Motives and Barriers for Regular Physical Activity among Medical Students from the Western Balkans (South-East Europe Region)

Regular physical activity (PA) has multiple beneficial effects on students’ health, effectively reducing the risk of various non-communicable diseases. Various factors play a role in an individual’s motivation to engage in and maintain regular PA. So far, no research dealing with the motives and barriers for regular PA among medical students has been conducted in the countries of the Western Balkans. The aim of this study was to identify the motives and barriers related to regular PA and compare them with different demographic, socioeconomic, and individual lifestyle factors among Western Balkans medical students. The research was conducted in a form of a cross-sectional study. It included 2452 medical students from 14 faculties in five countries (Slovenia, Croatia, Bosnia and Herzegovina, North Macedonia, and Serbia). The most commonly reported motive of medical students for regular PA is to feel better, followed by stress reduction, to look better, the desire to lose weight, and to control chronic disease. PA improvement motives are more frequently associated with the female gender, more advanced years of study, a normal weight, above average household income, and a non-smoking status. Faculty obligations are the most common barrier for regular PA among medical students, followed by other barriers, such as financial situation, current life situation, and health conditions. Barriers are more frequently reported by male students who are overweight or obese, who have a below average income, and are smokers. It is necessary for public health authorities to examine and take into account the perceived motives and barriers when forming activities and policies that aim at increasing the level of PA, in order to enhance the health of the student population.


Introduction
Physical activity (PA) is recognized as one of the major determinants of promoting well-being and enhancing overall health [1]. Regular PA has a significant impact on all human organ systems, mediating multiple beneficial effects on the overall health, effectively reducing the risk of various noncommunicable diseases (NCD), such as insulin resistance, diabetes, dyslipidemia, hypertension, and cardiovascular diseases [2,3].
Healthy life habits (proper nutrition and regular PA) are essential for the cognitive and social development of young adults and can play a key role in their overall academic success [4].

Study Design and Population
A cross-sectional study that included 2452 students from 14 medical faculties in the Western Balkans, was performed from November 2019 to February 2020. A convenience sampling of faculties of medicine was used. The participating medical faculties from each county were shown in Table 1. Female students made up 2015 (82.2%) and male students 437 (17.8%) of the sample.

Study Questionnaire
An online Google form survey was used as an instrument for data gathering. Accessible from any device, the survey was distributed using channels, such as emails, social networks (Facebook), or faculty websites. Participation was voluntary and participants were allowed to withdraw at any time. Only fully completed questionnaires were registered in a database and downloaded as a Microsoft Excel sheet, upon a study completion. The research method through Google's privacy policy guaranteed the anonymity of the respondents.

Variables
The survey was divided in two parts. The first part contained the questions about the general characteristics of the respondents (attended faculty, gender, year of study, body height and weight, household income, type of settlement), and the second part contained the questions about life habits (daily level of PA, alcohol consumption and student smoking status), and questions about reasons (motives) for engaging in regular PA, and excuses (barriers) for irregular PA.
Most common motivators (motives) were determined with the statements: "I engage in regular PA because I want: to feel better (mood improvement, energy boost, better sleep, fun, etc.), to reduce stress (relaxation and improving executive functions, e.g., thinking, learning, and judgment skills-to improve academic performance), to look better (better physical appearance), to lose weight (reduce adiposity), to control chronic disease (manage chronic conditions and disabilities), and I do not engage in PA." The perceived barriers for engaging in regular PA were determined with the statement: "I do not engage in regular physical activity due to: faculty obligations (lack of time), current life situation (special events, day-to-day or global circumstances, or personal circumstances that affect the person or their family or friends, e.g., illness or a situation that requires care), financial situation (e.g., high costs of equipment or access to sports centers), health conditions (injury, illness, chronic medical condition, etc.), other barriers (subjective or objective), and I engage in PA." Both statements were multiple-choice type, so respondents could select one or more offered answers.
Based on daily regular PA, students were divided according to those who engaged in some kind of regular PA and those who did not.
Other independent variables are analyzed as follows: Nutritional status was determined by calculating the body mass index (BMI), dividing the self-reported body weight (kg) and body height squared (m). Based on the obtained values, and using the WHO recommendations, the participants were classified as: underweight (<18.50 kg/m 2 ), normal weight (18.50-24.99 kg/m 2 ), overweight (25.0-29.99 kg/m 2 ), and obese (≥30.0 kg/m 2 ).
Students were divided in three groups by self-evaluated household income: below average (far below and below), average, and above average (above and far above).
Based on the number of inhabitants, the respondents were classified according to the type of settlement lived in before starting university education, and two categories were determined: rural and urban.
Alcohol consumption was determined by the self-reported answers, according to the students who do not drink, those who drink occasionally, or on weekends, students who consume alcohol several times a week, and daily drinkers.
Students were grouped, based on their smoking status, as "smokers" (for occasionally smoking or any other number of cigarettes smoked per day), and "non-smokers" (I am not a smoker).

Statistical Analysis
In the statistical analysis, the categorical variables were displayed as numbers and percentages. The association between the independent variables and the motives/barriers were examined using the χ 2 test. As a measure of association, the Fi coefficient (for 2 × 2 tables) and Cramer's V (for tables higher than 2 × 2), were used.
The relationship between the outcome (dependent) variable, i.e., the engagement in some form of regular PA and the motives/barriers, was tested using a multinomial logistic regression (MNLR).
In the first step, the univariate MNLR was conducted by examining the association of only one independent with the outcome variable, whereby "has engaged in some form of regular PA" was taken as the reference category. Those variables that showed a statistically significant association with the outcome variable were controlled for the possibility of other independent variables (multivariate MNLR).
Spearman's correlation coefficient was used, in order to examine the corelation between the two numeric variables.
SPSS Statistics for Windows version 24 (IBM Corporation) was used for the statistical analysis. The statistical significance was taken into account for the p values lower than 0.05.

Ethical Aspects of the Research
The study was conducted, according to the guidelines of the Declaration of Helsinki. The Ethics Committees/Commissions of the faculties that participated in the research gave an opinion that approval of the Committees/Commissions was not required, as the research did not include invasive methods and did not violate the privacy of the respondents.

Results
Medical faculties differed significantly in gender distribution (χ 2 = 50.032, p < 0.001, fi = 0.143) with the highest presence of female students (91.1%) at the Faculty of Medicine of the University of Rijeka, Republic of Croatia, and the lowest (73.7%) at the Faculty of Medicine of the University of Zenica, Bosnia and Herzegovina, compared to other faculties (not shown in tables).
Regardless of the attended faculty, most students engaged in some kind of regular PA (62.3%) (not shown in tables). Engagement in some kind of regular PA significantly differed between medical faculties (χ 2 = 78.203, p < 0.001, fi = 0.179) ( Table 2). The students of the Faculty of Pharmacy and Biochemistry of the University of Zagreb, Republic of Croatia, in the smallest percentage, engaged in some kind of regular PA (49.1%), while the students of the Faculty of Pharmacy of the University of Mostar, Bosnia and Herzegovina, were the most physically active, in comparison to students of other faculties (77.3%). Male students engaged in some form of PA significantly more often (68.6%) than female students (60.9%) (χ 2 = 9.197, p = 0.002, fi = 0.061) ( Table 3). Normal weight students were significantly more frequently engaged in some kind of regular PA (63.6%), while obese students most often were not regularly physically active (45.6%), in relation to the students with a different nutritional status (χ 2 = 10.742, p = 0.013, fi = 0.066). Aboveaverage household income medical students engaged in significantly more regular PA (69.0%), compared to students whose household income was below average (59.1%). The difference was statistically significant (χ 2 = 19.168, p < 0.001, fi = 0.088). There was no significant difference between the percentage of students who engaged in some form of PA and students who did not engage regularly in PA, in relation to the year of study (χ 2 = 0.511, p = 0.475, fi = 0.014), alcohol consumption (χ 2 = 1.253, p = 0.869, fi = 0.023), type of settlement (χ 2 = 1.339, p = 0.247, fi = 0.023), and student smoking status (χ 2 = 1.954, p = 0.162, fi = 0.028).

Motives for Regular Physical Activity among Medical Students
Taking whole sample into consideration, regardless of other independent variables, the motives for regular PA of medical students were, in order of frequency: to feel better (52.7%), to reduce stress (38.6%), to look better (38.6%), the desire to lose weight (18.6%), and to control chronic disease (5.5%) (not shown in tables).
The statistically significant difference in the percentage was determined in relation to the attended faculty, for the motives for regular PA: to feel better (χ 2 = 64.45, p < 0.001, fi = 0.162), stress reduction (χ 2 = 82.022, p < 0.001, fi = 0.183), and to look better (χ 2 = 47.471, p < 0.001, fi = 0.139) ( Table 4). The motives for regular PA-to feel better, stress reduction, and the desire to look better, was given by the students of the Faculty of Medicine of the University of Zenica, Bosnia and Herzegovina, in the largest percentage (74.6%, 61.0%, and 51.2%, respectively), compared to the other medical faculties (Table 4). Students from the Faculty of Pharmacy and Biochemistry of the University of Zagreb, Republic of Croatia, stated the motives for engaging in regular PA-to feel better and stress reduction in the lowest percentage (41.3%, and 30.3%, respectively), and the students from the Faculty of Pharmacy of the University of Belgrade, Republic of Serbia stated the desire to look better (29.0%), had the lowest percentage, in comparison to other medical faculties.
No statistically significant difference was found in the frequency of the responses from the medical students from the different faculties, for the motives for regular PA-desire to lose weight (χ 2 = 20.92, p = 0.075, fi = 0.092) and to control chronic disease (χ 2 = 14.277, p = 0.355, fi = 0.076) ( Table 4).

Barriers to Regular Physical Activity among Medical Students
Taking the whole sample into consideration, regardless of other independent variables, faculty obligations were the most common barrier for regular PA among medical students (59.3%), followed by other barriers (14.2%), financial situation (8.6%), current life situation (8.4%), and health condition (2.8%) (not shown in tables).
Obligations at the faculty was the most frequently given answer by students from the Faculty of Pharmacy of the University of Sarajevo, Bosnia and Herzegovina (76.9%), while from students from the Faculty of Pharmacy of the University of Belgrade, Republic of Serbia, faculty obligations was the lowest (44.4%), compared to other medical faculties ( Table 6).
The highest percentage of students who stated their current life sitation as a barrier for regular PA, was from the Faculty of Medicine of the University of Zenica, Bosnia and Herzegovina (14.6%), and the lowest was from the Faculty of Health Studies of the University of Mostar, Bosnia and Herzegovina (1.9%) ( Table 6). The financial situation was mostly stated as the barrier by students from the Faculty of Pharmacy of the University of Sarajevo, Bosnia and Herzegovina (14.9%), and it was the least stated reason by those from the Faculty of Medicine of the University "St. Cyril and Methodius" Skopje, Republic of North Macedonia (2.2%) ( Table 6).
Students of the Faculty of Medicine of the University of Rijeka, Republic of Croatia, stated other barriers, which fell in the highest percentage (21.9%), and students of the Faculty of Medicine of the University "St. Cyril and Methodius" Skopje, Republic of North Macedonia, stated other barriers, which fell in the lowest (8.4%) ( Table 6).
No statistically significant difference was found in the frequency of health conditions, as a barrier for regular PA, in relation to the attended faculty (χ 2 = 14.168, p = 0.362, fi = 0.076) ( Table 6).

Motives and Barriers for Regular Physical Activity as Predictors of Engagement in Physical Activity among Medical Students
The model of the univariate MNLR analysis showed that all motives and barriers for regular PA were significantly associated with the medical students' PA (Table 8). To feel better was the highest positive predictor among students engaging in regular PA (OR: 15.204, 95% CI: 12.335-18.741), while the highest negative predictor was a health condition (OR: 0.579, 95% CI: 0.359-0.935).
The model of the multivariate MNLR was created with the aim of controlling the independent variables for their mutual influence. To feel better remained highest positive predictor of students engaging in regular PA (OR: 7.859, 95% CI: 6.221-9.929), while the highest negative predictor was the financial situation (OR: 0.528, 95% CI: 0.385-0.725) ( Table 8).
Spearman's Rank-Order correlation analysis showed a statistically significant positive moderate correlation between the motives to feel better and stress reduction, the desire to look better and to lose weight ( Table 9). The desire to look better correlated moderately with a desire to lose weight. Other correlations between motives for regular PA were significant, but small. Table 8. Association between the independent variables (motives and barriers for regular physical activity) and engagement in regular physical activity among medical students.  A small, statistically significant, and positive correlation was determined between the barriers concerning the current life situation and financial situation. Other motives correlated negatively with faculty obligations. Other correlations between the barriers, although significant, were very small (Table 10).

Discussion
Our study shows that 62.3% of medical students engaged in some kind of regular PA. The male gender, normal weight, with an above average household income was positively associated with students' PA. Similar to a study in Martinović et al. [23] conducted in Split, Republic of Croatia, where more than half of biomedical students engage in some kind of regular PA, the impact of greater knowledge about healthy behavior for maintaining good health and preventing disease, was emphasized as the main factor that impacts PA [23]. Pavičić-Žeželj et al. [24], in a study conducted in Rijeka (Republic of Croatia), and Catović and Halilović [25], in a study conducted in Sarajevo (Bosnia and Herzegovina), among medical students, indicate that normal weight is highly associated with the regular engagement in PA, which was not statistically significant in our paper. The same studies indicate that male students engaged in some kind of PA more often and had higher levels of PA, compared to female students [25]. Different studies report that low levels of PA are associated with a low household income [26], while others associate it with high physical inactivity [27]. A study by Grujičić et al. [9], on medical students from the Western Balkans, on the influence of different factors on daily PA levels, states that students who have higher daily PA levels, are more likely to be normal weight males whose household income is above average.

Motives for Regular Physical Activity among Medical Students
This is the first known study to examine the motives for regular physical activity among medical students from the Western Balkans. Our results imply that the motives in this research were in the order of frequency: to feel better, to reduce stress, to look better, to lose weight, and to control chronic disease. The results of our research show that motives to feel better, to reduce stress, and to look better, significantly differed in the frequency among the different medical faculties. Similarly, Lustyk et al. [28], in a study conducted on college medical students from the Pacific Northwest, indicate that a linear combination of the three motives (for fitness and health reasons, to control weight, shape, and appearance, and to improve mood, have fun, and socialize) accounted for 8% of the variance of the quality of life derived from PA [28]. According to the results of the study by Roberts et al. [29], which was conducted among undergraduate students from the northwest of England, health-related motives, such as positive health and weight management, are stated as the primary motivation for doing PA in one's free time. A study by Dias et al. [30] indicates that competency/mastery factors and intellectual factors are the prime motivational factors that encouraged Indian college students to become involved in PA. Tao et al. [31] indicate that the autonomous motivation, such as improving one's own health, is the strongest motive for Chinese college students to engage in PA.
Compared to other college students, medical students generally have a higher consciousness of health [23,32]. It has been indicated that medical students report higher PA levels with a high autonomous motivation (personal reasons for health improvement vs. educational programs) than age-matched peers in the general population [33], which is consistent with the high motives of medical students in this research. Laishram et al. [34] also conducted a study on the motives of medical students from India, regarding PA, and showed that the intrinsic and motives identified above are the highest two motives for medical students to participate in PA, compared to any external regulation (requirements during formal education). Consistent with our results, research among health sciences students from Poland indicates that the pleasure of PA is the most important motivation for undertaking it, followed by strong motivating factors, including mental regeneration, maintaining health, building strength and endurance, appearance, and avoiding ill health [35]. In our research, to feel better and to control chronic disease were the highest and lowest motives of regular PA, separately, for all faculties, which could suggest that there is a strong internal drive that indirectly reflects the good health condition and the relatively low prevalence of chronic diseases, among medical students. A positive moderate correlation between motives to feel better and stress reduction, the desire to look better and to lose weight, emphasize the importance of the internal motivation for maintaining regular PA.
Our study shows that female students more often engaged in regular PA to feel better, reduce stress, and look better, compared to male students. Furthermore, the results of our study indicate that although male students engage in PA more frequently than the female students stated, their motives for regular PA were in a significantly higher percentage than the male students. This result indicates that males and females have distinct motives for participation in PA at different levels. Furthermore, many studies on the motivation for participating in PA, points to significant gender-related disparities [29,34,[36][37][38]. Romero-Blanco et al. [37], in a study conducted in Spain, found that male adults were more motivated than females by affiliation and challenge, whereas female adults were motivated more than males were, by a better appearance. Similar to these results, a study by Molanorouzi et al. [38] conducted among adults from Malaysia, shows that males have a higher motivation for mastery and competition/ego, whereas females have a higher motivation for appearance and physical condition [38]. In contrast with our results, the research from Malaysia suggested that there are no significance differences in the motives for taking part in PA, between the genders, among student-athletes [39]. Vanlalduhsaki et al. [34] show that there is a statistically significant higher intrinsic and identified motives for male medical students, compared to female medical students, from India.
The results of our study show that more advanced medical students have a significantly higher motive to feel better, with regard to PA, than less advanced students. Similar to our results, Roberts et al. [29], Chen et al. [40], and Martinez-Lacoba et al. [41] indicate that students above the age of 23 are more motivated than students in lower age groups (i.e., for stress, revitalization, and avoidance of ill health). The authors emphasize that it is possible that as college students grow older, they become more conscious of the value of exercise and good health [29,40,41]. Moreover, Roberts et al. [29], Chen et al. [40], and Martinez-Lacoba et al. [41] point out that, as a university students approach the end of their studies, their lifestyle management possibly improves. In contrast with our results, Egli et al. [36] reports that students under the age of 20 are more motivated for reasons connected to their health.
The obtained results of our research show that the motives of PA among medical students, had a significant connection with the BMI. Obese students showed significantly less stated motives to feel better, reduce stress, and to look better, but more often stated their motive to lose weight, compared to non-obese students. Baillot et al. [18] found that weight management is the key PA motive among people with obesity. In addition, in a study conducted by Rao et al. [32] among undergraduate medical students in India, the results show that the proportion of medical students who participate in PA increased, as the BMI increased [32]. The Congruence of such findings was also reported by Banerjee et al. [42], in a study conducted in India. Overall, those results suggest that the BMI is significantly related to different motivations for students who indulge in various types of PA [42]. In contrast with the results of our study, Pavičić-Žeželj et al. [24], in a study conducted in Croatia, point out that normal weight medical students more often engage in PA for maintaining a good health, which is not statistically significant and the least frequent motive for regular PA, in our research.
The result of our study indicates that students whose household income was above average, more often engaged in PA with motives stated were to feel better, to reduce stress, look better, and to lose weight, compared to the average and below average students. Dąbrowska-Galas et al. [43], in a study conducted in Poland and Grujičić et al. [9], in a study conducted in Serbia, indicate that the fact that the universities of the Western Balkans do not have programs that would enable free sports centers for all students, is the main reason why students from family with an above average household income are more often engaged in regular PA. Higher household incomes bring more chances to access more and better sports infrastructure, such as swimming pools, and other kinds of developed fitness equipment [9,43]. Berger et al. [44], in a study conducted on students from the Višegrad countries, indicate that a better economic situation in the Višegrad countries provides more free time and opportunities for participation in regular PA. The same findings were also reported in many other societies and groups [43][44][45][46]. More opportunity for practicing regular PA brings more pleasure and naturally more pleasure, in turn, increases the motivation to do engage in more regular PA [43][44][45][46]. Therefore, it is not difficult to understand that in our research, students with an above-average household income showed statistically significant higher motives, including all motives, except to control chronic disease.
Our research indicates that students who are non-smokers stated the desire to feel better, reduce stress, and to look better, as motives for regular PA, more often than smokers.
Smoking has been a significant public health problem among adolescents and college students [47,48]. Among global medical students, it is estimated that one in five students smoke [47,48]. The result of a study conducted in the Western Balkans, on smoking among medical students, shows that the percentage of smokers is significantly lower than that of non-smokers [48]. In parallel, the results of our study show that non-smokers had significantly higher motives (to feel better, reduce stress, and to look better), in regular PA. Smoking has been shown to have both short-term and long-term consequences on PA, including a poorer endurance, decreased physical performance, increased risk of injury and complications, etc. [49]. In a study conducted in Tehran, Heydari et al. [50] found that smokers have a higher odds ratio of 4.88, for having an unsatisfactory level of PA, in relation to non-smokers [50]. Heydari et al. [50] point out that the negative effects of smoking on PA possibly further contributes to lower motives in PA [50]. However, a study of the interaction effects of life satisfaction and PA on smoking initiation among students" indicates that lower levels of life satisfaction are associated with a greater likelihood of smoking initiation [51]. Thus, it is reasonable to believe that smokers, in our research, feel better when they smoke and that cigarette reduces stress for them, or they do not pay much attention to their looks because they already smoke [51]. Although, in contrast with our results, this research by Torchyan et al. [51] shows that high levels of PA increased the chance of smoking initiation among male students with high levels of life satisfaction [51]. Therefore, the detailed potential mechanism under this phenomenon should be further investigated.
More interestingly, the results of our research show that, compared with students who do not drink, students who drink alcohol, significantly recognize the need to feel better as a motive for regular PA. Sjödin et al. [52] indicate that the enhancement of mood and dealing with stress are the second strongest drinking motive, behind social motives among adolescents in Sweden. Among Korean students, Kim et al. [53] also show that among the various motives for drinking, the enhancement motives are the second most common, behind the social motives. Enhancement motives involve drinking to increase the positive affect because of the active dopamine system caused by alcohol [54,55]. Furthermore, regular PA makes people feel better, due to the endorphins [56]. The two systems have a similar role in developing behavioral habits, which may indirectly explain the significant motive for the need to feel better, in PA, for daily alcohol drinker students, compared to students who do not drink alcohol [54][55][56].
The result of our research shows that there was no statistically significant difference in the frequency of all motives between students from rural and urban settlements. Similarly to our results, a study by Moreno-Llamas et al. [57], that investigated the urban-rural differences in the trajectories of PA in Europe, from 2002 to 2017, showed that there was no significant difference of daily regular PA between students from rural and urban areas. The same study indicated that a trend of inactivity prevalence increased in both rural and urban environments, across time [57]. The same study also showed that the type of settlement does not affect the cognitive component of engaging in PA for medical students, including the frequency and motives for PA [57].

Barriers for Regular Physical Activity among Medical Students
The results of our research indicate that faculty obligations were the strongest barrier for medical students, concerning regular PA. Due to the particularity of the major of medicine, the course and practice trainings for medical students can be physically and emotionally demanding [58]. Thus, the faculty obligations facing medical students, including academic requirements, the nature of the contents, the heavy workload, and the exams, are larger than other university students [59,60], which could lead to the difficulty in finding time to participate in regular PA. Similar to our study, the results of a study by Likus et al. [61], show that workload is the biggest barrier to PA for Polish medical students. Furthermore, a significant amount of evidence has also demonstrated that, among university students, the lack of time, due to faculty obligations is the most common barrier to PA [19,37,62]. In a recent systematic review of various barriers to university students' PA, 22 studies with university students were included [63]. The authors have also concluded that a lack of time, due to faculty obligations, was the most cited barrier to PA, among university students [63].
Current life situation, financial situation, and other barriers, are leading barriers among the medical students in our research after faculty obligations. Similar to our study, Ferreira-Silva et al. [63] emphasize that personal circumstances are also barriers to regular PA. The same study shows that the barriers to regular PA in the psychological, emotional, and cognitive categories are similar in students from all parts of the world. In our research, only the current health condition was not recognized as a significant barrier by the students, which also indirectly reflects the possible good health condition among students, also consistent with lowest motive (to control chronic disease) for regular PA. Furthermore, the statistical significance in the frequency of the barriers (except health conditions), differed between medical faculties. More interestingly, in our study, the current life situation was significantly positively correlated with the financial situation, while faculty obligations was significantly negatively correlated with other barriers, indicating the relationship between the various socioeconomic and individual factors.
Contrary to our results, Hoare et al. [64] indicate that there is no gender difference in the perceived barriers to PA, between Australian females and males. In our study, female students more frequently recognized faculty obligations as a regular PA barrier, while they less frequently recognized their current life situation as a regular PA barrier, than male students. It is possible that female medical students might need more time for faculty obligations, but they hold stronger the ability or awareness of facing and handling current life situations, than men do. Similar to our research, a study by Shin at al. [65] also suggests that there are systematic differences between PA barriers related to the variables, including gender. In a study in Florence, Italy, Rosselli et al. [66] found that the number of perceived barriers to PA was higher among females than among males.
Our study shows that medical students whose household income was below average stated their current life situation and financial situation as a reason for irregular PA, more often, compared to average and above average medical students. A higher household income is associated with higher motives for regular PA because of more opportunities and more access to better sports infrastructure [43,44]. Equally, it is easy to understand that in this research, the financial situation was a significant barrier for PA and the above-average household income was significantly negatively associated with the barriers (current life situation and financial situation).
The result of our research shows that overweight and obese students stated their current life situation as a reason for not engaging in regular PA, which is almost two times more than the students with a different nutritional status. The results suggest that overweight and obesity might lead to a negative influence on students' current life situation, such as special events, day-to-day or global circumstances, or personal circumstances, that affect the person or their family or friends (e.g., illness or a situation that requires care) [67]. Further, it is supposed that the negative impacts caused by a previous unhealthy lifestyle, can have a stimulating effect in engaging in regular PA, among medical students [67].
The obtained results of our research indicate that smokers stated their financial situation more often than non-smokers, as a barrier for PA. A study carried out by Wamamili [68], investigated the change in smoking intentions among university students in New Zealand, following the cigarette price increase. According to the results of the study conducted in New Zealand, the proportion of students who would smoke declined substantially, as the price of cigarettes increased by NZD 5, 10, and 15 [68]. The authors point out that smoking accounts as a considerable financial expense for university students, therefore their financial situation is more often stated as a PA barrier by students who smoke [68].
Our study has several limitations. Conducted in the form of a cross-sectional study, only the currently observed situation was possible to be analyzed, and tracking changes over and the cause-effect relationship, could not be observed [69]. The reliability of the gathered data was unable to be determined, despite emphasizing on anonymity and confidentiality, the respondents could frequently be dishonest in giving answers while using an online, anonymously filled-in, self-administered questionnaire [69]. Finally, medical faculties were selected, using the convenience sampling method and were not randomly selected, so the obtained results cannot be generalized to all Western Balkan medical students. Although we were unable to gather the exact numbers (response rate) of the enrolled students at the period of the study conduction, the percentage of students from all of individual faculties exceeds a representative 10% [9,48].

Conclusions
The most reported motive among medical students for regular PA is to feel better, followed by stress reduction, to look better, the desire to lose weight, and to control chronic disease. PA improvement motives are more frequently associated with the female gender, more advanced years of study, normal weight, an above average household income, and a non-smoking status. Faculty obligations are the most common barrier for regular PA among medical students, followed by other barriers, such as their financial situation, current life situation, and health condition. Barriers are more frequently reported by male students who are overweight or obese, who have a below average income and who are smokers.
It is necessary for the public health authorities to examine and take into account the perceived motives and barriers, when forming activities and policies that aim at increasing the level of PA, in order to enhance the health of the student population.

Institutional Review Board Statement:
The study was conducted in accordance with the guidelines of the Declaration of Helsinki, and the Ethics Commissions/Committees of the faculties that took part in the research, who provided an oral standpoint that there was no approval required of the committees/ commissions, since the research did not incorporate invasive methods and did not violate the privacy of the respondents.
Informed Consent Statement: Data were collected by applying an online survey, and all participants involved in the survey gave their consent by submitting their answers. In the Google forms database, only fully completed surveys were taken into account, i.e., registered. The privacy of the respondents was guaranteed by the research method.

Data Availability Statement:
The data presented in this study are available upon reasonable request from the corresponding author.

Conflicts of Interest:
The author M.I. is a MDPI employee, however he does not work for the International Journal of Environmental Research and Public Health at the time of submission and publication.