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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 97-103

Perception and practices of homemakers regarding extra salt consumption in tripura: A rural versus urban comparison


Department of Community Medicine, Tripura Medical College, Dr. BRAM Teaching Hospital, Agartala, Tripura, India

Date of Submission08-Jul-2020
Date of Decision31-Jul-2021
Date of Acceptance08-Sep-2021
Date of Web Publication18-Oct-2022

Correspondence Address:
Nabarun Karmakar
Department of Community Medicine, Tripura Medical College, Dr. BRAM Teaching Hospital, Hapania, P O – ONGC, Agartala - 799 014, Tripura
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_91_20

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  Abstract 


Introduction: India has diverse dietary culture where salt and spices are used extensively, but up-to-date figures on population salt consumption are very limited. Objectives: The objective of this study is to assess the perception and practices of females doing household cooking regarding extra salt consumption and to have a rural–urban comparison on a specified population. Materials and Methods: A community-based cross-sectional study was conducted among 480 homemakers residing in a rural and urban (Madhupur, Sepahijala district and Dukli, West Tripura district, respectively) area of Tripura for a period of 6 months. A predesigned, pretested, semi-structured interview schedule divided into two parts was used to collect the required information, and scores were given for each response regarding perception and practice of the participants. Results: The mean age of the respondents was 38.48 ± 14.063 years and 37.30 ± 12.087 years, respectively, for rural and urban areas, and both the populations were comparable in their baseline characteristics. Majority of the participants believed recommended daily salt consumption per person daily was >5–10 g (62.9% of rural and 59.6% of the urban participants) which was too high, and significant difference (P value 0.002) was found in practice regarding extra salt consumption among rural and urban participants. Conclusion: This study revealed good perception and significantly better practice regarding extra salt consumption among the urban population. Social caste in the rural population and socioeconomic status in both the study groups were the factors responsible for extra salt consumption in this study.

Keywords: Added, household, intake, lowering, salt


How to cite this article:
Datta A, Karmakar N, Nag K, Bhattacharjee P. Perception and practices of homemakers regarding extra salt consumption in tripura: A rural versus urban comparison. CHRISMED J Health Res 2022;9:97-103

How to cite this URL:
Datta A, Karmakar N, Nag K, Bhattacharjee P. Perception and practices of homemakers regarding extra salt consumption in tripura: A rural versus urban comparison. CHRISMED J Health Res [serial online] 2022 [cited 2022 Nov 27];9:97-103. Available from: https://www.cjhr.org/text.asp?2022/9/1/97/358825




  Introduction Top


Adding salt to taste is an essential step of our daily household cooking. Without salt the food can go bland, and sometimes, taste is the only thing that matters when it comes to eating. However, the balance between taste and health is very crucial when it comes to adding salt when cooking. Because salt can give rise to high blood pressure among healthy individuals, which is a major risk factor for coronary artery disease, stroke, chronic kidney disease, loss of vision etc., if consumed in a higher quantity than the permissible limit over a period of time.[1]

It is not just hypertension that is the only concern with consuming more salt in our diet but excess salt intake can give rise to serious health problems, even if blood pressure-related complications are not there. For example, in the heart excess salt intake can cause hypertrophy of the ventricular myometrium, forcing the cardiac chambers to work more to pump blood and eventually leading to congestive heart diseases. Similarly, in the kidneys, excess salt consumption increases the excretion of protein and disrupts the normal waste excretion process by the kidneys. Over activity of fight to flight response of the brain and defective functioning of intimal layer of blood vessels are the other serious health hazards posed due to excessive consumption of salt.[2]

When it comes to the Indian scenario, salt and spices are used extensively, irrespective of differences in dietary habits between the different regions of India. The existing data reveal that amount of daily salt consumption varies across different regions of India with an average daily consumption ranging from 9 to 12 g per person per day. This salt consumption is higher among urban population than the rural in India. This level is quite alarming as compared to what World Health Organization (WHO) recommended to limit the daily intake of salt within 5 g for healthy individuals to avoid serious health complications arising out of high salt intake. This permissible limit of daily salt consumption is even lower for those who have already developed complications.[3]

There are no such data available for this part of the country to find out even the perception and practices regarding excess salt consumption by the people, which is important to identify the factors responsible for excessive consumption of salt and take corrective measure, which again warrants the need of a study like the present one.

Objectives

  1. To study the perception and practices of homemakers regarding extra salt consumption in their households among selected rural and urban settings of Tripura
  2. To compare their perception and practices regarding extra salt consumption in their households between rural and urban setting
  3. To find out relation between extra salt consumption and sociodemographic characteristics of the study population.



  Materials and Methods Top


A community-based cross-sectional study was conducted among homemakers residing in a randomly selected rural and urban (Madhupur, Sepahijala district and Dukli, West Tripura district respectively) area of Tripura. The study was conducted for a period of 12 months (March 2018 to February 2019). A total of 480 homemakers were selected for the study by using the following formula, n = 4pq/l2, where n = total sample size, 4 is constant (i.e., z2 = 3.86, considered as 4 for convenience of calculation), p = prevalence (in this study 48.1% was used as p which was the prevalence of salt added on table in the study by Sarmugam et al.), q = 1– p, l = allowable error (10% of prevalence) and 10% as nonresponse rate.[4] Finally, 240 homemakers each from the rural and urban areas were surveyed.

The unit for the sampling was individual household and the total number of the households in each area (1376 and 503 from rural and urban areas, respectively) was taken as the sampling frame, which was constructed from the family survey registers present in both rural and urban health training centers. The households were selected using the simple random sampling technique by the lottery method with replacement and from each household one homemaker was selected, and in case of more than one homemakers, the lady who is mainly involved in daily household cooking was interviewed. If during the survey, the participant was found absent the next selected house was surveyed and this process continued till the required sample size was achieved. Operational definition for extra salt for this study was, salt added on table with meal (not during the process of cooking). Tenants, migrants, or residents of <6 months were excluded from the study because their responses might not reflect the perception and practices of local rural and urban communities if the participants are not permanent rural or urban dweller and to avoid mixing of responses between our selected study groups.

The study tool used here was a predesigned, pretested, semi-structured interview schedule divided into two parts: Part A consisting of questions related to sociodemography and part B consisting questions related to perception and practices of the participants. Scores were given to each question of Part B, the most appropriate answer was given the score of 2 and rest of the answers were allotted a score of 1. The responses shown in [Table 1] and [Table 2] were included in Part B of the study tool. Individual total score of perception and practice were calculated and score ≥ mean was considered as good (for perception and practice as well). Data were entered and analyzed in software Statistical Package for the Social Sciences software (SPSS Inc. SPSS for Windows, Version 16.0. Chicago, Illinois, USA) and represented using appropriate tables in the form of frequencies and percentages. The Chi-square test, Fisher's exact test, and Student's t-test were applied to see the difference in the baseline characteristics of the two study groups, their perception and practices and factors associated with extra salt consumption, as appropriate (significance value was considered as <0.05 at α = 0.5).
Table 1: Frequency distribution of perception regarding extra salt consumption at household level of the participants (n= 480; 240 each from rural and urban areas)

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Table 2: Frequency distribution of practices regarding extra salt consumption at household level of the participants (n=480; 240 each from rural and urban areas)

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A well-explained consent in the local language (Bengali) was taken in written from all the participants before commencing the study. Ethical clearance was obtained from the Institutional Ethics Committee before conducting the study.


  Results Top


[Table 3] shows sociodemographic information of the participants. In the present study, the mean age of the respondents was 38.48 ± 14.063 years and 37.30 ± 12.087 years, respectively, for rural and urban areas. Majority were Hindu by religion (89.6% in rural and 100% in the urban population). Among the rural participants, 22.1% were illiterate, whereas only 12.9% among urban participants. They mostly belonged to nuclear families (67.15% among rural and 70.4% among urban population). Majority belonged to class IV as per B. G. Prasad's socioeconomic status (SES) classification (49.2% and 37.1% of rural and urban participants, respectively). Significant difference was found between rural and urban population in their religion, social caste, education, and SES class (P < 0.001, <0.001, 0.002 and <0.001, respectively).
Table 3: Frequency distribution of sociodemographic variables of the participants (n=480; 240 each from rural and urban areas)

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[Table 1] shows perception of the participants regarding extra salt consumption in their households. This table showed majority of the participants believed recommended daily salt consumption per person daily was >5 g and up to 10 g (62.9% of rural and 59.6% of the urban participants), followed by <5 g per day (27.1% of rural and 26.3% of the urban participants). Most of them were aware that high salt intake could cause serious health problems (86.7% of the rural and 94.6% of the urban population), and the difference was significant (P value 0.003). Furthermore, majority believed, lowering salt consumption is essential for well-being. Majority agreed that low salt-containing common food items, for example, puffed rice, pickle, etc., should be made available in the market and they also knew that less salt intake does not give less physical strength (60% in rural and 61.7% in urban participants). Most of them believed that salt consumption should not be increased during sickness as well as during pregnancy.

[Table 2] showed their practices regarding extra salt consumption. The table showed most of the participants (73.3% of the rural and 78.8% of the urban) were consuming extra salt during meal on table. Majority responded that they take processed food with high salt content e.g., puffed rice, pickle etc., and they always take it. Only 38.3% of the rural and 47.9% of the urban participants were cutting down the amount of salt they add during cooking while majority in the rural population did not cut down extra salt on table. Most of them (84.2% of rural and 79.58% of urban participants) did not check for salt content in food packaging.

[Table 4] shows significant difference (P value 0.002) in practice scores regarding extra salt consumption among rural and urban participants, especially better practice among the urban participants than the rural (P value 0.009).
Table 4: Difference between rural and urban perception and practice scores as well as association between good perception and practice among rural and urban participants (n=480; 240 each from rural and urban areas)

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[Table 5] shows social caste of participants (specially belonging to SC category) was significant predictor of extra salt consumption among the rural population (P value 0.021). Again extra salt consumption was found to be significantly higher among those who belonged to lower SES (SES class IV specially), both in rural and urban areas (P value 0.018 and 0.021, respectively).
Table 5: Frequency distribution table showing association between sociodemographic variables with the use of extra salt among the study population of rural and urban areas (n=480; 240 each from rural and urban areas)

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  Discussion Top


This present study showed that mean age of the participants was 38 and 37 years (rural and urban respectively) approximately and most of them were Hindu by religion. Majority belonged to general and scheduled caste. Majority had education of high school (class 8–10th) standard both in the rural and urban population and belonged to nuclear families as well. As per BG Prasad's classification, majority in both population belonged to SES class IV. The two study groups were comparable in their age and the type of family they belonged to but dissimilarity was found in other baseline characteristics included in this study.

In this study, majority (62.9% and 59.6% of rural and urban participants, respectively) believed that daily recommended level of salt consumption per person was >5–10 g per person per day, which is higher than the WHO recommendation of maximum daily intake of 5 g salt per person.[5] Similarly, Intersalt study revealed the average consumption of salt in their 52 study sites ranged between 5.9 and 11.7 g per day, which was also far in excess of the recommended level.[6] In this study, majority believed that high salt diet could cause serious health problems with significant association (P value 0.003) with urban population. Most of our study participants (87.1% of rural and 91.3% of urban) reported that lowering salt consumption in daily food was essential for well-being, whereas, Porimol Palma in their study in Dhaka city found only 19% of their study population recognized the importance of lowering salt intake.[1] This shows that even if majority of people in our study setting believed in the consumption of high amount of salt than the recommended but most of them were aware of the fact that salt intake needed to be lowered to maintain good health. This study also shows that majority of the participants (57.9% and 61.3% of rural and urban participants, respectively) believed that food items commonly consumed by them which were high in salt, for example, puffed rice, pickle, should be available in market with low salt type. This shows their attitude toward change from high salt containing food to low salt containing food without altering their common food habits. The WHO had strongly recommended social marketing to reduce salt intake because social marketing aims at changing behavior at individual as well as public level.[7],[8] “Skip the salt, help the heart” campaign in United States found that people commonly believe, a low-sodium diet would be bland or tasteless.[9] Therefore, low salt or low sodium preparations should not mean bland or tasteless food otherwise it will not be acceptable to the society for regular practice as food should satisfy our taste buds too. A similar study in Ghana showed that practicing salty “seasonings” while cooking significantly reduces sodium content in food. Incorporating salty seasoning might help in reducing heavy salt intake in our study population, which might create new avenues for future research in this respect.[10]

The present study revealed very high prevalence of adding extra salt (73.3% and 78.8% among rural and urban population, respectively) in contrast to the findings by Sarmugam et al. in their study among 530 Australian adults, where they found that 25.7% of the adults always or often used salt on table which was consistent to their National Health Survey 2001 report (25.5%).[4],[11] Similarly, Rasheed et al. in a similar study at costal Bangladesh among 400 adults for quantitative survey showed that 26% of their study population added extra salt to their meals.[12] Again the study by Porimol Palma in Dhaka city found that 54% of their respondents consumed additional salt during meals.[1] Although wide geographical variation between the Australian population and the present study population could possibly be the reason for this discrepant study results, the population of Tripura and Bangladesh are considered similar in their cultural and food habits which indicates that extra salt consumption practice was quite higher among our study population as compared to other studies and there was no significant association found with either of the study groups.

In contrast to the reports of District level Household Survey (DLHS-4), state fact sheet, Tripura, showing higher prevalence of hypertension (26.9% in the urban areas as compared to 18.2% in rural) as well as higher consumption of iodized salt (82.4% in urban compared to 73.7% in the rural population), this present study revealed significant difference (P value 0.002) in scores for practices in urban participants (10.17 ± 1.74) as compared to the rural (9.72 ± 1.48).[13] Similar to DLHS-4 reports, a survey by Public Health Foundation of India in collaboration on 14,000 adults over 24 years age in urban Delhi and rural Haryana revealed average daily population salt intake was higher in urban than rural areas.[3] This could mean that the urban population of this present study was more effectively restricting extra salt intake in their daily household meal than the rural population.

Limitation

Only females were interviewed in the present study and the practice assessed here was based on self-reporting of the respondents rather than any objective assessment method. The calculated sample size (480) was quite large to be sampled separately from each study group, considering the nonfunded nature of the study and limited resources; therefore, in total, 480 participants were included in the study equally from the rural and urban population.


  Conclusion Top


This study revealed good perception and significantly better practice regarding extra salt consumption among the urban population. Social caste in the rural population and SES in both the study groups were the factors responsible for extra salt consumption in this study. There are strong evidences that cutting down the access to salt intake will reduce the risk of hypertension and cardiovascular diseases not only among diseased but also among normal individuals.[3] The use of low salt and low sodium diet, spices to replace salt while cooking and salty seasoning instead of adding salt while cooking could be the possible way outs to reduce such high average daily salt intake in the entire country as well as in our study population. This knowledge should be percolated among the lower socioeconomic class of people, especially among the rural population with the help of well-directed awareness campaign.

Acknowledgment

We acknowledge all the women for giving us time to interview. We are also grateful to the health workers, Medical Social Workers of Madhupur and Dukli for their extensive collaboration, without which this study would not have been conducted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Porimol P. Halt the Extra Salt. Suggest Experts as Two BSMMU Studies Find Higher Level of Salt Consumption in Dhaka City. The Daily Star; 2017. p. 1-5. Available from: http://www.thedailystar.net/city/halt-the-extra-salt-1405372. [Last accessed on 2018 May 31].  Back to cited text no. 1
    
2.
Farquhar WB, Edwards DG, Jurkovitz CT, Weintraub WS. Dietary Sodium and Health: More Than Just Blood Pressure. Journal of The American College of Cardiology. 2015;65:1042-50.  Back to cited text no. 2
    
3.
Byerley C. Salt Consumption in India: The Need for Data to Initiate Population-Based Prevention Efforts. University of Birmingham; May 17, 2013. Available from: https://www.birmingham.ac.uk/news/latest/2013/05/17May-Salt-consumption-in-India-the-need-for-data-to-initiate-population-based-prevention-efforts.aspx. [Last accessed on 2018 Mar 28].  Back to cited text no. 3
    
4.
Sarmugam R, Worsley A, Wang W. An examination of the mediating role of salt knowledge and beliefs on the relationship between socio-demographic factors and discretionary salt use: A cross-sectional study. Int J Behav Nutr Phys Act 2013;10:25.  Back to cited text no. 4
    
5.
World Health Organization. Guideline: Sodium Intake for Adults and Children. Geneva, Switzerland: World Health Organization; 2012. p. 1-56.  Back to cited text no. 5
    
6.
Intersalt: An international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ 1988;297:319-28.  Back to cited text no. 6
    
7.
Bardfield L. Applying a Social Marketing Framework to Salt Reduction. Washington, DC, USA: Family Health International; 2012.  Back to cited text no. 7
    
8.
Weinrich NK. Hands-on Social Marketing: A Step-by-Step Guide to Designing Change for Good. Los Angeles, CA, USA: SAGE; 2011.  Back to cited text no. 8
    
9.
Health Communication Research Center, Missouri School of Journalism. Skip the Salt, Help the Heart. University of Missouri. Available from: http://hcrc.missouri.edu/case-studies/skip-the-salt-help-theheart/. [Last accessed on 2018 May 31].  Back to cited text no. 9
    
10.
Kerry SM, Emmett L, Micah FB, Martin-Peprah R, Antwi S, Phillips RO, et al. Rural and semi-urban differences in salt intake, and its dietary sources, in Ashanti, West Africa. Ethn Dis 2005;15:33-9.  Back to cited text no. 10
    
11.
Australian Bureau of Statistics: Occasional Paper: Measuring Dietary Habits in the 2001 National Health Survey Australia; 2001. Available from: http://www.abs.gov.au/ausstats/[email protected]/mf/4814.0.55.001#APPENDIX%20A%3A%202001%20NHS%20DIETARY%20INDI. [Last accessed on 2018 May 31].  Back to cited text no. 11
    
12.
Rasheed S, Siddique AK, Sharmin T, Hasan AM, Hanifi SM, Iqbal M, et al. Salt intake and health risk in climate change vulnerable coastal Bangladesh: What role do beliefs and practices play? PLoS One 2016;11:e0152783.  Back to cited text no. 12
    
13.
State Fact Sheet, Tripura. District Level Household and Facility Survey-4. Ministry of Health and Family Welfare. International Institute of Population Sciences (Deemed University), Mumbai; 2012-13. Available from: http://rchiips.org/pdf/dlhs4/report/TR.pdf. [Last accessed on 2018 May 31].  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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