Folate supplementation to prevent birth abnormalities: evaluating a community-based participatory action plan for refugees and migrant workers on the Thailand-Myanmar border

Abstract

ObjectivesPreconception folic acid (PFA) taken at least 3 months before conception can decrease the incidence of neural tube defects (NTDs) by approximately 46%. NTDs contribute significantly to neonatal morbidity and mortality in migrant and refugee populations on the Thailand-Myanmar border (incidence 1.57/1000 live births). This audit aimed to assess uptake of PFA among migrant and refugee women, evaluate knowledge about PFA among local healthcare workers and implement a participatory community intervention to increase PFA uptake and decrease NTD incidence in this population.Study designA mixed-methods baseline evaluation was followed by an intervention involving health worker education and a community outreach program. A follow-up audit was performed 18 months post-intervention.MethodsData were gathered via surveys, short interviews and focus group discussions. The intervention program included community-based workshops, production and distribution of printed flyers and posters, and outreach to various local organisations.ResultsUptake of PFA was <2% both before and after the intervention. Despite a substantial increase in local healthcare worker knowledge of PFA, no significant improvement in PFA uptake after the intervention was detected. Most pregnancies in this local community sample were reported to be unplanned.ConclusionsHigh rates of NTDs with low PFA uptake remains a major public health challenge in this transient population. Results indicate that improved health worker knowledge alone is not sufficient to enhance PFA uptake in this population. Integration of PFA education within expanded family planning programs and broad-based food fortification may be more effective.

‘Because the baby asks for it’: a mixed-methods study on local perceptions toward nutrition during pregnancy among marginalised migrant women along the Myanmar–Thailand border

“…Pregnant women and midwives posited that women would make improved dietary choices, within their social constraints, if they were provided with appropriate information regarding nutrition. However, the reach of clinic-based care during pregnancy is far from comprehensive in this border region, with limitations in clinic-based programming for maternal nutrition [24,54,55]. Awareness-raising at a community level should be considered to reach younger women whose diets may be tied to the choices of older members of the household.…”

“…However, recent analyses suggest that such lifestyle measures are of modest benefit during pregnancy [34,59,60] and change will likely require policy interventions to improve access to healthy foods along the border to influence pre-conception maternal nutrition [61]. Similar upstream interventions should focus on accessing and educating women prior to conception, as pre-conception care is exceedingly rare in these communities [55]. Such far-reaching public health interventions have the potential to break the intergenerational cycle of malnutrition and poverty.…”

“I can’t read and don’t understand”: Health literacy and health messaging about folic acid for neural tube defect prevention in a migrant population on the Myanmar-Thailand border

“…Evaluation 18 months later showed that preconception folic acid uptake in the community remained less than 2%. Themes derived from FGD included concern that low literacy diminished the impact of written educational materials [28].…”

Research ethics and refugee health: a review of reported considerations and applications in published refugee health literature, 2015-2018

“…Approximately 94% of the included articles reported review of the investigation by an ethics committee. Two (0.7%) stated no review was conducted: one was an audit, and therefore, according to the authors, did not meet the criteria for an ethics review; one was a student's thesis, and according to the authors, ethics approvals were neither required nor sought for student theses at their institution [15,16]. For 15 (5.2%) articles, it was not stated whether an ethics committee reviewed.…”

“…After the investigations, 9% (n = 25) of all of the 288 articles included presented results to participants, 1 No ethics reviews: (1) audit that did not meet the criteria for an ethics review, (2) an ethics review was not required/sought for student thesis [15,16] 2 Two of the unknown ethics reviews could have received an ethics review: (1) stated approval by hospital administration, (2) stated that prior study with same sample population had an ethics review [17,18] 3 Using the list of authors 4 248 (94%) mentioned an ethics review, 14 (5%) unknown, 2 (1%) no review 5 23 (96%) mentioned an ethics review, 1 (4%) unknown 6 Two investigations stated "no" consent was obtained, citing routine screening/clinical care and quality improvement as justifications [19,20] and 3% (n = 9) of all of the articles included presented results to the community. Approximately 13% mentioned post-investigation support to the participants or community (57% of these were postresettlement investigations), and 13% of the 39 interventional investigations provided the intervention to the wider community after the investigation concluded.…”