Health-promoting physical activities for refugees from Syria – physiotherapists’ clinical reasoning

ABSTRACT

Background

Refugees from Syria face health challenges with psychosocial dimensions due to disrupted networks, uncertain life situations, and language barriers. Additionally, a sedentary lifestyle increases the risk of noncommunicable diseases, so health-promoting initiatives involving physical activities are essential.

Purpose

To explore physiotherapists’ clinical reasoning and collaboration with refugee families in developing group-based health-promoting physical exercising to increase participants’ wellbeing, sense of togetherness, and self-efficacy.

Methods

The design was participating action research with 24 resettled refugees from Syria. Data consisted of field notes and three focus group interviews. Data gathering followed a phenomenological approach, and the four-step analysis was inspired by Giorgi.

Results

Based on clinical reasoning and collaboration with the participants and their wishes, the physiotherapists organized a physical exercise intervention integrating language learning. The physiotherapists based the intervention on social cognitive theory, focusing on the group’s and the individual’s capacity and working with the participants on exercise and organizational adaptations to the group and individual. The participants appreciated the joyful physical activities, body awareness, and a sense of togetherness. To accommodate that many suffered from musculoskeletal pain, the physiotherapists developed an intervention for therapeutic exercising that included individual assessment and pain management.

Conclusion

The physiotherapists’ clinical reasoning in working with refugees included the cultural, linguistic, and social context rooted in a salutogenic perspective. The participants’ wellbeing and self-efficacy in adhering to exercise increased. They experienced pain relief and increased confidence in using the body.

KEYWORDS:

• Social cognitive theory
• self-efficacy
• pain management
• salutogenic perspective
• group-based training

Introduction

Refugees constitute a vulnerable group with many physical and mental health issues (Satinsky et al., 2019). Due to the escalating Syrian civil war, almost 400,000 refugees traveled to Europe, including Denmark, in 2015, and many obtained asylum and residence permits and resettled in Denmark. Resettled refugees often face health problems with psychosocial dimensions due to disrupted networks, economic insecurity, language barriers, adaptation to a new culture, and worries about their children’s future. These factors can impact education and employment (Filler, Benipal, Torabi, and Minhas, 2021). Among common health issues are cardiovascular disease, diabetes, vitamin deficiency, musculoskeletal pain, and unspecified somatic symptoms (Andersen et al., 2020; Pfortmueller et al., 2016). Additionally, refugees from Syria are at risk of developing chronic diseases due to the traditional calorie-rich Syrian diet, physical inactivity, stress exposure, and sociodemographic factors (Masri et al., 2022). The increasing prevalence of lifestyle-related noncommunicable diseases in the Middle East and among refugees in Europe suggests that health promotion initiatives are essential for newly arrived and resettled refugees (World Health Organization, 2019).

The World Health Organization (WHO), (2022) ranks physical inactivity as the fourth leading cause of global mortality, mainly due to cardiovascular disease, diabetes, and hypertension. Sharara, Akik, Ghattas, and Makhlouf Obermeyer (2018) reported that the Arab region has a high prevalence of sedentary behavior, 82.3%, among Syrian women/girls. Inactivity was associated with lower education and unemployment but not religion (Sharara, Akik, Ghattas, and Makhlouf Obermeyer, 2018). Knowledge about healthy behavior is limited to hygiene, rest, and diet and the barriers to physical activity are low valuations, translating into low interest and motivation to exercise.

A Danish study of newly arrived refugees’ perspectives on health and physical activity reveals that Syrian, Kurdish, and Eritrean refugees perceived health holistically as part of life influenced by external and internal factors (Ryom et al., 2022). Health was associated with pleasure and wellbeing, while physical activities were associated with health benefits from sports and fitness. The study identified barriers as lack of time, pain, low income, job insecurity, mental strain, external expectations and demands, precarious living conditions, and general worrying (Ryom et al., 2022).

Thus, when physiotherapists work with health promotion for newly arrived and resettled refugees from Syria, the complexity of the barriers requires the physiotherapists to expand their scope of clinical reasoning beyond usual health promotion. The refugees’ life situation, health, and mental strain call for a salutogenic approach that emphasizes wellbeing and considers health and health determinants more than pathogenic but also rooted in the refugees’ social situation (Quennerstedt, 2008).

Traditionally, the patient-centered clinical reasoning process is based on a one-to-one practice, including hypothetic-deductive reasoning, pattern recognition, and narrative reasoning (Huhn et al., 2019). It is a complex and multifaceted process requiring skills and practice in an iterative, ever-evolving process. Group-based training is common in community settings, but we know little about how physiotherapists use their clinical reasoning skills when working group-based. Clinical reasoning is further challenged when language barriers are present, and the participants have little surplus in daily life and are unfamiliar with physical activity for joy and health promotion. More knowledge is needed about how physiotherapists use clinical reasoning to make adjustments and amendments for the group and simultaneously provide an individualized intervention that benefits each participant. The process requires the physiotherapists to use deductive and inductive clinical reasoning in the community-based context, where health is partly socially determined (Edwards and Richardson, 2008).

This paper describes a health-promoting physical activity intervention nested in a 3-year research project, Community with Immigrants – Steps on the Road to Employment (the main project), aimed at evaluating the effects of multi-component interventions to improve health and wellbeing among refugee families from Syria. Examination of the families’ health status and wellbeing when the main project started revealed various physical and mental health challenges (Nielsen et al., 2023). The study comprised 38 families randomized to an intervention group and a comparison group. The intervention group included 21 families with 40 individuals aged 18 years or above, 23 (58%) women. These were invited to the health-promoting physical activity intervention presented in this paper. In the main project’s initial planning phase, we invited the refugee families from the intervention group to participate in an appreciative inquiry (AI) workshop (Bellinger and Elliott, 2011) to generate ideas for activities in the multi-component intervention. Twenty-two adults representing 13 families and equal gender distribution participated. Among other themes, several families, especially the women, expressed wishes for physical and leisure activities. The men were more reluctant to express their wishes and talked about sports, which they followed on television. The AI workshop led to the project group’s physiotherapists developing a physical activity intervention.

This paper describes and analyzes how physiotherapists organized and implemented the health-promoting physical activity intervention aimed at the adults. Health promotion enables people to increase control over their health (World Health Organization, 1998). Health promotion for refugees often concerns structural factors, e.g., access to the health and social services system (Laverack, 2018; Nowak, Namer, and Hornberg, 2022). However, the present study addresses the individual perspective promoting control over health and developing the groups’ social relations. We address control over determinants for health, such as social aspects, wellbeing, self-confidence, and body knowledge. The paper aims to present the physiotherapists’ clinical reasoning and collaboration with the participants regarding organizing the intervention, the content of group-based and individual activities, and health education to meet the following objectives:

1. To introduce the participants to physical activities that represent the different forms of exercise and physical activities practiced in Denmark and encourage them to transfer physical activities to daily life.

2. To provide the participants with insight into group-based and individual exercise practice and various exercise methods to create a sense of togetherness and social relations through the joy of exercising together with others.

3. To increase the participants’ body awareness and understanding of bodily reactions and musculoskeletal pain.

4. To increase the participants’ wellbeing, self-confidence, and self-efficacy to adhere to being physically active.

Materials and methods

Research design

The health-promoting physical activity intervention was based on a qualitative participating action research (PAR) methodology. PAR includes social change through actions and systematic inquiries in direct collaboration with those affected by the activities and the context studied for action or change (Vaughn and Jacquez, 2020). The social change of the intervention focused on empowering and educating the participants and creating social connections, which characterize the approach. Involving participants as partners in all study aspects is a cornerstone of PAR (Cornish et al., 2023). However, in the present study, the overall planning was conducted with the local municipality integration department and the staff at the language school, who worked with the refugees. The actual involvement of the refugee families started with the project manager visiting each family as part of the recruitment process, followed by the AI workshop.

To address the power imbalance and ensure that participants felt confident and safe, the physiotherapists pre-defined the values promoting recognition, appreciative collaboration, and mutual support (Honneth, 2004). The values became fundamental in the intervention and any contact with the participants. Collaboration through dialogue and building relationships are essential elements in PAR (Cornish et al., 2023). The statements and wishes about physical activity expressed at the AI workshop were considered when organizing the activities throughout the intervention. Initial discussions about wishes and needs with those who showed up to participate in the physical activity sessions were conducted to establish a common understanding. Each session was concluded with an evaluation and discussion of participants’ wishes for the next time.

Ethics

The study was conducted in accordance with the Helsinki Declaration (World Medical Association, 2018), and the participants were included by oral and written consent based on information translated into Arabic. Ethical approval was obtained from the Region Zealand’s Committee on Health Research Ethics (SJ-715).

Research team

The research team conducting the physical activity interventions consisted of three experienced physiotherapists with insight into Middle Eastern culture. They were all associate professors at University College Absalon, the institution to which the main project was affiliated. They occasionally included and supervised physiotherapy students in some of the activities, an initiative that enabled increased individualized exercise guidance. A bi-lingual language teacher (Danish-Arabic) whom the participants knew from the municipal integration program participated in most sessions and acted as interpreter.

Participants

Of the 21 families in the intervention group above 18 years old (n = 40), 24 individuals representing ten families signed up and participated in the physical activities. Fourteen of them were women (58%). The mean age was 37.2 years; the standard deviation was 6.6, and the range 30–50 years. All participants were from Syria but had different backgrounds in Arabic, Kurdish, and Turkish cultures.

Context and organization of the interventions

In the following, we present an overview of the organization of three training interventions and the activities derived from them (Figure 1).

Figure 1. The three main physical activity interventions and derived activities for refugee families.

The interventions’ flow and content.

Abbreviations: CHP: community-based health promotion and pain-preventing exercises, IG: intervention group, PE: physical exercising, TE: therapeutic exercising.

Training intervention 1 physical exercising

The first intervention targeted health promotion during physical exercising (Figure 1). Nineteen individuals participated a varying number of times. Attendance was highest in the first three months while from August 2019, the participation rate decreased. The reason was that some participants had to prioritize their education in the new semester, and others did not perceive exercising with the aim of health promotion as appropriate for adults. Some male participants expressed to the male physiotherapist that in Arabic culture, men do not exercise for joy or health.

The physiotherapists’ observations during the intervention led to two events for women: a workshop with pelvic floor education and a cycling course (Figure 1).

Training intervention 2 therapeutic exercising

During training intervention 1, the physiotherapists observed that many participants suffered musculoskeletal pain that limited their physical functioning and mental surplus to benefit from activities in the municipality integration program. In cooperation with the participants, it was decided to transform physical exercising into therapeutic exercising targeting musculoskeletal pain (Figure 1). Simultaneously with the therapeutic exercising, the physiotherapists offered more demanding exercises and fitness training for the few participants who did not suffer from musculoskeletal pain but wanted to continue health-promoting physical activities. Twelve individuals participated, of whom nine were men, representing seven families.

The time and location of the weekly therapeutic exercising sessions were scheduled in collaboration with the participants to avoid practical barriers to participation, such as time, transportation, and caring for children. During the sessions, physiotherapy students engaged the participants’ children in playful physical activities in an adjacent room, enabling parents to participate.

Training intervention 3 community-based health promotion and pain-preventing exercises

Based on positive participant feedback and wishes, the project manager, the physiotherapists, and the municipality decided, together with the participants, to continue a training offer. It started in October 2020 (Figure 1). It was free of charge and invited a broader participant field of migrants and Danes to promote intercultural bonding and networking.

Assessments of methods used

Involving participants

The initial group discussions at the physical exercising clarified the participants’ exercise experiences and intervention expectations. With the interpreter’s help, the physiotherapists explained the physical and mental health effects of exercising. The training content was discussed jointly to create meaningful, inspiring, and motivating activities.

The participants expressed different attitudes to gender segregation during the activities. Participants with Kurdish backgrounds suggested group activities for men and women together. The Arabic participants preferred separation because the women appreciated exercising hard and taking off their scarf. Based on common discussions, the training sessions were initially conducted together. However, after a couple of months and further discussions, the group divided, and women and men performed only the warm-up exercises together. As the participants became more familiar with the training, the focus moved to the exercises’ effects on physical and mental conditions, and men and women agreed to exercise together. However, some women preferred shielding by physical screens while performing particular exercises.

Field notes

After each exercise session, the physiotherapists wrote field notes based on their observations and participant feedback. Each field note described the content and the process, including how the participants managed the exercises and the clinical reasoning resulting in adjustments. Didactical considerations were described, and so was the overall impression of the atmosphere, participants’ mood, difficulties, and motivation. Each note ended with a debriefing comprising the agreement about the following session. The field notes form the basis of the following presentation of the physiotherapists’ clinical reasoning and subsequent adjustments and amendments to the interventions’ content.

Clinical reasoning – group-based and individual

In the following, we describe and analyze how the physiotherapists used clinical reasoning in organizing group-based and individual activities in collaboration with the participants.

Training intervention 1 physical exercising

Physical exercising was targeted health promotion and initiated the physical activity intervention. Clinical reasoning included understanding the participants’ socio-cultural perception of physical activity. Therefore, we used the first session to give a mutual presentation and listen to their wishes for the course. Four topics were of importance to the participants. These were fitness, pain relief, learning Danish, and interaction with others. Fitness motivated them, as a woman expressed, “I would like to get in better shape,” and two men wanted “to get a stronger body.” A man expressed pain relief as essential, and two women agreed. Learning the Danish language was essential as a woman said, “I would like to speak Danish better to learn to know Danish women.” The other participants confirmed that linguistic improvement was essential for them to be part of society and important for the men to get jobs. Participants also looked forward to learning to get to know each other. Although they participated in the municipal integration program, they did not know each other very well. Each of the following sessions was introduced by talking about how they had been feeling bodily and mentally since the last time and which activities they wanted to work with on the day.

Emphasis was on involving the whole body with high intensity and speed, which created a positive atmosphere with lots of laughter and good interaction between the participants and the physiotherapists. Zumba rhythm was used for warm-up when only women were present. Examples of frequently used exercises are presented in Table 1.

Table 1. Examples of physical exercising and the physiotherapists’ observations.

Physical exercising
Purpose	Activity	Observations
Warm-up exercises	Walking with increasing speed, and forward, backward, sideward with different symmetrical and asymmetrical arm swings crossing – different speed equipment: balls, cones	Enjoying the speed and efforts Difficulties following the music Adjustments in speed for some due to pain
Balance	Lounges – different speed and direction Balance equipment Rhythm with simple dance steps	Poor balance, most participants needed support the first times
Strength the upper and lower body	Modified plank – support on the knees Squat – with and without a ball Step ups	Body-awareness increased rapidly
	Standing and sitting using elastic bands Push-ups	Difficulties using the whole range of motion
Improve aerobic capacity	Circuit training – fast walking, jogging, step ups, playing with balls, running between cones Playing badminton	Enjoying the activities and working together Adjustments in speed for some due to pain
Cool down Flexibility with use of respiration	Wide standing and stretching the whole body Supine and side lying stretching upper and lower body	Some needed adjustments and support Difficult to benefit from using the respiration

Based on the participants’ statements about training and their apparent fitness, the physiotherapists developed group-based training focusing on exercising large muscle groups, challenging strength, balance, coordination, and bodily flexibility.

The physiotherapists encouraged squeezing the pelvic floor muscles in connection with some demanding exercises. However, it took a lot of work for the participants to understand the meaning and localize the particular muscles. Therefore, the physiotherapists arranged a separate workshop focusing on pelvic floor education for the women (Figure 1). The following field note is an example of the physiotherapist’s observations of the participant’s difficulties:

We do exercises for transverse, vertical, and oblique abdominal muscles. I show the exercise and circulate to assist in ‘pulling in the belly button. They stop the activity until I get to the individual, but they remain lying down. It is not easy, but they catch all three exercises. We also perform different types of pelvic lifts, buttock exercises, and back exercises. It works well with simple exercises, but when we add the arms, coordination is difficult. We are working on counting each lift or contraction. (Field note 08.07.2019)

During the exercises, the physiotherapists observed physical and mental reactions and motor skills. They adjusted activities for the whole group or the individual and incorporated the biopsychosocial approach based on a socio-cultural understanding. It was pervasive that the physiotherapists recognized each person’s bodily limitations, such as back pain, cultural limitations regarding dressing, or reluctance to perform specific types of exercises.

Use of social cognitive theory

The physiotherapists worked with Bandura’s social cognitive theory (SCT), which stem from social learning theory as an overarching framework (Bandura, 2004). The social context of the group-based interventions stimulated participants’ mutual interactions, created a sense of togetherness and safety, and emphasized social reinforcement with praise and smiling, signaling recognition and acceptance. The following field note is an example of activities bringing the participants together:

We do sitting, lying, and standing stretches. In addition, we do balance exercises. We massage each other with balls and play a little ball seated in a circle. Several participants came up with suggestions for activities. R (female) has many ideas. A (female) and M (male) show one exercise each. (Field note 06.05.2019)

Positive outcome expectations and self-efficacy are essential subsets of SCT for behavioral change, and the physiotherapists emphasized participants’ expectations and self-efficacy. They used four sources of self-efficacy beliefs and worked with past performance, verbal persuasion, vicarious experiences, and psychological and affective states (Bandura, 2004).

Working with past performance, also called mastery experience, the physiotherapists focused on the participants’ recalling experiences with physical activity. They involved each participant in setting achievable training goals to build up the beliefs and experience of successful exercising. The physiotherapists verbally persuaded each participant using precise, appropriate, and relevant praise. In addition, the participants were encouraged to explore the bodily feeling of being exhausted, tense, or relaxed. The following field note is from a session when only women attended the physical exercise and illustrates the physiotherapist’s considerations.

We started the training with dancing as a warm-up. We danced a few short sequences and laughed together. The participants found some of the dance steps difficult and did their best. Therefore, I will continue with the same dance steps next time to reinforce the participants’ mastery experience. (Field note October 21, 2019).

Observational motor learning stimulates the mirror neurons, improves action perceptions and motor learning, and was used by the physiotherapists as a vicarious experience (Lago-Rodríguez et al., 2014). The participants worked together on counting and stimulating each other. Seeing others struggle and succeed strengthened the individual’s belief in mastering the exercises and achieving the same or equivalent.

The physical exercising was organized to influence the participants’ physiological and affective states. The physiotherapists created playful activities and encouraged much laughter, challenges to overcome, and a feeling of togetherness. The training was related to body awareness of physiological and psychological signals before, during, and after the training. Feeling the heartbeat, respiration, sweating, laughter, and joy were interpreted as positive signals that the exercises strengthened the body in a positive way that would benefit staying healthy for future aging.

Situated learning was used to support language learning, and the group-based training stimulated community and learning participation (White, 2010). The interpreter and the physiotherapists created meaning from the training activities, e.g., counting two and two together while performing several exercises and naming bodily designations, equipment, or clothing during the exercises. Additionally, labeling the executed actions and reactions in Danish was the focus.

Pelvic floor education

Because it was difficult to work with the pelvic floor muscles to prevent incontinence due to hard training, the concept of squeezing the pelvic floor muscles was arranged as a separate educational workshop. The aim was to increase the understanding, provide knowledge about the pelvic floor and incontinence, and increase mastery of pelvic floor problems. All women from the intervention group were invited, and 11 participated, six of whom participated in the physical exercise intervention.

At the workshop, a female gynecology specialist physiotherapist taught about themes including the female body in general births, sex life, hormones, continence, reproductive organs, and the pelvic floor. She used pictures, text, and written material in Danish and Arabic and demonstrated exercises with assistance from the interpreter and a female physiotherapist whom the women knew from the training sessions. She explained how to prevent urinary and anal incontinence and where to seek professional help. Through the discussions, it became clear that women usually share experiences about the female body with other women. However, being educated by health professionals, getting insight, and practicing exercises was a new experience and contributed to networking. The women participated actively; they were interested and expressed great satisfaction with the workshop. In the following sessions with physical exercising, the women were encouraged to use the new knowledge and skills appropriately.

Bicycling intervention

Some women had expressed a desire to learn how to cycle, and three physiotherapy students organized an intervention and invited women in the intervention group to participate. Denmark is one of the European countries where most people regularly use bicycling for transportation. The health benefits of cycling include increased cardiovascular fitness and lower body mass index when starting or increasing cycling as part of the daily routines (Aune et al., 2021).

Six women aged 38–48 signed up, three of whom were from the physical exercise group. They had different experiences with cycling, and their motivation was to lose weight and become independent regarding transportation. Wearing a bicycle helmet is common in Denmark and was mandatory in the intervention. University College Absalon donated bicycles and helmets.

The students’ based their clinical reasoning on SDT, as was physical exercising. During eight weekly sessions, the women learned how to handle the bike and perform balance exercises on the bike, followed by cycling in a closed area. They learned about traffic rules, traffic signs, cycling uphill and downhill, cycling on a track with cones, and in light and heavy traffic. Bicycling challenges cognitive-motor dual-tasking and requires gross motor skills and multitasking abilities to execute cycling in the traffic’s ever-changing context. Three adverse events with falls were registered during the intervention, but no one was hurt, and cycling was resumed immediately after the fall.

Training intervention 2 therapeutic exercising

Since problems with musculoskeletal pain, especially back pain, affected several participants in physical exercising, an intervention offering therapeutic exercises targeted at musculoskeletal pain was arranged as the physical exercising intervention ended (Figure 1). Twelve individuals participated; two did not suffer from pain but wanted to improve their fitness. The following field note describes one of the physiotherapist’s considerations about the participants’ pain and body awareness:

The participants seem willing to perform the training, but I doubt whether they feel their bodies, and they sometimes train without considering pain and limitations. We must pay attention to that!. (Field note 04.10.2019)

Because some participants suffered much pain, one of the physiotherapists offered individual assessments and developed individual exercise programs based on the findings (Figure 1). The physiotherapist’s approach was biopsychosocial, and she communicated the findings to the participants alongside pain education. Five participants were examined; each examination lasted about an hour. For one participant, there was a good association between clinical and earlier reported X-ray and scanning findings. For the others, the assessment indicated neoplastic pain with altered nociception. Furthermore, the assessment revealed red flags for one participant who was assisted in further contact with the health care system.

At the beginning of the therapeutic exercising, the physiotherapists tested nine participants with isometric back extension, strength in the abdominal muscles, core stability, and sit-to-stand test. Two had normal values, while the others had reduced strength in the back, abdominal muscles and legs, and lacked stability. The physiotherapists planned a re-test at the end of the intervention but primarily used the tests as a guide for individual exercising.

The physiotherapists continued to build their didactical approach, as in the physical exercising intervention and worked with self-efficacy and an appreciative approach. The therapeutic exercising included a low-dose biopsychosocial intervention to help the participants cope better, understand, and manage their pain (Hochheim, Ramm, Amelung, and Özden, 2022). The exercises were based on evidence and focused on core stability, flexibility, and body-weight strength training at a basic level (Table 2) (Hochheim, Ramm, Amelung, and Özden, 2022; Kongsted et al., 2019).

Table 2. Examples of therapeutic exercising and the physiotherapists’ observations.

Therapeutic exercising
Purpose	Activity	Observations
Warm-up exercises	Walking: forward, backward, sideward with different arm swings	Difficult to let arm swing propagate through the body Difficult to follow music Some show signs of fear-avoidance pain behavior
	Exercises with big ball: Sitting and working with the back Balancing with support inly from one foot Prone on the ball – elevating on arm	Moving very carefully the first times Enjoying and having fun Learning to adjust the resistance Difficulties stabilizing Enjoying the efforts
	Standing with elastic bands: One arm backward, forward and lateral
Core stability, body-awareness and strength	Squat Standing and training with elastic bands for the upper extremity and core Supine hook lying – elevating the buttock with both or one leg, knees to the abdomen Supine lying – knees to the chest for abdominal muscles Quadruped or prone extending leg, lifting arm one at a time or crossed	Individually adjusted regarding position and number of repetitions Weak abdominal muscles Difficulties stabilizing
Improve aerobic capacity	Circuit training, fast walking, step ups, squats, push ups	Individual adjustments, which the participants learned to use
Cool down Flexibility and respiration	Stretching the leg muscles Respiration exercises Stretching the whole body Shaking arms and legs	Enjoying relaxation Difficulties using respiration adequately Some got pain shaking

Patient education about back pain, pain management, physical activities, and prevention was essential to the program. Those examined reported that in Syria, health professionals had advised them to stay bedridden. The evidence has outdated this approach (Luna et al., 2019), but it took a thorough educational process before the participants accepted the modern, quite different methods.

Due to the participants’ interest in understanding their pain, an evening event concerning pain management was arranged (Figure 1).

Pain management course

Based on the interventions’ developing focus on pain and preventive training, an evening event with the topic Pain, what is it, and what can I do about it? was arranged. All families in the intervention group were invited and encouraged to bring their children. Physiotherapy students engaged the children in playing activities to enable the parents to participate. Five men and three women representing five families participated with 18 children. Four of the men were participants in the therapeutic exercising intervention. Two physiotherapists (a male and a female) whom the participants knew from the weekly training sessions presented lectures using words, drawings, pictures, and a video. The written materials were in Arabic to secure the optimal benefit of the course, and the interpreter translated the oral presentations. The focus was on recent pain research, which views pain as a cognitive process based on biological, psychological, social, and contextual conditions (Hochheim, Ramm, Amelung, and Özden, 2022). Strategies for pain management were provided and discussed, and the participants were encouraged to reflect on life, worries, emotions, lifestyle, and sleep. Methods for relearning the brain and the central nervous system to manage chronic pain were presented, and the importance of movement to relieve the pain was discussed. The participants listened intensely and expressed their interest by reflecting and asking questions.

Training intervention 3 community-based health promotion and pain-preventing exercises

The ten-week training intervention, offered at the end of the therapeutic exercise intervention, focused on health-promoting and pain-preventing physical exercises and education (Figure 1). Four physiotherapy students led the intervention following the principles of therapeutic exercising and used SDT in their clinical reasoning. One of the physiotherapists whom the refugees knew from the previous sessions supervised the intervention. We scheduled the intervention to be a recurring offer weekly in the coming autumn seasons.

Findings and evaluation

The evaluation of the physical activity interventions was based on the physiotherapists’ daily field notes that reflected the observations and informal conversations with the participants. In addition, focus group interviews with a phenomenological approach were conducted to establish experiences, beliefs, and perceptions of the intervention. The interviews were conducted on two occasions: 1) at the end of the bicycling intervention and 2) at the end of the second intervention, the therapeutic exercising. It was not possible to gather participants for interviews about the first intervention, the physical exercising, as they were engaged in work and education.

The analysis of the focus group interviews followed four steps inspired by Giorgi (Malterud, 2012): 1) getting a sense of the whole and familiarizing themselves with data, 2) organizing data elements and identifying preliminary themes, 3) systematically identifying meaning units (codes) related to the themes, and 4) re-conceptualizing data and synthesizing the transformed meaning units into themes.

The field notes

The field notes from all sessions during the two main interventions, physical exercising and therapeutic exercising, were analyzed. The field notes were between a half and one-and-a-half pages per session. Although the field notes were created to guide fellow physiotherapists about the program, didactics, and observations, they were analyzed for developments in the participants’ use of the body, expressions about their bodily and mental wellbeing, pain, and sense of togetherness. A researcher who had not been part of the training conducted the analysis. The physiotherapists observed improvements in some participants’ movement patterns and development in bodily expression. Likewise, the field notes described development in fitness, gross motor skills, and the joy of exercising. The latter was present during the whole season, but the situations creating joy and togetherness were developed to follow up on the participants’ mutual recognition.

It was consistent in the field notes that the men only showed up sporadically, although the physiotherapists offered them adjusted training. In therapeutic exercise, on the other hand, the men participated as much as the women did because they found it relevant to their pain. The participants understood the physical and mental benefits of being physically active. However, putting this knowledge into practice in a demanding everyday life was difficult, reflected in fluctuating attendance.

The field notes revealed that the participants needed help understanding the meaning of testing, so only three were tested twice. The first test was performed at the initial therapeutic exercise session, and the re-test at the end of the intervention. They had all improved between 30 and 200% despite the training only being once a week.

Evaluation of the bicycling intervention

The students who led the course conducted a focus group interview with the three women (W1-W3) who completed the intervention. Three themes were identified: increased self-confidence and independence, the multifunctional bicycle, and recommendations to others.

The women expressed that the intervention had been challenging but also very satisfactory. W2 had yet to learn how to cycle appropriately but continued practicing at home with help from her husband. The others were confident they would use bicycling for transportation and take trips in the countryside with the family. Learning the problematic task of cycling increased their self-confidence:

I also gain more faith in myself because when I can cycle alone in the traffic, I gain more self-confidence; I become stronger, yes, more confident. It is crucial for me to become like the other women in Denmark regarding everything. (W1)

The women felt more robust and independent, which had been their primary target, and they would encourage other women to do the same:

I am so pleased we have learned to ride a bicycle. Not just me personally, but it gives us women job opportunities in home-care. (W3)

Evaluation of the therapeutic intervention

A focus group interview evaluated therapeutic exercising. The project manager was the moderator of the interview conducted with eight participants. The interview guide is presented in Table 3. An assisting interviewer and the interpreter were present and assisted where necessary.

Table 3. Interview guide for focus group interviewing.

Overall impression of the sessions. Specifying what was good and what could be different. Understanding of reasons for suffering back pain. The individual assessments. Understanding the meaning of interaction between moving and resting for the back problem. Knowing how to relieve the pain. Beliefs about continuing the exercises at home.

The interview structure was open, and the participants were encouraged to bring up whatever they had on their minds. The moderator kept track and recognized the importance of the participants’ spontaneous expressions as they revealed what was essential for them. The interviews were audiotaped and transcribed verbatim.

The analysis generated six themes: overall satisfaction, individual assessment, individualized training, the students’ role, self-efficacy, and social connections. In the following, we present the themes.

Overall satisfaction

All participants expressed overall satisfaction with the organization and content of the training sessions. They appreciated that the children were cared for during the training. The participants valued the training because navigating the healthcare system was difficult. They felt safe and in good hands with the physiotherapists.

Individual assessment and individualized training

The participants appreciated the individual assessment offered to those suffering from back pain. They had never experienced such a thorough examination before. The analysis showed the participants felt recognized and appreciated the physiotherapist’s explanation of the findings. It was very satisfactory and provided insight into their back problem and pain management strategies. The follow-up in the training sessions with individualized practical learning and bodily awareness extended the understanding. The participants said they had learned how to relieve the pain and understood the importance of continuous movement despite the pain. One participant had been in so much pain throughout the intervention that he could not participate much in the exercises. However, he joined the sessions because he experienced the benefit of the feeling of togetherness. Another participant expressed that the training had decreased pain and increased her bodily wellbeing and functioning.

The two participants, who did not suffer from pain, expressed great satisfaction in being provided with more demanding, individualized exercises. They felt more robust and in better shape while they, at the same time, benefited socially from being part of the group.

The student’s role

The physiotherapy students’ role was a theme brought up by the participants. They emphasized that the students had been attentive and actively engaged in the training sessions. The students provided individual guidance during the exercises, which enabled the participants to feel the difference when performing correctly. Participants described the students as skilled, friendly, pleasant, and good at demonstrating and explaining individual exercises.

Self-efficacy and social connections

The participants’ self-efficacy regarding continued exercising at home testified to their awareness of the training as a preventing activity and a method to alleviate pain. This emerging awareness of self-care and behavioral change may be interpreted as individual empowerment.

The participants gained insight into various exercises and appreciated exercising together. Participants spontaneously expressed their sense of safety, mutual respect, and togetherness. They enjoyed being part of the training community and being together, which led to new social connections. One of the women expressed:

The most important thing about the exercise team is to get the body moving, and it is also lovely to meet every week, even if we are sometimes exhausted.

Although they met daily at the language school in the formal integration program, the participants had not previously felt part of the same social community. Through the training sessions, they interacted more and gained personal relationships. The families with small children expressed great joy in developing closer relationships with each other due to their children’s acquaintance during the childcare arrangement. Thus, relations among the families derived from friendships among the children, leading to private social meetings between the families. There was a large and unanimous wish to be part of a similar training intervention in the future.

Discussion

The study provides insight into many of the challenges physiotherapists face when working group-based with resettled refugees from Syria but also the benefits the participants achieve.

The physiotherapists’ multifaceted and expanded clinical reasoning is illustrated in Figure 2, which comprises the different elements physiotherapists must consider when working group-based with refugees. The challenges were partly language issues, but primarily that the group suffered poor health (Nielsen et al., 2023), little surplus, and faced many demands in their everyday life adapting to the Danish rules and requirements for themselves and their children. Physiotherapists must consider the individual’s resources and adapt the activities to the group and the individual.

Figure 2. Clinical reasoning model of health-promoting group-based interventions.

Clinical reasoning centered around the group’s interaction.

Read the detailed description of this figure

Pain management, the context, linguistic potentials, and the individual capacity affect each other and the group’s potential for development.

The adaptation also involved considerations and discussions within the group about addressing gendered training with separate rooms and shielding. However, it became less important as the group became familiar and got to know each other better. Gender was only an internal issue among the refugees, and it was never a problem that the male physiotherapist and the male students instructed exercises and manually guided the women. However, they always asked for permission to use a guiding hand.

The physiotherapists’ salutogenic perspective on health determinants implies that engaging refugees in health-promoting physical activities should primarily cause wellbeing and self-confidence and secondarily benefit disease prevention (Becker, Glascoff, and Felts, 2010; Quennerstedt, 2008). The refugees’ health was rooted in their situation as resettled in a foreign country, which made it essential for the physiotherapists to enhance a positive health perspective. The training provided the participants practical insight into exercising and a bodily understanding of the connections between physical activities, musculoskeletal pain, mood, and self-management. To some extent, the participants perceived increased control over their health, which aligns with the goal of health promotion (World Health Organization, 1998). Those who followed the training intervention 2, therapeutic exercising, primarily reported it. In addition to physical activity, it was also essential for the participants’ health to develop social connections and a sense of togetherness. Social participation and access to social capital seem to modify the risk of poor mental health (Lecerof, Stafström, Westerling, and Östergren, 2016).

The participants developed individual empowerment that also entails relational aspects because the individual’s self-efficacy and sense of control are socially embedded (Kearns and Whitley, 2020). However, the participants did not improve their control as a social group with decision-making power (Andersen and Bilfeldt, 2017). This could be because the activities were individually tailored and not a shared responsibility, although they worked together to practice the activities.

The participants also became familiar with the joy of movement and body awareness. They demonstrated self-efficacy beliefs in continuing physical activities and expressed their hopes and incentives for participating in future activities. However, the March 2020 COVID-19 lockdown may have affected the participants’ physical activities. It could go both ways; thus, they might have had more time to exercise, go for walks, and play with the children, or they may have stayed inside because of fear of getting the disease. A study from Qatar shows that the COVID-19 lockdown decreased physical activity and increased sedentary time (Hermassi et al., 2021), and a similar pattern may exist among our refugee study population, but we did not systematically examine that.

It was difficult for the male participants to change their views on physical activity as part of a health promotion perspective. This is consistent with the study by Ryom et al. (2022), which found that male refugees perceived physical activity as a means to cope with extrinsic factors such as sports or job demands. The findings indicate that health promotion efforts toward making men more physically active need a different approach (Ryom et al., 2022). In the present study, male participants only expressed their views in confident talks with the male physiotherapist. They did not express their attitude in the AI workshop or the initial training content discussions. This could be due to courtesy or because they would not share such barriers with the women. Future research should address how to involve men and identify their incentives to exercise as part of an active everyday life.

The action research approach with a high degree of participant involvement required physiotherapists to have a flexible mind-set and the ability to make adjustments and amendments based on observations and statements. Their clinical reasoning integrated cognitive, psychomotor, and affective skills to consider how the interplay between the cultural, linguistic, and social contexts interacted with the refugees’ physical and mental health (Figure 2). Although physiotherapists often use group-based training, we have yet to identify essential aspects of their clinical reasoning in working with groups. However, equally distributed attention from the physiotherapist to the group and individuals can positively affect a group and make each individual feel recognized (Arntzen, Øberg, Gallagher, and Normann, 2019; Lindahl, Madsen, and Dresner, 2022).

The current project’s physiotherapists built on their expertise and knowledge of the participants’ preferences, which were uncovered through mutual interaction. The physiotherapists’ clinical reasoning was adaptive, iterative, and collaborative, as described by Huhn et al. (2019). The biopsychosocial model’s interrelationships and pathways among biomedical, psychological, and social/contextual factors are complex as the factors influence each other reciprocally (Karunamuni, Imayama, and Goonetilleke, 2021). The refugees’ life context seemed to influence biomedical symptoms and psychological resources.

Physiotherapists’ clinical reasoning in health promotion initiatives is scarcely described, but Elvén, Hochwälder, Dean, and Söderlund (2015) developed a clinical reasoning model addressing behavior change. The model includes elements used by the physiotherapists in the present study. They, e.g. addressed contextual factors, the patients’ capabilities and skills, beliefs in outcome expectations, and self-efficacy (Elvén, Hochwälder, Dean, and Söderlund, 2015). The current study included an open mind and cultural sensitivity in the pre-defined values, recognition, appreciative collaboration, and mutual support. These components guided the physiotherapists in supporting the refugees in overcoming some barriers, which may be more important than a traditional outcome of physical activity. A qualitative study of trauma-afflicted refugees’ experiences with physical activity identifies an over-arching theme of physical activity as a process of building resilience as participants experienced improvements in physical and mental health domains (Nilsson et al., 2019). Increased self-awareness and self-confidence were seen as important additional benefits, and mitigating daily stressors provided a sense of relief and recovery (Nilsson et al., 2019).

The theoretical framework for the current study has proven robust, as self-efficacy is a determinant of adherence to physical activity (Areerak, Waongenngarm, and Janwantanakul, 2021). The SCT theory considers the individual’s past experiences as a factor to determine whether behavioral action will occur. These past experiences influence reinforcements and expectancies, shaping whether the individual engages in a specific behavior and why. Additionally, outcome expectations from oneself and significant others play a role (Bandura, 2004). A study of Iranian girls revealed outcome expectations and self-efficacy to antecedent physical activity. Social support and parents’ attitudes to physical activity positively influenced the habits of children and adolescents (Taymoori, Rhodes, and Berry, 2010). We consider the possibility that the refugee parents attending the physical activities will forward a positive attitude to their children.

There is some evidence that enjoyment determines adherence to being physically active (Creighton, Paradis, Blackburn, and Tully, 2022; Wilcox et al., 2000). In the current study, the joy and mutual support among the participants and their physical and mental health improvements may have encouraged outcome expectations and strengthened self-efficacy to maintain a positive attitude to physical activity. Including physical activities in the mandatory integration program could increase awareness of health and health actions. In line with the SCT, including refugees in leisure sports and other local physical activities in the community could provide social support with health and integrative benefits for refugees through a change in the surrounding environment.

Limitations of the study

The lack of a pre-and post-measurement of the participant’s physical capacity can be perceived as a limitation, as this would have provided knowledge of the physical effects of the interventions. It might have motivated some to increase their efforts and gain positive reinforcement through measurable improvement. However, we found it essential to create a safe environment without the pressure to perform but explore and enjoy bodily experiences and togetherness.

We used the advantages of the PAR approach and prioritized involving the participants as much as they could manage to elaborate on the content, organization, and mutual cultural knowledge sharing. The participants were involved from the start in the AI workshop, the specific content, organization, and adaptation of the physical activities, and the organizing of special issues of interest (pelvic floor, pain course, and bicycling). However, we did not fully exploit the method’s aim of social change, and the participants were not ready to, e.g., engage further in sports clubs due to little surplus and lack of economic resources.

The interviewed participants’ positive attitude to the intervention could be due to a social desirability bias as well-known project staff members conducted the interviews. However, we praised that the participants felt safe and confident during the interviews. We might have gained a different understanding if we had interviewed those who dropped out from the training intervention 1 Physical exercising. Field notes from informal conversations with the non-attendees indicated that reasons for their drop-out were related to a busy everyday life with mandatory obligations in the integration program, care for children and home, and challenges with transportation, which all contributed to little personal surplus. In order not to put further pressure on them, we decided not to elaborate on these statements in formal interviews.

Conclusion

The study presents the development of an extended framework for physiotherapists’ health-promoting clinical reasoning when working group-based with refugees and simultaneously considers the individual’s physical and mental capacity. The salutogenic perspective on health promotion formed the theoretical basis for the practical approach entwined with social cognitive theory and self-efficacy. The physiotherapists based the health-promoting intervention on a salutogenic approach and developed a clinical reasoning model integrating group-based training and the individual’s capacity in the light of socio-cultural and linguistic potentials. They worked with a high degree of user involvement and an appreciative approach, leading to ongoing organizational and socio-cultural amendments for the group and adjustments for the individual. The intervention stimulated the participants’ physical activities, wellbeing, sense of togetherness, and exercise enjoyment. They gained insight into the benefits of physical activity, and some expressed self-efficacy to continue and reported being more physically active, stronger, and in better shape. Those suffering from pain learned how to use strategies for self-management.

Implications of the study include that when physiotherapists work with people from a foreign culture, they must integrate the salutogenic perspective, be very attentive to each participant’s needs, and recognize cultural and personal limitations. Building up mutual trust is essential, and despite language barriers, user involvement and appreciative collaboration are the means. Future studies should investigate physiotherapists’ group-based clinical reasoning and further explore how to implement the salutogenic perspective in health promotion.

Acknowledgments

We would like to thank the participating refugees from Syria for their involvement and contribution to developing the intervention. We are also grateful to the four physiotherapy students who assisted during the therapeutic exercises, Andreas Lambrecht, Frederik Hvolbøll, Alexander Kehrenberg, and Jacob Skipper, and to the three students who led the cycling intervention: Maja Højer Andersen, Kathrine Bloch Køser, and Dorthe Frimand Hansen. Furthermore, we thank the four students who led the community-based health-promoting and pain-preventing exercise intervention: Katrine Mogensen, Sascha Hansen, Robert Berg Hansen, and Katrine Kindtler Krag-Andersen.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the A.P. Møller Relief Foundation [Grant number 12014].