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

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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.