Abstract
INTRODUCTION: Population-wide dietary sodium reduction is a global priority and a highly cost-effective strategy to lower blood pressure and reduce cardiovascular disease risk. In response, the Nigerian government launched the National Multi-sectoral Action Plan (NMSAP) in 2019, recommending evidence-based policy actions including limiting sodium in processed foods, restricting food advertising especially for children, promoting public awareness, integrating nutrition education in schools, and front-of-package labeling. We conducted a qualitative study to examine progress, barriers, and facilitators in implementing these policy actions 3 years post-launch. METHODS: Between March and September 2024, we conducted 47 key informant interviews and 5 focus group discussions with 22 participants from sectors relevant to sodium reduction, including government, education, food manufacturing and retail, civil society, non-governmental organizations and consumers. Guided by the Integrated Theoretical Framework, we identified determinants influencing policy implementation. Three coders independently coded the data, which were thematically analyzed. RESULTS: Policy characteristics that facilitated implementation included emerging nutrient profiling and dietary surveillance systems and ongoing nutrition education; however, limited baseline data, the absence of nationally endorsed front-of-pack labeling frameworks, and unreliable labeling impeded progress. Within inter-organizational relationships, challenges in coordination, governance, and cross-sector communication emerged as overarching barriers to implementation. Implementing agency capacity was constrained by inconsistent enforcement, limited funding, workforce turnover, low awareness of national sodium policies, and resistance from food manufacturers. Regarding attributes and responses of those affected by the policy, strong support for educating children as agents of household change facilitated school-based nutrition education, although entrenched cultural norms around salt use, financial constraints, and limited public knowledge of the health risks of excessive salt consumption hindered broader behavior change. Finally, within the policy context and external environment, the existing use of local herbs and traditional potassium-rich flavorings was identified as a promising opportunity to promote lower-sodium diets. CONCLUSION: These findings offer critical insights for enhancing implementation, sustainability, and scale-up of evidence-informed policy actions in Nigeria and in other low- and middle-income countries. CLINICAL TRIAL REGISTRATION: Trial Registration: NCT04765865.