Barriers and facilitators to implementing national sodium reduction programs in rural China: a qualitative study

Since 2017, China has begun to implement national sodium reduction programs, yet there are no existing studies to robustly evaluate factors influencing the implementation. The primary objective of this study was to identify barriers and facilitators to the implementation of sodium reduction programs in rural areas of Heilongjiang, Guangdong, and Guizhou provinces in China. In-depth interviews and focus group discussions were conducted with key stakeholders who had a significant role in implementation of sodium reduction programs including health administrators and primary healthcare providers. Potential participants were identified through existing professional networks and local contacts, and eligible participants were selected purposively based on pre-specified characteristics. The Practical Robust Implementation and Sustainability Model (PRISM) informed the development of the interview guides and provided a framework for interpreting and organizing the findings. Thirty-seven participants were included through 13 individual in-depth interviews and 4 focus groups, with a mean age of 42.9 years (SD 8.9) and 66.7% being male. Government-led, multi-sectoral collaboration in sodium reduction interventions, incorporation of sodium reduction education into existing health programs, and tailoring health education for different populations were identified as the main facilitators for the implementation of sodium reduction interventions. Low awareness of the perceived benefits of sodium reduction and potassium-enriched salt, difficulty in changing dietary habits, rigid and cumbersome intervention measures, and a lack of dedicated sodium reduction efforts (e.g. follow-up monitoring and evaluation due to insufficient funding and heavy workloads), were identified as major barriers to the implementation of sodium reduction programs in rural China. This study identified barriers and facilitators to implementing national sodium reduction programs in rural China. Strengthening implementation in rural areas requires a multi-level framework, including policy support, service delivery, and individual behaviour change.