Physical Activity Promotion in Primary Diabetes Care: A National Survey of Nurses in Bahrain

1. Introduction

1.1. Physical Activity in Type 2 Diabetes Management

Type 2 diabetes (T2DM) is a major public health challenge associated with substantial morbidity and mortality [1]. In Bahrain, T2DM affects an estimated 15% of adults [2] and places a substantial burden on the healthcare system [3]. Lifestyle modification is a cornerstone of T2DM management, with regular physical activity improving glycaemic control and several important cardiometabolic outcomes [4,5]. Current guidelines recommend at least 150 minutes of moderate-intensity aerobic activity per week, combined with resistance exercise at least twice weekly [6,7,8].

Despite these well-established recommendations, many people with T2DM remain insufficiently active [5,9,10]. This persistent gap between recommended and actual physical activity highlights the need to integrate physical activity assessment and promotion into routine diabetes care.

1.2. The Role of Nurses in Physical Activity Promotion

Nurses are well positioned to promote physical activity because of their frequent contact with patients and their established role in lifestyle counselling and behaviour change [11,12]. This provides opportunities to integrate the promotion of physical activity into routine diabetes care and to support patients in becoming and remaining more active. Previous studies have demonstrated that nurse- and other health professional-led interventions can improve physical activity participation and diabetes outcomes [13,14,15].

1.3. Current Evidence on Physical Activity Promotion by Healthcare Professionals

Despite the recognised role of healthcare professionals in promoting physical activity, its routine implementation in clinical practice remains inconsistent. Systematic reviews have reported that nurses and other clinicians support the promotion of physical activity but continue to face barriers to its routine implementation, including limited consultation time, insufficient training, competing clinical priorities, and organisational constraints [12,16,17]. This gap is also evident in primary healthcare, where clinicians frequently encourage patients to be physically active. However, structured assessment and promotion of physical activity are not routinely integrated into clinical practice [18]. Together, these findings suggest that positive professional attitudes alone may not be sufficient to ensure consistent implementation of physical activity promotion within routine healthcare [19].

1.4. Physical Activity Promotion in Bahrain: The Knowledge Gap

Halting the rise in diabetes is a key target of Bahrain’s strategy for the prevention and control of non-communicable diseases [20]. The promotion of physical activity is also supported by national policy and clinical guidance. Bahrain’s guidance for the management of type 2 diabetes in primary healthcare recommends that clinicians regularly reinforce lifestyle advice, introduce physical activity according to willingness and ability, set individualised goals, and progress towards recommended levels of aerobic and resistance activity [21]. The guidance also identifies nurses as members of the multidisciplinary care team responsible for delivering structured diabetes education [21]. The 2018 National Strategy on Diet and Physical Activity further identifies public education, healthcare professional training, and the development of primary healthcare services as components of national physical activity promotion [22].

Despite this policy and clinical framework, little is known about how diabetes nurses implement physical activity promotion in routine primary healthcare in Bahrain. Although physical activity behaviour among people with T2DM in Bahrain has been investigated [10], to our knowledge, no published studies have examined nurses’ perceptions of their role, awareness of physical activity guidelines, confidence in providing physical activity advice, or current promotion practices. Evidence from neighbouring Oman has identified opportunities to strengthen the promotion of physical activity within diabetes care, including training healthcare professionals, digital approaches to physical activity assessment and communication, and improved awareness of community resources [23]. However, this does not establish how physical activity promotion is currently delivered by diabetes nurses within Bahrain’s primary healthcare system.

Bahrain’s relatively small, nationally defined diabetes nursing workforce offers an opportunity to examine the promotion of physical activity across the primary healthcare system. Understanding current practice may therefore help identify gaps between national recommendations and their implementation and inform future professional education and service development.

1.5. Study Aim

The aim of this study was to examine the promotion of physical activity by diabetes nurses working in primary healthcare centres across Bahrain.

The objectives were to assess (i) nurses’ perceptions of their role and confidence in providing physical activity advice; (ii) their awareness and use of physical activity guidelines and assessment tools; (iii) current physical activity promotion practices; (iv) their knowledge of physical activity recommendations; (v) nurses’ perceptions of barriers to physical activity among people in Bahrain and explore their perspectives on strategies to overcome these barriers and strengthen the promotion of physical activity.

2. Materials and Methods

2.1. Study Design and Setting

This national cross-sectional mixed-methods study was conducted among nurses working in all 26 primary healthcare centres (PHCs) across the four governorates of Bahrain.

2.2. Participants

The target population consisted of nurses working in treatment rooms, Central Diabetes Clinics (CDCs) and Non-Communicable Disease clinics (NCDCs) within Bahrain’s primary healthcare centres. Eligible participants had at least one year of clinical experience and were actively involved in the care of people with type 2 diabetes within these clinics. Nurses who were unable to communicate in English were excluded. A census approach was used to maximise representation, with all 52 eligible nurses invited to participate, thereby reducing the potential for selection bias.

2.3. Survey Instrument

Data was collected using a structured online questionnaire (Supplementary Questionnaire). The questionnaire was adapted from the instrument developed by Bello et al. [24], which was itself based on earlier work by Lowe et al. [25]. Items were modified where necessary to reflect the nursing role and the Bahrain primary healthcare setting, while retaining five domains: (i) demographic characteristics; (ii) perceptions of the nursing role in physical activity promotion; (iii) awareness and use of physical activity guidelines and assessment tools; (iv) physical activity promotion practices; and (v) perceived barriers and facilitators to physical activity promotion. The questionnaire included multiple-choice, Likert-scale, and categorical response items.

Given the small, nationally defined target population and the need to maximise participation in the main study, separate pilot testing was not undertaken.

2.4. Data Collection

The questionnaire was administered online using Microsoft Forms. Participant recruitment was facilitated by the CDCs Nursing Coordinator, who distributed the participant information leaflet and survey link via email to all eligible nurses. Participants provided electronic informed consent through a mandatory item before accessing the questionnaire. No personally identifiable information was collected, and the survey was configured not to record participants’ email addresses. Responses were therefore anonymous, which was intended to reduce the potential influence of social-desirability bias. The survey opened for six weeks, from 28^th December 2025 through to 8^th February 2026, with reminders after two and five weeks to maximise participation. Participation was voluntary, and participants could withdraw at any stage before submitting their responses.

2.5. Statistical Methods

All quantitative questionnaire items were completed by all participants, and there were no missing data. Descriptive statistics were used to summarise participant characteristics and questionnaire responses. Categorical variables are presented as frequencies and percentages. Individual questionnaire items were analysed as separate variables, and no composite scores were calculated. For the correlation analyses, five-point Likert responses were coded from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating stronger agreement or confidence. Practice-frequency responses were coded from 1 (never) to 3 (always), with higher scores indicating more frequent physical activity promotion. Awareness and guideline-use responses were treated as categorical variables for chi-squared analyses. Responses to knowledge and multiple-response items were summarised as frequencies and percentages.

Associations between ordinal variables were examined using Spearman’s rank-order correlation. Associations between categorical variables were assessed using the chi-square test. All statistical tests were two-tailed, with statistical significance set at p < 0.05.

Statistical analyses were performed using IBM SPSS Statistics v31.0 (IBM Corp., Armonk, NY, USA) and R version 4.5.2 (R Core Team, Vienna, Austria).

2.6. Qualitative Analysis

Responses to the open-ended survey question (Question 20) were analysed using inductive thematic analysis, following the six-phase approach described by Braun and Clarke [26]. Free-text responses were imported into NVivo 15 (Lumivero, Denver, Co, USA) to facilitate data management and coding. Initial codes were generated directly from the data and grouped into broader themes through an iterative process of review and refinement. Representative quotations are presented to illustrate each theme.

3. Results

3.1. Participant Characteristics

Forty-nine of the 52 eligible nurses completed the survey, giving a response rate of 94.2% (Table 1). Three nurses did not participate as they were on leave at the time of data collection. The sample, therefore, represented 94.2% of the eligible national diabetes nursing workforce across Bahrain’s primary healthcare centres.

Participants were predominantly experienced and well-qualified. Most were aged 26-45 years (95.9%), held a bachelor's degree (85.7%), and had more than five years of nursing experience (91.8%). Undergraduate education in physical activity promotion was reported by 34 nurses (69.4%), while 9 (18.4%) reported no previous training, and 6 (12.2%) were unsure. Participants were recruited from all four governorates and worked across treatment rooms (42.9%), Central Diabetes Clinics (40.8%) and Non-Communicable Disease clinics (16.3%) (Table 1).

3.2. Perceptions of the Nursing Role and Confidence in Physical Activity Promotion

Nurses strongly endorsed physical activity promotion as part of their professional role (Table 2). Almost all participants agreed that discussing the benefits of physical activity (97.9%) and advising patients how to increase their physical activity levels (93.9%) were part of the nursing role. Similarly, 87.8% agreed that physical activity should be promoted during every patient contact. Most participants (83.7%) also agreed that nurses should be physically active to act as role models for their patients.

Participants also reported high levels of confidence in providing physical activity advice. Forty-three nurses (87.7%) agreed that they were confident providing general advice on maintaining a physically active lifestyle, while 38 (77.6%) reported confidence in recommending specific physical activity programmes.

Exploratory analyses showed that stronger perceptions of the nursing role were associated with greater confidence in providing physical activity advice (Figure A1). The strongest associations were observed between agreement that nurses should act as physically active role models and confidence in providing both general lifestyle advice (Spearman’s rho = 0.46, p = 0.001) and specific physical activity recommendations (Spearman's rho = 0.50, p <0.001).

3.3. Awareness and Use of Physical Activity Guidelines and Assessment Tools

Awareness and use of physical activity guidelines were considerably more variable than nurses’ perceptions of their professional role. Although 22 participants (44.9%) reported being aware of at least one physical activity guideline, only 12 (24.4%) reported both being aware of and routinely using these guidelines (Table 3). More than half of the participants (55.1%) were not aware of any physical activity guidelines, and almost two-thirds (65.3%) reported not using them in clinical practice. Awareness of physical activity guidelines was significantly associated with their use (c² = 17.7, df = 4, p = 0.001).

Awareness of tools to assess patients’ physical activity was also limited. Twenty-one nurses (42.9%) reported being aware of assessment tools, while 28 (57.1%) were either unaware of such tools or unsure of their availability. Awareness of physical activity assessment tools was significantly associated with guideline use (c² = 17.8, df = 4, p = 0.001) (Table 3).

3.4. Physical Activity Promotion Practices

Promotion of routine physical activity varied among participants (Table 4). Most participants reported recommending physical activity when clinically appropriate (75.5%) and encouraging healthy individuals to maintain an active lifestyle (77.6%). More than half (57.1%) also reported routinely initiating conversations about physical activity with their patients.

In contrast, routine assessment of patients’ physical activity status was considerably less common. Only 17 nurses (34.7%) reported always assessing physical activity irrespective of patients’ presenting health needs, while 27 (55.1%) did so only sometimes and 5 (10.2%) reported never undertaking routine assessment (Table 4).

Exploratory analyses demonstrated that nurses who reported greater confidence in recommending specific physical activity programmes were more likely to recommend physical activity when clinically appropriate (Spearman’s rho = 0.29, p = 0.04) and to initiate discussions about physical activity with their patients (Spearman’s rho = 0.30, p = 0.032).

3.5. Resources Used to Promote Physical Activity

Direct discussion with patients was the most commonly reported approach to promoting physical activity, used by 37 nurses (75.5%) (Figure 1). Printed educational materials were used by 21 participants (42.9%), while 15 (30.6%) reported directing patients to other services or community-based programmes. Online resources were used less frequently (22.4%), and only four nurses (8.2%) reported using mobile applications to promote physical activity. Seventeen participants (34.7%) selected the free text “Other” response.

3.6. Awareness of Physical Activity Initiatives

Awareness of local physical activity initiatives varied among participants (Figure 2). The Weight Management Clinic in Primary Healthcare was the most widely recognised initiative, with 42 nurses (85.7%) reporting awareness. In contrast, 12 participants (24.5%) were aware of the Obesity Does Not Suit Me initiative, while only one (2.0%) reported awareness of Balance. Six participants (12.2%) identified other initiatives.

3.7. Knowledge of Key Physical Activity Recommendations

Knowledge was strongest for general physical activity recommendations but less consistent for some specific guideline components (Figure 3). The most frequently recognised recommendation was that any physical activity is better than none, selected by 33 participants (67.3%). Approximately half recognised the recommendation to achieve at least 150 minutes of moderate-intensity physical activity per week (51.0%) and the importance of minimising prolonged sitting (49.0%).

Knowledge was less consistent for recommendations about resistance exercise, balance or flexibility activities. Nineteen nurses (38.8%) identified the recommendation to undertake muscle-strengthening activities on at least two days per week, while 15 (30.6%) identified balance and flexibility exercises.

3.8. Perceived Barriers to Physical Activity

Forty-one nurses (83.7%) perceived lack of time due to long working hours or other responsibilities as a barrier to physical activity among people in Bahrain (Figure 4). This was followed by a lack of motivation and support from family and friends, reported by 33 nurses (67.3%). Other perceived barriers included limited public awareness of the importance of physical activity for a healthy lifestyle (32.7%), traditional or cultural beliefs (32.7%), environmental factors such as limited access to suitable facilities (36.7%), and the perception among some individuals that exercise was unnecessary (38.8%).

3.9. Qualitative Findings

A total of 49 participants responded to the open-ended question exploring strategies to overcome barriers to physical activity among people with non-communicable diseases. Thematic analysis identified four overarching themes: (1) public awareness and health education; (2) access to physical activity facilities and opportunities; (3) strengthening motivation and behavioural support; and (4) enhancing healthcare and community support (Table 5). As individual responses could contribute to more than one theme, frequencies represent coding references rather than numbers of participants.

3.9.1. Public Awareness and Health Education

Participants highlighted that greater awareness and education were important for encouraging physical activity, with responsibility extending beyond individual patient education to wider community and public health approaches. Responses reflected a perceived need to promote understanding of the health benefits of physical activity through healthcare, community and media settings.

3.9.2. Access to Physical Activity Facilities and Opportunities

Participants highlighted the importance of improving access to safe, affordable and convenient opportunities for physical activity. Responses reflected a need for facilities and programmes that were accessible within local communities and workplaces, including free or low-cost options and environments that accommodated diverse needs, particularly those of women.

3.9.3. Strengthening Motivation and Behavioural Support

Participants identified motivation and behavioural support as important for helping people become and remain physically active. Suggested approaches emphasised encouragement, goal-setting, and practical strategies for overcoming barriers such as limited time, as well as group-based activities that could provide additional motivation and support.

3.9.4. Enhancing Healthcare and Community Support

Participants also emphasised a broader role for healthcare services and community initiatives in supporting physical activity. Responses highlighted opportunities to strengthen support within routine care through nurse-led promotion, referral to relevant services and multidisciplinary input, alongside wider workplace, government and community-based initiatives.

4. Discussion

4.1. Principal Findings

This national study found that diabetes nurses in Bahrain strongly perceived the promotion of physical activity as part of their professional role and reported high levels of confidence in providing physical activity advice. However, this professional commitment was not consistently reflected in practice. Awareness and use of physical activity guidelines and assessment tools were variable, and consistent assessment of patients’ physical activity was considerably less common than providing advice or initiating discussions about physical activity.

The findings also identified potential barriers to translating physical activity promotion into practice. Knowledge was stronger for general physical activity recommendations than for specific components related to muscle strengthening, balance, or flexibility, while awareness of local physical activity initiatives varied considerably. Nurses reported that lack of time due to work or other responsibilities was the most frequently perceived barrier to physical activity among people in Bahrain, followed by lack of motivation and support from family and friends. Their qualitative responses highlighted opportunities that extend beyond individual clinical encounters, including greater public awareness and health education, improved access to physical activity, behavioural and motivational support, and stronger healthcare and community support.

Taken together, these findings suggest that the principal challenge may be less about establishing physical activity promotion as part of the nursing role and more about supporting its consistent implementation within routine diabetes care.

4.2. Nurses’ Role and Confidence in Physical Activity Promotion

Nurses’ strong perception that promoting physical activity is part of their professional role is consistent with previous research showing that nurses generally consider it an important component of their practice, although its implementation varies across clinical settings [12]. Positive attitudes towards exercise promotion have also been reported among other healthcare professionals, despite recognised barriers to implementation in clinical practice [16]. The present findings extend this evidence to diabetes nurses working across primary healthcare in Bahrain, among whom the promotion of physical activity was strongly recognised as a professional responsibility.

Confidence in providing physical activity advice was also high, although participants were more confident in providing general advice on maintaining an active lifestyle than in recommending specific physical activity programmes. Similar findings have been reported among primary healthcare professionals, with confidence associated with physical activity promotion behaviour despite less consistent knowledge of current recommendations [18]. Variation in healthcare professionals’ preparedness to provide physical activity guidance to people with diabetes has also been reported [11]. In the present study, stronger perceptions of the nursing role were associated with greater confidence in providing physical activity advice. Although these associations were exploratory, they support a relationship between professional role perception and confidence. In contrast, the lower confidence in recommending specific programmes suggests that general confidence may not necessarily reflect preparedness to provide more specific physical activity guidance.

4.3. From Confidence to Practice: Guideline Use and Physical Activity Assessment

The contrast between high confidence and less consistent guideline use suggests an important gap between nurses’ confidence in promoting physical activity and the systematic implementation of these guidelines in practice. Fewer than half of participants were aware of at least one physical activity guideline, and almost two-thirds reported not using guidelines when providing advice. Similar discrepancies have been reported among healthcare professionals, who may recognise the importance of promoting physical activity and feel confident providing general advice, yet have less knowledge of specific recommendations or make limited use of guideline-based approaches [11,18]. Limited knowledge of guidelines, competing clinical priorities and insufficient training have also been identified as barriers to integrating physical activity promotion into routine clinical practice [12,16].

The same implementation gap was evident in physical activity assessment. Although most participants reported recommending physical activity and initiating discussions with patients, fewer than half reported always assessing patients’ physical activity irrespective of their presenting health needs. Routine assessment can help identify patients who are insufficiently active and provide a basis for subsequent advice or referral [7,27,28]. However, the measurement properties of brief physical activity assessment tools used in primary care vary, and current evidence does not identify a single optimal tool for routine practice [29].

Taken together, these findings suggest that the main gap may lie not in nurses’ willingness or confidence to promote physical activity, but in the systematic integration of guideline-informed assessment and promotion into routine diabetes care.

4.4. Knowledge of Physical Activity Recommendations and Local Initiatives

The variability in nurses’ knowledge of physical activity recommendations provides further evidence that high confidence does not necessarily correspond with detailed knowledge of current recommendations. Participants were more likely to recognise broad messages, such as that any physical activity is better than none, than recommendations related to muscle strengthening, balance, or flexibility exercises. Similar gaps have been reported among primary healthcare professionals, even when attitudes towards physical activity promotion and confidence in providing advice are positive [18]. Previous primary care research has also shown that healthcare professionals have incomplete knowledge of recommended levels and types of physical activity [25,30]. These distinctions are clinically relevant because current guidelines recommend ≥150 minutes/week of moderate-to-vigorous-intensity aerobic activity and 2-3 resistance-training sessions on nonconsecutive days for adults living with diabetes [6,8]. However, the lower recognition of balance or flexibility recommendations should be interpreted with caution, as these recommendations are more specifically emphasised for older adults or those at risk of falls [6].

A similar issue was apparent in awareness of local physical activity initiatives. Most participants were aware of the Weight Management Clinic within Primary Healthcare, but awareness of other initiatives was considerably lower. Limited awareness of available initiatives may reduce opportunities to direct patients towards additional support, although referral to these specific services was not assessed in this study. The finding that most participants supported the development of Bahrain-specific physical activity guidelines is particularly notable because relevant national guidance already exists. Physical activity is addressed within Bahrain’s national strategies for the prevention and control of non-communicable diseases and its National Strategy on Diet and Physical Activity [20,22,31]. In addition, national guidance for the management of type 2 diabetes in primary healthcare recommends individualised physical activity goals and progression towards 150 minutes per week of moderate-intensity aerobic activity and resistance training up to three days per week [21]. The perceived need for additional Bahrain-specific guidelines may therefore reflect limited awareness or use of existing guidance rather than an absence of national recommendations. Similar gaps between the availability of physical activity guidance and its use in clinical practice have been reported internationally [18,30].

4.5. Barriers and Opportunities for Strengthening Physical Activity Promotion

The barriers perceived by nurses highlight the importance of looking beyond knowledge and advice when considering physical activity promotion among people with T2DM. Nurses reported that lack of time was the most frequently perceived barrier to physical activity among people in Bahrain, followed by lack of motivation and support from family and friends. Cultural, socioeconomic and environmental factors were also reported. This is consistent with evidence showing that participation in physical activity among people with type 2 diabetes is influenced by interacting personal, social, and environmental factors. Recent systematic reviews have identified a lack of time, motivation, and social support, as well as health and environmental barriers, as important determinants of physical activity participation [32,33,34]. Social support appears particularly relevant, with support from family, peers and healthcare professionals facilitating engagement and maintenance of physical activity [32,33]. Taken together, these findings suggest that providing information about the benefits of physical activity alone is unlikely to be sufficient, and that promotion strategies also need to recognise the practical and social circumstances that influence patients’ ability to become and remain active.

The qualitative findings extend this interpretation by identifying potential opportunities for support at multiple levels. Participants emphasised public education, affordable and accessible opportunities for physical activity, motivational and behavioural support, and stronger healthcare and community involvement. These priorities broadly align with evidence supporting individualised physical activity programmes, social support, patient education, strategies to strengthen motivation and self-efficacy, and ongoing monitoring and feedback for people with T2DM [32,33]. They are also consistent with Bahrain’s National Strategy on Diet and Physical Activity, which identifies public education, supportive environments, healthcare professional training, and the development of primary healthcare services as components of a multisector approach to increasing physical activity [22]. Taken together, these quantitative and qualitative findings suggest that strengthening physical activity participation will require extending support beyond individual counselling, to include healthcare, community and environmental approaches.

4.6. Implications for Practice and Policy

The findings suggest that efforts to strengthen physical activity promotion within primary diabetes care in Bahrain should focus primarily on supporting implementation in routine practice. Given the strong professional role perception and confidence reported by nurses, priorities could include improving familiarity with existing physical activity recommendations, providing practical training in brief physical activity assessment and behaviour-change approaches, and incorporating simple assessment and documentation processes into routine diabetes consultation. Where patients require additional support, clearer referral pathways to existing services, including weight management and other appropriate physical activity services, may help nurses translate assessment and advice into further action. Such approaches are consistent with evidence favouring interventions that combine professional education with practical resources and changes to clinical systems rather than relying on education alone [17,35].

At a policy and service level, the findings support greater dissemination and implementation of existing national guidance rather than the development of additional physical activity guidelines. Bahrain’s guidance for the management of type 2 diabetes already provides specific recommendations for aerobic and resistance activities [21], while the National Strategy on Diet and Physical Activity identifies healthcare professional training, public education, and the development of primary healthcare services as components of national physical activity promotion [22]. Embedding this existing guidance more clearly within routine diabetes care, supported by standardised assessment processes, appropriate training, and clearly defined referral pathways, could help make the promotion of physical activity more systematic.

However, healthcare-based approaches alone are unlikely to address the broader barriers identified in this study. Community and environmental strategies that improve access to appropriate opportunities for physical activity and strengthen social and behavioural support may also be required. A coordinated approach that links clinical practice with existing community and national physical activity initiatives may therefore provide a more appropriate response to the multidimensional barriers identified by nurses.

4.7. Strengths and Limitations

A major strength of this study is its national coverage of diabetes nurses working within primary healthcare in Bahrain. The census approach and high response rate captured most of the eligible nursing workforce, reducing the potential for selection bias and providing a broader representation of current practice within this professional group. The mixed-methods design also allowed quantitative findings on role perception, confidence, knowledge and practice to be considered alongside nurses’ perspectives on strategies for overcoming barriers to physical activity. This combination provides a more comprehensive understanding of physical activity promotion in primary diabetes care than either component alone.

Several limitations should also be considered when interpreting the findings. The cross-sectional design does not permit causal inference, and the relatively small sample reflects the size of the national diabetes nursing force in primary healthcare, limiting the statistical power of exploratory analyses and the generalisability of findings beyond Bahrain. Given the exploratory nature and limited number of inferential analyses, no formal adjustment for multiple testing was applied. The statistically significant associations should therefore be interpreted cautiously, as some may have arisen by chance. The use of self-reported data may also have introduced recall and social desirability bias, particularly for questions concerning confidence and clinical practice. Social-desirability bias may have led participants to over-report their confidence and the frequency with which they promoted physical activity. Recall errors may have resulted in either over- or under-reporting of previous practices, and the magnitude of these potential biases cannot be determined. Confidence should therefore not be interpreted as evidence of objectively assessed competence. In addition, barriers to physical activity were reported from the perspectives of nurses rather than the members of the general population themselves. The qualitative component was based on responses to a single open-ended survey question and therefore did not provide the depth that could be obtained through interviews or focus groups. Finally, the questionnaire was adapted for the Bahrain primary healthcare context from previously published instruments [24,25]. However, it was not separately pilot tested in the target population, which should be considered when interpreting the findings.

5. Conclusions

This national study identifies an important gap between nurses’ strong professional commitment to physical activity promotion and its systematic integration into routine primary diabetes care in Bahrain. The findings suggest that the principal challenge is not establishing physical activity promotion as part of the nursing role but supporting its consistent implementation in practice. Greater dissemination and implementation of existing national guidance, together with practical support for routine physical activity assessment and clearer referral pathways, may help strengthen the promotion of physical activity within diabetes care. However, the broader social and environmental barriers perceived by nurses will also require coordinated approaches at the healthcare and community levels.

Future research should evaluate approaches to integrating guideline-informed physical activity assessment and promotion into routine diabetes care, including practical assessment processes, professional training and referral pathways [17]. Interventions studies are needed to determine whether these approaches improve nurses’ physical activity promotion practices and patient outcomes. Further research should also explore patients’ perspectives on barriers and facilitators to physical activity, complementing the nurse-reported perspectives identified in this study [32].