From street food samples to TikTok videos: a social behavioural change communication(SBCC) programme as part of a comprehensive approach to salt reduction in Malaysia

Hypertension affects over one third of adults in Malaysia, making it a primary risk factor for mortality and disability. Excessive salt consumption is a significant risk factor for high blood pressure and heart disease, with the average Malaysian consuming 7.9 g of salt per day 2 , more than 50% higher than the World Health Organization’s (WHO) recommended daily intake of 5.0 g of salt or 2.0 g of sodium 3. To combat this issue, WHO has recommended salt reduction interventions as best buys and set a global target to reduce mean population salt intake by 30% by 2025 for the prevention and control of noncommunicable diseases (NCDs). To promote salt reduction in Malaysia, the Ministry of Health (MoH) together with WHO, initiated a social behavioural change communication (SBCC) programme. By the end of December 2022, over five million people had been sensitized to salt reduction information, education and communication (IEC) materials, which had been shown to result in a measurable increase in knowledge, attitude and intention to practice salt reduction.

How did Malaysia, with the support of the WHO Secretariat, achieve this?

Since 2015, Malaysia has been implementing a salt reduction strategy in alignment with the WHO SHAKE technical package for salt reduction. The aim of this strategy is to reduce the population’s salt intake to 6.0 g per day by 2025 by means of various interventions. A midterm evaluation commissioned by the WHO in 2018 found that the strategy had made strong progress in Malaysia and recommended targeted interventions, including strategic communication towards the general population 5. As a result, a social behavioural communication campaign (SBCC) plan was developed and implemented by the WHO in collaboration with the MoH to encourage behaviour change through salt reduction messages.

To better understand the main sources of salt intake in the general population, WHO commissioned a study to survey 10 520 street foods from all the states of Malaysia, and analysed the nutritional content of the 210 most popular street foods in the country. The data collected will be uploaded onto the online Malaysian Food Composition Database (MyFCD). The data was used by WHO to develop tailored communication campaign materials for the general public and school children. The SBCC programme developed a memorable slogan, “cukup sedikit, elak penyakit” (“just a little, avoid disease”), which was used in all communication materials and social media campaigns. The programme produced posters, infographics, pamphlets and social media handles to promote salt reduction messages, as well as educational videos including a fully animated video for schoolchildren.

“ We found that 35% of the most common main meals available in the street foods of Malaysia contain more sodium than the recommended daily intake of 2.0 g of sodium. While we should encourage product reformulation to reduce the sodium content, it is important to share this information with the general public, so they can make better-informed food choices.” - Associate Professor Dr Hasnah Haron, lead researcher from the National University of Malaysia (UKM)

The SBCC programme used social media platforms such as TikTok and YouTube to reach a wider audience. TikTok was selected for its ability to create engaging content and reach a younger audience. Fifteen TikTok influencers were engaged by WHO to create unique videos on salt reduction, which were carefully reviewed and approved by WHO officers. In addition, WHO worked with a creative consultant to produce two videos shared on social media. YouTube was used to share informative and animated videos and advertisements for Malaysian audiences.

“ We have decided to focus on two main target populations, namely adults and children. We know that establishing healthy behaviours is more effective during childhood and adolescence. By working with the WHO, we were able to use these innovative distribution channels, allowing us to reach a wider audience. This campaign showed promising results and it is an important element of our overall salt reduction strategy.” - Dr Hamdan bin Mohamad, Dietitian at the Disease Control Division, MoH

WHO provided technical and financial support for an interim evaluation of the SBCC campaign in September 2022, which included a knowledge, attitude and practice (KAP) survey and social media reach analysis. The SBCC programme’s influencers reached a total of 5.1 million followers, with 661 000 views, 34 500 likes, 1800 shares and 683 comments. The KAP survey showed that the IEC materials were of high quality and reach, and increased respondents’ knowledge, attitude and intention to practice salt reduction. The evaluation found that the programme can maintain its visibility and upscale its communication campaign by going beyond mass transmission of messages to provide practical solutions that can positively impact salt reduction practices, such as interventions involving community and school engagements. To do this, WHO Malaysia also developed a health promotion toolkit focused on salt reduction for use in schools and a training module which can be used by the MoH. The training for school educators is under way.

Despite facing challenges, including COVID-19 restrictions, the SBCC programme in Malaysia has made progress towards reducing the population’s salt intake. Local data, varied communication channels and social influencers were important for the programme’s success, particularly with the younger generation. Continual monitoring and targeted interventions are needed to maintain the momentum, and a coordinated effort between community, industry and other stakeholders is necessary for a long-term health impact.

Knowledge

WHO country stories: delivering for all

“This impact story was published as part of the WHO country stories: delivering for all report, which presents a snapshot of how WHO has delivered on its mission in countries and contributed to health outcomes across a wide range of issues during 2022-2023.”