Readiness for behavioral change of discretionary salt intake among women in Tehran, Iran

Background It is vitally important to take into consideration women’s role in dietary pattern choice and family food management. Since women’s readiness for dietary behavioral change can be one of the most effective fundamental measures for preventing chronic diseases in developing countries, the present study is aimed to determine the readiness for behavioral change in voluntary salt intake as well as its determinants among women living in Tehran. Materials and methods The present cross-sectional study was conducted on 561 women referring to the women care units across city of Tehran. In this regard, demographic information of the participants was collected. The self-administered questionnaire included assessment of nutrition-related knowledge on salt intake and its association with diseases, discretionary salt intake, stages of change, and self-efficacy of women. In addition, the logistic regression test was used to determine the predictors of women’s readiness for behavioral change in voluntary salt intake. Results 40% women had someone in the family who had such a limitation (salt intake-limited exposure group), while 81.6% always or often added salt to their foods. Moreover, one-third of the participants were in the stage of pre-contemplation and 41.2% were in the stage of preparation for reducing salt intake. Stage of change increased with an increase in the self-efficacy score (r=0.42, p<0.001). Self-efficacy and salt intake-limited exposure were the two most important determinants of the women’s readiness for behavioral change in voluntary salt intake, respectively: (OR=1.1 95% CI: 1.06-1.14 p<0.001; OR=1.58, 95% CI: 1.03-2.42 p<0.038) Conclusions Results of the present study showed that increased self-efficacy is associated with higher levels of behavioral change among women. Since self-efficacy is very important for initiating and maintaining the behavioral change, women’s empowerment for reducing salt intake necessitates putting the emphasis on increased self-efficacy as well as community-based nutritional interventions.


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Behavior change is a process which occurs in individuals with different levels of motivation and 58 readiness for change [1][2][3]. Changing health-related behaviors can significantly affect some of the 59 most important causes of death and diseases. Behavior plays a pivotal role in health. Evidence  Studies which assess individuals' readiness to change health behaviors reveal that over one-third 65 of people are at the pre-contemplation stage and few (8-14%) at the preparation stage [5][6][7]. 66 Moreover, increase in age, level of education, and self-efficacy; and the existence of chronic 67 diseases such as hypertension which requires the limitation of salt intake, have been associated 68 with placing individuals at higher levels of change [5,[7][8]. 69 Hypertension is among the main risk factors for cardiovascular diseases, especially myocardial 70 infarction, stroke, and congestive heart failure [9]. Based on the report by the Institute for Health 71 Metrics and Evaluation of Iran, hypertension is the second risk factor among the 10 main risk Based on the most recent study (2014) on adults in Tehran, Iran, daily salt intake was 9 g for men 80 and 6.96 g for women, with 53.6% being discretionary salt intake or salt intake in cooking or at 81 the table [13]. At present, the per-capita salt intake in Iran is 10-12 g per day, higher than the 82 amount recommended by the World Health Organization (WHO), i.e. less than 5 g per day. In 83 other words, Iranians consume salt in their diet 5.2 times more than others [14]. A study reported 84 mean salt intake to be 10.3 g per day in urban and rural areas of Ilam Province, Iran [15]. Moreover, 85 it is 11.47 g per day for adults in Isfahan, Iran [16]. In terms of salt intake, Iran is similar to 86 Denmark (7.1 g per day in women), China (12 g per day), Spain (9.8 g per day), and Japan (7.8 g 87 per day) [17][18][19][20] is an easy, beneficial, independent, and low-cost method for reducing the burden of diseases, 104 decreasing related costs, and maintaining health, and is the most effective preventive approach in 105 most countries [31][32][33][34]. Therefore, national intervention programs, e.g. educational programs with 106 the cooperation of the Ministry of Health, households, and related organizations, seem necessary 107 for reducing discretionary salt intake. Considering these problems, it is vital to offer effective 108 interventions. Of course, the use of interventional approaches for reducing discretionary salt intake   The present study aimed to determine the readiness for changing the behavior of discretionary salt 122 intake and its determinants in women residing in Tehran capital city in Iran.      Maintenance: Individuals maintain change for some time, usually six months or more. In this stage, 139 the behavior is stable and permanent and individuals try to prevent regression [1][2][3].

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The model of stages of change have been employed in numerous diet-related studies in order to 141 determine the stages of change in diet behavior, including the reduction of fat intake and increasing 142 fiber, fruit, vegetable, and dairy intake, and its efficiency has been confirmed. Therefore, diet-    The second section focused on the discretionary salt intake. Over 60% of salt intake in Tehran is 173 the salt added in cooking or at the table [13]. Also, it is difficult to precisely measure salt intake 174 [6, 47]. Therefore, in order to prevent the recall bias and since self-reported avoidance of salt intake 175 has a high correlation with the actual behavior [48], the habit of adding salt in cooking and at the 176 table was questioned. Respondents could select one of the options of "always", "often", 177 "sometimes", "rarely", or "never" (respectively scored 1 to 4) for each item on salt intake in 178 cooking or at the table. To classify the responses, the answers given to these questions were 179 congregated as "salt users" or "non-salt users". Non-salt users were those who never, rarely, or contemplation (not ready for change), ready for change (including contemplation and preparation), 189 and action (change has occurred; including action and maintenance).

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The fourth section was on women's self-efficacy for reducing salt intake, including 6 questions 191 scored on a five-point Likert scale from "Not at all sure" to "Completely sure" (scored 1 to 5,  In the data collection procedure, first explanations were given by the researcher regarding study 206 objectives, confidentiality of data, and that no names or address had to be written on the 207 questionnaires. Then, eligible women entered the study if they were willing to participate.  Table 1.   Table 2 shows 249 the total discretionary salt intake based on demographic and other characteristics of women. In 12 250 general, 66% of women were salt users. Age and mean self-efficacy score were significantly 251 correlated to the total salt intake (p=0.048 and p<0.001, respectively).

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To determine the factors associated with women's readiness for behavior change, predictor  In the present study, occupation as another indicator of socioeconomic status showed no significant 354 correlation with levels of changing the behavior of discretionary salt intake. Chen Ji [53] showed 355 that the level of salt intake was higher in those with lower levels of occupation.

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These factors include a range, from individual determinants to environmental, social, and cultural 357 characteristics. They direct individuals to attach importance to the type and quality of food based 358 on economic conditions of the family, ensuring health, and meeting the needs.

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A significant positive correlation was observed between stages of change and self-efficacy scores.

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In other words, self-efficacy scores increased as individuals advanced in the stages of change 361 towards action and maintenance. In the action and maintenance stage, 87% of participants never 362 added salt in cooking. Moreover, 45% of women in this stage never added salt to food at the table.

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The study by Newson [6] showed that 22% of the sample often or always added salt to food before 364 tasting it and 58% never added salt to food at the  In recent study by Jeong, the most important aspect of readiness for changing a behavior was a 386 high self-efficacy score [54]. Participants considered environmental support and motivation as the 387 most important factors leading to behavioral change, consistent with the results of Chen [53].

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Assessing Iranian women's readiness for change is the first step towards the assessment and 389 promotion of food and nutrition literacy. Readiness for changing behaviors is a novel concept 390 which receives considerable attention today. However, few studies have been conducted on this 391 issue among women.

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According to studies, the assessment of readiness for changing behaviors has the best results when 393 the context is defined well. In the present study, women's readiness to change the behavior was This questionnaire needs further corrections before being used for extensive society-level studies.

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A strong validation process and a larger sample size are required. The present study could never be brought into practice without cooperation of the participating 412 women. Besides, the authors would like to appreciate the authorities of the women care units across 413 Tehran who provided the ground for conducting the present research project.