Introduction 1 2 3 4 5 5 6 7 8 3 9 10 11 11 12 11 13 14 15 Assess HCP knowledge of FA recommendations, including dosage and timing for prevention of NTDs, among different provider types: obstetricians/gynecologists (OB/GYNs), family/general physicians (FAM/GENs), nurse practitioners (NPs), certified nurse midwives (CNMs), physician assistants (PAs), and registered nurses (RNs). Assess current practices among HCPs with respect to recommending FA to women of childbearing age. Identify the best means of supporting HCP efforts to promote FA consumption in female patients of childbearing age. Methods Random sample telephone surveys lasting an average of 12–18 minutes in length, were conducted in 2002 and 2003 among HCPs working in either obstetrical/gynecology (ob/gyn) practice settings or family/general (fam/gen) practice settings. These practice settings were selected because they represent the settings where the highest proportion of women of childbearing age receive care on a regular basis. Geographic quotas were established to ensure a representation of respondents proportional to the actual distribution of office-based providers nationwide. Providers were identified through random sampling lists purchased from American Medical Information Inc., a division of InfoUSA. To identify sufficient representation of providers based in federally qualified health centers, a list of centers from the Health Resources and Services Administration’s Bureau of Primary Health Care website (http://ask.hrsa.gov/pc/) was added to the sampling frame. The identities of respondents were not revealed. This research met the requirements of Title 45 CFR part 46 for the protection of human subjects. To encourage participation, respondents were offered a $50 honorarium. The identity of the sponsors (CDC and MoD) was not divulged to respondents. A cover letter from the research firm was faxed to participants who requested additional background information about the survey. Health care providers were eligible to participate if they personally saw adult female patients for office or clinic visits, and worked in ob/gyn, or fam/gen medicine practices. The surveys were presented as a series of true/false, multiple choice, and open-ended questions. The survey sought to determine the level of HCP knowledge regarding the role of FA in the prevention of NTDs, when HCPs recommended FA, and how often HCPs recommended FA to women of childbearing age. T p Results 1 Table 1 Provider type and practice setting  Practice setting  Obstetrics/ Family/General a Gynecology Medicine OB/GYN 362  0 FAM/GEN  0 249 PAs 16 38 NPs 55 46 CNMs 200  0 RNs 77 63 Total 710 396 Note. a In 2002, 2552 physicians were screened as potentially qualified respondents. Of these 2552 physicians, 1213 (48%) did not participate in surveys, 366 (14%) requested additional information but did not schedule an interview, 184 (7%) did not meet practice setting requirements, 142 (6%) had fax numbers as the primary contact, 19 (1%) were qualified refusals and 11 (0.4%) had appointments set but not kept. The response rate for eligible physicians was 24%. In 2003, 650 nonphysician HCPs were screened as potentially qualified respondents. Of these 650 nonphysician HCPs, 73 (11%) did not participate in surveys and 75 (12%) were qualified refusals. The response rate for eligible nonphysician HCPs was 77%. p The following results were obtained from a series of true/false questions. p p 16 p p p p Predictors for recommending a multivitamin at a well-woman visit were determined. The type of provider and clinic setting variables were combined as the base variable, with OB/GYNs as the referent group. The dependant variable was whether the HCP always or usually recommended a multivitamin during a well-woman visit. Variables examined were number of weekly visits, provider age, sex, personal vitamin use, provider’s years in practice, ethnicity of patients, practice setting, socioeconomic status of patient base, patient age, clinic setting (urban, suburban, or rural) and region of practice. Clinic setting (urban, suburban, or rural), provider age, region of practice, provider’s years in practice, number of weekly visits, and patient age variables were not statistically significant in univariate analysis. 2 Table 2 Factors associated with recommending multivitamins at well-woman visits included in multivariate logistic regression model Variables Odds ratio 95% Confidence interval Provider Type    OB/GYN Referent Referent  FAM/GEN 0.64 *  CNM 1.56 0.96–2.53  NP in ob/gyn setting 3.06 *  PA in ob/gyn setting 0.89 0.30–2.66  RN in ob/gyn setting 0.80 0.45–1.43  NP in fam prac setting 0.90 0.45–1.79  PA in fam prac setting 0.63 0.30–1.34  RN in fam prac setting 0.92 0.48–1.77 Gender    Male Referent Referent  Female 1.62 * Provider takes a multivitamin    No Referent Referent  Yes 2.27 * SES of patient base    Middle or high income Referent Referent  Poverty or low income 1.49 * Minorities    <10% minorities Referent Referent  >10% minorities 1.46 * * Approximately three-quarters of all respondents had seen information about FA in the last year. Unprompted, both physician and nonphysician HCPs reported that the organization most likely to have provided that information was the MoD (25% and 46% respectively). Medical journals were identified most frequently as a way to effectively reach providers with information about FA (66% physicians, 62% nonphysicians). Nonphysician providers reported the Internet as the second most effective way (15%), and physicians reported either medical associations or conferences as the second most effective way to reach them with information about FA (12 and 11%, respectively). Providers identified up to two types of resources they would like to have to promote FA intake among patients. Printed materials were the most popular type of resource requested by HCPs. Sixty percent (60%) of physician and 69% of nonphysician providers requested brochures to distribute to their patients. Additional print resource requests included charts and articles. Free vitamins for patients were also requested (data not shown). Discussion 15  17 18 19 Providers in ob/gyn settings were more likely than providers in fam/gen settings to know the correct amount of FA needed for NTD prevention (400 μg daily). Less than a third of all providers knew the correct amount of FA needed for the prevention of recurrence (4 mg). Because women with a previous NTD-affected pregnancy are at an increased risk for another NTD-affected pregnancy, it is important for all providers to know the correct amount of FA needed for recurrence prevention. Only about half of providers in both practice settings knew that approximately 50% of pregnancies in the United States are unplanned. Without screening their female patients about pregnancy intention, perhaps providers should be recommending FA to all women of childbearing age. 20 21 11 22 24 This study has certain limitations. Physician HCPs had a low response rate compared to nonphysician HCPs. We cannot comment on the providers who did not respond to the survey. Providers answering the survey might differ in knowledge and practice than non-responding providers. Additionally, one provider group surveyed (PAs) had small numbers. Many of the variables examined were associated with one another. In the logistic regression modeling, female sex of the HCP was a significant factor in predicting recommending multivitamins to female patients of childbearing age. This is most likely because the majority of the providers surveyed in 2003 were women. Conclusions While it would be most beneficial for women of childbearing age to get adequate folic acid from fortified foods alone, alternatives include efforts to educate all childbearing aged women. Several approaches to educating and promoting folic acid consumption are endorsed by the U.S. Public Health Service. These approaches include direct to consumer marketing, public health awareness activities, health care provider outreach, and policy strategies. This study examined just one aspect (HCPs) of the multifaceted approach needed to increase FA intake among women of childbearing age. Collaboration between public health and medical care services is critical in educating women about FA and multivitamin use as health care providers are trusted professionals. Mobilizing folic acid awareness efforts to target HCPs might assist providers with patient preconception care education. Training providers while in school or residency programs, or by offering continuing education courses that cover methods of applied behavior change and health education might be useful for increasing the numbers of women hearing about folic acid from their health care provider. Additionally, further research on what barriers HCPs experience when providing preventive care, such as provider time constraints, self-efficacy, and what their perceptions are on the benefits of preventive care, is needed. As many preventive behavior and wellness messages exist, providers are forced to prioritize according to the length of and reason for patient visits. Finding a creative way to make FA counseling a priority is critical to making the FA message a consistent part of the patient/health care provider dialogue.