Rollins School of Public Health

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• Rollins School of Public Health
• Mary Beth Weber, MPH
• Anne Lifflander, MD, MPH
• Godfrey Oakley, MD, MSPM
• Karen Bell, MPH

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What is Folic Acid?

• Vitamin B9
• Required for the production of DNA
• Needed for the development of tissues and organs
  early and throughout pregnancy Prevents NTDS
• Metabolism of Homocysteine to Methionine
  probably prevents CVD and maybe some cancers

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Folic Acid is for Everyone!

• Prevents Neural Tube Defects
• May prevent other birth defects
• - Cleft lip/palate
• - Heart defects
• - Limb defects
• Lowers Homocysteine levels
• May reduce the risk of heart attack and stroke
• May reduce the risk of some cancers like colon
  cancer
• Lifespan vitamin for everyone!

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Neural Tube Defects in the US

• Based of NTD prevention, the US began fortifying
  enriched grains with folic acid in 1998
• Fortification prevent many NTDS
• But there are an estimated 3,000 affected
  pregnancies annually (MMWR 200453(17)362-365)
• Rate of 1/1,000 pregnancies
• At least 250,000 globally

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Georgia Projection

• Based on data provided by CDCs MACDP
• 2003 data is preliminary

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US Folic Acid Knowledge and Behavior 1995, 2003
and 2004
Percentage of women ages 18-45
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How Can we prevent the NTDs that Fortification
does not prevent?

• Need to reach all women of childbearing age with
  the folic acid message
• Over 50 of pregnancies in US are unplanned
• Neural tube formed in first 28 days of
  pregnancy, before woman knows she is pregnant

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Georgia Folic Acid Campaign

• Overall Goal Promote the daily consumption of
  400 mcg of synthetic folic acid among women in
  Georgia

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Georgia Folic Acid Campaign

• Rollins School of Public Health in Collaboration
  with
• GA Department of Human Resources
• GA Department of Community Health
• Georgia Folic Acid Task Force/Georgia Folic Acid
  Coalition
• March of Dimes

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Responding to the needs of low income women in
Georgia

• Six Family Planning Clinics in Georgia
• In the last two days did you take a folic acid
  pill or multivitamin? 17.1
• Cereal consumption in the last two days - 39.2
• Median serum folate levels
• All women 8.9 ng/mL
• NHANES 1999-2000 study median serum folate
  level 13.0 ng./mL

Than, Watkins and Daniel, MMWR (2002), Vol. 51.
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What Can We do to Increase Serum Folate Levels in
Low Income Women?

• Starting points
• More than half of pregnancies are unintended
• Georgia 1997 PRAMS data
• Mothers 15-19 years 71
• Mothers 20-24 years 54
• Income below federal poverty level 63
• Neural tube formed in first 28 days of pregnancy,
  before woman knows she is pregnant

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What Can We do to Increase Serum Folate Levels in
Low Income Women?

• Health behavior is difficult to change
• For multiple behaviors, including folic acid
  consumption, behavioral change lags behind
  knowledge

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Georgia Folic Acid Campaign-Where?

• County WIC and FP clinics
• Approximately 40 of live births in Georgia are
  to women enrolled in WIC
• Trained and motivated providers
• Inclusive programs low income is only
  eligibility requirement

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Georgia Folic Acid Campaign-What Message?

• Culturally, linguistically, and literacy
  appropriate
• Emphasis on womens health, rather than on birth
  defect prevention
• 50 unintended pregnancy rate
• Need to reach women not contemplating pregnancy

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Georgia Folic Acid Campaign-How?

• Things Women Reported Might Encourage them to
  Take a Multivitamin Daily
• March of Dimes Folic Acid Survey, 2004

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Georgia Folic Acid Campaign-How? (MOD Gallop
Poll)
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Georgia Folic Acid Campaign Pilot Intervention

• Provider Education
• Group training for all WIC and county health
  department nursing and nutrition personnel
• Academic Detailing to WIC/HD
• Lunch Learns and academic detailing in private
  offices
• Folic Acid Coordinators
• Distribution of promotional and educational
  material

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Georgia Folic Acid Campaign Pilot Intervention

• Social Marketing
• Participation in Community Events
• Health fairs
• Flea markets
• Breakfast for community leaders
• Media Campaign
• Radio spots

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Georgia Folic Acid Campaign Pilot Intervention

• How do we know if it works?
• Convenience sample of women in waiting area at
  county health departments.
• Self administered anonymous survey
• English and Spanish

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Folic Acid ConsumptionNon-pregnant Women
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Pre-Conception Multivitamin Use

• Were you taking a multivitamin before you became
  pregnant?

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Folic Acid KnowledgeNon-pregnant Women
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Sources of Folic Acid Information
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Consumer Practices

• 76 of participants read food labels
• Only 9 check specifically for folic acid
• Only 9 select cold cereals because of folic acid
  content and only 15 chose because of iron content

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Baseline Results

• Our baseline data shows higher MV and cereal
  consumption than previously found
• DHR, Family Health Branch policies on FA
  counseling, implemented after Than study may
  explain this

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Conclusions

• The following variables significantly changed
  with the intervention
• Cereal consumption increased
• Knowledge of importance of FA and when to take it
  increased
• Women who report learning about FA from health
  care providers increased
• Women who never heard of folic acid decreased

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Conclusions

• There is an urgent need to continue promoting FA
  consumption among women of childbearing age
• Only 31 of non-pregnant women took a
  multivitamin
• Only 24 of pregnant women reported taking a
  multivitamin before becoming pregnant

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Conclusions

• Education regarding label reading for folic acid
  content may be an effective strategy to increase
  consumption of fully fortified cereals and
  enriched grain products
• Infant and Child WIC visits may present an
  important (and missed) opportunity to ask mothers
  about future pregnancy plans and to promote folic
  acid.

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Conclusions

• Continued health professional training is
  important and effective.
• Combined individual and group training sessions
  are an acceptable and effective way to increase
  promotion of folic acid by health providers who
  care for women of reproductive age.
• Minimum disruption of clinic routine

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