Գլխավոր էջ Preventive Medicine Increased awareness, knowledge and utilization of preconceptional folic acid in Israel following a...
Preventive Medicine 39 (2004) 731 – 737 www.elsevier.com/locate/ypmed Increased awareness, knowledge and utilization of preconceptional folic acid in Israel following a national campaign Yona Amitai, M.D., M.P.H., a,b,* Nirah Fisher, F.N.P., M.S.N., a,b Miri Haringman, R.N., M.P.H., a,b Hana Meiraz, R.N., M.P.A., b,c Nira Baram, R.N., M.P.H., b,c and Alex Leventhal, M.D., M.P.H., M.P.A. b a Department of Mother, Child and Adolescent Health, Ministry of Health, Jerusalem, Israel b The Public Health Service, Ministry of Health, Jerusalem, Israel c Public Health Nursing, Ministry of health, Jerusalem, Israel Available online 15 April 2004 Abstract Background. To decrease the risk of neural tube defects (NTDs), the Israeli Ministry of Health (MOH) issued guidelines in August 2000 recommending daily folic acid (FA) supplementation for women in their childbearing age, and concurrently launched a national FA campaign. Campaign effects were assessed by comparing the results of a survey done in 2002 with a baseline survey done in June 2000. Methods. Both surveys were done within the network of the Public Health Services’ Mother and Child Health Clinics (MCHC). Nursing staff conducted structured interviews of pregnant women and mothers of newborn infants. Results. In the 2002 survey (n = 1661), awareness was 85%, correct knowledge was 77.7% and 30.5% utilized FA preconceptionally. Ratios of awareness, knowledge and utilization were highest among women with post-university education (93%, 84%, 46%), and awareness and utilization were significantly higher in the 25 – 29 year age bracket (90%, 35%). In the baseline 2000 survey (n = 1719), FA awareness had been 54.6%, knowledge of the benefits of FA was 17.6% and preconceptional utilization was reported by a mere 5.2%. Conclusions. A national periconceptional FA campaign in Israel resulted in significant increases in awareness and correct knowledge, and a sixfold increase in its intake. D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved. ; Keywords: Folic acid; Neural tube defects; Prevention; Pregnancy; Periconceptional Introduction Neural tube defects (NTDs) are severe malformations of the brain and spine that may occur in the developing fetus during the first 17 –30 days after conception. They are a major cause of stillbirth and infant morbidity and mortality. For those surviving infancy, NTDs are a cause of chronic medical care costs and human suffering throughout the life span. Daily consumption of a 400 Ag folic acid (FA) supplement preconceptionally and throughout the first trimester has been proven effective in reducing the incidence of NTDs by 50 –79% . Studies have shown an association between periconceptional multivitamin/FA supplements and * Corresponding author. Department of Mother Child and Adolescent Health, Ministry of Health, 20 King David St., Jerusalem 91010, Israel. Fax: +972-2-6228907. E-mail address: firstname.lastname@example.org (Y. Amitai). a decrease in the frequency of NTDs and other congenital anomalies [2– 13]. Lower incidences of congenital anomalies of the heart [6 –8], the genito-urinary system [8– 10], cleft lip and palate [10,11], limb reduction defects [7,8,10], imperforate anus  and omphalocele  have been reported. Prevalence of neural tube defects in Israel During the years 2000 – 2001, NTDs in Israel were diagnosed (prenataly and at birth) in 389 pregnancies (168 cases of anencephaly, 169 spina bifida, 44 encephalocele and 8 with other types of NTDs) . In the year 2000, the national birth registry in Israel recorded 2,742 infants with major congenital malformations. There were 136,434 live births and the congenital malformation rate was 20.1 per 1,000 live births . Of 892 stillbirths reported, 273 infants were diagnosed with congenital malformations and the most frequent organ system involved was that of the 0091-7435/$ - see front matter D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2004.02.042 732 Y. Amitai et al. / Preventive Medicine 39 (2004) 731–737 CNS (n = 100) . Over 600 terminations of pregnancy based on confirmed congenital fetal malformations were recorded in Israeli hospitals in the year 2000 . In Israel, the case for action for recommending FA supplementation to women in the childbearing age is stronger than in the United States and other industrialized countries for three reasons. The fertility rate of women in Israel is the highest of all developed countries. According to UNICEF data for 2000, the mean fertility rate for the 31 industrialized countries was 1.7, compared with 2.8 in Israel . The fertility rate among Moslem Arabs is 4.7 . Therefore, in Israel, a successful FA campaign would have a wider scope of influence per woman in regard to the number of pregnancies affected than in other first world countries. Secondly, the rate of NTDs in Israel in the years 1999 – 2000 was 1.1 per 1,000 live births in the Jewish population and 2.23 per 1,000 live births in the Arab population . Live-born, stillborn infants and electively terminated pregnancies after prenatal diagnosis were included in this analysis. By comparison in the United States in the years preceding the CDC, FA recommendation the prevalence of anencephaly and spina bifida in California was 0.90, Iowa 0.90 and Georgia 0.99 per 1,000 live-born and stillborn infants, adjusted to include pregnancy terminations . The higher prevalence rates in Israel are due in part to the high rate of consanguinity [14,20]. Other genetic birth defects are also more common in Israel and there is an argument to be made for the role of FA in minimizing these as well [6– 13,15]. Thirdly, due to religious factors, many Jewish and Arab women in Israel choose to continue with their pregnancy even when an NTD or other severe congenital anomaly is diagnosed [14,21]. For these women, the argument for primary prevention with periconceptional FA supplements is overwhelmingly compelling. Proper preconceptional FA utilization should result in an improved pregnancy outcome and a marked decrease in NTDs and other congenital malformations [1– 13,22,23]. Folic acid guidelines in Israel To promote FA utilization, the Ministry of Health (MOH) issued guidelines in August 2000, recommending a daily 400 Ag. FA supplement for all women in their childbearing years with special emphasis placed on the 3 months preceding conception and throughout the first trimester . The MOH had an existing recommendation for a combined iron and FA supplement from week 12 of the pregnancy onward. National guidelines to prevent the recurrence of an NTD with a daily 4 mg preconceptional FA supplement have been in effect since 1994. (MCHC) staff, FA ‘‘posters’’ for all MCHC, and a patient handout on FA, available in Hebrew, Arabic and Russian. Interviews were conducted on national radio programs; articles were published in local magazines and newspapers; and lectures were given in multidisciplinary settings. A health education kit that included articles, pamphlets and a magnetized reminder to take FA was prepared and distributed. Jewish and Moslem religious leaders were contacted and included in the campaign. Almost all marriages in Israel are conducted within a religious framework (>90%) and the clergy was asked to distribute the FA brochure to all couples registering for marriage. In addition, the FA brochure was distributed to all mikvaot (post-menstrual ritual baths). District offices of the MOH developed their own local strategies such as telex advertisements through cable television and community health education days. Baseline assessment in July 2000 Before issuing the MOH guidelines in July 2000, a baseline survey was conducted in June 2000, of pregnant woman and mothers of newborn infants followed by the Public Health Service at the MCHC. The baseline survey addressed FA awareness, knowledge and preconceptional intake and was conducted by the MOH via its MCHC network. In the 2000 survey, FA awareness was 54.6%, correct FA knowledge was 17.6%, and FA preconceptional utilization was 5.2% nationally, as reported by the 1,719 respondents. Demographic details were not requested on the baseline survey. Folic acid survey in August 2002 In August 2002, to assess the effects of our FA campaign and to determine the extent of its influence on FA awareness, knowledge and preconceptional utilization, we conducted a repeat survey. As in the baseline 2000 survey, the follow-up survey was conducted by the MOH via the MCHC network. The target population was the same for both surveys and consisted of pregnant woman and mothers of newborn infants (under age 2 months) followed by the Public Health Service at the MCHC. In our current survey, in addition, we attempted to ascertain if there were any demographically high-risk groups (religion, age, education and parity) regarding preconceptional FA awareness, knowledge and utilization to better evaluate our current campaign and plan future strategy. Folic acid campaign Methods A national FA campaign was launched concurrently with the issue of the guidelines. The campaign focused on the dissemination of FA knowledge and consisted of inservice education for all Maternal Child Health Clinics The target population consisted of all pregnant women and mothers of infants under age 2 months who presented at the MCHC for either prenatal or newborn care. Y. Amitai et al. / Preventive Medicine 39 (2004) 731–737 733 Results Fig. 1. Folic acid awareness, knowledge and utilization: 2000, 2002. The survey was conducted both on women in the prenatal service and women who entered the service for infant care. We surveyed the pregnant population to minimize bias recall. However, only approximately 60% of Israeli women are followed by the public health services clinics prenatally. Prenatal care is offered at the MCHC and also through the ‘‘kupot cholim’’ (sick funds), health maintenance organizations. In regards to the infant and toddler population, the government-sponsored MCHCs provide care to approximately 84% of all children from birth to school age. Both groups of women were therefore included to insure a representative population. A total of 2,334 questionnaires were distributed via district health offices to 521 MCHC throughout the country. Three to five questionnaires were distributed to each MCHC, in proportion to the population served. The public health nursing staff at the individual clinics conducted a structured interview. During the study period, sampling was done on the first women who presented at the individual Child Health Clinics. Folic acid awareness was defined as ever having heard of FA. A multiple-choice question was used to evaluate correct FA knowledge. ‘‘FA prevents many birth defects’’ was the designated answer. Folic acid intake was defined as having taken FA on a regular basis for the 2 months preceding the current pregnancy. Women were also queried as to when they had begun their prenatal care and whether they had taken FA in the first 3 months of their current pregnancy on a regular basis. Religion was classified as Jewish, Moslem Arab, Christian Arab, Druze and other. Due to the small numbers in the individual non-Jewish groups, they were combined and subsequently called Arab. Educational status was defined by years of education. Statistical analysis was performed using SPSS 11. A total of 1,661 (71%) questionnaires were returned from 395 MCHC (76%). The population was comprised of 784 (49%) pregnant women and 827 (51%) mothers of newborns (N = 1,611). The rates of FA awareness, FA correct knowledge and FA utilization were 83.8%, 76.2% and 28%, respectively, for pregnant women and 86.5%, 79% and 33% for the women who were mothers of newborns. When adjusted for age and education, there was no significant (P > 0.5) difference between the two groups and they were therefore combined for further variable analysis. Globally, FA awareness was reported by an overwhelming majority of the women (85%). This represented a significant improvement over our baseline survey finding of 54.6% (P < 0.001). Correct knowledge of FA periconceptional benefits quadrupled from 17.6% to 77.7% (P < 0.001) and FA intake increased sixfold from 5.2% to 30.5% (P < 0.001) (Fig. 1). Religion Of the 1,618 questionnaires received where religion was delineated, 521 belonged to the Arab population (31%) (Table 1). FA awareness, knowledge and utilization rates as defined by religion are presented in Table 2. The Arab population in our present survey demonstrated improved FA awareness (74%), knowledge (67%) and utilization (21%). The Jewish population in comparison exhibited significantly higher rates of FA awareness (91%), knowledge (83%) and utilization (35%). Education A majority of the women in our current survey (83%) had at least 12 years of education, 44% had completed some Table 1 Selected sociodemographic characteristics of survey women N (%) Mean age/ standard deviation Jewish 1,097 (66) 28.7* (5.3) Moslem 359 (21.7) 27 (5.2) Christian 68 (4.1) 27.1 (5.0) Druze 79 (4.8) 27.4 (4.4) Other 15 (0.9) 26.4 (5.5) Total Arab 521 (31.4) 27.1 (5.1) (Non-Jewish) Unknown 43 (2.6) 30.3 (5.8) Total 1661(100) 28.2 (5.3) * Significant at P < 0.001 vs. Arab. ** Significant at P = 0.008 vs. Arab. Mean number of children/ standard deviation Mean years of education/ standard deviation 2.3** 2.6 (1.5) 2.1 (1.3) 2.5 (1.5) 1.3 (0.6) 2.5 (1.5) 13.7* (2.6) 11.4 (2.9) 12.6 (2.4) 11.4 (2.7) 13.1 (2.6) 11.6 (2.9) 2.1 (0.9) 2.4 (1.7) 11.6 (5.8) 13.0 (2.9) 734 Y. Amitai et al. / Preventive Medicine 39 (2004) 731–737 Table 2 Folic acid awareness, knowledge and utilization as defined by religion FA awareness [N (%)] Jewish Moslem Christian Druze Other Total Arab (Non-Jewish) Unknown Total 991 266 46 58 12 382 (91.0)* (74.3) (67.6) (73.4) (80) (73.5) 34 (79.1) 1407 (85.2) FA correct knowledge [N (%)] 851 218 41 49 9 317 (82.5)** (67.5) (67.2) (64.5) (64.3) (66.9) 33 (80.5) 1201 (77.7) FA utilization [N (%)] 379 79 10 19 1 109 (34.8)*** (22.1) (14.9) (24.4) (7.1) (21.2) 15 (35.7) 503 (30.5) * Significant at P < 0.001 vs. Arab. ** Significant at P < 0.007 vs. Arab. *** Significant at P < 0.002 vs. Arab. post-secondary education, and 20% had completed at least 16 years of education. FA awareness, knowledge and utilization increased dramatically and were positively correlated with years of education (Fig. 2: P < 0.001). Age Folic acid awareness, knowledge and utilization rates varied by age. Women aged 25– 29 had the highest rates of awareness, knowledge and utilization (90%, 76%, 35%) when compared with women aged 17– 19 (67%, 58%, 18%). Data on awareness, knowledge and utilization of FA by age group are presented in Fig. 3. There was a significant correlation between age group and, FA awareness (P < 0.001) and FA utilization (P = 0.035). Knowledge of FA was not significantly correlated with age (P = 0.147). General indicators When the data was examined by logistic regression, the most consistent and significant predictors of FA awareness, Fig. 3. Folic acid awareness, knowledge and utilization as defined by age. knowledge and utilization were education and religion (Table 3). There was a significant correlation between FA knowledge and FA utilization. Women who had correct FA knowledge were two and a half times as likely to have utilized FA preconceptionally (P < 0.001, OR = 2.65, CI = 1.9 – 3.7), even after controlling for age (P = 0.002), education (P < 0.001) and parity (P < 0.001). An additional 156 women who had not taken FA on a daily basis preconceptionally reported taking FA in their first trimester and had begun prenatal care by the end of the sixth week of pregnancy. This group of women, however, was not factored in when we analyzed preconceptional utilization. Table 3 Folic acid awareness, knowledge and utilization predictors: adjusted for maternal status, parity, religion, age group and educational group Significance Adjusted OR 95% Confidence interval Awareness 12 Years educationa 13 – 15 Years educationa z16 Years educationa Age 25 – 29b Jewish religionc 0.008 0.000 0.000 0.004 0.000 1.7 3.7 4.2 2.2 2.5 1.144 – 2.401 2.218 – 6.014 2.343 – 7.514 1.283 – 3.614 1.813 – 3.475 Knowledge Parityd 12 Years educationa 13 – 15 Years educationa z16 Years educationa Jewish religionc 0.000 0.000 0.000 0.000 0.007 0.8 2.5 3.3 3.5 1.5 0.763 – 0.904 1.755 – 3.530 2.164 – 4.953 2.230 – 5.547 1.117 – 1.995 Utilization Parityd 13 – 15 Years educationa z16 Years educationa Jewish religionc 0.000 0.015 0.000 0.002 0.8 1.7 2.3 1.5 0.729 – 0.872 1.108 – 2.550 1.483 – 3.481 1.170 – 2.045 a Odds ratio: vs. 0 – 11 years education. Odds ratio: vs. age 17 – 19. c Odds ratio: vs. Arab. d Odds ratio: for each additional child. b Fig. 2. Folic acid awareness, knowledge and utilization according to level of education. Y. Amitai et al. / Preventive Medicine 39 (2004) 731–737 Discussion Our study revealed that the intake of FA in the critical preconceptional period had significantly increased between 2000 and 2002, in the 2 years following the issuing of the national guidelines and the onset of the FA campaign. Women have heard about FA, and an overwhelming majority knew about its potential benefit in preventing births defect. The highest rates of awareness, knowledge and utilization were found among women aged 25 – 29. The highest fertility rate in Israel is among women aged 25 –29 in both the Jewish and Arab populations . Our target population, women who are having babies, has been the one who has most benefited from the FA campaign. The campaign was less successful in women with less than 12 years of education. Women aged 17 – 19 also reported poor knowledge and utilization of FA. Education is a timely process and women aged 17– 19 who are having babies have by definition not had the time to invest in an education. In similar studies in the Netherlands and the United States, there is an apparent obstacle in communicating health-related messages to the young and poorly educated segment of the population, and studies have shown a relationship between less years of education and the prevalence of NTDs [25 –28]. New focus will have to target the needs of this particular population. An alternative form of appropriate communication will have to be developed and the education of future mothers will have to begin while they are in junior high and high school. The proportion of the Arabs in the general population in Israel is approximately 19%. Their representative participation in the survey, however, was 32%, which is equivalent to their proportion of births in 2001 . In our survey, the Arab population had significantly fewer years of education and was significantly younger than their Jewish survey counterparts. This highlights the question of how to best communicate a health message to those who are younger and with less years of education. The Arab population is in part non-Hebrew speaking and may not have fully benefited from some of the national media campaigns, although local programs were done in the Arabic language at the initiative of the local health district offices. There has been a significantly dramatic increase in FA awareness, knowledge and utilization following the campaign, but the fact remains that most women in Israel having babies are not taking FA preconceptionally although they are knowledgeable of its benefits. Some of the women might have been informed of FA during their prenatal care, and their knowledge when surveyed, did not reflect their preconceptional knowledge. That would explain in theory some of the discrepancy between knowledge and behavior. Significant gaps between knowledge and behavior, however, appear to be universal. The experience in the United States may very well serve as a flagship. The Public Health Service in the United States recommended in 1992 that all women in their childbearing 735 years consume at least 400 Ag of FA a day . In April 1998, the Food and Nutrition Board of the National Academy of Sciences in the United States revised the recommendation and specified a 400 Ag synthetic FA supplement due to its increased absorption, in addition to a diet rich in FA . In 2002, 10 years after the U.S. Public Health Service first recommended FA, a March Of Dimes survey reported that 80% of the women surveyed had heard of FA . Daily consumption of a multivitamin containing FA, however, was reported by only 31% of the women in their childbearing years . An increase in FA awareness has been observed in the United States following each of several campaigns; however, actual use of daily FA supplements by women aged 18 – 45 has only increased from 25% in 1995 to 31% in 2002 [19,26,32,33]. Clearly, health behavior habits are not easily modified. Our national FA campaign focused on the dissemination of information and the imparting of knowledge via the existing network of MCHC and through the media. Behavior modification is a challenging ongoing long-term process, and although imparting correct knowledge is a cornerstone of the program, it is clearly not the entire process. In Israel, the Maternal Child Health staff at the MCHC provides primary preventive care to women and children. As such, the nurse establishes an ongoing relationship with the woman, as her caretaker during the pregnancy and family planning clinics, and as a health provider to the infant and toddler. There are multiple opportunities to reinforce and follow-up on health education messages and the local public health nurse is aware of the fine nuances that can better serve the needs of individual communities. Any contact with a woman in the childbearing years must be viewed as an opportunity for FA health promotion, every birth control consultation is a potential birth, and every childhood immunization is an opportunity for parental health education, FA discussion and positive behavior reinforcement. Due to the huge gap between FA knowledge and its actual consumption, flour fortification is an alternate strategy that does not necessitate behavior modification. Mandatory fortification with FA has been implemented in the United States and Canada since 1998 and had begun with cereal grain enrichment in 1996 . Following FA fortification, a 23% reduction in the birth prevalence of NTDs occurred in the United States . It is assumed that this substantial reduction is attributable to fortification since no concurrent increase in FA dietary supplements has been documented, while folate blood level increases have been recorded [31 – 33,35 – 37]. In a report from Nova Scotia, a reduction of over 50% in the incidence of NTDs was observed in a local study, following FA fortification . However, the experience in the United States vs. the experience in China has shown that although flour supplementation is helpful, it does not equal the impact of a properly administered synthetic FA supplement [1,35 – 37]. 736 Y. Amitai et al. / Preventive Medicine 39 (2004) 731–737 In Israel, the Public Health Service adopted the ‘‘triple strategy approach’’ for optimal reduction of NTDs, by combining dietary modification instruction, FA supplementation guidelines and voluntary food fortification . Our survey findings suggest that a lot of work remains to be done on all fronts to improve preconceptional FA utilization. In particular, we will have to focus on the Arab population, on the younger women and on those with fewer years of education. The national initiative will have to be tailored to meet the needs of the particular groups we have delineated as having lower FA utilization, while at the same time working to promote increased preconceptional FA utilization across the board. Currently, our national campaign for increasing preconceptional FA utilization is being revamped and modified in line with our findings and voluntary FA fortification of grain has begun. Acknowledgments We are thankful to the nurses of the Tipot Halav (MCHC) throughout the country who were instrumental in interviewing the study women. Particular thanks to the following nurse supervisors for their role in organizing the distribution of the survey questionnaire: Yael Arbelli, Bracha Avraham, Chana Ben-Ari, Yardena Ben-Chamu, Gila Benztik, Zahava Dror, Naomi Eidelstein, Sara Hadar, Hannah Levensohn, Rachel Maoz, Ron Maybar, Yehudit Pasternak, Mirriam Payis, Mira Ron, Leora Shachar, Gila Stern, Liora Vasterman, Ilana Yaacobi. In addition, we would like to thank Professor Joel Zlotogora for his inspiration, Eve Fliesher and Yaffa Kurtsweil for their assistance in data analysis and Dr. Rosa Goffen for her helpful comments. References  Berry RJ, Zhu L, Erickson JD, Song L, Moore CA, Hong W, et al. Prevention of neural-tube defects with folic acid in China. China – US collaborative project for neural tube defect prevention. NEJM 1999; 341:1485 – 90.  Mulinare J, Cordero JF, Erickson JD, Berry RJ. Periconceptional use of multivitamins and the occurrence of neural tube defects. JAMA 1988;260:3141 – 5.  Czeizel AE, Dudas I. 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