Process Evaluation of an Application-Based Salt Reduction Intervention in School Children and Their Families (AppSalt) in China: A Mixed-Methods Study

Abstract

BackgroundSalt reduction is a cost-effective, and rather challenging public health strategy for controlling chronic diseases. The AppSalt program is a school-based multi-component mobile health (mhealth) salt reduction program designed to tackle the high salt intake in China. This mixed-methods process evaluation was conducted to investigate the implementation of this program across sites, identify factors associated with the implementation, and collect evidence to optimize the intervention design for future scale-up.MethodsMixed methods were used sequentially to collect data regarding five process evaluation dimensions: fidelity, dose delivered, dose received, reach, and context. Quantitative data were collected during the intervention process. Participation rate of intervention activities was calculated and compared across cities. The quantitative data was used for the selection of representative intervention participants for the qualitative interviews. Qualitative data were collected in face-to-face semi-structured interviews with purposively selected students (n = 33), adult family members (n = 33), teachers (n = 9), heads of schools (n = 9), key informants from local health, and education departments (n = 8). Thematic analysis technique was applied to analyze the interview transcripts using NVivo. The qualitative data were triangulated with the quantitative data during the interpretation phase.ResultsThe total number of families recruited for the intervention was 1,124. The overall retention rate of the AppSalt program was 97%. The intervention was implemented to a high level of fidelity against the protocol. About 80% of intervention participants completed all the app-based salt reduction courses, with a significant difference across the three cities (Shijiazhuang: 95%; Luzhou: 73%; Yueyang: 64%). The smartphone app in this program was perceived as a feasible and engaging health education tool by most intervention participants and key stakeholders. Through the interviews with participants and key stakeholders, we identified some barriers to implementing this program at primary schools, including the left-behind children who usually live with their grandparents and have limited access of smartphones; perceived adverse effects of smartphones on children (e.g., eyesight damage); and overlooked health education curriculum at Chinese primary schools.ConclusionThis process evaluation demonstrated the feasibility and acceptability of using smartphone applications delivered through the education system to engage families in China to reduce excessive salt intake.Clinical Trial RegistrationThe AppSalt study was registered at www.chictr.org.cn, identifier: ChiCTR1800017553. The date of registration is August 3, 2018.

Physician Views on the Provision of Information on Immune Checkpoint Inhibitor Therapy to Patients with Cancer and Pre-Existing Autoimmune Disease: A Qualitative Study

“…Most agreed that developing an educational tool for this population would be important, but few physicians provided solutions for implementing such a tool. Other studies have evaluated barriers and facilitators of educational tools in other medical contexts and, contrasting with our results, solutions provided include increasing the interest of physicians in the use of the tool, forming alliances between clinicians and researchers, and offering training in the use of the tool [36][37][38].…”

Process evaluation of an mHealth-based school education program to reduce salt intake scaling up in China (EduSaltS): A mixed methods study using the RE-AIM framework

“…The use of an online platform allows exible student participation [33], and schools can organize and manage activities without additional resources. However, participating in the program required primary skills to operate smartphones and register in the Health Cloud Classroom, which increased the di culty of participation for some caregivers, especially grandparents [14].…”

“…One approach has been the adoption of mobile health (mHealth) technology, offering standardized online health courses for salt reduction. An mHealth-based school health education initiative in China (AppSalt), incorporating both online and o ine activities, effectively reduced salt intake among children's parents, as evidenced by a cluster randomized controlled trial (cRCT) study [14,15].…”

An mHealth-based school health education system designed to scale up salt reduction in China (EduSaltS): A development and preliminary implementation study

“…In China, a recent cRCT proved the effectiveness of a novel multifaceted mHealth-based intervention for obesity prevention ( 49 ). In this study, a smartphone app was a tool to assist the intervention by strengthening family involvement and monitoring children’s key health indicators, but as our previous School EduSalt project, this study also delivered the key health education course by trained teachers in school ( 49 ), which is an additional task needs further consideration ( 24 ).…”

“…Thirdly, there were some children who lived with their grandparents and had limited access to smartphones. Finally, but most importantly, there were less administrative modules in AppSalt such as user management and performance evaluation to support routine project management, which would be a big barrier to the delivery of the innovative course in the real-world where the health education course is usually overlooked by primary schools ( 24 ).…”