Association of the personal factors of culture, attitude and motivation with health behavior among adolescents in Malaysia

Abstract This study was undertaken to determine the association of the personal factors of culture, attitude and motivation on health behavior among Malaysian adolescents. A cluster sampling technique was used and a total of 1,029 students with ages ranging from 15 to 17 years (M age = 15.9, SD = .637) were selected as respondents. The research instrument was a self-administered questionnaire covering health behavior, culture, attitude, and motivation towards health. The strongest linear relationship was found between culture and health behavior (r = .618, p = .001). Besides the culture of adolescents being the main predictor of health behavior (β = .365, p = .000), attitude (β = .283, p = .000) and motivation (β = .064, p = .033) also had significant independent effects on health behavior. Hence, culture, attitude and motivation should be taken into consideration in the promotion of health education, especially at school level.

adopt better habits if they are given better advice. Changes to such personal factors could alter health behavior and impact their health for the better in future.
In Malaysia, the Ministry of Health has over the years introduced various health programs to improve patient safety and the population's health to the public. The most and practical was The Primary Health Care programs which introduced since 1978. This program focus on the basic health care based on practical, scientifically sound and socially acceptable methods and technology was introduced to individual and families in the community. According to the Ministry of Health, Malaysia (2008), involved in this program also the first level of contact of individuals, the family and community with the health system, bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process. Primary Health Care also provides services for the older person, adolescents, female adults, male adults and children. Among the services are improving physical and geographical coverage, promotive, preventive, curative and rehabilitative care. To date, Primary Health Care still the best vehicle to ensure availability, accessibility and equitability of health for the whole community in Malaysia.

Adolescence and health behavior
Adolescence is defined as the period from the onset of puberty to the termination of physical growth, and attainment of final adult height and characteristics that occurs during the second decade of life. Hall (1904) sees adolescence as a process of physical and psychosocial development. During this period, there is a synthesis of profound corporal development with the evolution of a mature existential essence and integration of the emerging self with family, community, and culture (Arnett, 2000;Berzonsky, 2004). The WHO (2013) defines 'adolescents' as individuals between 10 and 19 years of age, 'youths' as between 15 and 24 years, and 'young people' as between 10 and 24 years (Blum & Nelson-Mari, 2004;WHO, 2015). Adolescents comprise about one fifth of the world population (WHO, 2013). Likewise, in Malaysia, out of the population of 30.27 million, slightly under one fifth, or 5.5 million, are adolescents aged 10-19 years (Department of Statistics Malaysia, 2015). While the percentage of adolescents in the country has remained stable, there had been a marked increase from 1970 to 2015 in terms of absolute numbers. It is estimated that by the year 2020, the number of adolescents in Malaysia would have increased to 6 million. Using a scholastic cultural framework in the present study, early adolescence is deemed to begin at the average age of 13, coinciding with entrance into high school, and end at the age of 17, generally coinciding with graduation from secondary school (UNICEF, 2015).
Health behavior is defined by WHO as any activity undertaken by an individual, regardless of actual or perceived health status, for the purpose of promoting, protecting or maintaining health, whether or not such behavior is objectively effective towards that end. In describing the concept of health behavior in a manner applicable to adolescents, Gochman (1997) saw health as a resource rather than simply the absence of disease. Hence, health behaviors show overt behavior patterns, actions and habits which relate to health maintenance or health improvement.
In many ways, adolescent development drives changes in the disease burden between childhood to adulthood. For example, adolescence is a time of learning, risk taking, development of habits, behavior, and lifestyles. Many of the health-related behaviors that arise during adolescence have implications for both present and future health development. Kulbok and Cox (2002) mention that the adolescent health behavior dimension is related to eating, sleeping, and exercise habits. Other primary factors that determine health behavior are gender, family structure, ethnicity, knowledge and attitudes. The American Dietary Guidelines Advisory Committee (2015) also highlights three behaviors that are very important to supporting health, namely eating a nutritious diet, being active, and getting a good night's sleep. A number of studies on health behavior have focused on eating and exercise (Ganasegeran et al., 2012;Hsu, Chiang, & Yang, 2014). The present study on health behavior took into consideration eating habits, exercise and sleeping patterns among adolescents.
Health behavior is influenced by multiple external and internal factors (Pate et al., 2013;Story, Neumark-Sztainer, & French, 2002;Viner et al., 2012). External factors include culture and environment, while internals factors include attitudes, perceived control, and subjective norms. Past research has also considered personal factors such as experiences, education, knowledge, personality and self-construal, values, world view, age, gender and chosen activities (Gifford & Nilsson, 2014). For this study, three personal factors, namely attitude, culture, and motivation were examined.

Attitude and health behavior
People's beliefs concerning their current and future health, and their level of health knowledge would modify their attitude towards health behavior. According to Ajzen and Madden (1986), attitudes towards behavior include beliefs and evaluations about outcomes of their state of health. Together with subjective norms (which concern beliefs about attitudes of others to health behavior and motivation to comply with others), attitude towards health behavior and perceived behavioral control shape an individual's behavior and behavioral intentions.
According to WHO (2013), health is defined as 'a status of physical, mental and social comfort and it is not only the absence of an illness' . With the definition in mind, important concepts of attitude to health can be streamed into three basic groups: (1) medical attitude focused on an illness; (2) bio-psychosocial attitude stressing the interconnection of physical, mental and social components; and (3) attitude focused on quality of health and illness from the viewpoint of everyday experience of an individual. In this study, the components of attitude to health include awareness of the importance of health as well as factors that support and threaten health. According to some researchers, attitudes towards health based on direct experience are more persistent or more likely to influence later behavior (Glasman & Albarracín, 2006).

Culture and health behavior
Culture, defined as what is learned, transmitted inter-generationally and shared or reflected in the values, behaviors, beliefs, norms, communication, and social roles of a community, can affect health-related behaviors both directly and indirectly (Kreuter & Haughton, 2006;Napier et al., 2014). Current literature on culture and health behavior is very limited. However, interest in culture is growing owing to numerous findings that an individual's or a group's cultural context is essential for targeting health behavior change and decreasing health disparities (Higgins, 2014;Kaplan, 2014).
Cultural influence refers to the degree to which values, beliefs, norms, and traditions of a particular group affect the behavior of individual members of the group (Riekert, Ockene, & Pbert, 2013). Culture can shape behavior through its influence on values, beliefs, and traditional roles. Social customs impact on what people see as acceptable and desirable behavior. Malaysian Dietary Guidelines and Health Diary (Ministry of Health Malaysia, 2013) suggest that the community can promote an active lifestyles to the adolescence by community-wide campaigns to spread physical activity messages to youth and families through television, radio, newspapers and billboards. This continuous public education will increase and encourage the adolescence to be an active towards of healthy behavior. The potential influence of health-related culture on health itself is vast. It affects perceptions of health, illness and death, beliefs about causes of disease, approaches to health promotion, how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer. Hence, the effect of cultural systems of values on health outcomes is huge, within and across cultures, in multi-cultural settings, and even within the cultures of institutions established to advance health (Sallis, Owen, & Fisher, 2015). In all cultural settings, be they local, national or worldwide, there is the need to understand the relationship between culture and health.

Motivation and health behavior
Health motivation independently influences individuals' preventive health behavior. In their theoretical research on human motivation, Xu (2009) define health motivation as being 'characterized by a strong desire to exercise, to eat well, to live in a healthy environment, to stay in shape and to be calm and restful while sleeping well, and to avoid stress' . Health motivation activates individuals and drives them to pursue health-promoting behavior which are seen as important goals or values (Celsi & Olson, 1988). Health motivation also moderates the impact of health ability (knowledge, skills, or resources) on health behavior. In other words, a motivated individual is more likely to use his health ability to improve his health behavior. As adolescents become adults, they are less dependent on their parents for the outcome of their future health. They focus more on their own actions as influenced by their beliefs, goals, motives and feelings to develop their health behavior. According to Issner, Mucka, and Barnett (2017), the self-determination theory could explain the intrinsic motivations for health behavior among the youth.
There are three psychological needs, namely autonomy, competence and relatedness, which are motivational key factors that support the values of behavior or health practice. For example, in autonomy motivation, someone may exercise because of the value to his health, but perhaps also because he is the president of the health association in school. He would feel guilty if he does not engage in health activity. Competence involves the need of the adolescent to achieve set goals to attain or maintain health. It compels the adolescent to take action and make decisions towards health care. Finally, relatedness explains the need to be close to others. As mentioned by Bronfenbrenner (2009), parents, peers, neighbors and school affect adolescent behavior. For example, adolescents living in a community that promotes an exercise campaign to combat obesity may also start their own exercise regime to identify with or relate to others in the community in its effort to promote positive health behavior. When adolescents are able to relate to others in the community and feel satisfaction in the process of doing so, they are more likely to behave in a manner in keeping with the expectations of those in their surroundings. The present study sought to investigate how and to what extent motivation predicted health behavior.

Conceptual framework
Within the framework of health behavior theories, research has shown that attitude, culture and motivation influence health behavior. The health belief model, introduced by Rosenstock (1974), contends that health behavior is determined by the individual's views on diseases as well as strategies to reduce illnesses. The individual's views are influenced by intrapersonal factors categorized as: (1) perceived susceptibility, (2) perceived severity, (3) perceived benefits, (4) perceived barriers, (5) cues to action, and (6) self-efficacy.
According to the Health Belief Model (Becker, 1974;Janz & Becker, 1984), a person who has no illness may not make any effort to improve knowledge concerning his health. Therefore, adolescents should be encouraged to participate in health awareness programs and activities to help them face the reality that it is possible to fall seriously ill, or catch a disease anytime and even succumb to it. Hence, they should be taught how to take proactive steps ensure that they enjoy good health for as long as possible. Lower levels of literacy in health matters would result in poor health and susceptibility to disease. In this regard, the social media and print media can play important roles in health literacy awareness programs. Various impediments to participating in health literacy awareness programs and activities need to be resolved. The health literacy measurement model can be used to encourage adolescents who are still lacking self-confidence to improve their own health.
Much research has been devoted to establishing relationships between certain health practices (behavior) and health status. Efforts have been made to examine the factors which influence the continuance of health behavior. From the literature, it is apparent that the interactions of the individual with social and environmental factors have a bearing on personal inclination (colored by culture, attitude and motivation) to adopt healthier behavior as well as to eliminate behavior tied to risks. Hence, this study was aimed at investigating how culture, attitude, and motivation influenced health behavior of adolescents ( Figure 1).
This study tested the following hypotheses: Hypothesis 1 (H1): Culture is positively related to health behavior.
Hypothesis 2 (H2): Attitude is positively related to health behavior.
Hypothesis 3 (H3): Motivation is positively related to health behavior.
Hypothesis 4 (H4): Culture, attitude and motivation act together to influence health behavior.

Population and sample
The target population for this study was adolescents in secondary schools between the ages of 15-17 years. Two phases of sampling techniques were used in selecting the respondents. In the first sampling phase from January to March 2017, the cluster sampling technique was used to select 13 out of 73 high-performance secondary schools in Selangor and Kuala Lumpur Federal Territory that had a total enrolment of about 100,000 students. After receiving approval from the Ministry of Education, letters seeking permission to conduct the survey were sent to the principals of the high-performance secondary schools. The final selection of the 13 schools was based on the favorable responses from the principals within the survey period. In the second sampling phase, students ranging from 15 to 17 years (M age = 15.9, SD = .637) were selected as respondents in a structured systematic sampling. The population size (N) for this study was 4116 students. The sample of 1029 students participated in this study. To select 1029 of these, we therefore needed to sample one in every four students. Teachers who was assigned by the principal of the school, helped the researcher with the name list of the students and called to participate in this study.
A survey was carried out among the selected students following verbal consent from the respondents who were assured that the information given by them would be kept confidential and anonymized. A small token was offered to participants to encourage participation and cooperation.

Dependent and independent variables
The selection of the variables was based on past research supported by empirical findings of the relationship between health behavior, culture, attitude and motivation. In this study, the dependent variable was health behavior and it was operationalized as the ability to perform knowledge-based health literacy tasks. The health behavior scale was also designed based on past research in the literature (Garcia & McCarthy, 1996;Vreeman, McHenry, & Nyandiko, 2013) and the reference standard was based on the Malaysian Dietary Guidelines and Health Diary (Ministry of Health Malaysia, 2013) recommendations for eating habits, exercise and cleanliness. This study investigated the action taken by the participants to maintain or improve their health, and required them to respond to 12 statements for dependent variable including the following statement: Items for habits: 'Breakfast is important to me' , 'I eat according to a meal schedule' , 'I really emphasize fruit intake in my diet' , 'I eat a variety of foods' , and 'I really emphasize vegetable intake in my diet' , 'Items on exercise: 'I work out 3 times a week' , 'I have quality sleep every night' , 'I engage in outdoor activities everyday' , and 'I begin to take care of my health from home' , and 'Items on cleanliness: 'I brush my teeth after each meal' , 'I frequently wash my hands thoroughly' , and 'I take a shower every day' . Participants responded to the survey questions on a 5-point Likert scale 1 = Strongly Disagree, up to 5 = Strongly Agree). High scores in the respective dimensions would indicate more balanced eating habits, exercise and cleanliness.
Next, the respondents were requested to indicate their responses to independent variable statements which reflect their culture including values, beliefs and social customs related to common or acceptable health practices. In this study, the culture scale was based on the Malaysian Dietary Guidelines and Health Diary (Ministry of Health Malaysia, 2013) and the indicators of health behavior were from Azzopardi, Kennedy, and Patton (2017). Eight items were selected, a sampling of which are as follows: 'I take care of my heath' , 'I am always positive about my health' , 'I have high self-worth on personal health' , 'I practice good health behavior' , 'I begin to take care of my health from home' , 'I have a good emotional health' , 'I have a strong passion to become a healthy generation' , and 'My diet is consistent with my health culture' .
In this study, the researchers adapted the research instrument for the Adolescent Health Attitude and Behavior Survey (Reininger et al., 2003) that measures risk behavior, attitudes towards adolescent behavior and youth developmental assets. This instrument also reflects individual, environmental and behavioral factors described in Bandura's Social Cognitive Theory (Bandura, 1998). There are 10 statements for independent variable, attitude towards health were asked, including: 'I am very health conscious' , 'I really put an emphasis on being physically healthy' , 'I really put an emphasis on being mentally healthy' , 'I realize that smoking is harmful to health' , 'I reduce eating unhealthy food' , 'I really emphasize having a balanced diet' , 'I am capable of controlling my appetite' , 'I have good emotional health' , 'I have a strong passion to be part of a healthy generation' , and 'I am knowledgeable about health' .
For the motivation independent variable, this study adapted the questionnaire from Xu (2009). Seven items that measured health motivation were asked as follows: 'I will take appropriate action to achieve my health-related goals' , 'I know my health problems' , 'I am concerned about my health condition' , 'I am concerned about my mental health' , 'I take preventive measures to avoid contracting diseases' , 'I am concerned about the rising rates of chronic illnesses among adolescents' , and 'I am motivated to perform physical activities to be healthy' .
A pilot study was conducted to assess the reliability of the instrument for which alpha values .934 were obtained. For this study, only content validity was employed. An assumption here is that a good working definition of the construct had been developed within which to frame the evaluation of the appropriateness of the content of the instrument. The questionnaire was adapted from those used by past researchers.

Statistical analysis
The results were analyzed using the SPSS version 23.0. A descriptive analysis was used to summarize the level of health behavior, culture, attitude and motivation of the respondents. The relationship between culture, attitude or motivation and the adolescent's health behavior was determined by the Pearson Product Moment Correlation. The extent by which culture, attitude and motivation collectively influenced health behavior among adolescents was assessed by multiple linear regressions.

Descriptive analysis
A total of 1029 Malaysian adolescents participated in the study. Their ages ranged from 15 to 17, with a mean age of 15.9. The respondents consisted of 38.9% males and 60.2% females. Most of the respondents were Malays (75.2%), while Indians (12.9%) and Chinese (12.2%) made up the remainder. More than half of the respondents were from city residential schools (62.5%) and sub-urban (26.3%) schools.
When respondents were asked about their health status, more than half declared that they were healthy (66%), or very healthy (20%). A small group (14%) stated that they were unhealthy (Table 1). Table 2 gives the descriptive characteristics of the subscales measuring the influence of culture, attitude and motivation on adolescent health behavior. Mean scores on the subscales ranged from 3.6 to 4.00 on a five-point Likert scale. Descriptive results also indicated that the respondents used all the response options available, thus decreasing the likelihood of subscales being skewed. Standard deviations ranged from .59 to .71. As shown in Table 2, the level of adolescent health behavior was high (M = 3.697; SD = .590). All three personal factors that influenced health behavior also showed high mean scores, the highest scores being for motivation (M = 4.033; SD = .717), followed by attitude (M = 3.766; SD = .609) and culture (M = 3.713; SD = .655).

The influence of culture, attitude and motivation on health behavior
The relationships of the three factors (culture, motivation, and attitude) influencing health behavior were evaluated by the Pearson Product-Moment correlation coefficients. Preliminary analyses were performed to ensure that there were no violations of the assumptions of normality and linearity. The result of the analysis showed that all factors were significantly correlated. As depicted in Table 3, the strongest linear relationship was found between culture and health behavior (r = .618, p = .0001). The results also showed positive significant correlations between attitude and health behavior (r = .601, p = .0001) and between motivation towards health behavior (r = .431, p = .0001). These results indicated that hypotheses H1, H2, and H3 were supported. Table 4 association resents the results of the multiple regression analysis, where the contribution to health behavior by the three independent variables are shown. H1 was supported, as culture was positively associated with health behavior (β = .365, p < .000). H2 was also supported as health behavior was positively related to attitude (β = .283, p < .000). Finally, H3 was supported as motivation reached statistically significant (β = .064, p < .033) towards health behavior. The unique variance of health behavior attributable to the three independent variables taken in combination was 42% (ΔF = 30.58, p < .001).

Discussion
The hypothesis proposed at the beginning of the study was that culture, attitude, and motivation were associated with health behavior, and that these variables might interact to predict higher levels of health behavior. The hypothesis was supported. The results for all three dimensions of personal factors showed consistency with past research (Glasman & Albarracín, 2006;Hsu et al., 2014;Sallis et al., 2015;Xu, 2009). The respondents who had higher levels of attitude, culture and motivation towards health tended to have more positive health behavior. It appeared that secondary school students who had better health education showed much concern for their own health. The Malaysian Ministry of Education, together with the Ministry of Health, introduced health education as a school subject since 1976, and health education thus became part of the school health service activities. The main purpose of the service is to ensure health care is maintained through community involvement. This effort has helped adolescents in Malaysian schools to practice good health behavior. In a similar finding, Hutchinson, Carton, Broussard, Brown, and Chrestman (2012) note that health services help adolescents make successful transitions to adulthood. The findings of the study also showed majority of the respondent were reported that they are healthy and very healthy. In this study, researchers were defined healthy according to WHO, the absence of an illness. It is in line with the effort of Ministry of Health, with the Primary Health Care program which offer the services to all community including adolescence. Consequently, the successful Primary Health Care Program for this group were setting interdisciplinary and intersectoral, and taking into account their physical condition, and also their personal, social, emotional and mental development. In addition, factors that influence the health of adolescence are interrelated. As mentioned earlier by Napier et al. (2014), cultures are transmitted inter-generationally with social roles that are shared and reflected in a group. Two of the statements agreed by most of the respondents were 'I begin to take care of my health from home. ' and 'My diet is consistent with my health culture. ' The findings in this study support the ecological theory of Bronfenbrenner (2009) whereby adolescent behavior is influenced by the macro and micro environment systems. Social agents in the microsystem including family, school, neighborhood and environment impact the relationship from two directions, i.e. from the adolescent to the environment, and vice versa. Therefore, adolescents who are more open to and connected with his culture are more likely to engage in healthy behavior.
Previous studies have frequently described the influence of attitude on health behavior. As mentioned by Glasman and Albarracín (2006), attitudes towards heath are based on direct experience. In this regard, the majority of the respondents in this study agreed with these statements 'I really put an emphasis on being physically healthy' and 'I really put an emphasis on being mentally healthy. ' Bandura (1998) holds the view that attitudes are learned through imitation and modelling. In this study, adolescents who stayed with their parents would be influenced by the attitudes of their parents and family members. In addition, the researchers of this study also observed that living in the city exposed adolescents to greater impact of the social media campaigns. The message of the campaigns that were typically oriented toward health awareness and the adoption of good health care habits benefited particularly adolescents who lived in the city.
The findings in the present study also showed motivation as being one of the personal factors positively influencing health behavior. This result is in line with the previous study by Xu (2009) who found that motivation encouraged a strong desire for individuals to practice health-related activities. Furthermore, the majority of the respondents agreed with the statement 'I am motivated to perform physical activities to be healthy. ' Other studies also confirm that the motivation raises awareness of health risks arising from past behavior by looking at several factors such as self-efficacy (Fitzpatrick & McCarthy, 2014).

Limitations
This study is limited by the fact that cross sectional data was used. Although the findings showed positive associations among variables, the variance in health behavior that was explained by the independent variables was only 42%. Future longitudinal studies would be helpful to understand better these interrelationships and to test extended hypotheses. This study is also limited by the use of a student sample which may not be generalized to other groups of adolescents. Future research should consider more diverse samples.
The findings may have an implication for designing intervention programs to improve health-related behaviors among adolescents. Many of the health-related activities carried out in Malaysian schools lack focus on specific goals such as culture, attitude, and motivation. To date, health-related services available in Malaysian school can be divided into three main components, namely school health service, school dental service, and school environmental health service. Given the importance of culture, attitude, and motivation to improving health behavior, these three components should be embedded in intervention programs introduced in schools.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by Ministry of Higher Education Malaysia (5524765).

Notes on contributors
Siti Rabaah Hamzah, PhD, is a senior lecturer at University Putra Malaysia. Her research interests on youth resource development. She conducts research on youth and volunteerism, youth and leadership, youth and health, and youth and organization. She has published numerous articles in international journals. She was the editor for the International Journal of Education and Training and Editorial Board member for Environment & Social Psychology journal.
Turiman Suandi, PhD, is a professor at University Putra Malaysia. He has dedicated 40 years of his life in pursuing the field of Youth and Professional Development as a field of study and practice. Presently, he is the resource fellow and consultant to the Ministry of Youth and Sports Malaysia, and has provided the lead in several researches on youth development and volunteerism.
Maimunah Ismail, PhD, is professor in human resource development (HRD) at Universiti Putra Malaysia. Her research interests include career development, community development, and gender studies. She has authored 12 books and numerous articles in international journals. She sits on the Editorial Advisory Board of Human Resource Development International, European Journal of Training and Development, Gender in Management, Organizations and Markets in the Emerging Economies, and Advances in Human Resource Development. She is a member of the Academy of HRD and the British Academy of Management.
Zulaiha Muda is a consultant paediatric haematologist-oncologist. She is the head of Paediatric Haematology Oncology unit at Institute Paediatric Hospital Kuala Lumpur, Malaysia. Her research interests focuses on childhood cancer clinical manifestation and management. She is one of editorial board members for Kuala Lumpur Hospital Journal of Quality Improvement. She has published widely on paediatric oncology and haematology diseases locally and internationally.