Digital Education to Limit Salt in the Home (DELISH) Program Improves Knowledge, Self-Efficacy, and Behaviors Among Children

Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia

OBJECTIVE

In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention.

DESIGN

Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models.

SETTING

Victoria, Australia.

PARTICIPANTS

Children aged 4-12 years.

RESULTS

Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged.

CONCLUSION

These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

An mHealth-based school health education system designed to scale up salt reduction in China (EduSaltS): A development and preliminary implementation study

Background

High-salt diet is an important risk factor for several non-communicable diseases. School-based health education has been found effective in reducing salt intake among children and their families in China. However, no such interventions have been scaled up in the real world. For this purpose, a study was launched to support the development and scale-up of an mHealth-based system (EduSaltS) that integrated routine health education and salt reduction and was delivered through primary schools. This study aims to elaborate the framework, development process, features, and preliminary scaling-up of the EduSaltS system.

Methods

The EduSaltS system evolved from previously successfully tested interventions to reduce family salt intake by empowering schoolchildren through school health education. EduSaltS was designed by following the WHO's conceptual framework for developing a scaling-up strategy which accounted for the nature of the innovation, the capacity of the implementing organizations, the characteristics of the environment, the resources available, and type of scaling up. The system was then developed step by step from determination of online platform architecture, definition of component interventions and activities, development of specific educational materials and tools, to the development of the online/offline hybridized system. The system was tested and refined by a pilot in two schools and a preliminary scale-up in two cities in China.

Results

EduSaltS was developed as an innovative health education system, including an online WeChat-based education platform, a set of offline activities, and an actual administrative website showing the progress and setting the system. The WeChat platform could be installed on users' smartphones to automatically deliver 20 sessions of five-minute well-structured cartoon video classes, followed by other online interactive activities. It also helps support project implementation and real-time performance evaluation. As a first-stage roll-out, a one-year course has been successfully implemented among 54,538 children and their families from 209 schools in two cities, and the average course completion rate was 89.1%.

Conclusion

As an innovative mHealth-based health education system, EduSaltS was developed based on successfully tested interventions and an appropriate framework for scaling up. The early-stage roll-out has shown its preliminary scalability, and further evaluation is ongoing.

The effect of Augmented-Reality media-based health education on healthy lifestyle knowledge, attitude, and healthy lifestyle behaviors among pregnant women during COVID-19 pandemic in Jakarta, Indonesia

Pregnancy is a critical period. Pregnant women need to perform healthy lifestyle behavior in order to ensure good fetal development. During COVID-19 pandemic, Augmented-Reality (AR) media may be used in pregnant women health education. However, there is a lack of research that investigated the effect of AR media use in pregnant women health education. Therefore, this research aimed to investigate the impact of AR media use on healthy lifestyle knowledge, attitude, and behaviors among pregnant women during COVID-19 pandemic. This cohort-longitudinal study involved 86 pregnant women aged 18-45 years. The subjects who participated in this research received health education interventions using AR media for 5 months. The data collection was performed at the pre-post-intervention through a survey with questionnaire. Changes in subjects' healthy lifestyle knowledge, attitude, and behaviors were analyzed by using t-test. The research results show that the AR media use in health education significantly improved the subjects' scores for healthy lifestyle knowledge (5.0 ± 10.9; p < .05) and behaviors (9.7 ± 17.5; p < .05). However, the subject score for attitude was not significantly improved (0.3 ± 7.1; p ≥ .05). This research results provide evidence of the importance of using AR media in health education for pregnant women during COVID-19 pandemic.

Effects of computer-based interventions on food consumption and anthropometric parameters of adolescents: A systematic review and metanalysis

This review aimed to systematically assess the effects of computer-based interventions for the promotion of healthy eating on anthropometric indicators and food consumption of adolescents at school. Relevant scientific articles were searched in MEDLINE/PubMed, Embase, Scopus, Lilacs, PsycINFO and Cochrane Library/CENTRAL following the recommendations by PRISMA guide in August 2021. The quality and risk of bias in the studies were assessed by two reviewers independently. The search strategy retained 13 studies for qualitative analysis. In total 9.603 adolescents of both sexes, were recruited in a school environment. According to studies with information for the meta-analysis, a reduction in the average consumption of fats in favor of computer-based intervention was identified (SMD: -0.14; 95% CI -0.24;-0.05). Considering the changes in the consumption of fruits and vegetables (SMD: 0.09; 95% CI -0.08; 0.26) and in the BMI (WMD: -0.02; 95% CI -0.18; 0.14), the analyses did not identify the effect of computer-based interventions on these parameters after follow-up. The results of this review demonstrate that there is evidence of the positive effect of using digital technology (website and CD-ROM) in educational programs with a focus on promoting a healthy lifestyle, with evidence on reducing fat consumption.

A model of digital health communication media use during the Covid-19 pandemic

Purpose

This research aims to develop and test a model of digital health communication media (DHCM) use for healthy food information – DHCM usage – during the Covid-19 pandemic. More specifically, this research investigated the simultaneous effects of perceived threat of Covid-19, e-health literacy, attitude toward DHCM usage, knowledge toward DHCM usage, facilitating conditions and information quality on the DHCM usage.

Design/methodology/approach

The empirical data were collected through a survey. The respondents of the survey are 192 DHCM users who lived in Tangerang Regency. Structural equation modelling (SEM) analysis was performed.

Findings

The DHCM usage during the Covid-19 pandemic is significantly affected by the attitude towards the DHCM usage and the facilitating conditions. However, the DHCM usage during the Covid-19 pandemic is not significantly affected by the perceived threat of Covid-19, e-health literacy, information quality and knowledge of the DHCM usage.

Research limitations/implications

This research was conducted only in Tangerang Regency and employed a purposive sampling technique. Future research should be conducted in other contexts to examine the stability of the research findings.

Practical implications

In order to improve DHCM usage for healthy food information, it is important for building a positive attitude towards DHCM usage and ensuring the availability of the facilitating conditions.

Originality/value

This paper is the first that develops and tests a model of DHCM usage for healthy food information during the Covid-19 pandemic.

The Promotion of Eating Behaviour Change through Digital Interventions

Diet-related chronic disease is a global health epidemic giving rise to a high incidence of morbidity and mortality. With the rise of the digital revolution, there has been increased interest in using digital technology for eating behavioural change as a mean of diet-related chronic disease prevention. However, evidence on digital dietary behaviour change is relatively scarce. To address this problem, this review considers the digital interventions currently being used in dietary behaviour change studies. A literature search was conducted in databases like PubMed, Cochrane Library, CINAHL, Medline, and PsycInfo. Among 119 articles screened, 15 were selected for the study as they met all the inclusion criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search strategy. Four primary digital intervention methods were noted: use of personal digital assistants, use of the internet as an educational tool, use of video games and use of mobile phone applications. The efficiency of all the interventions increased when coupled with tailored feedback and counselling. It was established that the scalable and sustainable properties of digital interventions have the potential to bring about adequate changes in the eating behaviour of individuals. Further research should concentrate on the appropriate personalisation of the interventions, according to the requirements of the individuals, and proper integration of behaviour change techniques to motivate long-term adherence.

A qualitative investigation of school age children, their parents and school staff on their participation in the Digital Education to LImit Salt in the Home (DELISH) program

This study explored the views of participants who completed a 5-week, online, interactive, family-based, salt reduction education program (Digital Education to LImit Salt in the Home). A secondary aim was to explore the views of school staff on the delivery of food and nutrition education in schools. Children aged 7-10 years, their parents and principals/teachers from participating schools located in Victoria, Australia, completed a semi-structured evaluation interview. Audio-recordings of interviews were transcribed verbatim and analysed using NVivo. Twenty-eight interviews (13 children; 11 parents; 4 school staff) were included. Thematic analysis revealed that the program was well received by all groups. Children reported that the interactivity of the education sessions helped them to learn. Parents thought the program was interesting and important, and reported learning skills to reduce salt in the family diet. School staff supported the delivery of nutrition education in schools but indicated difficulties in sourcing well-packed nutrition resources aligned with the curriculum. It appears that there is support from parents and teachers in the delivery of innovative, engaging, nutrition education in schools, however such programs need to be of high quality, aligned with the school curriculum and readily available for incorporation within the school's teaching program.

Factors that contribute to effective online nutrition education interventions: a systematic review

CONTEXT

The use of the internet and technology as a medium for delivering online nutrition education (ONE) has increased; however, evidence-based studies exploring factors that contribute to best practices in online interventions have not emerged.

OBJECTIVE

The purpose of this systematic review was to identify factors that contributed to successful ONE interventions in relation to research studies published between 2009 and 2018.

DATA SOURCES

Following the PRISMA guidelines, relevant studies were identified through PubMed, Medline, Web of Science, Science Direct, and Education Resources Information Center (ERIC) databases.

DATA EXTRACTION

Five authors screened and determined the quality of the studies using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and extracted the data from the articles.

DATA ANALYSIS

Twenty-seven studies were included: 21 studies were website-based, 3 were delivered through smartphone application, 2 were delivered as online courses, and 1 used text messages. Tailored messages/feedback, interaction between participants and investigators, identification of specific behaviors, use theory, adequate duration, and alignment between stated objectives and activities were factors that contributed to successful online interventions, while comparison bias and the lack of specific details on duration and dosage, tracking system, objective outcome measurements, and follow-up were factors that may have interfered with successful ONE interventions.

CONCLUSIONS

The findings underscore the importance of developing ONE intervention designs that utilize factors unique to online platforms for effective interventions aimed at behavior change.

A systematic evaluation of digital nutrition promotion websites and apps for supporting parents to influence children's nutrition

Background

Globally children’s diet quality is poor. Parents are primary gatekeepers to children’s food intake; however, reaching and engaging parents in nutrition promotion can be challenging. With growth in internet and smartphone use, digital platforms provide potential to disseminate information rapidly to many people. The objectives of this review were to conduct a comprehensive and systematic evaluation of nutrition promotion via websites and apps supporting parents to influence children’s nutrition, from three different perspectives: 1) current evidence base, 2) end user (parent) experience and 3) current commercial offerings.

Methods

Three systematic reviews were undertaken of (1) studies evaluating the effectiveness for digital platforms for improving nutrition in children and parents, (2) studies conducting user-testing of digital tools with parents, (3) websites and apps providing lunch-provision information to parents. Searches were conducted in five databases for reviews one and two, and systematic search of Google and App Store for review three. Randomised controlled trials, cohort and cross-sectional and qualitative studies (study two only) were included if published in English, from 2013, with the intervention targeted at parents and at least 50% of intervention content focused on nutrition. Search results were double screened, with data extracted into standardised spreadsheets and quality appraisal of included search results.

Results

Studies evaluating digital nutrition interventions targeting parents (n = 11) demonstrated effectiveness for improving nutrition outcomes, self-efficacy and knowledge. Six of the included randomised controlled trials reported digital interventions to be equal to, or better than comparison groups. User-testing studies (n = 9) identified that digital platforms should include both informative content and interactive features. Parents wanted evidence-based information from credible sources, practical tools, engaging content and connection with other users and health professionals. Websites targeting lunch provision (n = 15) were developed primarily by credible sources and included information-based content consistent with dietary guidelines and limited interactive features. Lunchbox apps (n = 6), developed mostly by commercial organisations, were more interactive but provided less credible information.

Conclusions

Digital nutrition promotion interventions targeting parents can be effective for improving nutrition-related outcomes in children and parents. As demonstrated from the lunchbox context and user-testing with parents, they need to go beyond just providing information about positive dietary changes, to include the user-desired features supporting interactivity and personalisation.

The Digital Education to Limit Salt in the Home Program Improved Salt-Related Knowledge, Attitudes, and Behaviors in Parents

Background

Currently, Australian children and adults are eating too much salt, increasing their risk of cardiovascular-related conditions. Web-based programs provide an avenue to engage the parents of primary schoolchildren in salt-specific messages, which may positively impact their own salt-related knowledge, attitudes, and behaviors (KABs).

Objective

This pilot study aimed to determine whether parents’ salt-related KABs improved following participation in the Digital Education to LImit Salt in the Home (DELISH) Web-based education program.

Methods

The DELISH program was a 5-week, home-delivered, Web-based intervention, with a pre- and posttest design, targeting schoolchildren aged 7 to 10 years and their parents. Parents received weekly Web-based educational newsletters and text messages and completed online pre- and postprogram surveys assessing salt-related KABs. Upon completion of the program, all parents were also invited to complete an online evaluation survey. Changes in KABs outcomes were assessed using McNemar tests and paired t tests.

Results

Of the 80 parents that commenced the program, 73 parents (mean age 41.0, SD 7.0 years; 86% (63/73) females) completed both pre- and postsurveys. Overall, mean score for salt-related knowledge improved (+3.6 [standard error (SE) 0.41] points), and mean behavior score also improved (+4.5 [SE 0.61] points), indicating a higher frequency of engaging in behaviors to reduce salt in the diet, and mean attitude score decreased (−0.7 [SE 0.19] points), representing lower importance of using salt to enhance the taste of food (all P<.001). Following participation, the proportion of parents aware of the daily salt intake recommendation increased from 40% (29/73) to 74% (54/73) (P<.001), and awareness of bread as the main source of salt increased from 58% (42/73) to 95% (69/73) (P<.001). The proportion of parents who agreed that salt should be used in cooking to enhance the flavor of food decreased from 30% (22/73) to 11% (8/73) (P=.002) and the proportion who agreed that sodium information displayed on food labels was difficult to understand decreased from 52% (38/73) to 32% (23/73) (P=.009). There was a reduction in the proportion of parents who reported adding salt during cooking (55% [40/73] vs 41% [30/73]; P=.03) and at the table (32% [23/73] vs 18% [13/73]; P=.002). Of the 16 parents who completed the evaluation survey, 75% (12/16) enjoyed the program, and all parents found the newsletters to be useful. Almost all parents (15/16, 94%) agreed that the DELISH program would be useful to other parents.

Conclusions

The improvement in salt-related KABs in the DELISH program indicates the potential for online technology, to disseminate simple salt reduction education messages to families with primary school–aged children. Future work should seek to improve the quality of data collected by including a larger sample size and a control group to integrate the program within the school setting to enable wider dissemination.

Salt Preference and Ability to Discriminate between Salt Content of Two Commercially Available Products of Australian Primary Schoolchildren

Australian children consume too much salt, primarily from processed foods where salt is often used to enhance flavour. Few studies have assessed children's salt preference in commercially available foods. This study aims to assess (1) children's preference and ability to discriminate between salt levels in two commercially available foods and (2) if preference or ability to discriminate between salt levels changes after an education program. Chips and corn flakes were tasted at three levels of salt concentration. Children ranked which they liked best (preference) and which was saltiest (ability to discriminate). The proportion of children across categorical responses was assessed (Chi squared and McNemar's test) together with changes in preference and ability to discriminate between salt levels from timepoint 1 (T1) to timepoint 2 (T2). Ninety-two children (57% female, mean age 9.1 years (SD 0.8)) participated. At T1 approximately one-half and two-thirds of children preferred the highest salt chip and cornflake, respectively, (both p < 0.05). Fifty-seven percent and 63% of children identified the highest level of salt in chips and cornflakes as the saltiest, respectively. Preference and ability to discriminate between salt levels were unchanged between timepoints. Results support product reformulation to decrease salt content of foods provided to children.