Salt intake in China is very high, which increases the risk of hypertension and cardiovascular disease. This study aimed to assess the levels of salt-related knowledge, attitudes, and behaviors (KABs) and the factors that influence them and to explore the relationship between the scores of salt-related KAB and 24-h urinary sodium excretion. In 2018, we collected data from 5453 individuals aged 18–75 years from six provinces in China. A face-to-face survey was carried out, focusing on the KAB related to salt reduction. All participants were asked to collect one 24-h urine sample. Of the 5453 participants, 5352 completed urine collection. The mean score for overall KAB was 31.27 (SD = 9.18), which was composed of three elements: knowledge 4.80 (SD = 5.14), attitude 9.33 (SD = 3.93), and behavior 17.14 (SD = 4.43). The average 24-h urinary sodium excretion was 187.70 (SD = 77.48) mmol, which was equivalent to a urinary sodium excretion of 4.32 (SD = 1.78) g/d. We found that salt-related knowledge, attitude, behavior, and overall KAB scores were all inversely associated with 24-h urinary sodium excretion. For every one-point increase in the KAB score, the 24-h urinary sodium excretion decreased by 0.851 mmol (95% CI: −1.095, −0.602). We also found that location (rural/urban), sex, age, and education are associated with salt-related KAB scores. These results suggest that large-scale health education is needed to reduce salt intake in the Chinese population. In particular, efforts should be focused on reaching those who live in rural areas with low educational levels and older people.

Public health emergencies have a significant impact on the health of citizens, the local economy, and society as a whole. Currently, in many parts of China, there is a widespread lack of the knowledge and skills required for emergency preparedness and self-rescue. By carrying out targeted health education and intervention activities, and by popularizing the knowledge and skills in health emergencies, the abilities of citizens to respond to public health emergencies and protect themselves, reduce property damage, and eliminate unnecessary panic may be greatly improved. The knowledge and skills of the public to respond to public health emergencies after an intervention in Sichuan province were surveyed. The conditions before and after the intervention were compared, and the effect of the intervention was evaluated. Four counties in Sichuan province were selected for baseline survey by means of a multistage random sampling method. Among the districts and counties, one of each was selected for baseline survey as an intervention group and another of each were selected as controls. After 1 year of intervention, respondents were selected from the intervention group by means of the method used for the baseline survey for effect evaluation. Results: After statistical analysis, it was shown that, after the intervention, the total awareness rate of knowledge to respond to public health emergencies increased from 42.6% to 58.4% among men and from 42.9% to 55.8% among women, both significant differences (p < .001). It was also shown that the total awareness rates of the 18–35, 36–45, 46–60, and 60+ age-groups, respectively, increased from 44.5%, 43.7%, 42.2%, and 37.8% to 62.1%, 56.0%, 56.8%, and 51.9%, which were also significant differences (p < .001). Intervention, educational level, occupation, discussion with the families, and disaster experience were the main influential factors for the knowledge and skills of sudden public health events. The study results show that, after the intervention in Sichuan province, the knowledge and skills of the public to respond to public health emergencies were significantly improved. It is also shown that health education interventions must be developed in accordance with geographical features, the educational level of the population, age characteristics, and other factors.

Background: Globally, cardiovascular diseases are leading causes of mortality and disability, with hypertension being a major risk factor. Reducing salt intake and blood pressure are among the most cost-effective health promotion strategies. While mobile health (mHealth)– and school-based salt reduction interventions have proven effective in trials, their impact when scaled up in real-world contexts remains uncertain. Objective: We evaluated the effectiveness of the real-world implementation of an mHealth- and school-based health education scale-up program to reduce salt intake (EduSaltS [mHealth and school-based education program to reduce salt intake scaling up in China]). Methods: A parallel cluster randomized controlled trial was conducted from April 2022 to July 2023 across 20 schools in 2 districts and 2 counties within Ganzhou City, Jiangxi Province, China. Schools were randomized 1:1 to intervention or control groups within each district or county. One third-grade class per school and 26 students per class were randomly sampled. One parent, or alternative family member (aged 18-75 years, residing with the student), of each student was invited to join. The EduSaltS intervention, spanning over 1 academic year, incorporated both app-based health education courses and offline salt reduction activities, with participation monitored through the backend management system. The intervention’s effectiveness was assessed by comparing changes in salt intake and blood pressure between groups from baseline to 1-year follow-up using surveys, physical examination, and 24-hour urine tests. Results: Of 524 children (boys: n=288, 54.96%; age: mean 9.16, SD 0.35 years) and 524 adults (men: n=194, 37.02%; age: mean 40.99, SD 11.04 years) who completed the baseline assessments in 10 intervention and 10 control schools, 13 (2.48%) children and 47 (8.97%) adults were lost to follow-up. All schools and participants showed satisfactory intervention adherence. Measured differences in schoolchildren’s salt intake, systolic blood pressure, and diastolic blood pressure, between the intervention and control schools, were –0.24 g/day (95% CI –0.82 to 0.33), –0.68 mm Hg (95% CI –2.32 to 0.95), and –1.37 mm Hg (95% CI –2.79 to 0.06), respectively. For adults, the intervention group’s salt intake decreased from 9.0 (SE 0.2) g/day to 8.3 (SE 0.2) g/day post intervention. Adjusted changes in the intervention (vs control) group in salt intake, systolic blood pressure, and diastolic blood pressure were –1.06 g/day (95% CI –1.81 to –0.30), –2.26 mm Hg (95% CI –4.26 to –0.26), and –2.33 mm Hg (95% CI –3.84 to –0.82), respectively. Conclusions: The EduSaltS program, delivered through primary schools with a child-to-parent approach, was effective in reducing salt intake and controlling blood pressure in adults, but its effects on children were not significant. While promising for nationwide scaling, further improvements are needed to ensure its effectiveness in reducing salt intake among schoolchildren. Trial Registration: Chinese Clinical Trial Registry ChiCTR2400079893; https://tinyurl.com/4maz7dyv (retrospectively registered); Chinese Clinical Trial Registry ChiCTR2000039767; https://tinyurl.com/5n6hc4s2

Background: While the mHealth and school-based scale-up intervention for salt reduction (EduSaltS) effectively reduced salt intake and blood pressure among adults living with participating schoolchildren, the sustainability of these effects remains uncertain. This study aimed to evaluate whether these effects persisted one year post intervention. Methods: A one-year follow-up of a cluster randomized controlled trial was conducted, involving 524 children and their 524 adult family members from 20 primary schools. At 24 months, 509 children (97.1%) and 486 adults (92.7%) completed the assessment. Mixed linear models were used to analyze the difference in changes in salt intake between the intervention and control groups at 24 months, compared to baseline and 12 months, as measured by consecutive 24 h urinary sodium excretions. Secondary outcomes included the differences in changes in blood pressure and salt-related knowledge, attitudes, and practices (KAP) scores. Results: The adjusted mean difference in changes in salt intake between groups was −0.34 g/24 h (95% CI: −0.94 to 0.26, p = 0.265) for children and −0.72 g/24 h (95% CI: −1.48 to 0.05, p = 0.065) for adults at 24 months versus baseline. The corresponding differences from 12 to 24 months were −0.09 g/24 h (95% CI: −0.69 to 0.51, p = 0.775) for children and 0.29 g/24 h (95% CI: −0.50 to 1.08, p = 0.468) for adults. The adjusted difference in changes in adult blood pressure showed a slight, nonsignificant rebound at 24 months. The intervention group maintained significantly higher KAP scores than the control group at both 12 and 24 months. Conclusions: The effects of EduSaltS on reducing salt intake and blood pressure in adults diminished slightly one year after the intervention ended. However, sustained improvements in salt-related KAP were observed in both children and adults. Ongoing support is vital to sustain long-term salt-reduction behaviors.

The use of low-sodium salt substitute (LSSS) has the potential to reduce sodium and increase potassium intake. LSSS has been available in the Chinese market for years. However, its real-world use and impact on sodium/potassium intake is unclear. Baseline data of 4000 adult individuals who participated in three similarly designed randomized controlled trials were pooled together for this analysis. Self-reported awareness and use of LSSS were collected using a standardized questionnaire, and the participants’ 24-h urinary sodium and potassium excretion was used to estimate their dietary intake. Mixed-effects models were developed to assess the relationship between LSSS and 24-h urinary sodium and potassium excretion. 32.0% of the participants reported awareness of LSSS and 11.7% reported its current use. After adjusting for location, sex, age, and education, compared with the group of participants unaware of LSSS, participants who were aware of but not using LSSS and those who were using LSSS had a lower 24-h urinary sodium excretion by −356.1 (95% CI: −503.9, −205.9) mg/d and −490.6 (95% CI: −679.2, −293.7) mg/d, respectively (p < 0.001). No significant difference was found for 24-h urinary potassium excretion or sodium-to-potassium ratio among the three groups (p > 0.05). In conclusion, the findings of low usage of LSSS and the reduced urinary sodium excretion associated with the awareness and use of LSSS provide further support for the prometon of LSSS as a key salt reduction strategy in China.

Objective: To systematically evaluate the impact of a school-based sodium reduction education program using mobile health (mHealth), known as EduSaltS, on salt-related knowledge, attitudes, practices (KAP) and sodium intake among adults and children during its real-world scaling-up and to examine geographic and population heterogeneity in its effects. Methods: A multi-center pragmatic pre–post study design was used. The EduSaltS program was implemented in three cities (Ganzhou in southern China, Zhenjiang in eastern China, and Qinhuangdao in northern China) between April 2022 and July 2024. Ten primary schools were selected from each city. Baseline and follow-up surveys were conducted approximately 12 months apart, aligned with the school calendar. Electronic questionnaires were used to collect baseline and post-intervention data on the primary outcome—salt-related KAP—from adults and children. In Ganzhou and Zhenjiang, 24 h urine collections were conducted to measure urinary sodium excretion. Results: A total of 721 adults and 770 children were included in the final analysis. After the intervention, the total KAP scores significantly increased in both adults and children across the three sites: by 8.7–10.0 points in adults and by 11.4–16.7 points in children (all p < 0.001). The changes in sodium intake showed significant heterogeneity. A significant decrease in urinary sodium was observed among adults in Ganzhou (−14.0 mmol/24 h, 95% CI: −26.1, −2.0, p = 0.022), corresponding to a reduction of 0.82 g in daily salt intake. No significant change was found among adults in Zhenjiang (adjusted difference: −0.7 mmol/24 h, 95% CI: −13.4 to 12.0, p = 0.912). In children, after the one-year intervention, urinary sodium excretion showed a significant increase from baseline to follow-up in both cities (Ganzhou: +12.9 mmol/24 h, p = 0.018; Zhenjiang: +14.0 mmol/24 h, p = 0.0002). Conclusions: The pre–post evaluation showed that the EduSaltS program was associated with significant improvements in salt-related knowledge across regions. Its effectiveness in reducing sodium intake, however, varied substantially by population and geographic location. The observed increase in children’s urinary sodium excretion may partly reflect normal childhood growth and the limitations of a pre–post design without a control group. Pragmatic randomized controlled trials are warranted to verify the effectiveness of such interventions in reducing sodium intake and blood pressure across diverse populations and settings.