The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
RESEARCH ARTICLE

Determinants of Health Literacy and Healthy Lifestyle against Metabolic Syndrome among Major Ethnic Groups of Sarawak, Malaysia: A Multi-Group Path Analysis



S. Froze*, M. T. Arif, Saimon R.
Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak,s Malaysia

Abstract

Introduction:

Non-communicable diseases like metabolic syndrome can be prevented and controlled by practicing healthy lifestyle.

Although health literacy is a critical factor in lifestyle modification to prevent non-communicable diseases and its complications, its role on metabolic syndrome prevention is still understudied.

Objective:

The main aim of this study was to identify the determinants of health literacy and healthy lifestyle practice against metabolic syndrome among multi-ethnic group of Sarawak based on health literacy skills framework.

Methods:

Using a stratified multistage sampling, a total of 1006 respondents were recruited to represent the major ethnic groups in Sarawak, Malaysia. Moderator variables, mediator variables and outcome variable (healthy lifestyle practice) were tested using path analysis to examine multiple and interrelated dependence relationships. Multi-group analysis was performed to compare structural models between major ethnic groups in Sarawak, namely Malay/Melanau, Native groups and Chinese.

Results:

Female respondents and those with higher education status were more likely to have better healthy lifestyle practice. Greater level of health literacy was positively significant with both disease knowledge and healthy lifestyle practice. Participants with good understanding of disease knowledge can directly influence healthy lifestyle. Simultaneously, health literacy and metabolic syndrome knowledge can mediate the relationship between sociodemographic variables, service accessibility, medical and family history with practice of healthy lifestyle. Multi-group path analysis indicated differences in causal pathway leading to healthy lifestyle practice among the ethnic groups.

Conclusion:

Health programs or interventions to increase health literacy skills and better understanding of metabolic syndrome will improve practice of healthy lifestyle. Culturally sensitive multidimensional approaches are needed to ensure health-related information can be delivered effectively across the state.

Keywords: Health literacy, Metabolic syndrome knowledge, Healthy lifestyle practice, Ethnic groups, Multi-group path analysis, Sarawak.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 172
Last Page: 183
Publisher Id: TOPHJ-12-172
DOI: 10.2174/1874944501912010172

Article History:

Received Date: 17/02/2019
Revision Received Date: 04/04/2019
Acceptance Date: 08/04/2019
Electronic publication date: 30/04/2019
Collection year: 2019

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 376
Abstract HTML Views: 367
PDF Downloads: 79
ePub Downloads: 81
Total Views/Downloads: 903

Unique Statistics:

Full-Text HTML Views: 167
Abstract HTML Views: 235
PDF Downloads: 56
ePub Downloads: 52
Total Views/Downloads: 510
Geographical View

© 2019 Froze et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia; Tel: 60198282525;
E-mail: samfroze85@yahoo.com





1. INTRODUCTION

The burden of Non-Communicable Diseases (NCD) is rising due to their risk factors. Sedentary lifestyle behaviours such as physically inactive, unhealthy food intake, alcohol consumption and use of tobacco products are the known risk factors. The World Health Organization stated that in 2016, more than 2/3 (40.5 million) deaths were contributed by non-communicable diseases [1Collaborators RF. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990 – 2015 : a systematic analysis for the Global Burden of Disease Study 2015 2017; : 1990-2015.]. Metabolic syndrome is a clustering of at least 3 to 5 diseases which are associated with the risk of developing type II diabetes and cardiovascular disease [2Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the metabolic syndrome: A joint interim statement of the international diabetes federation task force on epidemiology and prevention; National heart, lung, and blood institute; American heart association; World heart federation; International atherosclerosis society; And international association for the study of obesity. Circulation 2009; 120(16): 1640-5.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192644] [PMID: 19805654] ]. A secdentary lifestyle has been established as the main culprit [3Bradshaw PT, Monda KL, Stevens J. Metabolic syndrome in healthy obese, overweight, and normal weight individuals: The Atherosclerosis Risk in Communities Study. Obesity (Silver Spring) 2013; 21(1): 203-9.[http://dx.doi.org/10.1002/oby.20248] [PMID: 23505187] , 4Nettleton JA, Lutsey PL, Wang Y, Lima JA, Michos ED, Jacobs DR Jr. Diet soda intake and risk of incident metabolic syndrome and type 2 diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care 2009; 32(4): 688-94.[http://dx.doi.org/10.2337/dc08-1799] [PMID: 19151203] ].Presently, people are more inclined towards unhealthy lifestyles, which contributed to the rise in the prevalence of metabolic syndrome globally [5O’Neill S, O’Driscoll L. Metabolic syndrome: A closer look at the growing epidemic and its associated pathologies. Obes Rev 2015; 16(1): 1-12.[http://dx.doi.org/10.1111/obr.12229] [PMID: 25407540] , 6Ranasinghe P, Mathangasinghe Y, Jayawardena R, Hills AP, Misra A. Prevalence and trends of metabolic syndrome among adults in the asia-pacific region: A systematic review. BMC Public Health 2017; 17(1): 101.[http://dx.doi.org/10.1186/s12889-017-4041-1] [PMID: 28109251] ]. National Health Morbidity Survey Malaysia (NHMS) reported a worrying trend of unhealthy lifestyle practice among the general population of Malaysia [7Institute for Public Health. National Health and Morbidity Survey 2015 (NHMS 2015). Vol. II: Non-Communicable Diseases, Risk Factors & Other Health Problems. Vol. II, Ministry of health. 2015. 1-291 p]. The survey findings of the Department of Statistics, Malaysia reported ischemic heart disease as the principal cause of death regardless of ethnicity and gender among Malaysian population in 2017, [8Malaysia D of S. Department of Statistics Malaysia Press Release. Department of Statistics Malaysia Press Release Dep Stat Malaysia 2018 June; 5-9.]. In the early years, most of the models that describe health literacy were in the context of individual health literacy level. Freedman et al. (2009) in their article Public Health Literacy Defined discussed about the importance of public health literacy and how it is also vital to focus on primary prevention of diseases rather than just on the secondary and tertiary prevention [9Freedman DA, Bess KD, Tucker HA, Boyd DL, Tuchman AM, Wallston KA. Public health literacy defined. Am J Prev Med 2009; 36(5): 446-51.[http://dx.doi.org/10.1016/j.amepre.2009.02.001] [PMID: 19362698] ]. Health or disease knowledge means information, facts, and skills developed throughout the course of life either via experience or education [10Chin J, Morrow DG, Murray MD. NIH Public Access Heal (San Fr) 2012 August 2009; 16: 222-41.]. It allows us to have a greater understanding of health-related matters. Nutbeam (2000) proposed a model of health literacy which consists of three levels [11Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000; 15(3): 259-67.[http://dx.doi.org/10.1093/heapro/15.3.259] ]. Firstly, the functional health literacy requires a person to possess a basic skill in reading and writing. This is the basic stage of health literacy and its assessment involves tools such as printed health materials or documents. The second level, communicative health literacy, requires more advanced skills than the functional components as it is necessary to extract information and applying it depending on the situations. In the meantime, the third level of critical health literacy is a skill that enables us to analyse health information critically and applying it to employ a better control of any situation. Prevention of Metabolic syndrome, like other similar chronic diseases, has been proven to be effective with the intervention on nutritional intake, promotion of physical activity, psychosocial care and education. The objective of this study was to identify the determinants of healthy lifestyle practices against metabolic syndrome among the multi-ethnic population of Sarawak, Malaysia. we studied the relationship between sociodemographic characteristics, service factor, medical history, health literacy and metabolic syndrome knowledge using path analysis to determine the causal pathway which contributed to healthy lifestyle practice. The following hypotheses were tested: (1) The level of health literacy will influence the practice of healthy lifestyle. (2) Disease knowledge can mediate health literacy and practice of healthy lifestyle to prevent metabolic syndrome.

2. MATERIALS AND METHODS

2.1. Development of the Model

Reference was made to the conceptual model on health literacy skills framework [12Squiers L, Peinado S, Berkman N, Boudewyns V, McCormack L. The Health Literacy Skills Framework Journal of Health Communication 2012; 17(sup3): 30-54.[http://dx.doi.org/10.1080/10810730.2012.713442] ]. The principle of the model indicates the competencies related to the process of accessing, understanding, appraising and applying health-related information. In this case, health-related information was specifically based on metabolic syndrome. Health literacy component was based on Nutbeam (2000) theory of health literacy. This model demonstrates the relationship between determinants and preventive care of metabolic syndrome with health literacy and knowledge as a potential mediator. Existing evidence also suggested that variables such as age and gender have a strong direct and moderation effect on healthy lifestyle practice [13Suka M, Odajima T, Okamoto M, et al. Relationship between health literacy, health information access, health behavior, and health status in Japanese people. Patient Educ Couns 2015; 98(5): 660-8.[http://dx.doi.org/10.1016/j.pec.2015.02.013] [PMID: 25739344] , 14Yokokawa H, Yuasa M, Sanada H, Hisaoka T, Fukuda H. Age and sex-specific impact of health literacy on healthy lifestyle characteristics among Japanese Residents in a Rural Community. Health 2015; 07(06): 679-88.[http://dx.doi.org/10.4236/health.2015.76081] ]. Thus, a direct arrow was added linking socio-demographic construct and healthy lifestyle practice (Fig. 1).

2.2. Sample and Procedure

Study participants were citizens of Sarawak, which is one of the fourteen states of Malaysia. This is the largest state of Malaysia which consists of numerous major ethnic groups. This project was carried out between April 2017 and October 2018 (488 days). The respondents were 18 years old and above and recruited from the whole state through stratified multistage sampling. Medical and health personnel were excluded from these cross-sectional population surveys. The estimated sample size was 1200 calculated based on the prevalence of adequate physical activity in Sarawak (59.2%) from the National Health Morbidity Survey Malaysia in 2015 [7Institute for Public Health. National Health and Morbidity Survey 2015 (NHMS 2015). Vol. II: Non-Communicable Diseases, Risk Factors & Other Health Problems. Vol. II, Ministry of health. 2015. 1-291 p]. A total of 1119 respondents were recruited with response rate of 93.3%. After data cleaning and missing data analysis, a total of 1006 subjects were included for analysis. The state of Sarawak, located in the third largest island in the world, Borneo is divided into 12 divisions. It is known to have an ethnically diverse population. Multistage stratified sampling technique was used to select divisions and districts for data collection (Fig. 2).

2.3. Measures

Interviewer-assisted questionnaire was used. The first part of the questionnaire assessed socio-demographic variables and past medical illness. For health literacy, a three-level health literacy model was developed by Suka et al. (2013) which included five items for functional HL, five items for communicative HL, and four items for critical HL [15Suka M, Odajima T, Kasai M, et al. The 14-item health literacy scale for Japanese adults (HLS-14). Environ Health Prev Med 2013; 18(5): 407-15.[http://dx.doi.org/10.1007/s12199-013-0340-z] [PMID: 23689952] ]. Participants were required to rate each item on a 5-point Likert scale ranging from 1(strongly disagree) to 5 (strongly agree). Reversed scoring was required for functional health literacy component. Total scores of health literacy were calculated and higher scores signify better health literacy. Disease knowledge section consisting of 20 questions focused on metabolic syndrome. For every question, the respondents were required to select one correct answer out of 3 options (True, False or Don’t Know). Metabolic syndrome knowledge was assessed based on a 3 points likert scale (True, False or Don’t Know) questionnaire adopted from Yahia N. et al. (2014) [16Yahia N, Brown C, Rapley M, Chung M. Assessment of college students’ awareness and knowledge about conditions relevant to metabolic syndrome. Diabetol Metab Syndr 2014; 6(1): 111.[http://dx.doi.org/10.1186/1758-5996-6-111] [PMID: 25360161] ]. A total of 20 questions focused on risk factors, complications and prognosis of metabolic syndrome. Simple Lifestyle Indicator Questionnaire (SLIQ), developed by Godwin et al. (2008) was used to assess healthy lifestyle practices on non-communicable diseases [17Godwin M, Streight S, Dyachuk E, et al. Testing the simple lifestyle indicator questionnaire: Initial psychometric study. Can Fam Physician 2008; 54(1): 76-7.[PMID: 18208960] ]. In total, there were five constructs: Diet (3 questions), activity (3 questions), alcohol consumption (3 questions), smoking (2 questions), and stress (1 question). Subsequently, a raw score was obtained for every construct. Overall SLIQ scores ranged from 0 to 10. The higher the score, the healthier the lifestyle.

Fig. (1)
Model showing hypotheses of determinants influencing healthy lifestyle practice for prevention of metabolic syndrome.
*Ethnicity was used as a reference point for multi-group analysis


Fig. (2)
Diagram of the sampling method throughout the state of Sarawak, Malaysia.


2.4. Statistical Analysis

Data were assessed using the Statistical Package for Social Science (SPSS) IBM version 23. All the data were thoroughly checked and cleaned prior to analysis. Missing data analysis was performed to identify the percentage of missing data for all the variables and items. Prior to major analysis, outliers were removed. Once outliers were detected, they were first checked for coding errors. Descriptive statistics was used to describe the fundamental features of the data in this study. It provides simple summaries about the sample and the measures such as percentage and mean scores with standard deviation. Pearson correlation was run to determine the relationship between health literacy and preventive lifestyle practice. Independent t-test and one-way ANOVA were used to detect differences between the healthy lifestyle practice across the socio-demographic variables. For analysis involving ANOVA, Bonferroni adjustment was used. For every analysis, the significance level was set at 0.05.

2.5. Data Modelling

The main purpose of path analysis in this study was to examine multiple and interrelated dependence relationships [18Stage F, Carter H, Nora A. Path Analysis: An introduction and analysis of a decade of research. J Educ Res 2004; 98(1): 5-13.[http://dx.doi.org/10.3200/JOER.98.1.5-13] ]. Amos software version 23 was used to run the maximum likelihood to obtain an estimation of the coefficient. Firstly, the correlations of the main study variables were examined. Gender, education, chronic illness, family history of ischemic heart disease and distance of health care facilities were dummy coded. Subsequently, path analysis was conducted to test the associations between socio-demographic variables, health literacy, health knowledge and healthy lifestyle practice. In the presence of non-normality, bootstrapping was performed as a remedy. Bootstrapping analyses were done by replicating 3000 samples to obtain reliable 95% confidence intervals of not normally distributed parameters [19Cheung G, Lau R. Testing mediation and suppression effects of latent variables. Organ Res Methods 2007; 11(2): 296-325.[http://dx.doi.org/10.1177/1094428107300343] ] Subsequently, a multi-group analysis was conducted and the respondents were stratified into 3 groups, namely Malay/Melanau, Native and Chinese. For model fit, the Comparative Fit Index (CFI), Adjusted Goodness-of-Fit Index (AGFI), Root-Mean-Squared Error of Approximation (RMSEA), (TLI) and chi-square statistics were generated. The cut-off point was 0.07 and below for RMSEA [20Steiger J. Understanding the limitations of global fit assessment in structural equation modeling. Pers Individ Dif 2007; 42(5): 893-8.[http://dx.doi.org/10.1016/j.paid.2006.09.017] ], and 0.90 and above for AGFI, TLI and CFI [21Tabachnick B, Fidell L. Using multivariate statistics 5th ed. 5th ed.2007., 22Hu L, Bentler P. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling 1999; 6(1): 1-55.[http://dx.doi.org/10.1080/10705519909540118] ]. The acceptable range for CMIN/df was 1 – 5. The chi-square statistics was generated by bootstrapping sampling distribution and Bollen-Stine statistics [23Bollen K, Stine R. Bootstrapping Goodness-of-Fit Measures in Structural Equation Models. Sociol Methods Res 1992; 21(2): 205-29.[http://dx.doi.org/10.1177/0049124192021002004] ].

2.6. Ethical Consideration

Medical Research Ethics Committee of Universiti Malaysia Sarawak (UNIMAS) granted approval to conduct this research. Respondents were briefed about this project and participation was voluntary. Formal written consent was obtained, and confidentiality of information was assured.

3. RESULTS

3.1. Respondents’ Characteristics

The age range of our respondents was 18 to 93 years old with the mean age of 36.8 (14.53) years (Table 1). Majority of the respondents were married and obtained a secondary education. Out of 1006 respondents, the majority were employed, living within 5 to 10 km from the nearest health care facilities and without any chronic illnesses. In term of ethnic group distribution, 16.9% of them were Malays, 18.9% were Ibans, 19.1% from the Chinese ethnic group, 16.4% were Melanau, 15.6% were Bidayuh and Orang Ulu were13.1%. Prior to performing path analysis, a correlation among the variables was tested. Table 2 shows correlations between sociodemographic variables, health literacy components, metabolic syndrome knowledge and healthy lifestyle practices. Healthy lifestyle practice was positively correlated with gender, health literacy and metabolic syndrome knowledge. Advancement in age decreased healthy lifestyle practice. The ethnic groups were categorised into Malay/Melanau, Native and Chinese for multi-group analysis.

3.2. Path Analysis

A final path model was constructed after the removal of non-significant constructs and mediation analysis. Overall, the constructs accounted for 11 percent of the total variance in healthy lifestyle practice among the population of Sarawak (Fig. 3). As shown in Table 3, Gender directly influenced healthy lifestyle practice. Female respondents were more likely to practice better lifestyle behaviours compared to the male respondents we (beta = 0.277, 95% CI: 0.229 - 0.324, p = 0.002). Younger respondents reported to have better healthy lifestyle practice than older respondents (beta= -0.071, 95% CI: -0.119, -0.019, p =0.019). Service factor, the distance of nearest health care facilities also significantly affected health knowledge level. Individual who were living nearer to health care facilities (within 5km radius) reported to have better metabolic syndrome knowledge compared to those staying more than the 5km radius from the nearest health care facilities (beta= 0.085, 95% CI: 0.031 - 0.138, p = 0.010). Respondents who lived more than 5km from the health care facility reported to have better health literacy status compared to those who lived nearer to the health care facility. Respondents with chronic illnesses were more likely to have a higher level of metabolic syndrome knowledge. (beta= 0.087, 95% CI: 0.041 - 0.140, p = 0.003). Metabolic syndrome knowledge was reported to be positively significant with the practise of healthy lifestyle (beta= 0.080, 95% CI: 0.021- 0.139, p = 0.037).

Table 1
Demographic characteristics of study respondents according to healthy lifestyle practice.


Fig. (3)
Path model with standardized coefficient for overall respondents (n=1006).
Dummy coding:
Gender: male=0, female= 1
Education: primary and below= 0, Secondary and above= 1
Distance: less than 5 km= 0, more than 5 km = 1
Chronic illness, family history of IHD: no= 0, yes= 1


Table 2
Sample correlation matrix among theorized latent factors influencing practice of healthy lifestyle.


Table 3
Standardized regression weights of constructs for overall respondents.


Table 4
Path coefficients of the independent determinant variables on dependent variable, Healthy lifestyle practice.


The construction of the path diagram revealed that age, gender, health literacy and metabolic syndrome knowledge have a direct effect on healthy lifestyle practice. Gender has both direct and indirect effect on healthy lifestyle practice. Table 4 displays the indirect, direct and total effects of the independent and intermediate variables towards healthy lifestyle practice. The beta coefficient for the direct effect of gender on healthy lifestyle practice in the model is 0.279 (p value <0.05). Gender was dummy coded as 0= Male and 1= Female in this path model. Thus, the positive relationship indicates that females are more likely to have healthier lifestyle practice compared to males. In this model pathway, gender has an indirect effect towards healthy lifestyle practice which is mediated by health literacy (beta= 0.008, p < 0.05). The total effect (direct & indirect) from gender to healthy lifestyle practice is 0.287 which is also statistically significant (p < 0.05). Age only has a direct effect on the practice of healthy lifestyle with beta coefficient of -0.071 (p < 0.001). Negative correlation suggested that with every unit increase in age, healthy lifestyle practice is lowered. This was an expected direction in this relationship and and is statistically significant. An increase in the unit of family history of ischemic heart disease will improve metabolic syndrome knowledge. Health literacy has both direct and direct effect on healthy lifestyle practice. The direct effect of health literacy towards healthy lifestyle practice has the coefficient of 0.092 which is statistically significant (p < 0.05). This means every unit increase in health literacy will improve healthy lifestyle practice of an individual. Health literacy indirect effect towards healthy lifestyle practice is mediated by metabolic syndrome knowledge with the beta coefficient of 0.021 and is statistically significant. This shows that every unit increase in health literacy will indirectly improve healthy lifestyle practice. The total effect of this structural relationship is 0.113 (p < 0.005). This, illustrates the importance of better understanding of disease knowledge in order to practice a healthy lifestyle. Lastly, the direct effect of metabolic syndrome knowledge towards healthy lifestyle practice is 0.093 which is statistically significant (p < 0.05). This finding suggests that an increase in every unit of metabolic syndrome will positively impact healthy lifestyle practice.

3.3. Multi Group Analysis

A multi-group path analysis was developed to produce separate subgroup models based on ethnicity, which were divided into Malay/Melanau, Native and Chinese Figs. (4-6) Female respondents from Malay/Melanau and Native groups have a better healthy lifestyle practice than the male. However, there was no significant difference between gender for Chinese respondents towards the practice of a healthy lifestyle. For all 3 ethnic groups, the only sociodemographic factor that significantly affects health literacy was education level. Correspondingly, health literacy status positively influenced knowledge of metabolic syndrome. Age was reported to be negatively associated with healthy lifestyle practice for Malay/ Melanau and Chinese respondents. Distance of health care facility was a significant factor affecting health literacy for Malay/ Melanau respondents. Influence of having a chronic illness on health literacy was only significant among the Native respondents. Health care service factor (distance) influenced health literacy for Malay/Melanau ethnic group and metabolic syndrome knowledge for the Chinese respondents. Family history with ischemic heart disease only improved knowledge of metabolic syndrome of the Malay/Melanau respondents. Good health literacy was vital for respondents from Malay/ Melanau and Chinese ethnic group to practice a healthier lifestyle. For the Natives, knowledge of metabolic syndrome was an important determinant of healthy lifestyle practice.

Fig. (4)
Path model with standardized coefficient for Malay/Melanau respondents (n=335).
Dummy coding:
Gender: male=0, female= 1
Education: primary and below= 0, Secondary and above= 1
Distance: less than 5 km= 0, more than 5 km = 1
Chronic illness, family history of IHD: no= 0, yes= 1


Fig. (5)
Path model with standardized coefficient for Native respondents (n=479).
Dummy coding:
Gender: male=0, female= 1
Education: primary and below= 0, Secondary and above= 1
Distance: less than 5 km= 0, more than 5 km = 1
Chronic illness, family history of IHD: no= 0, yes= 1


Fig. (6)
Path model with standardized coefficient for Chinese respondents (n=192).
Dummy coding:
Gender: male=0, female= 1
Education: primary and below= 0, Secondary and above= 1
Distance: less than 5 km= 0, more than 5 km = 1
Chronic illness, family history of IHD: no= 0, yes= 1


Table 5
Goodness of fit for the overall and multi-group pathway model.


In summary, for all three ethnic groups, education status positively influenced health literacy status. Correspondingly, health literacy status positively affects knowledge of metabolic syndrome. Gender differences and history of chronic illness has no significant influence on health literacy for all the ethnic groups. However, being female was a strong determinant to practice a healthy lifestyle for Malay/Melanau and Native groups, but not for Chinese respondents. We observed different determinants influencing the practice of healthy lifestyle among the ethnic groups. For Malay/Melanau respondents, gender and health literacy status influenced healthy lifestyle practice. Knowledge of metabolic syndrome and gender were reported to contribute significantly on the practice of a healthy lifestyle for the Natives. For Chinese respondents, health literacy is the only factor that influences healthy lifestyle practice.

3.4. Model Fit

(Table 5) goodness of fit for both overall and multi group pathway model. Model fit for overall pathway model was reported to be good with AGFI = 0.987, CFI = 0.986 and TLI = 0.950. Additionally, χ2 (8) = 12.083, p = 0.148 and RMSEA = 0.023 (90% CI: 0.000 - 0.047). For multi group analysis, the model fit was also reported to be acceptable with AGFI = 0.962, CFI = 0.945 and TLI= 0.809. Additionally, χ2 (32) = 69.829, p < 0.001 and RMSEA= 0.024 (90% CI: 0.016 - 0.032). Table 5 contains the indirect, direct and total effects of the independent and intermediate variables towards healthy lifestyle practice.

4. DISCUSSION

This study examined theories on factors influencing healthy lifestyle practice among multi-ethnic Sarawakian adults. Two important mediation pathways between socio demographic variables, service factor, history of chronic illness and healthy lifestyle practice were discovered discovered in our study. Health literacy and metabolic syndrome knowledge significantly mediates pathway between independent variables and healthy lifestyle practice. Current study reported age gender differences, health literacy, and knowledge on metabolic syndrome are direct determinants of healthy lifestyle practice to prevent metabolic syndrome. Health literacy requires a combination of basic literacy skills, communication ability and critical thinking. The result is consistent with previous literature which emphasized on the importance of health literacy towards healthy lifestyle habits [24Hsu W, Chiang C, Yang S. The effect of individual factors on health behaviors among college students: The mediating effects of eHealth literacy. J Med Internet Res 2014; 16(12)e287[http://dx.doi.org/10.2196/jmir.3542] [PMID: 25499086] ]. Our study also reported that a better level of health literacy will improve the understanding of disease knowledge and subsequently leads to the practice of healthy lifestyle. The relationship between health knowledge, health literacy and the practice of healthy lifestyle habit has been widely established in other parts of the world [25Kudo N, Yokokawa H, Fukuda H, Hisaoka T, Isonuma H, Naito T. Analysis of Associations between Health Literacy and Healthy Lifestyle Characteristics among Japanese Outpatients with Lifestyle-related Disorders. J Gen Fam Med [Internet] 2016; 17(4): 299-306.[http://dx.doi.org/10.14442/jgfm.17.4_299] -27Hom JM, Lee JY, Divaris K, Baker AD, Vann WF Jr. Oral health literacy and knowledge among patients who are pregnant for the first time. J Am Dent Assoc 2012; 143(9): 972-80.[http://dx.doi.org/10.14219/jada.archive.2012.0322] [PMID: 22942 142] ]. This finding is beneficial since health literacy and knowledge are modifiable determinants of health. interventions can be administered on both components. We found that good socioeconomic status, such as education is associated with possessing a higher level of health literacy. Several existing studies reported similar findings [28Liu Y, Wang Y, Liang F, Chen Y, Liu L, Li Y. Health Literacy Status and Influencing Factors of Older Population in Xinjiang 2015; 44(7): 913-9.-30Wu Y, Wang L, Cai Z, Bao L, Ai P, Ai Z. Prevalence and risk factors of low health literacy: A community-based study in Shanghai, China. Int J Environ Res Public Health 2017; 14(6) E628[http://dx.doi.org/10.3390/ijerph14060628] [PMID: 28604645] ]. This should support the policy of focusing on developing health literacy and integrating the teaching of knowledge of specific diseases in school curriculum. These health-related knowledges should be delivered extensively since childhood to prevent lifestyle related disease. The Protection Motivation Theory which was developed and later revised by Ronald W. Rogers, offers a theory on influential communication, inducing fear that focused on the cognitive processes mediating change of behaviour [31Rogers R. Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation Soc Psychophysiological A Sourceb. 1983;(January):153–77. Available from: https://academic. oup. com/ jdsde/article- look up/ doi/10.1093/deafed/ent031]. Its main aim is not only to create preventive awareness but also induce fear on lifestyle related diseases. The clear understanding of diseases, its severity, complication and prognosis could deter sedentary lifestyle such as being physically inactive, eating healthy and avoiding or reducing alcohol and tobacco usage.

The current study reported that comorbidity leads to improvement of health literacy and a better understanding of disease knowledge contributed by having a family history of medical illnesses. A similar scenario was reported by Song Y. et al. (2013) [32Song Y, Ma W, Yi X, et al. Chronic diseases knowledge and related factors among the elderly in Jinan, China. PLoS One 2013; 8(6)e68599[http://dx.doi.org/10.1371/journal.pone.0068599] [PMID: 23826394] ]. However, the distance of the health care facility negatively affects metabolic syndrome knowledge. In contrary to our finding, He et al. (2016) in their community study among the elderly in China reported that the greater the distance of health care facility, the poorer the health knowledge [33He Z, Cheng Z, Shao T, Liu C, Shao P, Bishwajit G, et al. Factors Influencing Health Knowledge and Behaviors among the Elderly in Rural China 2016; 1-16.[http://dx.doi.org/10.3390/ijerph13100975] ]. This eventually led to an unhealthy lifestyle practice. Deficiency of knowledge is expected in the rural part of any country, but an effective method of delivering proper health information to the general public is vital. Health and disease-specific knowledge could be delivered in various ways. Currently, the most effective tool for information dissemination is social media. Malaysians prefer to spend time online than listening to radio, watching television and reading printed materials [34Wok S, Mohamed S. Internet and social media in Malaysia: Development 2017.]. Additionally, Malaysian social network users reported to have the highest number of friends on social network in the world [35Muniandy L, Muniandy B. The impact of social media in social and political aspects in Malaysia: An overview. Int J Humanit Soc Sci 2013; 3(11): 71-6.].

As public health personnel, our goal should focus on creating awareness and understanding of ailments among healthy population, instead of acquiring disease knowledge when they are ill. Failure to tackle underlying determinant will not improve the pattern of health problems. Burden and cost of curative care services will skyrocket. In this study, healthy lifestyle practices were made up of the following components: physical activity, dietary status, tobacco and alcohol consumption and stress level. Therefore, the score of every component counts in determining the level of healthy lifestyle status of the respondents. A more sedentary lifestyle will result in a lower score of Simple Lifestyle Indicator Questionnaire (SLIQ). Available literature demonstrated the effectiveness of healthy-lifestyle such as adequate fruits and vegetables consumption, not smoking regular physical activity and ability to maintain ideal body weight towards the prevention of metabolic syndrome. Under the principle of health promotion, health behavior is modifiable by addressing factors. Female respondents reported to have better healthy lifestyle practice than male respondents. Similar findings have been reported elsewhere [36Paulik E, Bóka F, Kertész A, Balogh S, Nagymajtényi L. Determinants of health-promoting lifestyle behaviour in the rural areas of Hungary. Health Promot Int 2010; 25(3): 277-88.[http://dx.doi.org/10.1093/heapro/daq025] [PMID: 20413403] , 37Ek S. Gender differences in health information behaviour: A Finnish population-based survey. Health Promot Int 2015; 30(3): 736-45.[http://dx.doi.org/10.1093/heapro/dat063] [PMID: 23985248] ]. Female participants practice better nutritional intake and higher physical activity compared to male participants. Women were more attentive towards information and worldwide issues related to health and diseases than the men. This is a vital discovery since numerous studies reported a higher prevalence of metabolic syndrome in women than men [6Ranasinghe P, Mathangasinghe Y, Jayawardena R, Hills AP, Misra A. Prevalence and trends of metabolic syndrome among adults in the asia-pacific region: A systematic review. BMC Public Health 2017; 17(1): 101.[http://dx.doi.org/10.1186/s12889-017-4041-1] [PMID: 28109251] , 38Bentley-Lewis R, Koruda K, Seely EW. The metabolic syndrome in women. Nat Clin Pract Endocrinol Metab 2007; 3(10): 696-704.[http://dx.doi.org/10.1038/ncpendmet0616] [PMID: 17893688] ]. Nevertheless, it is vital for both men and women to have healthy lifestyle practice. In this model, age has moderation effects on healthy lifestyle practice. Advancing age turned lifestyle into more motionless and riskier forms [39Harvey JA, Chastin SFM, Skelton DA. Prevalence of sedentary behavior in older adults: A systematic review. Int J Environ Res Public Health 2013; 10(12): 6645-61.[http://dx.doi.org/10.3390/ijerph10126645] [PMID: 24317382] , 40Yokokawa H, Yuasa M, Sanada H. Age-and sex-specific impact of health literacy on healthy lifestyle characteristics among Japanese Residents in a rural community. Health (Irvine Calif) 2015; (June): 679-88. [Internet].[http://dx.doi.org/10.4236/health.2015.76081] ]. However, the biological and social process of aging is likely to encourage discordant behaviours. Biologically, exercise becomes more difficult with age as cardiovascular function and balance decline, and the prevalence of joint problems increases. Older age individuals with inadequate health literacy status are less likely to utilise the written media as a source of health information. This leads to a serious and challenging problem where written information is the main method of information communication in health care settings. This situation is worrying since aging was also proven to elevate the risk of metabolic syndrome. Increasing in age deteriorate lipid profile in both men and women, a condition which is known as dyslipidaemia and can lead to ischemic heart diseases and stroke [41Hunter GR, Snyder SW, Kekes-Szabo T, Nicholson C, Berland L. Intra-abdominal adipose tissue values associated with risk of possessing elevated blood lipids and blood pressure. Obes Res 1994; 2(6): 563-8.[http://dx.doi.org/10.1002/j.1550-8528.1994.tb00106.x] [PMID: 163 55516] ].

Multi-group analysis demonstrated differences in the pathway leading to a healthy lifestyle among different ethnic groups. Health literacy plays an important role in predicting healthy lifestyle behaviors for Malay/Melanau and Chinese respondents. However, for the Natives, adequate knowledge on the disease itself will deter a sedentary lifestyle. Nevertheless, regardless of the ethnicity and cultural differences, intervention activities should be comprehensive, with emphasis on the cultural aspect of it. Cultural differences have a substantial effect on lifestyle. Studies have shown the importance of addressing issues related to health beliefs and practices of culturally diverse groups [42Hernandez L, Blazer D. Genes, behavior, and the social environment 2006., 43Swierad EM, Vartanian LR, King M. The influence of ethnic and mainstream cultures on African Americans’ Health Behaviors: A qualitative study. Behav Sci (Basel) 2017; 7(3): 49.[http://dx.doi.org/10.3390/bs7030049] [PMID: 28777312] ]. Our path model supported eight determinants (age, gender, education, chronic illness, family history of ischemic heart disease, health care facility distance, health literacy and metabolic syndrome knowledge) for healthy lifestyle practice against metabolic syndrome. The interaction between these determinants explained 11 percent of the total variance. Our findings are comparable to other studies that assess complex structural relationship predicating a healthy lifestyle habit [44Kim SH. Older people’s expectations regarding ageing, health-promoting behaviour and health status. J Adv Nurs 2009; 65(1): 84-91.[http://dx.doi.org/10.1111/j.1365-2648.2008.04841.x] [PMID: 1903 2514] -46Hart P. Using structural equation modeling to examine the effects of sex and physical activity on the metabolic syndrome and health-related quality of life relationship. Exercise Medicine 2018; 2: 3.[http://dx.doi.org/10.26644/em.2018.003] ]. The current study assessed a combination of all five healthy lifestyle habit elements (physical activity, nutrition, stress, tobacco and alcohol consumption) that prevent metabolic syndrome. Participants fulfilling all criteria of healthy lifestyle habit were considered to have a good preventive lifestyle of metabolic syndrome. To our knowledge, this is the first study to identify the causal model on healthy behaviours against lifestyle-related disease specifically metabolic syndrome among different ethnic groups of Sarawak. Therefore, the current study has practical implications for designing health promotion programs according to the target group. Since the gap for practicing a healthy lifestyle has been identified, it is timely to handle this issue comprehensively. To date, health literacy is a well-established concept and outcome of health promotion [47Sørensen K, Van den Broucke S, Fullam J, et al. (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012; 12(1): 80.[http://dx.doi.org/10.1186/1471-2458-12-80] [PMID: 22276600] , 48Van den Broucke S. Health literacy: A critical concept for public health Arch Public Heal [Internet]. 2014;72(1):10. Available from: http://archpublichealth.biomedcentral.com/articles/10.1186/2049-3258-72-10[http://dx.doi.org/10.1186/2049-3258-72-10] ]. It can be nurtured through proper health education. Health education, in a broader understanding, aims to influence not solely on personal lifestyle choices, but also raises awareness of the determinants of health, and encourages individual and collective actions which might lead to an adjustment of these determinants. it is high time that health care professional be the driving force to ensure that health literacy flourish in both individual and community level. The objective of a traditional community-based approach is to create equitable corporations of everyone in a specific community by emphasizing on generating strengths and allocating resources within the community itself [49Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. Am J Public Health 2010; 100(Suppl. 1): S40-6.[http://dx.doi.org/10.2105/AJPH.2009.184036] [PMID: 20147663] ]. Health and disease knowledge can be nurtured through health education activities. The effort to increase the practice of healthy lifestyle is not just an individual problem, but also societal. Thus, it requires a culturally acceptable approach which can be applied to the population. Simultaneously a multi-disciplinary and multi-sectoral involvement is important to target a bigger audience.

CONCLUSION

Current study shows the mediation effect of health literacy and knowledge towards the practice of a healthy lifestyle. Poor lifestyle practice can be explained by a lack of information and understanding of certain diseases and deprived health literacy skills. Education to increase the knowledge of important specific diseases will provide better practice of a healthy lifestyle. Additionally, culturally sensitive health education is essential to ensure that information can be delivered effectively across the State which is diverse in term of population. Primordial prevention should target vulnerable groups to inhibit the development of risk factors. From Public Health perspective, the best method of primordial prevention is school-based. Continuous long-standing lifestyle modification and changes in children and adolescents can diminish the development of NCD risk factors and disease onset in later-life. The teaching of disease knowledge and recognising the danger of metabolic syndrome lifestyle risk factors should be integrated into school curriculum.

STRENGTH AND LIMITATION

This study is one of the first to demonstrate the mediation effect of health literacy and disease knowledge towards the practice of healthy lifestyle in Malaysia. Sarawak is diverse in ethnic groups. Thus, population study with multistage stratified sampling methods allows for the proper representation of subgroups within the population. Several limitations of this study should be addressed. Firstly, cross-sectional study only permits us to assess independent and dependent variables concurrently. Hence only association can be identified but causality cannot be inferred. Secondly, data were collected by using interviewer-assisted questionnaire which could lead to interviewer bias that can cause distraction and affect the respondent’s willingness to disclose sensitive information [50Bowling A. Mode of questionnaire administration can have serious effects on data quality. J Public Health (Oxf) 2005; 27(3): 281-91.[http://dx.doi.org/10.1093/pubmed/fdi031] [PMID: 15870099] ]. However, it is important to point out that face to face interview facilitates precise screening and evades false information.

AUTHOR'S CONTRIBUTION

All the authors contributed equally.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Medical Research Ethics Committee of Universiti Malaysia Sarawak (UNIMAS) granted approval to conduct this research.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

Formal written consent was obtained, and confidentiality of information was assured.

FUNDING

This work was supported by the Institute of Borneo Studies, Universiti Malaysia Sarawak (Unimas) with the reference number of F05/NRC/1636/2017.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors would like to thank all participants of this study; lecturers and staffs of Department of Community Medicine and Public Health, Universiti Malaysia Sarawak; Medical Research Ethics Committee of Universiti Malaysia Sarawak; Institute of Borneo Study for the project grant and our research assistants for the excellent work.

REFERENCES

[1] Collaborators RF. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990 – 2015 : a systematic analysis for the Global Burden of Disease Study 2015 2017; : 1990-2015.
[2] Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the metabolic syndrome: A joint interim statement of the international diabetes federation task force on epidemiology and prevention; National heart, lung, and blood institute; American heart association; World heart federation; International atherosclerosis society; And international association for the study of obesity. Circulation 2009; 120(16): 1640-5.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192644] [PMID: 19805654]
[3] Bradshaw PT, Monda KL, Stevens J. Metabolic syndrome in healthy obese, overweight, and normal weight individuals: The Atherosclerosis Risk in Communities Study. Obesity (Silver Spring) 2013; 21(1): 203-9.[http://dx.doi.org/10.1002/oby.20248] [PMID: 23505187]
[4] Nettleton JA, Lutsey PL, Wang Y, Lima JA, Michos ED, Jacobs DR Jr. Diet soda intake and risk of incident metabolic syndrome and type 2 diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care 2009; 32(4): 688-94.[http://dx.doi.org/10.2337/dc08-1799] [PMID: 19151203]
[5] O’Neill S, O’Driscoll L. Metabolic syndrome: A closer look at the growing epidemic and its associated pathologies. Obes Rev 2015; 16(1): 1-12.[http://dx.doi.org/10.1111/obr.12229] [PMID: 25407540]
[6] Ranasinghe P, Mathangasinghe Y, Jayawardena R, Hills AP, Misra A. Prevalence and trends of metabolic syndrome among adults in the asia-pacific region: A systematic review. BMC Public Health 2017; 17(1): 101.[http://dx.doi.org/10.1186/s12889-017-4041-1] [PMID: 28109251]
[7] Institute for Public Health. National Health and Morbidity Survey 2015 (NHMS 2015). Vol. II: Non-Communicable Diseases, Risk Factors & Other Health Problems. Vol. II, Ministry of health. 2015. 1-291 p
[8] Malaysia D of S. Department of Statistics Malaysia Press Release. Department of Statistics Malaysia Press Release Dep Stat Malaysia 2018 June; 5-9.
[9] Freedman DA, Bess KD, Tucker HA, Boyd DL, Tuchman AM, Wallston KA. Public health literacy defined. Am J Prev Med 2009; 36(5): 446-51.[http://dx.doi.org/10.1016/j.amepre.2009.02.001] [PMID: 19362698]
[10] Chin J, Morrow DG, Murray MD. NIH Public Access Heal (San Fr) 2012 August 2009; 16: 222-41.
[11] Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000; 15(3): 259-67.[http://dx.doi.org/10.1093/heapro/15.3.259]
[12] Squiers L, Peinado S, Berkman N, Boudewyns V, McCormack L. The Health Literacy Skills Framework Journal of Health Communication 2012; 17(sup3): 30-54.[http://dx.doi.org/10.1080/10810730.2012.713442]
[13] Suka M, Odajima T, Okamoto M, et al. Relationship between health literacy, health information access, health behavior, and health status in Japanese people. Patient Educ Couns 2015; 98(5): 660-8.[http://dx.doi.org/10.1016/j.pec.2015.02.013] [PMID: 25739344]
[14] Yokokawa H, Yuasa M, Sanada H, Hisaoka T, Fukuda H. Age and sex-specific impact of health literacy on healthy lifestyle characteristics among Japanese Residents in a Rural Community. Health 2015; 07(06): 679-88.[http://dx.doi.org/10.4236/health.2015.76081]
[15] Suka M, Odajima T, Kasai M, et al. The 14-item health literacy scale for Japanese adults (HLS-14). Environ Health Prev Med 2013; 18(5): 407-15.[http://dx.doi.org/10.1007/s12199-013-0340-z] [PMID: 23689952]
[16] Yahia N, Brown C, Rapley M, Chung M. Assessment of college students’ awareness and knowledge about conditions relevant to metabolic syndrome. Diabetol Metab Syndr 2014; 6(1): 111.[http://dx.doi.org/10.1186/1758-5996-6-111] [PMID: 25360161]
[17] Godwin M, Streight S, Dyachuk E, et al. Testing the simple lifestyle indicator questionnaire: Initial psychometric study. Can Fam Physician 2008; 54(1): 76-7.[PMID: 18208960]
[18] Stage F, Carter H, Nora A. Path Analysis: An introduction and analysis of a decade of research. J Educ Res 2004; 98(1): 5-13.[http://dx.doi.org/10.3200/JOER.98.1.5-13]
[19] Cheung G, Lau R. Testing mediation and suppression effects of latent variables. Organ Res Methods 2007; 11(2): 296-325.[http://dx.doi.org/10.1177/1094428107300343]
[20] Steiger J. Understanding the limitations of global fit assessment in structural equation modeling. Pers Individ Dif 2007; 42(5): 893-8.[http://dx.doi.org/10.1016/j.paid.2006.09.017]
[21] Tabachnick B, Fidell L. Using multivariate statistics 5th ed. 5th ed.2007.
[22] Hu L, Bentler P. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling 1999; 6(1): 1-55.[http://dx.doi.org/10.1080/10705519909540118]
[23] Bollen K, Stine R. Bootstrapping Goodness-of-Fit Measures in Structural Equation Models. Sociol Methods Res 1992; 21(2): 205-29.[http://dx.doi.org/10.1177/0049124192021002004]
[24] Hsu W, Chiang C, Yang S. The effect of individual factors on health behaviors among college students: The mediating effects of eHealth literacy. J Med Internet Res 2014; 16(12)e287[http://dx.doi.org/10.2196/jmir.3542] [PMID: 25499086]
[25] Kudo N, Yokokawa H, Fukuda H, Hisaoka T, Isonuma H, Naito T. Analysis of Associations between Health Literacy and Healthy Lifestyle Characteristics among Japanese Outpatients with Lifestyle-related Disorders. J Gen Fam Med [Internet] 2016; 17(4): 299-306.[http://dx.doi.org/10.14442/jgfm.17.4_299]
[26] Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998; 158(2): 166-72.[http://dx.doi.org/10.1001/archinte.158.2.166] [PMID: 9448555]
[27] Hom JM, Lee JY, Divaris K, Baker AD, Vann WF Jr. Oral health literacy and knowledge among patients who are pregnant for the first time. J Am Dent Assoc 2012; 143(9): 972-80.[http://dx.doi.org/10.14219/jada.archive.2012.0322] [PMID: 22942 142]
[28] Liu Y, Wang Y, Liang F, Chen Y, Liu L, Li Y. Health Literacy Status and Influencing Factors of Older Population in Xinjiang 2015; 44(7): 913-9.
[29] Sun X, Shi Y, Zeng Q, et al. Determinants of health literacy and health behavior regarding infectious respiratory diseases: A pathway model. BMC Public Health 2013; 13(1): 261.[http://dx.doi.org/10.1186/1471-2458-13-261] [PMID: 23521806]
[30] Wu Y, Wang L, Cai Z, Bao L, Ai P, Ai Z. Prevalence and risk factors of low health literacy: A community-based study in Shanghai, China. Int J Environ Res Public Health 2017; 14(6) E628[http://dx.doi.org/10.3390/ijerph14060628] [PMID: 28604645]
[31] Rogers R. Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation Soc Psychophysiological A Sourceb. 1983;(January):153–77. Available from: https://academic. oup. com/ jdsde/article- look up/ doi/10.1093/deafed/ent031
[32] Song Y, Ma W, Yi X, et al. Chronic diseases knowledge and related factors among the elderly in Jinan, China. PLoS One 2013; 8(6)e68599[http://dx.doi.org/10.1371/journal.pone.0068599] [PMID: 23826394]
[33] He Z, Cheng Z, Shao T, Liu C, Shao P, Bishwajit G, et al. Factors Influencing Health Knowledge and Behaviors among the Elderly in Rural China 2016; 1-16.[http://dx.doi.org/10.3390/ijerph13100975]
[34] Wok S, Mohamed S. Internet and social media in Malaysia: Development 2017.
[35] Muniandy L, Muniandy B. The impact of social media in social and political aspects in Malaysia: An overview. Int J Humanit Soc Sci 2013; 3(11): 71-6.
[36] Paulik E, Bóka F, Kertész A, Balogh S, Nagymajtényi L. Determinants of health-promoting lifestyle behaviour in the rural areas of Hungary. Health Promot Int 2010; 25(3): 277-88.[http://dx.doi.org/10.1093/heapro/daq025] [PMID: 20413403]
[37] Ek S. Gender differences in health information behaviour: A Finnish population-based survey. Health Promot Int 2015; 30(3): 736-45.[http://dx.doi.org/10.1093/heapro/dat063] [PMID: 23985248]
[38] Bentley-Lewis R, Koruda K, Seely EW. The metabolic syndrome in women. Nat Clin Pract Endocrinol Metab 2007; 3(10): 696-704.[http://dx.doi.org/10.1038/ncpendmet0616] [PMID: 17893688]
[39] Harvey JA, Chastin SFM, Skelton DA. Prevalence of sedentary behavior in older adults: A systematic review. Int J Environ Res Public Health 2013; 10(12): 6645-61.[http://dx.doi.org/10.3390/ijerph10126645] [PMID: 24317382]
[40] Yokokawa H, Yuasa M, Sanada H. Age-and sex-specific impact of health literacy on healthy lifestyle characteristics among Japanese Residents in a rural community. Health (Irvine Calif) 2015; (June): 679-88. [Internet].[http://dx.doi.org/10.4236/health.2015.76081]
[41] Hunter GR, Snyder SW, Kekes-Szabo T, Nicholson C, Berland L. Intra-abdominal adipose tissue values associated with risk of possessing elevated blood lipids and blood pressure. Obes Res 1994; 2(6): 563-8.[http://dx.doi.org/10.1002/j.1550-8528.1994.tb00106.x] [PMID: 163 55516]
[42] Hernandez L, Blazer D. Genes, behavior, and the social environment 2006.
[43] Swierad EM, Vartanian LR, King M. The influence of ethnic and mainstream cultures on African Americans’ Health Behaviors: A qualitative study. Behav Sci (Basel) 2017; 7(3): 49.[http://dx.doi.org/10.3390/bs7030049] [PMID: 28777312]
[44] Kim SH. Older people’s expectations regarding ageing, health-promoting behaviour and health status. J Adv Nurs 2009; 65(1): 84-91.[http://dx.doi.org/10.1111/j.1365-2648.2008.04841.x] [PMID: 1903 2514]
[45] Sharifirad G, Yarmohammadi P, Azadbakht L, Morowatisharifabad MA, Hassanzadeh A. Determinants of fast food consumption among Iranian high school students based on planned behavior theory. J Obes 2013; 2013147589[http://dx.doi.org/10.1155/2013/147589] [PMID: 23936635]
[46] Hart P. Using structural equation modeling to examine the effects of sex and physical activity on the metabolic syndrome and health-related quality of life relationship. Exercise Medicine 2018; 2: 3.[http://dx.doi.org/10.26644/em.2018.003]
[47] Sørensen K, Van den Broucke S, Fullam J, et al. (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012; 12(1): 80.[http://dx.doi.org/10.1186/1471-2458-12-80] [PMID: 22276600]
[48] Van den Broucke S. Health literacy: A critical concept for public health Arch Public Heal [Internet]. 2014;72(1):10. Available from: http://archpublichealth.biomedcentral.com/articles/10.1186/2049-3258-72-10[http://dx.doi.org/10.1186/2049-3258-72-10]
[49] Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. Am J Public Health 2010; 100(Suppl. 1): S40-6.[http://dx.doi.org/10.2105/AJPH.2009.184036] [PMID: 20147663]
[50] Bowling A. Mode of questionnaire administration can have serious effects on data quality. J Public Health (Oxf) 2005; 27(3): 281-91.[http://dx.doi.org/10.1093/pubmed/fdi031] [PMID: 15870099]

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open