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Asian Journal of Medicine and Biomedicine

Knowledge, Attitude and Practice (KAP) on Salt Intake and its Relationship with
Blood Pressure among Chinese Adults in Johor

Pang Xin Yi1, Mohd Razif Shahril1, Hasnah Haron1*

1Faculty of Health Science, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala
Lumpur, Malaysia

*Corresponding author: hasnaharon@[Link]

Received: 19 June 2022 Accepted: 15 November 2022 Published: 30 November 2022

Abstract

Hypertension is one of the most serious health problem worldwide as well as in Malaysia with high salt
intake as the major risk factor related to it. Therefore, this study was aimed to determine knowledge,
attitude and practice (KAP) on salt intake and its relationship with blood pressure among Chinese adults
in Johor. This cross-sectional study comprised of 90 subjects (36 males, 54 females), aged 18 to 59 years
old. Subjects were required to answer the online questionnaire regarding KAP of salt intake. Self-reported
anthropometry data and blood pressure measurement were recorded. Sodium intake was determined
using a single 24-hour dietary recall method through face-to face or telephone interview. Results showed
that majority subjects were within normal Body Mass Index (BMI) range and optimal blood pressure range.
BMI was found to have significant correlation with systolic blood pressure (r=0.563, p<0.05) and diastolic
blood pressure (r=0.444, p<0.05). Mean sodium intake of subjects was 2399 mg/day, exceeded the WHO
recommendation of 2000 mg/day. Sodium intake was found to have significant correlation with systolic
blood pressure (r=0.220, p<0.05). Results indicated that the overall KAP score was fair (64.14%). The
knowledge of most subjects was fair (69.95%) besides having positive attitude towards salt intake
(74.17%). However, practice of healthy salt intake among them was inadequate (49.53%).
Sociodemographic characteristic of female gender was significantly associated (p<0.05) with better
attitude. Additionally, older subjects, married subjects and subjects with higher level of education were
significantly associated (p<0.05) with better practice towards healthy salt intake. In this study, there were
no significant (p>0.05) associations between KAP on salt intake with sodium intake and blood pressure. In
conclusion, BMI and sodium intake were significantly associated with blood pressure among Chinese
adults. Further effort and interventions are needed to reduce the salt intake among Chinese adults and thus
reduce the risk of hypertension.

Keywords
Knowledge, attitude, practice, salt, sodium, blood pressure, hypertension, Chinese adults

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Introduction
Salt is an inorganic compound composed of sodium ions and chloride ions [1]. Sodium is an essential
nutrient needed by the body for maintenance of plasma volume, acid-base balance, nerve impulse
transmission and normal cell function [2]. WHO [2] recommends that adults consume no more than one
teaspoon of salt a day, equivalent to 5 g of salt or 2000 mg of sodium. However, global sodium intake for
adults exceeded that recommendation [3]. Excessive sodium intake can increase blood pressure, which in
turn causes cardiovascular disease (CVD) [4]. WHO [5] published a Global Action Plan proposing a 30%
reduction in salt intake by 2025. Reducing salt or sodium intake has been identified as a priority action to
reduce non-communicable diseases. In Malaysia, the prevalence of hypertension among Chinese adults
aged 18 years and above is 28.1% [6].

Several previous studies conducted in Malaysia have shown that salt or sodium intake among Chinese
adults exceeded the WHO recommendation, which is 5 g salt (2000 mg sodium) per day [7,8]. According to
Haron et al. [9], the food group with the highest average salt content was gravy and sauce, followed by soup.
Furthermore, the highest sodium content information on sauces in Malaysia was displayed by fish or prawn
sauce, followed by light soy sauce and salty soy sauce [10]. Chinese regularly consume soup in their main
course [11], in addition to use soy sauce in food preparation [12]. This indirectly affected blood pressure as
sauce and soup were high in salt content. However, study on the prevalence of hypertension and its
association with high blood pressure among Chinese adults in Johor was limited. Thus, this study was
conducted to see the connection.

Salt intake was influenced by individual’s knowledge, attitude and practice (KAP) on salt intake [13]. People
continue to consume excessive sodium intake due to lack of awareness about the effect of excessive sodium
intake towards hypertension [14]. Therefore, KAP of Chinese adults on salt intake and its relationship with
blood pressure were determined in this study. Findings on KAP towards salt intake can be used to plan
strategies for changes in practices of individuals towards dietary salt intake

Materials and Methods

Study subjects
This study is a cross-sectional study conducted to determine knowledge, attitude and practice (KAP) on
salt intake and its relationship with blood pressure among Chinese adults in Johor. Conveniece sampling
was applied to select a sample of 90 Chinese adults aged 18 to 59 years old. The study was conducted from
September 2020 to February 2021. Sociodemographic information, health history, antropometry data,
blood pressure measurements and KAP on salt intake among subjects were collected using online
questionnaire. The questionnaire was in bilingual form which is Malay and English. Study information sheet
and consent form also included in the online questionnaire to explain the purpose of the study and their
involvement in the study. Face-to-face or telephone interview was conducted to determine sodium intake
among Chinese adults through 24-hour dietary recall method. Inclusion criteria of subjects were Malaysian
Chinese living in Johor, aged 18 to 59 years and not on high blood pressure medication. Ethical approval to
conduct this study was obtained from the Research Ethnics Committee of Universiti Kebangsaan Malaysia
(UKM PPI/111/8/JEP-2020-476) prior to the study.

Sample size calculation

Based on the study by the National Health and Morbidity Survey (NHMS) (2019) [6], the prevalence of
hypertension among adults aged 18 years and above in Malaysia was 30%. Thus, Cochran [15] formula was
used based on a confidence level of 95%, a prevalence of 30% and an accuracy level of 10%. The sample
size calculation was as followed:

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"
! #∝⁄" $ %('(%)
n= *"

n = sample size
𝑍+ /- = Z value at 95% confidence level = 1.96
p = Population (prevalence) = 30% = 0.3
e = Accuracy level = 10% = 0.1

('./0)" (1.2)('(1.2)
n=
1.'"

= 81 subjects

It is estimated that 10% of subjects will drop out,

Therefore, actual sample size = 81/0.9
= 90 subjects

Sociodemographic and health history

Subjects were required to fill in their sociodemographic information in the Section A of the questionnaire
including age category, gender, marital status, education level, employment and monthly household
income. For health history, subjects were required to record any undergoing therapy for illness such as
liver disease, kidney disease, stroke, heart disease and diabetes in Section B of the questionnaire.

Anthropometric data
Anthropometric data consisted height, weight and blood pressure. Data collection of subjects’ weight and
height were done using self-report method. BMI was calculated and classified based on World Health
Organisation [16]. Blood pressure of subjects were collected through self-measurement or measured by
researcher. Blood pressure measurements performed after subjects were rested for at least 5 minutes.
Subjects were required to be seated and the arm must be horizontal at the level of the heart. Readings were
taken when subjects were in a calm state. Blood pressure readings were taken twice to obtain the average
value. Classification of blood pressure was adopted from Malaysia’s Clinical Practice Guidelines:
Management of Hypertension 2018 [17]. Height, weight and blood pressure data were recorded in the
Section C of the questionnaire.

Knowledge, Attitude and Practice (KAP) on salt intake

The KAP questionnaire on salt intake in Section D used in this study was adapted from previous study by
Haron et al. [18]. The questionnaire consisted 18 questions, which were divided to three domains, namely
knowledge, attitude and practice. Each answer of KAP questions was scored in order to classify subject
based on scoring by Bakarman et al. [19].

Table 1: Cut-off score in categorizing the level of knowledge, attitude and practice

Score % Knowledge Attitude Practice Total KAP

< 60 Poor Negative Inadequate Poor
60-70 Fair Neutral Adequate Fair
> 70 Good Positive Good Good

Prior to the study, a content validity test was conducted to determine the validity and reliability of the
questionnaire. With the involvement of seven experts, 0.83 and above is considered the acceptable cut-off
score of CVI (Content Validity Index) [20]. Modifications have been made to the particular items that could
not achieve I-CVI (Item-Level Content Validity Index) values of 0.83 and above based on comments
provided by the experts. The average S-CVI (Scale-Content Validity Index) value of 0.93 was obtained,

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proving that all question items are reliable.

Sodium intake assessment

The food intake of subjects was determined using a single 24-hour dietary recall method. The dietary recall
method was carried out through face-to-face or telephone interview. Subjects were required to recall all
foods and drinks consumed during last 24 hours to determine the sodium intake in a day. Food serving size
estimation aids with the pictures of household measurement tool from the Food Atlas: Size Portion and
Exchange [21] was used to assist in estimating food portion size. All the data obtained were analysed using
the Nutritionist ProTM Diet Analysis Software [22]. Reported energy intake that was <500 kcal/day or >5000
kcal/day for women or >8000 kcal/day for men was considered under or over reporting, and it was
excluded from the study analysis [8,23].

Statistical Analysis
Data obtained from the results of the study were analysed using Statistical Package for Social Sciences
(SPSS) [24] version 25.0 software. Sociodemographic data, health history data, anthropometry data, blood
pressure data, sodium intake and knowledge, attitude and practice (KAP) of subjects on salt intake were
analysed using descriptive analysis tests to obtain frequency, percentage, mean and standard deviation.
Shapiro-Wilk test was used to test the normality of the data because the study sample size was less than
100 subjects. Comparison of anthropometry data, blood pressure data and sodium intake between genders
were analysed using independent t test. Besides, one-way ANOVA test was used to compare anthropometry
data, blood pressure data and sodium intake between age groups. Other than that, Spearman’s Rho test was
used to analyse the relationship between blood pressure with Body Mass Index (BMI) and sodium intake.
The relationship between KAP on salt intake with sodium intake and blood pressure were also analysed
using Spearman’s Rho test. Lastly, Fisher’s Exact and Chi-square tests were used to analyse the relationship
between KAP on salt intake with sociodemographic characteristics. Statistical significance was set at
p<0.05.

Results
A total of 90 subjects participated in this study, Table 2 shows the majority of the subjects were female
(60.0%), aged 18-29 years (75.6%), single (74.4%), had degree level of education (66.7%), student (50.0%)
and earned a monthly household income of less than RM4851 (64.4%). Most of them currently are not
undergoing therapy for any illness (98.9%). Majority of the subjects were within normal Body Mass Index
(BMI) range (70.0%) and optimal blood pressure range (52.2%).

Table 1: Sociodemographic Data of the Study Subjects (n=90).

Characteristics Frequency Means (SD)

(%)
Age (years)
18-29 68 (75.6)
30-39 4 (4.4)
40-49 10 (11.1)
50-59 8 (8.9)
Gender
Male 36 (40.0)
Female 54 (60.0)
Ethnicity
Chinese 90 (100)
Marital Status
Single 67 (74.4)
Married 23 (25.6)

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Education Level
Primary School 1 (1.1)
Secondary School 10 (11.1)
Diploma 14 (15.6)
Degree 60 (66.7)
Master 5 (5.6)
Employment
Student 45 (50.0)
Work 39 (43.3)
No work 6 (6.7)
Monthly Household Income
≤ RM4850 (B40) 58 (64.4)
RM4851-10970 (M40) 30 (33.3)
≥ RM10971 (T20) 2 (2.2)
Health History
Kidney Disease 1 (1.1)
None 89 (98.9)
Body Mass Index (kg/m2) 21.7 ± 3.2
Body Mass Index Categories (kg/m2)
Underweight (<18.5) 13 (14.4)
Normal (18.5-24.9) 63 (70.0)
Overweight (25.0-29.9) 13 (14.4)
Obese (>30.0) 1 (1.1)
Systolic Blood Pressure (mmHg) 114.1 ± 14.1
Diastolic Blood Pressure (mmHg) 72.6 ± 10.4
Blood Pressure Categories (mmHg)
Optimal (systolic <120 and diastolic <80) 47 (52.2)
Normal (systolic 120-129 or diastolic 80-84) 27 (30.0)
At risk (systolic 130-139 or diastolic 85-89) 12 (13.3)
Hypertension Stage 1 (systolic 140-159 or diastolic 90-99) 4 (4.4)

Table 3 shows the sodium intake of the study subjects based on WHO 2012 and Recommended Nutrient
Intake (RNI 2017) cut-off point. The mean sodium intake among subjects was 2399 mg/day, exceeded the
WHO recommendation of 2000 mg/day. According to the dietary sodium intake, 42.2% of subjects met the
WHO target of <2000 mg salt in a day and 23.3% subjects met the RNI of ≤1500 mg salt in a day.

Table 3: Sodium Intake of the Study Subjects Based on WHO 2012 and RNI 2017 Cut-off

Sodium intake (mg/day) Frequency (n=90) Percentage (%)

WHO 2012
<2000 38 42.2
≥2000 52 57.8
RNI 2017
≤1500 21 23.3
>1500 69 76.7

Table 4 shows the correlation between BMI and sodium intake with blood pressure. BMI was positively
and significantly correlated with systolic blood pressure (p<0.001) and diastolic blood pressure (p<0.001).
Besides, sodium intake was positively and significantly correlated with systolic blood pressure (p= 0.037).

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Table 4: Correlation between Body Mass Index and Sodium Intake with Blood Pressure.

Systolic blood pressure Diastolic blood pressure

Variables (mmHg) (mmHg)
r value p value r value p value
Body Mass Index (kg/m2) 0.563 <0.001*** 0.444 <0.001***
Sodium intake (mg/day) 0.220 0.037* 0.106 0.320
*p value < 0.05 is significant
***p value < 0.001 is significant

Table 5 shows the knowledge, attitude and practice scores on salt intake among study subjects. The
knowledge of most subjects was good (56.7%) with average overall knowledge score of 69.95 ± 13.43%.
Besides, most subjects had positive attitude towards salt intake (71.1%) with average overall attitude score
of 74.17 ± 10.02%. However, practice of healthy salt intake of most subjects was inadequate (73.3%) with
average overall practice score of 49.53 ± 13.41%. The total KAP of most subjects was fair (42.2%) with
average overall KAP score of 64.14 ± 9.40%.

Table 5: Knowledge, Attitude and Practice Scores on Salt Intake among Study Subjects.

Marks Average score Frequency Percentage (%)

(mean ± SD)
Knowledge
<60% (Poor) 50.46 ± 10.20 18 20.0
60 - 70% (Fair) 65.08 ± 2.08 21 23.3
>70% (Good) 78.84 ± 7.54 51 56.7
Overall 69.95 ± 13.43 - -
Attitude
<60% (Negative) 54.76 ± 4.45 7 7.8
60 - 70% (Neutral) 65.13 ± 2.07 19 21.1
>70% (Positive) 78.97 ± 6.98 64 71.1
Overall 74.17 ± 10.02 - -
Practice
<60% (Inadequate) 42.42 ± 6.11 66 73.3
60 - 70% (Adequate) 64.61 ± 2.98 15 16.7
>70% (Good) 76.50 ± 4.49 9 10.0
Overall 49.53 ± 13.41 - -
Knowledge, attitude and practice (total)
<60% (Poor) 54.32 ± 4.45 30 33.3
60 - 70% (Fair) 64.47 ± 2.70 38 42.2
>70% (Good) 76.97 ± 4.93 22 24.4
Overall 64.14 ± 9.40 - -

Table 6 shows the relationship between knowledge, attitude and practice (KAP) towards salt intake with
sociodemographic characteristics. Female subjects were significantly associated with better attitude
compared to males (p<0.025). Besides, older subjects (30 years and above) were significantly associated
with better practices compared to younger subjects (18-29 years) (p=0.009). Moreover, good practices
were found to be significantly higher among married subjects as compared to subjects who were single
(p=0.003). In addition, higher education level was significantly associated with the good practices
(p=0.017). However, there were no significant associations between knowledge and total KAP with
sociodemographic characteristics (p>0.05). Additionally, there were no significant associations between
knowledge, attitude and practice on salt intake with sodium intake and blood pressure (p>0.05).

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Table 6: Relationship between Knowledge, Attitude and Practice (KAP) Towards Salt Intake with
Sociodemographic Characteristics.

Sociodemographic Attitude, n (%) χ²

Characteristics Negative Neutral Positive (p value)
Age (years)a 0.690
18-29 6 (8.8) 15 (22.1) 47 (69.1)
30-39 1 (25.0) 0 (0.0) 3 (75.0)
40-49 0 (0.0) 3 (30.0) 7 (70.0)
50-59 0 (0.0) 1 (12.5) 7 (87.5)

Gendera 0.025*
Male 4 (11.1) 12 (33.3) 20 (55.6)
Female 3 (5.6) 7 (13.0) 44 (81.5)

Marital Statusa 0.782

Single 6 (9.0) 15 (22.4) 46 (68.7)
Married 1 (4.3) 4 (17.4) 18 (78.3)

Education Levela 0.958

Primary School 0 (0.0) 0 (0.0) 1 (100.0)
Secondary School 0 (0.0) 2 (20.0) 8 (80.0)
Diploma 1 (7.1) 3 (21.4) 10 (71.4)
Degree 6 (10.0) 12 (20.0) 42 (70.0)
Master 0 (0.0) 2 (40.0) 3 (60.0)

Employmenta 0.761
Student 5 (11.1) 8 (17.8) 32 (71.1)
Work 2 (5.1) 9 (23.1) 28 (71.8)
No work 0 (0.0) 2 (33.3) 4 (66.7)

Monthly Household Incomea 0.490

≤ RM4850 (B40) 5 (8.6) 14 (24.1) 39 (67.2)
RM4851-10970 (M40) 2 (6.7) 4 (13.3) 24 (80.0)
≥ RM10971 (T20) 0 (0.0) 1 (50.0) 1 (50.0)

Sociodemographic Practice, n (%) χ²

Characteristics Inadequate Adequate Good (p value)
Age (years)a 0.009**
18-29 55 (80.9) 8 (11.8) 5 (7.4)
30-39 1 (25.0) 1 (25.0) 2 (50.0)
40-49 7 (70.0) 2 (20.0) 1 (10.0)
50-59 3 (37.5) 4 (50.0) 1 (12.5)

Genderb 0.175
Male 30 (83.3) 3 (8.3) 3 (8.3)
Female 36 (66.7) 12 (22.2) 6 (11.1)

Marital Statusa 0.003**

Single 55 (82.1) 6 (9.0) 6 (9.0)
Married 11 (47.8) 9 (39.1) 3 (13.0)

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Education Levela 0.017*

Primary School 0 (0.0) 1 (100.0) 0 (0.0)
Secondary School 5 (50.0) 5 (50.0) 0 (0.0)
Diploma 11 (78.6) 2 (14.3) 1 (7.1)
Degree 47 (78.3) 5 (8.3) 8 (13.3)
Master 3 (60.0) 2 (40.0) 0 (0.0)

Employmenta 0.204
Student 36 (80.0) 5 (11.1) 4 (8.9)
Work 27 (69.2) 7 (17.9) 5 (12.8)
No work 3 (50.0) 3 (50.0) 0 (0.0)

Monthly Household Incomea 0.278

≤ RM4850 (B40) 41 (70.7) 12 (20.7) 5 (8.6)
RM4851-10970 (M40) 24 (80.0) 3 (10.0) 3 (10.0)
≥ RM10971 (T20) 1 (50.0) 0 (0.0) 1 (50.0)
*p value <0.05 is significant, **p value <0.01 is significant.
a Fisher’s Exact test, b Chi-square test

Discussion
In the present study, the mean sodium intake of Chinese adults had exceeded the recommendation of 2000
mg a day by WHO [2], similar to the previous studies conducted among Chinese adults in Malaysia [7,8].
Majority of the subjects in this study did not meet the WHO and RNI target of sodium intake in a day.
Previous study also reported the same findings, however, the number of subjects who met both WHO and
RNI target of sodium intake had increased in 2014 compared to 2003 [25]. According to the Malaysian Adult
Nutrition Survey [7], almost half of Malaysian adults often eat out or venture out to buy food. Sodium intake
among Chinese adults in this study exceeding recommended level could be due to the practice of eating out
among subjects.

In our findings, there were significant positive correlations between BMI with systolic and diastolic blood
pressure which is in line with the study by Haron et al. [18]. Subjects with higher BMI had higher systolic and
diastolic blood pressure. Individuals with higher BMI that is, in the category of overweight or obese,
associated with a higher prevalence of hypertension compared to individuals with normal BMI [26]. As such,
overweight and obese individuals are encouraged to carry out lifestyle modification interventions
especially weight management in order to reduce the risk of hypertension. Besides, there was significant
positive correlation between sodium intake with systolic blood pressure, meaning that subjects who
consumed more salt had higher blood pressure, that is in line with the study conducted by Yang et al. [27].
Other study also showed that sodium reduction resulted in a significant decrease in blood pressure in both
normotensive and hypertensive adults [28].

The knowledge of most Chinese adults in this study was good, that is in line with the previous study among
Chinese students of Faculty of Health Sciences in UKM Kuala Lumpur (KL) [29]. Majority of the subjects in
this study had knowledge about the recommendation of salt intake in a day. Furthermore, most subjects
knew that high salt intake could lead to a serious health problem. In agreement with previous studies
showing that most subjects were aware that high salt intake may lead to high blood pressure [30,31]. Most
Chinese adults in this study had positive attitude towards salt intake, that is in line with the previous study
among Chinese students in UKMKL [29]. Furthermore, another study in China revealed that residents in
Shandong province had a favourable attitude towards sodium reduction [31]. In the current study, majority
of the subjects claimed that reducing salt in their diet is important to them and agreed to minimize the salt
consumption. The practice of healthy salt intake of most Chinese adults in this study was inadequate,
similar to the previous study conducted among Chinese students in UKMKL [29]. Minority of the subjects
controlled their salt intake in a regular basis. Less than a third of the subjects reported to avoid eating foods

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prepared outside of home, limit the consumption of salty snacks, avoid adding salt or soy sauce during or
before eating, avoid or minimize the consumption of processed foods and buy alternatives food with low
salt. More alarmingly, less than 10% of subjects avoid adding salt when cooking and check the salt content
on the food labels. Therefore, more efforts and interventions are needed to reduce the salt intake among
Chinese adults in order to promote health and prevent diseases associated with excessive salt intake.

Based on the findings of this study, it can be concluded that having moderate level of knowledge and
positive attitude among subjects did not affect their daily practice of controlling salt intake. The total KAP
on salt intake was to some extent influenced by knowledge, attitude and practice scores. The results of this
study showed that majority of the subjects had a moderate level of awareness of salt intake. More
awareness programs on the importance of healthy salt intake should be conducted in order to raise the
community awareness about the risks of high salt intake.

This study showed female gender was significantly associated with better attitude. Previous studies
reported the same findings where females were more willing to take action in controlling salt intake [32,33].
Besides, older subjects were significantly associated with better practices compared to younger subjects.
Younger adults tended to add salt to food and had less control over salt intake [34]. Another study by
Nasreddine et al. [32] reported that younger adults took less action to cut down on salt, checking label for
sodium content and trying to buy alternatives food with low salt compared to older adults. Moreover, good
practices were found to be significantly higher among married subjects as compared to subjects who were
single. A study conducted by Vinther et al. [35] reported that unmarried subjects were associated with lower
health practices compared to married subjects. In addition, higher education level was significantly
associated with good practices that is in line with the study by Zhang et al [31] which reported the similar
finding.

Limitation and Recommendation

The limitation of this study is the reliability of weight, height and blood pressure readings reported by
subject itself. Another limitation of the study is the single 24-hour dietary recall provides an estimate of
mean intake of foods and nutrients, but do not represent the usual intake of subject. It is recommended that
all anthropometric and blood pressure measurements should be performed by researchers in the future to
ensure the accuracy of anthropometric and blood pressure measurement in subjects. Besides, it is
recommended to conduct multiple 24-hour dietary recall or 24-hour urine excretion which is the gold
standard method for assessing sodium intake more accurately.

Conclusion
Majority Chinese adults in Johor had normal BMI and optimal blood pressure. BMI was positively and
significantly correlated with systolic and diastolic blood pressure. The mean sodium intake among Chinese
adults was 2399 mg/day (6.00 g/day salt) which exceeded the WHO recommendation of 2000 mg/day
sodium or 5 g/day salt. Sodium intake was positively and significantly correlated with systolic blood
pressure. The knowledge of Chinese adults was fair besides having positive attitude towards salt intake.
However, practice of healthy salt intake among them was inadequate. The overall knowledge, attitude and
practice (KAP) of Chinese adults towards salt intake was fair. Sociodemographic characteristic of female
gender was significantly associated with better attitude. Additionally, older subjects, married subjects and
subjects with higher level of education were significantly associated with better practice towards healthy
salt intake. In this study, there were no significant associations between KAP on salt intake with sodium
intake and blood pressure.

Acknowledgements
The authors acknowledge all study subjects during the study.

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