Challenging Dogma

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Saturday, April 21, 2007

Getting the Message Across: How the Folic Acid Campaign Fails to Target Its Target Population-Eileen Mack

Importance of Folic Acid During Pregnancy

In order to help prevent brain and spinal cord birth defects, the National Folic Acid Campaign recommends that women consume .4 mg of folic acid daily (1). Women can take folic acid in the form of a multi-vitamin, consume a diet with folate-rich foods or eat foods that are fortified with folic acid. Foods with naturally occurring folate include fruits and vegetables such as oranges, cantaloupe, kiwis, strawberries, avocados and dark green leafy vegetables (2,3). A multi-vitamin ensures that the recommended amount of folic acid is consumed within a given day(4) if women are unable to eat a diet rich in fruits and vegetables. Folic acid has been shown to prevent neural tube defects such as spina bifida which form within the first few weeks of pregnancy (5). It is important for women to take the recommended amount of folic acid whether or not they are considering pregnancy; considering that about half of pregnancies are unplanned(6), a woman may become pregnant without realizing it and may not have the amount of folic acid she needs for a healthy baby. Therefore, it is important that women get into the habit of taking a multi-vitamin with folic acid or eating a diet rich in fruits and vegetables before becoming pregnant.

Campaign on Folic Acid: What is Being Done and What is Missing?

The National Folic Acid Campaign, led by the CDC, March of Dimes, and the National Council on Folic Acid, largely centers its efforts around awareness and education toward women of reproductive age to increase their use of folic acid. Their websites explain the benefits of folic acid and the possible consequences of not consuming the appropriate amount. Efforts to increase awareness and use of folic acid have been made in several states. Some state campaigns have included the community in their effort to increase public knowledge about folic acid, others have utilized interpersonal and organizational levels, and some state campaigns have addressed policies around fortifying food with folic acid(2). However, despite such efforts, many women are still not taking the recommended daily amount of folic acid (2,7).

If the message is not received in a way that prompts women to make a change in their daily lives with respect to folic acid, the message looses its purpose. As many women are still not using an adequate amount of folic acid supplementation, a question is raised here about the content of the message: how does the campaign recognize differences among and between its target population, women of reproductive age? Women’s reproductive years can span between ages 15-44, and sometimes even beyond that range. However, the message about folic acid remains largely information-based and addresses women of reproductive age as a single group without accounting for differences among women within this age range (8).

Information is an important part of the equation; yet it is not been sufficient to reach all of these women in a meaningful way that prompts them to take action. The message delivered through the folic acid campaign fails to incorporate important social science principles on what influences individuals to act and change their behavior.

Advertising Theory to Inform Public Health Messages About Folic Acid

When it comes to cars, cell phones, hair products, or any number of marketable products, advertisements frequently use different themes and approaches, depending on the target age group or other demographic characteristics. Most likely, these products are not delivered with one “silver bullet” message to address teenagers, college students, young professionals, and individuals advancing their career and raising families. There is something to be said for the way in which many commercials identify the values of individuals within particular populations and promise that a particular product will benefit them.

Advertising Theory provides some insight into how to deliver a message in an effective way. This theory addresses the benefit of doing a behavior and how it corresponds to a value individuals hold deeply (9). Advertising theory asks who the target audience is, what do we know about them and how should we talk to them or not talk to them?(9). In applying the concept of advertising theory to the folic acid message, we would go beyond presenting information under the assumption that one message affects such a large group of women in the same way.

Who are the women potentially receiving the folic acid message? The National Folic Acid Campaign recognizes that there are two target groups of women, “contemplators” or women planning a pregnancy (typically 18-35) and “non-contemplators” (typically 18-24) or women who are not contemplating a pregnancy(10). While it is useful to realize that a different approach is needed for women who are considering pregnancy or not, it is also critically important to consider the heterogeneity of women in this age range. An 18 year old and a 35 year old likely are in very different places in life with differing values and interests, even if they both are planning on becoming pregnant sometime in the near future. Dividing all women who could potentially become pregnant into two such broad categories overlooks important key socio-economic and socio-demographic characteristics. Among women of reproductive age, there are considerable differences depending on their age, education level and plans for education, interests, values, career decisions, place of residency, family influences and ethnicity/race. It is not surprising that a message that ignores the important differences between women within the “contemplating pregnancy” and “not contemplating a pregnancy” groups fails to reach women in a meaningful way.

Considering age and education, for example, a study on college age women’s awareness of folic acid found that while many women are taking vitamin supplements, more than half of the women in the study population did not take multivitamin supplements. Yet, 90 percent were interested in eventually becoming pregnant(11) . Consistent with other studies, it also found that their dietary patterns were poor in comparison to recommended guidelines. However, even among this narrower group of women within the larger category of “women of reproductive age”, the authors point out that the results may not be generalisable to all college age women(11) . It then follows that the interests and values college age women have around health habits are not necessarily generalisable to older women who have been out of college for ten or twenty years. College age women may have interests in other more immediate areas regarding their busy work schedules and plans for the future. Folic acid messages ought to bear in mind the gap between awareness and action and how it varies among sub-populations. College age women are just one example of the sub-populations of women within the umbrella age group of “women of reproductive age”.

One study found that the proportion of women who were more likely to be aware of folic acid were among women with a high level of education, older, white, married, wanted carry their pregnancy through to term, had a higher family income, and sought out information from a health care provider before becoming pregnant (7). As it currently stands, the campaign’s educational efforts seem to target a rather narrow portion of the “women of childbearing age” group: those who are interested in their health, considering pregnancy and looking for ways to be healthy about it, women with internet who would go to the CDC’s website either to discover this information intentionally or accidentally while looking for something else, women who are actively pursuing health–related information, women who heard someone else talk about it, women with friends and family members who already take a daily multi-vitamin; women who fit the above mentioned profile. While the campaign targets a broad section of the population, it seems to be most effective on women with particular socio-demographic characteristics.

Studies have also indicated that values and behavior may not be a direct relationship; values may affect attitudes which lead to behavior change (16). It also may be important to recognize complex relationships between values and behavior as well as the mechanisms and routes by which values translate into behaviors. The current campaign message does not accomplish this, however. To reach women who are not already seeking out information on how to have a healthy pregnancy, or not planning on getting pregnant, it is imperative that the message is presented or advertised in such a way that addresses the core values and attitudes of these women and shows how taking folic acid will deliver a benefit which is important to them. A public health message about folic acid that does not go beyond general distinctions on pregnancy intention among all women of reproductive age misses out on what really resonates with women as reflective of their values and concerns which may prompt them to act.

Cultural Considerations for Spanish Speakers

In 2001, the March of Dimes began a campaign that specifically targets Hispanic women. The campaign distributes materials such as posters, pamphlets and brochures in English and Spanish (12). However, translating campaign materials from English to Spanish does not necessarily mean that the folic acid message is adequately being communicated in a way in which truly resonates with this population. The campaign materials must go beyond translation alone. Key cultural insights and understandings may be very easily overlooked when translating a message that has largely been successful with white women of a particular demographic into another language (7).

Studies have found that Latinos feel disrespected and discriminated against in a health organization setting (13). Public health messages about folic acid need to be sensitive to such experiences. If public health messages on folic acid resonate with Latina women in a negative way similar to their previous health-related experiences, the message is not likely to be successful. Additionally, translation into Spanish does not account for important immigrant differences. One study found that pregnant women of Mexican descent had higher consumptions of key dietary nutrients-including folate-than those born in the U.S. Moreover, the longer Mexico-born immigrants lived in the U.S., the lower their diets were in important nutrients, such as folic acid, during pregnancy ( 14). Language along does not account for changes brought about by acculturation. A study on breast and cervical cancer education among Latinas found that interventions need to target men as well as women because of the cultural importance of male influence in the family. This understanding led the researchers to suggest a more family oriented intervention and message (15). Laying out the folic acid information is important, but it is equally important to consider the way in which this message is presented and how it considers values important to women’s lives. Translating current folic acid messages into Spanish does not mean that the message is truly communicated in a meaningful way to Spanish speakers.

Social Norms to Inform Public Health Messages About Folic Acid

Especially since the benefits of folic acid are tied to preventing specific birth outcomes, women may not think that the folic acid message applies to them if they are not considering pregnancy in the near future. While the campaign’s classification of “non-contemplators” and “contemplators” is quite broad and does not account for important differences between and among women, the campaign makes a useful point that some women are not contemplating pregnancy. As previously mentioned, half of pregnancies are unplanned and women need the recommended amount of folic acid in their system before they become pregnant. Campaign materials for women not contemplating pregnancy largely communicate the message that because they could become pregnant, they should take folic acid (17) . Moreover, in trying to reach these women, the campaign erroneously assumes that a new daily habit of taking a multi-vitamin with folic acid automatically occurs after hearing an informative message about poor birth outcomes. This habit is expected to remain a part of a woman’s life throughout her reproductive years. Is this group of women truly being targeted?

Taking a multivitamin or eating more food with naturally occurring folate is part of an overall healthy lifestyle for women whether they are considering pregnancy in the near future or not. In framing a public health message about folic acid, it is important to consider social norms about women’s health. Social norms tell us that people may underestimate or overestimate the beliefs and practices of others (18). These perceptions affect individual behavior to partake or not partake in a particular action. Interventions using social norms techniques have had positive effects with promoting healthy behaviors (19) by identifying people’s misperceptions about health habits among peers and then providing education on what the true health habits of others look like. Incorporating social norms concepts into health related messages can have an important influence on encouraging positive behavior change.

For the case of women’s health, the question must be raised about how women view the health behaviors of their peers. Do women believe that their peers are health-conscious? Do they believe that others do not spend much time thinking about their health and health concerns are really not a top priority? According to the framework that social norms presents, if women underestimate how concerned with health their peers are, they are more likely to perceive this understanding as the norm. If, on the other hand, women view healthy eating behaviors and healthy lifestyle choices as the norm, they will be more inclined to partake in these behaviors. The folic acid campaign does not, however, attempt to clarify misperceptions or to strengthen positive perceptions that women may hold with regard to the health habits of their friends, co-workers, and peers.

The National Folic Acid Campaign has a very important public health message for women and their reproductive health. It is equally important that this message be delivered in a way in which that relates to women’s lives and prompts them to take action. The campaign has not tailored the message about folic acid in a way that is reflective of the wide variation among and between its target population, women of reproductive age. Instead, the current folic acid message is based on information about folic acid and the adverse affects for pregnant women who do not take it. The campaign message overlooks important social science models such as advertising theory and social norms which could help inform a more effective message. In order for the campaign to truly be successful and this important public health goal met, women must make a behavior change about folic acid where they incorporate the recommended amount into their daily diet. The current folic acid campaign must go beyond the current approach to the campaign message to reach their intended target population.


1 Centers for Disease Control and Prevention (CDC). Folic Acid. Frequently Asked Questions.
2 Quinn LA, Thompson SJ, Ott MK. Application of the Social Ecological Model in Folic Acid Public Health Initiatives. JOGNN 34 (6). Nov/Dec 2005. pp.672-679.
3 Centers for Disease Control and Prevention. Appendices to Preventing Neural Tube Birth Defects: A Prevention Model and Resource Guide. Available at:
4 Centers for Disease Control and Prevention. All Women Every Day. Available at:
5 Centers for Disease Control and Prevention (CDC). Why Folic Acid Is So Important. Available at:
6 Centers for Disease Control and Prevention (CDC). Folic Acid Now Fact Sheet.
7T.W. de Jong-van den Berg, Hernandez-Diaz S, Werler M, Louik C, Mitchell A. Trends and predictors of folic acid awareness and periconceptional use in pregnant women.Am. Journal of Obstretrics and Gynecology. 192(1) Jan 2005. pp121-128
8 See downloadable campaign materials and resources from Centers for Disease Control and Prevention to see that they are not tailored to age. Available at:
9 The Copy Workshop Strategy Seminar. Based on Work done For Apple Computers. Available at
10 Centers for Disease Control and Prevention (CDC). Folic Acid Promotion Activities. Available at:
11 Burak L, Costello P. College Women’s Reported Behaviors and Beliefs Regarding Fish and Folic Acid and Their Roles in Birth Defects. Health Care for Women International. Oct 2006. 27(9) 793-806.
12 Geisel J. Folic Acid and Neural Tube Defects in Pregnancy: A Review. The Journal of Perinatal and Neonatal Nursing. 17(4). Oct/Nov/Dec 2003.pp 268-279.
13 Barr D.A, Stanley W. F. Listening to Patients: Cultural and Linguistic Barriers to Health Care Access. Family Medicine Journal. March 2005. 37(3). 199-204.
14 Harley K, Eskenazi B, Block G. The Association of time in the U.S. and diet during pregnancy in low-income women of Mexican descent. Paediatric and Perinatal Epidemiology. March 2005.19 (2), 125-134.
15 Erwin D, Johnson V, Trevino M, Duke K, Feliciano L, Jandorf L. A Comparison of African American and Latina Social Networks as Indicators for Culturally Tailoring a Breast and Cervical Cancer Education Intervention. Cancer. Jan 2007. 109 (2 Supp) 368-77.
16 McCarty, J., Shrum, L. The Role of Personal Values and Demographics in Predicting Television Viewing Behavior: Implications for Theory and Application. Journal of Adverstising. Vol 22(4), Dec 1993. pp. 77-101.
17 See downloadable campaign materials and resources from Centers for Disease Control and Prevention. Available at:
18 NSNRC. Best Practices Social Norms. Available at:
19 NSNRC. Best Practices Social Norms.

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