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. 2025 Aug 10;27(8):e70123. doi: 10.1111/jch.70123

Evaluation of Population‐Based Sodium Reduction Strategies in China: Protocol for a Study Using a Combined Quantitative and Qualitative Approach

Yuze Xin 1, Jianwei Xu 2, Zhifang Li 3, Xuejun Yin 4,5, Tengyi Wang 1, Beike Wu 1, Shuangjie Peng 1, Anqi Ge 1, Xinyan Liu 1, Min Liu 2, Hueiming Liu 6, Lei Si 7,8, Stephen Jan 6, Jixiang Ma 9, Yangfeng Wu 10, Jing Wu 2, Laura Cobb 11, Bruce Neal 6,12, Katrina Kissock 6, Maoyi Tian 1,6,13,✉
PMCID: PMC12336285  PMID: 40785139

ABSTRACT

Sodium intake in China is among the highest in the world, particularly in rural areas. A government‐led national sodium reduction program has been implemented but evaluations of its implementation and effectiveness remain limited. The study will use a combined qualitative and quantitative approach and a before‐after design, to monitor and evaluate the implementation and effectiveness of the sodium reduction program in the rural areas of four provinces geographically distributed throughout China: Heilongjiang, Shanxi, Guizhou, and Guangdong. Baseline data collected in 2021–2023 will be compared to follow‐up data collected in 2024–2025. Population surveys will quantify changes in community knowledge, behaviors, dietary patterns, and sodium intake. Food retail surveys will assess changes in the sodium content of packaged food products, while stakeholder interviews will assess the extent to which the program has been implemented as planned across government, industry, health, and community organizations. The study has received funding and ethics committee approvals though timelines and study processes were significantly delayed by COVID‐19. Baseline surveys of 2790 community members have now been completed, food composition data for 20 240 products has been collected, and there have been 37 stakeholders interviewed to date. This project will provide a robust evaluation of progress with implementation of China's national sodium reduction program in rural areas of the country. It will quantify impact to date and provide insight into what has worked, as well as what has not, and inform future sodium reduction strategies.

Keywords: rural China, sodium intake, sodium reduction

1. Introduction

Cardiovascular disease (CVD) is the leading cause of death globally, accounting for 20.5 million related deaths in 2021 [1]. High sodium intake is a major risk factor for CVD worldwide [2]. The World Health Organization (WHO) recommends a maximum daily sodium consumption of 2 g/day (5 g/day of salt) [3], but in most parts of the world this level is far exceeded [4]. Sodium intake in China is among the highest in the world, with most adults consuming above 4 g/day (10 g/day salt) [5]. In a recent study, high sodium intake was linked to nearly 0.79 million deaths and 1.93 million disability‐adjusted life years (DALYs) from CVDs in China in 2019 [6].

As a response to these findings, the Chinese government has initiated a series of sodium reduction programs in China and has included sodium reduction as a key component of China's health development agenda, Healthy China 2030 [7]. The action plan for “Healthy China 2030” released in 2019, included 15 goals with specific targets to be achieved between 2020 and 2030, one of which is to achieve a national average daily sodium intake of less than 2 g/day of sodium (5 g/day salt). The National Nutrition Plan (2017–2030) established a few years prior had set a less ambitious, but potentially more feasible, goal for a 20% reduction in national average daily sodium intake by the year 2030 [8]. Since 2019, national and provincial governments have developed and implemented a series of sodium reduction programs addressing those targets, including public education through mass media, distribution of 2 g salt restriction spoons to communities, and encouraging production and sale of low‐sodium salt (details in Supplementary  1 ) [9]. Studies to evaluate the effectiveness and implementation of the current ongoing programs are few but are vital to understand whether interventions are progressing to plan, and whether adjustments are required to optimize impact [10].

The WHO's latest report states that China's sodium reduction efforts should involve a series of multi‐sector actions to transform the food system and promote low‐sodium food choices to achieve healthy diets and optimal health among the population [11]. There are well‐established sodium reduction strategies, such as the “SHAKE” technical package promoted by the WHO [12], but they are often more suitable for high‐income countries that consume large amounts of packaged food and have well‐established packaged food industries. In China, and many other low‐ and middle‐income countries, while people are increasingly choosing to eat takeaway food or pre‐packaged food [13], most dietary sodium still comes from salt added at the table or in family cooking [14, 15]. As such, there is a strong case for including a national switch from using regular salt to potassium‐enriched salt as a sodium reduction strategy. This would prevent about a million strokes and heart attacks every year in China at a very low cost [16, 17, 18]. However, there are currently many challenges to the promotion and implementation of potassium‐enriched salt in China [19].

This study protocol describes a collaborative research initiative designed to quantify the effectiveness of China's national sodium reduction program in rural areas by completing a broad set of investigations based on population surveys, food retail surveys, and stakeholder interviews.

2. Methods and Analysis

2.1. Overall Study Design and Ethics

This study will use a before‐after design to assess the implementation and effectiveness of the government‐led sodium reduction programs in the rural areas of four provinces geographically distributed throughout China—Shanxi, Heilongjiang, Guangdong, and Guizhou. Figure 1 displays the geographical locations and demographic data of our four study sites [20]. The research will use a combined qualitative and quantitative approach with the population and food retail surveys based on quantitative evaluations, while the stakeholder analyses will use qualitative research methods. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE‐AIM) and the Practical, Robust Implementation Sustainability Model (PRISM) frameworks will be used to guide the research especially in terms of data collection and analysis [21, 22]. Ethics approval has been sought from The University of New South Wales (UNSW) Human Research Ethics Committee in Australia, the Ethics Committee of the National Centre for Non‐Communicable Disease Prevention and Control at the Chinese Centre for Disease Prevention and Control and the Changzhi Medical College Ethics Committee. Informed consent will be obtained from every individual involved in a survey or an interview.

FIGURE 1.

FIGURE 1

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Study site.

2.2. Overall Aim and Specific Objectives

The overall aim of this evaluation is to define the extent to which China's national sodium reduction program is delivering initial objectives according to the goals set out in “Healthy China 2030” and “The National Nutrition Plan”. The objective is to reach a population average salt intake of ≤5 g/day (2 g/day sodium) by 2030. It is anticipated that the research will identify opportunities for optimizing current implementation and evaluation strategies with the goal to maximize the likelihood of long‐term success.

Specific objectives for each of the three main components of the work are:

  1. Population surveys—will assess the effects of the national sodium reduction program in rural villages. The surveys will quantify changes in community knowledge and behaviors regarding (1) sodium consumption and health, (2) front‐of‐pack food labelling, and (3) potassium‐enriched salts and assess sodium intake.

  2. Food retail surveys—will assess the effects of the national sodium reduction program on the nature of foods and ingredients available for purchase in the community, with a specific focus on understanding whether the sodium content of commonly consumed processed foods have changed.

  3. Stakeholder interviews—will seek to explore the specific intervention strategies implemented in each province, then aim to understand the reasons why different aspects of the national sodium reduction program have been more or less successful, and finally define the system changes that will be required to achieve the sodium reduction goals set out in Healthy China 2030 and The National Nutrition Plan.

At both baseline and follow‐up phases, the population survey, food retail survey, and stakeholder interviews were conducted simultaneously in each study site.

2.3. Population Surveys

The population surveys will be repeated independent cross‐sectional surveys done among representative samples drawn from two counties in each of the four participating provinces, for a total of eight rural villages at baseline and eight rural villages at follow‐up in each county. The rural villages in each province will be purposively selected based on their proximity to the research team and their willingness to participate.

  • Participant selection— At baseline, at least eight rural villages will be selected in each county, with final numbers based on the feasibility of doing the field work, for a minimum of 16 rural villages in each province. At least 30 participants aged 18–69 years will be recruited from each rural village. Participants who are pregnant or highly dependent on medical care who may be unable to give consent will be excluded from the study. Recruitment will be done by making a random selection from a list of village members stratified by sex and age to ensure proportional representation. A minimum of 480 participants in each province will be surveyed at baseline, with a minimum total sample size at baseline of 1920 participants across all provinces. At follow‐up, the same procedure will be completed in the same provinces, counties, and villages, with a second, independent sample drawn using the same stratification strategy.

  • Data collection— Data collection will use a standard questionnaire modified from the INTERSALT study with input from the research team (Supplementary 2) and will be conducted by trained study staff [23]. We will organize and convene research personnel with the help of local staff, and informed consent will be obtained on‐site. Measurements of height, weight, waist circumference and blood pressure will be collected. Spot urine and 24‐h urine will be collected from all participants using detailed standardized instructions and participants will be provided with the materials required to complete the 24‐h urine collection. A day will be agreed for the urine collection and a second visit will be scheduled to collect the 24‐h urine sample. Urinary sodium, potassium and creatinine will be measured in a central laboratory. In addition, a 24‐h dietary recall will also be collected in a randomly selected 25% sub‐sample.

  • Outcomes —The primary outcome will be 24‐h sodium intake (mg/day) estimated from 24‐h urine collections. Secondary outcomes will be (1) the main sources of sodium in the diet measured using the 24‐h dietary recall, (2) systolic blood pressure and diastolic blood pressure, (3) knowledge and behaviors related to sodium consumption and health, front‐of‐pack food labelling and potassium‐enriched salts measured using a bespoke questionnaire, and (4) use of blood pressure lowering medications.

  • Statistical power —There will be a minimum of 1920 participants with survey data at baseline and the same number at follow‐up. Participants will be clustered in 64 villages. For the primary outcome of 24‐h urinary sodium excretion, there will be 90% power (p = 0.05) to detect a difference of 0.4 g sodium or greater in overall estimated mean intake between baseline and follow‐up. This calculation assumes a mean intake at baseline of 4.4 g/day and a standard deviation of 3.8 g/day [24].

  • Analysis plan— For the primary outcome, a linear mixed‐effects model will be used to account for the clustering of participants within villages, with adjustments for baseline covariates such as age and sex. A p value of <0.05 will be deemed significant. Pearson's Chi‐square test will be used to test for changes in categorical variables between baseline and follow‐up.

2.4. Food Retail Surveys

The food retail surveys will be repeated independent cross‐sectional surveys done at baseline and follow‐up among a sample of different retail outlets in the participating provinces.

  • Store selection— We will use information gleaned from local investigators, supplemented by desk research, to identify a range of sales outlets from which the population in each study county obtains packaged foods. In addition to offline retail outlets, we included the two most widely used online food retail platforms in China–Taobao and JD.com to reflect the growing importance of online food purchases. These platforms were selected based on their widespread use by Chinese consumers.

  • Data collection— The packaged foods available in each location will be recorded using the existing FoodSwitch Data Collector Application to capture images [25]. For packaged foods, the images will comprise the barcode, the front of the pack (including the name of the product), the nutrient declaration (if present), the manufacturer, nutrient content, and the ingredients list (if present). Images of foods will be geo‐tagged and uploaded to the FoodSwitch content management system for data entry and categorization. Volume of foods sales will be obtained through offline merchants’ sales records and online food website sales information.

  • Outcomes —The primary outcome measure will be the sodium content of the food (mg/100 g). Secondary outcome measures will be content of all other nutrients including energy (kJ/100 g), protein (g/100 g), saturated fat (g/100 g), sugars (g/100 g), and dietary fiber (g/100 g) in the food.

  • Statistical power— There will be more than 90% power (alpha = 0.05) to detect 10% or greater difference in the mean sodium content of products between baseline and follow‐up time points. This calculation assumes a mean sodium concentration of 400 mg/100 g (standard deviation 150 mg/100 g) across the food products [26].

  • Analysis plan— Change in sales‐weighted mean sodium content will be calculated between baseline and follow‐up. Differences in the mean sodium content of each category will be tested using a Kruskal–Wallis test.

2.5. Stakeholder Interviews

The stakeholder interviews will comprise semi‐structured interviews among a purposive sample of key stakeholders at baseline and follow‐up. Participants will include those who have influence on sodium consumption levels in China and those who play significant roles in sodium reduction implementation.

  • Participant selection— We will map the main stakeholders anticipated to influence sodium consumption levels in China and describe the key relationships between the parties (Figure 2) [27]. This model will inform our selection of individuals for interview but may be updated as the project progresses, and our insights are expanded. Stakeholders may include national, provincial and county governments, multilateral agencies, academia, community leadership, food industry, and civil society groups. Additionally, community members from the population survey sites will be interviewed. The same recruitment criteria will be used to recruit independent samples of participants at baseline and follow‐up. We aim to recruit about 70–90 participants for interviews at baseline and follow‐up combined. The final sample size will depend on thematic saturation.

  • Data collection— The data collection will comprise of in‐depth semi‐structured interviews competed by a senior qualitative researcher at two time points: baseline and final follow‐up (Supplementary 3). Obtain the contact information of participants through the provincial Centers for Disease Control and Prevention. Participants will be approached via SMS and invited to participate in the study. Informed consent will be collected at commencement of the interview. Participants will receive detailed information prior to the interview, outlining the purpose of the study, data confidentiality, and their right to withdraw at any time. At follow‐up, stakeholders will be briefed on preliminary findings from baseline to foster transparency and encourage reflective discussion. The duration of each interview is anticipated to be up to 60 min. Interviews and discussions will be held at locations convenient to participants and will be audio recorded for transcription. The interview guide will be piloted with a small subset of stakeholders to refine questions and ensure that terminology and focus areas are appropriate for different stakeholder levels. Tailored prompts will be developed to ensure that the framework is adaptable while maintaining consistency across interviews. The interviews will be conducted in Mandarin Chinese. The stakeholder's experience with elements of the national sodium reduction program will be explored in detail, focusing on the specific intervention strategies implemented in each province, implementation challenges, necessary adaptations, suggestions for future improvement, and both anticipated and unanticipated consequences for the broader health sector and community.

  • Outcomes —The primary outcome sought from the stakeholder interviews will be a comprehensive understanding of the landscape and contextual factors regarding the implementation successes and failures of the national sodium reduction program. The feasibility, barriers and opportunities will be identified such that the actions required to deliver a nation‐wide sodium reduction program more successfully are understood.

  • Analysis plan— We have adopted the PRISM framework to orient the interview and evaluate baseline data. The PRISM framework emphasizes multiple domains that should be considered to optimize the program, define modifications that need to be made and promote implementation success. The framework has a specific focus on understanding local contextual factors and organization allowing for adaptations to suit diverse environments. The follow‐up data will use the RE‐AIM framework to assess the extent to which these efforts have been successful, identify any new challenges that have arisen and provide an opportunity to measure any unanticipated consequences [21, 22]. All interviews will be recorded and transcribed verbatim. Both inductive and deductive methods will be adopted to analyze the data.

FIGURE 2.

FIGURE 2

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Stakeholder map.

3. Current Status

3.1. Population Surveys

Baseline surveys were completed in the years 2021–2023 in Shanxi (2023), Heilongjiang (2023), Guizhou (2023), and Guangdong (2023) with a total of 2790 participants surveyed. Follow‐up surveys are planned for October 2024 to March 2025.

3.2. Food Retail Surveys

Between 2021 and 2023, baseline data for 15 837 foods were collected from 18 physical stores and data for a further 4403 from online food retail outlets. All data have been uploaded into the FoodSwitch China database. Repeat data collection is planned for early 2025.

3.3. Stakeholder Interviews

We identified the main stakeholders as national government (Chinese Center for Disease Control and Prevention, National Nutrition Centre, Chinese National Health Commission), provincial government (Provincial Centre for Disease Control and Prevention, Provincial Health Commission), county government, community leadership (village heads, community leaders), village doctors, and primary health care providers. A total of 37 participants were interviewed at baseline between 2022 and 2023 across the four provinces. The follow‐up interviews are planned for early 2025.

4. Discussion

This study is well placed to evaluate the effectiveness of the national sodium reduction program in China and the current challenges it faces in terms of implementation. By documenting which measures are proving more or less effective, it should be possible to advise on adjustments to the program to ensure that the strategy reduces population sodium intake to the maximum extent possible in the shortest feasible timeframe [28]. While regular measurement of changes in population sodium intake and the processes driving the strategy are complex and costly, process evaluations such as this study can define the successes and failures of program implementation and are vital to ensuring successful delivery [9].

The coronavirus disease 2019 (COVID‐19) pandemic has influenced both the implementation of China's sodium reduction programs and our efforts to evaluate them [29]. In regard to program delivery, the main source of dietary sodium in China is discretionary salt added to food during cooking or seasoning in the home. The primary approach to reducing sodium intake has been to encourage behavior change through national and regional educational campaigns [15]. Often these educational programs involve a significant face‐to‐face component, and these elements have been significantly disrupted by COVID‐19 restrictions. The COVID‐19 pandemic has also impacted on our capacity to implement the research plan as originally intended with all components of field work delayed and baseline data collection occurring significantly later than initially planned. Accordingly, the study design was amended to remove the planned mid‐point assessments and only collect data at baseline and study close. There may be reduced power to detect effects of the sodium reduction strategy both because of incomplete delivery of the intervention and evaluation of effects over a shorter intervention period.

We had originally planned to make specific assessments of two forms of sodium reduction interventions to compare impacts—the nationwide effort led by the Chinese government and a complementary program targeted at particular provinces and supported by a non‐governmental organization, Resolve To Save Lives. Ultimately, the additional support provided by the Resolve To Save Lives program has been integrated into broader Chinese government efforts, and the design has been updated to evaluate the combined overall program. The three main components of evaluation—population surveys, food retail surveys and stakeholder interviews—remain unchanged with the goal being to identify which pieces of the program are achieving greatest impact on sodium consumption levels.

A significant development in sodium reduction strategies has occurred since the commencement of this project with the reporting of a large‐scale trial of the effects of potassium‐enriched salt on sodium intake, blood pressure and cardiovascular events [16]. Both were done in China and they showed that switching from regular salt (100% sodium chloride) to a reduced‐sodium, added‐potassium salt (75% sodium chloride, 25% potassium chloride) reduced blood pressure and protected against stoke and premature death. Furthermore, there was excellent acceptability of switching to potassium‐enriched salt, while gaining acceptability of reducing salt intake has been problematic due to the associated less salty taste. Accordingly, promotion of potassium‐enriched salt is now a part of some sodium reduction efforts in China and we have included evaluation of knowledge and behaviors related to potassium‐enriched salt within our evaluation [16, 30].

For many countries in Europe, as well as in North America, the majority of dietary sodium intake derives from salt added to processed and restaurant foods. In these settings gradually reducing sodium content in foods by setting maximum limits and using warning labels for high sodium products is the primary sodium reduction strategy [31, 32]. This approach is also recommended for China and may be particularly important in urban areas where more dietary sodium is likely to come from processed and restaurant foods. A key challenge to achieving widespread reformulation of food products is that industry must be fully engaged and this requires the active participation of thousands of different food companies. This can be very difficult to achieve, and few countries report success in reducing sodium levels in the wider food supply using this approach. Implementing mandatory targets would likely be effective but few governments have been willing to do this because of industry push back [32, 33].

In China, most countries have community education as a central part of their sodium reduction efforts [34]. While clearly important for raising awareness, community education efforts require significant financial support over the long‐term and this can be a significant barrier. Furthermore, health education alone is rarely sufficient for changing exposure to risks. There are few countries where simply providing information about healthy food choices has resulted in behavior change and benefits to health [35]. It is widely understood that health education will be successful only when other food environment interventions are implemented in parallel to increase the availability, accessibility, and affordability of healthier products including those lower in sodium. In the Asia‐Pacific region, Japan has reported a recent decline in average sodium intake following activities led by the Japanese Society of Hypertension Sodium reduction Committee [36]. There is ongoing work targeting education in Japanese schools, sodium reduction in take‐out foods, restaurants meals, and school lunches, as well as encouraging food enterprises to develop and promote low‐sodium foods, and advocating for the government to adopt various sodium reduction measures [28, 37]. Singapore's Ministry of Health Promotion Board has launched a strategy to encourage salt suppliers to replace regular salt with potassium‐enriched salt [38]. This has included reducing the price of potassium‐enriched salt toward that of regular salt with government funding support. It was reported recently that three major suppliers, accounting for close to half of the salt supplied to the Singaporean food and beverage market, now supply potassium‐enriched salt [39].

Key strengths of this study are the plan to use multiple different approaches to assess the breadth and effectiveness of different sodium reduction strategies being implemented in China. By using both quantitative and qualitative methods we will gain a deeper understanding of both the progress that has been made and the barriers and enablers to future change. It will also enable us to further explore the contextual and influencing factors that will guide subsequent sodium reduction work in China. Finally, this study has a particular focus in rural areas, where CVD burden is high and healthcare resources are constrained [40, 41]. Results from this study will provide evidence to guide sodium reduction efforts in resource‐limited areas, not just in China but across the globe. We have faced significant obstacles during the study, and this has required modification to the initial research design. We have, nonetheless, retained a strong methodology directly aligned with our original plan, and we should be able to provide the same quality insights that we initially set out to deliver. A limitation of this study is the non‐random selection of villages, which may introduce selection bias. To mitigate this, a random sampling strategy was applied within each village to select participants, with stratification by sex and age to ensure proportional representation. These, and other strengths and weaknesses specific to each piece of the evaluation, will be addressed in more detail in each of the upcoming reports focused on the population surveys, food surveys and stakeholder interviews.

5. Conclusion

This project will provide a robust evaluation of the national sodium reduction program in rural areas of China. It will quantify the changes that have occurred as a result of the program implementation. It aims to provide novel insights into which aspects of the program have been effective, which have not, and where further efforts are needed to enhance its impact, using a combined quantitative and qualitative approaches. Information around how changing environments, both in terms of the COVID‐19 pandemic and updates to the form and content of intervention programs, have affected opportunities for impact and evaluation will be particularly valuable.

Author Contributions

M.T., J.X., H.L., and B.N. designed research; Y.X. wrote the paper. K.K., X.Y., T.W., B.W., M.L., H.L., L.S., S.J., J.M., Y.W., J.W., and L.C. provided critical revision of the manuscript. M.T. had the primary responsibility for final content. All authors read and approved the final manuscript.

Ethics Statement

The study has received funding support from the National Health and Medical Research Council of Australia (APP1169751) and ethics approval from the Ethics Committee of National Centre for Non‐Communicable Disease Prevention and Control at the Chinese Centre for Disease Prevention and Control (202021‐01), Changzhi Medical College Ethics Committee (R72020023) and the UNSW Human Research Ethics Committee (HC200413).

Consent

Written informed consent was obtained from all participants prior to their inclusion in the study.

Conflicts of Interest

The authors declare that they have no competing interests.

Permission to Reproduce Material from Other Sources

This manuscript does not contain any previously published material that requires permission for reproduction.

Supporting information

Supplementary 1: National Actions and Guidelines and Strategies Related to Sodium Reduction in China.

Supplementary 2: Population surveys questionnaire.

Supplementary 3: Interview Guide.

JCH-27-e70123-s001.docx (92.4KB, docx)

Xin Y., Xu J., Li Z., et al. “Evaluation of Population‐Based Sodium Reduction Strategies in China: Protocol for a Study Using a Combined Quantitative and Qualitative Approach.” The Journal of Clinical Hypertension 27, no. 8 (2025): 27, e70123. 10.1111/jch.70123

Yuze Xin, Jianwei Xu, and Zhifang Li are first authors.

Katrina Kissock and Maoyi Tian are senior authors.

Funding: The study is funded by National Health and Medical Research Council of Australia (APP1169751).

Data Availability Statement

The data supporting this study are not publicly available but can be obtained from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary 1: National Actions and Guidelines and Strategies Related to Sodium Reduction in China.

Supplementary 2: Population surveys questionnaire.

Supplementary 3: Interview Guide.

JCH-27-e70123-s001.docx (92.4KB, docx)

Data Availability Statement

The data supporting this study are not publicly available but can be obtained from the corresponding author upon reasonable request.

Articles from The Journal of Clinical Hypertension are provided here courtesy of Wiley

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