Online meal delivery services have proliferated in China over the past few years, becoming one of the leading sources of prepared meals. Mobile ordering platforms typically provide little to no nutritional information to guide consumers towards healthier food decisions.
Most people in China consume too much salt, on average 9.3 grams per day from home cooking alone1, nearly double the recommended amount. Too much salt in the diet can lead to high blood pressure and can increase the risk for heart disease and stroke. More than a quarter (27.5%) of Chinese adults have high blood pressure (hypertension) and cardiovascular disease is the number one killer in China, accounting for more than half (53.2%) of all deaths caused by noncommunicable diseases.
To respond to this challenge, WHO China used the Communication for Health (C4H) approach to understand the social and behavioural drivers at play and create a behavioural insights intervention to test strategies that would lead to lower sodium intake.
The C4H approach uses communications as a tool for delivering better health. Central to the approach is the application of behavioural insights to generate an evidence-based understanding on how people actually behave and to measure the impact of communication strategies.
Data collected in 2019 suggested that, despite public awareness that high sodium consumption is unhealthy, many people still found it difficult reduce salt when eating out because of lack of options and because they were reluctant to ask for a dish to be modified.
To address these barriers, WHO China with the support of the global public health initiative Resolve to Save Lives, worked with the National Institute for Nutrition and Health of the Chinese Centers for Disease Control and Prevention (NINH, China CDC) and Tsinghua University to design a research study that would test and compare the effectiveness of communication and behavioural interventions on online food ordering.
Working with a popular online food delivery platform in multiple Chinese cities, the team tested the impact of health messages and changes to the choice architecture on the app. Interventions included: pinning a conventional educational health message to the top of the ordering page; offering an option for low sodium versions of individual dishes; changing default settings to a low sodium tick-box; and different combinations of the three. Restaurants that signed up to participate in the study were assigned to different treatment groups, with a control group providing a basis for comparison.
Findings from the study showed that a health message alone, compared to the control group, was not effective in nudging consumers towards lower salt dishes. In contrast, changes to the choice architecture in which consumers were presented with a sub-menu with options for ‘regular salt’ and ‘reduced salt’ was effective in prompting consumers to choose healthier options, compared to the control group.
Furthermore, to test whether consumers ordering the ‘low sodium’ options were truly eating less salt, that is, whether restaurants honoured the low salt requests of consumers, NINH led an effort with laboratory researchers to test randomly selected menu items. The results confirmed that dishes ordered as ‘low sodium’ options had on average 25% less sodium than dishes ordered with standard sodium settings.
The study holds promise for future research interventions, and WHO and its partners plan to use these results to further explore health promotion strategies in China and inform policy recommendations, where applicable.
1The State Council Information Office of the People’s Republic of China. Report on the Nutrition and Chronic Diseases Status of Residents in China [Internet]. 2020 Dec. Available from: http://www.scio.gov.cn/xwfbh/xwbfbh/wqfbh/42311/44583/wz44585/Document/1695276/1695276.htm