LaToya Artis, Cape Fear Regional Coordinator An example of a preconception health message: North Carolina Folic Acid Campaign LaToya Artis, Cape Fear Regional Coordinator NC Folic Acid Council October 28, 2009

About the Folic Acid Campaign The North Carolina Folic Acid Campaign is a statewide program whose mission is to improve health by promoting the benefits and consumption of folic acid

The goal of the Campaign Is to reduce the number of pregnancies affected by neural tube birth defects (NTDs), such as spina bifida and anencephaly

Objectives To increase women’s awareness of folic acid’s role in preventing birth defects To increase the percentage of women of childbearing age who take a multivitamin containing folic acid every day

Our target audiences All women of childbearing age Specific marketing messages around Women ages 18-24 who are not planning a pregnancy Women ages 18-24 who are planning a pregnancy Latino/Hispanic women

Folic acid: A preconception message Folic acid deficiency identified as a preconception risk factor in the CDC’s 2006 guidelines If taken BEFORE pregnancy, folic acid can prevent up to 70% of spina bifida and anencephaly The U.S. Public Health Service recommends that ALL women of child bearing age take 400 mcg of folic acid every day

Folic Acid Campaign methods We disseminate our preconception health message through… Media - TV, radio, print Free materials – brochures, reminders, videos, bulletin boards, etc Health Care Provider Education - Office Champion Peer education- Community Ambassador Program Latino Campaign Integration of message into existing programs/services Over 120 Community Ambassadors- close to 1000 community presentations in 24 counties Over 150 private medical practices have received inservice

Office Champion Program We provide an in-service about folic acid to family practice and Ob/GYN The training for all staff includes basic folic acid facts and how and when to talk with female patients about this topic A nurse or other staff member is appointed the “Office Champion” The Office Champion helps remind clinicians to talk to female patients about folic acid and keeps the practice stocked with educational materials for patients Program reaches more than 250 practices each year

Office Champion Program: Results Comparing provider knowledge before and after the folic acid in-service: Proper timing of folic acid supplementation: 87% of respondents answered correctly (at least one month before conception) before the in-service and 94% after the in-service. North Carolina providers have high knowledge about the importance of taking folic acid before pregnancy. Correct folic acid daily dose: Improvement from 53% to 73% of respondents who correctly identified 400 mcg. Correct recurrence prevention dose: Improvement from 24% to 45% of providers who knew that 4000 mcg before pregnancy is the correct dose to prescribe if a patient has a history of a prior NTD-affected pregnancy. The proportion of providers who reported discussing folic acid and multivitamin use with at least half their female patients of childbearing age at annual exams jumped from 51% before the in-service to 69% afterward. Talk about the office champion survey and it’s results: An evaluation of the Office Champion Program took place from 2006-2008 to examine the knowledge, attitudes and recommendation behavior related to folic acid and multivitamin use among private health care providers. Evaluators randomly selected OB-GYN and family practice offices from a statewide database. Prior to the in-service, staff administered a confidential survey to those in attendance to assess the baseline knowledge and behavior of providers. Three to four months later, a second survey was sent by mail to measure how individual health care providers’ knowledge, attitudes and counseling behaviors related to folic acid and multivitamins had changed as a result of the in-service and establishment of an Office Champion. A total of 104 respondents, including 57 nurses, 29 doctors, 14 mid-level providers and two health educators completed the survey.

Community Ambassador Program Basic health promotion program Community groups or individuals Regional coordination Community Ambassadors are: Motivated individuals High school or college students, employees at a company, members of churches, neighborhood moms, hair stylists, etc. Individuals that represent the diversity of the community The Community Ambassador (CA) Program is a lay health education program, in which local community members are trained about multivitamins and folic acid. Community Ambassadors give workshops and educational talks about folic acid in their local communities. This allows the North Carolina Folic Acid Campaign (NCFAC) to expand our reach on a grassroots level. Program reaches more than 10,000 individuals each year

Community Ambassador Program: Results Pre-test/ Post-test Results for Level of Importance Placed on Taking Daily Multivitamins Survey 1: How important is it for you to take a daily multivitamin? Survey 2: After hearing the presentation today, how important do you now think it is to take a daily multivitamin? Very important (20.9%) 96.7% maintained very important Important (35.7%) 80.5% shifted to very important 19.5% maintained important Not very important (27.6%) 56.9% shifted to very important 38.2% shifted to important Not at all (15.7%) 52.9% shifted to very important 38.6% shifted to important Talk about the results of the program and the way participants moved across the levels in stages of change model. Now in its eighth year, the NCFAC wanted to evaluate the effectiveness of the Community Ambassador Program. The evaluation effort sought to examine the knowledge, attitudes and behaviors of the community members who attended CA presentations. Designed by the NCFAC evaluation committee, the survey sought to capture respondents’ intent to change their behavior.   The survey was administered in two parts. Survey 1 was completed before the CA presented on folic acid to assess baseline knowledge, beliefs and behaviors, as well as to collect demographic information. Survey 2 was completed immediately following the presentation. The evaluation team will send out a third and final survey to those who have provided e-mail addresses to determine if a behavior change took place.

Latino Campaign Developed in response to increased risk for NTDs among Latinas. Health care provider education, including cultural competency workshops Educational materials are NOT direct translations; they are modified to be culturally appropriate Community ambassadors present to small groups of women Statewide Spanish-language media

Latino Campaign: Results From 2006 to 2008, knowledge of multivitamins and folic acid increased significantly in North Carolina Hispanic women ages 18 to 35, but overall still remains low. Hispanic women knew that a prescription is not necessary to buy multivitamins and that the best time to start taking a multivitamin every day is when young women first get their period. More Hispanic women knew that taking a daily multivitamin with folic acid could prevent a birth defect, but the same percent were taking a multivitamin as compared to the women surveyed in 2006. In 2006, the NCFAC did a preliminary survey with foreign-born Hispanic women ages 18-35 in 12 randomly selected counties throughout the state. Between May 2006 and May 2008, the North Carolina Folic Acid Campaign and the March of Dimes implemented a multi-faceted educational campaign to promote multivitamin use. All 12 counties participated in a paid media campaign consisting of a mix of Spanish-language television, radio and newspaper advertising and publicity. In addition, the six intervention counties received public health care provider education, cultural awareness information about Hispanics, and a lay health educator program. In 2008, the NCFAC completed a second survey to measure the success of the campaign.

Prevalence of Neural Tube Defects North Carolina, 1995-2005. N. C Prevalence of Neural Tube Defects North Carolina, 1995-2005* N.C. Birth Defects Monitoring Program *2004-2005 data are provisional

Lessons learned: planning Materials development Make sure audience participates in development and review of materials Work with partners at all agencies involved so that process goes smoothly Give yourself enough time for many rounds of approvals

Other successes Helped to introduce and pass legislature that will provide multivitamins to low income women of childbearing potential Received a grant from the CDC to test a “Promotora” curriculum that is much like the Latino Campaign’s model

Lessons learned: partnerships Partnerships are important Partnerships allow for leverage and expand resources beyond our capacity Find partners with compatible messages Partnerships can be tricky and time-consuming Too much work for everyone to be doing their own piece alone Eg. American Heart Assn, American Cancer Society, Diabetes group all are doing messaging together

Lessons learned: partnerships Non-traditional partners are essential Media Difficult to measure but much broader reach than public health reaches alone Media partners look for opportunities to work with positive messages Community-based organizations Schools and students Schools: our target audience is 18-24: how to reach? Via college campuses, community colleges (pre-service students); high school classes, etc.

Lessons learned: women Do not assume that women will be moved by our public health messages Knowledge does not necessarily lead to action Listening (and adapting) is important: women talk about competing priorities, barriers, stress, etc.

Lessons learned: women Most women don’t think much about pregnancy before it happens. So . . . consider other ways to talk about preconception messages Spanish-speaking women are receptive to pregnancy messages

Looking to the future Partnering with other organizations and agencies (e.g. schools) Combining the folic acid message with other preconception health messages Funding opportunities

Ideas? Questions? Contact us!

Join us! www.getfolic.com www.marchofdimes.com/northcarolina Blogger: http://getfolic.blogspot.com/ Myspace: www.myspace.com/getfolic Facebook: http://www.facebook.com/pages/North-Carolina-Folic-Acid-Campaign/16803568463 Twitter: www.twitter.com/getfolic Youtube: www.youtube.com/getfolic

For more information contact: Contact us By spreading the word about folic acid and multivitamins…YOU can make a difference for mothers and babies! For more information contact: LaToya Artis Megan Whelen Cape Fear Regional Coordinator Triad Regional Coordinator 910-822-3004 336-723-4386 lartis@marchofidimes.com mwhelen@marchofdimes.com Gina Smith Linda Morgan Eastern Regional Coordinator Western Coordinator 252-972-4900 828-213-0031 gsmith@marchofdimes.com cgclmm@msj.org