Contextualizing motivations and perceived barriers of healthy nutrition and lifestyle behaviours among Malaysian adults with metabolic syndrome

Nutrition and lifestyle behaviour of individuals have been associated with the risk of metabolic syndrome (MetS). In order to better control the prevalence of MetS nationwide, an effective health promotion program must provide age-appropriate care information that addresses critical factors such as physiological function, social psychology, and emotional and health literacy in order to empower these patients to self-manage their condition and to enhance their self-care-related motivation and confidence. This study qualitatively analysed FGD involving Malaysian adults with MetS to explore their understanding of MetS and their perceived motivation and barriers of healthy nutrition and lifestyle behaviour. A qualitative study with four focus groups (21 purposively sampled respondents) was conducted with adults diagnosed with MetS whom attending MONASH Medical Precinct in 2018. An interview protocol consolidating both responsive interviewing model and health belief model were prepared. The focus groups were audio recorded and transcribed. The data were analysed by emergent themes analysis. Data saturation was achieved in the fourth focus group.


Results
Seven main themes; three motivations and three perceived barriers and one subtheme on healthy nutrition and lifestyle behaviour were identified in the analysis of FGD.
Motivations for healthy nutrition and lifestyles behaviour were (i) weight gain and physical appearances; (ii)personal experience of adverse complications and (iii) good family and social support. The identified perceived barriers were (i) healthcare as a business model; (ii) healthy change is difficult and expensive and (iii) cultural influence on food intake.
Inadequate knowledge on MetS as most respondents were unaware of MetS as a clustering 3 of risk factors but were able to identify the components individually was also a strong theme identified in this study.

Conclusion
Nutrition and lifestyle behaviours of adults with MetS were highly affected by the several potent motivations and perceived barriers among individuals. Information delivery and lifestyle promotion should address these aspects to increase program adoption and adherence, ensuring success of a community-based lifestyle intervention.

Background
Unhealthy dietary behaviour and lifestyle factors such as sedentariness, alcohol and tobacco use, and sleep deprivation, may lead to poor health. Nutrition and lifestyle behaviour of individuals have been associated with the risk of metabolic syndrome (MetS) (1). MetS is a clustering of cardiovascular risk factors which places individuals at increased risk for cardiovascular morbidity and mortality (2,3). The increase in MetS prevalence among Malaysian adults for the past decade (4-6) reinforces the need of an effective health promotion program with age-appropriate care information that addresses critical factors such as physiological function (6), social psychology (7), and emotional and health literacy (1). Such programs can empower these patients to self-manage their condition and to enhance their self-care-related motivation and confidence.
An exploration of models for individual motivation to participate in intervention measures is necessary to develop hypotheses regarding the influence of various factors on participation (8). For instance, theoretical frameworks such as Health Belief Model (HBM) was used to explain individual's behaviours and behavioural changes (9,10). Furthermore, a deeper understanding on individuals' motivation and barriers to behaviour is among the key to ensure the success of lifestyle intervention measures (1). The HBM is made up of four constructs representing the perceived threat and net benefits: perceived 4 susceptibility, perceived severity, perceived benefits, and perceived barriers, which accounted for individual's "readiness to act." (11). Besides to better fit the challenges of changing habitual unhealthy behaviours, such as being sedentary, smoking, or overeating, cues to action and self-efficacy concept are added into the construct. Cues to action would activate that readiness and stimulate overt behaviour while self-efficacy is to instil one's confidence in the ability to successfully perform an action ( Fig. 1) (12,13). Overall, HBM is the best model to explain the motivation and barriers faced by individuals in order to initiate a healthy behavioural change (10).
Consequently, we have to better characterised and understand the lifestyle behaviour of Malaysian adults with MetS before developing an effective community-specific lifestyle intervention. Since our understanding on behavioural determinants that shaped the lifestyle behaviour among Malaysian with MetS is limited, this study aimed to explore the abstract information on nutrition and lifestyle behaviours through qualitative analysis of focus group. This study will qualitatively analyse a series of focus group discussions (FGD) involving Malaysian adults with MetS to explore their understanding of MetS and their perceived motivation and barriers of healthy nutrition and lifestyle behaviour.
Furthermore, HBM will be used as the conceptual model in the design of focus group question and overall script as it is the best model to chart out the awareness level and readiness of change among individuals (10).

Respondent
This study received ethical approval from Monash University Human Research Ethics Council (MUHREC) prior to respondent recruitment; (Project ID: CF16/56-2016000022).
Individuals attending MONASH Medical Precinct were invited for MetS screening.
Respondents were recruited using purposive sampling that sought out based on the MetS 5 status which is the focus of the study. All consented respondent whom fulfilled the Harmonised criteria (14) of MetS were invited to join the FGD led by a moderator.
Sociodemographic details and MetS components were recorded for all respondents.

Focus Group Discussion
Each session was decided based on the number of consented respondents which have to make a minimum group size of three. Moderated interviews were then arranged with respective groups. Four separate FGD sessions involving a total of 21 respondents took place in a private consultation room at Monash Medical Precinct. Each session was led and recorded by a moderator accompanied by a trained assistant. Moderator will use an interview protocol written based on responsive interviewing model (15). A protocol which consisted of a list of questions was developed based on Health Belief Model (HBM) domain framework (16) was used to introduce areas for open discussion. Since this study is keen to see how respondent would interact during the focus group, group dynamic and interactions were enhanced by reassuring all respondents that any views expressed in the focus group would remain confidential and that there were no 'right' or 'wrong' answers to the questions and that constructive criticism was a valued part of the process. Overall, the group structure would be a more compelling approach in evaluating one's lifestyle behaviours. As explained in an earlier study, the group dynamics response, that is the type and range of data generated through the social interaction of the group, can be deeper and richer than those obtained from one-on-one interviews (15).

Thematic Framework Analysis
All FGD session recordings were transcribed verbatim before undergoing thematic analysis. The steps of the thematic framework analysis (15,17) were implemented using a priori issues derived from HBM constructs. Two initiation HBM components, motivation and perceived barriers towards healthy lifestyle, were used as primary domains in the 6 thematic framework to facilitate textual, structural and composite descriptions of lifestyle behaviours among Malaysian adults with MetS; what do they know, what do they choose to do. Detection of salient phrases from the transcript followed by inductive coding was conducted line by line in each transcript. Comparison of codes was done both within and between the four transcripts with a constant reference was made to the coding framework and the study aim. Themes were developed by comparing codes within a category and by constant comparison of the codes across categories. This was done to ensure the interpretations remain grounded in the themes and its codes. In addition, to make sense of individual codes, relationship between the codes and the links between them were sought as a whole, to provide explanations for the findings and overarching themes.
Hence, after an analysis of the transcripts, themes were categorized into the a priori domain as informed by the HBM concept.

Sociodemographic Characteristic of Respondents
Respondents (n = 21) who fulfilled the Harmonised MetS criteria participated in the study.
On average participants were 51 (SD = 10.3) years old, ranging in age from 26 to 64. The majority were women (73%), married (73%) and all had equal to or more than a high school education. Slightly less than half 46% were employed full-time. All participants had abdominal obesity according to the Harmonised Criteria (14,18).  "You can eat all the pills but you will see the difference only once you sweat and eat better." Weight gain is seen as a health threat as well especially among male respondents. They raised their concern on the worsening knee pain, shortness of breath and constant fatigue.
Two of the participants said; "the tummy has become large until I feel tired carrying it."

"you know your body is having problem when you have shortness of breath after climbing the stairs and feel extremely sleepy past the afternoon lunch"
While weight gain is a concern, female respondents are more concern on the skin and physical beauty. Observable changes on their skin prompted the female participants to eat better and exercise. One of the respondent said; "I only started exercising when my dermatologist said it helps to get rid of my wrinkles."

Theme 2: Personal Experience of Adverse Complication
When being asked about what their view on MetS which accounts to increased risk of cardiovascular diseases and type 2 diabetes mellitus, participants shared their fears of being less healthy, or of being in such poor health that they could not continue in their normal roles, and how disability may affect their life. Four participants told stories of close family and relatives whom they knew who had strokes and rendered paralysed prior to it and how these had limit them. The participants expressed that they did not want their health compromised to the extent that they could not take care of themselves or their families. Hence, they are motivated to change to better. As one of the women said, when talking about all the things she still planned to do in life.
"I've made up in my mind but I'm not ready to go yet as I am not sure how to start."

9
The following quote is from a participant who shared how providing care for dad who got paralysed prior to stroke attack. Hence it has motivated her to make changes: Moreover, several participants voiced concerns that some illnesses were being used to financially benefit companies. This led to distrust for most participants, and communication and trust with their health care providers was a concern. One participant commented; "…sometimes when the doctors prescribed too many medications, they act like they work for the pharmacy." Two others commented: Based on their individual risk factors, participants were aware of the need to make lifestyle behaviour changes to improve their health. In addition, they had knowledge of appropriate behaviours in which they should be engaged. For example, several were aware that the appropriate healthy serving plate concept; Quarter, Quarter and Half (19).
However, they expressed a need for skill building to successfully make behaviour changes.

Discussion
HBM is the earliest theory developed to explain the process of lifestyle adoption and individual's behavioural choice. In the theory, three domains are suggested as the initiator in lifestyle and behaviour choices; motivations, perceived barriers and perceived threat (16). This study adopted HBM as the fundamental framework to understand nutrition and lifestyle behaviour of Malaysian adults with MetS. Findings from focus group analysis suggested three themes in each motivation and perceived barrier domains. Interestingly, in further analysis of themes, inadequate knowledge of MetS was found to be repeated which explains the perceived threat that underlies HBM concept and it is made as the seventh theme found in this study.
Weight gain and appearance is found to be one of the best motivation to adopt healthy lifestyle in our study. Gradual weight increase and localised fat distribution around central region among middle-aged respondents are hypothesised due to aging (20). This gradual weight gain increase the risk of fracture and disability (21,22). Furthermore, weight gain also has been found to reduce quality of life resulting in increased concern of adopting healthy lifestyle (20,21). Abdominal obesity is also raising a concern among respondents.
Despite poor physical appearances due to large tummy, abdominal obesity also increases the risk of multitude metabolic complications (23). Consequently, targeted interventions may exploit this concern by addressing the benefit of weight loss in term of physical appearances and healthy ageing. This is also suggested that intervention that target physical changes such as weight loss are more favourable as compared to blood parameters thus will increase interest and hopefully adherences among adults with concerning lifestyle-related condition such as MetS.
Besides, our respondents whom experienced adverse health complications are also highly motivated to adopt healthier lifestyle. A few qualitative studies done on stroke patients (24,25) and dialysis patient (26) also found relationship between experiences on health complications tend to make patients to more vigilant about their life choices. Moreover, respondent with family members whom affected by complications were also tend to become healthier. Earlier study has also found the same theme and conclude that they take by the lesson of observing poor quality of life affecting their family members (27,28). During the analysis of this theme, an overarching theme were sought; limited knowledge on MetS among respondents. Most respondents were unaware of MetS as a clustering of risk factors but were able to identify the components individually. As a result, lifestyle changes come later in life which is supposedly may act as an effective prevention step from MetS (2,29,30).
Another motivation of healthy lifestyle is to have good family and social support.
Individuals residing in a neighbourhood with active community body tend to engage in weekly physical activity. Surroundings with public parks, safe pedestrian walkway and gymnasium likely to increase the physical activity levels of adults. Community engagement however is only limited on physical activity as nutrition and dietary behaviour is more likely to be influenced by family members (31). Thus supportive family members are found to be as the biggest motivator in adopting healthy or bad lifestyle behaviour (25). Besides, a few respondents reported supportive peers are among the reason why they adopt better diet and lifestyle daily especially among pensioner. Studies involving peer support has found that peer may influence they group to adopt better lifestyle due to the same exposure towards a certain health condition and experience the same surroundings that may encourage better activity engagement among them (32)(33)(34).
In term of barriers, respondents assumed healthcare, especially preventative and primary care is a business model. This finding raised a red flag on general misunderstanding that aid the inaccessibility of primary care to reach the population. Patients argued that preventative medicine and primary care intentionally create the need to seek early but unnecessary medical attention. Hence, the perceived risk and threat are believed to be exploited in pharmaceuticals and nutraceuticals industry. Studies from India (35) and Singapore (36)  There is a perception that healthy lifestyle is tedious and expensive. Respondents were concern that tedious step in healthy meal preparation, healthy food choices and gradual increase in physical activity is hard and unsustainable. A study found out that a major barrier in integrating a lifelong healthy habit is the limitation to understand and translate available health information into easy and practical steps in daily life (37). Besides, another study found out that easy and realistic health goal setting plays a crucial role in sustainable lifestyle changes (38 intervention is demanded to manage and further prevent MetS to affect the country.

Study Limitation
The qualitative approach, the selectness of the population under study and the sample size are clear limitations of this study. As opposed to studies taking a phenomenological or grounded theory approach, qualitative descriptive studies that involves focus group may be less interpretive, however, they are superior than quantitative studies (15).
Despite, in the development of community-based lifestyle intervention, there is no onesize-fits-all solution. Thus addressing the qualitative components of a community that are often missed out in quantitative observation, may increase the acceptability of any lifestyle intervention among the community members (17). As the consent was sought and the confidentiality of all respondent is protected, the study poses no serious ethical question.

Conclusion
The qualitative insight informed by a thematic qualitative analysis of FGDs In this study has generated an perception of change in Malaysian adults towards healthy lifestyle.
Individual perceptions on disease threat, physical appearances, adverse health effect, functionality of healthcare system and benefit of changes will significantly modulate the need to change in them. Besides, supportive environment will increase the degree of adoption and sustainability of healthy lifestyle among individuals.

Data Availability
The datasets generated and/or analysed during the current study are not publicly available due identification tags on FGD excerpts but are available from the corresponding author on reasonable request. and the multidimensional health locus of control. Ind Health. 2011;49(3):365-73. Figure 1 The Health Belief Model (HBM) (16)