Presented By: Shivaun M. Nestor, MA San Francisco Department of Public Health Kitty Ha, MPHc San Jose State University

Disclosure The Go Folic! Project was funded by a grant from the California Vitamin Cases Consumer Settlement Fund created as a result of an antitrust class action. One of the purposes of the Fund is to improve the health and nutrition of California consumers.

Agenda Introduction Marketing Research: Creating the message Social Marketing Campaign Overview Evaluation Results Conclusions Implications

What is GO FOLIC? In 2008, DPH received funding for the Go Folic! Women’s Nutrition Project to promote and increase folic acid supplementation among reproductive-age women (14 to 44) in San Francisco Primary Focus Populations among San Francisco Women: Adolescents and transition age youth, ages 14-26; 2) African- Americans; 3) Latinas - recently immigrated and earlier generations; 4) Chinese immigrants - monolingual and English speaking Modeled on the March of Dimes Florida Chapter VitaGrant Project, which included social marketing and vitamin distribution components (Lefebvre, R. Craig; June A. Flora (1988)

Introduction In 1992, the U.S. Public Health Service recommended that all women of childbearing age in the U.S. capable of becoming pregnant consume 400 µg of folic acid daily to reduce their risk for having a pregnancy affected by NTDs ( Morbidity and Mortality Weekly Report, 1992: 41: 001) A 2005 March of Dimes survey found that only one-third of women of child-bearing age took a multivitamin daily containing 100% of the RDA for folic acid ( MMRW, 2005: 54(38): 955)

Introduction, continued In 2007, the San Francisco Department of Public Family Planning Program formed a “Pre/Interconception Health Advisory Group” to develop recommendations for incorporating preconception health into family planning Among the Advisory Group’s primary recommendations was incorporating distribution of multi-vitamins with 400 µg of folic acid into routine family planning care at DPH and DPH-funded community clinics

Go Folic! Intervention

Timeline of Project Project Year 1 (Jul – Dec 2008) Conduct baseline research/assessment to document current clinic activities and staff concerns Recruit initial clinics and design clinic intervention Project Year 1 (Jan – Jun 2009) Train clinic staff/initiate clinic distribution program Hire marketing firm Conduct social marketing research Project Year 2 (Jul – Dec 2009) Design and field test marketing messages Hire culturally and linguistically competent outreach staff Design and launch marketing campaign Expand vitamin distribution to additional clinics/DPH programs Project Year 2 (Jan 2010-June 2010) Conduct mid-project evaluation of both components Use findings to hone messages, materials and interventions Project Year 3 (July 2010-June 2011) Continue/expand project activities & final evaluation

Creating the Marketing Campaign - Concerns Cultural considerations- how to respond to a diverse population in terms of both age and ethnicity/culture in a linguistically and culturally competent manner with a small marketing budget Previous research finds that younger women do not relate to pregnancy or neural tube defect prevention messages, but might respond better to “beauty messaging” (Lindsey et al, 2007)

Marketing research Written surveys (English and Spanish) completed by 64 adult women (African American, A/PI, Latina and White), ages 21-54, at two community health events targeting low-income residents One-on-one interviews with 14 clients (African American, A/PI and Latina), ages 13-24, at two clinics serving primarily low-income youth Focus groups DPH Clinics and CBOs and via Internet): Group 1: 6 African American women, ages Group 2: 10 Latina women, ages (conducted in English and Spanish) Group 3: 18 Chinese women between the ages of 18 and 44 (conducted in Cantonese) Group 4: 12 high-school age women (Asian/Pacific Islander, African American, Latina, white)

Findings – Product & Benefits Needed to define “folic acid” – concern with term Most younger women had not heard of folic acid Older women had only heard of it in context of pregnancy and not before they conceived Concern about side effects Preconception health benefits were very important but shouldn’t be the first message – would “shut out” women who were not in contemplation phase Beauty benefits important for all groups – hair, skin and nails (some youth were already taking prenatals for this reason)

Findings – Pricing/Features Vitamins could be expensive –important to emphasize that they were available for free Taste, size and smell of the pill (all groups) Easy accessibility– alternative locations for women who were not DPH clients; alternative times for women with rigid work schedules Provide alternative for women who didn’t like pills (African American) – fortified cereal was acceptable Labels should be appealing and easy to read

Findings - Promotion Short, catchy tag-lines: Multi-generational (except for teens) Multi-ethnic – no group wanted to be singled out as “having a problem” Women of various sizes and shapes No men or celebrities Emphasize beauty and general health benefits Simple, clear information Clear call to action

Messaging: Clinic Intervention and Social Marketing Primary: Folic acid is “good for hair, skin, and nails” Secondary: A daily multivitamin is good for your health Third Message: A daily multivitamin with folic acid helps build a stronger body for future pregnancies and can help to prevent some serious birth defects

Go Folic! PSA

Locations (resources & findings) Posters at public clinics and community centers Radio PSAs on KMEL (youth-oriented Hip-Hop & R&B) & KDYA (African-American Gospel Station) Social Marketing– web site, blog, Facebook, MySpace, Flicker, YouTube, Twitter Ads - Voter Pamphlets & high school newspapers News Coverage: KTSF Channel 26 (Chinese) & KDYA Outreached at health fairs, cultural events, church revivals, and high school functions

Evaluation Surveyed women who received multivitamins and provided written agreement to participate in the evaluation process. Three to six months after women are given free vitamins, we surveyed their behavior, and knowledge about taking a daily multivitamin with folic acid. Surveys were conducted online using SurveyMonkey and over the phone. Surveys were available in English, Spanish, and Chinese. We invited 411 women to participate and 95 responded – roughly 25%.

Results Only 26% of women reported taking a multivitamin before being introduced to the project. Over 89% of women reported that they started to take a multivitamin after they got free multivitamins through the project. Over 60% reported that they started taking a multivitamin because it was “good for the skin, hair, and nails.” Over 65% reported that they continue to consistently take a multivitamin, at the time of the survey. Only 31% reported that women should start taking folic acid 3 months before getting pregnant.

Limitations Respondents may be biased positively toward the Go Folic! Project since the evaluation only captured women who signed up for the project. Respondents are not randomly selected, therefore, do not represent the general population. The study was unable to control women’s exposure to other folic acid messages.

Conclusions The majority of women who responded to the survey did not know about the benefits of folic acid before the project, which effectively increased women’s knowledge and intake of folic acid through “beauty messaging,” patient education, and free multivitamin distribution.

Implications Results suggest that a folic acid vitamin distribution project that focuses on beauty-related outcomes increase low-income women’s knowledge and intake of folic acid Upon the results to this study the intervention and campaign materials have been improved.

References Lefebvre, R. Craig; June A. Flora (1988). “March of Dimes Florida Chapter VitaGrant Project”. “Social marketing and public health intervention.” Health Education Quarterly (John Wiley & Sons) 15 (3): 300, 301. “Centers for Disease Control and Prevention. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects.” Morbidity and Mortality Weekly Report, 1992: 41: 001. “Use of dietary supplements containing folic acid among women of childbearing age — United States, 2005.” MMRW, 2005: 54(38): 955 Lindsey LL, Hamner HC, Prue CE, et al.(2007) “Understanding optimal nutrition among women of childbearing age in the United States and Puerto Rico: employing formative research to lay the foundation for national birth defect prevention campaigns.” J Health Commun 2007;12: Prue, Cristine E. and Daniel, Katherine Lyon (2006). “Social marketing: planning before conceiving preconception care.” Matern Child Health J 10:S79–S84

Questions?

Thank you! Contact Information Shivaun M. Nestor, MA San Francisco Department of Public Health 30 Van Ness Avenue San Francisco, CA Telephone: (415)