Barriers and Facilitators to Implementing Reduced-Sodium Salts as a Population-Level Intervention: A Qualitative Study

Abstract

Widespread use of reduced-sodium salts can potentially lower excessive population-level dietary sodium intake. This study aimed to identify key barriers and facilitators to implementing reduced-sodium salt as a population level intervention. Semi-structured interviews were conducted with key informants from academia, the salt manufacturing industry, and government. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to inform our interview guides and data analysis. Eighteen key informants from nine countries across five World Health Organization regions participated in the study from January 2020 to July 2020. Participants were concerned about the lack of robust evidence on safety for specific populations such as those with renal impairment. Taste and price compared to regular salt and an understanding of the potential health benefits of reduced-sodium salt were identified as critical factors influencing the adoption of reduced-sodium salts. Higher production costs, low profit return, and reduced market demand for reduced-sodium salts were key barriers for industry in implementation. Participants provided recommendations as potential strategies to enhance the uptake. There are presently substantial barriers to the widespread use of reduced-sodium salt but there are also clear opportunities to take actions that would increase uptake.

Stakeholder perspectives on Nigeria’s national sodium reduction program: Lessons for implementation and scale-up

“…The most prominent barriers affecting two or more implementation outcomes included: consumer level barriers (poor knowledge of excess salt intake and its impact on health, distrust in government-led work due to poor implementation of existing dietary policies, cultural practices on food preparation), organization barriers (poor design of nutrition labels, perceived loss of customers due to changing taste), and policy level determinants (lack of salt replacement, poor advertising regulation, high cost of public health campaigns, existence of multiple sources of salt, bureaucratic nature of public institutions, affordability of high-salt foods). These implementation barriers are similar to those identified in previous studies of national salt reduction programs [26][27][28][29].…”

“…This recommendation reflects other studies recommending a collaborative approach involving stakeholders across government, food industry, and individuals provides an important opportunity for implementing reduced sodium salt interventions [26]. This collaborative approach is important because while government may need to set salt reduction targets for food manufacturers, food industry needs to supply the reduced-sodium salt for food preparation to consumers, and consumers need to find these products acceptable before they will use the products [26]. However, even though collaborative approach is important towards salt reduction, the final decision on implementation of a national salt reduction program should rest with the government.…”

“…Key informants also highlighted the importance of engaging the food industry and other stakeholders including consumers in the design of policy implementation work to reduce dietary salt including the priority actions and improving food labeling. This recommendation reflects other studies recommending a collaborative approach involving stakeholders across government, food industry, and individuals provides an important opportunity for implementing reduced sodium salt interventions [26]. This collaborative approach is important because while government may need to set salt reduction targets for food manufacturers, food industry needs to supply the reduced-sodium salt for food preparation to consumers, and consumers need to find these products acceptable before they will use the products [26].…”

“…Participants in the present study stated that consumer education on salt reduction in Nigeria can be done through multiple sources such as religious and ethnic leaders, health professionals, and influencers and using local languages and dialects to minimize linguistic barriers to support grassroot mobilization. However, previous studies have shown that consumer education is more effective if complemented with fiscal incentives, such as government subsidies that lower the higher price of reduced-sodium salt [26,32] and structural or environmental interventions [33]. Hence, the Nigerian government should complement consumer education with fiscal and other policies to enhance impact of the NMSAP priority actions including food labeling.…”

Estimated Benefits and Risks of Using a Reduced-Sodium, Potassium-Enriched Salt Substitute in India: A Modeling Study

“…21 Implementation strategies could include retail price reductions through mass production or government subsidies; health education on the benefits of SS tailored to diverse socioeconomic subpopulations; mass media campaigns to improve knowledge, attitudes, and practice focusing on the benefit of replacing regular salt with salt substitutes; and food labeling initiatives. 21 Furthermore, even if all salt was replaced by salt substitutes, the mean sodium intake in India would still exceed recommendations. Thus, the promotion of salt substitutes should be accompanied with educational campaigns to use the salt substitute more sparingly, and not more frequently, than current use of regular salt.…”