Effect of Front-of-Pack Labels in Ethiopia

Study Overview
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Brief Summary
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Ethiopia is experiencing the type of rapid food system transformation that leads to a double burden of malnutrition and increased non-communicable diseases. Front-of-pack labels on packaged foods are an emerging public health strategy with the potential to address non-communicable diseases by discouraging the purchase and consumption of products with high levels of nutrients of public health concern. The aim of this study is to evaluate and compare the effectiveness of front-of-pack labeling systems to reduce the intent to purchase unhealthy foods among adults in Ethiopia. The study will recruit approximately 1200 adults using a street-intercept methodology. Participants will be randomized to 1 of 4 arms to complete a survey in which the presence and type of front-of-pack label differs across survey arms and asked to rate participants' intent to purchase unhealthy packaged foods.

Detailed Description
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In 2017, cardiovascular disease was the leading age-standardized cause of death in Ethiopia. The national prevalence of hypertension in Ethiopia in 2015 is estimated to be 16% (Gebreyes et al. 2018). Urban diets are rapidly changing, but not becoming healthier (Wolle et al. 2020). Diet quality remains poor: only 2.4% of the national population meets the WHO recommendation of five servings of fruit and vegetables per day. The mean estimated salt intake of 8.3 g/day exceeds the WHO maximum recommended intake (Challa et al. 2017). Processed foods are penetrating the market at a rapid pace (Melesse et al. 2019; Stuckler et al. 2012). Increasing income has increased demand for convenience foods (Minten et al. 2018). Ethiopia is experiencing the type of rapid food system transformation that leads to a double burden of malnutrition and increased non-communicable diseases (Popkin 2017). Front-of-pack labels on packaged foods are an emerging public health strategy with the potential to address non-communicable diseases by discouraging the purchase and consumption of products with high levels of nutrients of public health concern (Croker et al. 2020). However, front-of-pack labels have not been tested in the Ethiopian context. Additionally, there are multiple types of front-of-pack labeling systems in use around the world, such as Multiple Traffic Light/Guideline Daily Amounts, the Nutri-Score system, and nutrient-specific warning labels. Therefore, the study aims to to evaluate and compare the effectiveness of front-of-pack labeling systems to reduce the intent to purchase unhealthy foods among adults in Ethiopia. The study will recruit approximately 1200 adults using a street-intercept methodology. Participants will be randomized to 1 of 4 arms to complete a survey in which the presence and type of front-of-pack label differs across survey arms and asked to rate participants' intent to purchase unhealthy packaged foods.

Official Title
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Effect of Front-of-Package Labels on the Intent to Purchase Packaged Foods in Ethiopia

Conditions
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Cardiovascular Diseases

Intervention / Treatment
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* Other: Front-of-pack labeling


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥18 years Purchase foods outside of the household Exclusion Criteria: Age <18 years Do not purchase foods outside of the household Unable to complete the survey protocol

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: No label<br>In this arm, participants will view images of packaged food or beverage products without a front-of-pack label and respond to questions about the products. | |
| Experimental: Multiple Traffic Light (MTL)<br>In this arm, participants will view images of packaged food or beverage products which have multiple traffic light labels displayed on the front-of-pack and respond to questions about the products. | Other: Front-of-pack labeling<br>* The intervention being tested is the effect of front-of-package labeling on consumers' intent to purchase foods which are high in one or more nutrients of public health concern. Participants randomized to the control group will view images of packaged foods and beverages and answer a series of questions about those products. In the intervention arms, participants will view images of the same packaged foods and beverages, but with different front-of-package labels displayed that provide nutrition information about the product. Participants in each arm will be asked the same series of questions about the products shown.<br>|
| Experimental: Nutri-Score<br>In this arm, participants will view images of packaged food or beverage products which have a Nutriscore front-of-pack label and respond to questions about the products. | Other: Front-of-pack labeling<br>* The intervention being tested is the effect of front-of-package labeling on consumers' intent to purchase foods which are high in one or more nutrients of public health concern. Participants randomized to the control group will view images of packaged foods and beverages and answer a series of questions about those products. In the intervention arms, participants will view images of the same packaged foods and beverages, but with different front-of-package labels displayed that provide nutrition information about the product. Participants in each arm will be asked the same series of questions about the products shown.<br>|
| Experimental: Warning Label<br>In this arm, participants will view packaged food or beverage products which have front-of-pack warning labels if the product is high in one or more nutrients of concern and respond to questions about the products. | Other: Front-of-pack labeling<br>* The intervention being tested is the effect of front-of-package labeling on consumers' intent to purchase foods which are high in one or more nutrients of public health concern. Participants randomized to the control group will view images of packaged foods and beverages and answer a series of questions about those products. In the intervention arms, participants will view images of the same packaged foods and beverages, but with different front-of-package labels displayed that provide nutrition information about the product. Participants in each arm will be asked the same series of questions about the products shown.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Intent to purchase based on single product tasks | Participants will be shown images of four single products, two of which are high in sodium and two of which are high in sugar. For each product, participants will rate their intent to purchase the product on a likert scale. The investigators will calculate the mean of the responses to questions about the four products. | The outcome will be assessed during survey administration at a single time point (baseline). | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Purchase choice based on product comparison tasks | The investigators will evaluate responses to three product comparison tasks, each of which will present two packaged food items in the same food category and ask respondents which product they would choose to purchase. Specifically, the investigators will examine the proportion in each arm who report they would avoid purchasing the less healthy product. | The outcome will be assessed during survey administration at a single time point (baseline). | 
| Label understanding and acceptability | In the warning label, multiple traffic light, and Nutriscore arms, participants will be shown images of the respective labels. They will be asked a series of questions regarding their understanding of the label and its acceptability in Ethiopia and provide responses using a likert scale. | The outcome will be assessed during survey administration at a single time point (baseline). | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Nutrition, Packaged food