Process evaluation of Samoa\u27s national salt reduction strategy (MASIMA): what interventions can be successfully replicated in lower-income countries?

BACKGROUND: Evidence for recommended interventions to reduce population salt intake come from high-income countries, but it is unknown if these can be successfully replicated in low- and middle-income countries. This process evaluation investigated the reach, dose/adoption, fidelity, cost, and context of a national salt reduction program of interventions in Samoa. METHODS: Monitoring and Action on Salt in Samoa (MASIMA) was a pre- and post-intervention study of a government-led strategy to lower population salt intake comprising awareness campaigns, community mobilization and policy and environmental changes. Data relating to the five process evaluation dimensions were collected from routinely collected data, a post-intervention survey and stakeholder interviews. Chi-squared tests assessed differences in quantitative survey responses among groups. Thematic analysis of qualitative interview responses was undertaken and triangulated with the quantitative data. RESULTS: Awareness campaigns, school nutrition standards, and community mobilization interventions were implemented with moderate reach and fidelity. Higher than expected costs of campaigns and limited opportunity (one-off) to mobilize community leaders to disseminate salt reduction messages were key implementation challenges, which meant intervention dose was low. Environmental-level initiatives including engagement with the food industry to voluntary reduce salt in foods and the introduction of salt-related regulations were more challenging to implement within 18-months, particularly given the delay in the passing of the Food Act which provides for enforcement of regulations. Contextual factors that hindered the interventions\u27 mechanism of effect include the food culture, higher cost, and lower availability of healthy low-salt foods relative to unhealthy foods and salty taste preference. CONCLUSION: Although individual and community-based interventions helped increase awareness about the importance of salt reduction in Samoa, legislative backing was needed to alter the food environment to achieve population reduction in salt intake. It was not possible to engage the food industry to lower salt in foods through a voluntary approach in Samoa\u27s current context, although such initiatives were successful in some high-income countries. Future individual and environmental-level interventions to reduce salt intake need to address the contextual influences of food choices. In Samoa, this means salt reduction strategies need to ensure consuming lower salt is affordable, widely available, and perceived as flavorsome

Salt intake and iodine status of women in Samoa

The objective of this study was to determine iodine nutrition status and whether iodine status differs across salt intake levels among a sample of women aged 18-45 years living in Samoa. A cross-sectional survey was completed and 24-hr urine samples were collected and assessed for iodine (n=152) and salt excretion (n=119). The median urinary iodine concentration (UIC) among the women was 88 μg/L (Interquartile range (IQR)=54-121 μg/L). 62% of the women had a UIC <100 μg/L. The crude estimated mean 24-hr urinary salt excretion was 6.6 (standard deviation 3.2) g/day. More than two-thirds (66%) of the women exceeded the World Health Organization recommended maximum level of 5 g/day. No association was found between median UIC and salt excretion (81 μg/L iodine where urinary salt excretion >=5 g/day versus 76 μg/L where urinary salt excretion <5 g/day; p=0.4). Iodine nutrition appears to be insufficient in this population and may be indicative of iodine deficiency disorders in Samoan women. A collaborative approach in monitoring iodine status and salt intake will strengthen both programs and greatly inform the level of iodine fortification required to ensure optimal iodine intake as population salt reduction programs take effect

Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries.

Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control

Effects of a nationwide strategy to reduce salt intake in Samoa

Objective: Salt reduction is one of the most cost-effective interventions for the prevention of noncommunicable diseases, but there are no studies evaluating the effectiveness of national strategies in low or lower middle income countries. This study aimed to examine the effect of an 18-month nation-wide salt reduction strategy in Samoa. Methods: Two nationally representative cross-sectional surveys of adults aged 18-64 years, measuring 24-h urinary salt excretion and salt-related knowledge, attitudes and behaviours, were conducted before (2013) and after (2015) the intervention. Results: There were 234 participants at baseline (response rate 47%) and 479 at 18 months (response rate 61%). There was no change in mean population salt intake between 2013 (7.31g/day) and 2015 (7.50g/day) (0.19, 95% confidence interval-0.50 to 0.88; P=0.588). There were significant changes in the proportion of the population who always or often add discretionary salt when eating (-16.2%, P=0.002), the proportion who understood the adverse effects of salt (+9.0%, P=0.049) and the proportion using one or more methods to control their salt intake (+20.9%, P<0.001). A total of 73% reported that they had heard or seen the salt reduction messages. Conclusion: With widespread awareness of the salt reduction message and some improvements in salt-related knowledge and behaviours following the intervention, Samoa is now well positioned to implement much-needed structural initiatives or policies to reduce salt in the food supply

Additional file 2: of Process evaluation of Samoa’s national salt reduction strategy (MASIMA): what interventions can be successfully replicated in lower-income countries?

Semi-structured interview quotes about contextual factors affecting the intervention effects or mechanisms of impact. (DOCX 30 kb

Flow diagram of selection process, according to PRISMA Guidelines [32].

<p>Flow diagram of selection process, according to PRISMA Guidelines [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0173600#pone.0173600.ref032" target="_blank">32</a>].</p

Summary of cost-effectiveness results.

<p>Summary of cost-effectiveness results.</p

Additional file 1: of Process evaluation of Samoa’s national salt reduction strategy (MASIMA): what interventions can be successfully replicated in lower-income countries?

Semi-structured interview quotes about contextual factors of implementation. (DOCX 21 kb

Important definitions.

<p>Important definitions.</p

Study results–full economic evaluations.

<p>Study results–full economic evaluations.</p