Characteristics of participants
Table 2 displays the characteristics of the 54,435 third-grade students involved in health education, with 27,542 of them completing pre- and post-education self-report questionnaires. Additionally, twenty-three informants were interviewed, comprising 4 health experts from the CDC, 6 government officials, 6 principals, and 7 headteachers. Eight focus groups were held involving 40 students and 40 parents, with 10 participants in each group.
Table 2
Participant characteristics in the mixed methods evaluation
|
Quantitative methods
|
Qualitative methods
|
Participants in education activities
|
Self-report questionnaire investigation
|
Individual interview
|
Focus group
|
Sample size
|
54435
|
27542
|
23
|
80
|
Gender
Female
Male
|
Not collected
|
Not collected
|
16
7
|
40
40
|
Province, City
Jiangxi, Ganzhou
Jiangsu, Zhenjiang
|
34662
19773
|
15928
11614
|
11
12
|
40
40
|
Role
CDC health expert
Government official
Principal
Headteacher
Parent
Student
|
-
-
-
-
-
54435
|
-
-
-
-
-
27542
|
4
6
6
7
|
-
-
-
-
40, 4 groups
40, 4 groups
|
Program period
|
Nov 2021 to Jul 2022 and Oct 2022 to Jul 2023
|
Oct 2022 to Jul 2023
|
Nov 2021 to Jul 2022 and Oct 2022 to Jul 2023
|
Oct 2022 to Jul 2023
|
Reach - Student Enrolment:
A total of 54,435 students enrolled in this health education program, representing 97.7% of all third-grade students (55,715) across 1,260 classes selected from 208 schools. Parents demonstrated a willingness to participate in school-organized health activities, expressing trust in schools' ability to enhance their children's health. They also acknowledged successful registration in the "Health Cloud Classroom" under the supervision of headteachers (Parent, Mingzhu Primary School): “Because this is a school project, we were glad to participate in. The headteachers contacted me through a WeChat group. They guided us to register a mobile application.” During the registration, a small number of students encountered challenges due to (Principal, Henshun Primary School, Zhenjiang): “parents’ lack of primary skills to operate applications on mobiles,” which potentially hindered the program from reaching all the students and their families through the mHealth approach.
Effectiveness - knowledge and practice improvement:
As depicted in Table 3, the questionnaire results revealed a pre-post rise in awareness of salt reduction knowledge and the adoption of healthy behaviors. The standardized score for all knowledge and practice inquiries increased from 75.1 (95% CI: 74.9–75.2) to 80.9 (95% CI: 80.7–81.1).
Table 3
Salt-reduction knowledge awareness, practice and standard scores before and after education
|
Before education
|
After education
|
P
|
Awareness rate of health knowledge (n, %)
|
|
|
|
Recommendation of salt for adults less than 5 g/day
|
9589 (34.8%)
|
13283 (48.2%)
|
< 0.01
|
The composition of salt is sodium chloride
|
22847 (82.9%)
|
24376 (88.5%)
|
< 0.01
|
Main health risk of salt is hypertension
|
23759 (86.3%)
|
24603 (89.3%)
|
< 0.01
|
Sichuan pepper contains the lowest sodium than soy sauce, bean sauce, monosodium glutamate
|
23434 (85.1%)
|
25603 (93.0%)
|
< 0.01
|
Even if blood pressure is normal, it is necessary to reduce salt intake
|
23199 (84.2%)
|
25031 (90.9%)
|
< 0.01
|
Sodium content on nutrition label shows the salt content in food
|
22388 (81.3%)
|
24282 (88.2%)
|
< 0.01
|
Choose the lowest salt food among four options by analysing the sodium content in 100 g food
|
14854 (53.9%)
|
16124 (58.5%)
|
< 0.01
|
Adoption rate of health behavior (n, %)
|
|
|
|
Choose low or reduced-salt meals
|
9602 (34.9%)
|
12426 (45.1%)
|
< 0.01
|
Consume salty snacks less than 1 serve one week
|
17558 (63.8%)
|
18827 (68.4%)
|
< 0.01
|
Choose healthy snacks by checking nutrition label
|
24476 (88.9%)
|
25733 (93.4%)
|
< 0.01
|
No eating out
|
14873 (54.0%)
|
15607 (56.7%)
|
< 0.01
|
Standard scores of knowledge and practice (Mean, 95%CI)
|
|
|
|
In total
|
75.1 (74.9–75.2)
|
80.9 (80.7–81.1)
|
< 0.01
|
Knowledge awareness
|
72.7 (72.4–72.9)
|
79.5 (79.3–79.7)
|
< 0.01
|
Health practice adoption
|
79.3 (79.1–79.5)
|
83.4 (83.2–83.6)
|
< 0.01
|
Parents shared insights on their children's enhanced health behaviors, noting that they were more attentive to nutrition labels when purchasing food and beverages, opting for healthier choices. Some students also disseminated health information from EduSaltS to their family members, including elderly relatives who typically contend with noncommunicable diseases, to promote salt intake reduction (Parent, Mingzhu Primary School, Zhenjiang): “My son frequently checks nutrition labels and informs me about salt content. My child consistently reminds his grandmother to use less salt while cooking." Parents affirmed the health benefits of this program. They developed cooking skills aimed at reducing salt and progressively reduced their intake of salted vegetables, a common dietary practice in their communities (Parent, Tianzhushan Primary School, Zhenjiang): “Before this project, I used to put much salt and soy while stir-frying vegetables, but now I put just a little when cooking almost done. I use garlic instead of salt to increase taste.” Furthermore, the entire family changed their dietary practices to reduce salt intake (Parent, Mingzhu Primary School): “We used to eat out often on Sundays, but now we eat out less frequently and order takeaway less." The barrier to achieving greater salt reduction effects was the adverse influence of unhealthy off-campus environments. Convenience stores and restaurants around schools are major sources of salt intake for students (Principal, Henshun primary school, Zhenjiang): “In accordance with certain regulations, our schools no longer host on-campus stores, although such stores still operate in the surrounding areas. Furthermore, advertisements in the broader community entice students to consume heavily processed foods, particularly during their commute between home and school.”
School adoption and participation:
All 208 invited schools (all 108 primary schools in Zhenqing and all 100 primary schools in Ganzhou) agreed to participate in the health education program after a formal introduction meeting convened by local education bureaus. Two facilitators, student health needs and school health needs, were often mentioned by informants (Official, Danyang Education Bureau, Zhenjiang): “the accumulation of health issues among students exerted considerable pressure on school health, urging schools to actively take health actions.”
Second, there was a contextual need to improve school health (Health expert, Zhenjiang CDC, Zhenjiang): “The Opinions on Comprehensive Improvement of School Health and Health Education in the New Era, issued by Department of Education, advocated widening channels and innovatively integrating Internet technologies into health education.”
This policy perfectly resonated with the intervention measures employed by the EduSaltS.
Schools need to improve students’ health, but the challenge is prioritizing health issues among students. Notably, during the COVID-19 pandemic, schools experienced lockdowns, and more attention was given to mitigating infection risks (Principal, Hengshun Primary School, Zhenjiang): “Schools hesitated to adopt EduSaltS to reduce salt intake at the initiative period, which seems not directly relevant to the pandemic response.”
Implementation
The school effectively executed a variety of health activities proposed by the EduSaltS with a high degree of fidelity. The average completion rate for each of the 20 health cloud courses was 84.9%, and the rates fluctuated between 79.4% and 93.4% (Fig. 1). The participation rate for optional online activities, such as knowledge competition was 57.6%, and that for health materials self-learning was 81.1%.
Figure 1 Completion rate of health cloud classes
The average health activity score was 2353.6 (95% CI: 2343.5-2373.7). Online health activities played a predominant role, and the average score was 1790.5 (95% CI: 1784.9–1796.0).
In total, 1800 activities were conducted by 162 schools, with a median of 9.0, and 3999 activities were conducted at the class level, with a median of 3.0 (Table 4). The results show that there were more required activities than optional activities at either the school or class level.
Table 4
Offline health activities
|
Total
|
Ganzhou
|
Zhenjiang
|
|
N of schools or classes
|
N of Activities
|
Median
|
Interquartile Range
|
N of schools or classes
|
N of Activities
|
Median
|
Interquartile Range
|
N of schools or classes
|
N of Activities
|
Median
|
Interquartile Range
|
School level activity
|
162
|
1800
|
9.0
|
5.0–14.0
|
65
|
499
|
6.0
|
3.0–10.0
|
98
|
1301
|
10.5
|
7.0–16.0
|
Health theme activities (Required)
|
155
|
417
|
2.0
|
1.0–3.0
|
63
|
151
|
2.0
|
1.0–3.0
|
93
|
266
|
2.0
|
2.0–3.0
|
Putting up posters (Required)
|
151
|
724
|
5.0
|
3.0–6.0
|
56
|
228
|
3.0
|
3.0–6.0
|
96
|
496
|
6.0
|
. 3.5-6.0
|
Canteen chef health education (Required)
|
91
|
113
|
1.0
|
1.0–1.0
|
25
|
32
|
1.0
|
1.0–1.0
|
67
|
81
|
1.0
|
1.0–1.0
|
Health video playing (Optional)
|
66
|
228
|
3.0
|
2.0–4.0
|
16
|
37
|
2.0
|
1.0-3.5
|
51
|
191
|
3.0
|
2.0–5.0
|
Health audio broadcasting (Optional)
|
59
|
212
|
3.0
|
2.0–4.0
|
15
|
33
|
2.0
|
1.0–3.0
|
45
|
179
|
3.0
|
2.0–5.0
|
Evaluation and reward (Optional)
|
62
|
93
|
1.0
|
1.0–2.0
|
16
|
18
|
1.0
|
1.0–1.0
|
47
|
75
|
1.0
|
1.0–2.0
|
Class level activity
|
612
|
3999
|
3.0
|
2.0–8.0
|
296
|
1397
|
3.0
|
1.0-5.5
|
328
|
2602
|
6.0
|
2.0–10.0
|
Health theme activities (Required)
|
544
|
1212
|
2.0
|
1.0–2.0
|
244
|
490
|
1.0
|
1.0–2.0
|
312
|
722
|
2.0
|
1.0–2.0
|
Putting up posters (Optional)
|
286
|
532
|
1.0
|
1.0–2.0
|
110
|
132
|
1.0
|
1.0–1.0
|
187
|
400
|
1.0
|
1.0–2.0
|
Health lessons (Optional)
|
380
|
1736
|
3.0
|
1.0–6.0
|
174
|
638
|
2.0
|
1.0–5.0
|
218
|
1098
|
4.0
|
2.0–7.0
|
Evaluation and reward (Optional)
|
264
|
519
|
1.0
|
1.0–2.0
|
86
|
137
|
1.0
|
1.0–2.0
|
190
|
382
|
1.0
|
1.0–2.0
|
The informants attributed successful implementation to the attractiveness of health activities (Health expert, Danyang CDC, Zhenjiang): "Health education activities are enjoyable for both parents and children." The parents also expressed that both the students and family members were happy to perform the health activities together (Parent, Tianzhushan Primary School, Ganzhou): "My child and his father like doing knowledge competition together, finding it quite interesting, a valuable parent‒child interactive experience.”
Moreover, to reduce the workload for all the relevant individuals, the health cloud courses were issued automatically by the system on Monday, with checks and reminders by the headteachers before Monday.
Another robust measure for implementation was real-time monitoring and evaluation. A school principal appraised the efficiency of the management application (Principal, Mincheng Primary School, Zhenjiang): “Through ‘EduSaltS Manager’ and ‘Management Website’, we can promptly check completion rates, rank health activities, and compare the progress between schools. The delay and incompletion were timely identified by headteachers and shared with parents.” Efficient information sharing between schools and families was frequently cited by the parents (Parent, Shahe Primary School, Ganzhou): “Appreciated the headteachers’ timely reminder for consistent engagement in the salt reduction activities.”
In this circumstance, headteachers played the pivotal role of intermediaries between the program and the target population. One example of the importance of headteachers was that a school with a newly transferred headteacher who missed program training experienced a sudden decrease in the completion rate of cloud health courses.
To motivate headteachers in the implementation of health activities, schools implemented incentive measures (Principal, Wenqinglu Primary School, Ganzhou): “The headteachers who successfully completed health activities were evaluated with higher teaching performance and priority of year reward or promotion.”
Additionally, EduSaltS provided the teachers with ready-to-use health materials to relieve their workload. These health materials were developed by health professionals with input from health education experts and schoolteachers and can be downloaded from management websites. This approach gave teachers the flexibility to choose topics of interest for regular health education classes (Health expert, Danyang CDC, Ganzhou): “I looked through the health education materials in the app, and they're quite interesting and professional. …. I can choose lecture content according to own education needs.”
Insufficient family support was cited as an implementation barrier. One common issue was (Teacher, Xincheng Primary School, Zhenjiang): parents migrated from their poor hometown to affluent cities for better job opportunities.” Another barrier stems from the demanding schedule of parents, who are occupied by heavy workloads and constraints on the time available for their children (Parent, Shahe Primary School, Ganzhou): “We have our own jobs and responsibilities and might be overwhelmed by those school activities.” As a result (Teacher, Xincheng Primary School, Zhenjiang): “the children encountered difficulties in fulfilling health activities due to lack inspiration and support, typically provided by the parents.”
Maintenance and sustainability
As the health education program spans a school year, maintenance was proven to be a challenge. The completion rates of health cloud courses experienced a decline, starting at a peak of 93.4% at the beginning of the first semester and reaching a lower rate of 79.4% by the end of the semester. Notably, the completion rates fluctuated during the second semester but remained below 86.2%.
To launch and maintain the program, considerable governmental efforts were made. This includes 17 government documents and 10 capability training events delivered by provincial or city education and health authorities. In addition to routine supervision by class headteachers, local managers conducted 57 field supervisions and 60 online monitoring activities, mainly targeting poorly performing schools to identify and address problems (Table 5).
Table 5
Governmental administration activities
|
Total
|
provincial
|
Ganzhou
|
Zhenjiang
|
Government documents
|
17
|
2
|
4
|
11
|
Field supervision
|
57
|
19
|
16
|
22
|
Online monitoring and management
|
60
|
23
|
9
|
28
|
Capability training for health education
|
10
|
4
|
2
|
4
|
Support school's offline activities
|
5
|
0
|
1
|
4
|
The informants believed that opportunities for scaling up school salt reduction stemmed from bolstered intersectoral collaboration between local governments, and enhanced family engagement cultivated through the program (Official, Zhanggong Health Committee, Ganzhou): “Establishment of clear responsibilities in conjunction with health authorities, wherein health sectors provided professional and technological support, while the education sector took responsibility for motivating, organizing, and monitoring the schools to achieve project goals.” This articulated management mechanism holds promise for the scalable implementation of EduSaltS.
In terms of family engagement, parents believed that positive feedback from schools, such as commendations for their children's performance in the EduSaltS, significantly motivated their participation in future school health programs (Parent, Heyang Primary School, Zhenjiang): “My child received praise and recognition from teacher. As parents, we are very happy and motivated to continue doing well.”
Maintaining and scaling-up salt reduction in schools also face challenges according to the research findings. The informants claimed that the development of health regulations and policies was essential for fostering a supportive social environment (Official, Danyang Education Bureau, Zhenjiang): “Government should issue policy to require school cafeteria chefs to accept mandatory training for salt reduction.” Another informant mentioned (Health expert, Jiangxi CDC, Ganzhou): “a lack of guidelines will cause difficulties in the adoption and implementation of school salt reduction in the future.”
As an mHealth-based school health education, EduSaltS should remain accessible after its completion to assure maintenance and sustainability (Health expert, Danyang CDC, Zhenjiang): “The applications should be freely downloadable from mobile and website not only for the program participants but also for larger populations.”
This triggered a financial issue to sustain the whole IT system, as well as update education materials to cater to other grades of students.