Review of behaviour change interventions to reduce population salt intake.

BACKGROUND: Excess salt intake is a major cause of raised blood pressure-the leading risk factor for death and disability worldwide. Although behaviour change interventions such as awareness campaigns and health education programs are implemented to reduce salt intake, their effectiveness is unclear. This global systematic review investigates the impact of population-level behaviour change interventions that aim to reduce salt intake.

METHODS: A search for published and grey literature was conducted using PubMed, Cochrane Library, Embase, Web of Science, Sage, Scopus, OpenGrey, Google Scholar and other relevant organizations' websites. Studies were included if 1) published between 2005 and 2015; 2) the education or awareness-raising interventions were aimed at the population or sub-population and 3) salt intake and/or salt-related behaviours were outcome measures. Study and intervention characteristics were extracted for the descriptive synthesis and study quality was assessed.

RESULTS: Twenty two studies involving 41,448 participants were included. Most were conducted in high income countries (n = 16), targeting adults (n = 21) in the general population (n = 16). Behaviour change interventions were categorised as health education interventions (n = 14), public awareness campaigns (n = 4) and multi-component interventions (including both health education and awareness campaigns, n = 4). 19 of the 22 studies demonstrated significant reductions in estimated salt intake and/or improvement in salt-related behaviours. All studies showed high risk of bias in one or more domains. Of the 10 higher quality studies, 5 found a significant effect on salt intake or salt behaviours based on the more objective outcome assessment method.

CONCLUSION: Based on moderate quality of evidence, population-level behaviour change interventions can improve salt-related behaviours and/or reduce salt intake. However, closer analysis of higher quality studies show inconsistent evidence of the effectiveness and limited effect sizes suggest the implementation of education and awareness-raising interventions alone are unlikely to be adequate in reducing population salt intake to the recommended levels. A framework which guides rigorous research and evaluation of population-level interventions in real-world settings would help understand and support more effective implementation of interventions to reduce salt intake.