Women’s Health Issues 18 (2008) 413– 422
ARRANGING APPROPRIATE ACTIVITIES Immigrant Women’s Ideas of Enabling Exercise Marita Södergren, MSc*, Ingrid Hylander, PhD, Lena Törnkvist, PhD, Jan Sundquist, MD, PhD, and Kristina Sundquist, MD, PhD Center for Family and Community Medicine, Karolinska Institute, Stockholm, Sweden Received 12 August 2007; revised 23 May 2008; accepted 23 May 2008
Objective. Several studies have reported low levels of physical activity among immigrant women. However, few studies have attempted to explore possible causes underlying this phenomenon. This study intended to explore immigrant women’s attitudes and experiences of physical activity and exercise. The ultimate goal was to find methods that can increase levels of physical activity among immigrant women. Methods. A qualitative exploratory study was undertaken in Stockholm County, Sweden, involving 63 immigrant women from Chile, Iraq, and Turkey. Data were collected through interviews in 10 focus groups. The analysis was based on grounded theory approaches. Constant comparative analysis and theoretical sampling were employed to construct categories. Main findings. The model that emerged illustrated the core process, that is, enabling exercise. The model also described the women’s attitudes and experiences and their ideas of how exercise can be made possible. The women agreed that the local community should recognize the problem and arrange exercise in familiar places. In addition, they called for activities that felt appropriate. If appropriate exercise was arranged, the women sometimes decided to participate. Otherwise, they hesitated or waited. Conclusion. If appropriate activities are arranged, levels of physical activity and exercise might increase among immigrant women. Future studies could explore specific activities that can facilitate immigrant women’s opportunities to exercise.
Introduction and Background
D
espite the well-known, positive effects of physical activity on a number of health outcomes, many population groups are not sufficiently active, such as immigrant women (Centers for Disease Control and Prevention, 2007; Crespo, Smit, Andersen, Carter-Pokras, & Ainsworth, 2000; National Institute of Public Health, 2004; Sternfeld, Ainsworth, & Quesenberry, 1999). The present study sought to explore immigrant women’s attitudes and experi-
Supported by grants from the Swedish Research Council to Dr Kristina Sundquist (K2005-27X-15428-01A), ALF projektmedel, Stockholm, and the Stockholm County Council. * Correspondence to: Marita Södergren, MSc, Center for Family and Community Medicine, Karolinska Institute, Alfred Nobels allé 12, SE-141 83 Huddinge, Sweden. Phone: ⫹46 8 524 685 06; fax: ⫹46 8 524 887 06. E-mail:
[email protected]. Copyright © 2008 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
ences of physical activity and exercise and thereby increase understanding of the possible causes underlying their low level of physical activity. This is important because the morbidity from cardiovascular disease in Sweden increased among several groups of immigrant women during the 1990s, for example, among women from Southern Europe, Turkey, and Iran (Gadd, Johansson, Sundquist, & Wandell, 2005a). In addition, the proportions of immigrants are steadily increasing in many countries worldwide, including Sweden. Today, 13% of the Swedish population is foreign born. The largest number of immigrants come from Finland, the former Yugoslavia, Iraq, Iran, Poland, Germany, Turkey, Chile, and Lebanon (Statistics Sweden, 2006a). Many immigrant groups in Sweden suffer from poor health, including a higher risk of cardiovascular disease than the Swedish-born population (Gadd, Johansson, Sundquist, & Wandell, 2003). 1049-3867/08 $-See front matter. doi:10.1016/j.whi.2008.05.001
414
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
Immigrants also carry a heavier burden of many risk factors for cardiovascular disease, such as physical inactivity (Gadd, Sundquist, Johansson, & Wandell, 2005b). Swedish statistics show that immigrant women from Southern Europe, Iran, Turkey, and Chile are less physically active than Swedish-born women. For example, among Turkish women, only 1 out of 5 exercised regularly compared with 1 out of 3 among the Chilean women. About 60% of the Swedish-born women exercise regularly (National Institute of Public Health, 2004). Compared with people in many other European countries, Scandinavians have high levels of physical activity during their leisure time (Martinez-Gonzalez et al., 2001; Vaz de Almeida et al., 1999). Exercise promotion programs and the creation of proper conditions for exercise are needed to enable more people to satisfy the recommendations for regular physical activity (American College of Sports Medicine, 1998; U.S. Department of Health and Human Services, 1996). In Sweden, the government and nongovernmental organizations have promoted physical activity for several decades. Various sports associations and organizations offer exercise programs that receive subsidies from the government. In addition, many employers allow employees to exercise during working hours and/or grant subsidies for exercise during leisure time. The number of people in Sweden who exercise on a regular basis is increasing. However, there are substantial differences in individual factors such as age, gender, education, socioeconomic status, and country of birth (Bostrom, 2001). Some of these individual factors’ association with physical activity are discussed herein. In general, women have lower levels of leisure-time physical activity than men. Being a mother and wife, taking care of home and family, working part or full time, and a lack of time and money are common explanations given in previous studies (Kearney, de Graaf, Damkjaer, & Engstrom, 1999; Margetts, Rogers, Widhal, Remaut de Winter, & Zunft, 1999; Vertinsky, 1998). No motivation and no experience of exercise are other hindrances that have been reported (Eyler et al., 1997). Women have a tendency to identify themselves as nonexercising persons. They also feel that they get enough physical activity during the working day from housekeeping and care giving (Eyler et al., 1998). Maintenance of good health, weight reduction, and looks seem to be the most important reasons for women to exercise (Cash, Novy, & Grant, 1994; Schrop et al., 2006; Zunft et al., 1999). An important factor for exercise is social support (Eyler et al., 1999; Marquez & McAuley, 2006b), which is often insufficient among immigrants. Studies from the United States have shown that minority populations (defined as African Americans and Hispanics) are less physically active during leisure time than majority populations (de-
fined as non-Hispanic Whites; Lee, 2005). In addition, a study from the United States of minority women showed that African Americans and American Indians/Alaskan Natives have the lowest level of physical activity during leisure time (Brownson et al., 2000; Sternfeld et al., 1999). A low level of education, low socioeconomic status, and residing in a neighborhood that is perceived to be unsafe are other factors that have been linked to low levels of physical activity and exercise, although the results are diverse (Bennett et al., 2007; Bennett, Wolin, Puleo, & Emmons, 2006; Marshall et al., 2007). Immigrant women could, therefore, encounter several factors that worsen their opportunities to engage in regular physical activity and exercise in addition to the gender disparities described. A large proportion of immigrant women in Sweden have a low educational level, are unemployed, and live on limited resources. Although patriarchy is a more or less predominant ideology all over the world, many immigrant women living in Sweden come from markedly patriarchal cultures (Commission of the European Communities, 2006; Statistics Sweden, 2006b; Stockholm County Council, 2006). The 3 groups of immigrant women included in the present study come from Chile, Iraq, and Turkey. Although there are large disparities in the women’s situation both within and between these national groups, all of these countries probably represent cultures with strong paternalistic attitudes that could mitigate against the implementation of physical activity programs for women in these ethnocultural communities. There are also differences between the 3 countries. For example, the main religion in Chile is Roman Catholicism, whereas the main religion in Iraq and Turkey is Islam. More research is needed to capture these women’s experiences and attitudes. For this purpose, a qualitative approach is appropriate. Aim The aim of this study was to explore immigrant women’s attitudes toward and experiences of physical activity and exercise. The ultimate goal was to find methods that can increase the levels of physical activity and exercise among immigrant women.
Methods Considering the aim of the study, namely, to develop new theoretical knowledge in a relatively unexplored area, grounded theory was chosen as the method of analysis (Glaser, 1978; Glaser & Strauss, 1967; Strauss & Corbin, 1998). Data were collected through interviews in 10 focus groups.
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
Participants In this study, the concept immigrant women means women who have immigrated to Sweden. The women were born in Chile, Iraq, or Turkey and are now living in Stockholm County. The countries Chile, Iraq, and Turkey were selected because they represent large immigrant groups in Sweden. In addition, many women from these country groups are sedentary (National Institute of Public Health, 2004). The 63 women were recruited through women’s associations, child welfare centers, preschools, and courses in Swedish for immigrants. Key personnel at these organizations and institutions were contacted by letter, e-mail, personal visits, and telephone. These key personnel helped to provide oral information about the study to the immigrant women. The immigrant women who were interested in participating in the study also received written information about it. Women aged 18 – 65 were considered eligible for the study. However, the actual age range of the recruited participants was between 26 and 65. The focus group interviews were conducted in the women’s native language to make it easier for them to express themselves and discuss with others more naturally. Interpreters were present at all interviews with the exception of 1 Turkish focus group in which the participants were fluent in Swedish. Two female interpreters were used for each language (Spanish, Turkish, and Arabic). All interpreters were recruited through the official translation agency used by the Stockholm County Council. The interpreters were authorized by the Swedish Legal, Financial, and Administrative Services Agency, which is the oldest public authority in Sweden. The interpreters were familiar with the purpose and content of the present study because they had all also been involved in another of our studies in which we gathered quantitative data (questionnaires, activity monitors) from 2,100 foreign-born women living in Stockholm County. Data Collection The focus groups met at a time and place chosen by the women, often the place where the women had been recruited. The interviews lasted 1–1.5 hours and were audiotaped and transcribed verbatim. A trained moderator (the first author of this study) conducted the interviews with the help of interpreters. An observer took notes on such nonverbal communication as gestures and facial expressions. Before the interview started, the women were informed about the tape recorder and that only authorized researchers would listen to the tapes. It was also pointed out that the material would not be used in any context other than research. A semistructured question guide was used with the following themes: previous experiences of physical activity, knowledge of the effects of physical activity, and similarities and differences in physical
415
activity habits between the home country and Sweden. At the beginning of each focus group, the women were asked to define physical activity and exercise. The recognized definitions are the following: Physical activity has been defined as “any bodily movement produced by skeletal muscles that results in energy expenditure,” whereas exercise is a subset of physical activity defined as a “planned, structured, and repetitive bodily movement done to improve or maintain physical fitness” (Caspersen, Powell, & Christenson, 1985, p. 129). The question guide was gradually modified as new themes emerged from the participants. The interpreters were familiar with the question guide and the aim of the focus group interviews. The moderator talked directly to the participants, the participants discussed with each other and/or the moderator, and the interpreter translated simultaneously. The moderator ensured that all the topics in the question guide were covered. At the end of each focus group interview, the moderator summarized the session and the participants verified and/or added more information. Based on the nature of grounded theory, we decided that it was important for the researcher to collect the data and thus act as a moderator in the focus group interviews. Moderator, observer, and interpreter came together shortly after each interview to transcribe and reflect on the interview and to get ideas and develop the question guide for the next focus group. Data were collected between 2002 and 2005. Table 1 describes the focus group interviews in the order they were conducted. Data Analysis Data were collected and analyzed simultaneously. The analytical process started after the first interview. The transcribed interview was examined line by line. After a few further interviews, a process was discernible and a possible core category emerged. We considered saturation to have been reached when additional interviews gave no further information and patterns were recognized according to the grounded theory (Glaser, 1978; Strauss & Corbin, 1998). The identified core category constituted the core process with 2 main categories. Three additional subcategories crystallized in each of the 2 main categories. We returned to coded data to establish that the final model was well grounded in our data. Three researchers with different professions (general practitioner, nutritionist, and public health nutritionist) were involved in the analysis and they all arrived at the same main concern and core process, independently of one another. Validity The emergent results were constantly compared with our data in conformity with Grounded Theory. Thus,
416
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
Table 1. Description of the focus groups in the order in which the interviews were conducted (2002–2005) Focus Group
No. of Women
Country of Birth
Age (Mean ⫾ SD)
Years in Sweden (Mean ⫾ SD)
No. of Children (Mean)
Employment, n (%)
1 2 3 4 5 6 7 8 9 10
6 7 6 6 7 7 8 7 4 5
Turkey Iraq Iraq Iraq Turkey Turkey Chile Turkey Iraq Chile
48 ⫾ 8.1 38 ⫾ 4.5 46 ⫾ 2.7 31 ⫾ 2.7 49 ⫾ 7.9 45 ⫾ 5.8 57 ⫾ 10.8 55 ⫾ 5.2 49 ⫾ 11.6 55 ⫾ 7.8
20 ⫾ 1.9 4 ⫾ 1.7 4 ⫾ 2.5 4 ⫾ 2.1 27 ⫾ 8.6 22 ⫾ 12.2 18 ⫾ 6.0 29 ⫾ 5.7 11 ⫾ 2.9 22 ⫾ 5.8
3 4 5 1 3 3 3 2 3 3
0 0 0 0 5 (71) 3 (43) 4 (50) 3 (43) 2 (50) 3 (60)
Abbreviation: SD, standard deviation.
the validity check on the criteria fit, relevance, and work (Glaser, 1978) was integrated in the analytical process. A respondent validity check was performed on both the women who had participated in the focus groups and on immigrant women who had not participated. Both groups said that the collected data explained their situation well. The modifiability of the theory can be tested in another context when new relevant data are compared with existing data. Ethical Considerations Participation was voluntary and the women had the option to terminate their participation at any time. Verbal information about the purpose of the study was given to the participants when they were recruited and before the interviews. Ethical approval was obtained from the Ethics Committee of the Karolinska Institute (247/01).
Results The women described physical activity as any movement in their daily life, whereas they described exercise as being more structured and physically demanding than regular physical activity. The focus of the interviews was in accordance with the women’s own interests, that is, exercise rather than physical activity. One important factor that came forth was that the women expressed themselves in terms of we, us, and our and they emphasized that it is easier to do things in a group than by themselves. The model that emerged and that illustrated the core process and the variation in the women’s attitudes to exercise consisted of the core category enabling exercise (Figure 1). Enabling exercise included the 2 main categories, arranging exercise and appropriate exercise, each of which had 3 subcategories. Arranging exercise included organizing, planning, and instructing. Appropriate exercise included suitable, pleasant, and proper exercise. In addition, intermediate categories from discovering to actuating also emerged: inspiration
(from discovering to enabling) and channels of assurance (from enabling to actuating). This model can be regarded as an attempt to conceptualize the women’s attitudes to exercise and also as a tool that might possibly be further developed to help health care workers, program developers, and policy makers raise levels of exercise among immigrant women. Arranging Exercise Some women had tried by themselves to exercise but failed; they perceived a lack of officially arranged exercise. The few efforts that had been made had not led to regular exercise. For example, some women had received a referral to an exercise program, but it was time limited and the women did not understand why they could not continue to exercise. Some women had been advised by a doctor to swim, although they could not swim or the public swimming pools did not offer women-only hours. “They don’t leave any space for us . . . Tell them to give us a place to do sports and gymnastics and then we can go there” (Turkish, 50 years old). The women stated that it was important that the exercise was arranged and planned close to their home, preferably indoors in a familiar place, and in groups with only women. Some women asked for groups with women from their own culture. “In X they have a group of women who swim on Saturdays, they open . . . it’s just for women. That encourages women, even the ones who wear veils; it’s a good initiative, I hope it happens in other areas too, not just in X because that’s far away” (Iraqi, 52 years old). They also requested that the exercise should be arranged at times that did not conflict with their duties at home. In addition, not having time for themselves puts obstacles in the way of their exercising. “If you could have a bit of time for yourself, think about yourself and your health, leave everything to one side and just go out and take a walk or something” (Turkish, 37 years old). Because they were unaccustomed to exercising and needed to learn how, they wished to have access to an
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
417
Figure 1. A model illustrating the core process, i.e. “Enabling exercise.”
instructor. “None of us can do anything sensible ourselves, we need to be organized and have someone to lead this organized group . . . , the desire to take exercise will increase in that way” (Iraqi, 51 years old). Appropriate Exercise There were several aspects that decided what was suitable or not. It was a big step for the women to go to a gymnasium all by themselves and they felt that they did not belong there. Even putting on a pair of training shoes made them feel “different” (not normal). Other aspects included their age, economy, and number of children. The women also mentioned that they needed to get used to how the body responds to exercise and overcome feelings of fear when the heart rate increases, so that it could be pleasant for them to exercise. “When it beats that fast you wonder, oh, why is it beating so fast, am I sick, is something happening? Then when it calms down and beats slower it feels easier again” (Turkish, 50 years old). Demands for blameless behavior were very important for the women, and some activities were considered to be more proper than others. Activities they knew that others had performed felt “proper.” The women were therefore eager to talk about exercises that were appropriate for them. Most women thought that cycling, swimming, and gymnastics were suitable, pleasant, and proper activities. In addition, it was more acceptable to participate in exercise that was arranged by the school or the workplace because then participation was considered to be compulsory. “When we go to school we usually have exercise, we
do everything there is, we do as in Sweden when we’re in school” (Iraqi, 30 years old). Demands for blameless behavior did not only come from the family, but also from other persons from their own culture. Social control was strong and many women were expected to wear a veil and not go out by themselves. “That’s why you have to have strong self-confidence not to care about what others think” (Iraqi, 36 years old). However, many women said that that their own husbands and male relatives encouraged them to exercise. “In our case, we are encouraged by our husbands, because our husbands have also developed a lot and then they can allow us to go out any time to get exercise” (Chilean, 63 years old). All women asked for suitable and pleasant exercise. However, the women from Iraq and Turkey also said that it was important that the exercise was proper. “They say that it’s a sin if the men stand behind and watch while we work out, so we did it like this: The men stood in front and the women behind.” “I have told the teacher that it is ‘haram’, the men must stand first and we stand behind, and then it was all right” (Iraqi, 45 years old). Discovering Exercise Discovering exercise was the first step that could eventually lead the women to start exercising. With few exceptions, the women lacked earlier experience of exercise from their home countries. “We should do gymnastics but things we don’t do, like going out walking or going to the swimming pool . . . that we don’t do, we don’t have the same culture of using our leisure time as here” (Chilean,
418
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
45 years old). A few women had exercised as teenagers, but none of them had continued to exercise when they reached adulthood. Discovery took place when the women were presented with the possibility of exercising, which had the result that they were either inspired or they were not. The main reasons for not being inspired were health problems, economic difficulties, or that exercise was not suitable. Those who were inspired to exercise recognized that there are hindrances to doing so, but they also described ways to overcome these hindrances and how exercise could become possible. Many women were well aware of the positive effects of physical activity and that they should exercise more. However, they were not used to exercising in their home countries and they felt inept. Although they came from cultures where regular exercise was not common for adult women, they recognized the opportunities to start exercising in Sweden. They also hoped to take up activities like cycling and swimming, which they had to forsake when they were growing up. Actuating Exercise After enabling exercise, many women experienced difficulties getting started. Before actuating they needed help to take the final step. Some kind of assuring channels were often needed for them to get started. Examples of assuring channels were persons or organizations that facilitate the actuation. It could be a friend, husband, or some other family member who encouraged them to get started with exercise. The schools, workplaces, women’s associations, and primary health care provider were other important channels of assurance. The exercise often ceased if they lost contact with these channels. Strategies for Deciding to Exercise Four categories arose: deciding, waiting, hesitating, and abstaining. These categories can be regarded as strategies for deciding to exercise and consequences of the connection between arranged and appropriate aspects (Figure 2).
a. Deciding. When arranged and appropriate exercise was available, some women decided to start exercising. “I decided to buy the card, my daughter told me to buy it and now that I have one, it’s expensive . . . and that’s why I go there more often” (Chilean, 63 years old). However, few women had made the decision and we noticed a difference between the women, because mainly the women from Chile had really started to exercise (they said that they had gone from the decision to action). Lack of self-discipline and inspiration were some hindrances to exercise. b. Waiting. Many women had found appropriate forms of exercise and waited for it to be arranged. “Time and a good place are needed and we don’t have that here, we want to, but it doesn’t exist” (Iraqi, 32 years old). However, the women had different reasons for waiting. Women from Turkey and Iraq waited for special women-only groups to be started in their neighborhood, whereas women from Chile waited for the public authorities to take responsibility and wanted to increase the accessibility of exercise through information and subsidies. c. Hesitating. Arrangement of inappropriate exercise resulted in the women hesitating. Several women from Iraq and Turkey wanted some kind of assurance that the activities would be pleasant and proper and that it is legitimate to participate. d. Abstaining. If exercise was neither appropriate nor arranged, the women abstained from exercise. In addition, these women were probably not really prepared to exercise. Some of them wanted to exercise, but felt insecure and experienced many hindrances. Many women in our study were waiting or hesitating. However, a few women tried to arrange activities by themselves or went to other neighborhoods to exercise, although this was difficult and did not lead to any regularity. In addition, some of the women had participated in activities even though it did not really feel appropriate although somebody had told them that it was okay. “My children have tried to teach me to ride a bicycle, I’m ashamed, but my husband says it is possible” (Iraqi, 40 years old).
Discussion and Conclusion
Figure 2. Strategies for exercise decision– connection between arranged and appropriate.
The model that emerged illustrated the core process, namely, enabling exercise. The women agreed that the local community should arrange exercise that feels appropriate. If appropriate exercise was arranged, the women sometimes decided to participate. Few women had made the decision to start exercising; most of the women were waiting or hesitating. The present study has several strengths. Data were collected through interviews in focus groups, which
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
gave a large quantity of diverse and comprehensive data and an opportunity to analyze the interaction between the women. Thus, it was possible to acquire new knowledge (Krueger, 1994; Morgan, 1993). The groups were homogeneous and the same researcher conducted all interviews. This created a setting in which the women felt comfortable talking about their experiences, beliefs, and attitudes. Theoretical sampling was used—the emerging theory decided which groups to interview and which additional questions should be included in the interview guide. Thus, the data reflected the women’s beliefs and the result was a product that appeared in the interaction between the researcher and the data. The validity check showed that the data could also be considered valid among immigrant women who had not participated in the study (see Methods). This shows that the data are well grounded. Thus, the model is useful and can explain and predict what may happen (work). The model has emerged from data during the course of constant comparative analysis, which ensures the empirical grounding or fit. The model may also be modified by the contribution of new data (modifiability). The present study also has some limitations. The results cannot be generalized directly to other groups of immigrant women. Country of birth was used in this study to create homogeneous focus groups. However, these countries include people from many different cultures, religions, and traditions. Therefore, huge cultural and social differences may exist between different groups of people, which could have an important effect on exercise habits. Thus, there are limitations in research on country of birth in relation to physical activity. Finally, the use of an interpreter implied an obvious risk of misconstructions. We found that most of the women lacked experience of exercise in their home countries. The women had discovered the possibility of exercising in Sweden. They recognized the usefulness of exercise and expressed a strong desire to start. Their main concern was how to enable exercise and they talked about what was needed to make it possible for immigrant women to exercise. All women in the focus groups agreed that the local community should arrange for appropriate exercise. They felt that they were unable to change their situation by themselves. Through exercise, the women saw the opportunity for a better life, a life in which they could think of their own needs and have time on their own. Another important factor was their need to feel safe and secure. Such factors have also appeared in other studies (Guerin et al., 2003; Juarbe, Lipson, & Turok, 2003). They wanted the exercise to be arranged close to their homes and at times that did not conflict with their family duties. The women said that it is not considered appropriate for married women and mothers to exercise because exercise reduces the time
419
available for home and family. This has also been demonstrated in earlier studies (Guerin et al., 2003; Juarbe et al., 2003). An interesting result of this study was that the group concept is of vital importance. The women used the words “we” and “us” when they talked about themselves: “we need,” “we want” “it will be good for us,” and “it should be arranged for us.” Although the nature of this study did not allow us to draw any conclusions about why the women preferred group activities, it is possible that many immigrant women feel isolated and marginalized and that they therefore wish to be together in a group. It is also possible that they identify themselves as a collective based on similarities in cultural background. Many of these women spend their lives close to their homes and are dependent on other women in the same neighborhood. This could make it more efficient to aim efforts and resources at neighborhoods and groups of women instead of individuals. Such an approach could enable more women to start exercising, so that they in turn might inspire others. Apparent differences were found, however, among the included groups of immigrant women. For instance, all women wanted suitable and pleasant exercise, whereas the women from Iraq and Turkey also said that it is important that the exercise is “proper.” Thus, close collaboration with women from different immigrant groups is important to fully understand and adjust for their different needs (Ball, Salmon, Giles-Corti, & Crawford, 2006; Dye & Wilcox, 2006; Guerin et al., 2003; Tudor-Locke et al., 2003). In Sweden, exercise for health reasons is regarded as natural for young and old people of both genders. Although the women recognized the opportunities to exercise in Sweden and strove to conform to the Swedish system, they experienced a clash between 2 cultures. Negative attitudes toward women who exercise are found in some cultures; they are regarded as morally loose women who, among other things, jeopardize their fertility. In addition, their culture do not allow them to exercise in front of men or younger family members (Juarbe et al., 2003; Reijneveld, Westhoff, & Hopman-Rock, 2003), which is in accord with the results of this study. Nakamura (2002) described the influence of Muslim culture on physical activity patterns among women and found that a lack of prerequisites for participation rather than their faith hindered the women from participating in physical activity programs. For example, 3 prerequisites for participation were found to be important among the women: a flexible and modest dress code, gender segregation, and controlled access to their physical activity space (Nakamura, 2002). A study from Britain examined the family influence on young women from Muslim communities who had participated in a combined sport and education pro-
420
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
gram. The authors of that study found an “extensive parental influence on the young women’s involvement in the sports program and over their lives as a whole, and the significance of Islam within this. . .” and described how the women navigated between their family identity and their westernized experiences. They draw conclusions about the value of sport in illuminating the cultural experiences of minority groups (Kay, 2006, p. 357). Coakley and Donnelly (2002) have described how inclusive leisure and recreation participation can be a positive experience and assist in identity formation and social inclusion, which is of particular importance to many minority women. A Canadian study explored the perceived benefits and challenges of sport, recreation, and participation in physical education for culturally diverse adolescent boys and girls who are recent arrivals in Canada. The authors found that subcultural identity, perceived benefits, discrimination, and challenges had an influence on the attitudes to and experiences of sport and recreation among the culturally diverse youths participating in the focus groups (Taylor & Doherty, 2005). Many women said that they had received support and encouragement to exercise from their husbands, although attitudes and opinions from other people from their own culture made them feel insecure about what was appropriate. Social control was strong and high demands and expectations were put upon the women. Some women tried to find different ways to get around hindrances. However, if they decided to start exercising, some kind of verification or channel of assurance was often needed from, for example, a friend or family member. In addition, to learn to allot time, plan, and get into a group together with others is a big step, which has proved in 1 study to be more important than social support (Anderson, Wojcik, Winett, & Williams, 2006). It is possible that physical activity on prescription could help these women to start exercising. Another way is to arrange exercise in connection with school or work, because such exercise is considered compulsory. The arrangement of exercise could thus act as an enabler for immigrant women to participate. Eyler et al. (1998) used a qualitative approach to investigate environmental and personal enablers and barriers to increased physical activity among minority women. The authors found that one of the most important environmental enablers was access in connection with work, home, community, and church, whereas cost, lack of transportation, and lack of suitable programs constituted an environmental barrier. The theoretical model can be compared to a process of change (Bandura, 1986; Prochaska & DiClemente, 1982), although without distinct stages, and many factors determine which women start exercising. Moreover, to rule your own life and feel control is important to get away with a change (Godin, Lambert, Owen, Nolin, & Prud’homme, 2004). Consequently, it is important that there is public awareness, so that the process of change
can be supported and facilitated. Exercise can then be permitted, accessible, and given priority among immigrant women, who often face cultural forces that constrain their possibilities of exercising. Immigrant women also face structural forces that may act as barriers to exercise, such as a low educational level, sparse economic resources, and unemployment, which is often encountered in immigrant populations. In Australia, immigrants were at a disadvantage in the labor market (Maani, 1994) and, in Belgium, Moroccan immigrants had high rates of unemployment (Fossion et al., 2002). These structural barriers are well-known social determinants of poor health at the individual level. There are also determinants of poor health and a poor lifestyle that could act at the neighborhood level. For example, living in a disadvantaged neighborhood could hinder women from exercising because of fear of going out and fear of crime. In Sweden, newly arrived immigrants and people with social problems were directed by the authorities to segregated neighborhoods with low status (Kuusela, 1993), which is likely to restrict the integration of immigrants in the host country. Finally, some previous studies have shown that the level of physical activity increases with time in the new country (Dawson, Sundquist, & Johansson, 2005; Marquez & McAuley, 2006a). However, this was not the case in this study. Previous experiences of exercise seemed to be a more important factor for exercise than time in Sweden and language. The results of the present study show that it is difficult for immigrant women who lack previous experience of exercise to start exercising on their own. In addition, the study provides new information about cultural attitudes and social norms that hinder women from exercising in the new country. The immigrant women believed that it is important that the community arranges appropriate programs to enable exercise. Resources to create opportunities for immigrant women to exercise should be focused on the group level and especially on the women who are waiting or hesitating. Future studies could explore specific activities to improve immigrant women’s opportunities to exercise on a regular basis.
References American College of Sports Medicine. (1998). The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Position stands. Medicine and Science in Sports and Exercise, 30, 975–991. Anderson, E. S., Wojcik, J. R., Winett, R. A., & Williams, D. M. (2006). Social-cognitive determinants of physical activity: The influence of social support, self-efficacy, outcome expectations, and self-regulation among participants in a church-based health promotion study. Health Psychology, 25, 510 –520.
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422 Ball, K., Salmon, J., Giles-Corti, B., & Crawford, D. (2006). How can socio-economic differences in physical activity among women be explained? A qualitative study. Women & Health, 43, 93–113. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. Bennett, G. G., Wolin, K. Y., Puleo, E., & Emmons, K. M. (2006). Pedometer-determined physical activity among multiethnic lowincome housing residents. Medicine and Science in Sports and Exercise, 38, 768 –773. Bennett, G. G., McNeill, L. H., Wolin, K. Y., Duncan, D. T., Puleo, E., Emmons, K. M. (2007). Safe to walk? Neighborhood safety and physical activity among public housing residents. PLoS medicine, 4, 1599 –1606. Bostrom, G. (2001). Chapter 6. Habits of life and public health. Health in Sweden: The National Public Health Report 2001. Scandinavian Journal of Public Health Supplement, 58, 133–166. Brownson, R. C., Eyler, A. A., King, A. C., Brown, D. R., Shyu, Y. L., & Sallis, J. F. (2000). Patterns and correlates of physical activity among US women 40 years and older. American Journal of Public Health, 90, 264 –270. Cash, T. F., Novy, P. L., & Grant, J. R. (1994). Why do women exercise? Factor analysis and further validation of the Reasons for Exercise Inventory. Perceptual and Motor Skills, 78, 539 –544. Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985). Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports, 100, 126 –131. Centers for Disease Control and Prevention (2007). Prevalence of fruit and vegetable consumption and physical activity by race/ ethnicity-United States, 2005. Morbidity and Mortality Weekly Report, 56, 301–304. Coakley, J., & Donnelly, P. (2002). Working paper series monograph: Perspectives on social inclusion. Toronto, Ontario: Laidlaw Foundation. Commission of the European Communities. (2006). A roadmap for equality between women and men. Available: http://europa.eu/ scadplus/leg/en/s02310.htm. Accessed August 2007. Crespo, C. J., Smit, E., Andersen, R. E., Carter-Pokras, O., & Ainsworth, B. E. (2000). Race/ethnicity, social class and their relation to physical inactivity during leisure time: Results from the Third National Health and Nutrition Examination Survey, 1988 –1994. American Journal of Preventive Medicine, 18, 46 –53. Dawson, A. J., Sundquist, J., & Johansson, S. E. (2005). The influence of ethnicity and length of time since immigration on physical activity. Ethnicity and Health, 10, 293–309. Dye, C. J., & Wilcox, S. (2006). Beliefs of low-income and rural older women regarding physical activity: You have to want to make your life better. Women & Health, 43, 115–134. Eyler, A. A., Brownson, R., King, A., Brown, D., Donatelle, R., & Heath, G. (1997). Physical activity and women in the United States: An overview of health benefits, prevalence, and intervention opportunities. Women & Health, 26, 27– 49. Eyler, A. A., Baker, E., Cromer, L., King, A. C., Brownson, R. C., & Donatelle, R. J. (1998). Physical activity and minority women: A qualitative study. Health Education & Behavior, 25, 640 – 652. Eyler, A. A., Brownson, R. C., Donatelle, R. J., King, A. C., Brown, D., & Sallis, J. F. (1999). Physical activity social support and middle- and older-aged minority women: Results from a US survey. Social Science & Medicine, 49, 781–789. Fossion, P., Ledoux, Y., Valente, F., Servais, L., Staner, L., Pelc, I., et al. (2002). Psychiatric disorders and social characteristics among second-generation Moroccan migrants in Belgium: An age-and gender-controlled study conducted in a psychiatric emergency department. European Psychiatry, 17, 443– 450. Gadd, M., Johansson, S. E., Sundquist, J., & Wandell, P. (2003). Morbidity in cardiovascular diseases in immigrants in Sweden. Journal of Internal Medicine, 254, 236 –243.
421
Gadd, M., Johansson, S. E., Sundquist, J., & Wandell, P. (2005a). The trend of cardiovascular disease in immigrants in Sweden. European Journal of Epidemiology, 20, 755–760. Gadd, M., Sundquist, J., Johansson, S. E., & Wandell, P. (2005b). Do immigrants have an increased prevalence of unhealthy behaviours and risk factors for coronary heart disease? European Journal of Cardiovascular Prevention and Rehabilitation, 12, 535–541. Glaser, B. (1978). Theoretical sensitivity. Advances in methodology of grounded theory. Mill Valley, CA: The Sociology Press. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory, strategies for qualitative research. New York: Aldine de Gruyter. Godin, G., Lambert, L. D., Owen, N., Nolin, B., & Prud’homme, D. (2004). Stages of motivational readiness for physical activity: A comparison of different algorithms of classification. British Journal of Health Psychology, 9, 253–267. Guerin, P. B., Diiriye, R. O., Corrigan, C., & Guerin, B. (2003). Physical activity programs for refugee Somali women: Working out in a new country. Women & Health, 38, 83–99. Juarbe, T. C., Lipson, J. G., & Turok, X. (2003). Physical activity beliefs, behaviors, and cardiovascular fitness of Mexican immigrant women. Journal of Transcultural Nursing, 14, 108 –116. Kay, T. (2006). Daughters of Islam: Family influences on Muslim young women’s participation in sport. International Review for the Sociology of Sport, 41, 357–373. Kearney, J. M., de Graaf, C., Damkjaer, S., & Engstrom, L. M. (1999). Stages of change towards physical activity in a nationally representative sample in the European Union. Public Health Nutrition, 2, 115–124. Krueger, R. A. (1994). Focus groups, a practical guide for applied research. Thousand Oaks, CA: Sage. Kuusela, K. (1993). Integration i invandrartäta bostadsområden? (Integration in residential areas with a high immigrant population?). Dissertation. University of Gothenburg, Gothenburg, Sweden. Lee, S. M. (2005). Physical activity among minority populations: What health promotion practitioners should know—A commentary. Health Promotion Practice, 6, 447– 452. Maani, S. A. (1994). Are young first and second generation immigrants at a disadvantage in the Australian labor market? The International Migration Review, 28, 865– 882. Margetts, B. M., Rogers, E., Widhal, K., Remaut de Winter, A. M., & Zunft, H. J. (1999). Relationship between attitudes to health, body weight and physical activity and level of physical activity in a nationally representative sample in the European Union. Public Health Nutrition, 2, 97–103. Marquez, D. X., & McAuley, E. (2006a). Gender and acculturation influences on physical activity in Latino adults. Annals of Behavioral Medicine, 31, 138 –144. Marquez, D. X., & McAuley, E. (2006b). Social cognitive correlates of leisure time physical activity among Latinos. Journal of Behavioral Medicine, 29, 281–289. Marshall, S. J., Jones, D. A., Ainsworth, B. E., Reis, J. P., Levy, S. S., & Macera, C. A. (2007). Race/ethnicity, social class, and leisuretime physical inactivity. Medicine and Science in Sports and Exercise, 39, 44 –51. Martinez-Gonzalez, M. A., Varo, J. J., Santos, J. L., De Irala, J., Gibney, M., Kearney, J., et al. (2001). Prevalence of physical activity during leisure time in the European Union. Medicine and Science in Sports and Exercise, 33, 1142–1146. Morgan, D. L. (1993). Successful focus groups: Advancing the state of the art. Newbury Park, CA: Sage. Nakamura Y. (2002). Beyond the Hijab: Female Muslims and physical activity Women in Sport and Physical Activity Journal, 11, 21– 48. National Institute of Public Health. (2004). The relevance of birthplace. The health of various immigrant groups in Sweden (p. 2). Östersand, Sweden: National Institute of Public Health.
422
M. Södergren et al. / Women’s Health Issues 18 (2008) 413– 422
Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276 –287. Reijneveld, S. A., Westhoff, M. H., & Hopman-Rock, M. (2003). Promotion of health and physical activity improves the mental health of elderly immigrants: Results of a group randomised controlled trial among Turkish immigrants in the Netherlands aged 45 and over. Journal of Epidemiology and Community Health, 57, 405– 411. Schrop, S. L., Pendleton, B. F., McCord, G., Gil, K. M., Stockton, L., McNatt, J., et al. (2006). The medically underserved: Who is likely to exercise and why? Journal of Health Care for the Poor and Underserved, 17, 276 –289. Statistics Sweden. (2006a). Befolkningsstatistiken. Available: www.scb. se/templates/Product____25785.asp. Accessed August 2007. Statistics Sweden. (2006b). Women and men in Sweden. Facts and figures 2006. Stockholm: Statistics Sweden, Forecasting Institute. Sternfeld, B., Ainsworth, B. E., & Quesenberry, C. P. (1999). Physical activity patterns in a diverse population of women. Preventive Medicine, 28, 313–323. Stockholm County Council. (2006). Statistics. The Office of Regional Planning and Urban Transportation. Available: www.rtk.sll.se/ index.htm. Accessed September 2007. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing Grounded theory. Thousand Oaks, CA: Sage. Taylor, T., & Doherty, A. (2005). Adolescent sport, recreation and physical education: Experiences of recent arrivals to Canada. Sport, Education and Society, 10, 211–238. Tudor-Locke, C., Henderson, K. A., Wilcox, S., Cooper, R. S., Durstine, J. L., & Ainsworth, B. E. (2003). In their own voices: Definitions and interpretations of physical activity. Women’s Health Issues, 13, 194 –199. U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the Surgeon General Atlanta, GA: U.S. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Vaz de Almeida, M. D., Graca, P., Afonso, C., D’Amicis, A., Lappalainen, R., & Damkjaer, S. (1999). Physical activity levels
and body weight in a nationally representative sample in the European Union. Public Health Nutrition, 2, 105–113. Vertinsky, P. (1998). “Run, Jane, run”: Central tensions in the current debate about enhancing women’s health through exercise. Women & Health, 27, 81–111. Zunft, H. J., Friebe, D., Seppelt, B., Widhalm, K., Remaut de Winter, A. M., Vaz de Almeida, M. D., et al. (1999). Perceived benefits and barriers to physical activity in a nationally representative sample in the European Union. Public Health Nutrition, 2, 153–160.
Author Descriptions Marita Södergren, MSc, is a nutritionist with a special interest in physical activity and minority women’s health. She is a doctoral candidate at the Center for Family and Community Medicine at Karolinska Institute in Stockholm. Ingrid Hylander, PhD, is a senior researcher with a special interest in qualitative methods and Grounded Theory and Associate Professor at the Department of Behavioral Sciences, Linköping University, Sweden. Lena Törnkvist, RN, PhD, is a registered district nurse with a special interest in education and development in primary health care and a researcher at the Center for Family and Community Medicine at Karolinska Institute in Stockholm. Jan Sundquist, MD, PhD, is professor and head of the Center for Family Medicine at Karolinska Institute in Stockholm. Kristina Sundquist, MD, PhD, is a family physician with a special interest in environmental factors related to health and a professor at the Center for Family Medicine at Karolinska Institute in Stockholm.
