Consumers' knowledge, attitude, and practice regarding Front-of-package (FOP) labels at the point of purchase


 Background: Food labeling is one of the information promotion policies designed to support necessary information of the products that consumer purchase. However, food labeling giving incentives to the food industry to reformulate their products with healthier nutrients. Methods: This cross-sectional study was conducted as a point-of-purchase survey on 550 shoppers in chain stores in Tabriz, Iran. Data was collected using a structured questionnaire that assessed the respondents' knowledge, perception, and behaviors towards the information on food labels. Results: The results showed that 91.8% of the consumers had knowledge about food label information. Among all the nutritional information included on food labels, the participants were most aware of the information about the calories and fat content of the foods. Most of the respondents (84.7%) paid attention to food labels to observe the expiration and production dates, 51.6% were looking at food prices in food labels, and only 8.7% of the participants read food labels to obtain information about the food additives and artificial color contents. Conclusion: Our study suggests that food labeling could be an effective measure in health policy when the consumers' nutrition knowledge and awareness regarding how to use and interpret the information on food labels increases.


Introduction
Unhealthy food choices and diets can contribute to major non-communicable diseases (NCDs) such as obesity, type 2 diabetes, various cancers, and cardiovascular diseases (1) NCDs currently comprise over 35 million disease cases per year, two-thirds of the world's deaths, and are expected to account for 60% of the disease burden and 73% of all deaths in the world by 2020 (2). Unhealthy diet, physical inactivity, smoking, and stress in uence one's risk factors of NCD incidence. In 2004, the World Health Organization (WHO) released the global strategy on diet, physical activity, and health. For a healthy diet, it suggested several individual goals such as achieving an energy balance and a healthy weight, decreasing energy intake from total fats and shifting fat consumption away from saturated fats to unsaturated fats and near the elimination of trans-fatty acids, increasing the consumption of fruits, vegetables, legumes, whole grains, and nuts, limiting the intake of free sugars, and limiting salt consumption from all sources and ensuring that salt is iodized (3). Several factors such as economic (household incomes, prices of goods), social, and demographic determinants as well as consumers' beliefs and lifestyle affect their choices. In order to reduce NCD incidence and overcome unhealthy eating, countries have implemented several policies such as information measures supporting informed choice and policies aimed at changing the market environment.
Food labeling is one of the information promotion policies designed to report necessary information such as nutritional values or ingredients of the products that consumers purchase (1, 4-6). Moreover, food Page 3/14 labeling motivates the food industry to reformulate their products with healthier nutrients. Several studies have indicated that food labeling plays an important role in consumers' decisions of choosing a healthy and balanced diet. A study reported that patients with chronic diseases who read nutrition labels tended to consume fewer calories, saturated fatty acids, and carbohydrates (5). In another research using the data from the Korea National Health and Nutrition Examination Survey (KNHANES), it was reported that consumers who read nutrition labels had a lower risk of developing metabolic syndromes (7).
Experimental evidence, however, suggests that only two-thirds of the consumers with a particular interest in healthy eating, actually pay attention to food labels when shopping (1,8). These results suggested that in most countries the effectiveness of food labeling is varied by culture, nutritional knowledge, and demographic characteristics of the population.
It is important to identify the factors affecting consumers' use of food labels, in order to design food labeling regulations, improve public health, and enhance the pro tability of the food industry (9).
The present research is designed to assess consumers' knowledge, attitude, and practice (KAP) regarding the information on food labels of the products that they purchase from chain supermarkets in Tabriz City.

Study design
The present study was a descriptive cross-sectional study conducted as a point-of-purchase survey to assess the KAP of the customers of food chain store about the information of food labels on preprepared and canned food products. All data collection procedures, methods and informed consent procedures were approved by ethical committee of (citation removed for blind review) and performed in in accordance with the Declaration of Helsinki.

Sampling And Data Collection
According to a similar study, the sample size was determined to be 500 using a mathematical formula and, taking into account the likelihood of failure, 550 participants were eventually considered. Using convenience sampling from three major chain stores in the city (citation removed for blind review) city (citation removed for blind review), four branches of the (citation removed for blind review), two branches of (citation removed for blind review), and two branches of the (citation removed for blind review) chain stores were chosen for the survey. The percentage of interviewees per store was similar in all eight stores.
After obtaining the requisite permits from store managers and consent from participants, data collection started. The verbal consent from illiterate participants and the written informed consent from those who could read and write in Persian was obtained. Five trained research assistants asked general shoppers to participate in the 15-20-minute survey, explaining the study goal to them when the shoppers decided to participate.
It included only participants aged 18 years or older. The consumers participated voluntarily in the study without the impact of any incentives. The structured questionnaire comprising four parts was used for measuring respondents' background, knowledge, perception, and behaviors regarding information and contents of food labels.
The socio-demographic characteristics such as gender, age, household size, marital status, education level, occupation, and monthly income was asked in respondents' background. The knowledge section of questionnaire contained three multiple-choice questions that evaluated the basic knowledge and concept of food labels of the participants'.
However, the participants' perception and behavior about characteristics of food labels ,and also applicability of food labels during purchasing food products and the reasons for checking or not checking food labels was assessed on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) by ten questions. (9).
The questionnaire was piloted to recognize and solve potential problems. All the completed questionnaires were coded and the data were analyzed using SPSS statistical software (version 23, SPSS Inc, Chicago, IL, 2018). Data analysis was carried out in three stages. Data cleaning was carried out in the rst stage to get rid of the data that contain missing responses. The descriptive statistics tests was used to reveal the underlying patterns. Finally, in order to determine the relationships between the variables, chisquare tests were carried out. Table 1 presents the socio-demographic characteristics of the respondents. The majority of the respondents were female (59.2%), young (56.8%), married (83.2%), had a high school diploma or higher education (81.4%), and 78.4% of their household sizes were between 2-4 people. A large percentage of the subjects (40.8%) had a monthly income between 3 to 6 million Rials. Among the participants, 8.2% had no information about food labels. However, about 43.7% of men and 56.5% of women were aware of the nutritional information and type of applied front-of-package (FOP) food labels (Fig. 1).

Results
The consumers' awareness of the nutritional information components namely calories, macronutrients, micronutrients, ber, sodium, and cholesterol is shown in Fig. 2. Among all the nutritional information included on food labels, the participants were most aware of the information about the calories and fat content of the food.
The participants' practice on labels included packaging at the time of purchase was also examined and presented in Table 2 based on their demographic characteristics. The subjects' attention to food labels had a signi cant relationship with the level of education so that those with academic education had the highest level of attention to food labels and the other socio-demographic characteristics had no signi cant association with their level of attention. Among the subjects who always paid attention to labels at purchase time, 58% had higher education.  Table 3, there was a statistically signi cant difference between men and women in terms of reasons for paying attention to food labels, which included paying attention to the kind of the product, observing the price, and observing the weight of the products (p < 0.05).

Discussion
This study explored whether the subjects' knowledge and awareness of food labels were acceptable or not. Among the subjects, 92% had information about food labels and the level of knowledge in women was higher than men. The highest level of awareness was of price and date (expiration and production date) and the lowest level of knowledge was about food additives and arti cial colors. The results of studies on the use of nutrition labels by consumers and their awareness of these labels on packaged foods are very different. In some of these studies, little awareness has been reported, and in others, it is reported more often, which can be due to many reasons such as nutritional knowledge, education, age, health consideration, and nutritional contents (9)(10)(11)(12)(13)(14).
In the present study, most of the participants claimed that they always read food labels when they purchase food, and the level of attention in women was more than men (53% versus 47%). Similar results were also found in the study by Begum, in which 54% of the subjects stated that they pay attention to food labels on packages at sale points (15). Orozco et al. stated that more than 50% of the study subjects in Ecuador reported not using any of the nutrition label information on processed foods at the time of purchase due to the lower level of education and the accompanying high rate of illiteracy (16).
In this study, among the information that is included on food labels namely nutrients, calorie, carbohydrate, protein, fat, vitamins, iron, cholesterol, sodium, and ber content, the participants were most attentive to calories and fat content on the labels and this level of attention was higher in women compared with men (55.7% versus 37.3% for calorie and 53.9% versus 43% for fat). In the last years, people's thoughts have changed regarding body image and obesity in many countries including Iran. Haghighian Roudsari reported that attention to tness was one of the main determinants of choosing foods with low fat content and calories with the impression that these foods could improve their appearance (17). Abbot also revealed that most of the consumers use labels for a special interest such as health concerns regarding calorie and fat content (18). The minimum level of attention to the items in the table on food labels was related to the attention to the amount of iron and dietary ber which was approximately equal between men and women. Consistent with the results of previous studies, women are more interested in using food labels than men (14,19). In the study conducted by Kasapila and Shawa, it was reported that women have a higher tendency than men to use nutrition labels when purchasing food products (20).
The reasons for consumers' attention to food labels have also been studied. The evidence has revealed that the most important reason for using food labels is observing the expiration and production dates, followed by checking the product price. Many studies on food labels have shown similar results (9,(21)(22)(23). The present ndings revealed that women's attention to food labels for observing expiration dates, nutritional information, and food additives was higher than men's. Meanwhile, the weight of the product and its price were the main reasons for checking food labels in men. In the study by Jung (24), it was reported that women paid attention to food labels more often than men, and the key reason for assessing food labels was checking the expiration date (60%), food's ingredients (16.4%), and nutritional information (13.7%). This might be associated with the design of nutrition labels on food packages, the di culties to understand the concepts of the items on nutrition labels (15), and the non-user-friendly design (14).
Consumers with a higher education had better practice on food labels than those with lower education levels, which con rmed the results of previous studies (11,12,14). This nding revealed that higher education could lead to higher nutritional knowledge and literacy in people and help them to use nutrition labels better. Previous researchers have disclosed that women, married individuals, and highly educated people had a higher tendency to use nutrition labels.

Conclusion
Page 12/14 The results of this study demonstrated that consumers need to be trained to optimally use nutrition labels in order to be able to make healthy food choices. A well-designed educational program should be executed to clarify the meaning of the items and symbols as well as the value messages on the labels. This is especially important when they intend to compare several foods from a food group in order to choose healthy ones. Although nutrition labels are frequently used, the actual use is considerably lower. It should be mentioned that most of the time, consumers stated they read the nutrition labels, but this does not necessarily mean the use of the label (25). Thus, it is recommended to food industries to establish a nutrition label format with better quality in terms of color, font, size, and clarity so that it can be easily used by the general public.

Declarations
Ethical approval and consent to participate This study was approved by the Ethics Committee at Tabriz University of Medical Sciences. Data collection began after obtaining necessary permissions from store managers and informed consent from all of the participants.

Consent for publication
Not applicable Availability of data and materials

Not applicable
Competing interests