Understanding the Association of Self-Efficacy, Mood, and Demographics with Physical Activity in Syrian and Iraqi Refugees: A Cross-Sectional Study in Jordan

Objective This cross-sectional study aimed at investigating the influence of sociodemographic factors on physical activity among Syrian and Iraqi refugees in Jordan. In addition, it sought to determine the predictive ability of self-efficacy and mood in relation to the level of physical activity in this population. Methods A convenient sample of refugees residing in Jordanian cities was collected. Participants completed a self-administered questionnaire pack consisting of a demographic data sheet, a physical activity level questionnaire, the Brunel Mood Scale, and the General Self-Efficacy Scale. Descriptive analysis was used to analyze demographic details, while the chi-square test examined the association between physical activity and demographic factors. The independent t-test assessed differences in self-efficacy and mood subscales in relation to physical activity. Logistic regression analysis was employed to identify potential predictors of the two categories of physical activity. Results Most participants reported low levels of physical activity. The frequency of moderate-to-high physical activity was higher in male participants, those with higher education, better health, and higher income. Compared to participants of low physical activity, those in the moderate-to-high physical activity category expressed significantly higher mean score of self-efficacy but lower mean scores of tension, depression, anger, vigor, fatigue, and confusion, indicating better mood. The logistic regression analysis for physical activity indicated that the model was significant for education, income, good health perception, self-efficacy, and one mood subscale (vigor), with these variables collectively accounting for 11–18% of the variance (P value <0.001). Conclusion The higher physical activity level is significantly associated with being male, higher education, higher income, better health, higher self-efficacy, and increased vigor. These findings highlight the importance of considering sociodemographic factors and psychological aspects, such as self-efficacy and mood, when addressing physical activity among refugees in Jordan.


Introduction
Te infux of Syrian and Iraqi nationals seeking refuge in neighboring countries has been steadily increasing due to political and ethnic conficts [1].In Jordan, a signifcant number of Syrian and Iraqi refugees have sought asylum, with approximately 1.4 million Syrians and 58,050 Iraqis registered with the United Nations High Commission for Refugees in 2015 [2].Tese refugees face numerous challenges, including high unemployment rates, economic insecurity, and inadequate living conditions in housing facilities provided by nongovernmental organizations [3].
Te economic and social changes experienced by Syrian and Iraqi refugees have had a profound impact on their way of life [4,5].Te adoption of a sedentary lifestyle has become prevalent among the refugee population, increasing their susceptibility to obesity, type II diabetes, and cardiovascular disorders.Promoting a healthier and active lifestyle is crucial for the well-being of both refugees and their host nations [6,7].Global research indicates a signifcant increase in the prevalence of overweight and obesity, particularly among children, who are at risk of carrying excess body fat into adulthood [8].
In Jordan, a host country with limited resources, priority is given to the treatment and care of chronic conditions, communicable diseases, and mental health disorders [9].Consequently, resources dedicated to improving physical activity and sports participation among refugees are often lacking.Refugees experience high levels of stress, which is a known risk factor for various mental disorders [10] and strongly correlates with poor mental and physical health [11], thereby impacting their quality of life [2].
Although physical activity guidelines have been established to promote better health and quality of life, many adults struggle to maintain high levels of physical activity, which becomes increasingly challenging with age [12].Individuals with chronic diseases often fnd it overwhelming to make changes to their activity levels [12].
Self-efcacy, a crucial psychosocial factor, plays a signifcant role in determining physical activity behavior.Rooted in the cognitive theory, self-efcacy refects an individual's belief in their ability to accomplish specifc goals and missions [13].It empowers individuals to overcome barriers, invest efort and time, and attain their desired objectives.Self-efcacy has a substantial impact on the adoption of physical activity [14].
To the best of our knowledge, no previous study has examined the association between sociodemographic variables, physical activity, and self-efcacy specifcally in Syrian and Iraqi refugees in Jordan.Terefore, this study aims to address this research gap and investigate the predictive abilities of mood and self-efcacy on physical activity levels within this population.

Design.
Tis study employed a secondary analysis of a previously published cross-sectional study by Amr et al. [1] to investigate the association between physical activity and demographic variables, self-efcacy, and mood among Iraqi and Syrian refugees in Jordan.In addition, logistic regression analysis was conducted to identify potential predictors of the two categories of physical activity in this population.

Sample Size.
Power analysis was conducted on the basis of an estimated population size of one million, a confdence level of 95%, and a confdence interval of 3, and it indicated that a minimum sample size of 1030 participants is required for this study.

Participants. Convenience sampling was used to recruit
Iraqi and Syrian refugees living in Jordan.Te study enrolled a total of 1038 participants.Adults aged 18 and up who had been living in Jordan as refugees for at least two months met the inclusion criteria.Tere were no withdrawals from the study.

Setting.
Participants were recruited from four Catholic churches situated in the Jordanian cities of Amman, Madaba, and Zarqa.Tese locations served as the primary settings for data collection.Unfortunately, we did not have access to refugee camps or enough resources to include refugees from these sites in the study.

Ethical Consideration.
Te current study was conducted in accordance with the Helsinki Declaration guidelines.Te Ethical Committee of the American University of Madaba (AUM) approved all procedures related to this study.All participants provided written informed consent before data collection.
2.6.Data Collection.Participants were recruited from designated church facilities providing accommodation for refugees.Te data collection period occurred over a span of three months starting from September 2017 and was conducted by trained graduate students from the Department of Nutritional Sciences at AUM. Prior to participation, each participant received a comprehensive explanation of the study's objectives and procedures.In addition, informed consent was obtained from all participants through the signing of a consent form.Participants who encountered challenges related to reading comprehension were ofered assistance to ensure accurate completion of the questionnaire.On average, participants required approximately 30-40 minutes to complete the questionnaire.

Instruments.
A self-administered questionnaire pack written in Arabic was utilized to collect data in this study.Te questionnaire pack encompassed several instruments, including a demographic data sheet, a physical activity-level questionnaire, the Arabic version of the Brunel Mood Scale (BRUMS), and the General Self-Efcacy Scale (GSE).Te demographic and clinical information obtained from participants encompassed variables such as age, gender, educational level, marital status, employment status, number of family members, medication availability, and presence of chronic illness.
To assess participants' mood, the Arabic version of the BRUMS was employed.Te BRUMS scale consists of 24 items that measure six distinct mood states (tension, depression, anger, vigor, fatigue, and confusion) [15], whereby each mood state is represented by a subscale consisting of 4 items.Respondents rate a list of adjectives based on their emotional states during the previous week or at the time of evaluation, on a 5-point Likert scale ranging from 0 to 4 (0 � not at all; 1 � a bit; 2 � moderate; 3 � enough; and 4 � extremely).Te scores for each subscale range from 0 to 16, and individual scales are assessed separately, although they are interrelated [15].

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Te Scientifc World Journal Te General Self-Efcacy Scale (GSE), a self-report measure of self-efcacy, was employed in this study [16].Te GSE consists of 10 items and is associated with emotions, optimism, and work satisfaction.Negative coefcients have been found for depression, stress, health complaints, burnout, and anxiety.Te scale assesses an individual's general sense of perceived self-efcacy and aims to predict coping with daily challenges and adaptation after experiencing stressful events.Te total score is calculated by summing all the item responses.For the GSE, the total score ranges from 10 to 40, with higher scores indicating greater self-efcacy [16].
Te questionnaire also included inquiries about participants' weekly physical activity levels.Physical activity was classifed according to the guidelines of the 2005 International Physical Activity Questionnaire [17].High-level physical activity was defned as engaging in vigorous physical activity for more than three days a week at an exercise level of 1,500 metabolic equivalent (METs) or performing more than 3,000 METs of exercise level, including walking and moderate or vigorous-intensity exercise, for more than seven days a week.Moderate-level physical activity was defned as engaging in intense activity for more than 20 minutes on more than three days a week, or performing moderate-intensity exercise, or walking for more than 30 minutes each time and more than fve days a week, or achieving 600 METs of exercise level with walking, or activity of moderate or vigorous intensity.Lowlevel physical activity was defned as not falling into either of the two aforementioned groups [18].

Data Analysis. Te Statistical Package for the Social
Sciences (SPSS) software version 21 was used for data analysis.Te demographic variables were analyzed using descriptive analysis.Te chi-square test was used to examine the association between physical activity and demographic variables.In addition, the independent samples t-test was used to examine the diferences in self-efcacy and mood across physical activity categories.Tis was followed by logistic regression to examine the possible predictors of the two categories of physical activity.1 presents the demographic characteristics of the participants.Te majority of participants fell within the age range of 18-30 years (n � 477, 46%), were married (n � 809, 77.9%), identifed as female (n � 737, 61.4%), had primary school education (n � 306, 29.5%), were unemployed (n � 904, 78.1%), reported having chronic diseases (n � 609, 58.7%), were of Syrian nationality (n � 826, 79.6%), rated their health as good (n � 625, 60.2%), were nonsmokers (n � 789, 76%), and perceived their income as poor (n � 937, 90.3%).

Diferences in Self-Efcacy and Mood Subscales across
Physical Activity Levels.Te independent t-test revealed signifcant diferences in self-efcacy and each mood subscale among participants with diferent physical activity levels, as shown in Table 2. Te mean self-efcacy score was signifcantly higher in participants who were moderately to highly active compared with low active participants.Conversely, mean scores for anger, confusion, depression, fatigue, tension, and vigor were all signifcantly lower in participants in the moderate-to-high physical activity category compared with those in the low physical activity category.

Diferences in Physical Activity Based on Demographic
Variables.Te associations between demographic variables and physical activity were assessed using the chi-square test.Table 1 presents the results, indicating that a higher percentage of male participants had moderate-to-high physical activity levels compared with females (P � 0.004).Te proportion of participants with moderate-to-high physical activity increased with higher education levels compared with lower levels of education (P � 0.001).A higher percentage of participants reporting very good health were in the moderate-to-high physical activity category compared to those perceiving their health as good or bad (P � 0.005).Furthermore, a higher percentage of participants who perceived they had enough were moderately to highly active compared to those reporting not enough income (P � 0.001).

Predictors of Physical Activity. Logistic regression
analysis was performed to identify potential predictors of the two categories of physical activity.Only factors that showed signifcant diferences or associations with physical activity were included as predictors: gender, education, sufcient income, health status, self-efcacy, and the mood subscales.Table 3 presents the results of the logistic regression analysis, indicating that the model was signifcant (P � 0.001) and accounted for 11-18% of the variance.Te signifcant predictors of higher physical activity levels among participants were male gender, higher education, sufcient income, good health status, higher self-efcacy, and higher vigor.Tese fndings suggest that being educated, having enough income, good health, higher self-efcacy, and higher vigor are all predictors of higher physical activity levels.
Te Scientifc World Journal

Discussion
Te study population consisted primarily of Syrians, comprising approximately 80% of the participants, who reported low levels of physical activity.It is well established that refugees, including the present study's population, face challenges in maintaining an active lifestyle comparable to their home countries.Te fndings of this study revealed a signifcant disparity in activity levels between genders, with approximately 23% of males exhibiting moderate-to-high activity levels compared with only 16% of females.Tis gender diference aligns with the results reported by Teresa M Bianchini de Quadros et al. in their 2009 survey, which investigated sociodemographic factors infuencing the physical activity and found higher levels of inactivity among females [19].Several factors may contribute to this disparity, including the social environment in which women live, which may be less conducive to physical activity compared with men.In addition, Muslim women refugees encounter various obstacles and difculties in adopting active lifestyles due to traditional cultural norms.Female refugees often bear the responsibility of caring for family members, including children and other women, further complicating their ability to engage in regular physical activity.Consequently,  4 Te Scientifc World Journal maintaining adequate levels of physical activity poses signifcant challenges for females in this vulnerable population, potentially accounting for the observed gender diferences.Notably, it has been observed that men tend to overestimate their level of physical activity participation compared with women [20].Intriguingly, participants with higher education levels (secondary school and university) demonstrated greater levels of physical activity compared with those with lower educational attainment (participants below secondary levels).Tese fndings are consistent with previous research.For instance, Kaplan et al. investigated a cohort of 12,611 Canadian individuals aged 65 years and above, recruited from the Canadian National Population Health Survey, and identifed several factors associated with habitual physical activity, including gender (male), younger age, higher education levels, absence of chronic conditions, and lower body mass index.Interestingly, they also reported a positive correlation between lower psychological distress, as measured by the Generalized Distress Scale, and habitual physical activity [21].Similarly, Kaplan et al. [21] found that a greater number of participants engaged in moderateto-high activity levels among those reporting sufcient income.Our study's fndings align with previous research conducted in Korea, where individuals residing in lowincome households faced greater challenges in engaging in physical activity compared with those in higher-income households.Tis disparity can be partly attributed to environmental and social barriers, such as limited access to sports facilities, transportation services, and free time constraints [22].In Jordan, Syrian and Iraqi refugees residing in crowded housing camps with limited access to sports and recreational facilities further exemplify the impact of socioeconomic status on physical activity levels.Importantly, many studies have reported that socioeconomic status (SES) correlates with physical activity [23,24].Factors such as engagement in manual and industrial labor, lower income, lower literacy, and educational levels have consistently been associated with lower levels of physical activity [24].Various explanations have been proposed for the lower physical activity levels observed among individuals with low socioeconomic status.Tese include limited availability of parks and recreational facilities in their communities, fnancial constraints hindering the purchase of home exercise equipment, lack of social encouragement and support for leading physically active lifestyles, and limited knowledge about the health benefts of physical activity [25].In addition, individuals with lower income levels and low socioeconomic status may have limited opportunities to receive advice from healthcare professionals regarding preventive health measures and the importance of maintaining physical ftness and activity [26].Poor socioeconomic status has been correlated with lower compliance and adherence to clinical exercise programs, such as medical rehabilitation programs, which can be attributed to factors such as limited work fexibility, fnancial difculties, and the costs associated with healthcare coverage [27].
Te present study revealed a signifcant association between participants' health perception and their engagement in moderate-to-high levels of physical activity.Specifcally, a higher number of participants with a very good health perception reported being actively involved in physical activity compared with those with good or poor health perceptions.Notably, individuals with poor health perception, particularly older adults, faced the greatest obstacles in adhering to exercise routines [28].
Furthermore, a logistic regression model was employed in our study to examine the relationship between physical activity and mood.Surprisingly, none of the mood subscales emerged as strong predictors of physical activity, except for the subscale of vigor, which exhibited substantial predictive power.Tese fndings align with previous research conducted in Minneapolis, where a longitudinal study on 213 obese individuals demonstrated that an increase in energy expenditure was positively associated with an increase in vigor over a relatively short period of time (6 months).Moreover, exercise was found to be a signifcant predictor of both vigor and fatigue [29].Similarly, Werneck and Navarro Te Scientifc World Journal [30] explored the relationship between the physical activity level and mood in a sample of 41 adolescents (boys and girls) and discovered a benefcial efect of physical activity on total mood disorder and vigor.Te study revealed that higher levels of physical activity were associated with a stronger correlation with vigor [30].
Te present study employed a logistic regression model to investigate the predictive factors of physical activity, and the results indicated that self-efcacy played a substantial role in determining physical activity levels.Tis fnding is consistent with previous research in this feld.Resnick and D'Adamo [31] examined a group of 163 older adults residing in a retirement community and found a direct association between self-efcacy, negative outcome expectations, and exercise behavior [31].Similarly, a study conducted by White et al. [32] on middle-aged and older adults over an 18month period demonstrated that self-efcacy infuenced physical activity directly as well as indirectly through outcome expectations, another construct of social cognitive theory (SCT) [32].Across various time periods, self-efcacy consistently emerged as the strongest predictor of physical activity levels.Numerous empirical studies have emphasized the signifcant role of self-efcacy in adolescents' engagement in physical activity, with self-efcacy to overcome barriers to physical activity being a key predictor [33,34].In addition, a comprehensive review of determinants of physical activity in adolescence identifed a signifcant and positive correlation between self-efcacy and physical activity in 28 studies [35].It is worth noting that the relationship between self-efcacy and physical activity is complex, as other constructs of social cognitive theory, such as self-regulation and management, may mediate this efect [36].Furthermore, research has revealed that individuals with low self-efcacy levels exhibit higher physical activity levels when they engage more frequently in preparatory behaviors [37].In the logistic regression model used, the signifcant variables examined in this study, namely, education, income, good health perception, self-efcacy, and one mood subscale (vigor), collectively accounted for 11-18% of the variance.
Although this is the frst study to report the relationship between mood and self-efcacy with physical activity, it has limitations.Tis study is observational, and hence, causation may not be established.In addition, our inability to recruit participants from refugee camps may have introduced selection bias.However, our fndings are still relevant to at least a portion of refugees in Jordan and are consistent with the literature.
In conclusion, this study established statistically significant associations between gender, education level, income, health status, self-efcacy, and mood subscales with physical activity levels among Syrian and Iraqi refugees in Jordan, whereby being male and having higher education, higher income, better health, higher self-efcacy, and increased vigor correlated with higher physical activity.Tese fndings highlight the importance of considering sociodemographic factors and psychological aspects, such as self-efcacy and mood, when addressing physical activity among refugees in Jordan.[38].

Table 1 :
Association between physical activity and demographical factors.

Table 2 :
Diferences in self-efcacy and mood based on the physical activity level.

Table 3 :
Logistic regression for physical activity.