Introduction 1 2 3 3 4 5 6 7 8 9 10 11 Table 1 b Characteristic 1995 1997 1998 2000 2001 2002 2003 2004 2005 Awareness           Heard or read about folic acid 52 66 68 75 79 80 79 77 84 a           Knew folic acid can help prevent birth defects 4 10 13 14 19 20 21 24 19  Knew folic acid should be taken before pregnancy 2 6 7 10 7 10 10 12 7 Behavior           Take folic acid daily (all women) 28 32 32 34 29 33 32 40 33  Take folic acid daily (non-pregnant women) 25 30 29 32 27 31 30 37 31 a           Health-care provider 13 15 19 20 22 25 30 29 26  Magazine/Newspaper 35 36 31 30 27 27 25 28 26  Radio/Television 10 22 23 24 25 25 21 19 18 a           Green leafy vegetables – – – 24 23 27 28 25 26  Fortified cereals – – – 2 4 4 3 3 5 Source: Note a b Methods 12 Results 1 1 Table 2 awareness a Characteristic 2000 2001 2002 2003 2004 2005 Race/ethnicity        White 78 82 82 83 81 87  Non-White 62 69 71 68 68 71  Hispanic 62 69 69 72 71 73  Non-Hispanic 76 80 81 80 79 84 Age group (yrs)        18–24 68 73 70 73 70 72  25–34 76 82 84 82 80 88  35–45 77 80 81 81 80 87 Education        Less than high school 54 60 59 56 56 58  High school/Trade/Technical/ Vocational Training 66 72 73 76 70 78  College (any) 83 86 87 86 86 90 Annual household income        < $25,000 61 71 68 69 66 72  $25,000–$39,999 76 77 76 79 79 84  $40,000–$49,999 80 77 84 87 82 87  >=$50,000 84 88 88 86 87 90 Source: a 1 2 3 Table 3 taking folic acid daily a Characteristic 1995 1997 1998 2000 2001 2002 2003 2004 2005 Race/ethnicity           White – – 33 36 30 36 34 43 36  Non-White – – 26 26 23 25 28 31 23  Hispanic – – 29 36 23 26 29 38 27  Non-Hispanic – – 32 34 29 34 33 40 34 Age group (yrs)           18–24 21 23 23 29 22 22 25 31 24  25–34 30 36 34 34 32 37 34 39 36  35–45 30 35 34 36 30 36 35 46 37 Education           Less than high school 22 20 20 18 26 21 21 19 20  High school/Trade/Technical /Vocational Training 26 30 27 31 24 29 28 32 31  College (any) 30 37 36 38 32 38 37 48 36 Annual household income           < $25,000 20 22 28 26 22 23 24 30 27  $25,000–$39,999 31 32 29 34 26 34 31 40 28  $40,000–$49,999 32 34 31 37 28 33 39 48 37  >=$50,000 33 43 38 40 35 40 38 46 38 Pregnancy status           Currently pregnant – 79 79 84 80 74 82 81 90  Not currently pregnant 25 30 29 32 27 31 30 37 31 Source: Note a In 2005, 67% of childbearing age women reported they did not take daily supplements. The most common reasons for not taking any daily vitamin or mineral supplements are that they “forget to take them”, stated by 28% of women, or “don't feel they need them” as reported by 16% of women. However, in 2005, 86% of women who were not currently taking daily vitamins or mineral supplements reported they would be likely to start taking a multivitamin daily if advised by their health care provider or physician. Discussion 3 8 13 Recent educational efforts alone do not appear to be adequate to demonstrate an impact on changing behavior with regard to folic acid consumption. The findings from this report can be used to develop multi-pronged targeted public health programs to increase the number of women of childbearing age consuming a vitamin containing folic acid daily. Demographic, sociocultural, and environmental factors impact behavior and more attention must be given to these factors. Results from these surveys indicate that variations exist in folic acid awareness, knowledge, and use among women of different race/ethnicity, age groups, education levels, and socioeconomic status. This suggests that the linkage between folic acid awareness, knowledge, and use is more complicated than simply increasing awareness and knowledge. Non-white women, those between the ages of 18–24, those less educated, and those of a lower socioeconomic status are associated with both lower folic acid knowledge and lower use of a vitamin containing folic acid. Targeted messages and teachable opportunities of communication for younger women, women of racial and ethnic groups, and women of low socioeconomic status need to be identified and mobilized to increase the number of childbearing age women taking folic acid daily, regardless of pregnancy plans. Our results indicated that despite the fact that some women learn about folic acid from their health care provider, most women are not currently following their health care provider's advice even though they might feel the recommendation is important. This is apparent when looking at the proportion of women taking a multivitamin daily. In addition, women report they do not take a vitamin containing folic acid because they “feel they don't need to”, or are not receiving the folic acid message from their health provider. More research is needed to understand what the motivators and barriers are for consuming a multivitamin containing folic acid daily to design appropriate interventions (whether service delivery, policy, media messages, or educational in nature) for women of childbearing age. It is important to continue to target educational efforts at health care providers with emphasis on the importance of women of childbearing age taking folic acid daily to prevent NTDs. But, education of health care providers may not be enough by itself. Changing health care provider practices is not merely a matter of knowledge acquisition. Public health programs need to forge stronger alliances with the health care delivery systems at the local and national level to develop and incorporate meaningful folic acid messages into routine counseling and existing health programs and services, since preconceptional counseling is not available to all women of childbearing age. Strategies are needed to understand the context of patient and provider interaction to promote consumption of a daily vitamin containing folic acid among all women of childbearing age, regardless of whether or not they are planning a pregnancy. 11 12 Policy and practice implications 10 1 14 15 16 16 Conclusions Healthy People 2010 17 18 To succeed in eliminating all folic acid preventable birth defects beyond what fortification has already achieved, more must be done besides educating women and their health care providers. Pregnancies and births affected by spina bifida or anencephaly have profound physical, emotional, and financial effects on families and communities. This year there will be an estimated 3,000 NTD-affected pregnancies. This study reinforces the need for public health practitioners to mobilize multiple sectors, including health care professionals, government organizations, state and local organizations, advocacy groups, and concerned citizens to coordinate efforts and activities to help alleviate a devastating public health issue.