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Understanding the perspectives of Syrian refugee women toward their health and physical activity needs… Kallas, Nadine 2017

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UNDERSTANDING THE PERSPECTIVES OF SYRIAN REFUGEE WOMEN TOWARD THEIR HEALTH AND PHYSICAL ACTIVITY NEEDS AS THEY BECOME INTEGRATED INTO CANADIAN SOCIETY  by  Nadine Kallas  BKin, The University of British Columbia, 2013  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Kinesiology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   September 2017  © Nadine Kallas, 2017 ii  Abstract The inclusion of migration as a predictor of health is seen as a significant advancement in Canadian health research. However, further investigation concerning the health outcomes of different immigrant groups has been suggested, especially refugees whose health statuses may be lower than voluntary migrants (Vang et al., 2015). Physical inactivity has been reported by the female immigrant population as a result of migration stressors and barriers to participation in Western communities. With a specific focus on Syrian refugee women, this study used a feminist interpretive approach to examine their health and physical activity needs as they settle into Canadian society. The purpose was to examine how their views and lifestyles have been influenced by their integration into Western culture as well as to determine the roles of settlement-related support systems in this transition. Using qualitative research methods, Syrian women who have recently settled in the Metro Vancouver region (n=11, <2 years in Canada, 18+ years old) were identified and interviewed. Data was coded using Nvivo software and themes from interview transcripts were established using thematic analysis. A number of definitions of health were provided by the women early in the interviews where they attributed the maintenance of health to specific behaviors and qualities. These behaviours were also reflected in actions taken to attain healthy lifestyles. Since coming to Canada, the majority of the women reported a better overall state of health despite some experiencing mental health issues. Improvements in health status were primarily linked to an increase in accessibility to resources and healthcare, as well as to their increased physical activity levels in Canada. Social supports provided them with the ability to deal more effectively with their existing struggles as well as empowering them to challenge cultural and gender norms. Participation in formal physical activity pursuits and other forms of community engagement was limited for some women, however, due to the time required to fulfill other settlement needs. My findings suggest that this group of women have demonstrated a degree of resiliency in developing healthy lifestyles but clearly require more time and specific forms of support to achieve their goals.  iii  Lay Summary In communities hosting Syrian refugees, there have been a number of initiatives to conduct research on settlement, integration, and long-term health outcomes. The purpose of this study was to explore the perspectives of Syrian refugee women on health and physical activity and to understand how their views and actions are being influenced by their migration to Canada. This is particularly important given that Canada is considered to be a major immigrant-receiving country. Through the investment in studying this specific immigrant group, we are able to determine how Canadian society can best facilitate healthy integration and settlement as well as examine the role of community-based physical activity in promoting healthy lifestyles for immigrant women. iv  Preface This master’s thesis is original, unpublished, and independent work by author, N. Kallas. The study received ethical approval from the University of British Columbia’s Behavioural Research Ethics Board (UBC BREB # H17-00112). v  Table of Contents  Abstract .......................................................................................................................................... ii Lay Summary ............................................................................................................................... iii Preface ........................................................................................................................................... iv Table of Contents ...........................................................................................................................v List of Tables ............................................................................................................................... vii Acknowledgements .................................................................................................................... viii Dedication ..................................................................................................................................... ix Chapter 1: Introduction ................................................................................................................1 1.1 Purpose and research questions ...................................................................................... 4 1.2 Theoretical framework .................................................................................................... 5 Chapter 2: Review of Literature ..................................................................................................7 2.1 Exploring discussions of ‘health’ and ‘migrant’ ............................................................. 8 2.2 Immigration and health: distinguishing refugee health .................................................. 9 2.3 Physical activity trends in newcomers .......................................................................... 13 2.4 Women in displacement and conflict ............................................................................ 16 2.4.1 Experiences of Syrian refugee women ..................................................................... 18 2.5 Syria: Understandings of health and physical activity .................................................. 20 2.5.1 Role of education ...................................................................................................... 22 2.5.2 Influence of religion .................................................................................................. 24 2.6 Summary ....................................................................................................................... 27 Chapter 3: Methodology..............................................................................................................28 3.1 Research site ................................................................................................................. 28 3.2 Sample and recruitment ................................................................................................ 29 3.3 Data collection .............................................................................................................. 33 3.3.1 Semi-structured interviews ....................................................................................... 34 vi  3.3.2 Background questionnaire ........................................................................................ 38 3.4 Data analysis ................................................................................................................. 39 3.5 Ethical considerations ................................................................................................... 41 3.6 Methodological challenges and limitations .................................................................. 42 3.7 Reflexivity: my positionality in the research ................................................................ 46 Chapter 4: Findings and Discussion ...........................................................................................50 4.1 Background of study participants ................................................................................. 51 4.1.1 Participants’ demographic characteristics ................................................................. 51 4.1.2 Education and previous employment ........................................................................ 54 4.1.3 Experiences of displacement..................................................................................... 56 4.1.4 Syrian culture and lifestyle before displacement ...................................................... 59 4.2 Health literacy and physical activity practices.............................................................. 61 4.2.1 Perspectives and experiences of health ..................................................................... 62 4.2.2 Engagement in healthy lifestyles .............................................................................. 69 4.2.3 Syrian health and physical activity culture: prior knowledge and its effects ........... 72 4.2.4 Self-reported physical activity before migration ...................................................... 79 4.3 Cultural fluency and integration in Canada .................................................................. 81 4.3.1 Community engagement in Canada .......................................................................... 82 4.3.2 Self-reported physical activity after migration ......................................................... 86 4.3.3 Experiences of a new health and physical activity culture ....................................... 90 Perspectives of participants living with disability ............................................ 95 4.3.4 Attitudes towards western health and physical activity culture .............................. 101 Chapter 5: Findings and Discussion .........................................................................................107 5.1 Significance of study................................................................................................... 112 5.2 Study limitations and future directions ....................................................................... 113 References ...................................................................................................................................116 Appendices ..................................................................................................................................130 Appendix A : Interview questions .......................................................................................... 130 Appendix B : Background survey ........................................................................................... 132 vii   List of Tables Table 1: Study participant profiles ................................................................................................ 53 Table 2: Education attainment of participants .............................................................................. 54 Table 3: Broad definitions of health ............................................................................................. 62 Table 4: Self-reported health after migration ................................................................................ 63 Table 5: Self-reported physical activity prior to migration .......................................................... 79 Table 6: Community engagement in Canada ................................................................................ 83 Table 7: Physical activity participation post-migration ................................................................ 86 Table 8: Physical activity levels post-migration ........................................................................... 88               viii  Acknowledgements I would like to express my appreciation for, and acknowledgement of those who have inspired, guided, and supported me throughout the pursuit of this thesis. First and foremost, I would like to thank my supervisor Dr. Patricia Vertinsky who has guided me with her wisdom and provided me with support to pursue the research I am passionate about. Your mentorship is very appreciated as it has allowed me to develop as a researcher. Your passion to educate has provided me with endless encouragement to persevere and challenge myself intellectually.   I would like to thank members of my committee, Dr. Andrea Bundon and Dr. Deidre Kelly, whose knowledge and experience with qualitative research has provided me with valuable insight throughout the duration of this project.   I would also like to thank my friends, colleagues, and all who have supported, pushed, and continuously believed in me. In particular, I would like to thank my dear friend, Halah Zumrawi, for her support during the writing of this thesis. I would also like to thank Dr. Brian Wilson, Victoria Felkar, as well as my fellow Kinesiology graduate students and faculty for their help and support as they extended their assistance and wisdom throughout my graduate degree.   Finally, I would like to thank my dear family who have always been there to remind me of the importance of doing the things I love and who have provided me with the necessary supports to pursue higher education. I especially would like to thank my husband, Mohammad Badran, who has provided me with tremendous emotional support. Your experience as a fellow graduate student and encouragement as a loved one has made this process possible and I couldn’t have gone through it without you. Last but not least, I want to extend a special thank you to my baby whom I have been carrying during the last seven months of my degree program and who has continuously been my motivation to strive.   ix  Dedication This thesis is dedicated to the refugees worldwide whose lives have been compromised by violence and whose views and experiences have been under-represented. I especially dedicate this work to the millions of Syrian refugees who have been killed, displaced, or whose lives have been otherwise affected during the prolonged Syrian crisis.   1  Chapter 1: Introduction Syrian refugees currently represent the world’s largest refugee population with an estimated five million “persons of concern” who have been displaced from their homes since 2011 (United Nations High Commissioner for Refugees [UNHCR], 2017).  Canada has played a key role in responding to this humanitarian crisis by welcoming and supporting nearly 40,000 Syrian refugees to resettle at the end of 2016 (Citizen and Immigration Canada [CIC], 2017a). Women and children have been disproportionately affected by the conflict as they have faced gender-related hardships contributing to a persistent invisibility of their needs and well-being (Women U.N., 2013).  The experiences of women during humanitarian emergencies has presented challenges and health concerns as shown in previous crises where they have been at increased risk of mental and physical health deterioration. Migration to new environments has placed women in unfamiliar roles and heightened their vulnerabilities as victims of conflict (Gasseer et al., 2004).  In the context of the Syrian crisis, displacement has been shown to be a particularly heavy burden on Syrian women and girls as reported by a number of scholars and journalists (Sami et al., 2014).  In neighbouring, as well as distant regions, Syrian refugees have faced significant changes in lifestyle and have had to redefine their roles as women and caretakers while adjusting to new socio-cultural environments (Charles & Denman, 2013). Their displacement to neighbouring regions such as Lebanon, Jordan, and Turkey has been shown to have significant impacts on their well-being. This is important to note given that these regions are primarily where the majority of Syrian refugees are initially displaced for periods ranging from months to years, prior to migration to other countries such as Canada (El-Khatib, Scales, Vearey, & Forsberg, 2013). In these neighbouring regions, the vulnerabilities of Syrian women and children has been 2  concerning given the lack of opportunities and accessibility to appropriate health care and education (Samari, 2017; Charles & Denman, 2013).  As expected, these pre-Canada migration experiences that have encompassed conflict, war, and gender-based violence, will have had an impact on the mental and physical health of these women. It is important to consider these experiences when evaluating their abilities and struggles to integrate into Canadian society.  Integration into new societies presents not only the uptake of new lifestyles for migrant populations but also puts into sharp focus their ability or (lack thereof) to manage within new cultural environments. The inclusion of migration as a predictor of health is seen as a significant advancement in Canadian health research. However, it has been suggested that further research is needed to explore health outcomes of different socio-economic immigrant groups, especially refugees whose health statuses are far worse than selected immigrants and who may not come with a foreign-born advantage, as observed amongst many immigrant populations (Vang et al., 2015). This is particularly important given that Canada is considered to be a major immigrant-receiving country and in consideration of its large inflow of recent migrants (especially to urban areas like Greater Vancouver), the addition of Syrian refugees is adding to the country’s diversity (Bonikowska, Hou, & Picot, 2016). From the 2011 Canadian census, 21% of the Canadian population were identified as foreign-born who arrived to Canada as immigrants (Chui, 2011). The immigrant population is surely rising given that Canada continues to welcome significant numbers of Syrian refugees into its communities. Reflecting on the impact of migration on the health and well-being of these individuals becomes increasingly important and could suggest promising practices that consider the cultural, ethnic, and religious diversity in Canada.  3  Currently there is limited literature on physical activity behavior amongst immigrant women and how their activities change as they adapt to a Canadian lifestyle (Tremblay, Bryan, Perez, & Katzmarzyk, 2006).  There is, however, a growing body of evidence to suggest that physical inactivity is common in particular cultural and linguistically diverse migrant groups, especially amongst female migrants (Vang et al., 2016; Newbold, 2009). This can be influenced by factors such as culture, the reasons for displacement, socio-economic status, and gender. In combination with settlement-related challenges, these factors have often resulted in social isolation and exclusion for refugee women (Shishehgar et al., 2016; Vang et al., 2015). Such concerns can be interesting to look at in contexts of Western cultures with respect to the ways in which new practices and perceptions related to health and physical activity can be developed by immigrant women from different cultural and belief backgrounds.  Investigating the role of physical activity and leisure participation on the well-being of migrant women in Canada has been echoed by scholars as a needed and important area of research (Suto, 2017; Frisby, 2011). Participation in community-based physical activity has been shown to be a useful tool for health promotion and its ability to alleviate the stresses of settlement amongst immigrant women in Vancouver communities, as shown in previous research projects (Lee, 2015; Suto, 2012; Frisby, 2011). I intend to build upon this line of inquiry but will focus on a specific subgroup of migrant women.     4  1.1 Purpose and research questions  In communities hosting Syrian refugees, there have been a growing number of initiatives to conduct research on their settlement, integration, and long-term health outcomes. This attention has been advocated for by government, community partners, settlement agencies, and researchers. The appropriate reception and integration of Syrian refugees thus requires a substantial investment into learning about their experiences given their distinctness and classification as migrants. Examining the reception and integration of Syrian refugees to Canada requires an understanding of culturally weighted values and experiences with respect to their overall health and well-being. In my study, I placed a specific focus on Syrian women given the “hidden crisis” and “invisibility” of Syrian women who are most victimized by the conflict (Parker, 2015).  A consideration of pre-migration experiences may provide insight into their motivations towards and understandings of Canada’s physical activity culture. Moreover, Syrian refugee women may be particularly difficult to reach out to in Canadian communities because of language barriers and cultural differences. As a feminist researcher, investigating some of the distinct challenges these refugee women may be encountering in Canadian communities could be a challenge in and of itself. However, as an Arabic speaking Muslim, born and raised in Canada with Syrian roots, and a strong advocate of health and physical activity, I may have an advantage in reaching out to these women. My cultural knowledge could be useful in understanding and interpreting their attitudes and experiences and potentially enabling women to fulfil their interests towards improving their health and well-being while upholding cultural traditions and values.  The purpose of this study was to explore the perspectives of Syrian refugee women towards healthy physical activity and to understand how their views and actions are being 5  influenced by migration to Canada. Considering the vulnerability of the Syrian community at this time, the proposed study intends to add value to culturally appropriate inclusion practices that can be meaningful to health care professionals and community service providers. My study was guided by the following research questions: 1. What are Syrian refugee women’s understandings of the role of physical activity concerning to healthy lifestyles?  2. How have their views about healthy lifestyles and physical activity been influenced by migration and introduction to Western culture?  3. What roles have settlement-related support systems played in facilitating physical activity and healthier lifestyles for refugee women?  1.2 Theoretical framework Interpretivist paradigms are the most appropriate methodological approaches for a study of this nature. study. This conceptual framework views reality as socially constructed and allows the researcher to capture and describe “lived experience” where possible (Ponterotto, 2005). Capturing these lived experiences is unique to interpretive research and within the context of health, physical activity, and migration, this conceptual approach was suited to help make sense of the social realities of Syrian refugee women as they adapt to a Canadian lifestyle. Given my interest in the views of women, feminist inquiry was the most appropriate theoretical framework to guide my study. This type of inquiry recognizes the significance of the impact of gender and power to the female experience (Jansen & Davis, 1998).  6  Moreover, feminist approaches to research encourage a common interest in exploring differences amongst women and deconstructing meanings through various socio-cultural contexts. Hence, a feminist interpretive approach served the goal of my research which was to establish trust and provide Syrian women a space to share with me their views and experiences. My feminist framework was positioned in the hope of promoting the “justice and well-being of all women”, which is a critical focus amongst feminist researchers (Devault et al, 2012, p. 207). Through qualitative interviews, I intended to create opportunities for refugee women to reflect upon and evaluate their own perceptions and understandings about their health and physical activity behaviors. As a woman interviewing other women, I hoped to utilize this approach to empower interviewees to recognize, critique and build upon their current health and physical activity behaviours. This research will further inquire into the persistent invisibility of women’s interests and needs with respect to migration and health (Vissandjee et al., 2007; Shishehgar et al., 2016). Muecke (1992) highlights the importance of this inquiry by weighing the gendered experience of migration and how this importance is amplified in the context of forced displacement. Feminist perspectives therefore, carry messages of empowerment and are concerned with gender inequality and the role society can play in undermining women’s values (Hesse-Biber, 2012).  A feminist inquiry into the attitudes and experiences of Syrian women was therefore a well-rounded consideration. Throughout this thesis, I will also reflect on the impact of my own position, gender, and identity and its influence on the research process, which is a common contemplation amongst feminist researchers (Jansen & Davis, 1998).   7  Chapter 2: Review of Literature In this literature review, I present current research on immigrants and the experiences they face with respect to their health and physical activity participation in new communities - particularly in this case migration to Canada. With increasing attention to migration as a determinant of health, there is a growing arena of literature that addresses intersections of health with migration. Given the purpose of this study, I specifically focused on literature discussing migration experiences of ethnically diverse populations and how their views and understandings have affected their integration into Western communities. Because my focus was on Syrian refugee women in particular, I sought out and valued studies that identified women as a key demographic in their community or were studying communities that held similar cultural and religious values.  Firstly, I discuss key terms and contextualize the population of study within the broad concept of “immigrant”. In this section, studies are reviewed that explore the general effect of migration on newcomers’ overall health and well-being amongst ethnic, and socio-culturally diverse groups in Canada and how refugees might be impacted differently. In the second and third sections, I highlight the role of gendered experiences on migration and consider why an understanding of women’s experiences is particularly important in health and physical activity research. Studies discussing barriers faced by immigrant women in regard to participation in community physical activity and the availability of community inclusion practices are reviewed.  This knowledge has been valuable for contextualizing the situation of Syrian refugees in Canada as well as exploring how gender, amongst other important and related factors such as cultural beliefs and socio-economic status, affect migration. Finally, I explore understandings of health in the context of the Syrian culture to provide an insight into how members of this population have 8  developed their understandings towards their own health and physical activity related behaviours. Gaps in the literature are identified throughout the review to build a case for conducting this study.  2.1  Exploring discussions of ‘health’ and ‘migrant’ The meaning of health varies across cultures and can hold different meanings for different people. The first definition of health given by WHO in 1948 was equated with the absence of disease as “a state of complete physical, mental, and social well-being”. Since then, it has been increasingly challenged for not fitting into the contexts of our constantly changing demography of populations and nature of diseases over the decades (Huber et al., 2011). Individualizing the ways in which people have understood health has facilitated the promotion of health and how they should change or maintain their health (Sartorius, 2006). Researchers have proposed the formulation of health as “the ability to adapt and to self-manage” (Huber et al., 2011). These ideas will be interesting to explore with respect to refugees’ ability to adapt to new health cultures after migration. In the review of studies, it is important to recognize that “immigrant” is an umbrella term which has been used across the literature to imply a diversity of migrant groups. Accordingly, it is imperative to be mindful of the diversity of immigrant groups and how their places of origin have influenced the ways in which they understand their bodies and health. Within Canada’s immigration policy for example, immigrants are placed within three broad categories: economic, family, and refugee migrants (Chui, 2011). They can also be defined as voluntary and involuntary migrants. Voluntary immigrants who apply to come to Canada, are carefully selected based on a point system given they meet a number of criteria, including having language and 9  work skills and a reasonable state of health. These differences contribute to the reasons for migration to new communities and have been recognized for contributing to the differing health states observed across diverse migrant groups (Newbold, 2009). Within this system, refugees are considered involuntary immigrants along with asylum seekers (CIC, 2017b).  Refugees are internationally recognized as a distinct immigrant group who are displaced “for reasons of race, religion, nationality, political opinion or membership in a particular social group [and have been] forced to flee his or her country because of persecution, war, or violence” (UNCHR, n.d.). Therefore, unlike voluntary immigrants who carry protective factors, such as high socio-economic statuses, language skills, and job experience that would enable them to excel post-migration, they are considered a socially and economically different group (Vang et al., 2016). In comparison to other migrants, refugees may therefore face additional challenges post-migration due to the reasons for displacement.  Thus, before I reviewed studies that have addressed immigrants’ health and physical activity experiences, it was important to be mindful of these various classifications of migrant groups. This may suggest limitations as well as affect the generalizability of these studies with respect to how they apply to the context of broad term refugee groups and within the context of the Syrian crisis. Nonetheless, it was important to consider the kinds of health practices and living environments that immigrants occupied prior to migration and how these demographics influenced their values and understandings, regardless of their reason for migration.   2.2 Immigration and health: distinguishing refugee health  The impact of migration on health has been attributed to a number of factors such as age, gender, visible minority status, and household income (Kwak, 2016). Studies continue to reveal 10  that migrants face additional barriers to maintaining or achieving healthy lifestyles. Poor health has been linked to the stress of migrating and integrating into new socio-cultural environments which has created challenges for migrants and been attributed to declines in health over time (Vang et al., 2016; Dean & Wilson, 2010). These stressors have been commonly identified as including cultural and language difficulties, discrimination, employment insecurity, inadequate child care, and unmet health care access needs and have been shown to become barriers to mental and physical health (Dean & Wilson, 2010; Shishehgar et al., 2016; Kalich, Heineman, & Ghahari, 2015). Consequently, immigrant groups have at times felt socially isolated and excluded in new societies which has contributed to poor mental health and illness (Shishehgar et al., 2016; Thomson, Chaze, George, & Guruge, 2015).  Studies have focused on the healthy immigrant effect; a phenomenon described as immigrants having a foreign-born health advantage when first arriving to Canada, which may diminish over time with increased length of residency due to individual and post-settlement factors (Kwak & Rudmin, 2014; Newbold, 2005). Despite past studies confirming this effect in Canada and in Vancouver (Kwak & Rudmin, 2014; Ng, 2011; De Maio & Kemp, 2010; McDonald, & Kennedy, 2004), a recent systematic review suggests that this trend is not a universal phenomenon, concluding that we should be especially considerate of different migrant groups and the reasons they have moved to Canada. This is because immigrants’ health can be strongly influenced by factors such as length of residency in Canada, age, and ethnicity (Vang et al., 2016).  Vang and colleagues (2016) highlight how self and state imposed selection may play a role in post-migration health amongst diverse migrant groups. For example, voluntary immigrants not only choose to come to Canada, but are also carefully selected and meet the criteria of good health. They are identified as economically active individuals who generally 11  have fewer chronic conditions and better health compared with the average host population (Vang et al, 2016). A limitation of studies such as these conducted in Canada is that health trends are reported using demographic identifiers that are essentially umbrella terms that bracket a diverse set of migrant groups into one large group. As a result, it is not clear whether there are reported differences amongst distinct ethnocultural migrants in Canada.  Refugees have experienced significant declines in their health compared to economic immigrants post-arrival to Canada (Newbold, 2009). For example, when the two groups were asked to self-report on their health, refugees reported poorer levels of health than skilled workers who have come to Canada with the financial means of supporting themselves (Pottie, Spitzer, Mohammed, & Glazier, 2008). Without such advantages, refugees become more likely to experience unemployment and poverty, which increases their exposure to ill health and compromises access to adequate care (Beiser, 2005).  In addition, their political, social, and physical experiences pre-migration affect their understandings and perceptions of host communities (Mawani, 2014). Many refugees have been subjected to traumatic events, especially in politically unstable environments, that prevent them from meeting the health requirements that govern migration (Caperchione, Kolt, & Mummery, 2009).  Forced relocation can create pressing health needs that voluntary immigrants do not experience due to the fact that they are more likely better prepared both psychologically and practically to transition into new communities with some level of language competency (Vissandjee et al., 2007; Kramer, Ivey, & Ying, 1999). Consequently, refugees may be arriving to new societies with already compromised health states and therefore contradicting the healthy immigrant effect observed amongst previous migrant groups. It is important to acknowledge this relationship between migration and health outcomes as it can vary with incentives and reasons behind relocation.   12  Hassan and colleagues (2015) have shown that with respect to Syrian refugees who have fled their countries due to a well-founded fear of persecution, their pre-migration experiences can create significant vulnerabilities. Associated with their experiences of conflict are increased levels of poverty, loss of livelihood, high rates of unemployment and limited access to life necessities, health care and education, which have all had a devastating impact on their mental and physical health. Previous health surveys have not sufficiently taken into account immigrants’ pre-migration experiences and the importance of considering them when assessing post-migration health has been highly recommended (Vang et al., 2016). They have also reported overall health trends of migrant groups, hence a distinction between refugee and economic migrant health has not been made explicit. Other studies have also excluded refugee groups entirely where researchers have felt that including them in their study “may not provide an accurate picture of their health” given their unique socio-economic statuses (Setia et al., 2011, p.667).  With the already known compromises in the health status and social well-being of Syrian refugees, it can be expected that their transition and integration into Canadian communities may take time and require additional resources. It can therefore be speculated that this particular immigrant group will experience amplified settlement-related challenges compared to previous immigrant groups who are more socio-economically stable and haven’t been burdened by displacement. Consequently, studying these refugee communities and accessing them may be challenging as they navigate through difficult and stressful processes of migration.  Again, it is important to highlight that immigrants are not a homogenous group and refugees are not likely to come to Canada with the health advantages carried by voluntary immigrants. Their health statuses may in fact improve over time given necessary access to 13  resources and services. Furthermore, as it is expected that refugees are more likely to experience poor pre-migration circumstances that has negatively affected their health, such as exposure to violence, infectious diseases in poor living conditions, and inadequate access to food and health care (Clinton-Davis & Fassil, 1992), there is limited evidence in the literature comparing these groups with respect to the observed trend amongst economically active immigrants. It is therefore important to recognize this gap in the research literature and the conflicting health outcomes for refugees as they are a distinctive socio-economic group and have different reasons for leaving their countries of origin (Shishehgar et al., 2016).   2.3 Physical activity trends in newcomers   Physical activity has been associated with positive mental and physical health benefits, such as reducing symptoms of depression and preventing chronic diseases, and contributing to an overall better quality of life (Penedo & Dahn, 2005; Warburton, Nicol, & Bredin, 2006). There is also a large body of knowledge showing the significance of leisure, an umbrella term that encompasses physical activity, and its contribution to health, well-being, and quality of life (Stack & Iwaskaki, 2009). Across the world, the importance of physical activity on overall health has been demonstrated time and time again. In Canada, physical inactivity has been targeted as an important public health issue and recognized as a contributing risk factor to chronic disease, including in groups that migrate to Western societies (Caperchione et al., 2009; Tremblay et al., 2006).  In contrast to the trends seen with Canada’s healthy immigrant effect, groups of immigrants have often been shown to be physically inactive compared to non-immigrants (Perez, 2002). Low levels of physical activity have been noted during the initial period after settlement 14  as migrants’ participation in physical activity has been given a low priority in light of time constraints and other pressing needs post-migration (Stodolska & Alexandris, 2004). Overall, inactivity can result from a combination of barriers that limit participation, a lack of knowledge or experience with physical activity, and/or discouragement from starting physical activity after settlement. Common barriers that have been highlighted across studies include: lack of knowledge about health and fear of injury, socioeconomic, cultural, and environmental barriers, as well as lack of time and energy (Caperchione et al., 2009; Stodolska & Livengood, 2006; Stodolska, 2000). Acculturation factors, such as English language-proficiency, have also been identified as limiting leisure time and affecting overall health and physical functioning in ethnically diverse groups (August & Sorkin, 2011). Moreover, studies have looked closely at immigrants’ adaptation in new host communities in relation to culture and religion and the role leisure plays in helping with settlement (Stack & Iwaskaki, 2009; Stodolska & Livengood, 2006; Stodolska & Alexandris, 2004). Although these studies have considered physical activity within a broader concept of “leisure” which encompasses activity during free time as well through community engagement (Stack & Iwaskaki, 2009; Howley, 2001), they have highlighted its significance with easing settlement related stress and coping in new communities. The value of exercise for immigrants as well as their involvement in physical activity prior to migration become important questions when assessing the impact of new physical environments on participation. This is particularly important given the growing evidence that physical inactivity is common in culturally and linguistically diverse (CALD) migrant groups (Dogra, Meisner & Ardern, 2010; Caperchione et al., 2009). Statistics from the Canadian Community Health Survey (CCHS) have been used to identify trends amongst ethnically diverse immigrant groups with respect to their physical activity behaviors in Canada and the changes in 15  participation over time.  Immigrants of European ancestry for example, were generally more physically active than non- European immigrants (Tremblay et al., 2006). Few studies, however, describe participation among specific ethnic groups or consider how different groups variously view their physical activity needs.  A major limitation of using the CCHS to identify trends is that data represents self-reported physical activity (Tremblay et al., 2006). It is well known that the accuracy of self-reporting can vary across different types of data collected. In the case of physical activity, as one can imagine, overestimation in self-reporting can be an issue.  Another important issue to note is that many studies that have looked at physical activity patterns through self-reporting have not focused on activities beyond organized physical activity, such as occupational or household activities (Sternfeld, Ainsworth, & Quesenberry, 1999). This could imply a limitation across studies of identifying standardized and culturally sensitive measures of physical activity and therefore, trends need to be interpreted with caution. Across multiple studies there is limited evidence related to gender differences in physical activity amongst ethnic migrant groups. In Canada, female immigrants across all ethnic groups have generally reported engaging in less physical activity than males, regardless of time since immigration (Tremblay et al., 2006). In addition to the identified settlement-related barriers, the reality of finding appropriate time to engage in prescribed physical activity for some immigrant women may be a large source of discouragement. Thus, it is important to consider not only self-reported physical activity but also how it is defined across different contexts and cultures. Salas, Raine, Vallianatos, & Spence, (2015) for example, have found that Latin American immigrant women reported high levels of non-leisure time activities, such as household activities. This could be considered as physical activity given a number of factors, including gender, culture, familial responsibilities, and immigration status. The manner in which study participants, such as 16  newcomers from various ethno-cultural groups, define and understand concepts key to the study of health and physical activity is an important question.  A need for culturally relevant health promotion programs and facilities that fit the needs of specific cultural groups has also been expressed by researchers (Salas at al., 2015; Devlin et al., 2011; Lee, 2015). Only a limited number of studies have shown that once economic and social barriers that constrained their participation were removed, immigrants start participating in certain kinds of activities (Stodolska, 2000). However, it may be problematic to generalize this to all ethno-cultural immigrant groups assuming they do not all carry similar experiences, beliefs, and perceptions towards physical activity. It is important to note that all the mentioned studies have been conducted across CALD groups or on specific ethnic groups, as well as across different variables such as age and gender. In this sense, it would be e difficult to foresee the types of barriers to participation in physical activity for Syrian refugee women considering their differing personal circumstances as well as pre-migration experiences. Exploring the knowledge and perceptions towards physical and health activity in this specific population promises to be helpful in contextualizing attitudes and possible barriers in a Canadian environment.   2.4 Women in displacement and conflict  Although half of the world’s refugee population consists of women, they have been under-represented in studies focused on migration and health (Shishehgar et al., 2016). This under-representation has been noted repeatedly by feminist researchers who claim that there has been a “persistent invisibility of women’s interest and needs and corresponding gaps in gender sensitive management of migration” (Vissandjee et al. 2007, p. 226). In a systematic review of studies addressing the healthy immigrant effect in Canada, Vang and colleagues (2015) report 17  that the process of integration has been especially difficult for immigrant women. This is because of the responsibilities associated with maintaining family roles, language difficulties, and their lower socioeconomic status, all of which have affected their abilities to settle into new societies. These challenges have varied greatly across different ethnic groups and it is unclear whether women from particular regions or cultures might face more challenges with integrating into Western cultures than others. Generally however, insufficient social support networks, food insecurity, and unfamiliarity with new cultural environments has generated an increased risk of ill health and mortality for immigrant women (Vissandjee et al. 2007). Studies have shown that women are therefore particularly more vulnerable than male immigrants given the distinct challenges they face and the additional domestic responsibilities they carry. Gender differences have also been noted regarding challenges in finding employment, sustaining mental health, and maintaining cultural roles in host communities, all of which have caused an increased risk to women’s health over time compared to men (Shishehgar et al., 2016; Kwak & Rudmin, 2014; Kwak, 2016).  Refugee women are more susceptible to facing mental health issues than non-refugee women (Hollander, Bruce, Burstrom, & Ekblad, 2011). Specific circumstances, especially those involving the exposure to war and conflict, have been shown to increasingly facilitate poor mental and physical health. Researchers have highlighted the need to address gender specific issues with respect to the abilities of women to cope with trauma (Kastrup, 2006). The effects of war have caused long-lasting disruptions of familial organization with unfamiliar roles or additional responsibilities often being placed on women (Kastrup, 2006; Murthy & Lakshminarayana, 2006). For example, women in politically unstable environments may be placed in positions as primary caregivers and heads of households after losing their spouses or 18  with the destiny of their partners being unknown (Usta & Masterson, 2013). Hence there has been an increasing recognition in the literature of the historically acknowledged reality that women are more vulnerable than men at times of war and conflict.  2.4.1 Experiences of Syrian refugee women   A significant number of Syrian refugees have been forcefully displaced from their homes to camps and rural environments and then to urban host communities like Lebanon and Jordan (Guay, 2015). Consequently, movement to new environments has created challenges in fostering social cohesion between Syrian refugees and host communities due to differences in class and socio-economic status (Guay, 2015). Differences in living standards between origins and host communities have consequently influenced the ways in which people perceive and experience health and well-being (Gessert et al., 2015). The ways in which they have accessed health care and been exposed to health-related practices may also vary depending on where Syrian refugees are displaced to as they leave Syria. These lived experiences of displacement may also vary greatly depending, not only on differences in class and socio-economic status, but also on factors related to gender.  In the midst of the current Syrian crisis, women and girls in Syria have been shown to be disproportionality affected and amongst the most vulnerable (Women U.N., 2013).  Numerous reports have accentuated the “hidden crisis” that exists as a result of the Syrian war and hence the invisibility of women and girls that are most victimized by the conflict (Parker, 2015). Moreover, a range of sources have reported the rise of sexual and gender-based violence, stressing the hardships associated with war experienced by Syrian women and girls (Usta & Masterson, 2013; Same et al., 2014). Due to international media coverage of this growing level 19  of violence, an inter-agency report by the United Nations (2013) was conducted to understand the gendered risks associated with the conflict. Through qualitative methods, researchers were able to expose the alarming consequences of the conflict including the rise of children as main sources of household income, high rates of early marriage, and the limited mobility of women and girls whose social roles and access to resources were restricted (UN Women, 2013).  These gender specific issues associated with conflict have contributed to the high incidence of post-traumatic stress disorder (PTSD) amongst Syrians as a result of witnessing war effects and sexual violence (Alpak et al., 2015; Wolfe, 2013). Consequently, there has been a significant compromise in the mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement which has affected the ways in which they are able to access health care and social support networks (Hassan et al., 2015). These pre-migration experiences of Syrian women are important when considering their roles and attitudes towards health and physical activity in new host communities following migration. They may also be significant in impacting their capabilities and motivations to assimilate into a new society.  Recognizing gender roles and how they may influence migration allows for meaningful inquiry into the unique experiences of immigrant women. It also provides insight into the concept of resiliency which may have a significant influence on the abilities of immigrants to lead successful lives post migration. Resilience has been defined as “the ability to thrive, mature and increase competence in the face of adverse circumstances” (Gordon, 1996, p. 63). It is especially challenging for refugees whose individual resilience is often determined by how they deal with trauma (Doron, 2005).  Moreover, differences such as educational and professional qualifications, language competency, and cultural values, have all been noted to affect the post-migration experience (Vissandjee et al. 2007). These differences can affect the resiliency of 20  settlement, both at the individual and the community level and, therefore, the inability to cope in new environments. With the recent migration of Syrian refugees into host communities, their abilities to be resilient has been a growing area of interest. It is yet to be discussed and examined in a Canadian context.   2.5 Syria: Understandings of health and physical activity Examining the general health status and physical activity practices of the studied immigrant population when in their country of origin could be useful in contextualizing their behaviours upon arriving in Western societies. Hence a discussion in this section will focus on studies that have considered factors that relate to the accessibility and role of physical activity in the lives of Syrian women before migration. Before this consideration however, it is important to look at general health and physical activity trends in the Middle-Eastern region as they very much appear to be relevant to the context of Syria.  Studies of epidemiology in the Middle-East have demonstrated a growing concern in the past few years with poor levels of health and physical activity. These population health studies have found that Arab females are less physically active and generally face more barriers to obtaining healthier lifestyles than men (Kahan, 2015; Musaiger et al., 2013; Hallal et al., 2012).  Moreover, Arabic-speaking countries have been found to have growing obesity rates accompanied with decreased physical activity (Badran & Laher, 2011). Rates amongst Syrian women have been found to be particularly alarming. Findings from a recent study indicated that 74% of Syrian women are either overweight or obese (Bakir, Hammad, & Mohammad, 2017). This study also discussed the cultural barriers that have limited Syrian women’s access to physical activity opportunities. These barriers have contributed to the sedentary lifestyles linked 21  to the reported trends in weight status. Aside from this particular study that focused on Syrian women, a limitation of the above cited studies is their wide demographic scope. The sample populations these studies report are health behaviours of individuals from a variety of Arab countries (including Syria). Consequently, the factors that might differentiate Syria populace from other Arab nations and identifying specific behaviours related to maintaining healthy lifestyles amongst Syrians, are limited. In addition, although adult physical inactivity is very common in the Muslim world, high rates of inactivity among Muslims is primarily due to its prevalence among a single subgroup: Muslim Arabs (Kahan, 2015).  Inactivity among Arab females has been linked to barriers such as lack of motivation, limited support, time, and opportunities to engage in healthy lifestyles. In addition, studies have shown that poor health has been associated with low levels of formal education, physical inactivity, and diet (Asfar et al., 2007; Shara, 2010; Fouad, Rastam, Ward, & Maziak, 2006). Tackling health issues in the Middle-East through increased physical activity has been a growing area of interest but also recognized as challenging given cultural restrictions and the magnitude of the problem (Bull & Dvorak, 2013). In addition to these observed trends in the Middle-East and in Syria in particular, the current lifestyles of Syrians amidst the outbreak of war over the past few years may have further compromised health and restricted accessibility to resources. This could very much present additional barriers and more concerning health issues for Syrian women. Moreover, given that there has been a limited number of studies conducted within Syrian communities with respect to health and physical activity, it is unclear how views and experiences have changed throughout different Syrian regions.  22  2.5.1 Role of education Access to data on physical activity culture and participation in Syria is limited but there has traditionally been a long history of sport involvement of Syrian athletes at the elite level. Nine Syrian women have represented Syria at various Olympic games between 1972 and 2008 (Karfoul, 2011). Despite the beginnings of civil war, a Syrian delegation of ten athletes (six men and four women) competed in the 2012 Olympics. In 2016, Syria sent seven athletes to the games, four men and three women. Outside this elite participation in sport, Syrian woman have had limited access to sport and physical activity opportunities (Bakir et al., 2017). Initial exposure to physical activity for Syrians appears to come from Syria’s compulsory sport education in state schools (Karfoul, 2011). This is in the form of physical education classes, but not much is known about the nature of these classes and whether or not they remain as one progresses to higher levels of schooling. Through the Syrian government’s current website and according to Syria’s Ministry of Development which oversees education, subjects that secondary students are required to take are made public. Regardless of academic streams that students have the option of choosing from (humanities and sciences), no reference has been made to physical education as a compulsory subject matter. Hence considering the experiences and accessibility of physical activity through the Syrian education system becomes an important inquiry.  In addition, education has been associated with higher odds of better self-perceived health so it would also be interesting to consider health statuses of women in relation to education levels they have attained (Blair & Schneeberg, 2014). Inquiring about educational experiences amongst Syrian refugee women could be particularly helpful in identifying differences in the engagement of healthy behaviors and attitudes towards physical activity. 23  The enrollment of girls in school is also an interesting area of inquiry given data has shown inconsistences with attendance. Between 2008 and 2012 for example, 68% of Syrian females from the corresponding age group of secondary school students were enrolled in school, while a small percentage of them weren’t actually attending (UNICEF, 2013). Regional differences can also be observed where school attendance rates in rural areas have been significantly lower than the national average attendance rates with especially high dropout rates recorded amongst young women at the secondary school level (CIC, 2015). With just over half (57%) of Syria representing an urbanized population (UNICEF, 2013), it is important to consider the exposure to education and hence, sport and physical activity exposure for women in rural areas. Moreover, due to insecurity with the current crisis in Syria, school attendance rates have significantly dropped creating a serious compromise on Syria’s education system and jeopardizing the well-being of women and girls (CIC, 2015; Teschendorff, 2015). As such, one can assume that Syrian refugee girls whose education has been interrupted as a result of the civil war likely have had little exposure to schooling prior to their coming to Canada. Barriers to participating in physical activity have been identified in the literature with respect to the Middle-Eastern culture and how gender and cultural roles have restricted girls from accessing these opportunities. Low levels of physical activity have been commonly found amongst Arabic-speaking women who have larger than average family sizes and bear the burden of household duties and child care, limiting opportunities to find time for themselves and hence participation in recreational activities (Caperchione, Kolt, Tennent, & Mummery, 2011; Asfar et al., 2007).  Within the context of Syria, barriers related to the roles of women have also been pointed out as restricting their access to sport and physical activity (Musaiger et al., 2013; Bakir et al., 24  2017). These barriers have included a lack of systemic resources such as shortages of female coaches for elite sport participation, as well as a general lack of motivation to be physically active amongst Syrian women due to socio-cultural barriers (Karfoul, 2011). Interestingly, these barriers have been especially noted in rural areas where time commitment to family responsibilities in relation to agriculture and farming is common (Galie, 2013). In addition, married women appear to be particularly affected by these barriers. Not only are Syrian females generally more likely to report poorer health than males, married women have the lowest levels of health, particularly those with low socio-economic statuses (Asfar et al., 2007). Those conditions stemming from gender and culture have impacted involvement in physical activity and seriously compromised the health of Syrian women in refugee camps (Women U.N., 2013). As well, since the start of the war, Syrian women have faced further barriers to pursuing healthy lifestyles. Therefore, according to the literature, marital, socio-economic, and educational status, can be important predictors of health and physical activity participation amongst Syrian refugee women.  2.5.2 Influence of religion  While there is a variety of existing religious institutions in Syria, 87% of Syrians identify with Islam (CIC, 2015). Examining the value of physical activity and health in the context of religion may help illuminate some of the reasons for physical inactivity amongst many Syrian women. Taking special care of the body and one’s health through exercise is a fundamental part of Islam and an advocated for health behaviour amongst Muslim sport feminists (Al- Haidar, 2004; Ghazizadeh, 1992). There is an existing debate, however, about the meaning of the Islamic veil and the role of Muslim women in sport (Stodolska & Livengood, 2006; Hargreaves, 2000).  25  This debate stems from different interpretations of the Quran about the ways women “should” practice physical activity while upholding religious duty, leading to different opinions and representations of Muslim women in sport with respect to Islamic modesty (De Knop, Theeboom, Wittock, & De Martelaer, 1996; Benn, Dagkas, & Jawad, 2011).  As a result, the veil (head covering) has been represented as either an expression of freedom and right to practice cultural diversity or as a form of oppression against women’s rights by male hegemony (Hargreaves, 2000; Amara, 2012).  Consequently, we see different forms of Muslim feminism and the role of the veil as a central piece in observing acculturation to Western values. The need for upholding religious duties has led to a discrepancy between positive attitudes towards sports and actual participation in sport by Muslim women in non-Islamic societies (DeKnop et al., 1996). Muslim immigrant women have identified barriers, such as the need for public modesty and the lack of sex-segregated arenas, as being major deterrents in practicing physical activity in non-Islamic societies (Benn et al., 2011; Caperchione et al., 2011; Devlin et al., 2011; Walseth & Fasting, 2004).  Muslim women have also expressed anxiety about exercising in public venues (Hargreaves, 2006). This could indicate the discomfort towards Western sport culture and the Western forms of representation of women and body image. The discrepancy between how the women view their own bodies in comparison with Western standards of body image may result in feelings of alienation within spaces of sports culture or environments such as gyms. Moreover, some Muslim women have expressed walking as a preferred form of exercise (Devlin et al., 2012). This form of activity may be easier for managing the needs of religious dress codes given the low intensity of exercise and that it is a type of physical activity that many have been previously accustomed to. Walking has also been a regular form of rural mobility in 26  non-Western communities (Porter, 2002) which could be a continued form of exercise post-migration for some migrants. Women may also seek exercise during “non-leisure time”, where they don’t necessarily seek specific leisure opportunities to be physically active. Immigrant women have previously described household duties for example, as an important source of physical activity (Salas et al., 2015). Stodolska and Livengood (2006) investigated the influence of religion on leisure behavior among immigrant Muslims and found religion manifested through the types of activities sought and attitudes and barriers towards participation in Western physical culture. They particularly noticed the importance immigrants gave to upholding strong family ties through family oriented leisure and concluded that “Muslim immigrants’ struggle to redefine their leisure lives and their religious duties in a new environment following immigration” (p. 312). Such differences in cultural practices between Islam and the West, may also indicate that Muslim women are not necessarily practicing at formal exercise arenas, but pursue various forms of exercise in segregation or in family dominant environments with their children and partners. This could be a preferred form of exercise given it may alleviate the stress of being a newcomer or an “outsider” in public spaces.    Due to the various ideological interpretations of Islam, it is clearly difficult to relate the experiences of all Muslim immigrants in Western societies and interpret them as one. In fact, for some Muslim women, the discussed issues may not be of any relevance to them or issues that they would discuss as affecting their health and physical activity participation in new socio-cultural environments. Evidently it is important to acknowledge the variabilities in defining exercise and how the different meanings of health may influence healthy behaviours and physical activity across different groups of Muslim immigrant women. Moreover, the roles of women in sport are often interpreted and represented in comparison to western femininities, 27  which could pose negative stereotypes about gender equality in Islam (Hargreaves 2006). Personal agency with respect to religion and the ways of practicing exercise in public has been recognized as an important aspect of this debate, expressed both by Muslim women as well as academics (Devlin et al., 2011; Hargreaves, 2006). This highlights the importance of acknowledging diversity in the debate on sport and physical activity participation by Muslim women and how it may be very different across contexts of migration, conflict, and cultures. It also shows how experiences of Muslim women are often regulated and influenced by political, religious, and cultural discourses both in their countries of origin and in the West. Clearly learning about different perspectives and how personal values have affected experiences in healthy behaviours across Muslim cultures remains a gap in the literature.   2.6 Summary Throughout this chapter, I have explored literature relevant to health and physical activity and discussed how this documented knowledge varies according to different cultural attitudes of the studied demographic group(s). Most importantly, I have used a feminist lens throughout my review of the literature and placed a special emphasis on the context of forced migration.  I have found that the literature has not thoroughly examined individual perspectives on health and physical activity first hand, as much as it has considered trends. By illustrating some gaps in the literature, I have developed a case for conducting a qualitative study that invests in the perspectives of a specific population of refugee women in order to identify the factors significant to their maintaining their own healthy lifestyles.  28  Chapter 3: Methodology  In this chapter, I begin by providing an overview of the Vancouver community and how Syrian refugees were recruited as study participants. I then discuss specific qualitative methodologies that were used to collect data and some of the challenges I encountered along the way. This is followed by an overview of how the data I collected was analyzed. The chapter ends with a discussion about the concept of reflexivity and how I felt my position as a researcher affected the study.   3.1 Research site The research site was located in the Metro Vancouver region of British Columbia. According to the 2011 National Household Survey, the most recent statistics available, the total population of Metro Vancouver was 2,280,700 with immigrants representing 40% of the total population (Statistics Canada, 2014). NHS data also reveals that Metro Vancouver immigrants primarily came from China, India, and the Philippines amongst twenty diverse countries. With the recent wave of Syrian refugees, the diversity of our immigrant population is on the rise. From November 2015 to January 2017, 40,081 Syrian refugees have been resettled in Canada (CIC, 2017a). Data on the number of Syrian refugees settled in the British Columbia region is only available up to the end of July in 2016. This total number was 2,610 (CIC, 2017a). Since several participants interviewed in this study resettled after this July date, it is expected that the number of Syrian refugees settled in this region has increased as more refugees are continuing to settle in Metro Vancouver.   29  3.2 Sample and recruitment As I was interested in interviewing a particular refugee group in the Vancouver area, I had to set specific inclusion criteria and therefore utilized purposive sampling, a common qualitative strategy (Bryman, 2012).  My inclusion criteria included women who have recently arrived in Vancouver as a result of being displaced by the Syrian crisis, either directly or indirectly. This meant that if they were displaced temporarily elsewhere and then came to Canada because they could not return to Syria, they were still considered eligible to participate in the study. In fact, this was the case for all my participants who had been settled in neighbouring regions around Syria for some time, including Lebanon and Jordan, before coming to Canada. I was primarily interested in interviewing Syrian refugee women who have migrated to Canada within the past two years and are currently living in the Metro Vancouver region. These group of women are representative of the recent wave of Syrian refugees that have been welcomed in Canada since 2015. As a result, Statistic Canada’s definition of ‘recent immigrant’ as any individual who has immigrated to Canada within five years (Chui, 2011) was disregarded, since such individuals may not have qualified as “refugee” as required for this study. No specific age range or socio-economic class was pursued but Arabic or English-speaking refugees were sought since these are languages spoken by the researcher.  Participants were recruited in multiple ways including through local non-profit organizations which provide immigrant services in the Vancouver community and through the University of British Columbia (UBC). The primary method of recruitment however, was through snowball sampling. This sampling tool was helpful in recruiting Syrian refugee women who were not as active in the community and therefore hard to locate. It is often used as a useful technique for finding concealed populations (Bryman, 2012).  30  The primary site of recruitment began at Collingwood Neighbourhood House (CNH), a local intercultural community facility that offers a variety of immigrant services. Through a colleague at the University of British Columbia who had been involved with CNH, I was able to connect with a woman who was an Arabic-speaking staff member at CNH who worked regularly with immigrant families. She had developed an English learning program for Syrian refugee families and expressed interest in my involvement to help promote the program for women. After connecting with her, I began attending the program weekly to interact with attending families and help in any way possible. Over several weeks, I had the opportunity to establish genuine relationships with a few Syrian refugee families and engaged in meaningful conversations about settlement and the experiences of newcomers with both the refugees and the English teachers. To promote more participation in the program and CNH and to get a chance to interact with women in a more private space, I offered a Zumba exercise class for immigrant women on two occasions. I hoped that this would entice more women to come to the program and eventually provide a way in which I could meet more potential participants. During this time, I had concerns about my ability to recruit enough participants for the study as revealed in my following field note: I am very frustrated today that no new women showed up to Zumba. I waited an extra hour hoping more women would show up but nothing. Fruits and snacks were also provided and set up for after the class so it is frustrating to see that this is continuing to happen. I’ve spent many weeks and many Saturdays at Collingwood and I am worried that I should have sought other strategies to meet this community elsewhere.   I was having a difficult time meeting Syrian women in the community, more so than I had anticipated or been led to believe through the research literature. After interacting increasingly with two particular women who attended the CNH program regularly with their families, I was able to recruit them as research participants. Despite the challenges in meeting this community, 31  volunteering through CNH served the purpose of rapport building with both the organization and refugees. The development of these relationships was very important as I was able to establish trust and a sense of community before moving to recruit research participants. I had also identified myself as a university student who was interested in conducting health and physical activity research with Syrian refugees. Transparency and rapport building with ethnically diverse refugee communities who are difficult to reach, and who uphold cultural standards that are different from Western philosophies and values, has been strongly recommended by researchers (Johnson, Ali, & Shipp, 2009). CNH thus eventually became an appropriate site to recruit the participants for my study.           Through this period of community engagement and outreach, I gained valuable knowledge about the Syrian refugee community whereby I was able to observe and evaluate to some extent, how some Syrian refugees have been integrating into Canadian society. This became an important mechanism for building relationships in which I invested time in non-research activities, which promoted co-learning, trust, and respect for the community (D’Alonzo, 2010). Once I began the first two interviews, I was able to recruit more Syrian refugee women through a snowball sampling technique by contacting other women the interviewees suggested.   Another site of recruitment was through the Student Refugee program at the University of British Columbia. One woman was from this community and had been living on campus with her sister. I had met her through a colleague who informed me about UBC’s Student Refugee Program (SRP) and connected us. The SRP is supported by an organization called World University Service of Canada (WUSC), which facilitates the arrival and resettlement of refugee students to come to Canadian universities to pursue higher education (Peterson, 2012). My interest in engaging with potential participants specifically through the SRP was that it would 32  provide access to a very specific population. The potential participants would not only be refugees and migrants to Canada. In addition, their migration would have been specifically facilitated through the lens of access to higher education. I was interested in exploring this distinction as I thought that these refugee students might provide different insights. Educational level is commonly connected to socio-economic status and as such, this group, with their differing purposes of migration, might bring to light perspectives I would otherwise not have had access to. Drawing upon multiple sources of viewpoints and experiences allows for data triangulation which helps ensure a study’s trustworthiness in representing perspectives (Bryman, 2012). Recruitment of interviewees from the university community was intended to explore the impact of higher education on Syrian women’s health attitudes and practices. The role of education on Syrian women’s health has been previously considered. For example, obesity rates were found to be substantially lower in women with advanced levels of education compared to women with low levels of formal education (Fouad et al., 2006). Unfortunately, I was only able to access one interviewee from this program who met the inclusion criteria at the time of the study. While having only a single participant’s perspective is far from the ideal, it is not without its merits. With only this singular perspective I knew I would have to be cautious in deriving conclusions but I still felt that this perspective had value as a case study within the wider research. The impact on education with health-related behaviors will be considered where possible in more detail in the upcoming sections of this thesis.  A total of eleven women were interviewed for this study. All of these participants were contacted by the researcher through either face-to-face interaction or by telephone. They all received an initial letter of contact which provided information outlining the purpose of the study and what would be expected from them. At the start of the interview, the women were provided 33  with a consent form and were asked to state that they have given their consent to participate as well as consent to being audio recorded. Nearly all participants were interviewed in Arabic, since most were either unable to speak in English or did not feel comfortable doing so. One of the interviews was conducted in English as the participant was fluent in both Arabic and English. Interviewees also came from a few different regions in Syrian including, Damascus, Daraa, Douma, and Homs (see table 1). Tables 1 and 2 provide further information on the demographics of participants, including how long they have been in Canada, age, marital status, etc. This information was collected from both the interviews and background survey, which was filled out by the researcher with the participants before the interview. All forms used in this study including a letter of initial contact, informed consent, and background survey were available in both English and Arabic. All documents that were translated into Arabic were done so with the help of Arabic speaking colleagues of the researcher.   3.3 Data collection Qualitative research methods have proven useful in learning about the perspectives of recent immigrant women in the context of health and physical activity participation (Meadows, Thurston, & Melton, 2001; Frisby 2011; Lee, 2015). This methodological approach provides flexibility as concepts are developed and refined in the process of inquiry (Bryman, 2012). It also allows for a “dynamic interaction between the researcher and participant [which] is central to capturing and describing ‘lived experience’” (Ponterotto, 2005, p.131). In addition, for the purpose of better understanding the views of Syrian refugee women, the study was informed by feminist research perspectives. Feminist researchers focus on the impact of gender and power to 34  the female experience and its influence on the research process (Jansen & Davis, 1998). As such, I felt that it was not only important to view my research results through a feminist lens but that it was crucial to intentionally formulate my research methodology in such a way that the aforementioned impact of gender and power was recognized and challenged. I was helped by my knowledge of the Middle-Eastern culture and gender roles in approaching and interacting with my study participants. This feminist viewpoint has been useful in promoting personal and interactive communication with research participants and diminishes the typical power relationship present in conventional research (Jansen & Davis, 1998). Semi-structured qualitative interviews were the primary method used to collect data in this study.   3.3.1 Semi-structured interviews Interviews are useful in that they allow people to be heard, especially those who are at times silenced or those who have not been given the opportunity to voice their perspectives (Bryman, 2012). Through qualitative interviews I was able to engage in meaningful conversations with study participants, providing them an opportunity to share accounts of their lived experience, particularly experiences related to displacement and conflict. It also allowed me, the researcher, to capture the moments in which women opened up and shared personal narratives that sometimes went beyond the questions posed. Through a semi-structured approach, the women were provided a platform through which they were able to express themselves without feeling constraint (Bryman, 2012).  Twenty questions were prepared in an interview guide (see Appendix A) and were used to generate a meaningful discussion about who each participant was, how she practiced and understood health and physical activity, and to what extent had displacement impacted these 35  understandings and experiences. While I approached the interviews with the expectation that these guide questions would be touched upon during the interview, I was also conscious of the inherent value of the flexible interview format which might allow participants to better express their narratives of lived experience. This perspective allowed me to interview using these questions as a tool to promote a natural flowing conversation with the women so that they would be as comfortable as possible in opening up about their lives and experiences. However, where the interview format and conversation style was able to produce a narrative without the prompting of questions or the use of prepared questions, I allowed this to happen and studied the resulting ‘tangents’. Moreover, interview questions were semi-structured and used strictly as a guide, hence subjects of discussion did not necessarily flow in the same order nor were questions used to redirect conversation to certain topics.  I started each interview asking preliminary questions like “tell me about yourself…what do you like to do in your free time?” and “what are your hobbies and interests?”. These questions gave women the opportunity to introduce themselves in a manner in which they saw fit and were intended to make them feel comfortable before being asked more personal questions. It also allowed me to gather important background information about them, such as how long they have been in Canada, where they were before migration, and what kind of educational levels they have attained. These preliminary interview questions helped establish rapport with the interviewees and eased us into the subsequent parts of the interview that were more intimate and self-revealing.  Once I felt that I had begun to have a sense of who these women were, their lifestyles and their recent experiences of displacement, I began asking questions related to their understandings of health and the extent of their physical activity experiences either before displacement, during 36  the migration process or after settlement in Canada. Throughout some of the interviews, I drew upon my personal experiences of physical activity participation in Canada in order to prompt the interviewee to share similar experiences or to inquire about their perspectives on their own, and also of their perceptions of Western health and exercise culture. At times, I referred back to my experiences when in Syria that signified specific aspects of the culture and asked interviewees if they had similar experiences in their home communities. As highlighted by Warren (2012), the interview is a social encounter where the researcher can use various techniques during the interview, such as role-playing, as a tool to assist the interviewee to tell their story. I did this when I felt that the women were not providing enough depth within their accounts.  For example, I often provided accounts of my personal experiences exercising as a Muslim woman in public spaces in Canada, modeling the kinds of descriptive experiences I hoped I would hear from them. I also used a lot of probing questions like “why do you think this happened?” and “how is this different in Canada?” and “how do you feel about that?” to follow up on new issues and inquire further about how migration has impacted them personally. This technique was useful in revealing underlying issues of displacement that have affected their health and physical activity experiences.  As the interviewer, I needed to consider variables such as voice, tone, body language and context which point to different interpretations of knowledge and stresses diverse ways of explaining the social world (Kvale, 1996). This allowed me to learn more about my interviewees’ personalities and provided insight into what kind of issues held particular meaning for them. When I asked participants to talk about their lives in Syria or how their health may have changed as a result of being displaced, for example, some became emotional, changed their tones of voice, or began referring to personal stories of the conflict and why they had fled Syria.  37  One particular interviewee talked about how she has been struggling to settle in Canada and described how it was impacting her daily life and her interactions with her family. Her tone of voice and emotional expression during this part of the interview revealed how much her mental health had been affected. I was able to highlight this in my field notes so that it can be considered during data analysis.  Furthermore, from some perspectives I felt that I was at an advantage because I was the one who conducted all interviews. Firstly, I was able to change ways in which I asked questions when I felt that conversations were not running smoothly. I learned new ways of probing questions moving from one interview to the next, eventually feeling more confident conducting an interview without referring to the interview guide as frequently as I did in my first interview. Secondly, if an issue I recognized to be important came up during an interview, I would continue inquiring about it, even though it was meant to be discussed later in the interview according to the guide. Overall, I played the role of facilitating discussions rather than directing them. As Bryman (2012) highlights, this semi-structured approach allows the researcher to facilitate the interview in accordance with the interviewees’ direction and responsiveness, which facilitated meaningful inquiry. Lastly, I was able to inquire about the contingency of experiences of women coming from the same regions in Syria. For example, on several occasions, I asked interviewees to confirm particular things that I had heard from others about how services related to physical activity were delivered in rural regions in Syria. This allowed me to evaluate if women perceived their cultural contexts in which they lived similarly and if they shared the same values and experiences. The interviews ended by giving interviewees the opportunity to talk about any topic of their choice, along with the opportunity to ask me any questions. Nearly all the women asked 38  about my involvement in university education and made further inquiries into the purpose of this particular study. Transcripts were transcribed into English from the spoken Arabic as interviewees either only spoke Arabic or were only beginning their English language learning process and therefore felt more comfortable being interviewed in their native language. Because of the barriers to English faced by interviewees, it was difficult to invite participants to read, comment on their interview transcripts, and share the general findings of the study. Although this form of follow-up with interviewees, also known as member-checking, is a practice of ethical mindfulness and contributes to the quality of data (Roulston, 2010), it was difficult to achieve as transcripts were not available in Arabic for them to read. Because of my awareness of this limitation due to language in advance of the interviews, I paid special emphasis on answering the inquiries made by interviewees related to the purposes of the study.  3.3.2 Background questionnaire  An optional background survey (see Appendix B) was completed either at the beginning of the interview with participants, or after the interview, by the researcher based on observations during the interview. It provided background socio-demographic data about the women’s age, educational attainment, time in Canada and prior locations, current employment, and existing health conditions. This information was collected to aid in data analysis in case it was not already determined during the interview.  The reason this survey was optional because I did not want to risk making the women feeling uncomfortable prior to the start of the interview. I simply stated that it would be helpful but not necessary.   39  3.4 Data analysis  Interviews were audio-recorded and uploaded onto a password-protected computer where they were transcribed verbatim into Word document files. As I listened to the audio files of the interviews, I transcribed them directly from Arabic to English. Field notes were taken when meeting participants and after interviews and kept in a research journal to capture my thoughts and observations during these encounters. These field notes were not analyzed in and of themselves, but rather were used primarily to supplement the process of drawing conclusions from my data. These notes included personal information about the women’s lives that were valuable in helping me to correctly interpret our conversations as presented in the form of a written transcript. Once all the interviews were transcribed, they were uploaded into NVivo 11 software, a qualitative data analysis program which was extremely helpful in organizing data and accessing tools to better interpret the data from the interviews.  A code book was created prior to the use of Nvivo where I developed themes from my research questions and study of the literature. A thematic analysis was used to construct deductive and inductive codes to analyze the data from the qualitative interviews. I created codes using a deductive approach drawn from my research questions and theory as well as through observations from close readings of the transcripts, an inductive approach, which is a hybrid approach to theme development (Fereday and Muir-Cochrane, 2006). These themes or “parent codes” also had “child codes” which were sub-themes that were created to better understand large complex themes such as “community engagement in Canada”. Further breaking down parent codes was helpful in organizing the write-up of my results as I was able to go beyond merely the description of the data to construct meaningful discussions related to my research questions. This allowed for an interpretive inquiry which is helpful in constructing meaning out 40  of the lived experiences and understandings of others (Ponterotto, 2005). This kind of approach to data analysis has been used in studies that have demonstrated rigor by using a hybrid method to thematic analysis (Fereday & Muir-Cochrane, 2006). Analyzing qualitative data can be challenging, as it is not easily reduced to numbers but rather represents concepts, opinions, and values people hold in a social context (Bryman, 2012). I therefore was interested in using the Nvivo software so that I could organize quotes from the interviews according to themes, and most importantly, access and extract them as the themes were addressed in my written analysis. As Braun and Clarke (2006) state “your write-up needs to do more than just provide data. Extracts need to be embedded within an analytic narrative that compellingly illustrates the story you are telling about your data…” (p. 93). I found this process to be particularly challenging and time consuming because I had no previous experience using data analysis software. I also had to re-organize the themes and codes I created multiples times so that I could better draw conclusions from the data. This was, however, useful as I was able to go back at any time and look at interview extracts that spoke to particular issues that I was inquiring about.  Furthermore, data was also analyzed using other methods as I did not want to rely entirely on a single software to examine the data. I created simple tables that provided a sense of quantitative representation of some the interview questions I had asked. For example, for questions with binary answers such as, “Is there anything that prevents you from exercising in Canada?” I would create a table with “yes” or “no” columns which helped give me a better understanding about how the women felt the Canadian context posed barriers to being physically active.  41  3.5 Ethical considerations  Ethical approval for my study was obtained from the University of British Columbia’s Behavioural Research Ethics Board. This process allowed me to carefully consider how I recruited, sought consent, provided transparency, and represented refugee women so that I assured the ethical integrity of my research. Central to these principles involves “[recognizing] the value of human autonomy and respecting privacy and confidentiality of participants” (Heggen & Guillemin, 2012, p.468). At the beginning of each interview, I assured participants that information they disclosed would be kept confidential and would not put them at any risks or compromise their statuses as refugees or their affiliations with settlement or government services. Reiterating confidentiality was important in this study given participants are refugees who may disclose sensitive information pertaining to their views towards the conflict from which they sought refuge and the Syrian government, or towards their experiences with settlement agencies in Canada. They were also informed that their identities and all information pertaining to them would be kept confidential and reserved within the research team. With regards to the background survey, they were provided a space to choose a pseudonym that would be used instead of their real names if they desired. Interestingly, only a few women didn’t want their real names used while most were very open about having their real names used as they felt empowered to participate in research. Data was stored and secured in both a locked drawer and on password protected files on the computer.  The consent process was also carefully considered for this study. Interviewees were given the choice to provide either verbal or written consent. This was to avoid putting participants’ in any position of feeling uncomfortable or evoking fear to participate. Discomfort in using consent forms and negative associations with signing forms has been previously expressed in studies 42  involving vulnerable populations as it may be perceived to be culturally inappropriate and damaging to their trust (Metro, 2014; Adams et al., 2005). Warren (2010) has suggested verbal consent is more appropriate with such populations as it reduces the possibility that interviewees might walk away from the interview due to fear or threats perceived by consent forms. Participants were therefore informed that signing the consent form was optional and that they could provide verbal consent at the beginning of the interview instead.  At the beginning of each interview, I also asked participants to confirm that they had understood their upcoming roles and asked them to provide or confirm that they have provided consent to participate. I informed them of their right to refuse to answer any question and that withdrawal from the study could be granted at any time. Therefore, in order to maintain my status as an “ethically mindful” researcher, it was important that I was in a constant state of vigilance during the research process for the purpose of not inflicting harm or perceived harm to participants (Heggen & Guillemin, 2012).   3.6 Methodological challenges and limitations  Collecting data in one language and providing findings in another has methodological as well as ethical implications that need to be considered. Temple and Young (2008) highlight an ongoing lack of open discussion amongst researchers who have not been transparent when data is collected in a different language.  A common problem is the invisibility of translators and interpreters who play an important role in the research process but become invisible because of a lack of acknowledgment by researchers (Squires, 2009).  Although I did not use any translators and interpreters to transcribe my interviews, I did face challenges in working alone to translate and transcribe interviews.  43  Firstly, as a fluent Arabic speaker who is accustomed to use the language more for speaking than for reading or writing, I did not feel confident in, nor did I have the resources to first transcribe the interviews in Arabic and then translate these Arabic transcripts into English. This process would have been extremely difficult and time consuming. I therefore listened carefully to the Arabic audio recordings and translated them directly into English.  A second challenge with respect to this process was that, since I worked individually to prepare the English transcripts from an Arabic audio source, there may have be errors in translation along with potential bias since I did not seek a second opinion on the translation of data from another Arabic-English translator. Additionally, I encountered some difficulty translating a number of Arabic words that carried complex cultural meaning(s) and connotations that are not accurately captured when translated directly into English. In cases such as this, I would translate one word into a few English words to express the meaning as accurately as I could. Simon (1996) highlights this issue of cross-cultural translation nicely:  Translators must constantly make decisions about the cultural meanings which language carries, and evaluate the degree to which the two different worlds they inhibit are ‘the same’. . . In fact the process of meaning transfer has less to do with finding the cultural inscription of a term than in reconstructing its value. (pp. 137–8)  One example of a word I had difficulty translating is the word – nadi (يدان) – which can be literally translated to ‘club’, referring to an organized group brought together through a commonality or the place that hosts these groups and their activities. In Arabic, a qualifier after the word nadi can be used to specify the type of group or organization. However, in 44  contemporary Syrian Arabic, this word is commonly used without a qualifier to refer to a type of club akin to North American gyms. A nadi would normally provide its members access to a number of facilities including a football field, swimming pool, and training space, cafeteria…etc. Therefore, when I asked women if they have been to a nadi in Syria, they would likely be thinking about these kinds of exercise and sports facilities. In transcripts, I have chosen to translate nadi to “gym” as this word is a more accurate representation than the literal “club” which is less commonly used in North American English to describe the membership-based exercise facilities common to both cultural contexts. Another example was an ongoing dilemma I had with the word – nafsiyya (ةيسفن) – literally translated to ‘psychological’. For example, the word is used in the phrase– saha nafsiyya (ةحص ةيسفن)- which can literally be translated to ‘psychological health’ i.e. mental health. Saha nafsiyya (mental health) is a phrase that carries with it heavy social connotation (it can be associated with mental disorders). Modern colloquial users of Arabic however, regularly use the word nafsiyya in describing their negative mood, feelings, or state of mind in a way that does not carry with it such heavy social connotations. One can draw parallels between this use of the word and the ways in which an English speaker might speak of feeling sad, tired, mentally drained, or anxious without necessarily describing themselves as suffering from a mental illness such as depression or an anxiety disorder. For this reason, I most often chose not to translate uses of the word nafsiyya literally but rather to reflect these colloquial Arabic norms. In her study with polish migrants Gawlewicz (2016) describes similar dilemmas she had with Polish words in translating interviews, and highlights the importance of conscious research translation as there is often an assumed shared identity through language between migrant researchers and their migrant participants. Despite these shared challenges, I felt that I was at an 45  advantage because I speak the colloquial Syrian dialect, which is different than formal Arabic or other Arabic dialects spoken in other parts of the Middle East and North Africa. As a result, I had no issues for the most part communicating my questions to the interviewees and understanding their responses. Some interviewees came from rural regions of Syria and had a slightly different dialect that was specific to their region. In the cases where this regional dialect was difficult for me to understand, I would ask the women to clarify meanings of words that were unfamiliar to me. Thus, despite the discussed challenges in collecting and representing data in different languages, the outcomes of this kind of research is valuable as I am able to contribute to the literature by representing the experiences of a distinct group of migrant women. Representing my interviewees as accurately as I could in Arabic was important to the credibility of my study and my practice of ethical mindfulness. It was a great learning experience being in the “researcher/translator” role as I had this opportunity to self- reflect on cross-cultural meanings and interpretations of data.  Another challenge I encountered was the time, space, and place in which the interview took place. Although interviews were meant to run for an hour, I would often spend an entire afternoon with participants. This was because, in addition to transportation time, I would spend a few hours at their homes. Participants often insisted I stayed for a meal with their families or enjoyed sitting and speaking to me after the interview. The acceptance of their invitation for refreshments or a meal was a kind gesture but it was also culturally necessary for me to accept it. Moreover, during some interviews it was difficult to avoid the presence of spouses and children. This is because most living spaces were very small considering the size of families and it was difficult to have privacy with the women. The unintended presence of other people in an interview could affect the social interaction between the interviewer and the interviewee 46  (Warren, 2012). I did feel that this affected the flow of some interviews as they were disrupted by family members wanting to add to the conversation or by the interviewees who had to stop to attend to young children or household duties. During one particular interview, four children arrived from school and there was such constant disruption and noise during the interview that it was difficult to continue. Half way through another interview, a friend of the interviewee and her three children arrived to the interviewee’s home, so the interview had to be stopped and continued a few hours later at a more appropriate time. Before coming into these interviews, I did expect that there would be some challenges with arranging appropriate times and places to conduct interviews given that Syrian women are typically the primary caregivers for their family and children.  3.7 Reflexivity: my positionality in the research  The practice of reflexivity implies that I constantly considered the implications of my research, evaluating my presence during all stages of the research process, and interrogating my constructions of knowledge (Bryman, 2012; Finlay, 2012). I sought to do this by being open to critical evaluation and constantly considering my positionality with the research and the participants.  Firstly, it was important that I acknowledged my privilege as a Canadian-born woman who is fortunate to have been able to pursue higher education. I also recognized the fortunate life I have lived throughout which I have not experienced displacement and am assured my human rights and safety at all times. Secondly, it was important that I evaluated the extent to which I shared aspects of my identity with my research participants. Although I was born and raised in Canada for the most part, my parents were born and raised in Syria and I grew up in a traditional 47  Middle-Eastern household. I therefore speak Syrian-Arabic very well and carry strong cultural and religious values, despite living in a social context that does not always share the same social norms.  At the same time, I also carry strong Canadian values and grew up in a Canadian culture where being physically active from a very young age is very common, so in many ways I considered my position in the research to be that of an insider-outsider.  I felt I had an “insider” status because I shared racial and ethnic identity with my research participants, but this also had its limitations since I have not experienced conflict and displacement nor have I grown up in a household or society that imposed so many gendered expectations on women. On the other hand, through my own lived experience, I was able to relate to most issues about cultural barriers to physical activity such as the challenges with exercising in the hijab in public arenas. This understanding was very helpful during interviews as I felt I was in a good position to ask the right kinds of questions and comfortably dig deeper into issues women were expressing without feeling like I was crossing into a metaphorical territory in which I didn’t belong and was not welcome. My knowledge of certain Arabic words and the contextual meanings they carried, as discussed previously, was also very helpful in representing the views and understandings of the women. Additionally, most women, despite being aware that I’ve lived in Canada for a long time, still used language that emphasized this shared identity and made me feel connected to them. During interviews, we shared a sense of belonging as they would often refer to Syria as “our country” and say things like “you know how it is back home” and used the word “we” to include me in their cultural grouping.   Another implication of my shared identity with research participants is how it affected my role as the interviewer and will be discussed through the lens of relational reflexivity. This perspective allows me to consider the intersubjective and relational dimensions between myself 48  and the Syrian women who may consider me beyond that of a traditional researcher (Finlay, 2012). At the very beginning of my study, I worried that participants would wish to establish too much of a friendly rapport with me and would overlook my role as a researcher. It is not that I did not think friendliness and trust to be unimportant to the participant-researcher relationship, but rather, that I did not feel it would be fair to both me and the participants to allow them to feel that I could play a significant role outside of that of researcher. I felt that I could be a valuable resource for them since they may not have encountered many Middle-Eastern or Arabic-speaking females since arriving to Canada and may seek to contact me outside of the research context for support. This happened on several occasions but was not a problem since I felt a sense of responsibility to compensate them in some way for their kindness in participating in the study. While not consistent, I did help out a few times, for example helping one woman fix her resume for a job or translating a bank statement. The majority of women were very welcoming and generous when I went to their homes for an interview.  They treated me as a regular visitor and in the case of some interviews, invited me to stay for a meal with their families. For the most part I felt that these interactions did not affect the interview or the research, but became a regular part of the research process.  Overall, interviews went well and I was surprised and pleased by the trustworthiness women displayed and their abilities to comfortably express their feelings and views towards a number of issues. Having interacted with some women in the community previous to interviews, by the time the interview took place, it felt like we had been having a regular conversation between two acquaintances without losing my credibility as the researcher. Furthermore, the women never put me in an elevated position where I felt I carried the higher or privileged role.  49  Finally, while appreciating the fluidity and complexity of the human experience, as a qualitative researcher, I needed to be aware of my personal biases and preconceptions that could influence the way I understood the questions I was asking. This promoted confirmability or ‘objectivity’ and helped ensure that the study’s findings would be the result of true representations of the informants rather than the preferences of the researcher (Shenton, 2004). The diversity of Syrian refugees coming to Canada meant that they carried diverse experiences, identified with various religious and cultural practices, and wanted different things in Canada. I recognized that interviewees did not represent a coherent group identity, even though they all spoke Arabic, mostly identified with Islam, and were refugees. Some women were married; others single or widowed, and were at different stages in life wanting to pursue different things. They also came from different neighbouring regions around Syria and carried different experiences of displacement. Therefore, during interviews, I was cautious about facilitating discussion to avoid any underlying assumptions about their experiences as Syrian women and as refugees. This all impacted their understandings and views towards health and physical activity as will be discussed in the next chapter.   I hope that my position has allowed me to bring a sense of authenticity to the literature about Syrian refugee women and their experiences with health and physical activity. This shared identity with research participants played an ongoing presence during data collection and analysis and was important to reflect upon. It also has been a “negotiating” aspect of the research process amongst feminist researchers and noted as particularly important in community-based research arenas (Given, 2008; De Andrade, 2000). 50  Chapter 4: Findings and Discussion In this chapter, I describe and analyze findings from qualitative interviews that I conducted with Syrian refugee women who have recently migrated to the Greater Vancouver area of British Columbia.  These conversations provided insight into the needs of this group of women and their ability to integrate into new socio-cultural communities. They also provided insight into the ways in which migration affects the practice of healthy lifestyles and physical activity participation. Despite the fact that these refugees represent a specific diaspora community, I learned that they came to Canada from different regions in Syria and other countries on their refugee journeys and hence came from diverse life backgrounds, socio-economic classes, and cultural norms which have affected the various ways in which they are settling in and participating in local Canadian communities.     The following sections are presented in categories which echo major themes that were identified during data collection and analysis. Discussions of these findings will address my three research questions. First, I share the background of the study participants including information about their origins in Syria, experiences of displacement, and information about their health and physical activity experiences during this time. Next, I discuss their notions of health literacy and the ways in which these have impacted their participation in physical activity both back home and in Canada. Finally, I consider the idea of cultural fluency and how participants’ understandings of Canadian culture has facilitated –or not - their participation in healthier lifestyles and community based physical activity.   51  4.1 Background of study participants  In this section, I discuss the backgrounds of the women who participated in this study and include an overview of the lifestyles they described before being displaced from Syria. I also describe their experiences of displacement during the past few years which has eventually lead to their settlement in Canada. Considering those factors that distinguish the participants demographically was important as each participant had a unique experience of migration and its relationship to their health and lifestyle. I found that threads of common experience ran through their narratives and that these commonalities often reflected their pre-migrant lives (e.g. some were living in cities, others in rural regions). Participants could also be grouped by their migration experience: indicating if they had migrated directly from Syria and if not, where they had been displaced throughout neighbouring regions. These factors raised the question of how these (pre-)migration experiences (a) result in different sub-groups within the main category of Canadian-settled Syrian refugee women and (b) have an effect on their health statuses before and after coming into Canada and hence their participation in physical activity post-migration.  4.1.1 Participants’ demographic characteristics   The information provided in Table 1 shows that participants in the study range across a diversity of ages, marital statuses, as well as originating from different Syrian cities. It also provides information on the neighbouring regions they were displaced in before coming to Canada and the duration of time living in Metro Vancouver at the time of the interview. About half of the women were married and the other half single, with one who became a widow recently due to her husband’s death in Syria at the time of the conflict. Five of these women were mothers of between two and five children. Moreover, the women had been living in Canada from 52  three months up to nearly two and half years, all coming to the Metro Vancouver region in different waves of migration. Five of the eleven women had been living in Canada for less than one year so can be considered fairly new refugees. In addition, two of them have a physical disability, therefore presenting a unique experience which will be discussed in a separate section of this thesis. The names shown in the table reflect how each participant chose to be identified in the study, either by their original name or by a pseudonym of their choice.  53  Table 1: Study participant profiles  Name Age Years Marital Status City of Origin in Syria Location Prior to Canada Time living in Canada Elyaf <20 Single Daraa Jordan 4 months Eman 30-39 Married Damascus Saudi Arabia 8 months Hanan 30-39 Married Daraa Lebanon 2 years  Hiba 20-29 Single Daraa Jordan 3 months Huda 20-29 Single Douma Jordan 1.5 years Lina 30-39 Married Homs Lebanon 1.5 years Maha 20-29 Single Douma Jordan 1.5 years Noor 40-49 Married Daraa Jordan 1.5 years Samaher 30-39 Married Daraa Jordan 1 year 3 months Sumaia 20-29 Single Damascus Jordan 5 months Waed 30-39 Widowed Daraa Jordan 3 months  54  All the women who participated in the study are of Syrian decent and are originally from different regions in Syria including Damascus, Douma, Daraa, and Homs. Interestingly, most these women, eight out of the eleven, came from Daraa, the city that held the first protests against the government in 2011 and has been referred to as “the spark that lit the Syrian flame” (Sterling, 2012). As shared in the interviews, women from Daraa left their homes soon after the war broke out as this region was most affected during the early stages of the conflict in comparison to other regions in Syria. All the women who originally came from the city of Daraa were displaced to Jordan, which is the closest neighbouring country to border their region. The other women who originally came from the cities of Damascus, Douma, and Homs, were either displaced to Jordan or Lebanon. All of these women resided in these neighbouring regions for three to four years before coming to Canada. One Syrian woman who was living in Saudi Arabia as a Syrian expatriate with her husband at the time of the conflict, could not return to Syria and so became a refugee until she was able to come to Canada to join the rest of her family (mother and father).  4.1.2 Education and previous employment  Table 2: Education attainment of participants  Educational attainment Grades and Age Primary Education (3) Grade 1-6 (6-11 years) Lower Secondary Education (3) Grade 7-9 (12-14 years) Upper Secondary Education (4) Grade 10-12 (15-17 years) University (1)  (18+ years)   As illustrated in table 2, Syria has a twelve-year basic education system which is similar to the Canadian education system except that schools are separated into a primary, lower 55  secondary (similar to middle school), and upper secondary schools (Al Hessan, Bengtsson, & Kohlenberger, 2016). The majority of the women in this study did not attain high levels of education with three women indicating they dropped out of school after primary school (grade 6). Two of the women reported leaving at that early stage due to a physical disability which limited their capacity to leave home and access their classrooms. The third woman explained that she stopped school after grade six and for years after that worked with her uncle on a family-owned farmland until she got married at the age of 19. Women in rural regions have been discouraged from continuing their schooling because of the belief that farming was more important than formal education (Galie, 2013). For Hanan, she described a sense of disappointment because she was unable to pursue further education, as shown in the following quote: In the society we were in, a girl stops in elementary school (up to grade 6), there is no opportunity for her to continue her education. Even though I wanted to continue my education and I was really good in school… after I stopped school I stayed at home. (Hanan)   Habib (2010) explains the lack of educational opportunities as one of the driving forces that led to a historical rural migration in Syria where people in rural areas would abandon their lands and migrate to major cities to pursue higher education and better life opportunities. Generally, however, Syria has a well-developed higher education system (Hessan, Bengtsson, & Kohlenberger, 2016) but interestingly only one of the study participants had completed a university degree. This could speak to the classes and family structures these women came from, where pursuing education may not have been a high priority due to limited opportunities or the influences of gender roles in the families and communities they lived in. Currently in Canada, 56  two of the (single) women are pursuing education outside of the English language classes provided to Syrian refugees, one pursing a university degree and the other enrolled in a high school program designed for English language learners (English as a Second Language).  Furthermore, although I did not directly ask about employment before migration, I got a sense that most women were not working in professional jobs and obtaining regular incomes before displacement. One woman worked in a hair salon while she was displaced in Jordan and was an English teacher back in Syria. Two women from Daraa’s countryside mentioned that their lifestyle involved working with their families on farmlands. Most women however, talked about how their lifestyles encompassed a lot of housework and commitment to family responsibilities that filled up most of their times.   4.1.3 Experiences of displacement The internal and external relocation of Syrians that began in 2011 is viewed as one of the world’s largest mass displacements in recent history (Quosh, Eloul, & Ajlani, 2013). Although most of the women in this study were initially displaced to Jordan, Syrians have fled as refugees to other neighbouring regions including Lebanon, Egypt, Iraq, and Turkey, which is currently hosting the largest number of refugees compared to other regions (UNCHR, 2017).  These neighbouring regions have struggled to accommodate Syrian refugees and have experienced adverse social and economic instability due to the sudden and large influx of these Syrians in their communities (UNCHR, 2014).  During the interviews, the women emphasized the heartbreak of leaving their homes and how difficult it has been to be displaced twice or more over the past few years, firstly to a neighbouring region and then to Canada. The experience of displacement had affected them in a 57  number of ways including: halting education for themselves or their children, compromising their social lives, and also exposing them to potentially poor treatment and social tension with people in hosting communities. They also shared that they experienced difficulties when it came to accessing resources like housing, education, employment opportunities, and healthcare services. The competition for these resources has led to social tension and discrimination towards Syrian refugees in host communities, such as Lebanon and Jordan (Guay, 2015). None of the women specifically spoke of harassment or discrimination which has been reported by some Syrians, as prevalent in Lebanese and Jordanian communities hosting Syrian refugees. They did however share feelings of social exclusion, specifically feeling “estranged” or “isolated” in these neighbouring regions, despite being close to the borders of Syria.  During the interviews, more than half of the women recalled experiences of war, conflict, and living in fear, providing some insight into why it was necessary for them to flee their homes (as indicated by the quotations below).  Women with children particularly highlighted the compulsion to move because they feared for the safety of their children and families.   In Syria, it was tough to see things and hear sad things, your uncle passing away, your cousin getting killed in front of you…imagine this scenario, hugging your son and praying to God and being scared, unimaginable fear. No matter how much I describe it to you, if I described from now until tomorrow, it is not like the reality… and when we came here [Canada] you can put your head on the pillow restfully without hearing rockets and bombs. (Samaher)  The window of my house looks over the checkpoint and one of the bullets came right beside the window and I have little kids. I was on the second floor and I told my husband I can’t stay here anymore. (Hanan) 58  Women also described how the conflict and their displacement jeopardized their abilities as well as their children’s’ abilities to go to schools, write major exams, and continue pursuing their education during this period of time. Women who were pursuing education prior to the start of the conflict talked about how their schooling had been jeopardized. They were either not able to write exams because their schools would suddenly shut down or they were encouraged to stop going to school because their schools were situated in the middle of conflict areas which made their journeys to and from school unsafe. The conflict in Syria has severely compromised the education system reversing decades of educational achievement and is currently jeopardizing the futures of many young Syrians (Hessan, Bengtsson, & Kohlenberger, 2016). Accessing education in neighbouring regions was also difficult as indicated by some women. They particularly explained how in regions such as Jordan and Turkey, access to education was limited consequently leading them to temporarily stop school or actively seek opportunities to continue their education in other regions. This is what led one of the women in the SRP to come to Canada to continue her higher education. Generally, however, there was a burden on education systems in neighbouring regions such that schools were unable to accommodate the influx of Syrian. Over 69% of Syrian children in Lebanon for example, are currently not enrolled in school (UNICEF, 2015).  A few women did describe positive experiences during displacement in neighbouring regions, such as feeling safer and making new friends who shared the same culture, particularly in Jordan where Arabic is the same spoken language. Others however, described feeling uneasy about a shift in culture, were sad to be separated from family members, and had poor living standards. They spoke to the vulnerability of their refugee status and their political, economic, social exclusion. For example, one participant highlights the struggle of Syrians to find legal work in 59  Jordan suggesting how some Syrian refugees have been living in poverty and unable to financially support their family.   …well Jordan wasn’t good because of the lack of accommodation with the work situation. People want to go back to Syria because there they are not allowed to work. If they caught you, they would send you back to Syria. (Maha)  4.1.4 Syrian culture and lifestyle before displacement Within Syria there are a number of different cultures and spoken dialects (Al Hessan, Bengtsson, & Kohlenberger, 2016). As mentioned earlier, participants in this study came from different regions in Syria which is first observed in the interviews as they spoke in differing Syrian dialects and described different kinds of lifestyles. Differences in living environments were described by women who lived in major cities and those who grew up in surrounding villages or in the countryside. Women who lived in rural areas particularly emphasized a difference in lifestyle compared to “the city life”. They seemed to have taken on more responsibilities at a young age and led more active lifestyles in comparison to their city living peers as they described growing up working on farmlands and helping their families. Habib (2010) describes differences between rural and urban people in Syria highlighting that people in rural areas mostly live agricultural lifestyles and have limited access to resources, such as education and employment, compared to people in cities. This remains largely the case today with some families. Moreover, it seems that the women from rural areas married at particularly young ages compared to women from other regions in Syria. One woman for example, shared that she had been married since the age of 14. This may suggest that these women were raised with limited opportunities and accessibility to resources compared to women who lived in cities. 60  Most importantly, it reveals a sense of what the Syrian culture is like and how it evolves over time. It also reflects the importance of sustaining family growth, and hence, the implications on the role of women in these communities. Even with an increase in urbanization in Syria in the 21st century, there has been a historic difference between rural and urban regions with respect to the social, educational, and economic statuses of people in these societies (Habib, 2010) and this was evident amongst the women in this study.  Despite these linguistic and demographical variances, there was a cultural resemblance amongst all participants who shared similar values with respect to faith and cultural practices. All women in this study were Arab, which is the main ethnic group in Syria representing 90% of the population amongst Kurds and Armenians and other ethnic groups (Central Intelligence Agency, 2017). Moreover, although religion was not explicitly discussed during interviews, it was obvious that most women were practicing Islam as indicated by their references to religious practices or wearing of religiously significant clothing. Nearly all women who were married had married under the age of twenty and all but one had between two and five children. When asked to describe what their everyday lives were like, the majority of women talked about being the primary caregivers for their children and completing household duties before being able to do other things. From my perspective, they prioritized others over themselves as their lives seemed to be centered around the needs of their husbands and children. Valuing marital relationships and such value in family devotion is very common in Middle-Eastern cultures, where women historically are expected primarily to pursue the roles of wives and mothers (Keddie & Baron, 2008).  This was also highlighted when women talked about how the pursuit of migration was for the safety of their children and pursuit of better opportunities for their families and futures. Furthermore, even those who were not married described the obligations they held to their 61  families. As older daughters, they were relied upon by their mothers with responsibilities such as household duties or taking care of other family members.  The discussion about the lives of these women reveals the importance of family structure in Middle-Eastern cultures (Moghadam, 2004) and the high importance women attributed to their families. In addition, because these women married at ages younger than women typically do in the West, they have been committed to raising children which most likely constrained them to take part in other areas of society, such as higher education and employment. These things are important to consider after migration as will be considered in the next section.   4.2 Health literacy and physical activity practices    According to Sorensen et al. (2012), health literacy can be understood as “placing one's own health and that of one's family and community into context, understanding which factors are influencing it, and knowing how to address them” (p.1). With this approach in mind, this section examines levels of health literacy by focusing on how the women I interviewed understand the “context” and “factors” that influence their approaches to physical activity and health more generally. In our conversations, I begin by first inquiring about how participants understand and perceive their state of health. This discussion leads into further inquiry with respect to the health-related behaviours they engage in with the goal of maintaining a healthy lifestyle. I consider the sources of knowledge from which these behaviours stem by asking questions about their early childhood experiences of physical activity and involvement in in-school physical education. Finally, I consider the contexts within which they engaged in physical activity, either before or after migration to Canada, with the pre-migration context including both Syria and the neighbouring regions where they were temporarily displaced. All these lines of inquiry allowed 62  me to study the women’s understandings of health and their physical literacy through insight into the cultural, socio-economic and political context/factors within which they strive to lead healthy lifestyles. These questions also allow for an examination of how these contexts have influenced the ways in which the women are able to address various factors influencing their health and well-being. Through the following discussion and analysis, I aim to evaluate the extent to which Syrian refugee women have and continue to integrate into Canadian communities and how this ability to become culturally fluent affects health and physical literacy.  4.2.1 Perspectives and experiences of health Table 3: Broad definitions of health  Self-definitions of the term “health”  # of women  Absence of disease/illness/pain  2 Holistic perspective (physical and mental) 3  ‘Healthy eating’ (diet) and exercise  4 ‘Healthy eating’ and physical health  2  Study participants were asked to describe what being healthy meant to them. Understanding how they view health is important in that it allowed for a study of how it influenced the ways in which they attended and continue to attend to their health as well as how they perceive physical activity’s impact on their health. Women defined health in a number of ways: eating healthy foods and exercising (n=4), holistically, encompassing mental and physical health (n=3), being free of bodily pain or sickness (n=2), and healthy eating with the absence of illness (physical health) (n=2). As illustrated in table 3, definitions provided by the women were not rigid, with some participants attributing health to specific behaviours or qualities. It was therefore difficult to initially conclude that they held a single overarching view of health such as 63  is the case in other studies where the majority of the immigrant women interviewed defined health holistically (Dean & Wilson, 2010; Lee, 2015; Meadows et al., 2001). However, over the course of the interviews I conducted, my understanding of how participants defined health broadened through their answers to other questions. In fact, women did generally have a holistic view of health and seemed to understand health in a comprehensive way as expressed through their reflections on their own mental health and how displacement had affected their health and well-being. This observation is similar to what Dean & Wilson (2010) noted during their course of interviews where essentially the women had no difficulty viewing health in the broadest sense, despite some of them providing a narrower definition of health when directly asked for one.  Table 4: Self-reported health after migration   Perceptions of health in Canada # of women   Reported health as “better” 7 Reported health as “worse” 4  During interviews, women were given the opportunity to reflect on their current health and if it has been affected since coming to Canada or changed since the migration. They were specifically asked to reflect on whether their health has been affected by their refugee status and the journeys they experienced during displacement. It became evident that the majority of women highly valued their health, regardless of how they defined the concept. Evidence of this lies in the amount of interview time many of the women spent explaining how their experiences as refugees and their exposure to a new culture affected their health and well-being. All women acknowledged that their health has been affected by displacement, be it positively or negatively.  Table 4 illustrates that most women (n=7) perceived their state of health as being better in Canada. Some women attributed this to an improvement in their physical health specifically 64  while living in Canada. For example, as illustrated by the following quotation, one young woman in the study felt that her health had been negatively affected during the time she was displaced in Jordan before coming to Canada.    Yes, my health was great in Syria, but when we went to Jordan – in the last period of time there, I felt that I started having iron deficiency and other health related issues. And here I am now taking some supplements for iron and I am feeling better (Eylaf).   Eylaf, wasn’t aware that she had iron deficiency while in Jordan as access to any kind of health service was difficult because of her status as a refugee. This challenge has been prevalent amongst many Syrian refugees whose health status has been compromised during their displacement in neighbouring regions where accessibility to health care services and other medical needs was limited (El-Khatib, Scales, Vearey, & Forsberg, 2013).  In contrast, four women reported their health to be worse after coming to Canada. While two of these women had a physical disability and had particular reasons for reporting this (to be discussed in an upcoming section), overall, reasons for this decline in self-reported health was due to a compromise in social lives, the fact that they have given up their homes and personal spaces, and because of the language and culture gap in Canada. These factors were also echoed amongst the other women, despite reporting that their health has improved in Canada.  After an analysis of the conversations I had with the women, the majority of these newly arrived Syrian refugee women felt that their health was “better” in Canada. It seems that the major cause for this improvement in Canada lies in the increased number of opportunities to access healthcare in comparison to when they were temporarily displaced in regions outside of Syria. As well, the manner in which the participants answered the question highlighted a 65  limitation in its design. Due to the fact that I did not specifically ask if the women perceived their health in Canada to be better or worse than when they were originally living in pre-conflict Syria, consequently, the women may have been comparing their health in Canada to when they were temporarily displaced in regions neighbouring Syria after the conflict began. If this is the case, it is highly likely (and not at all surprising) that the women viewed their state of health as having improved since arriving in Canada. While displaced, the women reported having little to no access to resources and opportunities to address immediate health concerns. Moreover, although the perceived health statuses of these women were reported to be better in Canada, this seemed to be specifically in reference to physical health, as the women spoke of being able to access healthcare services, not getting sick, living in safe environments, and being more active.  Despite indications that the majority of participants perceive their health to have improved due to better opportunities to achieve good health after migration, nearly all of them shared that their mental health had been compromised at some point during displacement because of their experiences as refugees. As Newbold (2005) highlights, self-rated health amongst refugee arrivals in Canada is expected to be a lot worse compared to other classes of immigrants. This is due to the additional stresses refugees face in new socio-cultural environments where they may have poor language skills and are not as prepared psychologically and with the necessary resources to sustain new lives. For some, it is clear that the stressors of integration and adaptations in a new socio-cultural environment have taken a toll on their mental health. Two of the women in the study particularly highlighted the cost of displacement as having “destroyed” and “compromised” their mental health because they had been twice displaced, first to Jordan and then to Canada. The resulting detriment to their mental health can be attributed to the challenges in having to adjust to new cultures twice over a short period of 66  time as well as feelings of loneliness and estrangement from their Syrian communities. One of the women’s apparent severe depression was a self-reported result of feeling estranged in Canada and not receiving the help she needed:   I reached a point, I’ve never been like this in my whole life or ever thought this would come out of my mouth. Like, I was so mentally ill I said, ‘That’s it.’ ‘I want to kill myself,’ I told my husband. ‘I don’t want to stay here.’ (Name Withheld1).   Contributing factors to depression amongst Syrian refugees who have been displaced to new socio-cultural environments therefore appear rather different than the predictors of depression reported amongst Syrian refugees in Lebanon and Jordan. These have been due to the prevalence of newly diagnosed chronic diseases, mental health issues, and because of the constant fear of living in insecure host communities with unstable political environments (Naja et al., 2016; Gammoth et al., 2015).  In addition, despite women being far from their home region, it was clear that some of them were still pre-occupied with thoughts about the conflict and referred to the fact that it had caused them to be separated from family and loved ones, a common discussion point in most interviews. For example, although Lina reported her health to be better in Canada, she continues to think about loved ones she’s left behind:                                                      1 The quote above was selected from one of the study interviews for its direct portrayal of mental health issues and feelings of isolation. It was a distinctly emotional portion of the interview when the participant expressed the severity of her mental health. Due to the sensitive nature of the quote, the stigmatization of the mental health condition in both Arab and Canadian society, as well as to protect the autonomy of the speaker, I purposely chose to withhold the participant's name. 67  With respect to livelihood and such, of course, here is better but your thoughts are still always with your family and home… here there’s safety, there’s ... education, there’s everything, but in the end, our families are over there …our minds are preoccupied with that (Lina).   In this statement, Lina sheds light on the hardships of leaving behind ‘home’, especially after being displaced so far away from the region. Such hardships that involuntary migrants are often forced to face as they experience a loss of connection to their communities clearly affects their mental states and social cohesion with host communities.  Another common issue discussed during interviews was, an inability to speak English, which has severely restricted their lives in Canada and consequently impacted their health. Women shared that they were having difficulties achieving the levels of English that are required to function in Canadian society, including being able to communicate with health care providers without the need of translators, communicating with landlords, and finding employment. When I asked one of the women if her health has been affected by moving to a new country and culture, she said: Definitely, because you find yourself at times shocked at first, its happened to me on a few occasions when I go to a place and they speak to me in English and they speak to me asking for something, I don’t understand them. A new word, there is no one to translate and explain what is being said. (Noor)  Irrespective of how long they have been living in Canada, women were clearly struggling with learning the English language. Only one of the study participants is able to fluently speak English, and only because she had completed her studies in English in Syria. Since her move to Canada, she has started university and is continuing her higher education at UBC. Therefore, the 68  majority of women were struggling with integration as a direct result of their inability to speak English with confidence and fluency. Although this is common amongst newcomers (Vang et al., 2015), these women have faced specific barriers that are delaying the time it takes for them to acquire the language and are therefore facing additional sources of stress. Some of the women shared that they were not able to regularly attend to English classes because of other commitments such as scheduled appointments with settlement and healthcare services, as well as commitments with their families and children. This delay and lack of commitment in language learning has consequently hindered other opportunities for healthy social integration and development. Moreover, despite the women’s children often learning to speak English very well, something I observed during some interviews when I had the opportunity to interact with their children, the mothers do not seem to have the time to engage with the English language through their children. Therefore, for many women, this language gap has led to feelings of alienation and is a major factor in their not achieving physically active lifestyles in their communities, which consequently has been affecting their moods and mental health.  Quosh, Eloul, & Ajlan (2013), conducted a systematic review on the mental health of Syrian refugees and internally displaced persons in Syria. They found that the loss of socioeconomic status, meaningful social roles, and support were specific to worse mental health outcomes, regardless of age and gender.  All three of these factors are identifiable in the conversations I had with the women. These were driving factors that contributed to women sharing that their mental health has been compromised, despite reporting a better overall health. It is important to note that the women reported the cause of their poor mental health while in Canada to be related to difficulties in social integration rather than being directly caused by traumas associated with war and conflict, such as PTSD or anxiety, something that has been 69  found amongst Syrian refugees living in refugee camps (Quosh, Eloul, & Ajlan 2013). While the women have described factors that appear to contribute to their poor mental health, it is unclear whether these mental health issues first developed in Canada, are a result of or developed during displacement, or whether they are pre-existing underlying issues from pre-migration experiences.   4.2.2 Engagement in healthy lifestyles I began to inquire about understandings of health and physical activity culture by first asking what kind of healthy behaviours the women currently engage in, (or would like to engage in) in order to promote a healthy lifestyle. While they defined and self-reported their health in certain ways, their behaviours were shaped by: desires to maintain slim and healthy bodies, promote healthy lifestyles for themselves and their families, and to maintain a good nafsiya.  The concept of a good nafsiya in Arabic speaking cultures can be understood as states of mind and moods that reflect a good sense of mental health. Exercise and dieting were the most commonly cited means of establishing what they felt was being healthy. Although this is not surprising as these approaches to achieving better health are very common, it was interesting to note that nearly all women specifically stated that walking was something they continuously seek to pursue good health for reasons of satisfaction and because it made them feel good. Unlike the immigrant women in Devin and colleagues’ (2012) study who specifically defined walking as a form of exercise, the interviewees I engaged with were not explicit in indicating that walking was something they pursued solely as a form of physical activity. In the early stages of the interviews, it was unclear whether walking for the sake of walking itself was the way these women engaged in exercise or if the walking the women were already doing as a part of day to day life was being counted as a part of their overall effort to promote healthier lifestyles.   70  Women described walking as a part of their daily lives both in Canada and before displacement, such as by getting off at earlier stops when taking the bus and walking to do errands, although it seemed that this has increased since coming to Canada. Moreover, walking was not only mentioned for its benefits in achieving good physical health for the purposes of “keeping slim” and “burning calories”, but also for its role in promoting better mental health. In one case, a woman described walking as a coping strategy when her nafsiya is not good:  Well you see at times I would be emotionally tired, I’d be in my room and ok I would feel like I am suffocating so I would open the door and go for a walk. I walk outside and walk and walk. I get fresh air and I feel better. (Noor)  In this case Noor specifically identifies walking as a form of contending with her mental health issues knowing that she would come back feeling better. This was echoed by other women who mentioned that being physically active was useful for promoting a better nafsiya, given that they always “felt good” after exercising.   Being physically active was also mentioned by women as a way of maintaining and achieving healthy bodies. For two of the women this meant that their bodies were free from any sickness, as well as strong enough to tackle old age. One woman specifically states that if her physical health was compromised and she became sick, she would be a “burden” on her kids. Another woman noted that if she doesn’t take care of her body as she gets older, she would be weak and more prone to sickness. She was inspired to pursue exercise because she believed her body would stay strong and young and illustrated in the following:    71  You know I am in my 40’s now, the body after time …you know and I know that for a woman, her body after 50 will change so because she is exercising and going and coming, the body will stay strong, young. Even the sickness I have I think will disappear. (Noor)   Three of the women prioritized dieting over exercise as a way in which they promote good health for themselves. All of these women were single, two of them enrolled in full-time schooling and the other occupied with attending to a sick family member. As a result, it could be possible that eating healthily is a more convenient strategy due to the limited amount of time they have to commit to exercise. The subject of dieting was also echoed throughout some interviews when women acknowledged that some traditional Syrian foods were not entirely healthy because of the ways in which foods are typically cooked. One woman, Waed, shared that she began changing her cooking habits after coming to Canada in pursuit of better health for herself and family, as indicated in the following quote:    For food, I try to reduce the amount of vegetable ghee I use when cooking and use oil instead. The things that are to be fried, I now bake. This is all since I came here [Canada], of course. (Waed)  Waed noted two factors that lead to her feeling she had to make this change for herself and her family. Firstly, her diabetic mother fell very ill in Canada and secondly, she felt inspired by the health culture in Canada. The women’s pursuit of personal health therefore focused on physical aspects of health, encompassing both being active and eating healthy foods. It is interesting to note here that none of the women were overly concerned about their body image in their pursuit of achieving healthy lifestyles. Aside from two women who specifically stated they were interested in losing weight through diet and exercise, most women engaged in health-72  related behaviours to promote a good nafsiya, or state of mental health. In addition, although being overweight and obese are currently major health issues amongst Syrian women (Bakir et al., 2017), none of the women indicated that they were, or appeared to be, having these weight issues. Therefore, from my discussions with the women, I noticed that they have begun to reflect on healthy behaviours in a new cultural context. This will be further explored in another section of this chapter where cultural fluency will be discussed in relation to the ability to lead healthy lifestyles.   4.2.3 Syrian health and physical activity culture: prior knowledge and its effects All the study participants described how their introduction and initial exposure to physical activity was primarily in Physical Education (PE) classes and through activities organized by their schools. Historically, “schools, universities and physical education and sport institutes, are ideal settings for introducing a slow but persistent change in [Muslim] women’s sport”, (p. 290, Sfeir, 1985). As this was something that I had expected considering my familiarity with Syrian culture and as indicated in the literature (Karfoul, 2011), I was specifically interested in inquiring about the nature of these classes and the importance physical activity held as students progressed to higher grades. Women described their PE classes as if they were merely opportunities for children to run around, play, and take a break from their studies. It seemed that there was a lack of structure and consistency in the curriculum with respect to teaching children about different kinds of sports or opportunities to learn about specific movements. As Eylaf and Waed describe in the following quotes, PE class was not given much value or attention and teachers were not very invested in providing them with opportunities to participate in formal physical activities.   73  We used to take physical activity only in schools, not really a big thing at school, just running. It was all really, really simple movements. We didn’t get many opportunities. (Eylaf)  Yes [we were enrolled], but PE classes were silly. We would just be playing in the court and not do much. Some days we would do simple exercises. They weren’t really concerned. (Waed)  Other women however, indicated that they participated in extra-curricular sport teams, beyond PE classes, where they would travel to other schools in teams and play games. However, it seemed that this was mostly in primary and lower secondary school as they either dropped out of school or stopped taking PE once they got to upper secondary. Moreover, as indicated in Table 3, about half the women were not enrolled in any formal education after grade 9 and for those who did remain in upper secondary levels, PE class became optional and was perceived as less important than other classes. From the descriptions of their experiences it seemed that once girls reached older ages, a focus on formal studies was prioritized over participating in extra-curricular activities.  Some women indicated that this lack of support and opportunity originated from family members discouraging their participation in sport teams for cultural reasons.  The physical activity culture in Syria seems to be lacking for girls and women. Firstly, participation in physical activity outside of school settings were rare, particularly when girls got older as it was no longer considered “appropriate” and was culturally frowned upon by society. Secondly, there were very limited opportunities for women to pursue physical activity. Women discussed that they would play in neighbourhoods with their friends when they were younger but after a certain age they stopped.   74  We don’t have such a thing in our culture. That I, as a girl want to go out and play in the neighbourhood. Well, yes, when I was younger it was normal to go out and play with the boys and girls, play football with the boys and so on. But activity, after the age of 15 for example, why would I? I wouldn’t go and play. (Hiba)  Very rarely would you see a woman walking or doing exercise and if she does people around will talk “Oh look at her, she thinks she’s in the West”. So, most women go to the gyms because they can’t walk on the streets or run on the streets. (Noor)  I saw a lot people here [Canada] involved in exercise, unlike back home where there weren’t as many opportunities for exercise like here. We didn’t really consider it as  “exercise”, we used to consider it with a different meaning. (Eylaf)  These accounts portray a lack of social support, discouragement, and limited opportunities to participate in physical activity. Such barriers are commonly faced by Arab females in Middle-Eastern cultures (Mabry, Koohsari, Bull, & Owen, 2016; Musaiger et al., 2013).  Exercise is simply not as highly valued as it is in Canada. These quotes also illustrate that a distinctive physical activity culture is influenced by cultural norms and possibly, religious values.  Unlike the physical culture in Western societies, where it is common to find women exercising outdoors in public spaces, this is not a common practice in Syria. In fact, in some Syrian regions, significantly fewer women than men are present in public spaces (Yahia & Johansson, 2013). This was highlighted during interviews when women pointed out this difference when asked to make comparisons between the two cultures. Some of the women made reference to the fact that such practices would attract unwanted attention from men. Others highlighted that formal exercise was not a common practice in their region. For example, one of the women from the city of Homs, specified that although there was the opportunity for women 75  to go to an all-women’s facility to exercise in her town (ie. a gym), it was rare to find a woman who went regularly. She described her community as being particularly conservative and going to gyms was not a common practice either for men or women. Therefore, given that some regions in Syria are more conservative than others, this most likely further discourages women from exercising in public places. For those who wanted to, this social context did not make them feel comfortable given that the women noted if they ventured out to exercise, they would be subjected to whistles, shouts, or other comments of a sexual nature by males.   Women who did describe that they were physically active outside of their homes, did so in designated areas around their cities. These specific areas were considered more appropriate than others for women and families to exercise and seemed to be popular during specific times of the day, either early morning or early evening. These times were also more convenient and when the weather was more suitable for exercise. Some women shared that they used to walk with friends or family members around large football fields or common walkways around gardens or places known as a corniche. The corniche is a “linear landscape of movement [symbolizing the Arab culture], animated by joggers, walkers, and cars along its streets and walkways [and often overlooks a park or bay]” (p.216, Gharipour, 2016). In the following quote, Hiba reminisced about a regular walking routine that she did with her sisters during pre-conflict Syria:  We would wake up at 6am and have to go for a walk then. We would walk around a field and keep walking around. … it had to be very early morning because the fields would open later in the morning and at night it would be full of guys playing football and so on. So the morning is more convenient, the weather is cooler and we would all go out. (Hiba)  76  Here she had described an early morning exercise routine that was common to the other women who shared similar experiences involving family members and friends. While it is common for women to jog or walk along the corniche or other designated areas, cultural and social barriers continue to prevent Middle-Eastern women from exercising in open spaces, especially in conservative or low-income neighbourhoods (Matsuka, 2012).  Another factor that should be noted about the health culture in Syria as it was described during interviews, was the lack of awareness and commitment towards healthy eating. As mentioned earlier, there was a general acknowledgment amongst the women that their eating habits were not healthy. This is primarily because of the types and ways in which Arab foods are cooked, as well as the portion sizes of foods consumed. One of the women, who is living away from her family, stated that when her mom cooked, she “ate more” and “ate worse things” acknowledging that her diet was “not the healthiest”. The traditional Arab diet is known to be high in fat and consisting of high levels of simple carbohydrates and sugars in comparison to the Western diet (Hassan, & Hekmat 2012). Furthermore, it seemed that for some women pursuing a certain body type through specific diets and keeping “slim” or “losing weight”, was the way in which they attempted to achieve a “healthy” body, as opposed to pursuing active lifestyles. It appeared that this practice occured because of limited knowledge about healthy diets given they were concerned with “popular diets the other women tried” in their communities. Not having enough information about a healthy diet has been identified as a major barrier to healthy eating amongst Arabs (Musaiger et al., 2013).  In the following quote, Noor describes a culture very common amongst Middle-Eastern women:   77  You sit with women, they start drinking coffee and they start talking for example “ok so did you try this diet, did you see how I lost weight, I drank this, this and that until I lost weight, I didn’t eat for a week for example, did you see her and her body” that’s the first thing they talk about with each other and then they talk about other things. (Noor)  Lastly, I learned more about the physical activity culture in Syria by asking women to discuss what kind of facilities they had access to, particularly if they had been to gyms previously. As described in Chapter 3, in contemporary Syrian Arabic, nadi is used to refer to a club or large exercise facility with a designated gym space amongst other spaces such as a swimming pool or football field. All women during interviews were familiar with these spaces, although one woman from a rural region in Daraa didn’t have access to an exercise space for women in her town.  While most of the women shared that there were accessible gyms for them in their municipalities, it seemed that in some clubs, these facilities would be available to them only at specific times in which they became women-only spaces. I will assume that this is more prevalent in smaller towns like Daraa and Homs compared to larger cities like Damascus, given that one of the women from the city of Damascus described being able to access her gym at any time of the day. Generally, there is limited academic literature on the gym culture in Syria especially with respect to its use by women. From what I understood from the conversations I had with interviewees, the gym culture in Syria is very distinct from the gyms we may be familiar with in the Canada. Firstly, the spaces women accessed were all women-only and very rarely would you find a gym with men and women exercising in the same area. Secondly, because these are private closed-spaces, women would take off their head-scarves (hijabs), and could wear exercise attire and move without feeling restricted. As one woman describes, the 78  gyms in Syria were not as “appealing” as the gyms in Canada (even though the variation in equipment was primarily the same) and were usually located in basement spaces or on top floors, secluded spaces where “the blinds [would be] always closed”.  In addition, the environment in these spaces was not seen to be very motivating for those who wanted to pursue healthy physical activity. Women seemed to be interested in going there for “seeing friends”, “socializing”, and where women would “gather to have fun”. Below is an excerpt of an interview I conducted where one of the younger interviewees shared her perspective of the gym culture in Syria. For Hiba, she wasn’t particularly motivated to go to the gym because the environment was more social and didn’t encourage her to be healthy.  Nadine: So for a woman, for example, I want to go register in this place [gym], as a  woman there, why am I doing it? Is it to take care of my health or to go see my friends and have fun? Hiba: Some of them go just there to get out of the house, change their environment, an  excuse. Most of them actually. Nadine: So it’s rare to see a woman join, exercise, and lose weight? Hiba: Very rare! No one resists. The environment of the club has food. They order  pizza… I swear one time they ordered pizza. It killed us (laughter)…that time we told the instructor. Nadine: And what did she say? Hiba: Nothing - she said they can do what they want. Even the instructor her body wasn’t  ideal. You know not a “wow” body.   79  4.2.4 Self-reported physical activity before migration As shown in table 5, the majority of these women did not have a structured or regular commitment to physical activity. Activities that they reported doing before migration came from exercises they sought independently, formally (i.e. through recreational facilities), and for medical reasons. The main independent source of exercise that was reported was walking. Women reported going for walks in their town or with friends for the purpose of exercise. One woman reported doing exercise at home, primarily through traditional dancing, an activity that other women in her family also took part in. Two of the woman reported engaging in assisted exercise with a physiotherapist at home. Generally, it was not clear how often they pursued these activities and whether or not they perceived the exercise as “serious”. Therefore, the commitment level reported in the table was determined through my interpretation of the experiences they described. Table 5: Self-reported physical activity prior to migration Name Sources of Physical Activities Commitment Level  Elyaf Physical education class Regular Eman n/a n/a Hanan Independent (walking)   Temporary Hiba Independent (walking), gym Temporary Huda Physiotherapy  Temporary Lina Independent (walking) Regular Maha Physiotherapy  Temporary Noor Independent (walking), gym Temporary  Samaher Independent (belly dancing) Regular Sumaia Gym  Regular  Waed Gym  Temporary  80  One of the women noted in her interview that she was completely physically inactive prior to migration. Unlike the rest of the women, Eman was living in Saudi Arabia before migrating to Canada and shared that the lifestyle and environment severely restricted her from doing any physical activity. In addition to occasionally going shopping at the mall with her family, as illustrated in the following quote, household work was the only thing she did that made her feel that she was active.   I didn’t move much. I used to clean the house just to move myself around. Clean and clean the walls sometimes just to move my arms, legs, and my body. (Eman)  As in the case for women in Salas and colleagues’ (2015) study who reported household work as physical activity, during the conversation I had with Eman, it appeared that she was dissatisfied with this limit in mobility and didn’t consider it as exercise but rather something she did to perform some form of movement to keep herself busy and maintain physical health.  Four women reported going to indoor facilities that resemble gyms (nadis) at some point in their lives although they didn’t explicitly state how often and if it was something they pursued for a certain period of time. For example, Noor indicated that she used to go to the gym every now and then, depending on her work schedule. The last time she went regularly was when she was engaged, specifically to lose weight before her wedding. Waed also had been to gyms but it seemed that this was for a short period of time because the only time she could go was during the early mornings when her kids were asleep. She noted that after having her most recent son, it was difficult to leave him when he was a baby. Also after the conflict started, it became difficult to leave the house. During the interview, she says: “But then the war started so I stopped [going to the gym]. The road that had all the gyms was affected by the war first thing.” In Eylaf’s case 81  she was in her early teens when she was last in Syria, as she was temporarily displaced to Jordan for four years, so the last time she could recall formal physical activity was in PE class in school back in Syria.  Barriers to being physically active as discussed earlier included living in an environment where pursuing exercise was not encouraged by society and “joining the gym there is not easy. You know, a married woman wanting to go, she would hear a thousand words [get an earful!]”. This seemed to be because the women were expected to attend to other “priorities” related to their roles as mothers and wives.  Similar to what Donnelly and colleagues (2011) found amongst Arab women, “performing family roles and taking care of others took priority and were viewed as more important for these women than their own individual health care.” Amongst these roles were taking care of children which several women identified as being a barrier to going to the gym because they had young kids they could not leave behind at home. Despite the barriers of attending to children, two of the women shared that they were encouraged by their husbands to go to the gym. One of them noted that her husband was fond of her going because he knew she would came back with a better “nafsiya” and wanted to feel good about herself.   4.3 Cultural fluency and integration in Canada In the following section, I describe the lives of the study participants since their migration to Canada with the aim of understanding how their views about healthy activity have been influenced by migration and introduction to Western culture. First, I discuss their current lifestyles in Canada and describe to what extent and in what forms they have been engaging with their Canadian communities. I then describe their current physical activity participation and discuss how this has changed since displacement given their exposure to a new health and 82  physical activity culture. Lastly, I consider their views towards this new culture and how this has influenced their understandings and practices towards their own health and physical activity. I will examine to what extent they have developed a measure of health literacy in Canada by considering these experiences. Essentially this section’s discussion will also profile the abilities of this group of Syrian refugee women to develop cultural fluency, the ability to participate naturally within a new cultural context, as they adjust to new lives and integrate into Canadian society.    4.3.1 Community engagement in Canada As mentioned earlier in the chapter, the eleven women who were recruited for this study were recently displaced to Canada, and at the time of the interviews the length of their stay in Canada was between four months and two years. From the conversations I had with them, it is evident that the majority of them are still learning to adjust and acquire a completely new lifestyle in Canada, some of them still struggling to find the necessary time and knowledge to integrate socially. As illustrated in Table 7, their engagement with the wider Canadian community has been primarily through attending English classes which have been at community centers, neighbourhood houses, or formal institutions. This has been a major source of community engagement. Those that engaged with the community outside of these English classes did so by attending programs at community centers or neighbourhood houses with their families, volunteering, and through part-time employment. These engagements have been with both the local Syrian refugee community at community programs as well as the Metro Vancouver community through schooling, volunteering, and employment. Some women did 83  report however, that they have only engaged with other Syrian women because they still don’t feel comfortable speaking English and interacting with non-Arab speakers.  Table 6: Community engagement in Canada           Attending classes and being able to learn a new language was highlighted by the women as something they were happy to be participating in since coming to Canada. This was because they were encouraged to learn English and felt like they were accomplishing an important skill. For many of them an opportunity to pursue education was something they haven’t had since being enrolled in formal schooling in Syria. Despite this positivity, a lot of them echoed a lack of confidence in their abilities to speak English, even the ones who have been here for over a year. This was because they have been struggling with committing the time and energy to learn the language. Most were enrolled in a part-time program, where they would spend a few hours on several days of the week either in the evening or in the morning, to learn English with other non-English speaking newcomers. Some women were not committing to regularly attend these classes because of other appointments and priorities and this was clearly hindering their English language development. Some also switched out of language learning programs and entered others because of moving homes or dropped out completely because of their commitments to taking care of young children.  Engagement with community  Number of women English school  9 Community programs  3 Work (employment)  3 Other schooling  2 Volunteering  1 84  Even though immigrants have added to the overall community engagement in Canada through their involvement in public institutions, their participation has been lacking in social activities and areas where they interact first-hand with the host population (Kazemipur, 2012). For the women in this study, finding the time to acquire a new language as well as learn how to function in a completely new socio-cultural society with their families has been tough. This lack of time was echoed by nearly all of the women as being a major barrier restricting them from the diverse number of ways that they could be engaging with their communities. This was especially the case for Hiba and Waed, two sisters from Daraa who came to Canada with their older sister and mother. At the time of the interview, they were facing a unique family circumstance that restricted them from being able to participate in community physical activity and other social activities as they desire to. During their first few weeks in Vancouver, their mother fell ill and was taken to the intensive care unit at a local hospital. Consequently, they have been spending the majority of their days attending English classes in the morning (when possible) and visiting their mother in the hospital for the remainder of the day. Waed particularly highlights the burden of the responsibilities she has, because unlike her younger sister Hiba who is single with no children, she is a widow with four children between the ages of four and fourteen. When I asked her to tell me more about herself and the things she enjoys doing during her free time she says: “From the day we came here, I haven’t been able to have a moment to do something for myself. My kids, my mom, my sisters. All of these are responsibilities”. For this particular family, displacement to Canada has been more burdensome for them because of their isolation from family members who are still in Jordan and Syria and who would have supported them during this time.   85   Four of the women (Eman, Lina, Noor, and Samaher), were especially more active in engaging with the community in comparison to the others. They have been interacting with the community in ways other than just going to English school, which as some women discuss, hasn’t provided the opportunity to meet and interact with people from a diversity of cultures. The reason why these women were more active was because they either had more time to commit to community engagement, were actively seeking opportunities to improve their English language skills, or because they were interested in learning more about the Canadian culture. They have also been engaged through work experience since migrating. Lina for example was particularly active with a group of Syrian women who have established a cooking club in Vancouver and host traditional Syrian dinners for the public. Through this intercultural experience she has met other Syrian refugee women, as well as engaging with the Canadian community and has had the chance to get some work experience in Canada. Moreover, one of these actively engaged women, Noor, acknowledges the importance of taking initiative in new communities. She highlights that as a newcomer she needs to actively seek such opportunities for engagement “because if you didn’t do that, no matter how long you’ve been here, you will feel that you are in an unfamiliar place”. Her effort to be active in the community for establishing integration was evident when I asked her to describe what her day looks like in Canada:   My day before about four months ago [before taking a break from school], was me going to school, then after coming back home, fixing the house. Something like that. Then when I got to know people, I started for example to do some volunteering, seek opportunities to be in groups and watch people speak English. In the summer, especially, I didn’t sit at home, I’d go watch people how they speak the language. Most times, I didn’t understand what they were saying but I’d sit with them to [learn and] understand what they are saying. (Noor) 86  Unfortunately, this self-motivated engagement is not typical for many of the other women. Noor has also noticed this amongst her friends, Syrian women she has met at community events and frequently highlighted it during our interview. In her opinion, she felt that these women were struggling with integration and lacking in what she describes to be as the effort to integrate. This was because they have mainly been associating with other Syrian refugee women and have had limited interactions with people from other cultures. She also admits that their kids have been occupying their time, a major barrier to their engagement with the community, something she doesn’t have to worry about. As she shared during one point in the interview: “They have something to do at home all day. Kids go to school and come back. The women go to school to learn English, talk to Arab women like themselves.”  4.3.2 Self-reported physical activity after migration Table 7: Physical activity (PA) participation post-migration (in Canada)  Name Self-reported PA New PA experiences  Activities wanting to try  Elyaf PE class  No Gym, running  Eman Group fitness classes, walking Yes (Yoga, Zumba) Biking, running, swimming Hanan Walking, running Yes (running) Biking, gym Hiba Walking No Gym, skateboarding Huda n/a n/a n/a Lina Walking  No  Gym Maha n/a n/a  n/a Noor Walking  No Gym Samaher Walking, running  Yes (running) Biking, Zumba  Sumaia Walking  No Running Waed Walking, swimming Yes (swimming) Gym 87  Of the eleven women who were part of this study, nine reported being physically active since they have arrived in Canada. Maha and Huda did not report any physical activity because their physical disability restricts them from independently making any substantial movement. Their unique experiences will be considered in a separate section. Nearly all of the women who were asked about the kinds of physical activities they did in Canada mentioned walking. Walking appears to be a very important part of their daily lives in Canada but it is primarily used as a mode of transportation that happens to be a physical activity. In other words, it is not solely being done as a form of exercise in and of itself, for example, within a community setting, such as a part of a walking club. Rather, the walking that the women described and counted as exercise entailed non-exercise related priorities, such as in the case of walking to bus stops, walking kids to school, and walking to and from appointments.  In addition to walking, four women were pursuing new types of physical activity including group fitness classes, running, and swimming. These activities were pursued at community and recreation centres close to their homes. Many of the women also expressed a desire to pursue other forms of physical activity but have not had the time to participate in them yet because of other commitments such as going to school for English, work, or taking care of their children. Amongst the activities they wanted to pursue was going to the gym, an activity some of these women were involved in prior to migration. Other activities would be completely new to them and these included: running, outdoor biking, swimming, skateboarding, and group Zumba classes.     88  Table 8: Physical activity levels post-migration       As described in Table 8, nearly all of the women (n=7) were more physically active than they were prior to migration to Canada. Maha and Huda were two of the three women that reported being less physically active post-migration. During their displacement in Jordan, with the help of a therapist, they had participated in at-home physiotherapy despite their disability. While this service was provided by Jordanian government agencies, it was not regularly scheduled. Rather, a physiotherapist would come and do exercises with them once every six months.  They reported not having access to similar services here and as such, reported being less active in Canada than they were prior to migration. As for the women that reported being more active in Canada, although the source of this activity was primarily through walking, this active mobility formed a new lifestyle for these women. In particular, this novelty was a specific result of the mitigation of cultural and environmental barriers that had restricted them from walking in public (as much) prior to migration. Moreover, it appears that this new habit of walking is not at the level of intensity they want to achieve for the purpose of “exercise”. In fact, the women reported considering other kinds of physical activities they wanted to perform that are more strenuous. Unlike the Somalian immigrant women in Devlin and colleagues’ (2012) study who preferred walking as their main source of exercise because they believed it was most suitable in allowing them to uphold their cultural and religious beliefs, the Syrian refugee women in this study were walking because of convenience to active transportation as well as being part Activity Levels Number of women  More physically active 7 Less physically active  3 No change in level of activity 1 89  of family physical activity. It is interesting to note that despite their sharing the same religious affiliations, differences in culture may contribute to differences in reasoning between the two groups of women. Hence, it appears that for the Syrian women, walking is a convenient rather than preferred form of exercise considering that they are interested in pursuing other types of physical activity though as mentioned, haven’t had the opportunities to do so yet. Four women did not report being more physically active in Canada. One explained that this was because her new lifestyle in Canada has made her a lot busier than she used to be. In the following excerpt, it is clear that it would be difficult to fit in formal physical activity into her schedule.   I study English language, I go from 8:30 and I return 12:30, sometimes I go to programs in the afternoon. I come … and go home… and I’ve got [afternoon cooking] programs, or sometimes I go to the afternoon programs straight from school. And now we’ve got a sponsor. He occasionally comes over… for instance sometimes they organize programming, appointments… Well, I’m never really free... (laughter). (Lina)  Lina admits that she is not as free as she used to be and had more time for herself in Lebanon, where she lived prior to coming to Canada. In Lebanon, she used to go out every morning for a walk but here she hasn’t had the time to do so, thus perceives being less physically active although her current busy day may involve a lot of movement, which she hasn’t considered as “exercise”. On the other hand, Sumaia who is a university student, didn’t think she was particularly more active in Canada although she admitted that her movement as a student involved a lot of walking because she lived in a large university campus. When comparing this activity to her participation pre-migration, she felt that there was no change in her overall physical activity level. She admits that this was primarily due to the fact that she was a student 90  whose time was preoccupied with studying and other commitments which restricted her from going regularly to the gym and doing other forms of exercise. This lack of free time to engage in physical activity was very common amongst all women in this study and has been commonly reported by different immigrant groups due to the burden of other priorities that relate to socio-cultural integration and adaptation within Western communities (Wieland et al., 2015 Caperchione et al., 2009; Stodolska, 2000).    4.3.3 Experiences of a new health and physical activity culture During interviews, there was a strong consensus amongst my participants that they were exposed to a completely new health and physical activity culture in Canada. Each woman acknowledged that the Canadian lifestyle involved and encouraged a lot of physical activity. After analyzing the data, three themes emerged from very common responses when I asked about their views concerning how physical activity is encouraged in Canada, what they’ve noticed was new or unusual, and what were aspects of this culture that was appealing to them. Being exposed to an active lifestyle, organized physical activity, and an increase in opportunities and spaces to be physically active, were all motivating factors for these women seeking to pursue physical activity in Canada.  Active lifestyle in Canada All of the women acknowledged that the lifestyle in Canada was a lot more active than what they were previously accustomed to. This was because of a very dynamic transportation system where people walk, bike, and take public transit to get to places. Having experienced this system to some degree since migration, the women have realized that it has increased their 91  independent mobility and accordingly has forced them to move more often than they were used to.  It’s something nice, all the people walk here. In Canada, its obligatory to move around, going to a bus or sky train, crossing the street. (Noor) Here you are always running after buses, going there and coming here, walking distances.  You feel sometimes your legs are sore from all the walking (laughter). I wasn’t used to this. [It is different because] anywhere you want to go, you have to walk. (Eman)   Many of the women echoed this observation of an active lifestyle in Canada. A number of them particularly highlighted the perseverance of the elderly population whom they observed to be continuing with physical activity into their old age and taking care of their bodies. They seemed amazed by the number of seniors they’ve seen at recreation centers and on the streets, participating in physical activities. It was an aspect of the culture here that they admired as illustrated in the following quote.  Here [in Canada] what is totally different is that you see people that are 70 years old, their bodies… how they walk…and their health is amazing. (Waed).  A perception of maintaining good physical health at older ages and being able to participate in regular physical activity was new to them. Their views towards ageing appeared to come from cultural stereotypes about the elderly whereby negative views towards aging actually decreases physical activity participation in older people (Wolff et al., 2014). As one woman noted, “back home, if it was someone of the same old age, he would have given up a long time ago and is at home laying down all day”. Thus, their exposure to a culture that promotes positive attitudes towards activity within populations of older adults and their abilities to be physically active was a major source of inspiration for them to be active as young women.  92  Organized physical activity  Another aspect of the health and physical activity culture they noted with appreciation was the way it was “organized”. This meant that there were opportunities set aside for physical activity and that it was given a specific time and place to happen. This structure and commitment towards promoting a healthy lifestyle was something they also admired. They noted that it was a major source of motivation for them to participate. As one woman (Samaher) mentioned: “What’s motivated me here is the way it is organized. You feel like you have to participate, you have to join in”. Though most of the women haven’t participated in any organized physical activity in Canada (at least not yet), they have been happy with the increased opportunities for their children to enroll in sports programs such as soccer teams and swimming lessons. For Eman, it was through her kids’ involvement in community sport that she started pursuing physical activity.   Because my kids went to the YMCA, to be honest, I started going. When they entered they played a lot and they couldn’t get enough of it. [My son’s] always loved soccer and then he liked basketball too and started playing that too. So after I started going with them, I saw the people and how active they were, I became motivated to play sport after I saw them. I started trying them. I tried classes. It was amazing, it was really nice. (Eman)  This was a common thread amongst the women who spent a lot of time at recreational facilities and community centers with their families. Although some of them were not directly involved in activities at these locations they were nonetheless continuously being exposed to new opportunities and spaces to participate in all of kinds of physical activity.  As seen in table 7, participation in these organized community physical activities is something they mentioned they were open to trying as they integrate into new lifestyles in Canada   93  Increase in opportunities and spaces to be physically active  The number of facilities and programs designed specifically for sport and exercise was another thing the women noted about the health and physical activity culture here. Within the designated spaces they previously identified (spaces like gyms or specific spaces like the corniche) as being culturally appropriate spaces for people to exercise, women faced further cultural barriers with respect to when and how they were participating in physical activities. In Canada however, they noticed an increase in opportunities to pursue physical activity without these fixed restrictions. As Eylaf states in the following quote, the exposure to more spaces and opportunities has influenced her in a positive way.   [The physical activity culture] affected me. Now I have space to… to be honest I didn’t exercise formally, I didn’t play or think about it…here, one starts to think about it, because there are many opportunities. (Eylaf)  Some women also pointed out that these spaces (community recreational facilities), were easily accessible to them because of their status as refugees, which granted them a free pass during their first year in Canada. For those who were required to pay, they didn’t find membership fees expensive as they are provided with subsidized access. Unlike other migrant groups to Western societies who have expressed program costs as a barrier to participating in physical activity in new communities (Caperchione et al., 2009), affordability was an additional motivating factor for women to start joining gyms and recreational facilities with their families.  When I inquired about the gym culture in Canada and asked the women if it was any different to what they were previously exposed to, the women did indicate a few differences. Firstly, there were a lot more gyms here that were accessible to everyone and were open daily for 94  long hours. In Syria, the women described facing barriers to accessibility, such as only being able to access a women’s only space in some gyms, and even amongst these facilities, these spaces were sometimes only accessible during certain hours of the day. In contrast, here in Canada, there was more flexibility in committing a time (convenient to your own schedule) to exercise. Here, they’ve noticed the additional spaces that were available at any time of day including in community centers, institutions, and for some, in their housing spaces. This was important because despite other commitments such as going to school or taking care of their children, they could still find a time of day to go to the gym if they actively sought to. Secondly, they noticed that these spaces were open to both males and females and that although there were very few women only spaces they could access, they were not limited to them. The women stated that mixed gyms would not prevent them from participating and in fact, a number of them stated it is something they want to try. In addition, Sumaia noted a particular difference in the way gyms looked in Canada. She highlighted how these spaces were “appealing” and motivated her to want to start going to the gym as illustrated in the following quote:    Well it’s not that different in terms of like the machines but in terms of the facilities and how much they make it look appealing… its different because here they try and make it very nice and like…to attract more people and it looks much more… it looks [more visually appealing]. It looks fun to go to. (Sumaia)   It is clear that the extent to which physical activity is integrated and valued in Canada is something new for the group of women in this study. It has also been extremely motivating for them to pursue the same kinds of active lifestyles. Only one of the women noted that this environment and culture was not significantly new to her. This was because she had lived in Lebanon for a number of years before coming to Canada and was exposed to a similar kind of 95  “open society” where there were “similar norms” with respect to physical activity practices. For her, it was common to see both men and women running on the streets, although it is something she acknowledged not observing in Syria. In addition, as mentioned above, the only common barrier that women shared was not finding the appropriate time to commit and participate in the activities they would like to. There are not environmental barriers that are currently preventing them for participating. Barriers that I had suspected might have restricted the women’s participation such as the cost of participating in physical activity programs hadn’t been preventing them from participating or wanting to. Perspectives of participants living with disability    Amongst the eleven women I interviewed, I had the privilege of meeting and interviewing two Syrian refugee women in Vancouver, Maha and Huda, sisters who have been living with a physical disability because of a neuromuscular condition (muscular dystrophy) since a very young age. Since moving to Canada with their family, they have been featured in a number of local newspapers where they have spoken to journalists about the challenges of living as refugees with a disability requiring certain living and financial accommodations. (Carman, 2016; Dhillon, 2016). I was interested in further inquiring about their unique experiences as Syrian refugee women, especially with respect to how their displacement to Jordan and then to Canada has influenced the ways in which they have experienced their disability and whether their lives in Canada thus far have provided the promise of healthier lifestyles.    As briefly mentioned above, Maha and Huda were the only two women who reported no participation in any physical activity in Canada. They did, however, report some occasional physical activity during their temporary displacement in Jordan where they were provided with a 96  physiotherapist who visited them every year for a duration period of two-months. Prior to this, their last recollection of being physically active was when they were young children in Syria before the onset of symptoms associated with their muscular dystrophy. Since the development of this neurological disease, they have been unable to walk and have been confined to a wheelchair. Today, in the absence of a physiotherapist to assist, Maha and Huda cannot perform any exercise unless their older sister (who is their primary caregiver) spends time doing these prescribed exercises with them (which they admitted to not doing very much of in the absence of professional supervision). Thus, unless they perform prescribed exercises with a health care professional, physical movement plays a very minimal role in their lives.  During our interview, I asked Maha and Huda about their experiences living in a new health and physical activity culture. As highlighted by the other women interviewed, Maha and Huda acknowledged that Syrian culture did not typically pay as much attention to health and exercise as Canadian culture. Maha described Canadians as “… lov[ing] to take care of themselves through exercise…men, boys, [and] women”. Since migrating to Vancouver, not only have the sisters been exposed to both an increased number of physical activity opportunities and disability services and special accommodations, they have observed more people with visible disabilities in Canadian public spaces, in particular, wheelchair users like themselves. This experience, as Huda noted, resulted in feelings of empathy towards individuals whose disabilities were more severe than their own.   It’s not that you’re pleased to see this, it’s just that you see cases that are more severe than your own, you say, thank God, that I’m not as bad off as they are, they’ve got it worse. (Huda)  97  Here, Huda describes feelings of compassion towards individuals with visible disabilities more severe than her own. It can be argued that this sense of being fortunate could not have developed within Huda’s experiences of isolation and segregation living as a disabled woman in the Middle-East. Especially amongst refugees, there has been a reluctance amongst leaders in the Middle-Eastern region to accommodate disabled persons and acknowledge the problems they face (Peters, 2009). Consequently, there is a general lack of appropriate resources provided to assist displaced people with disabilities in Middle-Eastern societies. Due to previous experiences of marginalization, both women highlighted their experiences of observing people with physical disabilities in public spaces and expressed positive reactions, noting that it made them feel more included in Canadian society.  Since coming to Canada, Maha and Huda have been provided with customized electric wheelchairs for the first time in their lives which has helped them move around more easily. This significant increase in mobility was particularly amplified since prior to migration the wheelchairs they used had required someone to push them. They described a lack of environmental accommodations in Syria and Jordan which restricted them from leaving their homes. “They’ve got the road and pathways [which] are not paved for wheelchair users at all and not even [access to] the buildings.” In Canada, Huda and Maha have also noticed a disability “friendly” environment where public spaces have been modified to fit their needs. Amongst these were the availability of ramps leading up to sidewalks, buses, and designated spaces for wheelchair users.  Although they’ve acknowledged better access to resources and opportunities for disabled women in Canada, they also report feeling that this new lifestyle has been “tiring”. It is useful perhaps to note here that the access to services and accommodations provided to the sisters has 98  given them the opportunity to take part in a lifestyle that was inaccessible in Syria, such as going to school. This appeared to be a dramatic change from being trapped at home and excused from participating in a more engaging, dynamic life, which has been an overwhelming shift for the sisters. Maha and Huda also echo a sense of unfamiliarity with a more systematized and structured social environment. They particularly expressed a sense of annoyance at “slow services” where “[service providers] take a really long time to get you the things you need”. For example, although the sisters have enjoyed having access to an electric wheelchair, they were unhappy with having to wait nine months to receive them. In addition, there are other accommodations, such as specialized mattresses, they are “still waiting” to receive. Consequently, for Huda, she feels that this wait period compromises her state of health. As described in the following quote, during the interview, her sister Maha makes this association between waiting for accommodations and how it affects their mental health:  The wait here is really bad, it’s boring, and if you’re feeling optimistic about [getting] something, your optimism disappears, you get depressed about the situation (laughter). (Maha)  I suspect that the feelings expressed by these sisters towards service delivery in Canada stems from two things. Firstly, generally speaking, the perceptions of immigrants from developing countries include idealized misperceptions of services publicly made available to citizens by governments in more developed host societies such as Canada. It could be the case that the systems through which the sisters access services do not meet idealized expectations they had prior to migration. Secondly, in places like Syria, where these services are limited or do not exist entirely (Peters, 2009), individuals may often be obligated to rely on themselves and find their 99  own means of reaching required services. In such a system, one always knows where one stands in the process of reaching what one needs. It is possible that the process of accommodation was not communicated to Maha and Huda and hence their lack of awareness towards this system made them irritated by wait times. Despite this dissatisfaction, when services are finally provided, Maha and Huda seem pleased with the resulting health improvements.               In addition to starting a new life in a society that provides them more privileged access to services for individuals with disability, Maha and Huda have been happy that they have had the opportunity to go back to school in Canada, especially since they were forced to drop out of school in grade six because their physical disability had prevented them from being able to walk and move independently. Maha admits that “the nicest thing about being here in Canada is learning the English language, but it’s also really difficult”. Moreover, although it would be unrealistic, Maha and Huda expressed the desire to be back home in Syria with the necessary resources as more ideal because of personal items in their home that they miss having which they remembered as more suitable and comfortable. They both acknowledge however, that the environment in Syria is not safe to be in. Consequently, as illustrated in the following quote, Maha has established a greater sense of belonging towards Canada as well as her inner desire to be back in pre-war Syria:   It’s becomes your country. Now we have two homelands, Syria and Canada. We could go back to Syria but we’d always visit Canada. Always have a place here. We’ve come to know the people here., they could come visit us in Syria and we’d come to visit them in Canada. (Maha)   In this section, I was able to share the experiences and perspectives of Maha and Huda who have been affected in a number of ways as Syrian refugee women living with a physical 100  disability. Because a focus on disabled forced migrants has been “greatly invisible” and “rarely contemplated” in the literature (Pesani & Grech, 2017), it was helpful to have been able to interview and reflect on their unique experiences amongst (and in contrast to) the other Syrian refugee women living in Canada.  It was also interesting to capture their lived experiences in a new health and physical activity culture and see how this compares to how they have been living their lives as women with a disability in the Middle-East.  Through such an analysis I was able to consider the intersectionality between gender and disability.  Women living in the Middle East have had a historic disadvantage with respect to stigma, accessibility, lack of adequate care, and inclusion in society because of their being “disabled” (Abu Habib, 1997). Although Maha and Huda did not explicitly identify gender as being a barrier to disability services when in the Middle East, they did make reference to each of the abovementioned issues. In general, however, including here in Canada, “persons with disabilities are often pictured as the recipients of support and the beneficiaries of social programs rather than recognized as experts essential to the development of inclusive programs and policies” (Manning, Johnson, & Acker-Verney, 2016). Through Maha and Huda’s unique experiences in both Syria and Canada, and given the fact that they have been very vocal in sharing their opinions and experiences, they have the potential to be included in, and contribute to the development of inclusive, Canadian services for immigrants with disabilities, especially women. This is important not only because it can empower them as women living with disability but also helps create a shift in the praxis of health care services where service recipients become an integral part of service development and implementation.  101  4.3.4 Attitudes towards western health and physical activity culture  Through the process of meeting the women who participated in my study I began to realize how they were developing an optimistic attitude as a result of their new, emerging prosperity in Canada. In addition to sharing their experiences towards a new health and physical activity culture, they were all open to sharing their opinions about how they felt towards these new practices, despite some of these practices being very different than what they were used to previously. During interviews, they also had the opportunity to reflect on whether or not their lived experience had influenced their lives in Canada. In particular, I inquired about their positionalities within Canadian society as Syrians, refugees and women, and how these identities influenced their feelings towards Canadian people, culture, and practices. Amongst these three factors, it became evident that their new socio-cultural lifestyle in Canada is most influential with respect to their identities as women.  Despite their previous experiences of war, conflict, and displacement, the women reported their lives having changed in a number of positive ways.  Across all the interviews, the women expressed an inner sense of joy towards their “new life” in Canada which they described as being organized, prosperous and comfortable. Many of them foresee a stable future for themselves and families. For Eylaf, an eighteen-year-old, her joy lies in her ability to continue her education in Canada. She admits that although finding employment and exceling professionally within Canadian society might be a challenge, there are many more opportunities for youth and one can “strive for whatever you want, anything you like”. The challenge Eylaf spoke of was specifically related to the fact that the accounting career she was interested in pursuing required certification or a degree in Canada, while that wasn’t an absolute requirement in Syria. Despite this, in the following quote, she describes her ambitious plans for life in Canada, a sentiment which resonated with many of the other women.  102  You feel that we’ve seen a new life after the war because I never lived a good life. I was very young there and it was when I got older that the war started. So now I feel like my life is really starting. I feel like I want to see myself building my future here. (Eylaf)  A number of women perceived achieving success in Canada as being very difficult and admitted to feeling that life here takes “more effort” because “everything has a purpose” and is governed by a meritocratic system that everyone has to follow. As one woman stated “things don’t work through wasta like in Arab countries”. The word wasta here refers to the use of personal connections to make personal gains as in systems of nepotism. It appears that the women were cognizant of a having migrated to a society with more meritocratic values.  A number of women specifically expressed an admiration towards what they perceived to be a Canadian system within which everyone was treated fairly regardless of gender, age, religion, ethnicity, class or other visible identifiers. In particular, two of the women specifically made reference to equality with respect to religious identity noting that none were above the law as a result of religious affiliation. This specific reference to religion as a possible source of discrimination is particularly important as the women were coming from regions of conflict where sectarian violence was an issue and one of the factors that led to Syria’s current civil conflict (Carpenter, 2013). In the following quote Hanan makes note of her admiration of the respect present towards all religious groups in Canada:  I like the respect here, they respect all religions. Safety… there is no difference here between a Muslim, Christian, Sunni or Shia… In Lebanon there were these problems, ‘You are a Christian’, ‘You are a Muslim’, ‘You are this’, ‘You are that’. (Hanan)  103  In addition, the interviewees expressed a pride in their identities as women as well as feelings of empowerment, as women, within this new socio-cultural context. These feelings were cited as a source of motivation with respect to pursuing a healthier lifestyle. It appears that, as a result of the women’s perceptions of Canadian society and having seen successful Canadian women, they felt encouraged to challenge previously normalized gender roles.  This comes from the fact that Middle Eastern gendered cultural practices and expectations of women, especially in relation to roles as housewives and mothers, have limited upwards mobility within social spheres such as the workplace and politics (Metcalfe, 2008).  Some of these women had dropped out of school (and as a result, lowered physical activity) for reasons related to socio-cultural “expectations”. For some, they expressed that their new context had provided the opportunity for them to be able to experience some previously gendered (non-female) activities for the first time such as working or learning how to drive. For Samaher, the thing that made her “love” Canada was that “they fully give a woman her rights”. Waed shared a similar sense of freedom as a woman in Canada because she felt the burden of gendered expectations had been removed. The reason I am highlighting these feelings of female empowerment is their direct result on the level of physical activity the interviewees participated in. While many women indirectly expressed this cause and effect, Waed explicitly stated feelings of female empowerment as having directly affected the way she feels towards practicing physical activity. When I asked her how she felt about how physical activity is viewed in Canada, she says:    Here it’s great, everything is normal and everything is acceptable...there is nothing disgraceful. You can do whatever you want and no one can interfere with you. That’s what is really nice. I am not talking to the point where you can do absolutely everything and nothing is disgraceful, like not to the point where you are doing something against 104  your religion. But there are many things that one has always wanted to do there but couldn’t. Why? Because for example, you can’t, you’re a girl, you’re a woman. (Waed)  Only a few women stood out as having significant feelings of empowerment as women in Canada. One of them was Eman who was living in Saudi Arabia as a Syrian expatriate but found herself a refugee when she couldn’t return to Syria because of the war and then came to Canada. In comparison to her life in Saudi Arabia, she’s been able to pursue a completely different lifestyle in Canada, and has been involved in physical activity for the first time in her adult life (she participated in Physical Education class during school as well as childhood play). Through this experience, she been motivated to challenge gendered norms (including those related to physical activity), with her husband and other family members. I noticed she was the most enthusiastic interviewee when speaking about the opportunities she has had in Canada.  We (as Arabs) don’t have an understanding of exercise. Throughout her entire life, [a woman] hasn’t done any exercise. You look at the people… the culture changes. How can I explain this? If I was able to participate in Syria maybe I wouldn’t be as motivated. But here, no. When I saw the people and their culture, and the way they think, talk and interact, I wanted to be like them. It motivated me to change. And what also motivated me is that they look nice. They look really nice. Bodies are perfect. (Eman)   One of the often-cited factors that these women reference to explain their comfort in ambitiously pursing physical activity in Canada was the lack of explicit disrespect they observed in Canada, specifically disrespect by men directed at women. Nearly all the women I interviewed acknowledged the fact that they felt respected by the men around them, something that stood out for them in contrast to experiences pre-migration. A few women highlighted the fact that they weren’t “looked at” in public and that “men didn’t stare”. One women in particular felt 105  uncomfortable about going to a mixed gym when she first came to Canada, something her husband didn’t necessarily initially approve of either. She admitted feeling self-conscious about exercising in public because she was not used to doing so given her values and identity as a Muslim woman but “now I know that here [Canada], no one looks at anyone.” She admits that her views towards men have completely changed in Canada because of the level of respect she has noticed from them over time and that now, she would have no problem joining a mixed-gym, to the extent where she says “If I find a place and there was a male trainer, I would have no problem”. A sense of discomfort towards exercising in public venues around men was thus not a major issue, one that I previously predicted the women would identify as a major barrier to exercising in Canadian society.  Another woman highlighted that while she had no problem exercising in front of men, there were certain movements she wouldn’t feel comfortable doing because she felt that they would go against her values as a woman who wore the hijab. This was also expressed by another woman who admitted that although her involvement in physical activity in public spaces might not be “appropriate” in Syria, she had “set boundaries [for myself] and at the same time my husband approves of [my physical activity]”. These boundaries appear to be related to adhering to religiously appropriate clothing, and moving “appropriately”.  As such, it did not surprise me that, when I asked them to identify factors that would increase their participation in physical activity, several highlighted that access to women-only exercise spaces (spaces they felt were accessible to them as women who wore hijab) is something that would be convenient. I believe that, although they did not feel anything was preventing them from exercising in Canada, women-only spaces have the potential of further motivating them to be physically active. The 106  women pointed out that an all-women space would be a nice form of religious and cultural accommodation.  In summary, all women had positive attitudes towards Canadian society and its health and physical activity culture. Despite minor barriers discussed above, when directly asked about their acceptance of this culture, nearly all the women in this study responded positively, one of the women stating enthusiastically, “I’ve accepted it with a great smile.” Not only was there this shared overall acceptance of the Canadian culture, one woman brought up the fact that she felt a sense of privilege here in Canada, “[The culture] is something I wish my country had a little bit more of. So, I feel like it suits me and I think that I would… I fit in here.” It is important to note that this reception of a new physical activity culture is distinct from having a sense of belonging to a new country which is very different than feeling like you are living in a place like “home”. When asked during the interviews about whether or not Canada “felt like home”, not all the women answered affirmatively. Four out of the eleven women shared that they wanted to return to Syria if and when they were given the chance, stating that they missed their communities and their homes. The remaining women expressed a sense of belonging towards their  new home in Canadian society and were content with their new lifestyles. They also acknowledged that they were missing their communities of origin, friends, and families, but would only like to go back to Syria for visiting purposes. Although it may be hard to reflect upon and negotiate, considering the experience of displacement and the status associated with being a refugee, the discussion in this section was useful in considering to what extent Syrian refugee women were integrating physical activity into their new lives in Canada. It was also particularly useful in observing how these experiences played a role towards a change in attitudes towards western practices and values.  107  Chapter 5: Findings and Discussion This study has investigated the experiences of and perspectives towards health and physical activity of eleven Syrian refugee women who have been living in Vancouver for three months and up to two years. The purpose of this study was to talk to a number of Syrian refugee women about their background and recent experiences and explore how their views and practices have been influenced since migrating to a new socio-cultural environment. My first research question was “What are Syrian refugee women’s understandings of the role of physical activity in relation to healthy lifestyles?” I explored this question by examining their knowledge of healthy lifestyles and to what extent physical activity played a role in their lives before moving to Canada. This approach meant that I had to consider the experiences of displacement which have resulted in their distinct status as ‘refugees’ within the broader categorization as ‘migrants’. The women came from different socio-economic demographic groups and different geographic regions within Syria. These factors are reflected in their variations in history, dialects, practices, and styles of living. As migrant women in Canada, they have also experienced a number of cultural shifts including being refugees who were temporarily displaced for a number of years across a number of regions neighbouring Syria.  For all the women, their initial exposure to patterns of physical activity occurred through, but was not limited to, their childhood education as regulated by the Syrian school curriculum. This curriculum had a designated physical education lesson for students but it appeared that the teachings of movement and sport varied across different regions in Syria. Since these childhood experiences, the women were generally able to maintain some form of physical activity throughout their lives, mainly through walking in their communities and going to women-only exercise facilities. For many however, they faced various socio-cultural barriers 108  stemming from Syrian culture which limited or prevented the practice of regular physical activity. These barriers were also reflected in their lack of attainment of higher education. Most women had dropped out of school before completing their secondary education. One of the women however, came to Canada to continue her higher education at the University of British Columbia. Although she shared similar cultural experiences to the other women when she lived in Syria, she appeared to have lived a more privileged quality of life due to higher socio-economic status, age, and ability to speak fluent English. These factors appeared to have facilitated an easier transition into a Canadian lifestyle.  On the whole, my line of inquiry built upon existing research conducted on women from Middle-Eastern cultures, which is often interpreted and represented in relation to Western femininities and practices. Similar to my findings, these studies highlight how women living in Arab countries have tended to face more barriers to practicing physical activity compared to men due to various religious and social norms that have discouraged them from exercising (Musaiger and colleagues 2013; Hargreaves, 2006).  Consequently, insights into cultural, socio-economic and political factors became important indicators of understanding the health and practice of healthy lifestyles amongst this population. A number of definitions of health were provided by the women early in the interviews as they attributed health to specific behaviors and qualities, especially healthy eating and exercise. As my interviews progressed however, and the women reflected upon their experiences as refugees, it became evident that most women did in fact embrace a holistic view of health since they made close connections between their mental and physical health.  This finding related to my second research question, “How have their views about healthy lifestyles and physical activity been influenced by migration and introduction to Western culture?” Their 109  perceptions of health were generally more positive in Canada as the majority of women perceived an improvement in their state of health since living here. These improvements were primarily related to their physical health due to an increase in accessibility to resources, healthcare, and physical activity opportunities in Canada which facilitated better health practices and for some, and improved their mental health. For example, Maha and Huda, the two women with a physical disability, were able to access special accommodations related to their disability for the first time in their lives.  Forced relocation appeared to have created pressing needs for some women, given that they were not prepared psychologically or practically, to transition into a new community. Evidently, most of the women undoubtedly experienced depression at some point during their transitions across societies and for some, this remained an ongoing issue here in Canada. The women related the source of their mental health issues to the challenges they have been facing in rebuilding their lives in a completely new socio-cultural environment. A common issue faced by ethnically diverse newcomers to Canada (Dean & Wilson, 2010) and also highlighted by the women in this study, was the struggle of living in a community where the primary spoken language is foreign to them. It appeared that the women were either struggling or taking a lot of time to acquire levels of English necessary to function and engage with Canadian society. Nonetheless, what stood out about this population of study was their distinct experiences as refugees which I was able to conclude had a significant impact on their health in comparison to other voluntary migrant groups as has been shown previously (Newbold, 2009). This was because a separation from, or loss of, family members because of the crisis in Syria, in addition to being displaced a number of times, appeared to overwhelm some of the women, resulting in significant declines in mental health.  110  Since moving to Canada, most of the women reported a more physically active lifestyle which encompassed an increase in active mobility through which they pointed to walking as a major source of this activity. Unlike other migrant groups who found it expensive to be active in Canada (Dean &Wilson, 2010), these Syrian refugee women had no issues with accessing community physical activity as a result of cost barriers, mainly because, at the time of their settlement, they were provided with subsidized access to recreational facilities. In fact, time restraints because of commitments associated with resettlement, attending English programs, and attending to their roles as mothers, were common barriers that limited their abilities to participate in community-based physical activity. Once getting accustomed to a new lifestyle and having the appropriate time to do so, majority of the women expressed significant interest in pursuing physical activity in community-based facilities.  Through exposure to a new health and physical activity oriented culture, it became evident that the women in this study were already changing the way they perceived and understood their own health and related practices. This was because they observed a more active lifestyle norm in Canada as well as being provided with more opportunities and spaces to exercise. They’ve also been exposed to a population that maintains their health through exercise, with observations of active women and the elderly being particularly highlighted by the women. This has greatly motivated them to partake in or increase their levels of exercise. All women had no major issues with exercising in public spaces considering that nearly all of them chose to cover, following Islamic codes of dress. Several of them did note however, that being provided women-only facilities to exercise more comfortably (i.e. where they can remove their hijab) would be suitable for them and convenient. They also experienced living in a new social 111  environment where they report feeling less disrespected by men in public spaces, further motivating them to pursue active lifestyles.  For some of the women in this study, they have been able to overcome mental health issues through their exposure to physical activity opportunities in the community as well as through community engagement. This relates to my third research question, “What roles might settlement-related support systems play in supporting physical activity and healthier life styles for refugee women?” For most women language learning programs have been a major source of community engagement, although a number of them have sought social programs within their communities at neighbourhood houses and community centers. In fact, I met most of my interviewees within settlement-related support networks in the community. In these gathering areas, they have had the opportunity to interact with other members of the Syrian refugee community as well as other individuals from a diversity of backgrounds. The sense of social inclusion which the women have expressed since they have been introduced to Western culture and through community engagement, has encouraged and inspired them to change their lifestyles in a number of ways and not only in relation to health and physical activity. It is important to note that Syrian refugee women sought physical activity for a number of different reasons. For some women, it has been a means of challenging previous cultural norms that restricted their abilities to exercise. For others, it is a means of coping with mental health issues and the challenges of settling in Canada. For others still, it is about achieving a certain body image or health ideal. The experiences of social inclusion in Canada has therefore affected their attitudes towards a new culture and their desire to pursue healthier lifestyles. 112  5.1 Significance of study  My study has highlighted the gendered experiences that facilitate or hinder migration and has illustrated the ability of Syrian refugee women to embrace cultural flow across various cultural environments, both inside and outside of Canada. Since arrival in Canada and the exposure to a new community, they have been empowered to challenge some aspects of their own culture and the gender-related norms which restricted the activities accessible to them as women prior to migration. Observations of a physically active Canadian community and the ability to live in a more diverse and inclusive society has helped them to deal more effectively with their existing struggles as newcomers. Interviewees specifically highlighted experiences of freedom, equality, and having access to women’s rights through the Canadian system as providing a positive impact on their process of integration. Such social supports have been a critical predictor of refugees’ mental health across a number of studies (Shishehgar et al., 2016).  Accordingly, I have been able to demonstrate how resilient these women have been, which reflects their abilities to adapt and cope in new socio-cultural environments. As Quosh, Eloul, & Ajlan (2013) highlight, “few studies [have] looked at the complex interrelationship between past and current stressors, as well as the link between different aspects of wellbeing and mental health, including what contributes to resiliency and adaptation” (p.289).  Through the findings in my study, I was able to conclude that this particular group of Syrian refugees in Canada have shown their resilience as refugees and their abilities to transition into and out of several communities throughout their migration. In contrast to some other nations that have accepted Syrian refugees, Canadian approaches to multiculturalism and immigrant integration may have been particularly helpful in facilitating the development of this resiliency. From my 113  observations, the women I interviewed seem quite optimistic and hopeful about their Canadian futures, despite ongoing challenges in language acquisition and employment.   5.2 Study limitations and future directions   While the findings in this study provided rich insight into the experiences of refugee women in a Canadian context, something particularly valuable given the waves of Syrian refugees who have been displaced worldwide, the study had several limitations. Firstly, I was only able to interview a limited number of Syrian refugee women in Metro Vancouver. As the sample was limited by size and place of origin, the experiences of this group of women could be very much different than women settling in other regions in Canada and other Western communities. Study participants were also only Arabic speaking and Muslim although there are a number of languages and religious affiliations among Syrian refugees. Consequently, it would be inaccurate to generalize the findings to Syrian refugee women as well as other ethnically diverse immigrant women.  Moreover, while I was at an advantage and feel incredibly fortunate to have had the opportunity conduct this research in Arabic, this generated practical limitations in addition to those of time and resources. Initially, I was unable to access other Arabic speakers to cross-check my translations of transcripts which I had directly translated from Arabic to English. Secondly, I could not provide the women the opportunity to follow-up and assess preliminary findings that I had developed throughout the research given their very limited abilities to understand the English language. Hence, member-checking was inexecutable and the dissemination of findings was not feasible. Although this is important for research conducted on culturally diverse communities, I remained committed to being reflexive and upholding a genuine approach and 114  transparency throughout data collection and analysis. Despite these limitations, including my own abilities as a new researcher whose skills are still developing, I do not believe they affected the rigor of my data and the substantive insights into the lived experiences of the women. In fact, they have generated recommendations that would be useful for future studies.  This study began by examining how the views and practices of health and physical activity are influenced by the experiences of migration and the ability of a very specific group of ‘migrants’ to settle in a Canadian community. My intent was to build upon a growing initiative to conduct research on the settlement, integration, and long-term health outcomes of Syrian refugees who have fled and are continually being displaced to a number of ethnically diverse communities worldwide. As the commitment to study this population is of ongoing importance, I offer some recommendations for future studies.  Future studies invested in studying Syrian refugees across different Canadian communities should consider different subgroups of Syrian refugees and those with different experiences of displacement. For example, it would be insightful to compare refugees who lived in refugee camps to those who were displaced in cities prior to migrating to Canada. As none of the women I interviewed were displaced in camps, it would be interesting to speak with women who have been exposed to these environments and who may have developed additional health issues that would affect their integration in new communities. Furthermore, it would be interesting to compare Syrian refugees who have come to Canada as either governmentally sponsored refugees (GAR) or privately sponsored refugees (PSR). According to Citizen and Immigration Canada, GARs are usually referred by the United Nations Refugee Agency and are selected based on their protection needs rather than abilities to settle in Canada They also are usually less educated and have less knowledge of official Canadian languages than PSRs, which 115  could indicate a different socio-economic class of refugees with different needs and attitudes towards healthy lifestyles (CIC, 2016). Future studies could also invest in comparing refugees who have settled across different communities in Canada. A longitudinal study would also be useful in seeing the effects of long-term integration and how the views and practices of Syrian refugees change with length of time in Canada. The eleven women that I interviewed were fairly recent arrivals as none of them had been in Canada for more than two years at the time of the study, and about half were here for only a year or less. For some women, it was evident that they have not had sufficient time to fully integrate. Thus, a longitudinal approach could provide a more accurate account of their ability to integrate as well as evaluate their long-term health outcomes and physical activity practices.  Finally, as a feminist researcher who was specifically invested in the views of Syrian refugee women, my study focused on various aspects related to gender and cultural roles and how this influenced their resiliency and ability to accept new cultures. 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International journal of biometeorology, 57(4), 615-630.  130  Appendices  Appendix A  : Interview questions  Thank you for participating in this interview. I will ask you a series of questions around topics related to your experiences with health and physical activity before and after immigration. There are no right or wrong answers. I am interested in learning about your experiences, understandings, and views.  Preliminary questions  1. Tell me about yourself, what you like to do in your free time, what are your hobbies and interests?  2. Can you please describe your day? What are some things that you usually do?  a. (probe:) what does your usual day look like? 3. How is this any different than your lifestyle before you immigrated to Canada? a. Do you consider Canada as being your own home (why or why not?)  b. What do you like best about Canada? 4. When did you come to Canada and what were the reasons why you left your home? a. Were you in Syria or another place (refugee camp…etc)? Questions about health and physical activity  5. What does being “healthy” mean to you? a. What are some things you do or would like to do to make you feel healthy? b. Are any of these things related or affected by moving to a new country or culture? 6. How would you describe or did you perceive your health back in Syria?  a. How has this changed after coming to Canada? 7. When were you first exposed to physical activity? Tell me about this experience. 8. Do you think physical activity is important for women and why or why not?  131  9. How, if at all, has your status as a refugee affected: a. your health b. your participation in physical activity? If so, why do you think this is so? 10. Did you ever participate in physical activity in Syria? If not, why? Tell me more about this experience. 11. What, if anything, prevents you from participating in physical activity in Canada? 12. What do you think about how physical activity is delivered in Canada? What have you noticed? a. What are some things you like and dislike about the physical activity culture in Canada? 13. Have you ever participated in a community organized physical activity? a. Would you be interested in participating in a regular physical activity class in a local community center? Why or why not? b. What are some things that would make you feel more comfortable to participate? Wrap up questions  14. Is there anything else you think is important to discuss that we haven’t already covered in the interview? 15. Is there anything else you want to add about yourself, your family, or your views towards health and physical activity? 16. Is there anything you would like to ask me, about the study, or anything?   132  Appendix B  : Background survey Please provide a name (feel free to use a “made up name” called a pseudonym. This will be used when quotes are used in the study. No identifying information will be disclosed and will be kept confidential. The following information will only be collected to help guide the interview.   Name _________________________________________ City of Residence: _____________________________ Age:     <20 yrs    20-29      30-39      40-49       50-59       60+ What language do you mainly speak at home? ______________________ Please list any other languages spoken: ___________________________ What is your highest level of educational achievement?  Elementary School    Secondary School     None   University Degree      Graduate Degree   How long have you been living in Canada? _________________ Which part of Syria are you from? ___________________ Where was your last location prior to migration to Canada? ____________ Are you currently employed?  Yes    No If employed, do you work:  Full-time (30 or more hrs/week)    Part-time (less than 30 hrs/week)    Temporary Are you currently involved with any volunteer position? ____________________________ If yes, please explain: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Do you have any health conditions?  Yes    No    Unsure If yes, please specify: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________  


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