Family Practice Vol. 18, No. 3, 300-303
© Oxford University Press 2001
The use of pre-conceptional folic acid as an indicator of uptake of a health message amongst white and Bangladeshi women in Tower Hamlets, east London
Department of General Practice and Primary Care, St Bartholomew's and The Royal London School of Medicine and Dentistry, Medical Sciences Building, Queen Mary and Westfield College, London E1 4NS and
a MRC Epidemiology and Medical Care Unit, Wolfson Institute of Preventive Medicine, Charterhouse Square, London EC1M 6BQ, UK.
Correspondence to Dr S Howell, St Stephen's Health Centre, William Place, London E3 5ED, UK.
Howell SR, Barnett AG and Underwood MR. The use of pre-conceptional folic acid as an indicator of uptake of a health message amongst white and Bangladeshi women in Tower Hamlets, east London. Family Practice 2001; 18: 300–303.
Received 11 April 2000; Revised 5 September 2000; Accepted 8 January 2001.
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Abstract |
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Background. The benefit of folic acid is a simple health promotion message of proven effectiveness that is particularly pertinent to a young population with a high birth rate.
Objective. The aim of the present study was to compare the uptake of a folic acid health message in two different ethnic groups.
Methods. Community antenatal teams in Tower Hamlets were asked to recruit women attending for a booking between October 1997 and July 1998 to the study. Tower Hamlets, in east London, is one of the poorest areas in England and Wales, with an ethnically diverse population. A questionnaire enquiring about age, employment, level of education, use of folic acid in their current pregnancy, understanding of the benefits of folic acid and self-described ethnic group was administered verbally immediately before the booking appointment to those women who agreed to participate.
Results. Completed questionnaires were received on 249 women. Univariate analysis showed that white women were 5.7 [95% confidence interval (CI) 2.5, 13.2] times more likely to have taken folic acid supplements before conception than Bangladeshi women. Having controlled for the variables, age, school leaving age, social class, parity, planned pregnancy and ‘heard of folic acid’, ethnic status remained a significant predictor of taking folic acid, with the odds ratio dropping to 5.2 with a 95% CI (1.1, 25.2).
Conclusion. The Bangladeshi community in the UK have been shown to have poor access to health information sources, which is consistent with the results of this survey, which shows that a simple and important message has not been acted upon equally by white and Bangladeshi women in east London. This survey lends support to the view that resources and innovative forms of health promotion are needed to ensure that ethnic minority groups have adequate access to health promotion messages.
Keywords. Ethnicity, folic acid, health promotion.
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Introduction |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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The objective of this study is to compare the uptake of a simple health message in two different ethnic groups.
Following the publication in the UK of the Medical Research Council Vitamin Study1 in 1992, a Department of Health Expert Advisory Group recommended that, to reduce the number of first occurrence neural tube defects, all women planning a pregnancy should increase their daily folate intake by 400 µg until they have conceived and for the first 12 weeks of pregnancy. They also recommended major programmes of education throughout the UK on the benefits of folic acid supplements.2
In 1995, the Health Education Authority embarked on a £2.3 million, 3-year campaign to educate health professionals, the public and the food industry on the benefit of folic acid. Retrospective studies in Leeds,3 Glasgow,4 Portsmouth5 and Birmingham6 have shown that 21–31% of women have taken folic acid supplements before conception.
The benefit of folic acid is a simple health promotion message of proven effectiveness that is particu-larly pertinent to a young population with a high birth rate.
Tower Hamlets, an east London, inner city borough, is one of the poorest areas in England and Wales,7 with an ethnically diverse population. Indicators of social disadvantage are more common in minority ethnic groups in London and are linked to poor health.8 Approximately 37 000 Bangladeshis live in Tower Hamlets; they are a young population, over half are aged 15 years or under.9
The uptake of the folic acid message could be used as a marker for the effectiveness of health promotional activity in this community.
We describe a comparison of the use of folic acid supplements before conception by Bangladeshi and white women in the London Borough of Tower Hamlets.
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Subjects and methods |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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Community antenatal teams were asked to recruit women who attended for a booking appointment between October 1997 and July 1998 to the study. A brief questionnaire was designed and piloted that enquired about age, employment, level of education, use of folic acid in their current pregnancy, understanding of the benefits of folic acid and self-described ethnic group. The questionnaire was administered verbally to those women who agreed to participate. The questionnaire was administered immediately before the booking appointment to prevent information from this appointment affecting women's responses. Approval for the study was obtained from East London and City Health Authority Research Ethics Committee.
Sample size
The sample size was based on a usage of folic acid before conception rate of 10% in the Bangladeshi population and 25% in the white population, which required 224 women in total to find a significant difference at the 5% level with 80% power. To allow for women from other ethnic groups who would not be included in the analysis, an overall sample size of 250 was sought.
Odds ratios generated from a logistic regression model were used to compare the usage rates between white and Bangladeshi women. Chi-squared tests were used to look for differences in demographics and history between white and Bangladeshi women. The analysis was performed using SPSS for Windows version 6.1.3.
Social class was coded on the basis of employment data of the woman's partner or of the woman if she was single.10
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Results |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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Completed questionnaires were received on 249 women, with a small variation in response rate to individual questions. Though routine data were not collected on all women attending for a booking antenatal appointment, the age and ethnic mix of the respondents are similar to those of all women delivering in Tower Hamlets11 and so broadly representative of the target population (Table 1
). Results are summarized in Table 2.
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Univariate analysis shows that white women were 5.7 [95% confidence interval (CI) 2.5, 13.2] times more likely to have taken folic acid supplements before conception than Bangladeshi women.
Having controlled for the six variables: (i) age; (ii) school leaving age; (iii) social class; (iv) parity; (v) planned pregnancy; and (vi) ‘heard of folic acid’, ethnic status remained a significant predictor of taking folic acid, with the odds ratio dropping to 5.2 with a 95% CI (1.1, 25.2) (Table 3).
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Discussion |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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The Bangladeshi community in the UK have been shown to have poor access to health information sources,12 which is consistent with the results of this survey, which shows that a simple and important message has not been acted upon equally by white and Bangladeshi women in east London.
The results from the white group in our survey, of 29% pre-conceptional folic acid use, though poor, is consistent with other UK studies,3–6 and the 7% pre-conceptional folic acid use in the Bangladeshi group compares far less well.
Unlike previous studies, we ascertained uptake of pre-conceptual folic acid before the women had had significant antenatal care, and the results should therefore be less affected by recall bias. The overall uptake rates should be interpreted with caution because of the absence of an accurate population denominator; however, the uptake in the Bangladeshi group is unacceptably low.
Some possible confounding factors were not considered in the analysis, e.g. practice characteristics. Gathering accurate data for patients' practice characteristics would have been difficult as each midwifery team administrating the survey worked with a small number of women within several GP surgeries and community clinics.
A number of factors may contribute to the low use of pre-conceptual folic acid by Bangladeshi women. Though 59% of the Bangladeshi group said they had planned their pregnancy (55% in the white group), this planning may be culturally different between the two groups. Many Bangladeshi women would expect a pregnancy after marriage; pregnancy is perceived as a gift and therefore they would answer positively that they had planned their pregnancy. This may differ from the white group, when planning may involve actively stopping contraception at a time when pregnancy was specifically desired.
The Health Education Authority concentrated its campaign on written information, but as levels of literacy in both Syleti, the main language spoken by Bangladeshis in east London, and English are lower amongst Bangladeshi women, this limits the impact of written health promotional material. A government survey in 1984 found that 76% of Bangladeshi women speak English ‘slightly’ or ‘not at all'13 and, as the availability of advocates and translators in East London in primary care is poor, this may reduce opportunistic health promotion further.
Spina bifida is more prevalent in the white population than the Asian population in the UK,14 and the health message may have seemed less relevant to Bangladeshi women; however, 95% of white women claimed to have heard of folic acid compared with 46% in the Bangladeshi group.
Advice on folic acid supplements is often given during antenatal care and, as parity was greater amongst Bangladeshi women, one could expect them to have had more exposure to this particular health message and so greater folic acid supplement use.
This survey lends support to the view that resources and innovative forms of health promotion are needed to ensure that ethnic minority groups have adequate access to health promotion messages.
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Acknowledgments |
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We thank all the midwives and health advocates in the Department of Obstetrics of Tower Hamlets Health Care Trust, particularly Tower Group Midwives, for administrating the survey. SH's post was funded by LIZEI (London Initiative Zone Educational Incentives).
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References |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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1 MRC Vitamin Study Research Group. Prevention of neural tube defects: results of the MRC Vitamin Study. Lancet 1991; 338: 132–137.
2 Expert Advisory Group. Folic Acid and the Prevention of Neural Tube Defects. London: Department of Health, 1992.
3 Wild J, Sutcliffe M, Schorah C, Levene I. Prevention of neural tube defects. Lancet 1997; 350: 30–31.[Web of Science][Medline]
4 McGovern E, Moss H, Grewal G, Taylor A, Bjornsson S, Pell J. Factors affecting the use of folic acid supplements in pregnant women in Glasgow. Br J Gen Pract 1997; 47: 635–637.[Web of Science][Medline]
5 Mathews F, Yudkin P, Neil A. Folates in the periconceptional period: are women getting enough? Br J Obstet Gynaecol 1998; 105: 954–959.[Web of Science][Medline]
6 Carter YH, Lilford RJ. Keeping track of folic acid awareness in UK. Lancet 1996; 348: 818.[Web of Science][Medline]
7 Office of Population Census and Surveys. 1991 Census: Inner London. London: HMSO, 1993.
8 King's Fund Institute. The Health of Londoners. London: King's Fund, 1998.
9 East London and City Health Authorities. 1991 Census Manual. London: Information Unit, 1993.
10 Office of Population Censuses and Surveys. Social Classifications and Coding Methodology. Standard Occupational Classification Volume 3. London: HMSO, 1993.
11 Personal correspondence. Annual Return from Obstetric Database. London: Tower Hamlets Hospitals Trust Maternity Services, 1997.
12 Rudat K. Health and Lifestyles—Black and Minority Ethnic Groups in England. Health Education Authority, 1994.
13 House of Commons Report. Bangladeshis in Britain Volume 1. First Report from the Home Affairs Committee Sessions, 1986–7. London: HMSO.
14
Leck I, Lancashire RJ. Birth prevalence of malformations in members of different ethnic groups and of the offspring of matings between them, in Birmingham, England. J Epidemiol Community Health 1995; 49: 171–179.
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