Increasing Folic Acid Awareness and Knowledge of Future Health Care Providers to Reduce the Incidence of Neural Tube Birth Defects

Diane Zipley, State Director of Program Services, March of Dimes Arizona Chapter August 26, 2007

Folic Acid Awareness



Research now shows that adequate intake of folic acid before conception can prevent the incidence of neural tube birth defects by 70% 1



However, less than 50% of women are being informed about the importance of folic acid by their health care provider 2

To address this knowledge gap, the March of Dimes has developed various materials to educate health care professionals about folic acid.

March of Dimes “Folic Acid and the Prevention of Neural Tube Defects”

CD-ROM

• Created by Jordan Perlow, MD, Folic Acid Education Campaign Chairman for the Arizona Chapter of the March of Dimes and Associate Director, Maternal-Fetal Medicine for Phoenix Perinatal Associates • To examine the effectiveness of incorporating CD-ROM technology in the curriculum of future health care providers, a study was conducted

Importance of Patient Education & Awareness About Folic Acid

BEFORE

Pregnancy



It is estimated that throughout the world 500,000 infants are born every year with a neural tube defect (NTD)

3



Approximately 3,000 of these births occur in the United States

3

Differences in NTD rates based on Race/Ethnicity??

Relative Risk for Spina Bifida

By Race/Ethnicity, U.S.,

1983-1990 Adjusted Relative Risk (95% CI) RACE/ETHNICITY

White Black 1.00

0.80 (0.72-0.88) Hispanic Asian/ Pacific Islander Native American 1.41 (1.26-1.58) 0.51 (0.38-0.70) 1.13 (0.74-1.74)

* Based on 16 state-based birth defects surveillance systems Source: CDC, Teratology, July/August 1997 Prepared by March of Dimes Perinatal Data Center, 1999

NTDs Among Hispanic Infants

• Hispanic infants, particularly US-born Mexicans are at greatest risk for NTDs • In an analysis of 6 selected states, Hispanic infants had a significantly higher rate of NTDs than non-Hispanic white infants • Not all birth defects surveillance programs collect data on Hispanic ethnicity

20 18 16 14 12 10 8 6 4 2 0

Infant Deaths due to NTDs by Race/Ethnicity, United States, 1995-1998

8.5

Rate per 100,000 live births 10.5

Rate per 100,000 live births 15.9

17.6

11 3.9

11.7

Black non Hispanic White non Hispanic Hispanic Mexican Rican Central/ Southern American Source: National Center for Health Statistics, period linked birth/infant death file Prepared by March of Dimes Perinatal Data Center, 2001

Methodology

 Participants in the study were local, full-time, first year PA students enrolled in a Women’s Health course Total N= 73  The purpose of the course was to introduce PA students to gynecology and obstetrics with a primary care focus  Two of the course objectives were related to folic acid and birth defects: (1) assessment and management of perinatal women, and (2) identification of common fetal abnormalities

PROCEDURE

• Single-group, pretest/posttest survey design was used to evaluate the effectiveness of using CD-ROM technology to increase knowledge of folic acid • Format of the Folic Acid CD-ROM: Voice-over narration of a 45-minute PowerPoint presentation that includes graphs, photos, and text • Content: Includes the etiology of NTDs, clinical research on folic acid, the need for preventive education, and current recommendations for folic acid supplementation

Pre/Post Test Instrument

 18 multiple-choice questions, with each question listing 4 possible answers  Questions factually based and derived from a validated survey provided by the March of Dimes and additional information contained on the Folic Acid CD-ROM  Posttest consisted of the same 18 questions with the order changed to reduce recall from the pretest.

 Posttest included 4 evaluation questions using a 5-point Likert scale ranging from strongly agree to strongly disagree

Results

CONCLUSIONS

Generally, the definitive improvement in posttest over pretest scores shows the effectiveness of the Folic Acid

CD-ROM

for increasing knowledge and awareness among students

In Addition…

Evaluation responses from these students strongly suggested that the Folic Acid

CD-ROM

: *provided information in a clear and effective manner *adequately covered and delivered the information *encouraged students to commit to recommending folic acid to their future patients

THE FUTURE

• Educating women to supplement their food intake with synthetic folic acid will reduce the likelihood of infants with NTDs

1,2,,4

• Given the student responses in this particular study, it is likely that this group of future PAs will promote folic acid supplementation with their female patients, thereby potentially decreasing the number of NTD-affected pregnancies

1 0 4 3 2 10 9 6 5 8 7 Year of Birth

This represents a total 22% decrease in neural tube defects for Arizona over the course of the 7 year March of Dimes Folic Acid Education Campaign.

REFERENCES

1. U.S. Centers for Disease Control and Prevention. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR Morb Mortal Wkly Rep 1992;41(no. RR-14):1 –7.

2. March of Dimes. Folic Acid and the Prevention of Birth Defects: A National Survey of Pre pregnancy Awareness and Behavior Among Women of Childbearing Age. 1995 –2000. Conducted by the Gallup Organization. Publication no. 31-1404 –00. White Plains, NY: March of Dimes, 2000.

3. U.S. Centers for Disease Control and Prevention. Knowledge about folic acid and use of multivitamins containing folic acid among reproductive aged women —Georgia 1995.

MMWR Morb Mortal Wkly Rep 1996;45:793 –795.

4. U.S. Centers for Disease Control and Prevention. Knowledge and use of folic acid by women of childbearing age —United States, 1995 and 1998. MMWR Morb Mortal Wkly Rep 1999; 48: 325 –327.