Scaling up an mHealth-based school education programme to reduce salt intake in China

Excessive salt intake is the leading dietary risk factor for premature death and disability in China. Strategies such as setting maximum sodium targets and front-of-package labelling have proven effective in reducing salt intake, but these approaches are mainly suitable for pre-packaged food products. Although discretionary salt use during cooking or at the table remains the major source of dietary sodium in most countries, no effective and scalable programmes targeting this type of salt use have been successfully replicated across different regions or populations.

In China, 80% of dietary salt is added during cooking. The EduSaltS project seeks to assess the effectiveness and feasibility of an mHealth-based school-student-family health education platform, developed from the project team’s previous “Small Hands Leading Big Hands” interventions (validated by randomized controlled trials of School-EduSalt in 2013-2014 and AppSalt in 2017-2019) and the WHO conceptual framework for developing a scaling-up strategy.

 

Featuring standardized, auto-delivered online and offline cartoon lessons, activities, and timely performance evaluations, the EduSaltS platform was implemented as an innovative primary school health education course from 2020 to 2023 in three cities in Northern, Central and Southern China.

The education programme covered 308 schools in the selected districts of the three cities, with all 1,644 grade 3 classes and 72,498 students and their families participating over two school terms. The registration rate and course completion rate reached 98.0% and 83.5%, respectively. Pre-post evaluations showed that salt reduction knowledge, attitudes, and behaviours increased by 25% among children and 15% among adults, with a reduction of 0.4g in salt intake among adults. A parallel randomized controlled trial conducted demonstrated that the scale-up intervention reduced adult salt intake by 1g per day and lowered both systolic and diastolic blood pressure by more than 2 mmHg. These results strongly indicate that the EduSaltS platform is effective and scalable. If integrated into the national school education system, it could benefit the entire population. Furthermore, the project activities have generated significant impacts on policy, practice, capacity building and multisectoral coordination:

1. Policy integration: During the 2023 and 2024 Steering Committee meeting it has been proposed that the innovative model of the EduSaltS project be integrated into the current national health education curricular, so that the school-based salt reduction intervention could be scaled up in the whole of China; and the representative of the Ministry of Education highly recognized the EduSaltS outputs, showing huge potential for policy integration into the national education system. Moreover, EduSaltS program has contributed to a policy brief document “Deepening the Action on Salt Reduction in China – CHRPS Strategies”, which has been submitted it to the National Health Commission for China’s salt reduction policy improvement.
2. Multisectoral coordination: The local health and education authorities, the health facilities and schools have established a collaborative partnership demonstrating strong multi-sectoral collaboration which is essential to advance school-based health education programme in China. Through mobilizing stakeholders, EduSaltS has successfully explored an effective and efficient scale-up approach.
3. Capacity building: A great number of community health workers, schoolteachers and school chiefs from non-health sector have received knowledge on salt and health, leading to increased health awareness and behaviours among wider beneficiaries. Most importantly, the EduSaltS model has been presented as one of the best cases of setting-based health education and promotion for capacity building during the National Health Education and Health Promotion Conference in 2023, thus making remarkable contribution to the public health capacity strengthening in China.
4. Global impact: In 2021 the school-based salt reduction model has been recognized as one of the best practices by GACD and it featured in the BBC StoryWorks Facing Forward series, hosted by the NCD Alliance: The cultural sensitivities of salt reduction and as GACD case study Reducing salt intake through a school-based education programme in China. From 2020-2024, EduSaltS partners have facilitated hundreds of students to participate in the Global Art Competition organized by World Hypertension League to celebrate the World Hypertension Day. Partially due to the contribution of EduSaltS, The George Institute for Global Health, China was awarded 2024 Organizational Excellence Awards in Global Hypertension Control by the World Hypertension League (Awards – World Hypertension League – World Hypertension League). The successful scale-up of EduSaltS program will have major public health implications to many developing countries where dietary salt mainly comes from salt added during cooking or at the table.

The project partners will continue their efforts to ensure the sustainability and scalability of the EduSaltS system across the whole of China through high-level policy advocacy and programme integration into the existing national system. This would be of great significance for achieving China’s goal of reducing salt intake by 20% by 2030 and contribute to Healthy China Actions. Watch a video highlight about EduSaltS 中英