Sunday, January 2, 2011

Folic Acid Supplementation in Spanish-Speaking Populations: A Critique on the CDC Folic Acid Campaign – Laura Fuerstman


One of the greatest achievements in the reduction of birth defects has been the discovery of the link between folic acid deficiency and increased risk for neural tube defects (NTDs). (1) NTDs are a classification of birth defects that result from the incomplete closure of the neural tube during the third and fourth week of embryonic development. (1) NTDs have a wide range of severity, depending on size and location of the defect. Classic forms of spina bifida often leave an individual paralyzed; severe forms of anencephaly cause an absent brain and an unviable fetus. (1)

In the late 1980s, researchers discovered a correlation between maternal serum deficiency of folic acid and an increased incidence of NTDs. (1) In order to be preventative, adequate serum levels of folic acid must be achieved before and maintained during the development of the fetal neural tube. (1) Studies showed that supplementation with folic acid reduce the risk of NTDs by 50-70%. (1) This finding led to an imminent recommendation by the CDC in 1992 that all women of childbearing age should have a minimal intake of 400mg of folic acid daily. (1) The continuing CDC campaign that followed includes raising awareness of folic acid, promoting folic acid supplementation to women of childbearing age, and mandating folate-fortified foods, including breakfast cereals and breads. (1)

The Hispanic population in the United States has an increased prevalence of spina bifida compared to the general population. (2) The CDC folic acid mandate has been successful in reducing the overall prevalence of spina bifida, however, the prevalence of this birth defect in the Hispanic population has remained the same. (3) The etiology of this increased prevalence has not been studied, but may be attributable to an underlying genetic predisposition for NTDs in this ethnic population, an inadequate dietary intake of folic acid, and increased number of unplanned pregnancies. A study in California suggests that Hispanic women have reported lower folic acid intake (30%) than their White counterparts (50%). (4) Aware of these ethnic differences, the CDC and local public health authorities have placed additional focus on the Hispanic population as part of the continuing campaign to promote folic acid intake for the prevention of NTDs. (5)

The effort to date that CDC has put forth to increase folic acid intake in the Hispanic population has merely included translating into Spanish various CDC lay campaign materials on the importance of folic acid intake prior to. (6) The “Before You Know You’re Pregnant” and “Before you Know It” campaign posters have previously been studied in a controlled research study, however, these posters and other materials have not been scrutinized on the basis of their ability to change beliefs based on social behavior science theory. (7) While the English versions have their flaws to begin with, the translated versions take an additional hit, based on cultural differences, in their ability to have their desired effects.

Critique #1: Reliance on the Health Belief Model

The Health Belief Model (HBM) is a classic behavioral theory that predicts the likelihood that an individual will engage in a positive health promotion behavior by weighing the benefits and barriers of engaging in the action. (8) Important factors in this equation are the individual’s perceptions of perceived susceptibility and perceived severity of the disease, which contribute to the overall threat of the disease, and the drawbacks to engaging in the health behavior, which may include discomfort, cost, and inconvenience. (8) The HBM often serves as a foundation for designing and evaluating public health campaigns and is the likely model used by CDC to increase folic acid awareness and consumption in both the general United States population, as well as the growing Hispanic subpopulation. (9) The general strategy of the CDC Folic Acid campaign is to prevent NTDs by presenting the threat of such birth defects and informing how folic acid supplementation is a positive health behavior that can prevent such conditions.

Regardless of what the true nature of the increased incidence of NTDs among Hispanic women is – whether it is genetic predisposition or the lack of knowledge about NTDs and folic acid– increasing awareness regarding the public health issue is the first step. This might not be so farfetched in this population, as qualitative research using interviews has suggested that Hispanic women do not receive adequate knowledge in their home countries about the prevention of NTDs with folic acid supplementation. (9) The CDC took the logical step and translated their English campaign materials into Spanish. If these materials are readable and accessible in various public settings, then surely they have the capacity of increasing the perceived the threat of NTDs.

Strictly sticking to the HBM, there are two problems with the “Before You Know You’re Pregnant” and “Before you Know It” campaign posters (see English and Spanish versions below), which are representative of other CDC Folic Acid campaign materials. (6) The first is the failure to increase the perceived threat. The terms neural tube defects, spina bifida, and anencephaly are never explicitly stated in either of these posters. The preferred phrase, “serious birth defects of the baby’s brain and spine,” is ambiguous, subjective, and does not concretely convey the potential severity of the these birth defects. Just as some individuals may personally label cleft lip as a “serious” birth defect and not actually perceive it as severe, they may be imagining a condition of similar magnitude. These posters fail to accurately describe the potential of children with NTDs to have severe disabilities, be handicapped and require the use of a wheelchair, or perhaps not even develop a brain. The perceived susceptibility is also not acknowledged in any of the translated material. Usually we see some form of statistics, which would include the overall incidence of babies to have a NTD. Not only is this number omitted in these posters, but there is not even the mention that there is a higher rate of NTDs in Hispanic women in the translated version. The combination of these factors does not provide a particularly high perceived threat of NTDs.

The second failure of the using the HBM approach is that an increase in perceived threat of NTDs does not necessary lead to the desired behavior, which is an increase in folic acid intake. In fact, a research study in Hispanic communities showed that knowledge about the link between folic acid and pregnancy or birth defects does not result in daily supplementation. (10) This can be attributed to the inattention to barriers of folic acid intake. Sources of folic acid that are recommended in these materials are multivitamins and enriched foods, such as cereal, bread, and pasta. In fairness, these are the most robust sources of folic acid available to the majority of the United States population; however, they are likely not as appealing to many Hispanic women. In addition, the cost of vitamins being is potentially prohibitive. It has also been documented that many Hispanic women believe that vitamins cause you to have an increased appetite and gain weight. (9, 11) This potentially causes negative social reinforcement both from the fear of “becoming fat,” but also perhaps the fear of social derision if peers discover you are taking vitamins. Other barriers include the smell or taste of vitamins, difficulty making it a habit or remembering to take them, and an upset stomach. (9,11) Additionally, the foods fortified with folic acid that are listed and currently available are not as likely to be a part of the diet of many Hispanic individuals in the United States. To the credit of the CDC, current efforts are underway to mandate fortification of processed foods, such as those made with masa corn flour, that are regularly consumed by Hispanic Americans. (5)

Critique #2: Communication of Risk Leads to Optimism Bias

One of the biggest challenges faced by CDC in the folic acid campaign is the striking statistic that 49% of all pregnancies in the United States are unplanned. (12) At 54%, this number is slightly higher for Hispanic women and leads to a higher rate of unintended births than White women: 40 per 1,000 vs. 17 per 1,000. (12) In other words, among women of childbearing age, 4% of Hispanic women will have unintended pregnancies compared to just 1.7% among White women. (12) The concern surrounding such a high percentage of unintended pregnancies is important to the folic acid campaign because most of those women who did not plan to become pregnant will not realize that they are pregnancy until they have missed their first menstrual period. By this point in gestation, the fetus has already begun crucial development of the neural tube and it is likely too late to prevent NTDs with folic acid supplementation. Serum levels of folic acid must be adequate prior to pregnancy in order to have the 50-70% chance of preventing a NTD. (1) Logically, a campaign would want to target women before they become pregnant.

The approach that a campaign uses to address the health of women who are at risk for an unplanned pregnancy is a sensitive topic. Almost all of the CDC Folic Acid campaign materials broadcast the above statistic that roughly 50% of pregnancies are unplanned. Perhaps it is a scare tactic that is intended to evoke an internal dialogue that goes something like, “Oh, I’m at risk for getting pregnant by accident. In that case, I should take folic acid so that the baby I didn’t plan to have doesn’t have a neural tube defect.” The more plausible effect, however, is the elicitation of optimistic bias, in which individuals have the tendency to underestimate their personal chances of negative outcomes and overestimate their personal chances of positive outcomes, despite the fact that they have just been given the overall chances of the group to which they belong. (13) In the case of unplanned pregnancies, a woman who views the 50% statistic will optimistically say to herself, “Well, I’m not part of that 50% and my chances of getting pregnant by accident are actually much lower.” Consequently, the intended health outcome of the campaign material immediately becomes useless to this woman as she processes in her mind, “If I’m not going to have a baby, I don’t need folic acid.”

Optimism bias also accounts for the above stated failure of the HBM in achieving a substantial level of perceived susceptibility of personal risk to have a baby with a NTD. Every healthy couple has a chance of having a child with a NTD or other birth defect, regardless of their personal medical or family history, an important fact that the campaign posters fail to explicitly point out. Women, therefore, may perceive their own risk as even lower than the general population if they themselves are healthy, have healthy family and friends, and especially if they have previously had children who are healthy. A woman may feel that she is already in control of the chances of having a child with a birth defect if she is already taking measures to ensure her own health and experiences healthy adults and children around her who do not have NTDs. This illusion of control is classically part of optimism bias. (14)

Studies have shown that even when Hispanic women do take folic acid supplements in the form of prenatal vitamins or multivitamins during pregnancy, they have a tendency to discontinue use after the birth of their child. (7) One cannot ignore the fact that it is undoubtedly difficult for a woman to grasp whether or not her use of folic acid before and during her recent pregnancy actually prevented a potential NTD. But part of the internal reasoning for this action lies in optimism bias: they have just experienced the birth of a healthy baby, which decreases their personal perceived risk of having a child with a NTD, despite the fact that the overall risk remains the same. The CDC campaign fails to bluntly inform women that her risk is the same as every other woman and does not decrease if she has had healthy pregnancies unless she gets enough folic acid. Additionally, the translation of the CDC Folic Acid campaign material verbatim into Spanish passes up the opportunity to point out that Hispanic women are actually at an increased risk for NTDs. This fact has the potential to garner the attention of Hispanic women and reduce optimism bias by providing information that is more meaningful to the woman.

Critique #3: Cultural Disparities Invoke Psychological Reactance

People do not like to be told what to do – especially by authority figures. One of the core values held by individuals is the sense of freedom and control of one’s own actions. When someone is told what to do, they have a psychological and physiological response to the message that results in the very opposite behavior. (15) This psychological reactance is familiar response to public health messages. How does this apply to folic acid, which seems like a pretty simple and benign beneficial health behavior? Lack of folic acid supplement is not labeled as a risky behavior and is not necessarily a rebellion against authorities if not everyone needs to ensure adequate daily folic acid intake.

The source and delivery method of the folic acid message, however, can greatly instill a psychological reactance in particular populations. This is where the CDC Folic Acid campaign runs into trouble. Research by Silvia found that the source of message greatly impacts psychological reactance and, consequently, the degree to which an individual will agree with the given message. (15) Broadly speaking, people are less likely to experience psychological reactance in response to those who are similar to them (i.e. peers) and more likely to agree with the message provided; in contrast, individuals are more likely to experience psychological reactance and therefore less likely to agree with messages provided by those who are less similar (i.e. authority figures). (15)

The CDC is generally regarded as a trusted source of health information. However, we cannot ignore that it is part of our central government, and not everyone holds the government in high regards. Immigrant populations, which include many Hispanic populations, are at risk for distrust of the government and the CDC may be viewed as part of this distrusted authority. With the CDC proud to plaster their logo over all printed material, it is obvious who the message is coming from. Hispanic women have stated that information about folic acid supplementation and NTDs is knowledge that they want, but they prefer to receive such information from their community members and local health care provider, i.e. people who are most similar to them and who are trusted figures. (7)

Additionally, the CDC fails again in the translation of their campaign posters. Visuals can be effective modes of communication in campaign posters. The “Before You Know You’re Pregnant” campaign poster strategically uses several images of average women in order to influence the source of the message, i.e. peers rather than authority. These are women who represent the majority of the United State population that should be taking folic acid: young, married, and Caucasian. The perception that the average women appearing on these posters have the knowledge about folic acid is intended to reduce psychological reactance and increase the degree to which the viewer agrees with the message and ultimately takes her folic acid! The CDC fails to change these pictures in the translated versions. The image of a Caucasian woman in a white wedding dress may not best represent the peers of an immigrant Hispanic woman.CDC brochure tells the story of “Emma,” a young woman who carefully plans her pregnancy, takes the recommended amount of folic acid, and has a healthy child. (6) The translated Spanish version fails to change the spelling of “Emma” to “Ema,” the Spanish version. It may seem like a minor detail, but it can drastically decrease the perceived of the message source. The dismissal of such considerations on behalf of the CDC is likely to induce psychological reactance in the Hispanic population. Again, the source of the message may be a dissimilar and even disrespected population in the eyes of a Hispanic woman. Such psychological reaction, consequently, diminishes the effectiveness of the message regarding folic acid and NTDs for a Hispanic woman and the likelihood that she will engage the desired health behavior.

Intervention Strategies

Basic information about the link between folic acid intake and NTDs is essential to raise awareness about this relatively new finding and recommendation. Various campaigns, including the CDC Folic Acid campaign, that employ a traditional HBM, have been effective in motivating many women of child-bearing to ensure adequate folic acid supplementation. (16) The CDC has not been as effective in reaching certain populations at risk, including younger women at risk for unplanned pregnancies and the Hispanic population. (3, 16) Strategies that target the Hispanic populations are outlined below, and, with minor tweaks, are applicable to other populations.

Strategy #1: Change the Source of the Message

As stated above, the source of any public health message is essential to the success of a campaign. The various flaws in simply translating English Folic Acid materials into Spanish have been described and we now know that one of the keys to success is to have the message appear to come from people who are more similar to our target audience. (15) Our goal is to reduce psychological reactance to the folic acid message and ultimately increase folic acid intake. We can achieve this by discarding the authoritative components of the majority culture and utilize the peers of the Hispanic community as well as public figures and pop stars.

There are potential pitfalls when choosing icons, because the larger Hispanic population in the United States is comprised of several smaller groups, based on country or region of emigration. Hispanic women have pointed out that care should be taken to avoid exemplifying a specific Hispanic group, such as Mexican-Americans or Cuban Americans, that may be identified by language dialect or specific phrases, mannerisms, or general outward appearance. (17) Instead, using individuals with unidentifiable origins has the effect of reaching a larger sector of the Hispanic population. In essence, using a nondescript representative, we are further decreasing any potential of psychological reactance that may arise between Hispanic subgroups.

Additionally, research has already been done on focus groups of Hispanic women to find out where they want to hear these messages. They want to hear this information at Women and Infant Care and medical clinics, grocery stores, churches, community members, and media outlets, such as the Internet, magazine, and television. (7) These are trusted outlets that we must take advantage of when considering the placement of printed campaign materials.

The CDC does recognize the need to involve influential community members and spokespeople when planning a folic acid campaign. (18) “Preventing Neural Tube Birth Defects: A Prevention Model and Resource Guide” offers this important token of wisdom for those who are planning a local folic acid campaign. (18) It would have been helpful if they had followed some of their own advice when developing their own materials! Changing the source of the message, as we will see below, is this first step towards greatly improving the positive effects of other strategies. We cannot expect to increase awareness of NTDs and the benefits of folic acid unless our audience is listening.

Strategy #2: Increase Risk Perception

The HBM states that increasing threat of a disease is an essential part of motivating individuals to engage in positive health behaviors. Women of childbearing age must understand that their risk of having a child with a NTD is real and applies to them and not just to other women. The goal is not to make them understand their actual risk of having a child with an NTD, which, according to 2002 data, is .00041% for spina bifida alone in the Hispanic population, but rather to raise the perception of the risk high enough that it motivates them to want to reduce that risk. (2) Increasing this threat should be accomplished by increasing awareness of the severity of the disease, as well as increasing personal susceptibility of the disease.

We know that many forms of NTDs, including spina bifida occulta, are quite mild and may not be associated with any symptoms or disabilities; however, we are more concerned with more severe, debilitating forms. Communication of the potential severity of information in some manner rather than labeling it as an ambiguous “severe birth defect” is important to increasing the perceived severity of the condition. Perhaps the CDC is afraid to plaster information regarding the most severe forms of NTDs, which include anencephaly, or the absent development of the brain, and myelomeningocele, which include involvement of the spinal nerves. A simple method to achieve this goal is to provide a brief description, similar to the previous sentence along with the image of a child in a wheelchair. With the exception of one lengthy brochure, Healthy Mothers have Healthier Babies with Folic Acid: Emma's Story, the CDC folic acid campaign materials advertise images of healthy children, communicating that this is the goal of folic acid supplementation. (6) Showing the image of a disabled child has more potential effect because of the law of small numbers. (19) By providing only examples of the potential health threat, the chance of a NTD is overrepresented in the eye of the viewer and consequently perceived as an increased threat.

The law of small numbers should be expanded to media outlets by providing additional examples. The story of a nondescript Hispanic family that has a child disabled by a NTD should be developed along with a simple message coming from this family about the benefits of Folic Acid supplementation. Essential to this message would be the communication from the mother that her chance of having the a child with an NTD is the same as the chance of the woman viewing receiving the message, thereby breaking down the optimism bias. This story can be utilized in a series of pamphlets and posters available for view in common public areas, such as the local grocery stores, medical clinics, and community centers, as well as television and radio advertisements to air on Spanish language networks. Again, the use of such a story employs the law of small numbers by overrepresenting the actual risk of NTDs. We are also starting to break down the optimism bias

Strategy #3: Promote General Health, not Pregnancy Health

One of the major challenges that folic acid campaigns face is reaching out to the very women who are at most risk – those 50% who have unplanned pregnancies. It is certainly a powerful statistic that drives the need for folic acid and NTD campaigns. What we have learned, however, is that you cannot show that number and scare women into believing that they could be part of that statistic.

The first step to address this problem is just to omit this information about unplanned pregnancies. Leaving information is not straightforward lying; it’s simply not telling the whole story. It serves to weaken the association between folic acid and pregnancy. If we omit this information, we eliminate the optimism bias that relegates the need for folic acid in the eyes a woman who is not intending to become pregnant. Weakening the association between pregnancy and folic acid is exactly what we want to do for part of this new intervention approach. It turns out that folic acid is believed to be beneficial for the prevention of a multitude of other health condition, including heart disease, stroke, and cancer. (20) Everyone could use a little more folic acid and as we know, many processed foods are already fortified with folic acid and many multivitamins contain an adequate amount of this vitamin.

The next big step is to break down the barriers to daily use of multivitamins by Hispanic Americans that the HBM predicts will decrease the likelihood of engaging in this positive health behavior. Again, these barriers include prohibitive cost, lack of routine, distaste for vitamins, and social stigma linked to the false belief that vitamins make you gain weight. (9,11) Use of vitamins needs to perceived as a cultural norm, or a general practice that is adopted by all members of a given population, in order for this population to change their overall behavior. (21) Various strategies need to be employed to create this new social norm.

We can start to create the perception of a social norm using media. A partnership can be created with the Hispanic television industry, which would show characters of all ages in popular television programs taking their morning multivitamin and perhaps discussing their benefit and even joking about the myth that vitamins make you fat. A partnership can also be created with school districts to identify teenage peer leaders who can model behavior and spread the message about their own benefits of multivitamins, including information most relevant to these kids, such as increased energy and performance in sports or dance classes, and improved concentration in school. One particularly strategy that can be taught to these kids is to use rebellion against to their advantage. Parents can try to feed their kids what they want and authorities can try to preach to kids about what to eat, but if we assume that kids are going to eat what they want to eat, multivitamins can be reframed as method of rebellion and used as the anti-junk food. Again, it is of upmost importance in each of these strategies to utilize individuals who are viewed as similar to the individuals we are trying to reach and well respected.


We have made great strides in discovering the benefits of folic acid and preventing many cases of neural tube defects. The current strategies that have gotten us this far are not adequate to reach certain at-risk populations, including Hispanic American women. The future of this campaign must pay close attention to who is delivering this message and ensure that is it a nonthreatening message with accurate, real information that promotes the wellbeing of all.


1. 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. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 1992.

2. Williams LJ, Rasmussen SA, Flores A, Kirby RS, Edmonds LD. Decline in the prevalence of spina bifida and anencephaly by race/ethnicity: 1995-2002. Pediatrics. 2005;116(3):580-586.

3. Centers for Disease Control and Prevention. Racial/ethnic differences in the birth prevalence of spina bifida - United States, 1995-2005. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2009.

4. Centers for Disease Control and Prevention. Trends in folic acid supplement intake among women of reproductive age – California, 2002-2006. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2009.

5. Centers for Disease Control and Prevention. CDC Grand Rounds: Additional Opportunities to Prevent Neural Tubes Defects with Folic Acid Fortification. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2010.

6. Centers for Disease Control and Prevention. Folic Acid Publications. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2010.

7. Mackert M, Kahlor L, Silva K, Padilla Y. Promoting folic acid to Spanish-speaking Hispanic women: evaluating existing campaigns to guide new development. Women & Health 2010; 50(4):376-395.

8. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.

9. Mackert M, Kahlor L, Silva K, Padilla Y. Promoting folic acid to Spanish-speaking Hispanic women: evaluating existing campaigns to guide new development. Women & Health. 2010;50(4):376-395.

10.                   Prue CE, Hamner HC, Flores AL. Effects of folic acid awareness on knowledge and consumption for the prevention of birth defects among Hispanic women in several U.S. Communities. Journal of Women’s Health. 2010;19(4):689-698.

11.Centers for Disease Control and Prevention. Folic Acid and Birth Defects Prevention: Focus Group Research and Materials Pre-Testing with Hispanic At-Risk Women. Atlanta, GA: Hispanic Executive Summary, 2000.

12. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-6.

13. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39:806-820.

14. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975; 32:311-328.

15.Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

16. Centers for Disease Control and Prevention. Use of Supplements Containing Folic Acid Among Women of Childbearing Age - United States, 2007. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2008.

17. Quinn GP, Thomas KB, Hauser K, Rodríguez NY, Rodriguez-Snapp N. Evaluation of educational materials from a social marketing campaign to promote folic acid use among Hispanic women: insight from Cuban and Puerto Rican ethnic subgroups. Journal of Immigrant and Minority Health. 2009;11(5):406-414.

18. Centers for Disease Control and Prevention. Preventing Neural Tube Birth Defects: A Prevention Model and Resource Guide. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2009.

19. Tversky A, Kahneman D. Belief in the law of small numbers. Psychological Bulletin 1971; 76:105-110.

20. Office of Dietary Supplements, National Institute of Health. Dietary Supplement Fact Sheet: Folate. National Institute of Health, 2010. National Institute of Health

21. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.


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