Excess dietary sodium is a major contributor to hypertension and a critical public health issue in China. In 2011, the estimated average intake of sodium among adults (18 to 69 years old) in Shandong province was 12.5 gram/day. Lower than 10% of residents were below the recommended maximum intake of 6 gram/day (unpublished data). However, only one third of the subjects perceived themselves as consuming excess amounts of sodium. Nevertheless, sodium reduction in the diet was practiced by 52.7% of the population in the urban areas and 38.3% in rural areas. Findings from the other component of SMASH base-line survey indicated that 81% of the sodium comes from condiments, including salt, soy source and monosodium glutamate (MSG).
A simplistic approach for reducing sodium reduction is to increase population-level awareness that most are getting too much sodium, then expect changed behaviors that result in lower sodium intake. However, changing dietary sodium intake in a population that has adapted to a high sodium diet is not easy and requires a number of complementary strategies. This study has provided important information on the current state of knowledge, attitudes, and practices related to sodium and hypertension among residents in Shandong province. In the present study, we found good levels of knowledge and a favorable attitudes towards sodium reduction. Residents in Shandong province seem prepared to accept the importance of reducing sodium intake. Our findings provide evidence that will enable the development of effective public education initiatives. Such initiatives may aim to educate the public on the relationship between sodium and health, to increase the public’s demand for lower sodium diets, and promote individual dietary change.
The Health Belief Model postulates that when an individual perceives a threat from a disease and perceived benefits from preventive actions exceed the barriers then the individual is likely to take preventive action. 
Our study revealed that Shandong residents had a good knowledge about the links between sodium and hypertension, and those who were aware of the links, were more likely to take action towards sodium reduction. However, they still lacked specific knowledge on the 2007 recommendations concerning the maximum intake of salt at 6 gram/day. 
This may partly explain why many residents did not think their sodium intake was a problem. Additionally, our study suggests that those who perceived themselves at risk of consuming excess sodium were more likely to take action towards sodium reduction. Furthermore, previous findings suggested that people may have resistance to adopting reduced-sodium diets because they are largely asymptomatic, and may fail to perceive a benefit from a diet that they consider too restrictive. 
In fact, sodium reduction is beneficial in both normotensive and hypertensive people. A review of randomized controlled trials which aimed at reducing dietary sodium with follow-up of 6 months or longer, found that systolic and diastolic blood pressure were reduced by an average of 1 mmHg in normotensives and by an average of 2–4 mmHg in hypertensives. 
Hence, the recommended limit of salt intake, as well as the relationship of sodium to hypertension should be key messages in public education initiatives to help the public understand problems of excess consumption of sodium. In addition, it is important to highlight that reduced sodium intake is beneficial for both hypertensive and normotensive people, although it affects hypertensive people to a greater degree.
The majority of Shandong residents believed that low sodium diets have less taste, and many residents reported low sodium intake reduces physical strength. Our study suggests that persons who had unfavorable attitudes towards sodium reduction, were less likely to take action towards sodium reduction. Therefore, public education initiatives should also focus on these perceived barriers of taste and lost physical strength. Preliminary results from this study suggested that survey participants who were older were more likely to report that less sodium intake results in less physical strength. The Chinese Nutrition Guidelines make recommendations that Chinese people should avoid consuming too much sodium. Effective public education should also inform people that cooking with less sodium without affecting physical strength.
The Social Cognitive Theory suggests that people need mastery of both knowledge and skills to perform a given behavior. 
It has been suggested that spreading information in an education campaign is definitely a requirement for dietary sodium reduction, but equipping population with the skills to make the necessary changes is equally important. 
Therefore, effective public education initiative should not only disseminate information on the links between sodium and health, but also provide practical and culturally appropriate means to change their diet. First, public education initiatives should promote less use of “hidden sodium”. Soy sauce, monosodium glutamate (MSG), and pickles, are major dietary sources of sodium in China. For example, regular soy sauce contains 1.5 grams sodium/10 milliliter. The per capita consumption of soy sauce in china is 10 milliliter per day. 
Hence, soy sauce consumption already provides 25% of the recommended maximum intake. Awareness campaigns should aim to increase people’s awareness on this “hidden sodium”, and help people understand that there are other sources of sodium in the diet, in addition to salt. Second, the use of low sodium condiments, or alternative forms of flavoring should be recommended. Our study found that the most frequently reported practice to reduce sodium intake was reducing sodium while cooking, while relatively few reported increased use of non-sodium containing condiments, such as vinegar, green onions, and garlic. Third, the ‘salt spoon’ has been proven to be an effective strategy to help people make the change towards sodium reduction. 
We found the ‘salt spoon’ was acceptable in Shandong province, in particular in the urban areas, although about one third of those who used a salt spoon did not know how to use it correctly. In terms of the source of salt spoons, 26–38% of them were distributed by health professionals, and 30–45% was purchased by individuals themselves. Therefore, public education initiatives should focus on training the public how to use ‘salt spoons’ in addition to distributing them.
With urbanization and globalization in China, there are signs of a gradual transition from traditional diets to consumption of more imported foods, processed foods and eating meals outside the home. The base-line survey reported that 32.7% of residents (40.0% of urban and 29.8% of rural residents) ate meals outside the home. Processed food and restaurant food often contain higher sodium contents for either palatability or food safety reasons, and thus the trend is likely to contribute to high sodium consumption.
Food labeling has been shown to be effective in reducing sodium intake in developed countries. 
China started implementing voluntary food labeling in 2007. This program requires manufactures optionally to provide sodium in the list of nutrients on packaged food labels. We found that most Shandong province residents supported food labeling, and believed food labeling would help them follow a low sodium diet However, very few residents reported reading food labels while purchasing. Public education initiatives should encourage manufactures to provide sodium content information on packaged food labels, and educate the public how to read food labels to enable them to make healthy food choices.
Women, gatekeepers to food and health in the household, are an important group to target with the educational initiative. In the UK, in 2003, the Food Standards Agency (FSA) coordinated a public awareness campaign which mainly targeted adult females. This campaign successfully educated consumers on the relationship between sodium and health, increased consumer’s demand for low-sodium products, and educated consumers on making healthy food choices. 
We found dietary sodium intake KAPs of urban residents were generally better than for those living in rural areas. Hence, special attention should be given to all residents, and especially women, in rural areas. Rural residents often were not well educated indicating that awareness campaigns should aim to develop messages that can be easily understood by the rural residents with lower education levels.
Limitation of this study includes self-reported attitude and practices of participants for having low or high sodium diet, which may overestimate or underestimate their actual attitude and practices related to sodium consumption. However, findings presented in this study demonstrate that most residents in Shandong province will accept dietary sodium reductions. Future effective public education initiative should highlight the benefits of sodium reduction, with a focus of perceived barriers of physical strength and tastes, but also provide practice and culturally appropriate meals to change their diet. The public education and awareness efforts should target all women and should also focus on rural populations.