Zholdybayeva A. A.

Kazakh national medical university

The use of folic acid for the prevention of birth defects in Kazakhstan

Periconceptional folic acid supplementation is effective in preventing соngenital defects [1-3]. However, debate exists regarding the effectiveness of public and physician education on patient knowledge and compliance.

Folic acid, also known generically as folate or folacin, is a member of the B-complex family of vitamins, and works in concert with vitamin B12. Folic acid functions primarily as a methyl-group donor involved in many important body processes, including DNA synthesis.

We examined the level of knowledge about the usefulness of periconceptional folic acid supplementation in a sample of patients from primary care practices.

Our research was a retrospective cross-sectional survey. A confidential, anonymous questionnaire was completed by patients before physician encounters. A maximum of 20 consecutive female patients from each of 3 age groups (16-24, 25-32, and 33-40 years) were recruited from each primary care practice.

A survey was conducted of female patients in woman consultations. Packages containing a cover letter and questionnaire were mailed to primary care practice personnel for distribution. Patients completed the questionnaire before doctor assessment and returned their anonymous responses by mail in a sealed envelope.

Based on a literature review, a 36-item questionnaire was developed. After collecting demographic information, the questionnaire evaluated pregnancy status (complete obstetric history) and knowledge about folic acid supplementation.

Family history of congenital anomalies and other known risk factors were determined. Questions also assessed knowledge of preventive issues during pregnancy (smoking, alcohol consumption, and exercise). The questionnaire was self-administered, required less than 15 minutes to complete, and contained no specific references to folic acid.

The sample was evenly distributed among the 3 age categories; mean age was 28.6 years. Overall, 78% of patients surveyed had seen their family physician at least 2 times in the previous year; the average number of visits was 5.6 per year. One hundred fifty-two patients (13.5%) were pregnant at the time of the survey. Fourteen respondents (1.2%) reported a family history of Congenital anomalies; 6 previous Congenital anomalies births had occurred (4.1 per 1000 births).

More than half of the respondents (62.7%) were familiar with the term “congenital defects”, and this percentage increased with age (P,.001). Most respondents (77.5%) were unaware that taking medicines or vitamins could prevent birth defects. Only 201 women (17.9%) stated that supplementation with folic acid could prevent Congenital anomalies. This knowledge was greatest among 25- to 32-year-olds.

Although 116 respondents (10.3%) knew that folic acid supplementation was necessary, fewer understood that it was required for Congenital anomalies prevention or before conception. Knowledge of the direct link between folic acid supplementation and Congenital anomalies prevention was indicated by only 88 respondents (7.8%). Moreover, only 20 respondents (1.8%) were aware of the periconceptional requirement for folic acid supplementation. Pregnant participants were more knowledgeable than nonpregnant respondents in all aspects of the folic acid– Congenital anomalies prevention link. Again, this knowledge was highest among 25- to 32-year-olds and lowest among 16- to 24-year-olds. Women who were pregnant were also more likely to have appropriately taken periconceptional folic acid compared with respondents who were not currently, but had previously been, pregnant (odds ratio, 2.0; 95% confidence interval, 1.2-3.3). Interpractice variation was observed with respect to knowledge of periconceptional folic acid supplementation, with a range of 5% to 20% among women in each primary care practice sampled.

This large-scale survey found consistently poor knowledge of the association between periconceptional folic acid intake and Congenital anomalies prevention in a sample of female patients of reproductive age. Only 18% of respondents could identify the need for this supplementation before pregnancy, and less than 2% knew the reasons for this intake. The group of 16- to 24-year-olds was the least likely to identify these links. These results are disturbing because, for supplementation to succeed, knowledge must exist before planning a pregnancy.

Only 23% of the sample was aware of the benefits of any medications or vitamin supplementation in pregnancy. Moreover, this knowledge was of a general nature and was not associated with the link between supplementation and prevention of Congenital anomalies. Some respondents mentioned the folic acid– Congenital anomalies prevention link, but few recognized that periconceptional intake was necessary. Although women may not need to understand the rationale for supplementation to benefit, actual compliance may be higher if this link is understood. Few patients in the sample were attempting to become pregnant (2%); however, fewer than half (44%) were using contraception. This should not be surprising because at least 50% of all pregnancies are unplanned. Moreover, because 80% of sexually active couples not using contraception will conceive within a year, all sexually active women of reproductive age should consider folic acid supplementation.

Results of this study indicate that educational information distributed by family physicians has the potential to be influential. For example, most patients were visiting their physicians for reasons other than pregnancy on the survey days. Overall, most patients had seen their family physician at least 2 times in the past year. These results reinforce the role of family physicians in counseling patients about the need to consume folic acid before pregnancy.

Factors associated with high-risk status were infrequently identified in this sample, suggesting that case finding might be an ineffective solution. However, the rate of Congenital anomalies births in many northern communities and in our sample is high. Thus, there is a more urgent need to change the knowledge and behavior of these patients, who seem to be unaware of their risks.

A health strategy designed to change these results may need to be multifactorial. First, fortification of foods with folic acid may be an effective intervention.

Further research into dietary habits and possible benefits of fortification should become a priority. Second, patient education interventions may be effective, but the efficacy of verbal and visual information (eg, pamphlets and videos) needs further evaluation. Timing of educational interventions may be similarly important, and this also requires further study. In addition, although it is possible that physician education may increase their own knowledge, how this translates into patient knowledge and behavior is not clear. Finally, public education may have a role to play because it may not be sufficient to contact patients directly.

Literature

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5. Canfield MA, Przybyla SM, Case AP, Ramadhani T, et al. Folic acid awareness and supplementation among Texas women of childbearing age. Prev. Med 2006 Jul;(1):27–30.

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