Behaviour change and what SA is doing - · PDF fileResearch Council, Nutrition Society of SA •Local and international expert advisors ... •Most useful medium for information about

Erika Ketterer

RD(SA)

August 2013

Behaviour change and what SA is doing

for salt reduction

Introduction

Why the need for behaviour change?

What SA is doing to reduce salt intake

Knowledge and behaviours about salt in SA

What Salt Watch SA is doing

Presentation Outline

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• Why salt reduction?

- Strong association between high salt intake and hypertension

- Prevalence of hypertension in SA is unacceptably high and rising

- Economic burden posed by hypertension

Introduction

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WHO, 2012; Bradshaw, et al 2010; Pestana et al. 1996; Webster et al 2011)

Why the need for behaviour change?

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Salt intake source % contribution

UK study

Table salt / cooking (discretionary salt) 15%

Natural 5%

Food industry 80%

Europe

Table salt / cooking (discretionary salt) 15%

Natural 10%

Food industry 75%

SA study

Table salt / cooking (discretionary salt)

Black 46%

Mixed ancestry 33%

White 42%

Natural 5%

Food industry (bread, hard marg, soup powders, salty snacks, cereals, meat products)

55%

Henderson, et al. 2003; Charlton et al. 2005

40% on average

How can we achieve our salt reduction goal?

Salt intake Source g/day Reduction

needed

Target intake

g/day

Table/cooking (40%) 4.4 g 55% reduction 1.9 g

Natural (5%) 0.6 g No reduction 0.6 g

Food Industry (55%) 6.0 g 55% reduction 2.5 g

Total 11 g Target 5 g

In order to reach target of 5g/day, a 17 - 55%

reduction is needed over 7 years

Salt intake in SA = 6 – 11 g/dayWentzel-Viljoen, et al; 2013

• Why an awareness campaign and public education? – Success stories i.e. Finland, UK

• What is this campaign?– Reviewed global salt reduction strategies & SA experiences around

tobacco control lobbying and HIV awareness campaigns to identify • What worked and what didn’t

• Who to reach e.g. consumers, health professional, catering industry, media, religious groups, etc.

• Who to partner with

• Assessed SA consumer behaviour from different LSM groups

• Design campaign

How do we get the public to reduce discretionary salt = awareness campaign to change behaviour

Reviewing global salt reduction strategies

AWASH, Journal of Hypertension 2011, 29:1043–1050

Webster et al. 2011

Review of 32 country salt reduction initiatives

South Africa

26 led by government5 led by NGOs1 led by food industry

√

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x28 working with food industry to reduce salt in foods √

28 had consumer awareness or behaviour change programmes

In progress

27 had set max population salt intake targets √

28 had some baseline data on salt consumption ±

5 with evidence of programme efficacy (Finland, France, Ireland, Japan, UK) To be assessed

Effective global practices and what SA is doing

AWASH, Journal of Hypertension 2011, 29:1043–1050

Webster et al. 2011

GOALTo reduce the average salt intake of the South African population to <5g per day

by 2020

Effective strategies to reduce sodium

South Africa

Partnership and regulation of the food industry

√

Reformulation of processed foods √

Target consumer education about the effects of excess dietary sodium on health

In progress

Consumer-friendly food labelling to identify low-sodium products

x

Increased access and availability of low-sodium foods

±

Mohan et al., 2009

Finland> 40% drop in salt intake from 14g to 8 g/day 10mmHg decline in BP 70% reduction in deaths due to stroke & CHD

UK15 % drop in salt consumption from 9.5 to 8.1 g/day increase in consumer awareness

(1/3 population aware of recommended level)

UK

Salt Watch SA – driving salt reduction in SA

1st inter-sectoral meeting – May 2012

Salt Watch – March 2013

• HSF, North-West University, University of Pretoria,

Consumer Goods Council SA, ADSA, Medical

Research Council, Nutrition Society of SA

• Local and international expert advisors

(Profs McGregor, Bruce Neal, Karen Charlton)

• Independent platform

• Intersectoral collaboration

• Coordinated by the HSF

• Member of WASH

1. Educate South Africans on the dangers of high salt intake on health2. Lobby stakeholders to support legislation

Role of Salt Watch SA

The overarching goal is to reduce salt intake in the South African population to < 5g per day by 2020

Reduce discretionary salt

Food industry reduces salt in processed foods

Public health education

Choose lower salt products

Salt reduction through

behaviour change

Awareness of high salt and hypertension

Lower discretionary salt

Choose lower salt productsMedia

Journalist training

Lobby catering industryTraining bodies, faculties and associations

Clinics / hospital menus

Industry meetings

Restaurant, fast food

Lobby health professionals & healthcare industry

Professional bodies e.g. ADSA, NSSA

Training curriculum

Industry e.g. Dieticians, Pharmaceutical, Pharmacies, insurance etc

Congresses, CPD, Journals

Collaboration

Government

Food industry

NGO’s

Advertising / marketing campaign

Consumers & all South Africans

• Preliminary insights from only research and consumer surveys (K.Charlton, Bletchley Park, Unilever)

• Ongoing data collection to inform initiative

• Some of the questions to ask:- Link between high salt in diet and hypertension?

- How much is too much?

- Sources of salt in their diets?

- Cultural beliefs and myths?

• Recognize barriers for reducing salt?- Is food security an issue?

- Is economics an issue? Salt is a cheap alternative to add taste

• Do we know how to read labels?

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Understanding the knowledge and behaviours of South African consumers

• Charlton• Cross-sectional study of on diet and BP in 3 ethnic groups

(n = 325; hypertensive and normotensives)

• Only 21% of people with hypertension indicated “avoidance of salt and salty foods”

• Knowledge was poorest in Black (10%), then mixed ancestry (23%), then White (26%) race groups

• Dennison• Cross-sectional study on determinants of hypertension care &

control in 3 townships in SA: Hi-Hi study(n = 403; hypertensive black patients)

• Private sector hypertensive patients more aware of need to reduce salt than public sector patients

Charlton et al. 2005; Dennison et al. 2007


• Unilever • Consumer research on sodium intake & behaviour change

(Online survey, FFQ sodium intake; n = 996; LSM A/B)

• Results• Majority (62%) started contemplating or changing behaviour already• Majority (66%) didn’t know about sodium intake recommendations• Respondents with high intake were not aware of their high current intake• Respondents were confident they could reduce sodium intake (taste less of an

issue in last stage of behaviour change)• Most helpful strategies for reducing sodium were: use of herbs/spices, then

labels indicating salt content• Prefer to be told about salt reduction by medical professional• Most useful medium for information about salt reduction - TV

Van Zweden et al. 2012

Insights from consumers

• Flavour

• Salt’s primary role is to add more flavour to food

• This is most acute in lower income households, where salt is the cheapest and most readily available way to flavour bland food

• This can be in the form of:- salt added during cooking- use of stock cubes- spices such as Aromat, Barbecue Spice

and Chicken Spice- discretionary salt added at the table

FLAVOURInsights from consumers

Bletchley Park, 2013

• Taste

• Cross-sectional study on diet and BP in 3 ethnic groups in SA(n = 325; hypertensive and normotensives)

₋ more black than other ethnic subjects reported adding salt to food before tasting it and reported that they liked their food to taste very salty

₋ important economical sources of sodium used in these groups were soup powders, stock cubes and flavour enhancers


Charlton et al. 2005

• Preservative

• In rural and township communities, salt is liberally added to meat to preserve it from the elements

• Roadside butchers are particularly responsible

• In shisa nyamas, where huge amounts of meat are consumed, salt, spices and Aromat are used generously

• Meat is part of culture and salt is seen as going hand in hand with meat



• Health and cultural beliefs

• In traditional, lower to lower-middle income communities, there is a widely held belief that salt has considerable health benefits

• Especially in Eastern Cape, KZN• Drinking salt water regularly and salt-

water enemas is seen as part of a healthy lifestyle

• This is encouraged by traditional doctors for general cleansing purposes and for treating specific health complaints (e.g. stomach)

FLAVOURInsights from consumers


• Link between salt and health

• Township consumers are aware of salt and health link (via family or friends who had seen doctor)

• But don’t know why it is bad, so they distrust message

• Only those who had heard first hand from a doctor that too much salt is bad for their heart accept it as fact



• Spiritual and cultural beliefs

• There are some strong beliefs in rural and lower income communities that food left unsalted will be eaten by the Tokolosh

• Also, salt mixed with water is often sprinkled around homes to remove evil spirits

• As mentioned before, salt cleansing is also prescribed by traditional healers, and large religious groups like the Zionist Christian Church(estimated at over 5 million members nationwide)



HSRC

Food security & knowledge• Cross-sectional population health survey

• SANHANES-1; n = 25 532; all age groups

• Over 1 in 4 were food insecure

• Only 1 in 7 considered nutrient content of food when shopping

Barriers to changing behaviours

HSRC, 2013

Bletchley Park

Economy

• Consumers in lower LSM’s are not living in circumstances they would consider to be ideal or healthy and are faced with many health trade-offs every day

• Life is often very hard, and they are aware that they could be living healthier, but anything that makes life a little easier (especially in basic necessities like making food palatable) is hard to give up

• The benefits must be seen to outweigh the sacrifice HSRC 2013; Bletchley Park, 2013;


• Nutritional survey of black African patients with heart failure in Soweto (n = 50)

• High salt intake was major problem, mainly due to bread, take-away foods, stock cubes and salt added at the table

• Barriers• Lack of knowledge of high salt foods and

healthy affordable alternatives• Perceptions that meals without added salt

were tasteless and boring• Lack of support of dietary change from

family members

Pretorius et al, 2011

MRC• Qualitative research assessing perceptions

and barriers to healthy eating in lower socio-economic communities

• n = 167; 22 focus groups in 4 provinces

Barriers• Many participants reported that cooking

healthily was expensive, not tasty and meant for people with existing chronic diseases

• There was also a general lack of knowledge and skills on how to cook more healthily


De Villiers et al, 2012

“I’m always fighting with my sister! She has hypertension and likes salt and aromat. I say NO,

you mustn’t use aromat. Aromat is wrong for your HBP, you will end up with kidneys. She said “I don’t care whether I die, you are here, you are

going to bury me”.

NONHLANHLA’S

STORY

NOGAME’S

STORY

Typical consumer portraits

Nonhlanhla’s Story

Hi I’m Nonhlanhla, but my boss calls me ‘Pretty’ because he cannot pronounce my name. I am a 40 year old African woman and I live in a 3-room RDP house in the heart of Khayelitsha. I live with my mother, sister and my 3 kids; in total we are 6 in the house. Sadly my father passed away last year from a stroke.

We love our home. It has running water and electricity; such a change from the 2 room corrugated iron shack we lived in last year. I work in Cape Town CBD as a shop assistant at Spar. I work from 7-5 every weekday and from 7-2 on Saturdays. It is tough, but I am really happy to have a job. Most people I know, including my sister, are unemployed. Along with my mother’s state pension of R1500, I support the household with my salary.

Attitude and ambitionsI am hardworking but I do also hold some resentment towards those better off than myself. It is hard for me to get a better job, because I have no tertiary qualifications. I want my children to get a good education so that they can support me in my old-age; they are my hope for the future.

Food purchasing behaviour

My sister and I do a bulk shop once a month after pay-day. This food must last us the entire month, because we have other expenses to cover. Here is what I buy: Rice, maize-meal, pap, samp and beans; stocks, gravy powders and soup-mix; tea and coffee; sugar, salt and fish oil- occasionally Aromat/Chicken Spice/Barbecue Spice; potatoes, cabbage and carrots; Chicken pieces and sometimes eggs. We store all food either in the cupboard or in the fridge.

Health status

The doctor says that I am overweight, but I don’t think so. I don’t want to be thinner, because then people may think I have Aids. He also says I have high blood pressure and that I should eat less salt and sugar and drink more water. Why must I do these things? When I eat salt and sugar I don’t get sick. They are so nice and I don’t know what else I must use in their place. Everything else, even Aromat, is too expensive. My food would be flavourless without salt. I will rather just take blood pressure tablets; I think these will help me more and at least they are free.

Consumer journey surrounding salt

Every day I wake up and make soft pap. I cook the pap with salt, and I eat it with sugar so that it is sweet. I also drink tea with 3 sugars in it. I have another 3 cups of sweet tea/coffee during the day; one mid-morning, one in the afternoon and one after dinner.

I eat again at lunch time. For lunch I mainly eat bread; most of the time with margarine and jam. I like white bread. Brown bread is for people with Diabetes.

I eat again at supper time; at around 6pm. For supper I will eat either rice/stiff pap/mielie meal and meat; that is if we have meat. If we have no meat then maybe some veg. I put salt in the water that I cook with and also on the food I eat. It gives it so much flavour. I also like to use stocks and gravy powder to add flavour. With meat though, Chicken and Barbecue Spice are the best. They come in paper sachets and are so cheap; this is good for us.


• Barriers

• Food insecurity• Cultural beliefs• Taste• Cost and lack of knowledge of

- affordable alternative spices- flavourants

• Lack of knowledge of high salt foods• Assessing nutrient content of food is

not a priority when shopping

• Conducting an advertising/marketing campaign

• Building partnerships with government and other programmes

• Lobbying catering industry

• Raising awareness and building capacity of health professionals and healthcare

What is Salt Watch SA doing?

Salt reduction through

behaviour change

Awareness of high salt and hypertension

Lower discretionary salt

Choose lower salt productsMedia

Journalist training



Industry meetings


Lobby health professionals & healthcare industry


Training curriculum



Collaboration

Government

Food industry

NGO’s



Media

Journalist training

Collaboration

Government

Food industry

NGO’s

• Established support from DOH as partner in advertising campaign – Integrate message into government campaigns

(e.g. NNW – “Use salt and foods high in salt sparingly”)

– Integrate message in educational TV programmes

• CGCSA – Expertise and funding

• NGO’s – Commitment from CANSA and Diabetes SA as

initiative partners

• Media – Key stakeholder to disseminate message

– Media training (presenting to health journalists, e.g. Rhodes University end August 2013)

Building partnerships



Industry meetings


• Public/patients are no longer exposed to high salt foods in clinics, hospitals, canteens, restaurants and fast food establishments

• Lobby

– Training bodies to include salt message and alternative cooking methods in curriculum

– DOH and private hospitals to serve lower salt meals to patients

– Catering industry associations to reach canteens and restaurants• Remove salt shakers

• Reduce salt in cooking methods

Raising awareness in catering industry

Lobby health professionals & healthcare providers


Training curriculum



• Health professionals, including dietitians and healthcare service providers are key stakeholders for disseminating messages to patients, clients, public

• Lobby – Training bodies to include salt message in training curriculum

of health professionals and other relevant faculties

– Professional societies (HPCSA, ADSA, NSSA) in the healthcare space to get salt reduction messaging into newsletters and publications (e.g. HPCSA’s ‘Bulletin’, ADSA newsletters, etc)

• Present at all relevant local congresses, conferences, events(e.g. Nutrition Congresses, Symposiums) to spread our message

• Create CPD-linked articles

Raising awareness & building capacity of health professionals



Conducting national advertising/marketing campaign

• Created concept document and a funding proposal

• Identified key funders to approach

• Selected advertising / PR agency

• Presented draft concept to Salt Watch partners

• Finalising campaign concept

• Official launch of national campaign planned for March 2014

Salt Watch’s proposed advertising and marketing campaign

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Objective

To conduct a 10-year long national awareness campaign to educate South Africans and drive behaviour change

to reduce salt intake

• Increase awareness on high salt consumption and effects on health

• Carry call to action on behaviour modification:

₋ use less discretionary salt

₋ choose lower salt products

Primary:

• Parents and grandparents in rural and urban households in LSM 3-7

Secondary:

• Commercial entities like fast food chains, restaurant groups, enterprise catering companies

Target audience

LSM PROFILE% OF POPULATION

44Source: AMPS 2012

By targeting the LSM 3-7 market Salt Watch will be able to directly communicate to a large

percentage of the South African population. The message will also have spill over to upper as well

as lower income segments

Target audience

Communication objective

Key messages

YEAR PRIMARY SECONDARY

1 TOO MUCH SALT CAN LEAD TO HEART ATTACKS AND STROKES

• Use less salt with your food• Reduce it slowly and use

alternatives

2 EAT LESS SALT NOT MORE THAN 1 TSP/DAY

• Too much salt can lead to heart attacks and strokes

• Learn which foods are high in salt and how much you’re eating

3 CHOOSE FOODS THAT ARE BETTER FOR YOU

• Too much salt can lead to heart attacks and strokes

• Understand how much salt you’re eating

Strategic approach

Conversion funnel

Conversion funnel

CONSUMER

TV

RADIO

PR

MOBILE

WEB

USSD

SMS

ACTIV-

ATIONS

MOBISITE

MATERIALS

FLYERS &

PAMPHLETS

SOCIAL

MEDIA

AMBASSADORS

SCHOOL

PROGRAMSWORD OF

MOUTH

INFLUENCER

CAMPAIGNS

SEARCH

OUT OF

HOME

PARTNERS

COMMUTER GENERIC

STORY

INTEGRATIONGENERIC

STORY

INTEGRATION

HELLO DOCTOR

AWARENESS

PERSUASION

ACTION

STAKE-

HOLDERS

HEALTHCARE

INDUSTRY

CATERING

INDUSTRY

COMMUNITY

GROUPS

• Television

• Radio

• Hello Doctor Platforms

• Commuter activations

• Rank TV

• Transit Taxi TV

• Bus branding

• Mobile messaging

• Influencer campaigns

• Social media

Awareness communication channels

HELLO DOCTOR PLATFORMS

Hello Doctor TV Show:Television will flight on SABC 2 on

Sundays @ 13h30 reaching mass

consumers

Hello Doctor Website:Website is a portal for information

to get information to live a healthier

lifestyle and to get access to

doctors. Salt Watch can take part in

the community forum to give advice

on the benefits of lowering salt

consumption

Hello Doctor Mxit:Hello Doctor has a Mxit portal

where people can take part in

community forums. Currently has

over 400 000 members. Salt

Watch will be able to contribute

the community forums

Mobile App:Hello doctor will be launching

their mobile App soon. Thus a

doctor will be available with the

click of a button. Advertising

opportunityies are available for

partners

Hello Doctor Radio

Show:Hello Doctor will also have a show

available on Algoa FM, OFM, Kaya

FM and Vuma FM

Mobile Clinics:Mobile clinics will be placed at

major train stations. Salt Watch

can place communication at the

mobile clinic

• Television

• Radio



• Rank TV

• Transit Taxi TV

• Bus branding



• Social media


A roaming stage and actors will

travel throughout South Africa

performing an educational show

about Salt Watch

• Television

• Radio



• Rank TV

• Transit Taxi TV

• Bus branding



• Social media


Rank TV allows for a captivated audience when

people are queuing for public transport

• Television

• Radio



• Rank TV

• Transit Taxi TV

• Bus branding



• Social media


Transit TV will allow Salt Watch to communicate to a captive

audience. The commuter classes will also allow for detailed

messages to be communicated to the commuters and will

also allow for interaction with the ambassadors

• Television

• Radio



• Rank TV

• Transit Taxi TV

• Bus branding



• Social media


The back of bus branding will be used as mobile billboards to keep the message top of mind

Channels Reach Reach % Frequency

Television 19 644 800 80% 15

Radio 19 896 840 81% 40

Activations 50 taxi ranks(12,5 million commuters)

Rank TV 3 000 000viewers per week

Transit TV 2 400 000 viewers per month

Bus Branding 50 buses

Digital (Please call me) 12 000 000 messages

Television and Radio performance is measured by using media planning tool (Telmar)

The commuter reach is calculated by the foot count of commuters that make use of public transport at the public transport hubs

Bus branding is seen by commuters but also seen by general public on the roads

Performance summary

SCHOOL

PROGRAMSWORD OF

MOUTH

INFLUENCER

CAMPAIGNS

• We will also have influencer campaigns to carry the message into communities

• These influencers will work in urban townships giving talks, distributing materials and taking a house-to-house approach in lower income communities

- To persuade consumers to change their discretionary salt behaviour

- We need a ‘train the trainers’ methodology to equip consumers to spread the message in communities

• Social cooking projects through our influencers

- They can go to community groups and religious groups in lower income areas

- Show consumers how to cook traditional foods using less salt and using alternatives for flavour

Awareness: word of mouth

SCHOOL

PROGRAMSWORD OF

MOUTH

INFLUENCER

CAMPAIGNS

• In addition, these influencers, can work in the secondary school system to carry messages to parents and grandparents through school children

• Salt Watch will also be responsible for lobbying the Education Department to add our required salt reduction messaging into health segments of the school curriculum

Awareness: word of mouth

• Facebook, Twitter and MXiT will be cornerstones of Salt Watch’ social media plan

- will deepen education and make it easier for consumers to change their cooking and salt use behaviour

• Partnerships with our stakeholders play a critical role in helping us amplify our messages. These include:

- State/Private Healthcare: doctors, dietitians, nurses, clinics, hospitals

- Private Healthcare: Pharmaceutical companies, related disease management companies, NGO’s, medical schemes

- Blue collar catering suppliers- Community action groups and large religious entities

• Salt Watch will provide various support materials (presentations, posters, brochures, etc.)

• Salt Watch will undertake a roadshow to these stakeholders before the start of the campaign

STAKE-

HOLDERS

HEALTHCARE

INDUSTRY

Persuasion

• Steps in the ‘roadshow’ process will be to:

1. Reach professional bodies (HPCSA, ADSA, NSSA) in the healthcare space

- to get the salt reduction messaging into newsletters and publications (e.g. HPCSA’s ‘Bulletin’, ADSA newsletters, etc)

2. Do talks at trade conferences, events, congresses (e.g. Nutrition Congresses/Symposiums) to spread our message

3. Partner with Government to roll our Heart Health info packs to state hospitals, clinics and doctors which include:

- training materials and evidence-based ‘case’ for salt reduction for doctors, dietitians, nurses

- consumer-facing booklets and posters on heart health linked to salt reduction

4. Partner with pharmaceutical providers to influence the preventative care message through their distribution channels to doctors

STAKE-

HOLDERS

HEALTHCARE

INDUSTRY

Persuasion

CONSUMER

MOBILE

WEB

USSD

MOBISITE

MATERIALS

FLYERS &

PAMPHLETS

SMS

• Salt Watch website will be built to carry- Primary messaging- Health damage evidence from medical doctors- FAQ’s- Easy steps to reducing salt (alternatives, easy lower salt

recipes, etc.)

• This will be in clear, simple style, with graphics and videos

• Provision of supportive materials will play a critical role in the campaign

- for awareness purposes- more importantly as a tool to take consumers from

consideration to action

• There are many factors at play in the household, and we need to support our ‘activist’ consumers with the tools to convince others and understand how to break the salt habit

MOBILE

MATERIALS

Action

• R30 078 053 p.a.

Budget

• At end of first year, campaign will be evaluated

• Based on awareness-based targets:

• % South Africans

– aware that too much salt is bad for their heart

– trying to cut down on salt in their diets

Campaign evaluation

Erika Ketterer

[email protected]

Thank you!

mailto:[email protected]

• Salt intake in SA

– 6 – 11 g/day (24-h urinary excretion or spot urine methodology)

• WHO, HSF recommendation

– < 5g/day

– < 2000 mg sodium/day

Why the need for salt reduction in SA?

Wentzel-Viljoen, et al, 2013; WHO, 2012

4 Stages of behaviour change and mindsetcomponents

+ + + + = 16 g

Breakfast Snack Lunch Snack Supper

1.4g 1.1g 3.6g 3.5 g 6.2g

Salt intake adds up quickly!

16 g = more than 3 teaspoons of salt!!!

Stats

• CVD is leading cause of global deaths - 17.3 million deaths every year

- 9.4 million due to hypertension

• Hypertension is a key risk factor for CVD - 51% of stroke and 45% of heart disease

• Increase in salt intake raised BP- adults, children

• Lowering salt intake lowered BP - with/out hypertension, all age groups, all ethnic groups

• Population interventions to lower salt intake are cost-effective and have potential to reduce NCDs

• Globally, NCDs main contributors to mortality and morbidity

WHO, 2008/9/11/12; Lim, et al. 2012 ; He, et al. 2004; Murray, et al. 2003; Webster, et al. 2011

• SA has massive burden of hypertension– almost half (48% men, 44% women) of adults 25 or older have high BP 9

– hypertension has been increasing dramatically over past 10 years 10-12

Why the need for salt reduction in SA?

South African Demographic and Health Survey 1998. DOH, 2002 Ardington C, Case A. National Income Dynamics Study Health 2008. UCT 2009

WHO, 2010; Bradshaw , et al. 2010

Target audience

Documents

Behaviour change and what SA is doing - · PDF fileResearch Council, Nutrition Society of SA •Local and international expert advisors ... •Most useful medium for information about