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Making every school a health-promoting school: global standards and indicators

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Supportive and empowering societies through addressing health risk factors

[COUNTRY STORY]

From street food samples to TikTok videos – a Social Behavioural Change Communication (SBCC) programme as part of a comprehensive approach to salt reduction in Malaysia

Malaysia

Photo: WHO Malaysia Malaysia’s Social Behavioural Change Communication (SBCC) campaign aimed to increase knowledge and change attitudes so that salt reduction practice would change across the population.

Social Behavioural Change Communication to reduce salt consumption

Hypertension affects around one third of adults in Malaysia, making it a primary risk factor for mortality and disability. Excessive salt consumption is a major contributor to high blood pressure, with the average Malaysian consuming 7.9 g of salt per day, more than 50% higher than the World Health Organization's (WHO) recommended daily intake of 5.0 g of salt. This is equivalent to 2.0 g of sodium, the component of table salt which contributes to hypertension. To combat this issue, WHO has recommended salt reduction interventions as best buys and set a global target to reduce mean population salt intake by 30% by 2025 for the prevention and control of non-communicable diseases (NCDs). To promote salt reduction in Malaysia, the Ministry of Health (MoH) together with WHO, initiated a Social Behavioural Change Communication (SBCC) programme. By the end of December 2022, over five million people had been reached by salt reduction Information, Education and Communication (IEC) materials, shown to result in a measurable increase in knowledge, attitude, and intention to practice salt reduction.

Key WHO Contributions

Leveraging SHAKE Technical Package for Salt Reduction to assist Member States with the development, implementation and monitoring of salt reduction strategies
Developing Malaysia’s SBCC plan with the Ministry of Health
Commissioning a nutritional survey of street food
Developing tailored communication campaign materials and media
Engaging social media influencers
Conducting an interim evaluation of the campaign
Developing a health promotion toolkit for schools

How did Malaysia, with the support of the WHO Secretariat, achieve this?

Since 2015, Malaysia has been implementing a Salt Reduction Strategy in alignment with the WHO SHAKE Technical Package for Salt Reduction [1]. The aim of the strategy is to reduce the population's salt intake down to 6.0 g per day by 2025 through various interventions. A midterm evaluation commissioned by the WHO in 2018 found that the strategy had made strong progress in Malaysia and recommended targeted interventions, including strategic communication towards the general population [2]. As a result, the Social Behavioral Communication Campaign (SBCC) plan was developed and implemented by the WHO in collaboration with the MoH to encourage behavior change through salt reduction messages.

^{The memorable slogan 'cukup sedikit, elak penyakit' (just a little, avoid disease) was incorporated into all communication materials and social media campaigns, including this animated video.}Photo credit: WHO.

To better understand the main sources of salt intake in the general population, WHO commissioned a study to survey 10,520 street foods from all states in Malaysia and analysed the nutritional content of the 210 most popular street foods in all the states of Malaysia [3]. The data collected will be updated in the online Malaysian Food Composition Database (MyFCD). It was also used by WHO to develop tailored communication campaign materials for the general public and school children. The SBCC programme developed a memorable slogan, ‘cukup sedikit, elak penyakit’ (just a little, avoid disease), which was used in all communication materials and social media campaigns. The programme produced posters, infographics, pamphlets, and social media handles to promote salt reduction messages, and educational videos were created, including a fully animated video for school children.

“We found that 35% of the most common main meals available in the street foods of Malaysia contain more sodium than the recommended daily intake of 2.0 g of sodium. While we should encourage product reformulation to reduce the sodium content, it is important to share this information with the general public, so they can make better-informed food choices”.

- Associate Professor Dr Hasnah Haron, the lead researcher from the National University of Malaysia (UKM).

The SBCC programme used social media platforms like TikTok and YouTube to reach a wider audience. TikTok was selected for its ability to create engaging content and reach a younger audience. Fifteen TikTok influencers were engaged by WHO to create unique videos on salt reduction, which were carefully reviewed and approved by WHO officers. In addition, WHO worked with a creative consultant to produce two videos shared on social media. YouTube was used to share informative and animated videos and advertise them to Malaysian audiences.

“We have decided to focus on two main target populations, namely adults and children. We know that establishing healthy behaviours is more effective during childhood and adolescence. By working with the WHO, we were able to use these innovative distribution channels, allowing us to reach a wider audience. This campaign showed promising results and it is an important element of our overall salt reduction strategy”.

- Dr Hamdan bin Mohamad, Dietitian at the Disease Control Division, MoH.

WHO provided technical and financial support for an interim evaluation of the SBCC campaign in September 2022, which included a Knowledge, Attitude and Practice (KAP) survey and social media reach analysis. The SBCC programme’s influencers reached a total of 5.1 million followers, with 661,000 views, 34,500 likes, 1,800 shares, and 683 comments. The KAP survey showed that the IEC materials were of high quality and reach, and increased respondents’ knowledge, attitude, and intention to practice salt reduction. It also showed that the programme needs to maintain its visibility and upscale its communication campaign by going beyond mass transmission of messages to provide practical solutions that can positively impact salt reduction practice such as ground interventions like community and school engagements. To do this, WHO Malaysia also developed a health promotion toolkit focused on salt reduction for use in schools and a training module which can be used by the MoH. The training for school educators is underway.

Despite facing challenges, including COVID-19 restrictions, the SBCC programme in Malaysia has made progress towards reducing the population’s salt intake. Local data, varied communication channels, and social influencers were important for the programme’s success, particularly with the younger generation. Continuous monitoring and targeted interventions are needed to maintain the momentum, and a coordinated effort between community, industry, and other stakeholders is necessary for a long-term health impact.

References

Non-Communicable Disease (NCD) Section, Disease Control Division, Ministry of Health Malaysia. 2021. Salt Reduction Strategy to Prevent and Control NCD for Malaysia 2021-2025
Reducing Salt Intake in Malaysia: An Interim Evaluation of What Works (2019). Putrajaya, Malaysia: Ministry of Health Malaysia.
Haron, H.; Zainal Arifen, Z.N.; Shahar, S.; Mohamad, H.; Mohd Yazid, S.F.Z.; Michael, V.; Abeyasinghe, R.; Taketo, T.; Trieu, K. Street Food in Malaysia: What Are the Sodium Levels? Foods 2022, 11, 3791. https://doi.org/10.3390/foods11233791