Implementation of a salt substitute intervention using social marketing in resourced-limited communities in Peru: a process evaluation study.

Objective: This study aimed to conduct a process evaluation of a salt substitute trial conducted in Peru. Methods: Through semi-structured interviews of intervention participants, we documented and analyzed process evaluation variables as defined by the Medical Research Council Framework. This study was a stepped wedge trial conducted in Tumbes, Peru in 2014. The intervention was a community-wide replacement of regular salt (100% sodium) with "Salt Liz" (75% sodium and 25% potassium) using social marketing strategies to promote the adoption and continued use of the salt substitute in daily life. The components of the social marketing campaign included entertainment educational activities and local product promoters ("Amigas de Liz"). Another component of the intervention was the Salt Liz spoon to help guide the amount of salt that families should consume. The process evaluation variables measured were the context, mechanism of action, and implementation outcomes (acceptability, fidelity and adoption, perceptions, and feedback). Results: In total, 60 women were interviewed, 20 with hypertension and 40 without hypertension. Regarding context, common characteristics across the four villages included residents who primarily ate their meals at home and women who were responsible for household food preparation. As the mechanism of action, most participants did not notice a difference in the flavor between regular salt and Salt Liz; those that did notice a difference took around 2 weeks to become accustomed to the taste of the salt substitute. In terms of implementation outcomes, the Salt Liz was accepted by villagers and factors explaining this acceptability included that it was perceived as a "high quality" salt and as having a positive effect on one's health. Participants recognized that the Salt Liz is healthier than regular salt and that it can help prevent or control hypertension. However, most participants could not accurately recall how the compositions of the Salt Liz and regular salt differed and the role they play in hypertension. Although the use of the Salt Liz was far-reaching at the community level, the use of the Salt Liz spoon was poor. Educational entertainment activities were well-received, and most participants enjoyed them despite not always being active participants but rather sideline observers. Conclusion: This process evaluation identifies key intervention components that enabled a successful trial. Seeking and incorporating feedback from the target population helps deepen the understanding of contextual factors that influence an intervention's success. Furthermore, feedback received can aid the development of the intervention product. Some factors that can be improved for future interventions are acknowledged. Clinical trial registration: NCT01960972.

Applying Customer Journey Mapping in Social Marketing to Understand Salt-Related Behaviors in Cooking. A Case Study.

Worldwide, salt consumption exceeds the World Health Organization's recommendation of a daily intake of 5 g. Customer journey mapping is a research method used in market research to understand customer behaviors and experiences and could be useful in social marketing as well. This study aimed to explore the potential of customer journey mapping to better understand salt-related behaviors performed during the preparation of household cooking. We tracked the journey of four women in their kitchens for approximately two hours to observe the preparation of lunch. Individual journey maps were created, one for each woman, that were composited into a single journey map. We found that customer journey mapping was a suitable research method to understand how food preparers made decisions around adding salt and artificial seasonings at each stage of the journey. In contrast to the interviewee' responses, it was observed that the four women added salt and artificial seasonings consistently and incrementally with little control and without any standard measure. In this study, we demonstrate the utility of customer journey mapping in a novel context and nudge social marketers to include this tool in their repertory of research methods to understand human behavior.

Effect of salt substitution on community-wide blood pressure and hypertension incidence.

Replacement of regular salt with potassium-enriched substitutes reduces blood pressure in controlled situations, mainly among people with hypertension. We report on a population-wide implementation of this strategy in a stepped-wedge cluster randomized trial (NCT01960972). The regular salt in enrolled households was retrieved and replaced, free of charge, with a combination of 75% NaCl and 25% KCl. A total of 2,376 participants were enrolled in 6 villages in Tumbes, Peru. The fully adjusted intention-to-treat analysis showed an average reduction of 1.29 mm Hg (95% confidence interval (95% CI) (-2.17, -0.41)) in systolic and 0.76 mm Hg (95% CI (-1.39, -0.13)) in diastolic blood pressure. Among participants without hypertension at baseline, in the time- and cluster-adjusted model, the use of the salt substitute was associated with a 51% (95% CI (29%, 66%)) reduced risk of developing hypertension compared with the control group. In 24-h urine samples, there was no evidence of differences in sodium levels (mean difference 0.01; 95% CI (0.25, -0.23)), but potassium levels were higher at the end of the study than at baseline (mean difference 0.63; 95% CI (0.78, 0.47)). Our results support a case for implementing a pragmatic, population-wide, salt-substitution strategy for reducing blood pressure and hypertension incidence.

Parents' Perceptions about Salt Consumption in Urban Areas of Peru: Formative Research for a Social Marketing Strategy.

BACKGROUND: Salt intakes in Latin America currently double the World Health Organization's recommendation of 5 g/day. Various strategies to reduce the population's salt consumption, such as raising awareness using social marketing, have been recommended. This study identified parents' perceptions of salt consumption to inform a social marketing strategy focused on urban areas in Peru. METHODS: Using a sequential exploratory methods design, parents of pre-school children, of high and low socioeconomic status, provided qualitative data in the form of interviews and focus groups. Following this, quantitative data was obtained via questionnaires, which were sent to all parents. The information was analyzed jointly. RESULTS: 296 people (mean age 35.4, 82% women) participated, 64 in the qualitative and 232 in the quantitative phase of the study. Qualitative data from the first phase revealed that the majority of mothers were in charge of cooking, and female participants expressed that cooking was "their duty" as housewives. The qualitative phase also revealed that despite the majority of the participants considered their salt intake as adequate, half of them mentioned that they have tried to reduce salt consumption, and the change in the flavor of the food was stated as the most difficult challenge to continue with such practice. Quantitative data showed that 67% of participants would be willing to reduce their salt intake, and 79.7% recognized that high salt intake causes hypertension. In total, 84% of participants reaffirmed that mothers were in charge of cooking. There were no salient differences in terms of responses provided by participants from high versus low socioeconomic groups. CONCLUSIONS: The results point towards the identification of women as a potential target-audience of a social marketing strategy to promote reductions in salt intake in their families and, therefore, a gender-responsive social marketing intervention is recommended.

Taste, Salt Consumption, and Local Explanations around Hypertension in a Rural Population in Northern Peru.

Interventions to promote behaviors to reduce sodium intake require messages tailored to local understandings of the relationship between what we eat and our health. We studied local explanations about hypertension, the relationship between local diet, salt intake, and health status, and participants' opinions about changing food habits. This study provided inputs for a social marketing campaign in Peru promoting the use of a salt substitute containing less sodium than regular salt. Qualitative methods (focus groups and in-depth interviews) were utilized with local populations, people with hypertension, and health personnel in six rural villages. Participants were 18-65 years old, 41% men. Participants established a direct relationship between emotions and hypertension, regardless of age, gender, and hypertension status. Those without hypertension established a connection between eating too much/eating fried food and health status but not between salt consumption and hypertension. Participants rejected dietary changes. Economic barriers and high appreciation of local culinary traditions were the main reasons for this. It is the conclusion of this paper that introducing and promoting salt substitutes require creative strategies that need to acknowledge local explanatory disease models such as the strong association between emotional wellbeing and hypertension, give a positive spin to changing food habits, and resist the "common sense" strategy of information provision around the causal connection between salt consumption and hypertension.

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.