to … follow the diet or whatever, we need to start initially from our house. We have a lot of people employed in the Ministry of Health. Now, 27 000 people are now employed in the Ministry of Health.’ (Participant 6)
In order for the Ministry of Health to address physical inactivity, several participants emphasized the need for more staff with related experience in physical activity and for improving primary prevention within health-care settings:
‘We need to have a very well-established well clinic … Now we have this national screening programme for above 40. But we need to have a well clinic starting from 20. We need to go just to the health centres to check annually… We don't have this service. We don't have this person. We have health educators; we have dietitians. But their capacities really to that extent to direct people … they need to be monitored.’ (Participant 8)
Coordinate with other stakeholders – ‘We need to have other partners’
Most participants highlighted the importance of working with other sectors and suggested that the Ministry of Health does more advocacy in order to gain political support and engagement from key stakeholders:
‘I think what the Ministry of Health should demonstrate … the trend in chronic diseases, how this could affect the population and should demonstrate it to all the State Council [upper house of parliament, membership is by appointment], the Shura Council [lower house of parliament, membership is by election], and to the Cabinet.’ (Participant 7)
Half of the participants advocated the establishment of a high-level national body on health promotion:
‘We should have national health promotion committee or council, let us say, or even organization or … health promotion body that can gather all the sectors together to work in this issue. Ministry of Health cannot do it alone.’ (Participant 5)
Perceptions about prolonged sitting – ‘We're a culture that likes to sit’
The participants’ responses regarding prolonged sitting were limited compared with those regarding physical inactivity. The key influences on prolonged sitting identified by the participants can be grouped into three main levels consistent with ecological models: (i) intrapersonal (limited awareness of the adverse effects of prolonged sitting); (ii) the social environment (sedentary culture); and (iii) the physical environment (limited places for active leisure). As one participant noted:
‘Not most of them they like to go to the beach. And if they go to the beach, BBQ and sitting. Okay? We have few malls, and again, the kids are playing and parents sitting. Know what I mean? So we have limited facilities to go outside.’ (Participant 8)
Several participants noted that women, in particular, had limited culturally appropriate options available besides staying at home:
‘The ladies … which have no job, what [option] will they have except sitting at home? … They cannot just go around roaming between the houses … socially it's not acceptable.’ (Participant 5)
Solutions to address prolonged sitting were similar to those regarding physical inactivity, such as coordinating with other sectors and doing more in school and workplace settings. The most common solution for the Ministry of Health focused largely on raising awareness. Although community participation was suggested by some of the participants as a way to address physical inactivity, community-based activity and voluntarism was mentioned more often as a way to reduce prolonged sitting at home, the alternative choice, particularly for women:
‘They can participate in schools in their own community. They can participate to support in the health-care facilities … on a voluntary basis. We don't encourage people to participate and be part of their society and I think that's why people are sitting at home.’ (Participant 1)
Discussion
The perceptions of public health managers about physical inactivity is an important influence on whether or not available evidence on the health impact of this health risk behaviour will be translated into relevant policy and practice( Reference Allender, Gleeson and Crammond 17 ). The responses from the current qualitative study reflect perceptions of the multidimensional influences on this behaviour and the multilevel public health solutions that will be needed to address it, consistent with ecological models of health behaviour( Reference Sallis, Owen and Fisher 11 , Reference King, Stokols and Talen 12 ). Given that sedentary behaviour is a new area of research( Reference Owen, Healy and Matthews 4 ), the more limited discussion on prolonged sitting time is not surprising.
The socio-cultural barriers observed by the participants, particularly the restrictions for women, are seen in other countries within the GCC( Reference Ali, Baynouna and Bernsen 18 – Reference Amin, Suleman and Ali 20 ). For example, a recent qualitative study from the United Arab Emirates reported that women do not have space at home for indoor exercise and families do not allow them to go for a walk alone( Reference Ali, Baynouna and Bernsen 18 ). Similar barriers have been reported from other Arab communities in the Middle East( Reference Daoud 27 , Reference Shuval, Weissblueth and Araida 28 ) and the USA( Reference Kahan 29 , Reference Jaber, Pinelli and Brown 30 ). The social norms that limit women's involvement in physical activity may be an important contributor to the prevalence rates of overweight/obesity and the metabolic syndrome, which are much higher for women than for men in the GCC region( Reference Ng, Zaghloul and Ali 8 , Reference Mabry, Reeves and Eakin 9 ).
Several of the other barriers mentioned by the participants (i.e. dependence on motorized transportation, sedentary work settings, dependence on domestic workers) reflect the socio-economic transition in the country. Evidence indicates that in many parts of the world, this transition is resulting in higher intakes of meats, fats and total energy, and increased physical inactivity, particularly in the occupational and transport domains, that, in turn, is increasing the prevalence of chronic diseases( Reference Siegel, Narayan and Kinra 31 – Reference Monda, Gordon-Larsen and Stevens 33 ). Limited evidence is available on the trends in physical inactivity prevalence in countries of the GCC. However, given the other available evidence from the GCC region, such as the increasing consumption of fats and total energy( Reference Musaiger 34 ) and the increasing prevalence of overweight, obesity, hypertension and type 2 diabetes( Reference Ng, Zaghloul and Ali 8 , Reference Al-Lawati, Mabry and Mohammed 35 ), it is likely that the prevalence of physical inactivity is also increasing.
Recommendations by participants on how to address physical inactivity focused largely on population-based interventions such as mass media health communications and building appropriate physical infrastructure to support physical activity. These recommendations are in line with The Toronto Charter for Physical Activity( 16 ) and the supporting document on the seven best investments for physical activity( 26 ). Many such interventions, as clearly articulated by the participants, require intersectoral engagement. However, a whole-of-government approach in promoting health has not yet taken root in the region( Reference Ali, Baynouna and Bernsen 18 , Reference Al-Lawati, Mabry and Mohammed 35 ). Since ministries of health bear the cost of managing chronic disease in the GCC, the onus is on the health sector to advocate for multisectoral interventions. These interventions can be based on available evidence( Reference Kahn, Ramsey and Brownson 36 , Reference Heath, Brownson and Kruger 37 ), global public health guidance( 16 , 26 , 38 ) and experience from within the GCC region, such as the Kuwait National Physical Activity Plan( Reference Ramadan, Vuori and Lankenau 39 ) and the development of culturally appropriate built environment (i.e. gender-segregated walkways and exercise facilities) in some communities in Oman( 40 , Reference Al-Siyabi 41 ).
Individual-level interventions, such as incorporating physical activity screening and patient education for chronic disease prevention in primary health-care services( 26 ), were mentioned by only a few participants, despite the Ministry of Health being the main provider of health-care services in the country. Researchers have begun to test such individual-level interventions, adapted for the Arab context, with some success( Reference Jaber, Pinelli and Brown 30 , Reference Abduelkarem and Sackville 42 – Reference Midhet and Sharaf 44 ). However, given the sparse evidence available, further research on appropriate interventions for Arab populations is urgently needed.
The more limited discussion on prolonged sitting, including the limited number of suggested interventions, is an indication that sedentary behaviour as an independent health risk factor is a relatively new concept – not only in Oman but also globally( Reference Owen, Healy and Matthews 4 ). Only seven countries have guidelines, most of which target children and focus on limiting television viewing time and other screen time( 45 ). Raising awareness in concert with continued behavioural epidemiology research is required. Making use of the growing body of evidence on prolonged sitting( Reference Owen, Sugiyama and Eakin 13 ) can guide the research agenda appropriate for the region.
The main limitation of the present study is the restriction of the sample to mid-level public health programme managers. Obtaining their views is important in the context of public health planning and was the main purpose of the study; however, they are not representative of all health professionals working in the Ministry of Health, Oman or of society at large. The interviewer, author R.M.M., has worked with all study participants for several years, which facilitated the arrangement of interviews; however, familiarity may also have led to bias, with participants providing socially desirable responses. All participants have a very good working knowledge of English, but their responses may have been limited since the interviews were not conducted in their mother tongue, Arabic.
Study findings are important given the increasing prevalence of chronic disease and the limited evidence available regarding physical inactivity in Oman and the GCC. Advocacy related to study implications has already been initiated through formal presentations of the findings at the Ministry of Health and the College of Medicine, Sultan Qaboos University by the lead author. Opportunities for advocacy through national seminars, meetings with key stakeholders and informal discussion groups are also emerging.
Conclusion
As the economies of countries of the GCC, including Oman, continue to grow, efforts are needed to offset the negative health impacts of socio-economic development. Urgent multilevel action to reduce physical inactivity and prolonged sitting is required and should be sensitive to the socio-cultural context of the population of the GCC and well as the physical and built environment, particularly the harsh weather conditions. Community-based interventions addressing physical inactivity should be expanded, based on locally successful models( 40 ). Given the high prevalence of chronic disease in the region, significant behavioural epidemiology research on physical inactivity and prolonged sitting is required to fill the knowledge gap and guide policy makers.
Acknowledgements
Sources of funding: M.M.R., N.O. and E.G.E. are supported by Programme and Fellowship Grants from the National Health and Medical Research Council of Australia and by Research Infrastructure funding from Queensland Health. N.O. is also supported by Research Infrastructure funding from the Victorian Government. Conflicts of interest: The authors declare to have no conflicts of interest. Authors’ contributions: R.M.M. was responsible for the initial research concept, preparation of the study questionnaire, data collection, data analysis and interpretation, preparation of the manuscript and tables, and revision of the paper. Z.Q.A. contributed to the study design, assisted with data collection, analysis and interpretation, helped in preparation of the tables and assisted in manuscript editing. M.M.R. contributed to the initial concept and study design, data interpretation and manuscript editing. N.O. assisted with the initial concept and study design and manuscript editing. E.G.E. supervised design and implementation of the study and assisted with the manuscript writing and editing. Acknowledgements: The authors wish to thank the participants for sharing their thoughts and for the pleasant, honest and often humorous interactions.
