In China, much of the sodium consumed is from salt added while cooking at home. With this in mind, WHO China applied the Communication for Health (C4H) approach to change home cooking practices, using popular channels of communication to help home cooks picture the maximum daily recommended amount of salt and give recipes a healthy makeover.
The C4H approach leverages the power of communication as a tool for improving health. When communication is evidence based and strategic – that is, when it uses principles and processes to target a particular audience for a specific purpose, based on known audience needs and preferences – it can improve awareness, shift attitudes and change behaviours. Central to C4H is data collection and evaluation techniques to uncover behavioural barriers and motivations and to understand the effectiveness of tailored strategies.
This C4H initiative in China stemmed from an understanding that most people in the country consume too much salt: on average, 9.3 grams per day from home cooking alone, almost double the recommended amount. Too much salt in the diet means too much sodium, a major risk factor for high blood pressure (hypertension) and cardiovascular diseases such as stroke and coronary heart disease. In China, more than a quarter (27.5%) of adults are hypertensive, and cardiovascular disease is the number one killer in the country, accounting for more than half (53.2%) of deaths caused by noncommunicable diseases.
To better engage home cooks with health messaging that would help reduce sodium consumption, in 2018 WHO China, with the support of Resolve to Save Lives, conducted quantitative and qualitative pre-campaign information gathering from the target audience of people who prepare meals at home for their children and older parents. Information was collected on their estimated daily salt consumption, knowledge about the health impacts of high-sodium diets, attitude towards salt reduction and home cooking practices. This also provided an opportunity to gather information about preferred media channels and get feedback on campaign slogans and visual designs.
Face-to-face focus group discussions, followed by an online questionnaire covering urban and rural areas, showed that:
- Half of the target audience respondents correctly identified the maximum recommended daily salt intake, but most could not visualize the amount, with most underestimating it.
- Most indicated that they find it difficult to find practical ways to reduce salt, especially when eating out.
- Many indicated that they do not actively read health websites or blogs authored by popular physicians, but rather use social media to follow entertainment and popular culture stories.
Equipped with these insights, in 2018 WHO China partnered with Trends Health, a popular monthly lifestyle and wellness magazine in the country, to launch a 6-month salt reduction campaign. The print and social media campaign featured design elements tested in the focus groups to address the health impacts of sodium, uncover hidden salt in common foods, explore myths and misperceptions, and offer easy tips for cooking low-sodium meals at home. Each month, the campaign produced a micro-video in which a celebrity or an influencer appealing to the target audience reformulated their favourite recipes with tips on low-sodium cooking.
In line with the C4H approach, which uses measurement and evaluation to assess the health outcomes and impacts of activities and identify lessons to inform and improve future activities, WHO China conducted follow-up engagement with the target audience in 2019, again through focus groups and online information collection. Among the findings:
- Eighty-five per cent of respondents claimed a “big” or “somewhat big” impact of campaign materials on their attitudes and behaviours;
- Participants reported having taken actions to reduce salt intake, such as eating vegetables cooked with less salt and reducing the use of salty condiments; and
- Ninety per cent indicated an intention to reduce salt intake.
While these results were encouraging, obstacles remained. Half of the target audience participants reported difficulty maintaining a low-sodium diet in the long run, and a third expressed difficulty in controlling the amount of salt in foods prepared outside of the home.
In response, in 2021, WHO China continued to support interventions to reduce sodium consumption by partnering with the National Institute for Nutrition and Health (NINH) of the Chinese Centers for Disease Control and Prevention, and Tsinghua University to test different communication interventions on consumers’ selections on a meal delivery platform.