Folate supplementation to prevent birth abnormalities: evaluating a community-based participatory action plan for refugees and migrant workers on the Thailand-Myanmar border.

A Stevens,S Nosten,K Chotivanich,S.E.T Toe,Rose Mcgready,Shawn Somerset,A Hashmi,B.B Doh,M.E Gilder,P Moo

doi:10.1016/j.puhe.2018.04.009

Abstract

ObjectivesPreconception folic acid (PFA) taken at least 3 months before conception can decrease the incidence of neural tube defects (NTDs) by approximately 46%. NTDs contribute significantly to neonatal morbidity and mortality in migrant and refugee populations on the Thailand-Myanmar border (incidence 1.57/1000 live births). This audit aimed to assess uptake of PFA among migrant and refugee women, evaluate knowledge about PFA among local healthcare workers and implement a participatory community intervention to increase PFA uptake and decrease NTD incidence in this population.Study designA mixed-methods baseline evaluation was followed by an intervention involving health worker education and a community outreach program. A follow-up audit was performed 18 months post-intervention.MethodsData were gathered via surveys, short interviews and focus group discussions. The intervention program included community-based workshops, production and distribution of printed flyers and posters, and outreach to various local organisations.ResultsUptake of PFA was <2% both before and after the intervention. Despite a substantial increase in local healthcare worker knowledge of PFA, no significant improvement in PFA uptake after the intervention was detected. Most pregnancies in this local community sample were reported to be unplanned.ConclusionsHigh rates of NTDs with low PFA uptake remains a major public health challenge in this transient population. Results indicate that improved health worker knowledge alone is not sufficient to enhance PFA uptake in this population. Integration of PFA education within expanded family planning programs and broad-based food fortification may be more effective.

Highlights

Preconception folic acid (PFA) taken at least 3 months before conception can prevent a significant proportion of congenital birth abnormalities caused by neural tube defects (NTDs)[1] and cleft palate.[2]
132/371 (35.6%) women surveyed were aware that folic acid tablets prevented NTDs, prevented brain abnormalities or improved the health of mother and baby
The community-based participatory action plan approach used in this intervention led to enhanced knowledge and awareness of the importance of PFA in NTD prevention among health workers

Summary

Introduction

Preconception folic acid (PFA) taken at least 3 months before conception can prevent a significant proportion of congenital birth abnormalities caused by neural tube defects (NTDs)[1] and cleft palate.[2] PFA is safe and is recommended for all women of child-bearing age,[3] either through fortification of food supply or supplements. High-income countries have seen an increase in PFA uptake as a result of awareness campaigns, with increases from baseline 2.4%e25.1% to post-campaign levels of 8.3%e53.5% in Norway, the Netherlands, the UK, Israel and Australia.[6] awareness of PFA improved significantly, less than half of eligible women in most countries took PFA, and about half of those who did take it reported taking it incorrectly. Many countries have introduced population-based food fortification,[8] which has been associated with a 46% decrease in NTDs.[4]

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Conclusion