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Knowledge, Attitude and Practice (KAP) on Salt Intake and its Relationship with Blood Pressure among Chinese Adults in Johor

Pang Xin Yi1, Mohd Razif Shahril1, Hasnah Haron1*

1Faculty of Health Science, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia

*Corresponding author: hasnaharon@ukm.edu.my

Received: 19 June 2022 Accepted: 15 November 2022 Published: 30 November 2022

Abstract

Hypertension is one of the most serious health problem worldwide as well as in Malaysia with high salt intake as the major risk factor related to it. Therefore, this study was aimed to determine knowledge, attitude and practice (KAP) on salt intake and its relationship with blood pressure among Chinese adults in Johor. This cross-sectional study comprised of 90 subjects (36 males, 54 females), aged 18 to 59 years old. Subjects were required to answer the online questionnaire regarding KAP of salt intake. Self-reported anthropometry data and blood pressure measurement were recorded. Sodium intake was determined using a single 24-hour dietary recall method through face-to face or telephone interview. Results showed that majority subjects were within normal Body Mass Index (BMI) range and optimal blood pressure range.

BMI was found to have significant correlation with systolic blood pressure (r=0.563, p<0.05) and diastolic blood pressure (r=0.444, p<0.05). Mean sodium intake of subjects was 2399 mg/day, exceeded the WHO recommendation of 2000 mg/day. Sodium intake was found to have significant correlation with systolic blood pressure (r=0.220, p<0.05). Results indicated that the overall KAP score was fair (64.14%). The knowledge of most subjects was fair (69.95%) besides having positive attitude towards salt intake (74.17%). However, practice of healthy salt intake among them was inadequate (49.53%).

Sociodemographic characteristic of female gender was significantly associated (p<0.05) with better attitude. Additionally, older subjects, married subjects and subjects with higher level of education were significantly associated (p<0.05) with better practice towards healthy salt intake. In this study, there were no significant (p>0.05) associations between KAP on salt intake with sodium intake and blood pressure. In conclusion, BMI and sodium intake were significantly associated with blood pressure among Chinese adults. Further effort and interventions are needed to reduce the salt intake among Chinese adults and thus reduce the risk of hypertension.

Keywords

Knowledge, attitude, practice, salt, sodium, blood pressure, hypertension, Chinese adults

Asian Journal of Medicine and Biomedicine

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Introduction

Salt is an inorganic compound composed of sodium ions and chloride ions [1]. Sodium is an essential nutrient needed by the body for maintenance of plasma volume, acid-base balance, nerve impulse transmission and normal cell function [2]. WHO [2] recommends that adults consume no more than one teaspoon of salt a day, equivalent to 5 g of salt or 2000 mg of sodium. However, global sodium intake for adults exceeded that recommendation [3]. Excessive sodium intake can increase blood pressure, which in turn causes cardiovascular disease (CVD) [4]. WHO [5] published a Global Action Plan proposing a 30%

reduction in salt intake by 2025. Reducing salt or sodium intake has been identified as a priority action to reduce non-communicable diseases. In Malaysia, the prevalence of hypertension among Chinese adults aged 18 years and above is 28.1% [6].

Several previous studies conducted in Malaysia have shown that salt or sodium intake among Chinese adults exceeded the WHO recommendation, which is 5 g salt (2000 mg sodium) per day [7,8]. According to Haron et al. [9], the food group with the highest average salt content was gravy and sauce, followed by soup.

Furthermore, the highest sodium content information on sauces in Malaysia was displayed by fish or prawn sauce, followed by light soy sauce and salty soy sauce [10]. Chinese regularly consume soup in their main course [11], in addition to use soy sauce in food preparation [12]. This indirectly affected blood pressure as sauce and soup were high in salt content. However, study on the prevalence of hypertension and its association with high blood pressure among Chinese adults in Johor was limited. Thus, this study was conducted to see the connection.

Salt intake was influenced by individual’s knowledge, attitude and practice (KAP) on salt intake [13]. People continue to consume excessive sodium intake due to lack of awareness about the effect of excessive sodium intake towards hypertension [14]. Therefore, KAP of Chinese adults on salt intake and its relationship with blood pressure were determined in this study. Findings on KAP towards salt intake can be used to plan strategies for changes in practices of individuals towards dietary salt intake

Materials and Methods Study subjects

This study is a cross-sectional study conducted to determine knowledge, attitude and practice (KAP) on salt intake and its relationship with blood pressure among Chinese adults in Johor. Conveniece sampling was applied to select a sample of 90 Chinese adults aged 18 to 59 years old. The study was conducted from September 2020 to February 2021. Sociodemographic information, health history, antropometry data, blood pressure measurements and KAP on salt intake among subjects were collected using online questionnaire. The questionnaire was in bilingual form which is Malay and English. Study information sheet and consent form also included in the online questionnaire to explain the purpose of the study and their involvement in the study. Face-to-face or telephone interview was conducted to determine sodium intake among Chinese adults through 24-hour dietary recall method. Inclusion criteria of subjects were Malaysian Chinese living in Johor, aged 18 to 59 years and not on high blood pressure medication. Ethical approval to conduct this study was obtained from the Research Ethnics Committee of Universiti Kebangsaan Malaysia (UKM PPI/111/8/JEP-2020-476) prior to the study.

Sample size calculation

Based on the study by the National Health and Morbidity Survey (NHMS) (2019) [6], the prevalence of hypertension among adults aged 18 years and above in Malaysia was 30%. Thus, Cochran [15] formula was used based on a confidence level of 95%, a prevalence of 30% and an accuracy level of 10%. The sample size calculation was as followed:

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n = ! #∝ " $*""%('(%) n = sample size

𝑍+ /- = Z value at 95% confidence level = 1.96

p = Population (prevalence) = 30% = 0.3

e = Accuracy level = 10% = 0.1

n = ('./0)" (1.2)('(1.2) 1.'"

= 81 subjects

It is estimated that 10% of subjects will drop out, Therefore, actual sample size = 81/0.9

= 90 subjects

Sociodemographic and health history

Subjects were required to fill in their sociodemographic information in the Section A of the questionnaire including age category, gender, marital status, education level, employment and monthly household income. For health history, subjects were required to record any undergoing therapy for illness such as liver disease, kidney disease, stroke, heart disease and diabetes in Section B of the questionnaire.

Anthropometric data

Anthropometric data consisted height, weight and blood pressure. Data collection of subjects’ weight and height were done using self-report method. BMI was calculated and classified based on World Health Organisation [16]. Blood pressure of subjects were collected through self-measurement or measured by researcher. Blood pressure measurements performed after subjects were rested for at least 5 minutes.

Subjects were required to be seated and the arm must be horizontal at the level of the heart. Readings were taken when subjects were in a calm state. Blood pressure readings were taken twice to obtain the average value. Classification of blood pressure was adopted from Malaysia’s Clinical Practice Guidelines:

Management of Hypertension 2018 [17]. Height, weight and blood pressure data were recorded in the Section C of the questionnaire.

Knowledge, Attitude and Practice (KAP) on salt intake

The KAP questionnaire on salt intake in Section D used in this study was adapted from previous study by Haron et al. [18]. The questionnaire consisted 18 questions, which were divided to three domains, namely knowledge, attitude and practice. Each answer of KAP questions was scored in order to classify subject based on scoring by Bakarman et al. [19].

Table 1: Cut-off score in categorizing the level of knowledge, attitude and practice

Score % Knowledge Attitude Practice Total KAP

< 60 60-70

> 70

Poor Fair Good

Negative Neutral Positive

Inadequate Adequate

Good

Poor Fair Good

Prior to the study, a content validity test was conducted to determine the validity and reliability of the questionnaire. With the involvement of seven experts, 0.83 and above is considered the acceptable cut-off score of CVI (Content Validity Index) [20]. Modifications have been made to the particular items that could not achieve I-CVI (Item-Level Content Validity Index) values of 0.83 and above based on comments provided by the experts. The average S-CVI (Scale-Content Validity Index) value of 0.93 was obtained,

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proving that all question items are reliable.

Sodium intake assessment

The food intake of subjects was determined using a single 24-hour dietary recall method. The dietary recall method was carried out through face-to-face or telephone interview. Subjects were required to recall all foods and drinks consumed during last 24 hours to determine the sodium intake in a day. Food serving size estimation aids with the pictures of household measurement tool from the Food Atlas: Size Portion and Exchange [21] was used to assist in estimating food portion size. All the data obtained were analysed using the Nutritionist ProTM Diet Analysis Software [22]. Reported energy intake that was <500 kcal/day or >5000 kcal/day for women or >8000 kcal/day for men was considered under or over reporting, and it was excluded from the study analysis [8,23].

Statistical Analysis

Data obtained from the results of the study were analysed using Statistical Package for Social Sciences (SPSS) [24] version 25.0 software. Sociodemographic data, health history data, anthropometry data, blood pressure data, sodium intake and knowledge, attitude and practice (KAP) of subjects on salt intake were analysed using descriptive analysis tests to obtain frequency, percentage, mean and standard deviation.

Shapiro-Wilk test was used to test the normality of the data because the study sample size was less than 100 subjects. Comparison of anthropometry data, blood pressure data and sodium intake between genders were analysed using independent t test. Besides, one-way ANOVA test was used to compare anthropometry data, blood pressure data and sodium intake between age groups. Other than that, Spearman’s Rho test was used to analyse the relationship between blood pressure with Body Mass Index (BMI) and sodium intake.

The relationship between KAP on salt intake with sodium intake and blood pressure were also analysed using Spearman’s Rho test. Lastly, Fisher’s Exact and Chi-square tests were used to analyse the relationship between KAP on salt intake with sociodemographic characteristics. Statistical significance was set at p<0.05.

Results

A total of 90 subjects participated in this study, Table 2 shows the majority of the subjects were female (60.0%), aged 18-29 years (75.6%), single (74.4%), had degree level of education (66.7%), student (50.0%) and earned a monthly household income of less than RM4851 (64.4%). Most of them currently are not undergoing therapy for any illness (98.9%). Majority of the subjects were within normal Body Mass Index (BMI) range (70.0%) and optimal blood pressure range (52.2%).

Table 1: Sociodemographic Data of the Study Subjects (n=90).

Characteristics Frequency

(%)

Means (SD) Age (years)

18-29 68 (75.6)

30-39 4 (4.4)

40-49 10 (11.1)

50-59 8 (8.9)

Gender

Male 36 (40.0)

Female 54 (60.0)

Ethnicity

Chinese 90 (100)

Marital Status

Single 67 (74.4)

Married 23 (25.6)

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Education Level

Primary School 1 (1.1)

Secondary School 10 (11.1)

Diploma 14 (15.6)

Degree 60 (66.7)

Master 5 (5.6)

Employment

Student 45 (50.0)

Work 39 (43.3)

No work 6 (6.7)

Monthly Household Income

≤ RM4850 (B40) 58 (64.4)

RM4851-10970 (M40) 30 (33.3)

≥ RM10971 (T20) 2 (2.2)

Health History

Kidney Disease 1 (1.1)

None 89 (98.9)

Body Mass Index (kg/m2) 21.7 ± 3.2

Body Mass Index Categories (kg/m2)

Underweight (<18.5) 13 (14.4)

Normal (18.5-24.9) 63 (70.0)

Overweight (25.0-29.9) 13 (14.4)

Obese (>30.0) 1 (1.1)

Systolic Blood Pressure (mmHg) 114.1 ± 14.1

Diastolic Blood Pressure (mmHg) 72.6 ± 10.4

Blood Pressure Categories (mmHg)

Optimal (systolic <120 and diastolic <80) 47 (52.2) Normal (systolic 120-129 or diastolic 80-84) 27 (30.0) At risk (systolic 130-139 or diastolic 85-89) 12 (13.3) Hypertension Stage 1 (systolic 140-159 or diastolic 90-99) 4 (4.4)

Table 3 shows the sodium intake of the study subjects based on WHO 2012 and Recommended Nutrient Intake (RNI 2017) cut-off point. The mean sodium intake among subjects was 2399 mg/day, exceeded the WHO recommendation of 2000 mg/day. According to the dietary sodium intake, 42.2% of subjects met the WHO target of <2000 mg salt in a day and 23.3% subjects met the RNI of ≤1500 mg salt in a day.

Table 3: Sodium Intake of the Study Subjects Based on WHO 2012 and RNI 2017 Cut-off

Sodium intake (mg/day) Frequency (n=90) Percentage (%)

WHO 2012

<2000 38 42.2

≥2000 52 57.8

RNI 2017

≤1500 21 23.3

>1500 69 76.7

Table 4 shows the correlation between BMI and sodium intake with blood pressure. BMI was positively and significantly correlated with systolic blood pressure (p<0.001) and diastolic blood pressure (p<0.001).

Besides, sodium intake was positively and significantly correlated with systolic blood pressure (p= 0.037).

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Table 4: Correlation between Body Mass Index and Sodium Intake with Blood Pressure.

Variables Systolic blood pressure

(mmHg) Diastolic blood pressure (mmHg)

r value p value r value p value Body Mass Index (kg/m2) 0.563 <0.001*** 0.444 <0.001***

Sodium intake (mg/day) 0.220 0.037* 0.106 0.320

*p value < 0.05 is significant

***p value < 0.001 is significant

Table 5 shows the knowledge, attitude and practice scores on salt intake among study subjects. The knowledge of most subjects was good (56.7%) with average overall knowledge score of 69.95 ± 13.43%.

Besides, most subjects had positive attitude towards salt intake (71.1%) with average overall attitude score of 74.17 ± 10.02%. However, practice of healthy salt intake of most subjects was inadequate (73.3%) with average overall practice score of 49.53 ± 13.41%. The total KAP of most subjects was fair (42.2%) with average overall KAP score of 64.14 ± 9.40%.

Table 5: Knowledge, Attitude and Practice Scores on Salt Intake among Study Subjects.

Marks Average score

(mean ± SD)

Frequency Percentage (%) Knowledge

<60% (Poor) 50.46 ± 10.20 18 20.0

60 - 70% (Fair) 65.08 ± 2.08 21 23.3

>70% (Good) 78.84 ± 7.54 51 56.7

Overall 69.95 ± 13.43 - -

Attitude

<60% (Negative) 54.76 ± 4.45 7 7.8

60 - 70% (Neutral) 65.13 ± 2.07 19 21.1

>70% (Positive) 78.97 ± 6.98 64 71.1

Overall 74.17 ± 10.02 - -

Practice

<60% (Inadequate) 42.42 ± 6.11 66 73.3

60 - 70% (Adequate) 64.61 ± 2.98 15 16.7

>70% (Good) 76.50 ± 4.49 9 10.0

Overall 49.53 ± 13.41 - -

Knowledge, attitude and practice (total)

<60% (Poor) 54.32 ± 4.45 30 33.3

60 - 70% (Fair) 64.47 ± 2.70 38 42.2

>70% (Good) 76.97 ± 4.93 22 24.4

Overall 64.14 ± 9.40 - -

Table 6 shows the relationship between knowledge, attitude and practice (KAP) towards salt intake with sociodemographic characteristics. Female subjects were significantly associated with better attitude compared to males (p<0.025). Besides, older subjects (30 years and above) were significantly associated with better practices compared to younger subjects (18-29 years) (p=0.009). Moreover, good practices were found to be significantly higher among married subjects as compared to subjects who were single (p=0.003). In addition, higher education level was significantly associated with the good practices (p=0.017). However, there were no significant associations between knowledge and total KAP with sociodemographic characteristics (p>0.05). Additionally, there were no significant associations between knowledge, attitude and practice on salt intake with sodium intake and blood pressure (p>0.05).

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Table 6: Relationship between Knowledge, Attitude and Practice (KAP) Towards Salt Intake with Sociodemographic Characteristics.

Sociodemographic Characteristics

Attitude, n (%) χ²

(p value)

Negative Neutral Positive

Age (years)a 0.690

18-29 6 (8.8) 15 (22.1) 47 (69.1)

30-39 1 (25.0) 0 (0.0) 3 (75.0)

40-49 0 (0.0) 3 (30.0) 7 (70.0)

50-59 0 (0.0) 1 (12.5) 7 (87.5)

Gendera 0.025*

Male 4 (11.1) 12 (33.3) 20 (55.6)

Female 3 (5.6) 7 (13.0) 44 (81.5)

Marital Statusa 0.782

Single 6 (9.0) 15 (22.4) 46 (68.7)

Married 1 (4.3) 4 (17.4) 18 (78.3)

Education Levela 0.958

Primary School 0 (0.0) 0 (0.0) 1 (100.0)

Secondary School 0 (0.0) 2 (20.0) 8 (80.0)

Diploma 1 (7.1) 3 (21.4) 10 (71.4)

Degree 6 (10.0) 12 (20.0) 42 (70.0)

Master 0 (0.0) 2 (40.0) 3 (60.0)

Employmenta 0.761

Student 5 (11.1) 8 (17.8) 32 (71.1)

Work 2 (5.1) 9 (23.1) 28 (71.8)

No work 0 (0.0) 2 (33.3) 4 (66.7)

Monthly Household Incomea 0.490

≤ RM4850 (B40) 5 (8.6) 14 (24.1) 39 (67.2)

RM4851-10970 (M40) 2 (6.7) 4 (13.3) 24 (80.0)

≥ RM10971 (T20) 0 (0.0) 1 (50.0) 1 (50.0)

Sociodemographic Characteristics

Practice, n (%) χ²

(p value)

Inadequate Adequate Good

Age (years)a 0.009**

18-29 55 (80.9) 8 (11.8) 5 (7.4)

30-39 1 (25.0) 1 (25.0) 2 (50.0)

40-49 7 (70.0) 2 (20.0) 1 (10.0)

50-59 3 (37.5) 4 (50.0) 1 (12.5)

Genderb 0.175

Male 30 (83.3) 3 (8.3) 3 (8.3)

Female 36 (66.7) 12 (22.2) 6 (11.1)

Marital Statusa 0.003**

Single 55 (82.1) 6 (9.0) 6 (9.0)

Married 11 (47.8) 9 (39.1) 3 (13.0)

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Education Levela 0.017*

Primary School 0 (0.0) 1 (100.0) 0 (0.0)

Secondary School 5 (50.0) 5 (50.0) 0 (0.0)

Diploma 11 (78.6) 2 (14.3) 1 (7.1)

Degree 47 (78.3) 5 (8.3) 8 (13.3)

Master 3 (60.0) 2 (40.0) 0 (0.0)

Employmenta 0.204

Student 36 (80.0) 5 (11.1) 4 (8.9)

Work 27 (69.2) 7 (17.9) 5 (12.8)

No work 3 (50.0) 3 (50.0) 0 (0.0)

Monthly Household Incomea 0.278

≤ RM4850 (B40) 41 (70.7) 12 (20.7) 5 (8.6)

RM4851-10970 (M40) 24 (80.0) 3 (10.0) 3 (10.0)

≥ RM10971 (T20) 1 (50.0) 0 (0.0) 1 (50.0)

*p value <0.05 is significant, **p value <0.01 is significant.

a Fisher’s Exact test, b Chi-square test Discussion

In the present study, the mean sodium intake of Chinese adults had exceeded the recommendation of 2000 mg a day by WHO [2], similar to the previous studies conducted among Chinese adults in Malaysia [7,8]. Majority of the subjects in this study did not meet the WHO and RNI target of sodium intake in a day.

Previous study also reported the same findings, however, the number of subjects who met both WHO and RNI target of sodium intake had increased in 2014 compared to 2003 [25]. According to the Malaysian Adult Nutrition Survey [7], almost half of Malaysian adults often eat out or venture out to buy food. Sodium intake among Chinese adults in this study exceeding recommended level could be due to the practice of eating out among subjects.

In our findings, there were significant positive correlations between BMI with systolic and diastolic blood pressure which is in line with the study by Haron et al. [18]. Subjects with higher BMI had higher systolic and diastolic blood pressure. Individuals with higher BMI that is, in the category of overweight or obese, associated with a higher prevalence of hypertension compared to individuals with normal BMI [26]. As such, overweight and obese individuals are encouraged to carry out lifestyle modification interventions especially weight management in order to reduce the risk of hypertension. Besides, there was significant positive correlation between sodium intake with systolic blood pressure, meaning that subjects who consumed more salt had higher blood pressure, that is in line with the study conducted by Yang et al. [27]. Other study also showed that sodium reduction resulted in a significant decrease in blood pressure in both normotensive and hypertensive adults [28].

The knowledge of most Chinese adults in this study was good, that is in line with the previous study among Chinese students of Faculty of Health Sciences in UKM Kuala Lumpur (KL) [29]. Majority of the subjects in this study had knowledge about the recommendation of salt intake in a day. Furthermore, most subjects knew that high salt intake could lead to a serious health problem. In agreement with previous studies showing that most subjects were aware that high salt intake may lead to high blood pressure [30,31]. Most Chinese adults in this study had positive attitude towards salt intake, that is in line with the previous study among Chinese students in UKMKL [29]. Furthermore, another study in China revealed that residents in Shandong province had a favourable attitude towards sodium reduction [31]. In the current study, majority of the subjects claimed that reducing salt in their diet is important to them and agreed to minimize the salt consumption. The practice of healthy salt intake of most Chinese adults in this study was inadequate, similar to the previous study conducted among Chinese students in UKMKL [29]. Minority of the subjects controlled their salt intake in a regular basis. Less than a third of the subjects reported to avoid eating foods

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prepared outside of home, limit the consumption of salty snacks, avoid adding salt or soy sauce during or before eating, avoid or minimize the consumption of processed foods and buy alternatives food with low salt. More alarmingly, less than 10% of subjects avoid adding salt when cooking and check the salt content on the food labels. Therefore, more efforts and interventions are needed to reduce the salt intake among Chinese adults in order to promote health and prevent diseases associated with excessive salt intake.

Based on the findings of this study, it can be concluded that having moderate level of knowledge and positive attitude among subjects did not affect their daily practice of controlling salt intake. The total KAP on salt intake was to some extent influenced by knowledge, attitude and practice scores. The results of this study showed that majority of the subjects had a moderate level of awareness of salt intake. More awareness programs on the importance of healthy salt intake should be conducted in order to raise the community awareness about the risks of high salt intake.

This study showed female gender was significantly associated with better attitude. Previous studies reported the same findings where females were more willing to take action in controlling salt intake [32,33]. Besides, older subjects were significantly associated with better practices compared to younger subjects.

Younger adults tended to add salt to food and had less control over salt intake [34]. Another study by Nasreddine et al. [32] reported that younger adults took less action to cut down on salt, checking label for sodium content and trying to buy alternatives food with low salt compared to older adults. Moreover, good practices were found to be significantly higher among married subjects as compared to subjects who were single. A study conducted by Vinther et al. [35] reported that unmarried subjects were associated with lower health practices compared to married subjects. In addition, higher education level was significantly associated with good practices that is in line with the study by Zhang et al [31] which reported the similar finding.

Limitation and Recommendation

The limitation of this study is the reliability of weight, height and blood pressure readings reported by subject itself. Another limitation of the study is the single 24-hour dietary recall provides an estimate of mean intake of foods and nutrients, but do not represent the usual intake of subject. It is recommended that all anthropometric and blood pressure measurements should be performed by researchers in the future to ensure the accuracy of anthropometric and blood pressure measurement in subjects. Besides, it is recommended to conduct multiple 24-hour dietary recall or 24-hour urine excretion which is the gold standard method for assessing sodium intake more accurately.

Conclusion

Majority Chinese adults in Johor had normal BMI and optimal blood pressure. BMI was positively and significantly correlated with systolic and diastolic blood pressure. The mean sodium intake among Chinese adults was 2399 mg/day (6.00 g/day salt) which exceeded the WHO recommendation of 2000 mg/day sodium or 5 g/day salt. Sodium intake was positively and significantly correlated with systolic blood pressure. The knowledge of Chinese adults was fair besides having positive attitude towards salt intake.

However, practice of healthy salt intake among them was inadequate. The overall knowledge, attitude and practice (KAP) of Chinese adults towards salt intake was fair. Sociodemographic characteristic of female gender was significantly associated with better attitude. Additionally, older subjects, married subjects and subjects with higher level of education were significantly associated with better practice towards healthy salt intake. In this study, there were no significant associations between KAP on salt intake with sodium intake and blood pressure.

Acknowledgements

The authors acknowledge all study subjects during the study.

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