To study the knowledge, attitudes and behaviours of people in relation to dietary intakes of sodium/salt and potassium in the city of Dapaong and its surroundings in Togo.

- To determine the levels of knowledge, attitudes and behaviours of respondents on dietary sodium/salt and potassium intakes;

- To assess the quality of respondents’ knowledge, attitudes and behaviours regarding dietary sodium/salt and potassium intakes;

- To establish relation between respondents’ knowledge, attitudes and behaviour and socio-demographic factors.

The study took place in the town of Dapaong and its surrounding villages in the Savanes region, one of the most populated regions of Togo.

This was a cross-sectional, analytical study that ran from 1 November to 15 December 2022.

The target population was adults aged 25 - 64 in the city of Dapaong and surrounding villages. The primary target was the people surveyed in the households and the secondary target the resource persons, decision-makers living in Dapaong.

Sampling was done using the probability method and the multistage random sampling technique with proportional allocation. These two methods were applied to select villages, households, and primary targets in each locality according to whether the area of residence was urban or rural. According to the MICS 2017 survey in Togo, urban and rural areas represented 44% and 56% of the population respectively. The 1st degree was made up of villages and city neighbourhoods. From the list of these villages and town districts, 10% were randomly selected. The 2nd stage consisted of household concessions and the 3rd stage consisted of individuals in households. The sampling step was determined by dividing the number of households in the identified locality by the total number of households to be surveyed in each area. A random number between 1 and the sampling increment was given to the first randomly selected household. The other households were selected by adding the step to the previous number. The head of the household was chosen for the selection of the subjects to be surveyed. When both the father and mother were present at the time of the survey and are all eligible, a simple random selection was applied to identify the successful respondent. For the focus group, 5% (20 persons) were randomly selected from outside the primary target group to take part in the interview. The choice of health facility managers was exhaustive (28/28).

This study was carried out on the advice of the ethics committee N˚019/2021/CBRS of 27/05/2021. The agreement of the local authorities (Prefect, Mayor, Regional and Prefectoral Director) was sought before data collection. Information notes were written for the population of Dapaong and its surroundings specifying the dates when the interviewers would be passing through for the collection. The objectives and procedures for data collection were clearly explained to the respondents before the questionnaires were administered. Only subjects who gave their free and informed consent were included in the sample. The data were collected and kept strictly confidential within the study team.

A total of 400 people participated in the study after giving their consent (100%). The median age of the respondents was 37 years (30; 49) and 72.25% of the participants were women. The majority of participants lived in the city (65.75%). Of those surveyed, 47.25% had not attended school and most were housewives (42%). Most had never been diagnosed with hypertension (96.50%) and some (20%) had participated in previous studies that assessed salt consumption levels and the quality of food consumed by the population (Table 1).

All respondents reported using salt (99.25%) for salting food and seasoning sauces. The survey revealed that 26.75% of the respondents thought that foods high in sodium/salt had a serious impact on health and high blood pressure was cited by 89.11% as a health problem related to excessive salt consumption. Half of the participants (50%) felt that they knew which foods provided more salt and a similar proportion (57%) felt that the food that provided more sodium/salt was cooking salt. About 34% knew the amount of salt that should not be exceeded per day (5 g/day). Of the participants, 42.99% thought it was quite important to reduce salt consumption. 44% of the respondents sometimes added salt to their meals.

Among the respondents, 4% knew the beneficial effects of potassium on health; 28% declared that they knew the foods that provide more potassium. The survey revealed that 98.5% of the participants did not know the recommended amount of potassium per day and per person. Only 9% knew the portions of fruit and vegetables to be consumed per day and 75.75% were unable to situate their level of dietary intake of potassium. Secondly, 28% felt it was important to increase their potassium intake. From a practical point of view, 36% felt that they should eat potassium-rich foods several times a week.

Overall, the respondents had poor knowledge of salt (80.25%, 95% CI 76.04 - 83.87) and adopted poor attitudes towards the use of foods that provide more sodium/salt (88.50%, 95% CI 84.97 - 91.28). Similarly, they adopted behaviours that were not favourable to reducing excessive salt consumption, i.e., 92.75% (95% CI 89.75 - 94.92).

With regard to potassium, the same trend was observed due to 91% (95% CI 87.76 - 93.76) for the quality of knowledge, 72% (95% CI 67.38 - 76.190) for the quality of attitudes and 73.75% (95% CI 69.20 - 77.84) for the quality of practices favourable to increasing dietary intakes of potassium (Table 2).

- In the course of this study, individual and focus group interviews were conducted with influential community members and decision-makers in order to assess their opinions on the issue of consumption of foods rich in sodium and potassium and, above all, on strategies for a healthy diet. Thus:

- 80% of health facility managers think that salt reduction and potassium intake can be achieved through mass awareness raising and counselling using role models;

- 20% of them think that laws and disciplinary sanctions for structures that do not respect the salt content of food products would be effective measures to combat this problem;

- 100% of community women interviewed by focus group do not know the recommended quantities of salt and would like to be provided with the necessary tools to quantify salt and potassium intake.

The low knowledge of the people surveyed about sodium/salt intakes is similar to that of other studies that used the same evaluation tool as ours [20] [21] [22] [23] and could be explained by the low accessibility of the populations to health programmes, particularly to communication in the community. In most cases, awareness-raising sessions do not focus on CVD issues and even less on nutritional behaviours favourable to the fight against NCDs. Unlike other studies where people’s knowledge of salt was much better in urban than in rural areas [24] [25] , our study showed that knowledge was low in both rural and urban areas. The value of reducing dietary salt intake and the efforts to reduce it are also found in other studies [26] [27] [28] [29] . These efforts consist mainly of not adding salt to meals. Half of the people who felt they knew about sodium/salt source foods referred mainly to cooking salt, many were unaware that sodium/salt intake could come from other foods they consumed. This perception could be a barrier to initiating action to reduce salt consumption overall [30] [31] [32] . Obviously, the participants of our study were also composed of people who reported suffering from hypertension and among them about 77% had poor knowledge about salt contrary to the results of the study of Vandana Garg et al. carried out in India where 44% of the rural participants and 93.1% of the urban participants undergoing treatment, took measures to reduce excessive salt consumption The observations of the present study have important implications for the formulation of appropriate strategies to reduce salt consumption in Togo, where cardiovascular disease is the most common cause of premature mortality and hypertension is the main risk factor. A modest reduction in population dietary salt intake could significantly reduce cardiovascular events and medical costs and should therefore be a public health priority [33] [34] [35] .

The action of potassium in the fight against hypertension is no longer in question and the consumption of foods rich in potassium remains the best source [36] [37] [38] [39] [40] . In our study, the low level of knowledge of the people surveyed about the skills needed to increase the chances of potassium intake is similar to other studies [41] [42] [43] . It is clear that a handful of people are aware that eating fruit and vegetables is good for their health, but most have difficulty estimating the portions of fruit and vegetables to be consumed per day, let alone the recommended amount of potassium. This could be explained by the low quality of awareness-raising among the population, especially in non-local languages. The proportion of people who have at most a primary level is predominant in our study, so communication in the local language would be advantageous. Also, most of them did not know which foods were sources of potassium and could not estimate whether they were consuming enough or not. The same observations are made in some studies [44] [45] and could be explained by the lack of importance given to the consumption of foods rich in potassium. Usually many people consume them occasionally or opportunistically or according to seasonal availability.

Studies have shown that increased dietary intake of minerals such as potassium, magnesium and calcium reduces blood pressure in patients with hypertension [46] . Knowing the food sources of these minerals will enable people to adopt the best behaviours through the choice and use of food in the household. In our study, it was shown that the KAP of the people studied was not optimal, contrary to some countries where the knowledge levels were improved following awareness raising in the community [47] [48] [49] . It is therefore necessary to improve the knowledge level of our populations if we want to have healthy behaviours. Most of the socio-demographic factors were statistically associated with the KAP levels of the people studied. Taking these factors into account in the policy and communication plan will help to achieve a better impact of nutrition interventions. Some countries, in addition to mass awareness raising, have implemented policies to reformulate certain manufactured foods with reductions in salt intake at the population level [50] [51] [52] . It is therefore important to think of a multisectoral action if we want to have convincing results.

The strengths of our study lie in the high participation of the respondents. It was able to determine the different WTP levels of the participants for both sodium and potassium intakes, using a reference tool adapted to the context of our country. Our study was able to make available factual data that policymakers can use to make decisions that benefit people. This experience could be scaled up to the country and also to the African continent. On the other hand, the data provided were based on self-reports and could be a source of bias.