Strategies for Salt Reduction in Australia

This document discusses the issue of high blood pressure and its association with cardiovascular diseases. It explores the efforts made in Australia to reduce salt intake and prevent non-communicable diseases. The document also highlights the initiatives, partnerships, and research methods used in this process.

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Problem statement
Globally, the issue of high blood pressure has risen to great level, which is associated
with cardiovascular disease and ischemic heart disease to 62% and 49% respectively (WHO,
2002). Due to above-stated reason, it requires universal effort to give guidance for maintaining
diet that will focus on lower intake of sodium. According to report of world health which got
published by WHO in 2002, the best cost-effective method to lower the risk of cardiovascular
disease is to implement strategies to lower the sodium intake by the growing population globally
(WHO, 2002). In the year 2003, a practical report by WHO and FAO of United Nations
highlighted that daily intake of sodium should not be more than 5 gram by the peoples (WHO,
2003).
Federal government of Australia, in the year 2013, set a goal to lower the intake of
sodium (salt) worldwide by 30 % by 2025. The objective was one of the nine targets of the
United Nation that focused on diminishing the incidence of non-communicable disease (NCD)
by 25% by 2025 (World Health Organization, 2008). Cardiovascular disease among the NCDs is
the primary reason for high mortality rate than other combined causes (World Health
Organization, 2008). In 2012, Out of three dead, one death was because of cardiovascular disease
in Australia and ischemic heart disease followed by the cerebrovascular disease is another reason
for high death rates (Australian Bureau of Statistics, 2018; Australian Bureau of Statistics, 2012).
It is evident from the study that by lowering the intake of sodium, blood pressure will
also get reduced which links with reduction in premature deaths due to heart stroke and disease
(He & MacGregor, 2008). Further, it can be said that the most cost-effective way to reduce

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problem of NCDs is to lower the salt intake in Australia and worldwide (World Health
Organization, 2011; Cobiac, Magnus, Barendregt, Carter & Vos, 2012).
Australian Division of World Action on Salt and Health (AWASH)
AWASH got recognized in the year 2005, demonstrated on cash of UK and affiliated
with World Action on Salt and Health (WASH). In 2005, WASH was established, is a global
association with motive to improvise the population health by targeting worldwide reduction of
the salt intake (WASH, 2014). In the year 2007, a campaign ‘DROP THE SALT” was launched
by AWASH to influence the government to construct a strategy for reduction of national salt.
VicHealth salt reduction partnership
A health promotion foundation of the which is situated in the Victoria called VicHealth
resides about 6 millions of peoples and 1/4th of which is Australian population. VicHealth has
recognized public health benefit and established the partnership at state level to lessen the
population salt intake (Webster et al., 2015). In 2015, an action plan was to be launched that
intends to work in association with the food industry, government and NGO, public of Victoria
with aim to develop share word to salt strategies. This comprises of initiatives to include
Victorian's view on high level of sodium in foods. It also includes to support leadership and
governmental policy; working with partners of food industry to search new solutions for
lowering the salt in foods and a platform to observe and analyses the progression of the
initiatives (Webster et al., 2015).
Solution generation- description of initiative
In the year 2014, at The George Institute, WHO Collaborating Centre for Population Salt
Reduction prepared a study on “A Case for State action on salt in Australia – evidence and

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opportunities for action” majorly for the VicHealth promotion foundation. According to the
report and its recommendation, VicHealth is headed as the taskforce for reduction of salt and
device five key steps to lower the salt intake in Victoria; those steps are as follows:
1. To construct partnership
2. To promote public awareness regarding significance of salt reduction and its behaviour.
3. To reinforce federal and state policies to build supportive atmosphere to lower the salt
consumption.
4. To develop new approach to involve the food industry to lower the salt in the food.
5. To undertake new research monitoring and its examination to regulate the influence of
the initiative.
In the logic model, reflects the work of the intervention components, its interaction and
pathways to attain the low salt intake in Victoria. VicHealth and the Heart Foundation are the
leaders for implementing such interventions, with support from groups.
Strategic Partnership
The first part of the strategy focused on the state-level association to lower the salt by
mounting a strategic partnership. This included involving the non-governmental organizations
(NGO), organization concerned to health, government and academia and recognizing opportunity
for organizing and assimilating efforts to lower the salt intake into the current initiatives. An
association of the nine organizations gives guidance regarding strategic intervention, with the
collaboration of another group.

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Increase Public Awareness to Improve Attitudes and Change Behaviors
The campaign of public awareness comprises of the many steps which focus on
communicating thoughts related to the health risk of salt intake, level of consumption of salt,
what is the source of salt in the diet and way to approach to lower it. The campaign aims to
improvise the behaviour related to action of reduction of salt and acquiring salt lowering attitude.
The leading target group for such campaign are women of 35-45 age and children of 0-12 years.
Information related to the campaign focusing on the knowledge and attitude of people towards
low salt is communicated by formative research.
Further, knowledge about the behaviour and examination of each step of the campaign is also
communicated. Another way to spread information is online mode, use of static and social media
advertisement. Those channels are paid; however, outstanding experience for the campaign is
produced with the help of media coverage through heart foundation.
Policy Development and Strengthening
Another different part of the strategy is to influence the current federal and state health
policies regarding salt reduction and advocate for important government action. Utilizing the
examination of the situation, current system was known which comprise of nutrition standard of
food acquired in the institution, guideline for nutrition catering, labelling of nutrients 2018, 10,
9985 out of 12 foods and to include government action to involve in food industry with motive to
encourage healthy eating (Healthy Food Partnership). The partnership strategy sustenance policy
action and strengthen the component for salt reduction.
Furthermore, the partnership encourages the government to obligate three salt reduction
initiatives. Those actions are as follows:

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1. Begin reformulation of sodium in foods
2. Begin investigation systems to observe sodium levels in foods and salt intake of
population.
3. Start a campaign for healthy eating focusing on sodium intake in the diet.
Innovative Approaches with Food Industry
It is known that in Australia more than 75 % of salt intake comes from consumption of
the processed and packaged food, it is vital for the partnership to develop strategy for making
investment and applying new idea and approach to involve all the small and large food
manufacturer to reduce the salt content in the food products. This also calls for educating the
manufacturers to make them understand the basic need to lower the amount of salt in the
packaged food. This can be done by establishing and making them know that salt can be reduced
without any loss of market share. To encourage the manufacturer to make product lower in salt,
the partnership will arrange meeting with the food industries.
Research, Monitoring and Evaluation
The current informational and ongoing investigation is initiated to enlighten and
improvise the structure of the interventions. Such involves study to understand the knowledge
and worth of Victorians regarding salt, to communicate key message about the campaigns,
examination of the campaign, to analyses the situation to determine the options to work with the
food industry and observe the engagement of the sector with the linked partnership interventions.
Resource mobilization
1. Highlight the potential obstacles and enablers that could be the reason for influencing the
method of implementation of the strategy.

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2. Give details about the strategy that can be employed to recognize those obstacles and
enablers.
Implementation/outcome assessment
The method of examination of the complex intervention is conducted relied on the
guidance of the UK Medical Research Council. This involves a detailed understanding of the
intervention program and way to how the framework affects the implementation process and its
related outcome and the mechanism of its influence. For the public health interference, two
structural frame has been developed, and conversion of the indication into the setting of real-
world was utilize to inform the process of evaluation and its related dimension. The framework is
guided by the Linan and Steckler, where the process of assessment inspected the dose, its fidelity
and theory. The structure that was selected with the reason that it used many different
frameworks, thereby ensures all the inclusiveness and its flexibility to various complex
interventions.
Furthermore, the dimension was used from the framework based on RE-AIM, which say about
the Reach, Effectiveness, Adoption, Implementation and Maintenance. This helps to understand
the influence of the health of public program, which is beyond its efficacy and result. The
acceptance which relates to the portion and representativeness of the organization that approved
the interference and related policy. All such procedure is more pertinent for the intervention for
reduction of salt. It is regarded as recruitment. Another term effectiveness' is used to reflect the
positive and the negative effect of each of the interventions and its components which need to be
included. The data given on the cost of each of the response gathered for the evaluation of cost-
effectiveness, is also used in the steps and process of assessment to establish the level of its
implementation and replicability of the information.

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Data Collection Methods and Analysis
For collection of data and its analysis, pragmatic mixed approach is used which is known
to minimize the overload and burden so that it cannot affect the delivery of the interferences,
while it maximizes the understanding of the process of the interventions. For each of the step of
intervention and it is component, particular indicator which is related to each examination can be
mapped. The method of data collection is determined by initial examining all the documents and
then calls for its recognition of short methods to gathers that residual data.
The six important methods are as follows:
1. Collect the data routinely
2. Survey of the population of the Victoria
3. Evaluation and tracking of the campaign
4. Investigation of the sodium content available in the packed food.
5. Investigation of the organization, the public institution and food industry.
6. Semi-structured survey which involves the implementers, the key stakeholder and the
partnership members.
The data collected from the survey of Victorian peoples and its related sodium level,
which is high in the packaged food is quantitative. The data were analyzed using the STATA IC
version 13.0 windows (StataCorp LP, College Station, TX, USA). The qualitative data was being
generated, and with the help of matric, it will be uploaded by the utilization of NVivo 11. The
quantitative data will be aligned with the qualitative data to provide information about the
dimension of evaluations. For example, to understand the efficiency of the reformulated food
product, the quantitative measure would be like to want to extend there is change in sodium

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content in the target category of food. The information collected will then be considered for the
interview process and give response to the stakeholder of the food industry that whether the case
studies are useful for motivating people to lower the content of salt in the food product.
Routinely Collected or Administrative Data
The data which is collected in routinely manner tends to have information which is
provided regularly by the implementer of the interventions such as partnership action plan, media
reports, group meeting, and costing information. The descriptions of the action plan and meeting
minutes are employed in collecting detailed data based on the interference that is being
delivered. The reports give details about the number of audiences that have managed to reach
with the help of media, social media activity, website click and type of public dialogue. All such
supported reduction of salt and they are collected with the media release, advocacy events and
campaign phase. In association, excel template was constructed to gather detail information
about the activities which is implemented, the staffs which are involved in the delivery of the
interference, the amount of time that is taken and reacted cost from perspective of health sectors.
Each of the organization has to complete their respective template related to the component of
intervention that are included in the implementation process. The data collected focus to inform
reach delivered dose, effectiveness and cost involved in the element of interventions. The
documents will then be uploaded and generated in NVivo.
Surveys of the Victorian Adult Population
The questions which are prepared administered pre-intervention and as well as post
interventions. Such questionnaires are then used to collect data which is based on the exposure to
the component faced by the community and intellectuality of the populations related to the salt.

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The parents and care giver of the children who were of less than 18 years of age were
interviewed additional questions related to their behaviour in salt consumption. Total of 2000
member will be recruited based on the age of 18 to 65 years old, their socio-economic status and
the locality, the member will be the representative of the Victorian population. In the year 2015,
for pre-intervention, the method of recruitment involved intercept survey which is held in the
Shopping Centre, through social media or the consumer panel. The detail information about the
cross-sectional survey has been already published. In the year 2018 and 2019 mid-point survey
was conducted with the motive to recruit analogous sample total of 2000 peoples which have
used consumer research panel only. The method is the most reliable to get better result. The end-
point survey was conducted in the year 2020 aim to use the method of consumer research panel
and the study of intercept held in shopping Centre. Such survey gives idea about the reach,
effectiveness and dose (which is related to the change in information and salt lowering attitude of
peoples).
Furthermore, if the difference is noticed in the reach, dose and effectiveness among the
various demographic and clinical features which comprise of the age, sex, race, ethnic,
education, responsibility of the household for shopping the grocery, the detail history of the
cardiovascular illness and utilization of the antihypertensive drugs, then multivariate regression
analysis is done.
Targeted Campaign Tracking and Evaluation
In association with the survey, to examine the reach, dose and effectiveness fidelity an
independent consumer research group are being used. The process of evaluation happens will
takes place one after the other of each phase of campaign. The detail information regarding the
contextual influence and key message among the selected audience is used to improvise the

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phase of campaign and confirms the critical information that has been understood before
progress to next stage of change of attitude. Those evaluations are employed for the short term
output that needs to be detailed and documented to the VicHealth executive board.
Surveys to Food Industry Organizations and Public Institutions
Pointed questions will then be transferred to the food industry and its related organization
such as food manufacturer, the importer, the retailer and caterers.) Besides with the public
institutions. The main goal is to understand its involvement with the Victorian salt reduction
nutrients 2018, 10, 998 9 of 12. The main aim of the survey is to involve representative samples
or the organization related to the sodium levels of foods. The data collected from the
examination and interview and the data collected routinely will inform the reach and adoption.
Sodium Content in Packaged Foods
The survey of the processed and packaged food and the information related to the
nutrition will be systematically composed of the four leading supermarket in Australia. The data
collected from each of the product, and it will be entered using food switch.
Semi-Structured Interviews
The interview will be held with participation of the strategic partnership of federal and
state government, the food industry and the NGO who are working in the field of health during
the pre and post intervention. The survey with the industry will focus to include each
representative sample of the organization.

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Dissemination
The result of the process of evaluation is given back to the Victorian salt reduction
partnership implementation team. The information will be sent from very first year of the
application with details updates of 3-6 months. Hence the adaption can be easily made. Data can
be disseminated with the help of approaches which included the media, meeting with maker of
the policy and international audience. Further, the process of the examination will be
disseminated to other governmental state and federal legislation to encourage the support for the
development of the multicomponent regarding the salt reduction interventions.