Stakeholder perspectives on the lower-sodium salt substitutes (LSSS) uptake in Malaysia: a qualitative study

Excessive salt intake is a major contributor to hypertension and cardiovascular disease in Malaysia. Lower-sodium salt substitutes (LSSS) can replace regular salt in home cooking and help manufacturers reduce sodium levels in packaged foods to meet maximum sodium targets. Although LSSS is a promising intervention, uptake remains limited. This study aimed to explore stakeholder perspectives on awareness, barriers and strategies to promote LSSS uptake in Malaysia. A qualitative study was conducted in February 2026 involving representatives from ministries and government agencies, civil societies (non-governmental and international organisations), and academic or research institutions in Malaysia. A total of 24 stakeholders participated (mean age 45.3 ± 5.8 years; 75.0% women). Data were collected through focus group discussions (FGDs), guided by a semi-structured questionnaire adapted from a 4 A’s framework developed by Ajenikoko et al. (2021). FGD recordings were transcribed verbatim, coded using NVivo 12 software and analysed using a hybrid inductive-deductive thematic approach. Socio-demographic data were summarised descriptively using SPSS version 25. Three major themes emerged based on participant accounts: (i) perceived awareness and knowledge gap: Government and civil society stakeholders reported superficial LSSS awareness, driven by self-reported incomplete knowledge and a lack of media coverage, while academic informants highlighted widespread public conceptual overlap between general salt reduction and functional salt substitution; (ii) barriers to adoption: key informants across sectors highlighted structural and economic challenges, including high costs, price disparities, limited local suppliers, low consumer demand, clinical safety concerns for vulnerable populations, potential iodine deficiency risks and an absence of mandatory potassium labelling. Crucially, sensory-related industry resistance was recognised not as a direct experimental finding, but as second-hand feedback from food manufacturers concerned about product quality; and (iii) multi-sectoral strategies for promotion and implementation: all stakeholders recommended driving demand through awareness and education, strengthening supply through industry engagement, implementing economic and fiscal measures, building local evidence on LSSS safety to inform regulatory and labelling, and improving product accessibility and visibility. Participants perceived LSSS awareness among relevant stakeholders and the public to be limited, while identifying various substantial perceived barriers to its uptake. Coordinated advocacy and stakeholder-proposed multi-sectoral action are needed to strengthen consumer and professional confidence, support industry adoption, and inform policy implementation. Successful scale-up should also address affordability, iodine fortification, and clinical safety considerations.