Process evaluation of an mHealth-based school education program to reduce salt intake scaling up in China (EduSaltS): A mixed methods study using the RE-AIM framework

Abstract Background An mHealth-based school health education program (EduSaltS) has been implemented in China for reducing salt intake among children, but the scaling up is challenging, and the effectiveness could be jeopardized by deviations in its implementation. This study aims to explore the implementation process and the factors that impact its implementation in the real world. Methods Mixed methods RE-AIM framework were employed for the process evaluation. The quantitative data were retrieved from the management website that monitoring 54435 participants from the third-grade students in two cities. Before-after questionnaire surveys were conducted to evaluate the education effectiveness. Analysis of variance and Chi square-test were used to examine differences for numerical data and category data respectively, and statistical significance was set at p < 0.05. Qualitative methods were used to identify the facilitators and barriers by conducting individual interviews (n = 23) and eight focus-groups (n = 80). Qualitative data analysis followed the thematical protocol. The findings from the mixed methods were triangulated for integration. Results The percentage of students who registered with the EduSaltS was significantly high (97.7%) due to the participants’ strong preferences and school support. Knowledge and behaviour related to salt reduction improved, and the standard score of knowledge and practice increased from 75.1 to 80.9 out of 100. All 208 invited schools adopted the program and hosted 3999 class activities and 1800 school activities during the two-term program. The completion rates of the 20 health cloud courses fluctuated between 79.4% and 93.4%, with an average of 84.9%. Qualitative interviews showed that the implementation of the EduSaltS was strongly facilitated by policy support from the education sector as well as app-aided auto delivered courses, home-school cooperation, proper incentives, real-time monitoring and management, but hindered by parents' lack of smartphone skills at the initial stage, competing school health priorities and unhealthy off-campus environments. Conclusions mHealth-based innovative school health education is scalable given the wide coverage, high acceptability and expected implementation effects of the EduSaltS. The findings regarding the barriers and facilitators can be used to enrich further scaling-up of EduSaltS and similar strategies in larger populations and various settings.