Improved Information and Educational Messages on Outer Packaging of Micronutrient Powders Distributed in Indonesia Increase Caregiver Knowledge and Adherence to Recommended Use

Abstract

The objective of this study was to examine the influence of improved information and educational messages on outer packaging of a micronutrient powder (MNP), locally known as &ldquo;Taburia&rdquo;, on knowledge and adherence to recommended use. A community-based cluster randomized controlled trial was conducted among 1149 caregivers and their children aged 6⁻36 months. Caregiver⁻child dyads were randomized by their villages to receive 30 sachets of Taburia with the: (i) original outer packaging; (ii) improved outer packaging; or (iii) improved outer packaging combined with cooking demonstrations. Adherence to Taburia use was assessed through caregiver interviews and observation of unused sachets during home visits; &ldquo;high&rdquo; adherence was defined as consuming 13⁻17 sachets in the previous month. Data collection included surveys and focus groups discussions. The majority of caregivers (>80%) preferred the improved packaging because it was more attractive and contained more comprehensive information. Caregivers who received the improved packaging had better knowledge regarding the recommended use of Taburia (p < 0.001) and higher adherence with the prescribed use of Taburia (43% with &ldquo;high&rdquo; adherence) (p < 0.001) than those who received the original packaging (29% with &ldquo;high&rdquo; adherence). Caregivers who participated in cooking demonstrations generally had better knowledge regarding the benefits of Taburia and recommended use, but this did not lead to higher adherence to recommended use. &ldquo;Underconsumption&rdquo; of Taburia (&le;7 sachets) was much less prevalent than &ldquo;overconsumption&rdquo; (&ge;23 sachets), and original packaging users were more likely to consume Taburia daily instead of every two days as recommended. We conclude that the design of the outer packaging and comprehensiveness of information provided are important influencers of recommended MNP use by caregivers.

Keywords: Indonesia; adherence; infants and young children; micronutrient powders; packaging.

Figure 1

Packaging layout and messages (in Bahasa Indonesian) included in the box of Taburia containing 30 individual 1 g sachets. English translations of the messages are shown in the Supplementary Materials. (a) The original packaging approved by the Ministry of Health (MOH), decree number 2409 and enacted June 2011. (b) The improved packaging approved by the MOH, decree number 51 and enacted October 2016.

Figure 2

Study design and number of infants and young child/caregiver dyads participating in each study phase.

Figure 3

Caregiver knowledge regarding Taburia benefits and recommended use 30 days after distribution by study group. Group 1: Original outer packaging, as regulated by the MoH; Group 2: Improved design and messages content of outer packaging; Group 3: Improved outer packaging combined with cooking demonstrations. Error bars represent 95% confidence intervals. For all variables, differences between groups are statistically significant (p < 0.005) using a nested design, Generalized Linear Model (GLM) applying the Binomial distribution as base distribution via a Logit link function. Within a variable, values with different superscript letters are significantly different using Wald’s Chi-square adjusted for multiple comparisons (least significant difference) post-hoc analysis (p-value < 0.05).

Figure 4

Adherence to prescribed use of Taburia 30 days after distribution among children who consumed Taburia without sharing. Adherence was defined as “high” (13–17 sachets), “medium” (8–12 or 18–22 sachets) or “low” (≤7 or ≥23 sachets). (a) Group 1: Original outer packaging, as regulated by the MoH; (b) Group 2: Improved design and messages content of outer packaging; and (c) Group 3: Improved outer packaging combined with cooking demonstrations. Differences between groups are statistically different (p < 0.001) using multinomial distribution via Cumulative Logit function. Values with different superscript letters are significantly different using Wald’s Chi-square adjusted for multiple comparisons (least significant difference) post-hoc analysis (p-value < 0.05).

Figure 5

Odds ratios comparing “high” (13–17 sachets) versus “medium/low” (≤12 or ≥18 sachets) adherence with prescribed use of Taburia 30 days after distribution among the three study groups. Group 1: Original outer packaging, as regulated by the MoH; Group 2: Improved design and messages content of outer packaging; and Group 3: Improved outer packaging combined with cooking demonstrations. Odds ratio pairwise comparisons were performed using a nested design in a Logistic Regression Model. The X represents the odds ratio and the error bars represent 95% confidence intervals.