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Salt Intake and Health Risk in Climate Change Vulnerable Coastal Bangladesh: What Role Do Beliefs and Practices Play?

Sabrina Rasheed*
Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh

A. K. Siddique
Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh

Tamanna Sharmin
Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh

A. M. R. Hasan
Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh

S. M. A. Hanifi
Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh

M. Iqbal
Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh

Abbas Bhuiya
Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh

Abstract/ Executive Summary:

Background High salt consumption is an important risk factor of elevated blood pressure. In Bangladesh, about 20 million people are at high risk of hypertension due to climate change-induced saline intrusion in water. The objective of this study is to assess beliefs, perceptions, and practices associated with salt consumption in coastal Bangladesh. Methods The study was conducted in Chakaria, Bangladesh between April-June 2011. It was a cross-sectional mixed-method study. For the qualitative study 6 focus group discussions, 8 key informant interviews, 60 free listing exercises, 20 ranking exercises and 10 observations were conducted. 400 adults were randomly selected for the quantitative survey. For analysis, we used SPSS for quantitative data, and Anthropac and Nvivo for qualitative data. Results Salt was described as an essential component of food with strong cultural and religious roots. People described both health benefits and risks related to salt intake. The overall risk perception regarding excessive salt consumption was low and respondents believed that the cooking process can render the salt harmless. Respondents were aware that salt is added in many foods even if they do not taste salty but did not recognize that salt can occur naturally in both foods and water. Conclusions In the study community people had low awareness of the risks associated with excess salt consumption and salt reduction strategies were not high in their agenda. The easy access to and low cost of salt, as well as the unrecognized presence of salt in drinking water, has created an environment conducive to excess salt consumption. It is important to design general messages related to salt reduction and test tailored strategies especially for those at high risk of hypertension.

Keywords: Salt Intake, Health Risk, Climate Change, Coastal Bangladesh

Location: Chakaria, Bangladesh

Start Date: 00-04-2011

End Date: 00-06-2011

Program Area: Risk Management in Agriculture

Commodity: Soil salinity, Health hazard

Objectives:

The objective of this study is to explore the sources of dietary salt, assess beliefs, perceptions, and practices associated with salt consumption particularly, among the coastal population of Bangladesh who are likely at high risk of hypertension due to exposure to environmental salinity.

Methodology:

Study area The study was conducted in Chakaria (sub-district)-a rural area of the Southeastern coastal region of Bangladesh during April-June 2011. Chakaria has an existing health and demographic surveillance system (HDSS) run by Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and a quarterly survey of health and demographic events is collected through the HDSS. The total HDSS area is about 288 KM² . About half of the HDSS area belongs to the low-lying coastal areas and the rest of the area has plain land and hilly area. Availability of the HDSS allowed us to sample respondents for our quantitative study. Details of the study area and the HDSS have been provided elsewhere.

Study design: The study was cross-sectional in design where both qualitative and quantitative data collection techniques were deployed. For qualitative data, six qualitative methods were used- key informant interviews (KII), focus group discussion (FGD), free listing, ranking and observation. The respondents were selected through purposive homogeneous sampling to encapsulate a wide range of perspectives regarding the use of salt. Some criteria used for selecting respondents were gender and age. At the preparatory stage, the free listing was used to lists food where salt is added. The names of foods that were listed were written on small cards for ranking exercise. The respondents were then asked to rank the foods in the order of preference. Observation, FGD, and KII were performed to understand community perception regarding salty food, salt consumption, and the practice of salt use. The FGDs and KIIs were conducted in the time and place chosen by the respondents. The KII took 45 minutes to an hour while the FGDs took about 1.5 hours on average. All the KIIs and FGDs were audio-recorded and transcribed in Bangla for analysis by the researchers themselves. Extensive field notes were maintained during fieldwork to supplement the data collected. The qualitative field team consisted of 2 male and 2 female researchers with a Master's degree in Anthropology and social science, as well as 4-5years of experience in collecting qualitative data. All the researchers who collected data were trained by a medical anthropologist (TS) and a public health specialist (SR). Among those who collected data 2 are the authors of this paper (TS and AH). Qualitative study results were used to form the quantitative survey instrument. For the quantitative study to calculate the sample size we assumed that 50% of the population will consume more than 5g of salt/day. Based on this assumption and considering a 5% refusal to participate we needed 403 people for the survey. From the list provided by HDSS, 609 people were approached, 421 people were available, 15 were excluded and finally, data from 400 respondents over 18 years of age was available for analysis. The respondents were randomly selected from 5 villages representing the coastal area, plain land and hilly area. The respondents were approached for a survey, anthropometric data and collection of 24 hours urine output (not reported in this paper). Data was collected on perceptions regarding the risk of hypertension, behaviour and risk perception regarding salt use and frequency of eating salty foods identified during listing and ranking exercises. Details of the methodology of the quantitative survey are provided elsewhere. For this paper quantitative data was used to support the qualitative insights. All the participants of the study provided written consent and the study received ethical clearance from the Ethical Review Committee of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). During data collection, digital recorder was used to record the conversation after ensuring consent.

Data analysis Data from free listing and ranking exercises was analyzed with computer software ANTHROPAC (Borgatti, 1996). The data obtained was coded for emerging themes using Nvivo. Constant comparative analysis was conducted to come up with the sub-codes. The emergent themes were triangulated using data collected through both FGDs and KIIs. Peer debriefing was conducted within the study team to understand the issues and consolidate the findings. The quantitative data was analyzed using SPSS version 12. Descriptive statistics were generated from the quantitative survey to support the qualitative analysis.

Source of Information: PLOS ONE April 4, 2016

Article Link (Online Journal): DOI:10.1371/journal.pone.0152783

Funding Source:

1.

Budget:

Total Budget (Tk.) :

Achievement/Findings:

In summary, the people in the study community had low awareness of the risk of excess salt consumption and salt reduction strategies were not high in their agenda. With easy access and low cost of unrefined salt and the cultural preference for salt consumption, the unrecognized presence of salt in drinking water can push the salt consumption in this population to an unacceptable and unsafe level. Such excessive salt intake can in turn put a large number of people such as pregnant women at risk of hypertension and even death. While it is imperative that awareness-raising campaigns are designed for the coastal areas such as Chakaria, given the intractable nature of much of human behaviour it is important to design and test tailored strategies of salt reduction for those at higher risk of hypertension. As there are very strong cultural and religious influences on dietary salt use, and therefore, the reduction might be difficult: lowering salt in drinking water (e.g. through offering alternative freshwater sources) would, therefore, also be a promising solution to look into. In terms of future research, it is important that the effect of environmental salinity on human health is studied over time. With the focus on building resilience against the health effects of climate change articulated within the overall goal of Universal Health Coverage, the findings from our study were of critical importance.

Knowledge Management: Journal