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Original Research (Original Article) 


Amira Ahmed Nemri et al, 2019;3(1):060–066.

International Journal of Medicine in Developing Countries

Folate deficiency knowledge and use of folic acid among women of childbearing age in the Kingdom of Saudi Arabia: a population-based cross-sectional study

Amira Ahmed Nemri1*, Shahd Al Aslany1, Orjwan Abulaban1, Ghaidaa Sindi1, Shahad Zuhairy1, Raoom Farsi1, Salma Ayman Almosallam1, Osama Yousof Safdar2

Correspondence to: Amira Ahmed Nemri

*King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

Email: a.nemri [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 19 November 2018 | Accepted: 11 December 2018


ABSTRACT

Background:

Folic acid deficiency is one of the most common deficiencies among women of childbearing age. This deficiency can lead to neural tube defects, which are fatal for infants. This study was done to assess the knowledge of folate deficiency and use of folic acid among women of childbearing age in the Kingdom of Saudi Arabia.


Methodology:

A population-based cross-sectional study was carried out among 1,458 women aged 18–60 years in the 32 Kingdom of Saudi Arabia (population: 28,160,273). A questionnaire survey was conducted to evaluate awareness about folic acid.


Results:

In total, 64.1% of women used folic acid, 27.9% of women did not use it, and the remaining 8% did not remember using it. High willingness (84.2%) to use folic acid was reported. Women were very aware of defects and the major sources of information about folic acid were from gynecology clinics (62.1%) and electronic media (31%). No significant differences (p-value = 0.023) were reported among women of different regions. However, educational level and occupation were related to significantly improve awareness. Material status and presence of pregnancy also affected the level of awareness.


Conclusion:

The findings indicate the importance of improving the awareness level of the importance of folic acid supplementation among women of childbearing age in Saudi Arabia. Promoting the advantage of taking folic acid during the ideal time to reduce incidents of neural tube defects through proper education provided to women by health-care providers is suggested.


Keywords:

Folate deficiency, knowledge, folic acid, women of childbearing age, Saudi Arabia.

Introduction

Folic acid deficiency is one of the most common vitamin deficiencies among childbearing-aged women [1]. It can lead to neural tube defects (NTD), which are a major cause of serious disabilities and mortality among the infant population. Related disabilities include anencephaly, spina bifida, and encephalocele [2].

The onset of NTD is very early (prenatal). Therefore, the best medical solution is to prevent it [3]. Studies showed that up to 50% of NTD cases can be prevented by using folic acid containing supplements [2]. The absorption of folic acid-containing foods, such as broccoli, spinach, and lettuce and some fruits (oranges, bananas) in the body is very low. In addition, because damage happens before most women know that they are pregnant, the World Health Organization (WHO) recommends that all women planning to become pregnant take at least 400 mcg of supplemental synthetic folic acid daily, in addition to eating a folate-rich diet, from 3 months before conception up to 12 weeks of gestation [1,4].

Many studies have shown a high prevalence of NTD in the Kingdom of Saudi Arabia [5]. Moreover, insufficient research has been conducted on awareness and intake of folic acid in childbearing-aged women in Arabian countries. Thus, the aim of this study was to determine the level of knowledge in this population about folic acid and its impact on reducing birth defects. The significance of this research is the possible potential results that can lead to interventions to increase folic acid intake and increase awareness of folic acid use.

Subjects and Methods

This cross-sectional study was conducted in August 2017. We enrolled 1,458 women aged 18–60 years in Saudi Arabia (population: 28,160,273). Women who were 18–60 years old, women who did not have children and planned to become pregnant, and women who had children were included in this study. Participation in the survey was voluntary through a link shared on social media. Electronic format consent was signed before participation.

The questionnaire focused on folic acid awareness and was developed with reference to previous studies [68]. It was a closed-ended questionnaire, which consisted of four categories: sociodemographic data (age, region, educational level, occupation, marital status, gravity, and parity), knowledge about folic acid, folic acid deficiency symptoms, and prevention of congenital anomalies that are associated with improper intake of folic acid during pregnancy.

Assessment of the level of knowledge about folic acid included questions asking about folic acid intake, its source, and its requirement. Awareness of the role of folic acid in the prevention of congenital anomalies (i.e., NTD) was assessed by asking about the dosage and the proper period to start folic acid supplements intake. Proper intake of folic acid was defined as taking the supplement 12 weeks before conception and continuing to use it during the first 12 weeks after conception. Improper intake was defined as taking it after conception only. The questions regarding knowledge of folic acid, symptoms of folic acid deficiency, and prevention of NTD required the respondents to choose as many answers as they thought were correct from five options. The options included two correct answers, two incorrect answers, and “I do not know.”

Data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS) version 16. Variables such as age, education, knowledge, attitudes, and practices were presented in the form of frequencies and percentages. ANOVA and independent t-test were used to compare awareness scores in different groups. P-value of <0.05 was considered significant.

Results

Table 1 showed the demographic data for the study participants. Table 2 showed usage and detailed answers regarding questions related to folic acid. Correct answers reflecting an awareness of participants were marked with an asterisk (*). The percentage of women who used folic acid was 64.1%.

Table 3 showed awareness regarding folic acid. Participants’ scores ranged from 0 to 15, and the mean ± SD was 7.7 ± 3.4. The percentage of participants who were aware of folic acid was 54.3%. ANOVA and independent t-test were used to compare awareness scores in different groups, as shown in Table 4. Awareness scores were significantly different between the different age groups (p-value < 0.001), as shown in Figure 1. The highest mean score was in the group aged 31–50 years (8.3 ± 3.3) and the lowest was in the group of less than 20 years old (6.1 ± 3.4). There was no significant difference in scores between participants from different regions of the Kingdom of Saudi Arabia (p-value = 0.23), as shown in Table 5 and Figure 2.

Table 1. Demographic data.

Demographic data N %
Age
<20 78 5.3
20–30 711 48.8
31–50 594 40.7
>50 75 5.1
Region
Western Region 1,001 68.7
The northern area 64 4.4
Central Region 191 13.1
Southern area 114 7.8
Eastern Province 88 6
Education
Less than high school 36 2.5
High school. 230 15.8
University 973 66.7
Advanced studies 219 15
Occupation
Student 371 25.4
Governmental job 398 27.3
Job in the private sector 164 11.2
Not employed 525 36
Marital status
Married 972 66.7
Unmarried 485 33.3
Pregnant
Yes 166 11.4
No 1146 78.6
I plan to be pregnant 146 10
Do you have children
Yes 843 57.8
No 615 42.2

Table 2. Usage and detailed answers to questions about folic acid.

Answers N %
Have you ever had taken folic acid supplements
Yes 935 64.1
No 407 27.9
I do not remember 116 8
What is folic acid?
One of the minerals 611 41.9
An alternative to Vitamin C-C 119 8.2
Alternative to Vitamin E 152 10.4
One of the B vitamins* 576 39.5
How many times are you supposed to take your folic acid supplement?
Every day* 1,060 72.7
5–6 times a week 106 7.3
4–5 times a week 108 7.4
3–4 times a week 58 4
2–3 times a week 77 5.3
Once a week 33 2.3
Much less than once a week 16 1.1
The best way to get enough folic acid is to
Eat vegetables and fruits* 939 64.4
Eat meat and liver* 705 48.4
Eat rice and pasta* 220 15.1
Take the daily dose as tablets—tablets* 1143 78.4
Folic acid deficiency can lead to
Spina bifida—defects of the neural tube* 790 54.2
Folic acid deficiency anemia* 880 60.4
Cleft lip and cleft palate* 472 32.4
Folic acid anemia can lead to:
Tongue cracking* 418 28.7
Weak hair and skin* 843 57.8
Poor appetite and fatigue* 788 54
When should folic acid be used to reduce the incidence of congenital malformations?
Three months before conception and during the first 3 months of pregnancy* 1,059 72.6
During the first 3 months of pregnancy 272 18.7
During the second trimester of pregnancy 104 7.1
During the third trimester of pregnancy 23 1.6
The required amount of folic acid is
400 µg daily* 343 23.5
400 mg daily 721 49.5
40 g daily 394 27
If you are married or after you get married, will you use folic acid?
Sure because I believe in its importance. 1228 84.2
Yes. For precaution, even if not convinced of its importance 123 8.4
No. Because many did not use it and gave birth to healthy children. Those are the fate of 107 7.3
Have you ever heard of spina bifida or neural tube defects?
No 972 66.7
Yes 486 33.3
Do you have children with a cleft lip or neural tube defects?
No 1,446 99.2
Yes 12 0.8
If you answered yes, how many of your children have a cleft palate or neural tube defects
1 10 83.3
2 2 16.7
Sources of information
Obstetrics and Gynecology 906 62.1
Primary care physician/general practitioner 139 9.5
I read about it in a magazine/newspaper 295 20.2
I saw something on the Internet or TV 452 31
I cannot remember 307 21.1

Table 3. Awareness of the participants in the study.

Awareness
N %
Not aware 666 45.7
Aware 792 54.3
Total 1,458 100
Range 0–15
Mean ± SD 7.661 ± 3.393

There was a significant difference in scores of those with different educational levels (p-value = 0.013), as shown in Figure 3. In addition, awareness scores were significantly different between those with different occupations (p-value < 0.001), as shown in Figure 4. Women who were employed in the government sector were found to be more aware of folic acid than the employees of the private sector. There was a significant difference in scores of those with different marital status (p-value < 0.001), and those pregnant versus not (p-value = 0.011), as shown in Figure 5. Married women scored higher (8.1 ± 3.2) than unmarried women (6.7 ± 3.6) and pregnant women scored higher (8.2 ± 2.8) than non-pregnant women (7.5 ± 4.4).

Discussion

The appropriate use of folic acid is recommended to prevent NTD during early pregnancy. Therefore, awareness among women about folic acid is essential to ensure safe pregnancy and reduce mortality and morbidity [4]. Even though other similar studies were conducted in certain cities in Saudi Arabia (Jeddah, Hail), the present study was the first to include all regions of the country. This study showed that 45.7% of participants knew about the importance of folic acid use. A similar study carried out among pregnant Croatian women revealed that 72% of women were aware of the role of folic acid [9]. Other studies carried out among different countries reported different levels of awareness about folic acid among women in recent years: 60% (Lebanon), 77% (South Australia), 62.4% (Egypt), 91.0% (Hail region of Saudi Arabia), 91.8% (Jeddah, Saudi Arabia), 98% (London), 73% (Benghazi, Libya), 53.7% (Qatar), and 70% (Europe) [4,7,8,1015]. These studies showed an increase in awareness level about folic acid due to campaigns and planned conception. In this study, women aged between 31 and 50 years and women in the southern region had more knowledge about the benefit of folic acid as compared with other age groups and regions. In one study carried out in the Hail region of Saudi Arabia, the highest awareness was observed among the age group of 26–35 [13]. A study carried out in Egypt also reported high awareness about folic acid among women aged 25–45 years [12]. Moreover, a study conducted in Ireland among young women aged less than 22 years demonstrated a higher awareness level [10]. The present results were in accordance with the above findings and points at age as a significant factor that influences awareness of folic acid.

While educational level has also been shown to relate with awareness [9], one study showed that awareness level was not significantly different in women who had formal versus basic education, indicating that along with formal education, public health education was also necessary to increase awareness [14]. In this study, women who were employed in the government sector were more aware of folic acid, whereas employees of the private sector were less aware of it. The reason for this is yet to be uncovered and further research is required. Employment status affects awareness level and it was reported that women who were employed and were professionals showed high awareness [7]. However, employment has less effect as compared to the educational level and number of pregnancies [12].

Table 4. Comparison of awareness scores among different groups.

Demographic data N Awareness F or T ANOVA or T-test
Mean ± SD Test value P-value
Age <20 78 6.077 ± 3.407 F 15.465 <0.001*
20–30 711 7.364 ± 3.367
31–50 594 8.295 ± 3.273
>50 75 7.120 ± 3.605
Region Western Region 1001 7.665 ± 3.401 F 1.400 0.232
The northern area 64 7.531 ± 3.920
Central Region 191 7.262 ± 3.403
Southern area 114 8.061 ± 3.194
Eastern Province 88 8.068 ± 3.081
Education Less than high school 36 5.889 ± 4.180 F 3.590 0.013*
High school. 230 7.543 ± 3.294
University 973 7.738 ± 3.413
Advanced studies 219 7.740 ± 3.201
Occupation Student 371 7.235 ± 3.356 F 11.215 <0.001*
Governmental job 398 8.430 ± 3.176
Job in the private sector 164 6.988 ± 3.704
Not employed 525 7.592 ± 3.381
Marital status Married 972 8.123 ± 3.199 T 7.502 <0.001*
Unmarried 485 6.734 ± 3.582
Pregnant Yes 166 8.247 ± 2.827 T 2.532 0.011*
No 1146 7.538 ± 3.445

Figure 1. Awareness scores in different age groups.

Figure 2. Awareness scores in different regions of the Kingdom of Saudi Arabia.

Folic acid awareness was highest among married and pregnant women as compared to unmarried women, attributed to the fact that Saudi Arabian society is conservative regarding premarital sexual activity. Regarding the source of information about folic acid, this study showed that 71.6% of women reported their health care providers as being the main source, consistent with other research [8]. Alternative sources included magazines, newspapers, TV, and social media. Thus, physicians should educate women about folic acid during their visits for prenatal and antenatal care, as well as during child vaccinations as suggested by Ali et al. [16]. Another strategy to increase the intake of folic acid is through the use of folate-fortified food. For example, the prevalence of NTD affected pregnancies was reduced after mandatory fortification of flour with folic acid in both Canada and the United States, which was shown to be the most effective public health intervention for NTD in 1998 [17].

This study was limited to people that could be reached by online questionnaire, thus excluding women who did not receive the link or did not have access to the Internet. The lack of credibility may be considered as a limitation as well. In addition, bias might be found in results comparing regions as the sample size, which differed from one region to another.

Table 5. Awareness level of folic acid in different geographical regions among women.

Year of Publication Authors Country Study type Sample Size Level of folate awareness (%)
2006 Gjergja et al. Croatia Population based 569 72
2006 Bener et al. Qatar cross-sectional 1480 53.7
2007 Chan et al. Australia Population based 730 77
2009 deRosset et al. USA (among Hispanic women North Carolina a) Cross-sectional 896 54
2012 Claudine Nasr Hage Lebanon Cross-sectional 600 60
2013 Al-Holy et al. Hail Region of Saudi Arabia Population based 300 91.0
2013 Bitzer et al. European Union (Austria ) Population based 22,925 70
2014 Maher and Keriakos UK Cross-sectional 603 98
2014 Al-Darzi et al. Egypt cross-sectional 660 62.4
2014 Liu et al. China Cross-sectional 1736 85–92
2016 Bukhari et al. Jeddah, Saudi Arabia cross sectional 501 91.8
2016 Cawley et al. Ireland (Dublin) Population based 587 96
2017 Kim et al Korea cross-sectional 439 65.6
2017 Abdulmalek Benghazi, Libya cross-sectional 131 73

Figure 3. Awareness scores for different educational levels.

Figure 4. Awareness scores for different occupations.

Figure 5. Awareness scores by marital and pregnancy status.

Conclusion

In conclusion, the findings indicate the importance of improving the awareness level of the importance of folic acid supplementation among women of childbearing age in Saudi Arabia. It is suggested to promote the advantage of taking folic acid during the ideal time to reduce incidents of NTD through proper education provided to women by health-care providers. The need for short-term education such as campaigns and long-term education such as adjusting the school curriculum to teach about the proper use of folic acid for a safe pregnancy and to encourage consumption of folate-fortified meals among females of childbearing age is also suggested.

Acknowledgment

None.


List of Abbreviations

NTD neural tube defects

WHO World Health Organization


Funding

None.


Declaration of conflicting interests

None.


Consent for publication

Informed consent was obtained from the patients.


Ethical approval

This study was approved by the Institutional Ethics Committee, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.


Author details

Amira Ahmed Nemri1, Shahd Al Aslany1, Orjwan Abulaban1, Ghaidaa Sindi1, Shahad Zuhairy1, Raoom Farsi1, Salma Ayman Almosallam1, Osama Yousof Safdar2

  1. King Abdulaziz University Hospital, Jeddah, Saudi Arabia
  2. Pediatric Nephrologist Center of Excellence, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

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How to Cite this Article
Pubmed Style

Mansour AE, Alsager AH, Alasqah AA, Alsuhaibani AA, Aldughaim AI, Alayed AA, Aljlali AA, Almogbel HA, Aljuraifani IM, Altamimi AS. Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia. IJMDC. 2019; 3(11): 60-65. doi:10.24911/IJMDC.51-1567545145


Web Style

Mansour AE, Alsager AH, Alasqah AA, Alsuhaibani AA, Aldughaim AI, Alayed AA, Aljlali AA, Almogbel HA, Aljuraifani IM, Altamimi AS. Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia. http://www.ijmdc.com/?mno=64061 [Access: November 22, 2019]. doi:10.24911/IJMDC.51-1567545145


AMA (American Medical Association) Style

Mansour AE, Alsager AH, Alasqah AA, Alsuhaibani AA, Aldughaim AI, Alayed AA, Aljlali AA, Almogbel HA, Aljuraifani IM, Altamimi AS. Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia. IJMDC. 2019; 3(11): 60-65. doi:10.24911/IJMDC.51-1567545145



Vancouver/ICMJE Style

Mansour AE, Alsager AH, Alasqah AA, Alsuhaibani AA, Aldughaim AI, Alayed AA, Aljlali AA, Almogbel HA, Aljuraifani IM, Altamimi AS. Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia. IJMDC. (2019), [cited November 22, 2019]; 3(11): 60-65. doi:10.24911/IJMDC.51-1567545145



Harvard Style

Mansour, A. E., Alsager, . A. H., Alasqah, . A. A., Alsuhaibani, . A. A., Aldughaim, . A. I., Alayed, . A. A., Aljlali, . A. A., Almogbel, . H. A., Aljuraifani, . I. M. & Altamimi, . A. S. (2019) Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia. IJMDC, 3 (11), 60-65. doi:10.24911/IJMDC.51-1567545145



Turabian Style

Mansour, Ali E, Ahmad Hamad Alsager, Abdulrahman Abdullah Alasqah, Abdulaziz Abdullah Alsuhaibani, Abdullah Ibrahim Aldughaim, Abdulaziz Abdullah Alayed, Abdulmalik Abdullah Aljlali, Hassan Abdullah Almogbel, Ibrahim Musaad Aljuraifani, and Abdullah Saleh Altamimi. 2019. Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (11), 60-65. doi:10.24911/IJMDC.51-1567545145



Chicago Style

Mansour, Ali E, Ahmad Hamad Alsager, Abdulrahman Abdullah Alasqah, Abdulaziz Abdullah Alsuhaibani, Abdullah Ibrahim Aldughaim, Abdulaziz Abdullah Alayed, Abdulmalik Abdullah Aljlali, Hassan Abdullah Almogbel, Ibrahim Musaad Aljuraifani, and Abdullah Saleh Altamimi. "Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia." International Journal of Medicine in Developing Countries 3 (2019), 60-65. doi:10.24911/IJMDC.51-1567545145



MLA (The Modern Language Association) Style

Mansour, Ali E, Ahmad Hamad Alsager, Abdulrahman Abdullah Alasqah, Abdulaziz Abdullah Alsuhaibani, Abdullah Ibrahim Aldughaim, Abdulaziz Abdullah Alayed, Abdulmalik Abdullah Aljlali, Hassan Abdullah Almogbel, Ibrahim Musaad Aljuraifani, and Abdullah Saleh Altamimi. "Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia." International Journal of Medicine in Developing Countries 3.11 (2019), 60-65. Print. doi:10.24911/IJMDC.51-1567545145



APA (American Psychological Association) Style

Mansour, A. E., Alsager, . A. H., Alasqah, . A. A., Alsuhaibani, . A. A., Aldughaim, . A. I., Alayed, . A. A., Aljlali, . A. A., Almogbel, . H. A., Aljuraifani, . I. M. & Altamimi, . A. S. (2019) Knowledge and practices of primary school teachers about first aid management of minor injuries among children in the Qassim region, Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (11), 60-65. doi:10.24911/IJMDC.51-1567545145