Poor health literacy (HL) is a risk factor for developing metabolic syndrome. In Malaysia, about 93% of adults' population has limited HL-a huge prevalence yet understudied phenomenon. This study aims to determine the predictors of preventive lifestyles on metabolic syndrome among adult population in Sarawak are timely. This was a population-based study, conducted from September 2016 till December 2017 using a multistage stratified sampling method. Health Literacy Scale and Simple Lifestyle Indicator Questionnaire were used to measure health literacy and preventive lifestyles respectively. Analysis of Variance and logistic regression were used to analyze the data. A total of 743 respondents were involved in this study with half of them have acceptable score for health literacy (M = 46.9, SD = 6.3) and good preventive lifestyles (M = 7.3, SD = 1.4). Critical health literacy was a significant influence of preventive lifestyles. The Malay ethnic group has the highest scores for both critical health literacy [F (3, 739) = 17.82, p < 0.001] and preventive lifestyle compared to other ethnic groups [F (3, 739) = 3.12, p = 0.025]. The other Native groups scored the lowest for critical health literacy. Individual with higher score of critical health literacy tend to perform physical activities. Gender, education level, distance of health facilities, critical health literacy and employment status were identified as predictors for preventive lifestyle in this study. Health literacy is a key to preventive lifestyle behaviors in metabolic syndrome among adult population in Sarawak. Future program should focus on improving HL status with specific program targeting ethnic minorities.

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.