Effectiveness of digital education approaches to improve knowledge, attitude, and practice towards salt intake in a sample of UAE population
Background: According to the World Health Organization (WHO), total deaths due to Cardiovascular diseases (CVDs) recorded are ranged 24-46 % in the Gulf Cooperation Council (GCC) countries. High blood pressure (≥ 130/80 mmHg), is considered one of the major risk factors for CVDs and salt reduction is an effective strategy to prevent adverse risk. This doctoral work aims to translate and validate the original validated- Knowledge attitude and practice (KAP) questionnaire toward salt into Arabic, to assess intake of sodium and potassium in healthy United Arab Emirates (UAE)-residents using 24-hour urinary sodium excretion which is considered the gold standard method recommended by WHO, to estimate salt intake, alongside their (KAP) toward salt. It also aims to evaluate the effectiveness of digital intervention approaches to deliver educational material regarding salt intake. Methods: KAP questionnaire for salt intake was translated to Arabic and validated for the UAE population with 156 participants. Then, a cross-sectional study with 191 UAE participants evaluated the KAP towards salt intake along with measuring 24-hour urinary sodium and potassium. Food records were used to identity the highest sodium food sources consumed by participants. The effectiveness of digital educational material to reduce salt intake delivered via weekly short WhatsApp messages versus fortnightly brochure email attachment was tested in a randomised controlled parallel study (N= 121). Forty participants from the two intervention groups were later interviewed retrospectively to provide insights into the educational material and their delivery methods. Results: The internal reliability for the Arabic KAP questionnaire was confirmed with Cronbach’s α exceeding 0.7 and validity was confirmed by content validity ratio and construct validity. The mean urinary sodium and potassium were 2816.2± 675.7 and 1948.7± 473.1 mg /day, respectively, which were significantly higher in sodium and lower in potassium compared with the WHO recommendation. Compared to the control, sodium intakes decreased significantly in both the WhatsApp and e-mail groups with improvements in salt intake-specific food and health related knowledge. Qualitative analysis revealed that 95% of the interviewees preferred receiving digital education through WhatsApp over the email. Nonetheless, 35 out of 40 identified benefits from the educational material but pointed to the lack of low-salt bakery product in the market and recommended having dedicated low-salt aisles or labels for low-salt products. Conclusion: The Arabic KAP questionnaire is a valid tool to assess KAP towards salt intake and this is the first study used validated Arabic KAP questionnaire. Two-thirds of the study population exceeded WHO recommendation for salt intake with poor food-related knowledge. Digital platforms could be an effective tool for providing awareness on salt intake in the UAE region with WhatsApp being preferable over email communication. The lack of low salt alternatives was indicated as the main barrier for lowering salt intakes. Salt alternatives, their visibility and availability can be recommended in future studies to measure their effectiveness in salt reduction in this part of the world. This study also highlighted important of nutrition education to improve KAP toward salt intake and reduce intake if salt intake in sample of UAE population.
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