School-based education programme to reduce salt: Scaling-up in China (EduSaltS)

Lead Research Organisation: Queen Mary, University of London
Department Name: Wolfson Institute of Population Health

Abstract

High salt intake increases the risk of high blood pressure, strokes, heart disease, and several other chronic diseases such as stomach cancer. Salt intake in China is very high with an average of 12-14 gram per day, more than double the WHO recommended level of 5 gram per day.
Unlike the UK and other developed countries, 75%-80% of the salt in the Chinese diet is added by the consumers during cooking or in sauces. An effective strategy to reduce salt from home cooking is of great urgency and importance, not only for China, but also for many other developing countries. However, it is very difficult for individuals to change their eating habits.
Our proposed research will build upon a successfully-tested pilot study entitled "School-based education programme to reduce Salt" (School-EduSalt) in China, in which primary school children were educated, during their usual health education lessons, about the effects of salt on health and how to reduce salt intake. Children then instructed their family members to reduce the amount of salt used during food preparations at home. The results of this pilot study have shown that the school-based education is very effective in reducing salt intake in children and adults. The pilot study was carried out in one city called Changzhi, in northern China.
We now propose to do a study to test whether we can scale up a refined School-EduSalt programme in multiple settings, to reduce salt in larger populations in China, including the poorest population living in the remote and rural areas. This scale-up study will be carried out in three regions of China including Beijing (capital of China), Shijiazhuang (in the north) and Zhenjiang (in the south), covering a population of over 1 million school children and 2.2 million adults.
The study will involve a number of important stakeholders, including governmental organisations, and the health and education authorities of the three regions. Based on WHO's Conceptual Framework for Scaling up, we will work with these stakeholders to develop, implement and evaluate a feasible scale-up package, which will be integrated into the existing school health education system to ensure sustainable scaling-up.
The scale-up package will be evaluated in three aspects: effectiveness, process and health economics. We will assess whether the education programme can improve the participants' knowledge, attitudes and practices towards salt reduction. Additionally, we will assess whether the education programme can achieve a sustainable reduction in salt intake which will be measured by the gold standard method of 24-hour urine collection.
Our ultimate aim is to incorporate the refined education programme into the national school curriculum, so that all schools in China will follow. A nation-wide implementation will have an enormous impact on reducing population salt intake. A reduction in salt intake across the whole population, even by a small amount, will lower population blood pressure and prevent hundreds of thousands of strokes, heart attacks and heart failure each year, and also lead to major cost-savings to individuals, their families and the health service.

Technical Summary

Based on the WHO's Conceptual Framework for Scaling up, our proposed research aims to conduct a scale-up study on the school-based education programme to reduce salt in China with an implementation science approach. We will use one group pre-post design with mixed (both qualitative and quantitative) methodology. The study will be carried out in 3 regions, i.e. Beijing (the capital of China), Shijiazhuang in the north and Zhenjiang in the south with a population of >1 million children and 2.2 million adults.
The study will follow a 4-phase model of implementation spanning preparation (0.5 yr), pilot (0.5 yr), scale-up study (2 yrs), and national roll-out and sustainment phase (1 yr).
During the scale-up study, a refined education programme will be implemented in grade 4 (aged approximately 10 yrs) in all primary schools. We will conduct 3 representative cross-sectional surveys to assess the changes in KAP (Knowledge, Attitudes and Practices) and salt intake (measured by 24h urinary sodium), at baseline (yr 0), at the end of the 1-yr intervention (yr 1), and after an additional year of follow-up (yr 2), with an aim of evaluating the effect of the intervention and its sustainability. KAP questionnaires will be completed in a randomly selected sample of 4050 children from 54 schools, and 8100 adult family members. Salt intake will be assessed by 24h urinary sodium excretion in a randomly selected sample of 726 children from 33 schools and 726 adult family members.
The primary outcome is the change of salt-related KAP, and the secondary outcome is the change of salt intake in children and their families as measured by 24h urinary sodium. Process evaluation will be conducted to assess the uptake rate of the scale-up package, and to examine facilitators and barriers to implementation. For health economic evaluation, an incremental cost effectiveness ratio will be calculated.

Planned Impact

Our research will achieve a broad range of impacts. The biggest impact is on the policy, with the local education/health authorities issuing policies to support the scale-up study and the scale-up package integrated into the existing school health education system. This will set a good model for other regions in China to follow, leading to larger influence on national rollout. The school-based salt reduction programme will also be integrated into the on-going national Health Promoting School Initiative, so that all schools in China will implement the programme.
The research will have an important academic impact, advancing the scientific knowledge across and within various disciplines, e.g. nutrition, blood pressure, public health, school education, particularly enhancing the understanding and application of the theories, methodologies and practices of the implementation and translational sciences, which will bridge the knowledge gap between the effective interventions and their translation into daily practice. Chinese researchers will be the major beneficiaries in this regard, with enhanced knowledge and skills for translating the research output into policy.
Most importantly, our scale-up study will achieve an enormous impact on health and the economy. The immediate benefit from a reduction in salt intake is to lower blood pressure. For adults, this will have a significant effect on reducing the risk of suffering a stroke, heart attack or heart failure. For children, a lower salt intake will prevent the development of high blood pressure and cardiovascular disease later in life. A reduction in salt intake not only saves lives, but also saves money for individuals, their families and the health service.
Furthermore, our study will contribute to the promotion of healthy diets and lifestyle among Chinese population including both adults and children who will maintain the healthy lifestyle with the knowledge and skills developed at an early age throughout their lifetime.
Last but not the least, global health impact will be achieved through dissemination and adaptation of our research outputs to other countries. In this regard, we will seek various opportunities to work with WASH (World Action on Salt and Health), WHO Collaborating Centre for Population Salt Reduction, Queen Mary University of London's global development network, the NIHR large cohort of Global Health Research Units and Groups, Global Alliance of Chronic Diseases (GACD)'s network to translate our findings to other settings in the world.

Publications

10 25 50
 
Title A series of cartoon video course on salt reduction and health education 
Description 20 cartoon videos on salt reduction and other health education topics have been developed, which will be broadcast regularly in the smartphone application or in the classroom in 2021/22. The cartoons will help schoolchildren develop knowledge and skills to reduce salt intake and establish healthy lifestyle and dietary habits. 
Type Of Art Film/Video/Animation 
Year Produced 2021 
Impact Schoolchildren and their parents will have access to the cartoon videos in late 2021. 
 
Title A series of well-designed leaflets, posters and brochures on salt reduction 
Description A series of well-designed leaflets, posters and brochures have been developed to deliver knowledge on the harmful effects of high-salt intake and provide practical advice and skills to help school children and their family members reduce salt intake. 
Type Of Art Image 
Year Produced 2021 
Impact Not been used. 
 
Description A formal working group, expert panel or dialogue - Speech on Revision Seminar on the book of 'Dietary Guidelines for Chinese Residents', Director Changning Li
Geographic Reach National 
Policy Influence Type Participation in a advisory committee
Impact Changning Li,Director of CCHE and Co-I of EduSaltS programme, was invited to attended Revision Seminar on the book of 'Dietary Guidelines for Chinese Residents' in Sept. 2020. In the seminar, he publicized the school salt reduction program and shared the experience of the education program with nutrition and public health experts. His speech has improved the nutrition education experts' understanding of salt reduction and has played a significant role in the promotion of the project.
 
Description Contributing to GACD annual scientific meeting 2020, Dr. Yuan Li
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact Dr Yuan Li, gave a presentation on EduSaltS(a scale-up school-based salt reduction program) in the GACD annual scientific meeting 2020. Her contribution to this conference will have a potential impact on improving salt reduction policy and practices in longer term.
 
Description Contributing to community engagement discussion in the George Institute Global staff meeting
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact Dr Yuan Li gave a presentation on EduSaltS(a scale-up school-based salt reduction program) as a case study of healthier societies at the George Institute for Global Health, to promote discussion on community engagement in practice. There will be some potential impacts on policy and practice.
 
Description Education authorities in Zhenjiang City support shcool-based salt reduction intervention
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Citation in other policy documents
Impact Local education authorities of Zhenjiang provide substantial policy support to facilitate the implementation of salt reduction interventions at schools, with government documents released for all schools to carry out the interventions with the technical support from health authorities.
 
Description Presentation on EduSaltS programme in GACD annual scientific meeting 2020 , Dr. Yuan Li
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Presentations on school-based salt reduction in Annual China Hypertension Conference and Nutrition conference
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
Impact China director of ASC program A/Professor Puhong Zhang gave presentations on school-based salt reduction in Annual China Hypertension Conference and Nutrition conference. The conference was attended by huge number of participants from China, mainly NCD prevention and control officials, managers, professionals and nutrition practitioners. The impact on policy and practices will be significant.
 
Description Speech on "Healthy Chinese" series roundtable forum, Director Changning Li
Geographic Reach National 
Policy Influence Type Participation in a national consultation
Impact Changning Li, Director of CCHE, Co-I of EduSaltS programme, was invited to attend "Healthy Chinese" series roundtable forum. The representatives of the National People's Congress and Chinese People's Political Consultative Conference and relevant experts discussed and exchanged opinions on the key issues (including salt reduction) in the field of health in China, so as to help build a healthy China. Salt reduction is one of the important components of health education. Changning Li's speech raised the awareness of all sectors of society and science popularization on salt reduction and health education.
 
Description Development of country support tools to promote salt action in SEAR member States
Amount £19,098 (GBP)
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start 10/2020 
End 12/2020
 
Description Establishing salt reduction targets in the EMRO region and implementing a salt reduction strategy in Malaysia
Amount £206,006 (GBP)
Organisation Vital Strategies 
Sector Charity/Non Profit
Country United States
Start 11/2020 
End 09/2022
 
Title Electronic management and evaluation system 
Description This system has been developed with a number of components and purposes: (1) electronic data capture and management, to collect evaluation data and perform quality control; (2) monitoring application, to track and monitor the implementation of intervention;(3) management website, to delivery intervention and support project process management in the whole research process. 
Type Of Material Improvements to research infrastructure 
Year Produced 2021 
Provided To Others? No  
Impact The information system plays a significant role in facilitating the implementation and evaluation of salt reduction interventions via comprehensive data management. It will also serve as a platform for effective dissemination, communication and promotion related to research outputs. 
 
Title Salt reduction and health education smartphone application 
Description EduSaltS programme is a wide-scale implementation of the education program in multiple settings at three cities in China and eventually across the whole country in China, which will ultimately prevent the development of hypertension, CVD and other NCDs. The programme will develop a feasible, sustainable and adaptable scale-up package with the core component of the school-based salt reduction education program in children and families, in the form of online and offline. To test the feasibility and effectiveness of the scale-up package, one group pre-post design with mixed (both qualitative and quantitative) methodology will be used in the study. It will follow a four-phase model of implementation spanning preparation, pilot, scale-up and sustainment. A robust information management system with an innovative smartphone application will be developed focusing on salt-reduction health education, which is used by children's parents. There are several functions in this application to promote children and their parents' performance: cartoon teaching, practice and test, knowledge competition, salt-intake evaluation, healthier diet support, salt-reduction health education material library (posters, promotional videos, picture books, brochures etc.). 
Type Of Material Improvements to research infrastructure 
Year Produced 2021 
Provided To Others? No  
Impact In the pilot study, the participants including teachers, students and parents showed great interests in the smartphone application and other salt reduction activities. Improvement of salt-reduction health knowledge and awareness was achieved through the two-month intervention. 
 
Title Mobile Electric Data Capturing (mEDC) System 
Description The mEDC systems were developed for data collection and process management in the local sites. The questionnaires for salt-reduction knowledge, attitude and practice (KAP) assessment, and functions supporting 24-hour urine collection were integrated into the system. The data collected could be checked, monitored and managed in mEDCs. 
Type Of Material Database/Collection of data 
Year Produced 2021 
Provided To Others? No  
Impact Local investigators received trainings on how to use the mEDC systemIn. In the pilot study, trained staff applied this innovative tool in their fieldwork for data collection and monitoring. They reported that this new approach has more advantages on the process and quality control compared with the traditional method. 
 
Description Beihang University 
Organisation Beihang University
Country China 
Sector Academic/University 
PI Contribution Professor Feng He and Graham MacGregor's research team from QMUL have been providing strong technical support to the study design, operation manual, data management and statistic etc. QMUL team also supports project management and oversees the implementation of the programme.
Collaborator Contribution Beihang University has substantial experience in mHealth innovation and information management system which has been applied to large-scale RCTs led by The George Institute China. Beihang is also a key partner of Action on Salt China programme, in which Beihang is responsible for the development of intervention application, EDCs and project management system. In this EdusaltS programme, Beihang University is leading the development of 1) mobile phone intervention application on salt-reduction health education used by children and their parents, 2) monitoring application used by teachers and School Board, 3) EDCs tools, and 4) project management system.
Impact 1) Completed the development of mobile phone intervention application on salt-reduction health education used by children's parents;2) Completed the development of monitoring application used by teachers and School Board;3) Completed the development of EDCs tools; 4) Completed the development of electronic project management system.
Start Year 2019
 
Description Chinese Center for Health Education (CCHE) 
Organisation Chinese Center for Health Education
Country China 
Sector Public 
PI Contribution Professor Feng He and Graham MacGregor's research team from QMUL have been providing strong technical support to the study design, operation manual, data management and statistic etc. QMUL team also supports project management and oversees the implementation of the programme.
Collaborator Contribution The China National Center for Health Education (CCHE) is a national professional organization on health education and promotion. CCHE has successfully implemented several national campaigns, e.g. Tobacco Control, Healthy China, Health Literacy Promotion and Health Promotion Schools etc. CCHE is a key partner of Action on Salt China programme (ASC) led by QMUL and TGI and has been leading nation-wide salt-reduction communication of ASC. In EduSaltS project, CCHE will support the design of proposal and case report forms, lead the development of health education graphic design materials and audio materials on salt reduction, submission of IRB/ China Human Genetic Resources Approval, and coordinate local sites to implement the project.
Impact 1) completed the design of proposal and case report forms; 2) completed the development of series of posters and radios on salt reduction; 3) obtained the approval of IRB;4) organized project meetings;5) coordinated local sites to implement pilot study from June-Sept. 2020.
Start Year 2019
 
Description The George Institute for Global Health (TGI) China 
Organisation The George Institute for Global Health China
Country China 
Sector Academic/University 
PI Contribution Professor Feng He and Graham MacGregor's research team from QMUL have been providing strong technical support to the study design, operation manual, data management and statistic etc. QMUL team also supports project management and oversees the implementation of the programme.
Collaborator Contribution The George Institute for Global Health China (TGI) is a leading research institute focusing on implementation research on chronic diseases and have collaborated with China Health Education Center closely for many years. Nutrition and Lifestyle is one of their key programmes in China with salt reduction among the priorities. Through the implementation of an app-based programme to reinforce and maintain lower salt intake in schoolchildren and their families in China (AppSalt) led by QMUL and TGI China, the team has gained extensive experience in delivering salt reduction health education in school settings. In this scale-up programme, TGI China will lead research design, part of intervention development and project management, such as organising regular project meetings, communication (newsletter, information and progress sharing etc.) as well as monitoring and evaluation etc. TGI China also plays a leading role in coordinating China partners and QMUL to ensure the overall plan, operation and implementation of the project.
Impact 1) Completed the development of research protocol, operation manual etc. 2) Supported the development of mobile phone application on salt-reduction health education used by children's parents and intervention monitoring use by teachers and School Board; 3) Supported the development of EDCs and project management electronic platform. 4) Prepared materials for IRB/Human Genetic Resources Approval, pilot study, local staff training etc.; 5) Carried out project management, including finance management, regular project meeting, coordination and communication between partners etc.
Start Year 2019
 
Title School-based health education interventional programme to reduce salt consumption 
Description The salt-reduction intervention package in EduSaltS programme includes two core components: 1) online education to school children and their parents using smartphones and computers, such as cartoon courses, health knowledge test and competition, and 2) offline activities in school leading by teachers, such as lectures, training, broadcasting the video/audio etc. Currently, the intervention materials and tools are being developed. 
Type Preventative Intervention - Behavioural risk modification
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2021
Development Status On hold
Impact A series of cartoon video courses, radio drama and picture book on salt reduction are the first of their kind in China and are well received by school children and teachers in the pilot study. The health education smartphone application can reform its health education approach from the traditional way to an innovative and mobile-based way. 
 
Title An applet of WeChat on salt reduction and health education 
Description The applet of WeChat on salt reduction and health education is a key component of the intervention package. Schoolchildren and their parents can learn health knowledge and skills, participate in online quiz competition, evaluate individual and family's salt consumption, and choose healthier package foods. 
Type Of Technology Webtool/Application 
Year Produced 2021 
Impact The applet will help achieve a sustainable reduction in salt intake in both children and their families. It will deliver health education lessons in a more attractive way. The online education lessons will also reduce the burden on teaching staff compared with the traditional school education method. 
 
Description 2020 EduSaltS Programme Steer Committee Meeting and investigator meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact In September 2020, the project steering committee meeting was held online. Project leaders and local investigator representatives Experts and leaders listened presented to the progress of the project and shared experience from the implementation the summary of pilot study. experience, and Experts and project leaders put forward pertinent opinions and suggestions on the project work. At the same time After the SC meeting, TGI and CCHE organized online work seminars for the staff of the three project provinces and cities to further discussclarify the work requirements and work plans.
Year(s) Of Engagement Activity 2020
 
Description EduSaltS Programme Launch Meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact On 12th of December 2019, the Chinese Center for Health Education, the George Institute for Global Health Research (China) and Queen Mary University of London, jointly launched the EduSaltS in Beijing. Over 50 people, including project leaders from three project provinces (cities), and representatives of the British Embassy in China and World Health Organization, as well as experts and scholars in related fields, attended the launch meeting.
Year(s) Of Engagement Activity 2019
URL https://www.sohu.com/a/360744995_100232727
 
Description First issue of newsletter produced in 2020 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The first issue of newsletter/factsheet in both Chinese and English have produced in Jan 2020. The study design of EduSaltS programme, and introduction of the scientific facts on salt-reduction were reported in the newsletter.
Year(s) Of Engagement Activity 2020
 
Description Local staff trainings on the implementation of pilot study 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact On June 18, 2020, China Health Education Center and George Health Research Institute (China) jointly held an online training. More than 50 persons from the health and education departments of Jiangsu Province and Zhenjiang city attended the meeting. Later, the experts of Jiangsu Provincial CDC and Zhenjiang city CDC held operational training to local investigators who conducted field survey and assessment in pilot study. An intervention training was also delivered to teachers from 2 pilot schools.
Year(s) Of Engagement Activity 2020
 
Description Presentation on EduSaltS as case study of Healthier Societies research by Dr. Yuan Li 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Dr. Yuan Li gave a presentation on EduSaltS as case study of Healthier Societies research in the George Institute Global staff online meeting in Dec. 2020
Year(s) Of Engagement Activity 2020
 
Description Presentation on School-based education programme to reduce salt: Scaling-up in China,Yuan Li 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Dr. Yuan Li attend the GACD annual scientific meeting in Nov. 2020 to give a presentation on School-based education programme to reduce salt: Scaling-up in China.
Year(s) Of Engagement Activity 2020
 
Description Presentations on school-based salt reduction in Annual China Hypertension Conference and Nutrition conference 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact China director of ASC program A/Professor Puhong Zhang gave presentations on school-based salt reduction in Annual China Hypertension Conference and Nutrition conference. The conference was attended by huge number of participants from China, mainly NCD prevention and control officials, managers, professionals and nutrition practitioners.
Year(s) Of Engagement Activity 2019
 
Description Press release on Wechat to promote EduSalt programme 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The press release about EduSaltS programme was issued at Wechat platform in May 2020, around of on Chinese Student Nutrition Day in May 2020. Some The article was disseminated by several mainstream media disseminate this article. It will make and made significant contribution to communication and promotion of the health education programme on salt reductionproject.
Year(s) Of Engagement Activity 2020
 
Description Speech on "Healthy Chinese" series roundtable forum, Director Changning Li 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Changning Li, Director of CCHE, was invited to attend "Healthy Chinese" series roundtable forum. The representatives of the National People's Congress and Chinese People's Political Consultative Conference and relevant experts discussed and exchanged opinions on key issues (including salt reduction) in the field of health in China, so as to help build a healthy China.
Year(s) Of Engagement Activity 2020
 
Description Speech on Revision Seminar on the book of 'Dietary Guidelines for Chinese Residents',Director Changning Li 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact CCHE's Director Changning Li attended Revision Seminar on the book of 'Dietary Guidelines for Chinese Residents' in Sept. 2020, and publicized the school salt reduction program for and shared the experience of the EduSaltS program with nutrition and public health experts. and exchange the experience of the program.
Year(s) Of Engagement Activity 2020