Breast-feeding initiation

Breast-feeding initiation is relevant to the current review because there are some similarities with the decision to begin taking folic acid supplements. For example: there are relatively low breast-feeding initiation rates in women who are living on a low income and/or who are younger; and promotion of breast-feeding can begin before conception (e.g. in schools), although in reality most interventions begin in the antenatal period.

The most recent paper identified consisted of a systematic review and a meta-analysis⁽Reference Dyson, McCormick and Renfrew⁸⁾. It included only randomised controlled trials, and identified seven studies for inclusion. The meta-analysis was carried out on five of these studies. Overall the interventions were effective in increasing breast-feeding initiation; however, there was some variation in effectiveness between the different approaches. For example, one-to-one support from lactation consultants, in an intervention based on the participants’ needs and interests and including follow-up, proved to be effective. On the other hand, breast-feeding promotion packs (non-commercial) were not effective among women of middle–higher income.

The same research group published an earlier systematic review of the same topic⁽Reference Fairbank, O’Meara, Renfrew, Woolridge, Sowden and Lister-Sharp¹¹⁾ that differed in covering not only randomised controlled trials, but also other controlled studies and quasi-experimental studies. The types of intervention that were effective among women from different income and ethnic groups included: small informal health education classes; one-to-one health education; peer counselling; or a combination of these. Multifaceted interventions comprising a media campaign, together with a peer support programme and other activities, also resulted in increased initiation rates. The types of intervention that did not appear to be effective included: breast-feeding literature alone or in combination with more formal, non-interactive health education; social support from health professionals; programmes directed at health professionals increased knowledge, but did not change attitudes; and media campaigns alone had the potential to improve attitudes, but not behaviour.

The findings of the other four reviews identified cover similar material to the two described above.

Screening

One review covered prenatal screening⁽Reference Rowe, Garcia and Davidson²²⁾, and this focused specifically on the UK. The types of screening covered were for Down’s syndrome, NTD, haemoglobin disorders and HIV. Only six studies reported data according to women’s social class or education level and although none found any significant social inequalities in testing, some studies suggested that women of South Asian origin might be less likely to participate in screening.

The other three reviews identified all concentrated on cervical screening, and there was overlap between them. The most recent was a systematic review of the effectiveness of community-based strategies⁽Reference Black, Yamada and Mann²¹⁾. The most frequently used interventions were: mass-media campaigns, alone or combined with individual strategies; individual education using lay health educators; and letters of invitation. Improvements ranged from 61 % for educational videos to 12 % for a physician letter compared with a no intervention group. Of the four studies that used mass-media campaigns alone, only one was effective and that study targeted a specific subpopulation with language-specific material. All of the studies that combined mass-media campaigns with other strategies were effective. Letters of invitation were effective but required a centralised registry to identify eligible women.

Minimising the risk of unintended teenage pregnancy

This topic is particularly relevant to the issue of use of folic acid supplements. There are parallels in terms of the required behaviours being positive and precautionary and the at-risk population groups are similar. There is also a direct interaction between the two topics, since folic acid supplements are less likely to be taken by women who did not intend to become pregnant.

Three of the included studies were published in the UK by a research group from the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI Centre). The most recent of these⁽Reference Harden, Brunton, Fletcher, Oakley, Burchett and Backhams²⁵⁾ covered all dates in electronic databases, all types of study including qualitative research and process evaluation, and studies including young people under 20 years of age. Six of the included intervention studies provided sound evidence of the value of two particular approaches: (i) early childhood interventions consisting of pre-school education, parenting support and social skills development; and (ii) youth development programmes combining community service and student learning, or providing a programme of academic and social development. A meta-analysis indicated that these approaches reduced the risk of pregnancy by 39 %. The next review from this research group⁽Reference Kavanagh, Trouton, Oakley and Powell²⁶⁾ looked at the role of incentive schemes in encouraging positive health and social behaviours in young people. The main findings were that: (i) the behaviours need to be logged and rewarded consistently; (ii) interventions need to be implemented properly and consistently; (iii) large-scale incentive-based schemes require staff with the necessary skills and commitment, and sound systems in place to support them; and (iv) the size or type of incentive on offer needs to be sufficient to motivate change in young people.

The third review from this group⁽Reference Harden, Weston and Oakley³¹⁾ addressed the use of peer-delivered health promotion interventions. There were two relevant interventions and these were both in school settings. The conclusions from the first of these included the importance of focusing the intervention on one topic; incorporating it into a wider programme of sex education; and reflecting the principles of ‘good practice’ in health promotion, including empowerment and participation.

Of the remaining reviews identified, one described some specific studies that may be relevant to the use of folic acid supplements⁽Reference Moos, Bartholomew and Lohr²⁷⁾. This review assessed the usefulness of counselling in a clinical setting to prevent unintended pregnancy and included all types of studies including those using qualitative methods. In one of the included studies, women who were more likely to take the contraceptive pill consistently took it at the same time each day, read and understood all of the package information, and took the pill at a routine time other than immediately before going to sleep.

Preconception care

The systematic review identified in Review 1 focused more on the effectiveness of preconception interventions in reducing the risk of diseases rather than the approaches used⁽Reference Korenbrot, Steinberg, Bender and Newberry³³⁾. However, it provided a basis for a more in-depth exploration of literature on preconception care in Review 2.

The eighteen studies that were finally included in Review 2 were organised by research methodology and within that by country of publication.

Increasingly, policies and guidance for preconception care have been developed in countries around the world⁽Reference Boulet, Parker and Atrash^34–36). The USA appears to be at the forefront of this. The Centers for Disease Control and Prevention⁽Reference Johnson, Posner, Biermann, Cordero, Atrash, Parker, Boulet and Curtis³⁷⁾ published a detailed evaluation of the available evidence and recommendations in 2006, and forty-two States have performance measures which relate to preconception care.

There is some evidence that preconception care has a positive impact on health behaviours, and there are also indications that participation in preconceptional care may decrease the number of unplanned pregnancies.

Two prospective studies were identified. The first of these was carried out in the USA⁽Reference Moos, Bangdiwala, Meibohm and Cefalo³⁸⁾ and reported that women who were offered a preconception health promotion programme were more likely to identify their pregnancies as intended than a group who did not take part in the programme. The authors concluded that preconception programmes could prove useful for promoting intendedness of pregnancy in low-income women. The other prospective study⁽Reference Czeizel³⁹⁾ followed women who participated in the Hungarian periconceptional care programme over a 10-year period. The results indicated that the programme was effective in improving many aspects of periconceptional care, including reducing smoking and alcohol consumption, and increasing the use of folic acid-containing multivitamin supplements.

Cross-sectional studies from The Netherlands⁽Reference Poppelaars, Cornel and Ten Kate^40–Reference van Heesch, de Weerd, Kotey and Steegers⁴²⁾ and one from the UK⁽Reference Heyes, Long and Mathers⁴³⁾ indicated that most women, doctors and other relevant health professionals support the idea of preconception care, although in practice it happens rarely. Lack of time and possibly motivation and prioritisation among health professionals appear to be important barriers. The one randomised controlled trial which was identified in this section⁽Reference Jack, Culpepper, Babcock, Kogan and Weismiller⁴⁴⁾ found that informing doctors and women about identified preconception risks did not encourage them to do more. However, a trial without a control group was identified⁽Reference Bernstein, Sanghvi and Merkatz⁴⁵⁾ which indicated that providing education and standardised forms was effective in increasing screening, although this did not affect staff knowledge and attitudes.

Systematic reviews

The systematic review that is most relevant to the current work covered worldwide literature up until 2003, but differs from the current work in that it focused specifically on three aspects of folic acid supplement use⁽Reference Ray, Singh and Burrows⁴⁶⁾: (i) the rate of use (i.e. not awareness) pre- and periconceptionally; (ii) the demographic characteristics associated with low rates of use; and (iii) folic acid use in relation to public awareness campaigns only. Review 3 conducted in the present work includes all types of research, including evaluations of campaigns. It also includes information on awareness of folic acid/folate recommendations.

A total of fifty-two studies were included in the review. The authors drew out a number of lessons for the future: family planning initiatives should promote folic acid supplement use; in view of the low rates of planned pregnancy in many countries, better approaches are needed to ensure that folic acid is taken as soon as possible after conception; the best public health programmes reach, at most, 50 % of women; and some women may not receive or comprehend the folic acid message, particularly young, single women, those without a formal education and those who are recent immigrants.

The other systematic review that was identified⁽Reference Quinn, Thompson and Ott⁴⁷⁾ focused specifically on state-wide programmes of folic acid education in the USA which used the social ecological model. This model is a multifaceted approach to health promotion, which includes environmental, behavioural and social policy changes that help individuals adopt healthy behaviours. Most state-wide folic acid campaigns did not incorporate all levels of the social ecological model, although most included interventions in at least two levels.

Research trials on the effectiveness of different types of intervention

There were five controlled trials in total. The main characteristics of these trials are shown in Table 2.

Table 2 Review 3: characteristics of controlled trials organised in alphabetical order by first author

Watson et al.⁽Reference Watson, Watson, Bell, Halliday, Burford and Brennecke^48, Reference Watson, Watson, Halliday and Bell⁴⁹⁾ reported a randomised community intervention trial from Australia, which assessed the effectiveness of using only a printed communication. Folate awareness increased in the intervention group, but was sustained only in women aged 35–44 years. The intervention was also less effective for socially disadvantaged women.

Three of the controlled trials from the USA focused on health sector interventions providing free supplements. Lawrence et al.⁽Reference Lawrence, Watkins, Ershoff, Petitti, Chiu, Postlethwaite and Erickson⁵⁰⁾ evaluated the effect of information and ‘starter kits’ of multivitamins being mailed to one group, while another group received the information through primary-care providers. There was a small but significant increase in the percentage of women using multivitamins in the direct mail group at the beginning of the intervention period, but this increase was not sustained after the interventions ended. However, in two trials, free folic acid supplements were provided either during routine gynaecological visits (Robbins et al.)⁽Reference Robbins, Cleves, Collins, Andrews, Smith and Hobbs⁵¹⁾ or in family planning clinics (Watkins et al.)⁽Reference Watkins, Brustrom and Schulman⁵²⁾. Both of these studies reported significant increases in reported consumption, and in the Robbins study⁽Reference Robbins, Cleves, Collins, Andrews, Smith and Hobbs⁵¹⁾ weekly folic acid intake increased in the intervention group by 68 % compared with 20 % in the control group. Those who were most influenced by the intervention were black and lower-income and not planning pregnancies.

The remaining controlled trial from the USA, reported by Johnson et al.⁽Reference Johnson, Stadler, Feldkamp and Webber⁵³⁾, indicated that a short educational intervention was effective in increasing knowledge in high-school students.

There were eight trials which did not have a control group. The main characteristics of these trials are shown in Table 3.

Table 3 Review 3: characteristics of trials without a control group organised in alphabetical order by first author

Of the eight trials, three were small studies with students and are not described further here (DiPietro and Kier, Quillin et al., Morgan et al.)⁽Reference DiPietro and Kier^54–Reference Morgan, Klein and Selbst⁵⁶⁾.

Two of the remaining trials described preconception interventions led by health professionals. De Weerd et al.⁽Reference de Weerd, Thomas, Cikot, Steegers-Theunissen, de Boo and Steegers⁵⁷⁾ in The Netherlands assessed whether preconception counselling improves the folate status of women planning pregnancy. This showed significant increases four months after the intervention, with higher figures in those women who were not already taking a supplement. In the USA a trained health educator implemented a folic acid promotion programme at three clinics (Chacko et al.)⁽Reference Chacko, Anding, Kozinetz, Grover and Smith⁵⁸⁾. When a young woman indicated interest in taking a daily multivitamin, she was given a 3-month supply of multivitamin tablets. Daily multivitamin intake increased significantly from 9 % to 67 % at 3 months after the intervention.

Another two trials focused on approaches to increase health professionals’ knowledge of folic acid advice. Edwards and Wyles⁽Reference Edwards and Wyles⁵⁹⁾ in the UK evaluated the effectiveness of training sessions. Before the training sessions 42 % of the health professionals thought that women could eat enough folic acid from food alone, and after the training this had fallen to just 1 %. In Florida, Hauser et al.⁽Reference Hauser, Lilly and Frias⁶⁰⁾ assessed the effects of a state-wide educational initiative on health professionals’ knowledge and practice. The initiative included articles in professional publications, presentations at continuing medical education courses, direct mailings, and educational booths at professional meetings. This resulted in a significant increase in knowledge and the percentage of health-care providers who recommended periconceptional use of folic acid.

The final trial described here measured the impact of a 12-month multimedia folate education campaign, with and without the use of health claims (Williams et al.)⁽Reference Williams, McHenery, McMahon and Anderson⁶¹⁾. In the first six months of the campaign no health claims were made on folate-rich food, but in the second half of the campaign health claims were introduced. Awareness of the recommendation to take folate before pregnancy rose by 8 % in the first six months of the campaign (without health claims) and by 22 % in the second half (when health claims were incorporated on some food labels and in television advertisements and publications). It seems that including a specific health claim explaining the role of folate in preventing birth defects may increase the impact of a folate education campaign. This was in the context of foods rather than supplements, but the finding is also potentially relevant to the sales of supplements.

Integrated national or regional campaigns

Four integrated campaigns were identified which appear to have been successful in increasing intake of folic acid supplements to some extent. These four campaigns were carried out in South Australia, Canada, the UK and The Netherlands. In Australia⁽Reference Chan, Pickering, Haan, Netting, Burford, Johnson and Keane⁶²⁾ a short campaign with a fairly limited budget covered both health professionals and women of childbearing age. The proportions of women taking periconceptional folic acid supplements increased significantly, and folic acid tablet sales doubled. However, there was no evidence that the effects would be sustained. In Canada⁽⁶³⁾ a range of national and local educational initiatives were undertaken. Evaluation at three sites was carried out prior to mandatory fortification and for 2 years after the introduction of fortification. There were increases in the use of folic acid-containing supplements in Newfoundland, but not Ontario. In England⁽Reference Raats, Thorpe, Hurren and Elliott⁶⁴⁾, the percentages of pregnant women and new mothers claiming to have taken folic acid before conception rose from 24 % to 38 %. However, the authors of the evaluation report drew attention to the short duration of the campaign, particularly when compared with sustained health initiatives around smoking and HIV. Their concerns appear to have been justified, because a later study indicated a decline of about 10 % in supplement intake 5 years after the campaign finished (NJ Wald, personal communication, 2005). In the Netherlands⁽Reference van der Pal-de Bruin, de Walle, Jeeninga, de Rover, Cornel, de Jong-van den Berg, Schouten, Brand and Buitendijk^65, Reference van der Pal-de Bruin, de Walle, de Rover, Jeeninga, Cornel, de Jong-van den Berg, Buitendijk and Paulussen⁶⁶⁾ a national campaign included advertisements in newspapers and women’s magazines, television and radio commercials, posters in the waiting rooms of general practitioners, midwives and gynaecologists, and information for women wishing to conceive available free from the pharmacist. An additional local campaign was targeted at women in lower socio-economic groups. Periconceptional folic acid use increased from 16·8 % to 48·6 %, but socio-economic differences in supplement use remained and persisted in a study carried out 3 years after the campaign⁽Reference de Walle, Cornel and de Jong-van den Berg⁶⁷⁾. Socio-economic differences widened in the national campaign, but remained similar where the additional local campaign was implemented.

Two other campaigns were reported, from Germany⁽Reference Egen and Hasford⁶⁸⁾ and south-west Virginia⁽⁶⁹⁾, where the effects of the interventions were limited, in particular with respect to socio-economic differences and knowledge about the appropriate timing for supplement use.

The final campaign identified, from Northern Ireland⁽⁷⁰⁾, included data on awareness of the folic acid recommendations, but not on reported supplement use.

Cross-sectional and prospective cohort ‘monitoring’ surveys: awareness and intake of folic acid, and sources of information on folic acid

Fifty-six cross-sectional and two prospective cohort ‘monitoring’ surveys were identified; they are listed in Table 1.

Fifty-five of these covered various aspects of awareness of the folic acid/folate message, use of supplements and sources of information. The two main sampling approaches used were either to collect information among women of childbearing age or to collective retrospective information from pregnant women or new mothers. The main comparable findings are summarised in Table 4 by country. The source papers were those listed in Table 1: Australia⁽Reference Watson, Brown and Davey^71–Reference Bower, Miller, Payne and Serna⁷³⁾; Canada⁽Reference Einarson and Koren^74–Reference Tam, McDonald, Wen, Smith, Windrim and Walker⁸⁰⁾; Croatia⁽Reference Gjergja, Stipoljev, Hafner, Tezak and LuzarStiffler⁸¹⁾; Denmark⁽Reference Knudsen, Orozova-Bekkevold, Rasmussen, Mikkelsen, Michaelsen and Olsen⁸²⁾; Ireland⁽Reference McDonnell, Johnson, Doyle and Sayers^83–Reference Ward, Hutton, Mc Donnell, Bachir, Scallan, O’Leary, Hoey, Doyle, Delany and Sayers⁸⁵⁾; The Netherlands⁽Reference de Walle, Cornel and de Jong-van den Berg^67, Reference Bakker, Cornel and de Walle^86, Reference de Jong-van den Berg, de Walle, van der Pal-de Bruin, Buitendijk and Cornel⁸⁷⁾; New Zealand⁽Reference Allen, Thomson, Emmerton and Poulton^88, Reference Schader and Corwin⁸⁹⁾; Norway⁽Reference Braekke and Staff^90–Reference Vollset and Lande⁹²⁾; Poland⁽Reference Szumska and Mazur⁹³⁾; Spain⁽Reference Cano-Serral, Rodriguez-Sanz, Borrell, Perez Mdel and Salvador^94–Reference Garcia Carballo, Gonzalez Gonzalez and Jimenez Garcia⁹⁶⁾; the UK (NJ Wald, personal communication, 2005)⁽Reference Blake, Herrick and Kelly^97–Reference Sillender and Pring¹¹⁰⁾; and the USA⁽Reference Ahluwalia and Daniel^111–Reference Rosenberg, Gelow and Sandoval¹²⁵⁾.

Table 4 Comparable levels of awareness and use of folic acid, and sources of folic acid information, by country

NA, not available.

*Among women of childbearing age.

†Among women with planned pregnancies/unplanned pregnancies.

‡Percentage in 1998/2000.

Although there is a great deal of data about awareness and knowledge of folate and folic acid supplements, much of it is not directly comparable between studies. For example, some studies have just assessed familiarity with the term ‘folic acid’, some have asked about knowledge in relation to NTD or pregnancy, whereas others have assessed whether women know about the advice on when to take supplements. So, although these data can be invaluable for individual monitoring exercises, they are of restricted use when comparing results from different studies.

Data on supplement use (as recommended) are far more useful for this purpose, and some of the cross-sectional surveys described here indicate that use (as recommended) reported by pregnant women and new mothers ranged from 7 % (in Croatia) to 53 % (one study from the USA). However, most countries reported levels between 25 % and 35 %. Much lower levels are reported when data were collected from samples of women of childbearing age. New Zealand reported levels as low as 3 %. Case studies described by Eurocat in 2005⁽¹²⁶⁾ indicated that similar levels are reported from France, Spain, Germany and Italy.

The works described in this section consistently indicated some factors that were particularly associated with lower awareness, knowledge, and rates of folic acid supplement use.

One of the most important of these is the link with unintended pregnancy. The rates of unintended pregnancy vary considerably within and between populations. In terms of variation between countries, some such as Poland report very low levels of planned pregnancy (10–20 %), some such as the UK and USA are intermediate (about 50 %), and others including Croatia and The Netherlands have very high rates of planned pregnancy (75–80 %).

Other factors that were identified as being associated with lower awareness and use included: lower household income; lower educational attainment; being a lone parent, unemployed, from a lower socio-economic group, younger or from particular racial/ethnic groups; lacking awareness/knowledge of the potential benefits and not being convinced of efficacy; and having a less healthy lifestyle.

Only one qualitative study was included⁽¹²⁷⁾. This was from the UK and provided additional insights into the influences on young women, women in low-income groups, and those with poor educational backgrounds. The most relevant findings included: a fatalistic view of becoming pregnant; the importance of advice from mothers and friends compared with health professionals; and the difficulty in actively making contact with women in these groups.

The most common sources of information for women mentioned in these cross-sectional surveys tended to be mass-media advertising, magazines, newspaper articles, and family and friends. However, although health professionals were usually cited less frequently, their advice was regarded as more credible. Generally, family doctors seemed to be a more frequent source of advice than other health professionals, including midwives. In the UK, one of the trials mentioned earlier⁽Reference Edwards and Wyles⁵⁹⁾ also indicated that practice nurses appear to be the group who are asked most frequently about folic acid (82 %) compared with general practitioners (55 %) and dietitians (13 %). Pharmacies were mentioned very infrequently.

The remaining three cross-sectional studies provided some information on the knowledge, attitudes and practice of selected health professionals. One of the studies⁽Reference Lynch¹²⁸⁾ was a very small student study from the USA, which is not described further. A more powerful study of obstetricians and gynaecologists in the USA showed good levels of awareness of the relationship between folate and NTD, with a high proportion saying that they already advise non-pregnant patients about folate intake⁽Reference Power, Holzman and Schulkin¹²⁹⁾. The final cross-sectional study was of midwives in Sweden; it indicated they played an important role, but could be more effective if supported by local routines, guidelines and training⁽Reference Lundqvist, Wennberg, Lovgren and Sandstrom¹³⁰⁾.