UAE Women’s Knowledge and Attitudes towards Physical Activity during...

[Full title: UAE Women’s Knowledge and Attitudes towards Physical Activity during Pregnancy]

Citation: AlBlooshi, S.; Hijazi, R.; Kennedy, L.; Al Rajabi, A. UAE Women’s Knowledge and Attitudes towards Physical Activity during Pregnancy Int. J. Environ. Res. Public Health 2023 , 20 , 6669. https:// doi.org/10.3390/ijerph 20176669 Academic Editor: Linda G. Kahn Received: 11 June 2023 Revised: 29 July 2023 Accepted: 1 August 2023 Published: 29 August 2023 Copyright: © 2023 by the authors Licensee MDPI, Basel, Switzerland This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/) International Journal of Environmental Research and Public Health Article UAE Women’s Knowledge and Attitudes towards Physical Activity during Pregnancy Sharifa AlBlooshi 1 , Rafiq Hijazi 2 , Lynne Kennedy 3, * and Ala Al Rajabi 3,4 1 Department of Health Sciences, College of Natural and Health Sciences, Zayed University, Dubai P.O. Box 19282, United Arab Emirates; sharifa.alblooshi@zu.ac.ae 2 Department of Mathematics and Statistics, College of Natural and Health Sciences, Zayed University, Abu Dhabi P.O. Box 144534, United Arab Emirates; rafiq.hijazi@zu.ac.ae 3 Department of Health Sciences, College of Natural and Health Sciences, Zayed University, Abu Dhabi P.O. Box 144534, United Arab Emirates; ala.rajabi@zu.ac.ae 4 Department of Human Nutrition, College of Health Sciences, Qatar University, Doha P.O. Box 2713, Qatar * Correspondence: lynne.kennedy@zu.ac.ae Abstract: The benefits of being physically active during pregnancy are widely acknowledged. It is important for the prevention of chronic diseases and the promotion of good health for mothers and children. However, physical activity by women in the UAE is notoriously low and reduced further during pregnancy. The same can be said regarding research about the knowledge and understanding of the benefits and risks associated with exercise as a predictor of behavior. We aimed to assess knowledge and attitudes towards physical activity during pregnancy amongst Emirati women A cross-sectional digital survey was designed to assess knowledge and attitudes and distributed to women, aged 18–40 years, using non-randomized, purposeful snowball sampling. A total of 1538 women were recruited. Most participants were aged 20–29 years (53.5%), were Emiratis (88.9%), and had no history of chronic disease (68.6%). The participants self-reported very low levels of PA (75.5%) and had a below-average level of knowledge overall (40.6 ± 20). Younger ages ( p < 0.001), lower educational levels ( p = 0.004), being employed ( p = 0.014), and having a history of chronic disease ( p = 0.016) were significantly associated with lower mean knowledge scores, while being married ( p = 0.003) was significantly associated with higher scores. The participants also exhibited a positive attitude towards physical activity during pregnancy by selecting answers that they supported it. To encourage physical activity, women living in the UAE could benefit from clear advice about safe physical activity during pregnancy Keywords: physical activity (PA); United Arab Emirates; women; knowledge; attitudes; mothers; pregnancy 1. Introduction The benefits of physical activity (PA) during pregnancy are clear. Remaining physically active during pregnancy can help reduce backaches, relieve constipation, improve heart health, and aid in maintaining a healthy weight [ 1 ]. In contrast, physical inactivity during pregnancy is reportedly linked to several risk factors and adverse health outcomes for mother and baby; being inactive increases the risk of maternal obesity, which has been associated with increased risk of premature birth, emergency cesarean sections, and preeclampsia [ 2 , 3 ]. In addition, gestational diabetes mellitus (GDM), a condition in which hormones from the placenta block the body from successfully utilizing insulin, is more likely to develop in pregnant women who are physically inactive. GDM increases the women’s chance of having a c-section, experiencing severe respiratory problems that may cause complications for surgery, and having greater future risk of acquiring type 2 diabetes [ 3 ] The prevention of GDM is critical in the UAE, a region with one of the highest and still rising levels of type 2 diabetes amongst the adult population and above-average GDM [ 4 ]. Int. J. Environ. Res. Public Health 2023 , 20 , 6669. https://doi.org/10.3390/ijerph 20176669 https://www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 2 of 18 According to both the WHO and the American College of Obstetricians and Gynecologists (ACOG) guidelines, all pregnant and postpartum women without contraindication should aim for at least 150 min of moderate-intensity physical activity each week, even if they were inactive before pregnancy [ 1 , 5 ]. The advice varies depending on prior fitness, general health, and participation in physical activity [ 2 ]. Current guidance on physical activity during pregnancy recommends that women who are determined by a physician to be fit and healthy and were physically active before their pregnancy should remain active at safe levels during the three trimesters. Raising awareness and knowledge about the importance of physical activity for pregnant women is of great importance to help minimize health risks to mothers and their children The majority of women are aware that exercise and physical activity is encouraged during pregnancy, and yet despite this most do not partake in or actively avoid physical activity whilst pregnant. Several studies have shown that despite being aware of the benefits of exercise, most women lack information or confidence in their knowledge about the risks associated with physical inactivity during pregnancy [ 6 – 11 ]. Furthermore, some have suggested that physical activity decreases further or stops entirely with pregnancy [ 6 , 7 , 12 , 13 ]. In the past 50 years, following the discovery of oil, the UAE has transitioned from the Bedouin culture based on pastoralism and farming, traditional to the Middle East and North African (MENA) region, to a wealthy, highly industrialized, and heterogeneous society. Though traditional cultural values and pastimes remain strong, most Emiratis no longer engage in manual work, have hired help, and follow modern, sedentary lifestyles in the cities. Though research into the physical activity levels of Emiratis is scant, surveys have shown that daily PA levels are very low. Even less is known about the PA levels of pregnant women [ 14 – 18 ]. Research has suggested that limited or lack of knowledge or confidence in and interpretation of the scientific guidelines for exercising safely during pregnancy may be important factors mediating PA levels amongst pregnant women [ 11 – 16 ]. For most pregnant women, there is no additional risk of miscarriage from engaging in regular physical activity during an uncomplicated pregnancy [ 2 , 15 ]. Women have expressed a lack of detailed understanding of the advice, for example, regarding the types of exercise considered safe and suitable during pregnancy [ 12 ]. Theoretical models, such as the Theory of Planned Behavior (TPB), have helpfully been used to shed light on this important contradiction in studies of PA behavior among pregnant women, albeit in non-Arab populations. Several studies highlighted intention to be physically active as a strong predictor of PA-related behavior and attitude as a strong predictor of intention [ 17 – 19 ]. These studies also concluded that women adopted more positive attitudes, subjective norms, and intentions towards resting, i.e., increasingly sedentary behavior, as their pregnancy progressed [ 17 , 18 ]. Thus, interventions that encourage regular PA may want to focus on early antenatal periods or earlier Furthermore, several factors were found to influence women’s motivation or willingness to participate in physical activity during pregnancy. Firstly, there is the perceived difficulty or ease of participating in regular exercise while pregnant. Secondly, there are the social norms of the community they live in. Finally, women who had been participating in regular physical activity prior to their pregnancy were more likely to continue exercising while pregnant [ 19 ]. Understanding women’s attitudes, opinions, beliefs, and knowledge about PA during pregnancy as well as encouraging a supportive community may assist in the development of effective interventions promoting PA during pregnancy With many women acknowledging that regular PA is beneficial for health, they also believe that physical activity may increase complications and the risk of miscarriage [ 13 ]. For most pregnant women, the actual risk of miscarriage from engaging in ‘regular’ physical activity is relatively low [ 2 ]. However, perceived risk is likely to be relatively high due to the perceived severity of the outcome, i.e., miscarriage and loss, and this may therefore inhibit any risk-taking behavior during pregnancy. Downs and Hausenblas [ 17 ] and Newham et al. [ 18 ] concluded that women in their respective studies adopted more positive attitudes, subjective norms, and intentions towards resting, i.e., increasingly seden-

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 3 of 18 tary behavior, as their pregnancy progressed. Additionally, attitudes towards PA during pregnancy were the strongest determination of intention. Thus, interventions that encourage regular PA may want to focus on early ante-natal periods or earlier. Understanding the attitudes, opinions, beliefs, and knowledge about PA during pregnancy may assist in the development of effective interventions promoting PA during pregnancy We know that social and cultural traditions are resistant to shortand medium-term change and are therefore more difficult to influence and change [ 20 ]. Notwithstanding this, providing greater clarity in the advice around physical activity and safety guidelines may realistically be achieved and help increase women’s knowledge and confidence to be physically active during pregnancy. In countries and regions where levels of physical activity amongst women are already below the recommended levels, avoiding further reductions due to pregnancy is an important public health goal. For women already physically active, greater clarity of the advice around safe exercising during pregnancy may have additive benefits, helping improve maternal and child health. To inform such developments, we first need to clearly understand women’s current levels of knowledge and attitudes towards physical activity during pregnancy in Arab countries such as the UAE This study aims to investigate the knowledge and attitudes of women living in the UAE, towards physical activity during pregnancy, to assess the need for targeted interventions 2. Materials and Methods 2.1. Study Design This study aims to investigate how much women living in the UAE know about physical activity during pregnancy in terms of both risks and benefits and their attitudes on whether or not they are willing to participate in physical activity during pregnancy. This knowledge can be used to assess the need for targeted interventions. We have conducted a quantitative cross-sectional study across the seven Emirates of the country: Abu Dhabi, Dubai, Sharjah, Ajman, Umm Al Quwain, Fujairah, and Ras Al Khaimah, and the data were collected from August 2021 to December 2021 2.2. Sampling In this study, we have recruited 1537 women from different emirates in the UAE; we used non-probability convenience snowball sampling; and data were collected using an electronic survey that was distributed to the participants via email, WhatsApp, Instagram, and Snapchat. The inclusion criteria were being female, capable of proving consent, able to read and write in English or Arabic, living in the UAE, and being 18 years and older. The exclusion criteria were women below 18 years of age who are not living in the UAE and those who declined participation. Having a previous or chronic health condition was not an exclusion criterion 2.3. Data Collection Data were collected through a structured electronic survey. The questions regarding the physical activity knowledge were adapted from a self-administered questionnaire, tested, and validated earlier then modified to match the study’s purposes taking into consideration the WHO guidelines [ 21 , 22 ]. The PA and exercise were defined to the participants as per the WHO guidelines “bodily movement produced by skeletal muscles that results in energy expenditure” [ 5 ]. A semi-structured online (digital) questionnaire was designed using Google Forms, to collect data. The survey consisted of 20 questions in two parts. The first included ( n = 9) questions regarding socio-demographic data (e.g., age, education level, marital status, nationality, age, health status, and employment status). The second part included ( n = 11) questions regarding knowledge, attitude, and practice of physical activity (e.g., benefits of physical activity during pregnancy, types, harmful, and situational barriers to physical activity). It was initially created in English before being translated into Arabic; then, it was reviewed by the authors and pilot-tested on 20 participants for face validity.

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 4 of 18 2.4. Data Analysis Statistical analysis was performed using IBM SPSS Statistics 28 (IBM, Armonk, NY, USA). Frequencies and percentages were used to summarize demographic, health-related, and physical activity variables. Independent samples t-test and One-Way Analysis of Variance (ANOVA) were utilized to compare participants’ knowledge on physical activity during pregnancy based on their demographic characteristics. A multiple linear regression model was developed to identify the factors associated with the physical activity knowledge of participants. Finally, the Chi-Square Test of Independence was used to test the association of demographic, health, and physical activity characteristics of participants with their attitudes toward physical activity during pregnancy p -Values less than 0.05 were considered statistically significant A knowledge index was created using the 14 knowledge items. All items were given equal weight, and for each item, the correct response was coded as 1, while the wrong one was coded as 0. The response codes for each woman were added to generate a score for that woman, and the score ranged from 0 to 14 as there were fourteen knowledge items The results were calculated out of 100 after converting it to a 100 percent scale for more effortless reading by dividing the score of each item by 14 and then multiplying the result by 100 The regression model was used to further analyze the correlation of the knowledge about PA during pregnancy among women in UAE. The model was developed using potential factors such as current PA activity and medical history while controlling for sociodemographic characteristics of the participating women 2.5. Ethical Considerations The study was designed and implemented according to the ethical standards of Zayed University. Ethical approval was granted by the College of Natural and Health Sciences (CNHS), Ethics Application Code ZU 21_061_F. Before starting the survey, participants were provided with an informed consent form that clarified the purpose of the study, what was expected of the participants, and contact information. Participants were advised that the survey was voluntary and that they had the right to withdraw at any stage of the study. Confidentiality and anonymity were assured throughout the study. Participants were not harmed during the study process, and no significant ethical issues resulting from participation were identified 3. Results 3.1. Demographic Characteristics The questionnaire was completed by 1537 women aged 18–40 years, residing in the United Arab Emirates. Table 1 displays the women’s demographic characteristics. Most (53.5%) of the participants were aged 20–29 years, were Emiratis (88.9%), were residing in Abu Dhabi (48.1%), were residing in urban areas (88.0%), were married (82.1%), held a bachelor’s degree (40.3%), and were unemployed (59.7%) Table 1. Demographic information of the study population ( n = 1537 women) Categories Frequency Percentage Age (years) 18–20 105 6.8% 20–29 821 53.5% 30–39 359 23.4% 40+ 251 16.3% Nationality Non-Emirati 170 11.1% Emirati 1367 88.9% Emirate Abu Dhabi 739 48.1% Dubai 496 32.3% Northern Emirates 302 19.6%

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 5 of 18 Table 1. Cont Categories Frequency Percentage Residential area Rural 184 12.0% Urban 1353 88.0% Marital status Married 1262 82.1% Divorced/Widowed/Separated 275 17.9% Educational level Less than High School 97 6.3% High School Degree 541 35.2% Bachelor’s degree 787 51.2% Master or PhD Degree 112 7.3% Employment status Employed (Full-time, Part-time, Self-employed) 620 40.3% Unemployed (Student, Retired, Housewife) 917 59.7% 3.2. Medical History and Physical Activity Table 2 shows that most participants had no history of chronic disease at 68.6%. The most common chronic diseases were migraine headaches (7.6%) and diabetes (7.1%). Other chronic diseases including cardiovascular disease, cancer, hypertension, kidney disease, arthritis, parathyroid, hypothyroid, gastrointestinal disease, asthma, and respiratory disease affected between 2.0% to 5.7% of participants. Most of the participants reported various levels of physical activity: 1–2 times/week (40.5%), 3–5 times/week (19.5%), and daily (5.4%), while 35.0% of participants reported being inactive or rarely active. In addition, among the participants, 23.8% were pregnant, and 13.3% were breastfeeding Table 2. Medical history and physical activity among study population ( n = 1537 women) Category Frequency Percentage Chronic diseases N % Cardiovascular diseases 30 2.0% Diabetes 109 7.1% Cancer 43 2.8% Asthma and respiratory diseases 87 5.7% Hypertension 79 5.1% Kidney diseases 34 2.2% Arthritis 55 3.6% Migraine headaches 117 7.6% Parathyroid 36 2.3% Hypothyroid 76 4.9% Gastrointestinal diseases 69 4.5% Has a medical history of chronic disease N % No 1054 68.6% Yes 483 31.4% Current physical activity N % Never and rare 538 35.0% 1–2 times per week 623 40.5% 3–5 times per week 293 19.1% Daily 83 5.4% Breastfeeding or Pregnant N % Breastfeeding 205 13.3% Pregnant 366 23.8% Neither 864 56.2%

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 6 of 18 3.3. Participants’ Knowledge toward Physical Activity during Pregnancy To assess knowledge on physical activity during pregnancy, participants were asked two “select all that apply” questions (Recommended physical activity during pregnancy. Benefits of physical activities during pregnancy) and a single “agree/disagree” question (Some types of physical activity should be avoided during pregnancy; Table 3 ). All options included in the “select all that apply” questions and the “agree” response were correct Table 3. Participants’ knowledge about physical activity during pregnancy Categories Frequency Percentage Recommended physical activity during pregnancy N % Swimming 480 31% Walking 1222 80% Running 176 11% Yoga 17 1% Some types of physical activity should be avoided during pregnancy 1200 78% Benefits of physical activities during pregnancy (tick more than 1) N % Weight gain management 578 38% Cardiovascular system enhancements 778 51% Musculoskeletal improvements and bone strengthening 772 50% Better sleeping patterns 632 41% Decreased risk of gestational diabetes 924 60% Improves respiratory function 564 37% Decreased risk of gestational hypertension 679 44% Enhance Endocrine and gastrointestinal system 387 25% Increased amniotic fluid 327 21% Table 3 lists frequencies and percentages of participants who selected the correct response to a question. When asked “Which type of physical activity is recommended during pregnancy”, 80% of participants selected walking; 31% selected swimming; 11% selected running; and only 1% selected yoga. A total of 78% agreed that some types of physical activity should be avoided during pregnancy In addition, many participants believed that physical activity during pregnancy decreases the risk of gestational diabetes (60%), enhances the cardiovascular system (51%), and strengthens the musculoskeletal system (50%). In addition, less than half agreed that physical activity during pregnancy decreases the risk of gestational hypertension (44%), provides better sleeping patterns (41%), helps manage weight gain (38%), and improves respiratory function (37%). Finally, only 25% believed that it enhances the endocrine and gastrointestinal systems, and 21% believed it increases amniotic fluid 3.4. Knowledge Index among Women in the UAE As per the literature review, it has been demonstrated that a scoring system for the questions that assess participants’ knowledge of physical activity best suits this study. A knowledge index was created using the 14 knowledge items in Table 3 . Overall, the mean knowledge of the participants was 40.6 ± 20.1 with the maximum score being 92.9 and the minimum score being 7.1. This indicates a below-average level of knowledge overall. Table 4 shows the mean knowledge index scores according to demographic characteristics. Older age ( p < 0.001), being married ( p < 0.001), higher educational attainment ( p < 0.001), and absence of chronic disease history ( p = 0.004) are all significantly associated with higher knowledge index scores.

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 7 of 18 Table 4. Regression analysis of knowledge index by demographic characteristics Unadjusted Comparison a Regression b N Mean SD p -Value Coefficient p -Value Age (years) <0.001 18–20 105 34.35 19.51 <0.001 − 10.34 <0.001 20–29 821 39.93 19.82 − 5.67 <0.001 30–39 359 41.35 20.07 − 3.70 0.025 40+ 251 44.39 20.79 Ref Nationality Emirati 1367 40.93 20.21 0.064 1.76 0.281 Non-Emirati 170 37.90 19.36 Ref Emirate 0.787 Abu Dhabi 739 40.77 19.96 0.603 0.77 0.574 Dubai 496 40.97 20.66 1.00 0.500 Northern Emirates 302 39.57 19.70 Ref Residential Area Urban 1353 40.70 20.17 0.581 − 0.25 0.874 Rural 184 39.83 19.90 Ref Marital status Married 1262 41.67 20.01 <0.001 4.19 0.003 Divorced/Widowed/Separated 275 35.66 19.99 Ref Educational Level 0.004 Less than High School 97 33.51 17.35 0.001 − 8.13 0.004 High School Degree 541 39.64 19.81 − 2.21 0.307 Bachelor’s Degree 787 41.91 20.33 − 0.42 0.837 Masters or PhD Degree 112 42.16 21.20 Ref Employment status Employed (Full-time, Part-time, Self-employed) 620 39.55 20.10 0.093 − 2.70 0.014 Unemployed (Student, Retired, Housewife) 917 41.31 20.13 Ref Medical History Yes 483 38.42 20.12 0.004 − 2.72 0.016 No 1054 41.60 20.06 Ref Current physical activity 0.107 Never and rare 538 39.95 19.96 0.188 − 4.86 0.038 1–2 times per week 623 40.11 19.70 − 4.12 0.076 3–5 times per week 293 41.78 20.57 − 2.39 0.332 Daily 83 44.32 22.55 Ref a . The associations between participants’ knowledge on physical activity during pregnancy with their sociodemographic characteristics were assessed by using independent samples t -test (significance at p < 0.05) b . The associations between participants’ knowledge on physical activity during pregnancy with their sociodemographic characteristics were assessed by using One-Way Analysis of Variance (ANOVA) (significance at p < 0.05) The regression model was used to further analyze the correlates of the knowledge about PA during pregnancy among women in the UAE. The model was developed using potential factors such as current PA activity and medical history while controlling for sociodemographic characteristics of the participating women. The results are illustrated in Table 4 . Being younger in age ( p < 0.001), having a lower educational level ( p = 0.004), being employed ( p = 0.014), and having a history of chronic disease ( p = 0.016) were significantly associated with lower mean knowledge score, while being married ( p = 0.003) was significantly associated with higher scores.

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 8 of 18 3.5. Attitudes toward Physical Activity among Women during Pregnancy Table 5 shows the attitudes of participants toward physical activity during pregnancy Overall, participants exhibited a positive attitude toward physical activity during pregnancy. A total of 90.9% of the participants agreed that physical activity benefits both the mother and the child. Some 80.8% agreed that mothers without pregnancy complications should begin PA program during pregnancy. Furthermore, 85.6% concurred that pregnant women who used to be physically active should be encouraged to continue an exercise program throughout pregnancy. On the other hand, 69.7% disagreed that physical activity during pregnancy increases the risk of low-birth-weight babies. Finally, 70.7% concurred that the possible harmful effects of physical activity during the pregnancy on the fetus are minimal or non-existent Table 5. Attitudes toward physical activity among women during pregnancy Strongly Agree Agree Disagree Strongly Disagree Frequency (%) Frequency (%) Frequency (%) Frequency (%) Physical activity during pregnancy is beneficial for both mothers and infants 637 (41.4%) 761 (49.5%) 103 (6.7%) 36 (2.3%) A woman without complications during pregnancy should not begin an exercise program during pregnancy 172 (11.2%) 123 (8.0%) 855 (55.6%) 387 (25.2%) Pregnant women who used to exercise should be encouraged to continue an exercise program throughout pregnancy 565 (36.8%) 750 (48.8%) 187 (12.2%) 35 (2.3%) Physical activity during pregnancy increases the risk of a low birth weight 174 (11.3%) 291 (18.9%) 930 (60.5%) 142 (9.2%) The possible harmful effects of physical activity during the pregnancy on the fetus are minimal or non-existent 282 (18.3%) 805 (52.4%) 390 (25.4%) 60 (3.9%) Each attitude item was compared to demographic characteristics, as seen in Tables A 1 – A 5 . In Table A 1 , regarding the statement “Physical activity during pregnancy is beneficial for both mothers and infants”, those who were older women ( p < 0.001), were married ( p < 0.001), had a high education level ( p < 0.001), and had no chronic diseases ( p < 0.001) were more likely to strongly agree or agree with this statement. In Table A 2 , considering the statement “A woman without complications during pregnancy should not begin an exercise during pregnancy”, women from Abu Dhabi ( p < 0.001) were more likely to strongly agree or agree with this statement In Table A 3 , about the statement “Pregnant women who used to exercise should be encouraged to continue an exercise or PA program throughout pregnancy”, those who were older women ( p < 0.001), were from Abu Dhabi ( p < 0.001), were married ( p < 0.001), had a high education level ( p < 0.001) and had no medical history ( p = 0.001) were more likely to strongly agree or agree with the statement In Table A 4 , concerning the statement “Physical activity during pregnancy increases the risk of a low birth weight”, those who were unmarried ( p < 0.001), were employed ( p = 0.001), and had a high education ( p = 0.001) level were more likely to strongly agree or agree with this statement. In Table A 5 , regarding the statement “The possible harmful effects of physical activity during the pregnancy on the fetus are minimal or non-existent”,

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 9 of 18 women from Abu Dhabi ( p < 0.001) were more likely to strongly agree or agree with this statement 4. Discussion The present study has examined current levels of awareness, knowledge, and practice regarding safe engagement in physical activity during pregnancy among Emirati women living in the UAE. Since it is widely accepted that many factors mediate KAP (Knowledge, Attitude, and Practices), studies aimed at understanding or moderating KAP should also be socially and culturally situated. To the best of our knowledge, this is one of two published studies on this issue in this population group and social and cultural context. Furthermore, this study is the first to include women from all seven Emirates of the UAE. Data were collected from 1537 women who completed the online survey, and the majority (88.9%) self-identified as Emirati, which is a key strength of the current paper, with most of the women (80%) residing in Abu Dhabi (48%) or Dubai (32.3%), the two most populated of the seven Emirates. The remaining 20% were recruited from the minor emirates; nearly all respondents (88%) lived in urban as opposed to rural areas. As the section below indicates, we were able to describe differences according to pregnancy; however, future studies might also collect details about parity and trimester of pregnancy to enable us to examine the influence of this on KAP 4.1. Physical Activity Levels Adopting regular physical activity during pregnancy improves health and well-being, results in safer birthing, and protects against excessive gestational weight gain, avoiding manifestations such as gestational hypertension or diabetes [ 5 ]. Women participating in the present study self-reported very low levels of PA. The majority (75.5%) rated their current activity as ‘rarely’, i.e., occasional (35%) or only 1–2 times/week (40.5%), and only 1 in 20 (5.4%) women reported daily engagement in PA, suggesting as a population, women residing in the UAE are extremely sedentary and inactive. Our findings support recent surveys indicating that physical activity levels are low in the Arab region, including the UAE [ 13 – 15 ]. This situation has not changed considerably over time, as indicated by earlier surveys of PA undertaken in the UAE [ 23 – 25 ]. Reports also suggest that levels tend to be particularly low among women [ 13 – 15 , 25 ]. Moreover, as the study of PA knowledge and practice among Emirati women living in Dubai [ 26 ] reported, the majority (87.9%) of the women in their study were classified, based on objective assessment using the validated PPAQ, as engaging in light sedentary activity, i.e., being inactive; moreover, sitting or watching TV were cited as the women’s preferred activity, especially when pregnant International guidance strongly recommends that most women should continue with or engage in regular physical activity (PA) during pregnancy, and those who previously participated in sports, exercise, or regular physical activity should try to maintain this under the supervision and guidance of their physician or maternity care providers, since most forms may be continued safely. Despite this recommendation, our findings suggest that participation in regular PA by Emirati women may decline or stop completely with pregnancy. We also posit that women in the UAE are becoming increasingly sedentary. This claim is supported by a recent objectively quantified study of physical activity and sedentary behavior in a young UAE population [ 15 ]. Thus, as energy expenditure is drastically reduced and energy intake, especially during pregnancy, continues to exceed requirements, women in the UAE are likely to face rising risks of gestational obesity and its complications 4.2. Factors Influencing PA In order to influence and encourage regular PA amongst Emirati women, a better understanding of why PA levels are low is needed. With respect to all lifestyle behavior, levels of PA are compounded by specific social and cultural factors [ 26 ].

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 10 of 18 A high proportion (83.7%) of the women in our sample were aged between 18 and 40 years and of reproductive age, with most women aged between 20 and 29 years (53.5%) with 23.4% aged 30–39 years. Also, most women were married (82%), representing local cultural traditions. Since the UAE was established in 1971, it has undergone rapid social and economic change, facilitated by many successful government initiatives designed to protect the indigenous population and promote Emiratization, including the promotion of women in the workplace and participation in higher education. Thus, not surprisingly, many (40%) of the women surveyed reported being in full or part-time employment, with those women who are studying included in the unemployed (59.7%) (studying, retired, or staying at home), whilst overall, a relatively high proportion of respondents (40%) were in receipt of a high school degree or bachelor’s degree. Although cultural traditions in support of marriage appear to remain strong in this region, only a third were currently pregnant or lactating (23.8% self-identified as pregnant with a further 14% breastfeeding), suggesting that whilst marriage remains traditional and valued in the UAE, this is no longer as strong a predictor of childbirth. As national statistics highlight, the number of births per family has and continues to fall sharply [ 27 ]. So, although birth rates are decreasing, the individual and societal costs of sedentary behavior amongst pregnant women are rising, placing an unnecessary burden on the health system. Furthermore, despite this, a recent study on UAE women [ 26 ] reports that educational attainment, age (i.e., being younger), and parity (having fewer children) may still positively mediate PA during pregnancy in this region. Since marriage, parity, and education appear to mediate PA practice amongst women during pregnancy, future research might focus on better understanding the role of socio-demographic factors over time and in this rapidly changing context Our study points to low levels of physical activity amongst Emiratis during pregnancy and is consistent with published reports claiming Arab and UAE populations, especially women, are disinterested in exercise and prefer sedentary practices [ 14 , 27 – 29 ]. Similarly, a recent systematic review of the contextual barriers to PA during pregnancy [ 30 ], undertaken in the Middle East and North African (MENA) region, also emphasized the importance of environmental factors, including lack of time (due to homemaking), absence of social support, tiredness, and lack of knowledge and information from healthcare providers as relevant factors mediating PA generally and during pregnancy in a similar geographic area. However, since our study was not aimed at exploring specific factors hindering inactivity, we refer to relevant research undertaken in the region to interpret our findings Regardless of positive behavioral intention, low levels of PA among women in the region can be attributed to the inhospitable climate, which prevents people from being active and increases sedentary behavior (labor, transportation, or leisure time), especially outdoors. A comprehensive systematic review of PA levels reports that the UAE climate is a major barrier to PA, especially the intense heat of the summer months (June–September), when outdoor temperatures exceed 40 degrees Celsius [ 28 ]. Others indicate gender-specific barriers; for example, the lack of female-only facilities [ 14 , 15 , 27 – 29 ]. This concurs with studies of attitudes towards PA amongst women living in the region (e.g., [ 7 , 13 , 24 , 29 ]). It should be noted that the UAE is a country of rapid economic and social transition Since 1971, the UAE has experienced unprecedented industrialization, and the social context has changed considerably; therefore, earlier studies into the barriers and enabling factors (i.e., Geeber and Person [ 30 ]) may no longer be relevant. For example, the general accessibility and affordability of opportunities to engage in PA, even during the summer, has increased dramatically, as the number of indoor and air-conditioned gyms and walking and cycling arenas has increased beyond recognition. Dress codes have also relaxed including sportswear designed to meet modesty and Hijab (faith) requirements, whilst attitudes towards PA appear to be changing for the better, especially since major sporting events such as the 2022 World Cup have been increasingly hosted in this region. This is consistent with the study by Harrison and colleagues [ 31 ], in their systematic review of attitudes towards PA during pregnancy. Further research, especially qualitative studies, is needed to better understand the social and cultural nuances associated with barriers and enabling

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 11 of 18 factors for PA amongst pregnant Emirati women. Future health promotion campaigns for awareness raising or health education might usefully target younger, unmarried, and employed groups. This recommendation resonates with other research, whereby genderspecific social marketing campaigns may be more effective in overcoming real or perceived lack of support or accessibility to PA facilities and cultural norms that place low value on female participation in sports and physical activity [ 31 – 33 ]. Consistent with other research, we acknowledge the increasing attention on the role of the physical environment. In particular, accessing opportunities for PA is very important for encouraging increased participation in PA, especially the engagement of females and women of childbearing age in this region. Special consideration on the cultural values of this region, and the climate should also be considered [ 34 ] when policies aimed at increasing PA levels are developed 4.3. Knowledge of the Health Benefits of PA It is widely acknowledged that knowledge and beliefs relating to the benefits or risks associated with health-related behavior positively mediate behavioral intention and practice. When asked whether regular exercise or PA was safe during pregnancy, one-third (36.6%) agreed it was ‘not harmful’, i.e., safe. When asked about which type of physical activity is recommended during pregnancy, the majority (78%) agreed that ‘some’ forms of physical activity should be avoided during pregnancy, while walking (80%), swimming (31%), and running (11%) are, however, acceptable. Only 1% of women mentioned yoga as safe to undertake during pregnancy, although this is not surprising given that it is not common or widespread in the UAE. According to the American College of Obstetricians and Gynecology (ACOG), walking, swimming, and yoga are the safest options for PA during pregnancy and, moreover, can easily be incorporated into most lifestyles, whereas highintensity activity, contact sports, scuba diving, and activity with a high risk of abdominal trauma are unsafe and should be avoided [ 2 ]. Internationally recognized authorities also approve and promote yoga (e.g., ACOG) [ 2 ]. Therefore, future campaigns promoting PA during pregnancy in the UAE might specifically encourage greater awareness about its safety and health benefits Many of our participants believed in the health benefits of physical activity during pregnancy, specifically by helping to decrease risks of developing gestational diabetes (60%), which may improve health associated with the cardiovascular system (51%) and improve musculoskeletal strength (50%). Additionally, almost half agreed that physical activity during pregnancy decreases the risk of gestational hypertension (44%), provides better sleeping patterns (41%), helps avoid gestational weight gain (38%), and improves respiratory function (37%), while 25% believed it might enhance health associated with endocrine and gastrointestinal systems. This concurs with a study of the knowledge and participation in exercise and physical activity among pregnant women in Ghana [ 35 ]. Of the total participants ( n = 77) recruited, 57 (74%) scored high in PA knowledge, with the majority of 48 (62.3%) agreeing with the statement that PA promotes healthy pregnancy Compared with other published studies, the overall mean index score for knowledge of 40% (cf. 92% max score; SD 20%) is lower than expected. This contradicts previously published studies, albeit in other social and cultural contexts, whereby relatively high levels of knowledge and awareness of the guidance and professional advice around PA during pregnancy have been reported. For example, Alaglan reported in a study conducted in Saudi Arabia that the majority of women had high knowledge levels (mean = 77; median = 75) about types and amounts of physical activity and they thought that physical exercise during pregnancy was necessary [ 36 ]. Similarly, a study of physical activity during pregnancy and the state of Polish women’s knowledge reported that the majority (92.5%) of women were aware of the benefits of physical activity during pregnancy, and 80.0% and 82.4% of the participants were identified as aware of the reduced risks of GDM and preeclampsia, respectively, which was positively associated with their physical activity. Moreover, greater awareness was associated with higher educational attainment ( p = 0.001) [ 37 ].

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 12 of 18 As mentioned, overall the mean knowledge scores in our sample are lower than expected. Regression analysis for knowledge and socio-demographic data indicates a significant positive association between knowledge scores and age, marital status, educational attainment, employment status, and having a chronic condition. Although consistent with similar research based on the lower-than-expected levels of knowledge reported, this may be exacerbated for women who are younger, i.e., below 20 years, become pregnant in their teen years ( p < 0.001), are of lower educational attainment (high school) ( p = 0.004), are employed ( p = 0.014), or have a history of chronic disease ( p = 0.016), since these factors were significantly associated with lower mean knowledge score. Conversely, being married ( p = 0.003), of higher social status, and being of higher age may be slightly protective, in that these were significantly associated with higher knowledge scores. Thus, future planning for awareness raising or health education campaigns might usefully target younger, unmarried, unemployed, and student sub-groups. Since the majority of our respondents were Emirati (89%), were of childbearing ages (78% aged 20–29; 30–39), and had low overall knowledge index scores, policymakers might consider the need for more specific campaigns to raise awareness and educate women living in the UAE on the importance of regular and safe forms of PA during pregnancy. Furthermore, utilizing social marketing techniques to specifically target a relatively small and dispersed female Emirati population, to capture all ages, social statuses, and marital statuses, is also recommended to take into account specific social and cultural nuances in this diverse and dispersed population Further research might also be warranted to establish knowledge and awareness levels, including health and physical activity literacy and the various levels of ability to translate health information more precisely into practice. Furthermore, approximately 1:5 women (21%) believed that amniotic fluid and thus the health of the unborn are adversely affected by physical activity [ 38 , 39 ]. More research into the health beliefs of Arab women, especially in the Gulf Cooperation Council (GCC) countries, and carefully targeted messages that acknowledge alternative belief systems are recommended for this region. Finally, since knowledge and attitudes are essential predictors or mediators of behavior, including PA, greater involvement of midwives and physicians in promoting safe PA is highly recommended. As previous research shows, some professionals lack confidence in raising issues of diet, PA, or gestational weight gain with mothers to be, for fear of upsetting them or undermining their confidence, and therefore professionals involved with childbirth should receive adequate training [ 40 ]. 4.4. Limitations of the Study Self-reported rating of physical activity level was used in the present study, and since we did not quantify physical activity level, consequently, we were unable to assess the percentage of participants that meet global recommendations (150 min/week) for the general population. In terms of validity, we asked participants to qualitatively assess their physical activity levels, which in hindsight is less reliable than objective assessments; however, as a cross-sectional survey with limited resources and time, we acknowledge the shortcomings and suggest caution when interpreting findings relating to the activity Another limitation is that this study did not further investigate the parity/gravidity, the status of the participants in terms of former pregnancies, the status of current pregnancies, the number of months ante-natal or post-natal, the number of children, and knowledge of how many were mothers, as it could it just be that some may not have engaged with any thought or material around PA during pregnancy. Furthermore, considering the socio-demographic variables associated with PA levels would have provided a better understanding of behavior among women in the UAE Through addressing gaps in the understanding of the association between knowledge and practice relating to PA during pregnancy in this region, this study provides additional support for designing interventions tailored towards women, especially Emirati women.

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 13 of 18 5. Conclusions Our findings suggest that most Emirati women are aware of the health benefits of physical activity during pregnancy, and yet despite this, few women of reproductive age participate in PA, and this appears to decline further during pregnancy and lactation Furthermore, knowledge surrounding the safety of physical activity and exercise is lacking. Given the health benefits of physical activity during pregnancy, especially in helping prevent gestational diabetes and related complications, women living in the UAE could benefit from clear advice about safe physical activity during pregnancy. Additionally, more research utilizing behavioral theories to help model practice, including the intention to participate (in PA), may increase understanding of how PA behavior is mediated in this socio-cultural context. Understanding women’s knowledge and beliefs will help inform future interventions or messaging campaigns and demands a culturally relevant approach Author Contributions: Conceptualization, S.A.; methodology, S.A.; software, R.H.; validation, S.A and R.H.; formal analysis, R.H.; investigation, S.A.; resources, S.A.; data curation, S.A. and R.H.; writing—original draft preparation, S.A. and L.K.; writing—review and editing, S.A., R.H., L.K., and A.A.R.; visualization, S.A., R.H., L.K. and A.A.R.; supervision, S.A.; project administration, S.A. All authors have read and agreed to the published version of the manuscript Funding: This research received no external funding Institutional Review Board Statement: This study was approved by the Research Ethics Committee at Zayed University, UAE (ZU 21_061_F). All study participants provided informed consent at the beginning of the online questionnaire Informed Consent Statement: Informed consent was obtained from all subjects involved in the study Data Availability Statement: The data presented in this study are available on request from the first author Conflicts of Interest: The authors declare no conflict of interest Appendix A Table A 1. First attitude item according to demographic characteristics Physical Activity during Pregnancy Is Beneficial for Both Mothers and Infants Strongly Agree Agree Disagree Strongly Disagree N % N % N % N % p -Value Age Less than 20 years 34 32.4% 49 46.7% 17 16.2% 5 4.8% <0.001 20–29 years 329 40.1% 414 50.4% 57 6.9% 21 2.6% 30–39 years 154 42.9% 175 48.7% 23 6.4% 7 1.9% 40+ years 120 47.8% 122 48.6% 6 2.4% 3 1.2% Nationality Non-Emirati 74 43.5% 86 50.6% 7 4.1% 3 1.8% 0.490 Emirati 563 41.2% 675 49.4% 96 7.0% 33 2.4% Emirate Abu Dhabi 326 44.1% 355 48.0% 40 5.4% 18 2.4% 0.323 Dubai 191 38.5% 256 51.6% 38 7.7% 11 2.2% Northern Emirates 120 39.7% 150 49.7% 25 8.3% 7 2.3% Residential Area Rural 73 39.7% 90 48.9% 15 8.2% 6 3.3% 0.663 Urban 564 41.7% 671 49.6% 88 6.5% 30 2.2% Marital status Married 547 43.3% 620 49.1% 68 5.4% 27 2.1% <0.001 Divorced/Widowed/ 90 32.7% 141 51.3% 35 12.7% 9 3.3% Educational Level Less than High School 35 36.1% 40 41.2% 16 16.5% 6 6.2% <0.001 High School Degree 219 40.5% 281 51.9% 28 5.2% 13 2.4% Bachelor’s degree 338 42.9% 388 49.3% 49 6.2% 12 1.5% Masters or PhD Degree 45 40.2% 52 46.4% 10 8.9% 5 4.5% Employment status Employed (Full-time, Part-time, Self-employed) 243 39.2% 313 50.5% 44 7.1% 20 3.2% 0.159 Unemployed (Student, Retired, Housewife) 394 43.0% 448 48.9% 59 6.4% 16 1.7%

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 14 of 18 Table A 1. Cont Physical Activity during Pregnancy Is Beneficial for Both Mothers and Infants Strongly Agree Agree Disagree Strongly Disagree N % N % N % N % p -Value Has a medical history No medical history 451 42.8% 528 50.1% 58 5.5% 17 1.6% <0.001 Medical History 186 38.5% 233 48.2% 45 9.3% 19 3.9% Current physical activity Never and rare 230 42.8% 271 50.4% 27 5.0% 10 1.9% 0.005 1–2 times per week 251 40.3% 321 51.5% 38 6.1% 13 2.1% 3–5 times per week 111 37.9% 141 48.1% 32 10.9% 9 3.1% Daily 45 54.2% 28 33.7% 6 7.2% 4 4.8% Table A 2. Second attitude item according to demographic characteristics A Woman without Complications during Pregnancy Should Not Begin an Exercise Program during Pregnancy Strongly Agree Agree Disagree Strongly Disagree N % N % N % N % p -Value Age Less than 20 years 8 7.6% 13 12.4% 66 62.9% 18 17.1% 0.048 20–29 years 92 11.2% 72 8.8% 449 54.7% 208 25.3% 30–39 years 38 10.6% 26 7.2% 190 52.9% 105 29.2% 40+ years 33 13.1% 12 4.8% 150 59.8% 56 22.3% Nationality Non-Emirati 20 11.8% 15 8.8% 90 52.9% 45 26.5% 0.898 Emirati 152 11.1% 108 7.9% 765 56.0% 342 25.0% Emirate Abu Dhabi 82 11.1% 78 10.6% 374 50.6% 205 27.7% <0.001 Dubai 60 12.1% 29 5.8% 297 59.9% 110 22.2% Northern Emirates 30 9.9% 16 5.3% 184 60.9% 72 23.8% Residential Area Rural 17 9.2% 12 6.5% 98 53.3% 57 31.0% 0.232 Urban 155 11.5% 111 8.2% 757 55.9% 330 24.4% Marital status Married 151 12.0% 100 7.9% 688 54.5% 323 25.6% 0.117 Divorced/Widowed/ 21 7.6% 23 8.4% 167 60.7% 64 23.3% Educational Level Less than High School 11 11.3% 6 6.2% 53 54.6% 27 27.8% 0.824 High School Degree 50 9.2% 48 8.9% 302 55.8% 141 26.1% Bachelor’s degree 96 12.2% 59 7.5% 439 55.8% 193 24.5% Masters or PhD Degree 15 13.4% 10 8.9% 61 54.5% 26 23.2% Employment status Employed (Full-time, Part-time, Self-employed) 77 12.4% 51 8.2% 345 55.6% 147 23.7% 0.502 Unemployed (Student, Retired, Housewife) 95 10.4% 72 7.9% 510 55.6% 240 26.2% Has a medical history No medical history 124 11.8% 88 8.3% 585 55.5% 257 24.4% 0.504 Medical History 48 9.9% 35 7.2% 270 55.9% 130 26.9% Current physical activity Never and rare 58 10.8% 41 7.6% 290 53.9% 149 27.7% 0.272 1–2 times per week 68 10.9% 62 10.0% 343 55.1% 150 24.1% 3–5 times per week 34 11.6% 16 5.5% 172 58.7% 71 24.2% Daily 12 14.5% 4 4.8% 50 60.2% 17 20.5% Table A 3. Third attitude item according to demographic characteristics Pregnant Women Who Used to Exercise Should Be Encouraged to Continue an Exercise Program throughout Pregnancy Strongly Agree Agree Disagree Strongly Disagree N % N % N % N % p -Value Age Less than 20 years 25 23.8% 49 46.7% 24 22.9% 7 6.7% <0.001 20–29 years 292 35.6% 408 49.7% 100 12.2% 21 2.6% 30–39 years 150 41.8% 160 44.6% 44 12.3% 5 1.4% 40+ years 98 39.0% 132 52.6% 19 7.6% 2 0.8% Nationality Non-Emirati 66 38.8% 77 45.3% 17 10.0% 10 5.9% 0.006 Emirati 499 36.5% 673 49.2% 170 12.4% 25 1.8% Emirate Abu Dhabi 292 39.5% 359 48.6% 76 10.3% 12 1.6% <0.001 Dubai 158 31.9% 244 49.2% 83 16.7% 11 2.2% Northern Emirates 115 38.1% 147 48.7% 28 9.3% 12 4.0% Residential Area Rural 83 45.1% 68 37.0% 24 13.0% 9 4.9% <0.001 Urban 482 35.6% 682 50.4% 163 12.0% 26 1.9%

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 15 of 18 Table A 3. Cont Pregnant Women Who Used to Exercise Should Be Encouraged to Continue an Exercise Program throughout Pregnancy Strongly Agree Agree Disagree Strongly Disagree N % N % N % N % p -Value Marital status Married 478 37.9% 624 49.4% 143 11.3% 17 1.3% <0.001 Divorced/Widowed/ 87 31.6% 126 45.8% 44 16.0% 18 6.5% Educational Level Less than High School 34 35.1% 35 36.1% 24 24.7% 4 4.1% <0.001 High School Degree 180 33.3% 274 50.6% 74 13.7% 13 2.4% Bachelor’s degree 305 38.8% 399 50.7% 67 8.5% 16 2.0% Masters or PhD Degree 46 41.1% 42 37.5% 22 19.6% 2 1.8% Employment status Employed (Full-time, Part-time, Self-employed) 224 36.1% 304 49.0% 72 11.6% 20 3.2% 0.213 Unemployed (Student, Retired, Housewife) 341 37.2% 446 48.6% 115 12.5% 15 1.6% Has a medical history No medical history 400 38.0% 526 49.9% 111 10.5% 17 1.6% 0.001 Medical History 165 34.2% 224 46.4% 76 15.7% 18 3.7% Current physical activity Never and rare 210 39.0% 262 48.7% 54 10.0% 12 2.2% 0.069 1–2 times per week 225 36.1% 311 49.9% 78 12.5% 9 1.4% 3–5 times per week 99 33.8% 138 47.1% 47 16.0% 9 3.1% Daily 31 37.3% 39 47.0% 8 9.6% 5 6.0% Table A 4. Fourth attitude item according to demographic characteristics Physical Activity during Pregnancy Increases the Risk of a Low Birth Weight Strongly Agree Agree Disagree Strongly Disagree N % N % N % N % p -Value Age Less than 20 years 16 15.2% 24 22.9% 58 55.2% 7 6.7% 0.074 20–29 years 100 12.2% 166 20.2% 474 57.7% 81 9.9% 30–39 years 40 11.1% 59 16.4% 233 64.9% 27 7.5% 40+ years 18 7.2% 42 16.7% 164 65.3% 27 10.8% Nationality Non-Emirati 23 13.5% 28 16.5% 97 57.1% 22 12.9% 0.200 Emirati 151 11.0% 263 19.2% 833 60.9% 120 8.8% Emirate Abu Dhabi 85 11.5% 147 19.9% 448 60.6% 59 8.0% 0.477 Dubai 50 10.1% 86 17.3% 306 61.7% 54 10.9% Northern Emirates 39 12.9% 58 19.2% 176 58.3% 29 9.6% Residential Area Rural 26 14.1% 29 15.8% 105 57.1% 24 13.0% 0.100 Urban 148 10.9% 262 19.4% 825 61.0% 118 8.7% Marital status Married 127 10.1% 223 17.7% 792 62.8% 120 9.5% <0.001 Divorced/Widowed/ 47 17.1% 68 24.7% 138 50.2% 22 8.0% Educational Level Less than High School 22 22.7% 19 19.6% 48 49.5% 8 8.2% 0.001 High School Degree 54 10.0% 96 17.7% 356 65.8% 35 6.5% Bachelor’s degree 82 10.4% 156 19.8% 461 58.6% 88 11.2% Masters or PhD Degree 16 14.3% 20 17.9% 65 58.0% 11 9.8% Employment status Employed (Full-time, Part-time, Self-employed) 90 14.5% 128 20.6% 342 55.2% 60 9.7% 0.001 Unemployed (Student, Retired, Housewife) 84 9.2% 163 17.8% 588 64.1% 82 8.9% Has a medical history No medical history 100 9.5% 198 18.8% 660 62.6% 96 9.1% 0.006 Medical History 74 15.3% 93 19.3% 270 55.9% 46 9.5% Current physical activity Never and rare 65 12.1% 94 17.5% 333 61.9% 46 8.6% 0.852 1–2 times per week 64 10.3% 128 20.5% 374 60.0% 57 9.1% 3–5 times per week 33 11.3% 55 18.8% 176 60.1% 29 9.9% Daily 12 14.5% 14 16.9% 47 56.6% 10 12.0%

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 16 of 18 Table A 5. Fifth attitude item according to demographic characteristics The Possible Harmful Effects of Physical Activity during the Pregnancy on the Fetus Are Minimal or Non-Existent Strongly Agree Agree Disagree Strongly Disagree N % N % N % N % p -Value Age Less than 20 years 19 18.1% 45 42.9% 35 33.3% 6 5.7% 0.025 20–29 years 140 17.1% 418 50.9% 225 27.4% 38 4.6% 30–39 years 69 19.2% 199 55.4% 80 22.3% 11 3.1% 40+ years 53 21.1% 143 57.0% 50 19.9% 5 2.0% Nationality Non-Emirati 41 24.1% 88 51.8% 37 21.8% 4 2.4% 0.130 Emirati 241 17.6% 717 52.5% 353 25.8% 56 4.1% Emirate Abu Dhabi 146 19.8% 395 53.5% 175 23.7% 23 3.1% <0.001 Dubai 66 13.3% 278 56.0% 132 26.6% 20 4.0% Northern Emirates 70 23.2% 132 43.7% 83 27.5% 17 5.6% Residential Area Rural 41 22.3% 80 43.5% 59 32.1% 4 2.2% 0.017 Urban 241 17.8% 725 53.6% 331 24.5% 56 4.1% Marital status Married 223 17.7% 679 53.8% 312 24.7% 48 3.8% 0.118 Divorced/Widowed/ 59 21.5% 126 45.8% 78 28.4% 12 4.4% Educational Level Less than High School 23 23.7% 43 44.3% 26 26.8% 5 5.2% 0.125 High School Degree 92 17.0% 277 51.2% 141 26.1% 31 5.7% Bachelor’s degree 144 18.3% 430 54.6% 192 24.4% 21 2.7% Masters or PhD Degree 23 20.5% 55 49.1% 31 27.7% 3 2.7% Employment status Employed (Full-time, Part-time, Self-employed) 129 20.8% 306 49.4% 158 25.5% 27 4.4% 0.123 Unemployed (Student, Retired, Housewife) 153 16.7% 499 54.4% 232 25.3% 33 3.6% Has a medical history No medical history 195 18.5% 569 54.0% 258 24.5% 32 3.0% 0.026 Medical History 87 18.0% 236 48.9% 132 27.3% 28 5.8% Current physical activity Never and rare 108 20.1% 276 51.3% 132 24.5% 22 4.1% 0.723 1–2 times per week 108 17.3% 337 54.1% 160 25.7% 18 2.9% 3–5 times per week 53 18.1% 148 50.5% 76 25.9% 16 5.5% Daily 13 15.7% 44 53.0% 22 26.5% 4 4.8% References 1 The American College of Obstetricians and Gynecologists. Exercise During Pregnancy. Available online: https://www.acog.org /womens-health/faqs/exercise-during-pregnancy (accessed on 16 February 2023) 2 The American College of Obstetricians and Gynecologists. Physical Activity and Exercise during Pregnancy and the Postpartum Period Obstet. Gynecol 2020 , 135 , e 178–e 188. [ CrossRef ] 3 Echols, H. Physical Activity during Pregnancy Lowers Risks of Complications and Preterm Births. Available online: https://ww w.uab.edu/news/health/item/12509-physical-activity-during-pregnancy-lowers-risks-of-complications-and-preterm-births (accessed on 1 June 2023) 4 Sadiya, A.; Jakapure, V.; Shaar, G.; Adnan, R.; Tesfa, Y. Lifestyle Intervention in Early Pregnancy Can Prevent Gestational Diabetes in High-Risk Pregnant Women in the UAE: A Randomized Controlled Trial BMC Pregnancy Childbirth 2022 , 22 , 668. [ CrossRef ] 5 World Health Organization. Physical Activity. Available online: https://www.who.int/news-room/fact-sheets/detail/physicalactivity (accessed on 1 June 2023) 6 Janakiraman, B.; Gebreyesus, T.; Yihunie, M.; Genet, M.G. Knowledge, attitude, and practice of antenatal exercises among pregnant women in Ethiopia: A cross-sectional study PLoS ONE 2021 , 16 , e 0247533. [ CrossRef ] 7 Shum, K.W.; Ang, M.Q.; Shorey, S. Perceptions of physical activity during pregnancy among women: A descriptive qualitative study Midwifery 2022 , 107 , 103264. [ CrossRef ] 8 Weir, Z.; Bush, J.; Robson, S.C.; McParlin, C.; Rankin, J.; Bell, R. Physical activity in pregnancy: A qualitative study of the beliefs of overweight and obese pregnant women BMC Pregnancy Childbirth 2010 , 10 , 18. [ CrossRef ] 9 Hamilton, K.; Fleig, L.; Henderson, J.; Hagger, M.S. Being active in pregnancy: Theory-based factors associated with physical activity among pregnant women Women Health 2018 , 59 , 213–228. [ CrossRef ] 10 Aljehani, M.; Alghamdi, L.; Almehwari, O.; Hassan, A.-H. Exercise among Pregnant Females in Maternity and Children Hospital in Jeddah, Saudi Arabia, 2019: Prevalence and Barriers J. Fam. Med. Prim. Care 2021 , 10 , 2394. [ CrossRef ] 11 Im, E.-O.; Lee, B.; Hwang, H.; Yoo, K.H.; Chee, W.; Stuifbergen, A.; Walker, L.; Brown, A.; McPeek, C.; Miro, M.; et al. “A waste of time”: Hispanic women’s attitudes toward physical activity Women Health 2010 , 50 , 563–579. [ CrossRef ] 12 Bull, F.C.; Al-Ansari, S.S.; Biddle, S.; Borodulin, K.; Buman, M.P.; Cardon, G.; Carty, C.; Chaput, J.P.; Chastin, S.; Chou, R.; et al World Health Organization 2020 guidelines on physical activity and sedentary behaviour Br. J. Sports Med 2020 , 54 , 1451 [ CrossRef ]

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 17 of 18 13 Sharara, E.; Akik, C.; Ghattas, H.; Makhlouf Obermeyer, C. Physical Inactivity, Gender and Culture in Arab Countries: A Systematic Assessment of the Literature BMC Public Health 2018 , 18 , 639. [ CrossRef ] 14 Dalibalta, S.; Majdalawieh, A.; Yousef, S.; Gusbi, M.; Wilson, J.J.; Tully, M.A.; Davison, G. Objectively Quantified Physical Activity and Sedentary Behaviour in a Young UAE Population BMJ Open Sport Exerc. Med 2021 , 7 , e 000957. [ CrossRef ] 15 Yammine, K. The prevalence of physical activity among the young population of UAE: A meta-analysis Perspect Public Health 2017 , 137 , 275–280. [ CrossRef ] [ PubMed ] 16 Pullia, A.; Jeemi, Z.; Reina Ortiz, M.; Dantas, J.A. Physical activity experiences of South Asian migrant women in Western Australia: Implications for intervention development Int. J. Environ. Res. Public Health 2022 , 19 , 3585. [ CrossRef ] [ PubMed ] 17 Downs, D.; Hausenblas, H.A. Exercising for two: Examining pregnant women second trimester exercise intention and behaviour using the framework of the theory of planned behaviour Women’s Health Issues 2003 , 6 , 222–228. [ CrossRef ] 18 Newham, J.J.; Allan, C.; Leahy-Warren, P.; Carrick-Sen, D.; Alderdice, F. Intentions toward Physical Activity and Resting Behavior in Pregnant Women: Using the Theory of Planned Behavior Framework in a Cross-Sectional Study Birth 2015 , 43 , 49–57 [ CrossRef ] 19 De Vivo, M.; Mills, H. Laying the Foundation for Pregnancy Physical Activity Profiling: A Framework for Providing Tailored Physical Activity Advice and Guidance to Pregnant Women Int. J. Environ. Res. Public Health 2021 , 18 , 5996. [ CrossRef ] 20 Jost, J.T. Resistance to change: A social psychological perspective Soc. Res 2015 , 82 , 607–636. Available online: http://www.jstor. org/stable/44282124 (accessed on 4 June 2023). [ CrossRef ] 21 Watson, E.D.; Oddie, B.; Constantinou, D. Exercise during pregnancy: Knowledge and beliefs of medical practitioners in South Africa: A survey study BMC Pregnancy Childbirth 2015 , 15 , 245. [ CrossRef ] 22 Krzepota, J.; Sadowska, D.; Biernat, E. Relationships between Physical Activity and Quality of Life in Pregnant Women in the Second and Third Trimester Int. J. Environ. Res. Public Health 2018 , 15 , 2745. [ CrossRef ] [ PubMed ] 23 Al-Mahroos, F.; Al-Roomi, K. Obesity among Adult Bahraini Population: Impact of Physical Activity and Educational Level Ann Saudi Med 2001 , 21 , 183–187. [ CrossRef ] 24 Musaiger, A.O.; Lloyd, O.L.; Al-Neyadi, S.M.; Bener, A.B. Lifestyle factors associated with obesity among male university students in the United Arab Emirates Nutr. Food Sci 2003 , 33 , 145–147. [ CrossRef ] 25 Carter, A.; Saadi, H.F.; Reed, R.L.; Dunn, E.V. Assessment of Obesity, Lifestyle, and Reproductive Health Needs of Female Citizens of Al Ain, United Arab Emirates J. Health Popul. Nutr 2004 , 22 , 75–83. Available online: https://www.jstor.org/stable/2349901 (accessed on 4 June 2023). [ PubMed ] 26 Siyad, S.; Mustafa, N.; Banu, S.S.; Buharoon, M.A.; Al Mulla, M.A.; Ankarali, H.; Carrick, F.R.; Abdulrahman, M. Pregnant Women’s Perceptions of Physical Activity: Adaptation of the Pregnancy Physical Activity Questionnaire in Dubai, a Multicultural Society J. Public Health Res 2022 , 11 , 2261. [ CrossRef ] 27 World Bank. Birth Rate, Crude (Per 1000 People)—United Arab Emirates. Available online: https://data.worldbank.org/indicat or/SP.DYN.CBRT.IN?view=chart (accessed on 1 June 2023) 28 Mabry, R.M.; Al-Busaidi, Z.Q.; Reeves, M.M.; Owen, N.; Eakin, E.G. Addressing physical inactivity in Omani adults: Perceptions of public health managers Public Health Nutr 2014 , 17 , 674–681. [ CrossRef ] [ PubMed ] 29 Al-Youbi, G.M.; Elsaid, T. Knowledge, attitude, and practices on exercise among pregnant females attending Al-Wazarat Health Center, Riyadh, Saudi Arabia J. Fam. Med. Prim. Care 2020 , 9 , 3905–3915. [ CrossRef ] 30 Berger, G.; Peerson, A. Giving young Emirati women a voice: Participatory action research on physical activity Health Place 2009 , 15 , 117–124. [ CrossRef ] 31 Harrison, A.L.; Taylor, N.F.; Shields, N.; Frawley, H.C. Attitudes, barriers and enablers to physical activity in pregnant women: A systematic review J. Physiother 2018 , 64 , 24–32. [ CrossRef ] 32 Okafor, U.B.; Goon, D.T. Applying the ecological model to understand pregnant women’s perspectives on the modifiable constraints to physical activity during pregnancy Medicine 2020 , 99 , e 23431. [ CrossRef ] 33 Chaabane, S.; Chaabna, K.; Doraiswamy, S.; Mamtani, R.; Cheema, S. Barriers and Facilitators Associated with Physical Activity in the Middle East and North Africa Region: A Systematic Overview Int. J. Environ. Res. Public Health 2021 , 18 , 1647. [ CrossRef ] 34 Ali, H.I.; Baynouna, L.M.; Bernsen, R.M. Barriers and facilitators of weight management: Perspectives of Arab women at risk for type 2 diabetes Health Soc. Care Community 2010 , 18 , 219–228. [ CrossRef ] 35 Asante, D.O.; Osei, F.; Abdul-Samed, F.; Nanevie, V.D. Knowledge and participation in exercise and physical activity among pregnant women in Ho, Ghana Front. Public Health 2022 , 10 , 927191. [ CrossRef ] [ PubMed ] 36 Alaglan, A.A.; Almousa, R.F.; Alomirini, A.A.; Alabdularazaq, E.S.; Alkheder, R.S.; Alzaben, K.A.; Alonayzan, G.A.; Saquib, J. Saudi Women’s Physical Activity Habits during Pregnancy Women’s Health 2020 , 16 , 174550652095204. [ CrossRef ] [ PubMed ] 37 Szatko, A.; Kacperczyk-Bartnik, J.; Bartnik, P.; Mabiala, E.; Goryszewska, M.; Dobrowolska-Redo, A.; Romejko-Wolniewicz, E. Physical activity during pregnancy—The state of Polish women’s knowledge Ginekol. Pol 2021 , 92 , 804–811. [ CrossRef ] [ PubMed ] 38 Brown, E.; Carroll, J.; Fogarty, C.; Holt, C. “They Get a C-Section . . . They Gonna Die”: Somali Women’s Fears of Obstetrical Interventions in the United States J. Transcult. Nurs 2010 , 21 , 220–227. [ CrossRef ] [ PubMed ]

Int. J. Environ. Res. Public Health 2023 , 20 , 6669 18 of 18 39 Abuelezam, N.N.; El-Sayed, A.M.; Galea, S. The Health of Arab Americans in the United States: An Updated Comprehensive Literature Review Front. Public Health 2018 , 6 , 262. [ CrossRef ] [ PubMed ] 40 Basu, A.; Kennedy, L.; Tocque, K.; Jones, S. Eating for 1, Healthy and Active for 2; Feasibility of Delivering Novel, Compact Training for Midwives to Build Knowledge and Confidence in Giving Nutrition, Physical Activity and Weight Management Advice during Pregnancy BMC Pregnancy Childbirth 2014 , 14 , 218. [ CrossRef ] [ PubMed ] Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.