The Development of a Web-Based Program to Reduce Dietary Salt Intake in Schoolchildren: Study Protocol

Assessing Dietary Salt Intake and Pilot-Testing a Home-Based Intervention to Lower Salt Intake Among Filipino College Students

PURPOSE

To assess the knowledge, attitude, and behaviors related to dietary salt intake and develop a home-based intervention that helps lower salt intake among Filipino college students.

DESIGN

Two-phase program development study utilizing descriptive and quasi-experimental design.

METHODS

Phase 1 determined the knowledge, attitude, and behaviors alongside the frequency of dietary salt intake of a consecutive sample (n = 118). Phase 2 involved the development and pilot-testing of a home-based intervention wherein a random sample (n = 35) selected from Phase 1 joined for pilot-testing. The study was conducted from October - November 2021 and utilized valid and reliable measures to test the knowledge, attitude, and behavior of the participants.

FINDINGS

Initial assessment showed knowledge regarding health risks of high salt intake and positive attitude toward health-promoting behaviors. Post-intervention showed improvement in attitude (p = 0.0004) and behavior (p = 0.001) related to dietary salt intake alongside health literacy (p = 0.036). There was no significant change in knowledge (p = 0.054).

CONCLUSION

The home-based intervention involving the use of health education materials is successful in improving dietary salt intake patterns.

CLINICAL EVIDENCE

Community health nurses may utilize home-based interventions to help develop health-promoting behaviors among young adults.

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.

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.

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.

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

OBJECTIVE

To determine the efficacy of a Web-based salt reduction program on children's salt-related knowledge, attitudes, and behaviors (KABs), self-efficacy, and intake of dietary salt.

DESIGN

Pretest and posttest. An online survey determined KABs and self-efficacy and a 24-hour urine collection revealed salt intake.

SETTING

Victoria, Australia.

PARTICIPANTS

Child-parent dyads (n = 102) recruited from 5 government schools.

INTERVENTION

A 5-week behavior-based education program delivered via weekly online interactive education sessions.

MAIN OUTCOME MEASURES

Change in KABs, self-efficacy, and daily salt intake.

ANALYSIS

Changes in outcomes were assessed using McNemar test, paired t test, and Cohen's δ (CD).

RESULTS

A total of 83 children participated (mean age, 9.2 years [SD, 0.8 years]; 59% girls); 35% to 76% of children viewed weekly education session. Children with complete survey data (n = 75) had improved scores for salt-related knowledge (+3.6 ± 0.4 points; P < .001; CD: 1.16), behaviors (+1.3 ± 0.1 points; P < .001; CD: 1.08), and self-efficacy (+0.9 ± 0.2 points; P < .001; CD: 0.64), but not attitude. Children with valid urine collections (n = 51) showed no change in salt intake.

CONCLUSIONS AND IMPLICATIONS

Participation resulted in improvement of salt related knowledge, self-efficacy and behavior. Further research is required to confirm these results using a more robust study design which includes a control group. In addition, the long term impact on children's salt intakes of comparable education programs needs to be assessed.

Sodium Content of Lunches and Snacks Provided in Australian Long Day Care Centres: A Cross-Sectional Study

We determined the average amount of sodium provided in lunches and snacks and the average amount of sodium consumed at lunch in a convenience sample of Australian preschool children attending Long Day Care (LDC). Sodium content of lunches and snacks was determined from standardised recipes. Individual children's sodium intake was estimated by a validated visual plate waste scale method. Five recipes (lunch n = 35, snacks n = 70) collected from 7 LDC centres; 95 children (50 boys) mean age 3.5 (SD) (0.2) years lunch intakes were assessed. Average total amount of sodium provided from two snacks and one lunch: 590 (146) mg, representing ~59% of the Australian Upper Level (UL) of intake (1000 mg/day sodium). Average total amount of sodium consumed: 541 (98) mg representing ~54% of the UL. Across all centres, the average sodium and energy consumed from lunch: 186 (108) mg (~19% of UL); 948 (437) kJ (38% of energy allowance); morning snacks: 63 (45) mg (6% of UL), 535 (183) kJ (21% of energy allowance); afternoon snacks: 291 (97) mg (29% of UL), 464 (171) kJ energy (46% of energy allowance). Australian LDC centres providing lunches cooked on site resulted in relatively low-sodium lunches.