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Factors Influencing Salt-Reducing 

Behavior in Young Adults: a Pilot 

Cross-Sectional Study from 

Kazakhstan 

 

Mina Aubakirova1, Marat 

Sultanov1, Aidarkhan Izimov1, 

Yesbolat Sakko1, Torekhan Bex1, 

Anuar Mussagazin1, Raushan 

Alibekova1* 
 
1School of Medicine, Nazarbeyev 
University, Nur-Sultan, Kazakhstan 
 
*Corresponding author: Raushan 
Alibekova MD, MPH, PhD 
School of Medicine, Nazarbayev 
University 5/1 Kerei and Zhanibek Khans 
Street, Nur-Sultan 010000, Kazakhstan 
Telephone: +7 (7172) 70-67-02 
Email: raushan.alibekova@nu.edu.kz 

 

Vol. 9, No. 1 (2020)   |   ISSN 2166-7403 (online)  

DOI 10.5195/cajgh.2020.415 |   http://cajgh.pitt.edu 

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Abstract 

Introduction: In Kazakhstan, a post-Soviet country in Central Asia, salt intake is estimated as high, potentially contributing to the 

morbidity and mortality from cardiovascular diseases. The aim of this study was to explore salt intake in residents of the capital of 

Kazakhstan, Nur-Sultan. 

Methods: An online cross-sectional survey of knowledge, attitudes, and behaviors on salt intake among young adult residents of 

the capital city of Kazakhstan was conducted (n = 237). Bivariate and multivariate linear regression analyses were performed.  

Results: Although 95% (n=225) reported knowledge on the adverse health effects of high salt intake, older respondents were more 

aware of its association with high blood pressure (p = 0.007), heart disease (p = 0.037), and heart attack (p = 0.002). Only one-third 

(n=79) correctly identified the recommended level of daily salt intake. Females reported more awareness of Kazakhstani people 

consuming salt more than recommended (p = 0.0027) and that processed products constituted the major source of salt in diet (p = 

0.007).  General dietary concern (p < 0.001), high self-assessment of salt intake (p < 0.001), and older age (p = 0.012) were found 

to be adjusted predictors of salt-reducing behavior. 

Conclusion: Lack of reported knowledge on salt-health relationship is of concern, especially among young males. A greater dietary 

concern and individual awareness of the excessive salt consumption is likely to assist in reducing salt intake. Further studies are 

required to validate the findings of this pilot study on a bigger population level in order to provide a basis for future salt related 

interventions and policy changes in Kazakhstan. 

Keywords: Attitudes; Behaviors; Kazakhstan; Knowledge; Salt 

Factors Influencing Salt-Reducing 

Behavior in Young Adults: a Pilot 

Cross-Sectional Study from 

Kazakhstan 

 

Mina Aubakirova1, Marat Sultanov1, 

Aidarkhan Izimov1, Yesbolat Sakko1, 

Torekhan Bex1, Anuar Mussagazin1, 

Raushan Alibekova1 
 
1School of Medicine, Nazarbeyev University, 
Nur-Sultan, Kazakhstan 

 

 

Research 

Central Asia has been reported as one of the 

regions with the highest burden of cardiovascular 

diseases (CVD) in the world1. In Kazakhstan, incidence 

of CVDs increased from 8,600 cases per 100,000 in 2005 

to 15,500 cases per 100,000 in 20162, 3. 

Diet has been identified as one of the preventive 

measures for decreasing risk of chronic illnesses along 

with exercising and avoiding smoking and consuming 

alcohol 4. Among dietary practices, excessive salt intake 

is commonly recognized as the factor associated with 

cardiovascular diseases5-7. Excessive salt intake has been 

determined to be a risk factor for high blood pressure, and 

a related global target of 30% reduction has been 

included in the Global Action Plan for the Prevention and 

Control of Noncommunicable Diseases for 2013-20208. 

The World Health Organization (WHO) advises 

the daily intake of salt not to exceed five grams9. Multiple 

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studies report that this threshold is crossed in numerous 

regions,10, 11 including Central Asia region12. According 

to the WHO, in Kazakhstan, the daily intake of salt 

surpasses the WHO recommended limit by nearly 

fourfold13. 

Studies vary with regard to how awareness of 

the negative impact of salt on health and attitudes toward 

salt consumption in general influence dietary behaviors. 

Some have found that the higher the knowledge, the more 

conscientious food choices are7, while other studies have 

observed absence of willingness of people to change their 

eating habits, even when they realize the negative side-

effects of high amounts of salt consumption14.  

Given the high incidence of CVDs and the 

higher than recommended levels of salt consumption 

among the Kazakhstani population, we have conducted a 

survey of knowledge, attitudes, and behaviors (KABs) 

related to salt intake among young residents of the city of 

Nur-Sultan. The city was chosen because it is the capital, 

so it attracts, and therefore represents, residents from all 

over the country.  

 

Methods 

Study design and participants 

Since knowledge, attitudes, and behaviors are 

more easily altered in young people, the study population 

of the research was chosen to be young people aged 18 

and above residing in Nur-Sultan. The younger 

generation has widespread access to the Internet. 

According to the Department of Statistics of the Republic 

of Kazakhstan, in 2018, 90.1% of Nur-Sultan population 

in the 16-44 age group had access to the Internet, while 

among all Internet users of Nur-Sultan, 13.4% and 67.9% 

fell in the 16-24 and 25-64 age groups, respectively15. 

Lack of a common sampling frame for mobile phone 

users, as well as the unpopularity of landline phones 

among the target group, made random digit dialing an 

unfeasible means of data collection. Therefore, an 

Internet survey was decided to be conducted.  

Data collection 

A survey was devised and pilot tested on 20 

participants. After collecting feedback from the 

respondents, appropriate amendments were 

implemented, and the final survey was launched using 

Qualtrics platform, where it was accessible during 15 - 

30 March 2018. Snowball sampling was used to recruit 

participants through ads on social network pages relevant 

to the target demographic, outlining the survey aims and 

offering interested young adults to participate. Such 

pages included those related to local universities and 

leisure activities in social media, namely Vkontakte and 

WhatsApp. Since no individual invitations were sent, 

estimating the response rate was not possible. A small 

number of responses were excluded from the final sample 

due to completion of only the initial questions related to 

demographic information.  

Before proceeding to the questionnaire, the 

participants were presented with information on the 

survey’s purposes and their right to withdraw from 

completing the survey at any point; therefore, informed 

consent was assumed for all participants that completed 

the survey. It also stated that by filling out the survey, 

they confirmed that they were over the age of 18. No 

personal identifiable information was collected from the 

participants. The respondents could choose to complete 

the questions either in Russian or Kazakh language. No 

requirement was imposed on the participants to complete 

all the questions. Ethical approval for the study was 

obtained from Nazarbayev University Institutional 

Research Ethics Committee. 

Questionnaire 

A questionnaire containing 18 questions was 

adapted from a questionnaire of KABs related to dietary 

salt used in the study by Grimes et al16. Some alterations 

to the original survey instrument were introduced. Then, 

the survey was translated into Russian and Kazakh by 

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two independent translators, and discrepancies in the 

translations were further assessed by a third translator. 

The demographic questions included gender, age, 

region of origin, education level, and level of 

involvement in cooking. Age was categorized into four 

groups (18-20, 21-23, 24-26, and 27-30), which was 

aimed at facilitating usage of mobile devices. The two 

questions related to country of birth and language spoken 

at home were substituted with a question on the region of 

origin within the country to potentially compare regional 

dietary differences. The options provided in the question 

related to education level, which apart from directly 

reflecting level of education also serves as a proxy to 

socio-economic status, were redesigned to represent the 

local education system’s specifics. 

Several questions similar to the ones in the original 

survey instrument were used to assess the knowledge 

related to dietary salt intake. The questions were 

concerned with the knowledge on: (a) the relationship 

between sodium and salt, (b) the recommendations 

related to salt intake, (c) the level of salt consumption in 

Kazakhstan (in comparison to recommendations), (d) the 

main source(s) of salt in the diet of Kazakhstan’s 

population, (e) health risks associated with high salt 

intake, and (f) association of high salt intake with several 

health outcomes. Categorical response options were 

provided for each question. For the purposes of 

multivariate analysis, a knowledge score variable was 

constructed. A score of 1 was assigned for each correct 

answer, while 0 was given for wrong responses and if the 

respondent chose the ‘I don’t know’ option. Thus, the 

knowledge score ranged from 0 to 9. 

The correct responses for the question related to the 

level of salt consumption in Kazakhstan were assumed to 

be ‘More than needed’ and ‘Too much’, since sodium 

intake for Kazakhstan and the Central Asia region as a 

whole has been ranked among the highest in the world12, 

13. For the question related to the main sources of salt in 

the diet, the correct response was assumed to be 

‘Processed foods’, which is consistent with a WHO 

report from Kazakhstan13.  

Two questions assessed the participants’ attitudes 

regarding salt intake. A block question was used to assess 

the participants’ level of concern for several food-related 

issues (healthy eating and sugar/salt/fat/saturated 

fat/calorie content). Scores were assigned for each 

answer on a Likert type scale with 1 to 5 assigned to 

answers from ‘Not at all concerned’ to ‘Very concerned’. 

The concern score was created by combining response 

scores and used in the multivariate model. 

The other question in this section was related to the 

participants’ own assessment of their salt intake levels in 

view of the recommendations. If a respondent indicated 

that their personal consumption of salt was higher than 

the recommended level, then the response was assigned 

a score of 1, with all the other response categories given 

a score of 0. This variable was used in the regression 

analysis as a binary predictor variable. 

These questions were concerned with the 

participants’ past and current behaviors regarding salt 

intake. Three questions were designed with a 5-point 

frequency scale from ‘Never’ to ‘Always’, asking 

participants about their habits of (a) adding salt during 

cooking, (b) adding salt while eating, and (c) placing a 

saltshaker during meals. Scores were assigned from 1 to 

5, with 1 representing the lowest salt-reduction behavior 

(e.g. if the respondent reported always adding salt while 

cooking).  

The next four questions assessed several behaviors 

related to salt reduction strategies that the participants 

may have employed in the past month on a 5-point 

frequency scale from ‘Never’ to ‘Always’. If a person 

reported to have never engaged in a particular behavior 

related to salt reduction, the response was assigned a 

score of 1, while the highest score was given for the 

highest salt-reducing behavior.  

All the scores from 1 to 5 for the seven questions 

on salt-reduction behavior were combined to form a 

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behavior score ranging from 7 to 35 for the multivariate 

model.  

Data analysis 

The data collected through the Qualtrics survey 

system17 were exported into spreadsheet format. Chi-

square test of independence and Fisher’s exact test were 

used for bivariate analyses. Multivariate linear regression 

models were constructed with salt reduction behavior 

score as the outcome and knowledge score as the primary 

predictor, adjusted for dietary concern score, perception 

of personal salt consumption, gender, age, and region. 

Statistical analysis was performed using Stata software 

version 14.218. Statistical significance was reported at  

= 0.05.  

 

Results 

Knowledge related to salt intake 

The majority of the respondents (62.87%, n=149) 

correctly indicated that salt contains sodium (Table 2). 

Females were better informed than male respondents that 

Kazakhstani people consumed salt more than 

recommended (p = 0.0027) and that processed meat and 

other processed products constituted the major sources of 

salt in diet (p = 0.007) (Supplementary Table 1). Almost 

95% (n=225) of the participants replied that eating too 

much salt could damage health. However, older age 

groups were more aware than the younger age groups of 

the association between excessive salt consumption and 

high blood pressure (p = 0.007), heart disease (p = 0.037), 

and heart attack (p = 0.002). Similarly, respondents with 

general secondary education had lower awareness than 

those with higher levels of education of the association 

of excess in salt with heart disease (p = 0.007) and heart 

attack (p=0.013). 

 Attitudes related to salt intake 

Roughly half of the participants were concerned 

about the salt content in their diet (Figure 1). Women, 

however, showed higher concern regarding salt content 

in food compared to men, although this finding was not 

significant (p = 0.064). With regard to concern on other 

dietary contents, the respondents with general secondary 

education had lower levels of concern about the amount 

of fat in food (p = 0.013), whereas female respondents 

were concerned with the amount of saturated fat in 

products more than males (p = 0.018) (Supplementary 

Table 2). 

Behaviors related to salt intake 

More than 90% of the sample reported never or 

rarely asking to have a meal prepared without salt when 

eating out (Figure 2). Among the respondents, the oldest 

age group (27-30 years old) was more likely than the 

other age groups to avoid eating at fast food restaurants 

as a salt-reducing practice (p = 0.002) (Supplementary 

Table 3). Respondents with higher and general secondary 

education levels were more likely to avoid adding salt to 

food during meals than those with professional secondary 

education (p = 0.007).  

Multivariate analysis 

Level of knowledge was not associated with salt-

reducing behavior at p = 0.069, adjusting for age, gender, 

region of birth, and level of dietary concern variables. On 

the other hand, dietary concern score was found highly 

associated with salt reduction behavior at p < 0.001, as 

was the variable of self-assessment of salt intake. Among 

demographic predictors, a statistically significant 

difference in salt reducing behavior was observed 

between the 18-20 and 27-30 age groups (p = 0.012). 

Neither gender nor region of origin was significantly 

associated with the person’s salt-related behavior.  

 

 

Discussion 

The main findings of the study suggest that level of 

knowledge is not a significant predictor of salt-reducing 

behavior, adjusting for age, gender, region of birth, and 

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Characteristic N % 

Gender 
  

Male 84 35.44 

Female 153 64.56 

Age group 
 

18-20 78 32.91 

21-23 42 17.72 

24-26 74 54.02 

27-30 43 18.14 

Region of origin 
  

Nur-Sultan 46 19.41 

Almaty 25 10.55 

Central Kazakhstan 28 11.81 

East Kazakhstan 14 5.91 

North Kazakhstan 50 21.09 

South Kazakhstan 44 18.57 

West Kazakhstan 30 12.66 

Language of survey completion 

Kazakh 11 4.6 

Russian 226 95.4 

Level of education 
 

Higher 188 79.32 

Professional secondary 10 4.22 

General secondary 39 16.46 

Level of involvement in cooking   

Always 46 19.41 

Often  76 32.07 

Sometimes 57 24.05 

Rarely 48 20.25 

Never 10 4.22 

Table 1. Socio-demographic characteristics of participants (n=237) 

 

 

 

 

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Question N % 

Salt may be defined in the product’s contents as ‘salt’ and as ‘sodium’.  

What is the relationship between salt and sodium? 

They are exactly the same 39 16.46 

Salt contains sodium  149 62.87 

Sodium contains salt 9 3.80 

Don't know 40 16.88 

Health professionals recommend that we should eat no more than a certain 

amount of salt each day. How much salt do you think it is?  

3 grams 94 39.66 

5 grams 79 33.33 

8 grams 17 7.17 

10 grams 13 5.49 

15 grams 5 2.11 

Don’t know 29 12.24 

Do you think eating too much salt could damage your health? 

Yes  225 94.94 

No 3 1.27 

Don’t know 9 3.8 

Which, if any, of the following do you think is linked to eating too much salt? 

High blood pressure 

Yes  145 61.18 

No 20 8.44 

Don’t know 72 30.38 

Kidney disease 

Yes  198 83.54 

No 9 3.80 

Don’t know 30 12.66 

Heart disease  

Yes 139 58.65 

No 27 11.39 

Don’t know 71 29.96 

Heart attack  

Yes 108 51.05 

No 30 13.08 

Don’t know 83 35.86 

In your opinion, how much salt do Kazakhstani people consume? 

Too much  19 8.02 

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More than needed 146 61.6 

Normal amount 62 26.16 

Less than needed 2 0.84 

Don't know 8 3.38 

Which of the following do you think is the main source of salt in the diet  

of Kazakhstan’s population? 

Salt added during cooking or at the table 101 42.62 

Salt contained in processed meat products and in other processed products  124 52.32 

Salt contained in natural food products 4 1.69 

Don't know 8 3.38 

How do you think your daily salt intake compares to the amount of salt  

recommended by health professionals? 

Less than recommended 25 10.55 

About the right amount 124 52.32 

More than recommended 69 29.11 

Don’t know 19 8.02 

*Correct responses for knowledge questions are in bold 

Table 2. Knowledge & attitudes related to salt intake 

level of dietary concern variables. Young adults who 

were concerned in general about their diet and those who 

self-assessed their salt intake level as high reported salt-

reducing behaviors more frequently. Participants aged 

27-30 reported higher engagement in salt-reducing 

behavior than those aged 18-20. 

The local relevance of the research topic is set to 

increase in the coming years as the burden of 

cardiovascular diseases continues to exacerbate, thereby 

increasing the demand for preventive population-wide 

interventions.  

Although an overwhelming majority were aware of 

the increased health risk as a result of high salt intake, 

which is consistent with similar studies conducted in  

other cities of Kazakhstan13 and internationally16, 19, 

younger participants were less aware of the association 

of salt with specific cardio-vascular health outcomes. 

Educating on these relationships could be the purpose of 

salt-related local interventions, especially given the  

morbidity and mortality rates associated with CVD in 

Kazakhstan, and should specifically target younger 

populations.  

Yet the effectiveness of purely educational 

interventions may be debatable. For example, a KABs 

study in Australia revealed that despite a decent level of 

awareness of adverse health impacts of excess salt 

consumption, the respondents were not willing to reduce 

these consumption amounts due to abundant promotion 

of inexpensive products high in salt and the lack of proper 

food labelling6. Therefore, public health programs should 

target these aspects apart from focusing on awareness-

raising. 

In the current study, the main perceived sources of 

salt (added during cooking or at the table and salt 

contained in processed products) were also among the 

identified leading sources of salt in a study of salt intake 

in Turkey20. Again, awareness of the main sources of salt  

is not sufficient for encouraging salt-decreasing 

behaviors and an emphasis on practical skills may be 

necessary19. Thus, specific interventions targeting

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Predictor variables Coefficient 95% CI P 

Knowledge score 0.263 -0.021; 0.547 0.069 

Concern score 0.269 0.142; 0.396 <0.001 

Assessment of own level of salt consumption compared 

to recommendations* 

-3.023 -4.211; -1.834 <0.001 

Gender** -0.518 -0.169; 0.653 0.385 

Age*** 

21-23 0.759 -0.873; 2.392 0.361 

24-26 0.535 -0.808; 1.878 0.433 

27-30 2.079 0.452; 3.705 0.012 

Region of 

origin**** 

Central Kazakhstan 0.772 -1.066; 2.610 0.409 

West Kazakhstan 0.409 -1.329; 2.146 0.644 

South Kazakhstan 1.273 -0.054; 2.600 0.060 

East Kazakhstan 0.193 -2.229; 2.614 0.876 

*Binary variable with all responses except for ‘More than recommended’ combined as reference group 

**Females as reference group 

***18-20 as reference group 

****North Kazakhstan as reference group 

 

Table 3. Multivariate model: predictors of salt-reducing behavior

cooking practices may be useful. In Kazakhstan, such 

practical interventions should target women, who are 

better informed about the primary sources of salt in food 

and are usually the primary cooks in traditional Kazakh 

families. 

Among the respondents, those generally concerned 

with food contents reported higher engagement in salt-

decreasing behaviors. Specifically, women were more 

concerned with the amount of saturated fat in food; 

therefore, interventions on salt-reduction practices for 

women could be integrated into saturated-fat reduction or 

into general healthy diet interventions. Higher self-

assessed salt intake level in our study was associated with 

frequent salt-reducing behavior, similarly to the findings 

of a previous study from Australia16. A recent report on a 

WHO study of salt-related KABs in two regions of 

Kazakhstan did not examine specifically the association 

between attitudes and behaviors; however, it claims that 

only 10% of the respondents evaluate their consumption 

of salt as excessive13. 

Salt-reduction behaviors were higher in the oldest 

participants than in the younger ones. These findings are 

similar to results of a cohort study by Vega-Vega et al. 

(2018),  measuring sodium in urine and through dietary 

recall, which also observed associations of age (p = 0.03) 

and male gender (p < 0.001) with sodium intake, 

adjusting for intake of calories, median urinary iodine 

excretion, and body-mass index21. A study from two 

Kazakhstani regions also shows that males have higher 

sodium concentration in urine than females13. 

The study is subject to coverage bias due to the 

selected data collection mode. However, our target 

population of young adults are predominantly active 

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Figure 1. Level of concern for food-related issues 

 

Figure 2. Behavioral practices to reduce salt intake performed in the past month 

107

112

141

115

133

171

74

86

69

92

81

60

56

39

27

30

23

6

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Calorie content

Sat. fat content

Fat content

Salt content

Sugar content

Healthy eating

Extremely or very concerned Somewhat concerned Not very or not at all concerned

100

74

92

12

69

59

64

13

68

104

81

212

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Avoided using packaged, ready-to-eat foods?

Used spices/herbs instead of salt during cooking?

Avoided eating food from fast food restaurants?

When eating out, asked to have your meal prepared without

salt?

Proportion

Always or often Sometimes Rarely or never

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 9, No. 1 (2020) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.415 | http://cajgh.pitt.edu 

 

 

Internet users; moreover, the anonymous online data 

collection may have reduced the possibility of social 

desirability bias. The results have limited generalizability 

because of the sampling technique and given that the 

majority of the respondents had higher education, 

younger age, and urban status. Furthermore, there is a 

possibility of answering the questionnaire twice or 

multiple times in the Internet survey. Finally, due to the 

cross-sectional design study, results need to be 

interpreted with caution. 

Future research could use other methodology to 

address the limitations of the current paper and add to the 

validity of the present results. Also, further studies will 

be required to evaluate the effectiveness of salt-related 

interventions.  

 

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