Background:
Neural tube defects (NTDs) are serious birth defects of the brain and spine. Up to 70% of NTDs can be prevented if women consume 400 mcg of folic acid (FA) daily preconceptionally and through the first trimester. Women view health care providers (HCPs) as trusted sources for information.


Objectives:
In 2006, we conducted a qualitative needs assessment among HCPs to identify barriers and facilitators to recommending FA.

Methods:
Eleven focus groups were conducted among HCPs attending four national conferences. Eligible HCPs included physicians, advanced practice nurses, and registered nurses. Groups were segmented into those who “always/usually” recommend FA and those who “occasionally/never” recommend.

Results:
A total of 102 HCPs participated. Most HCPs knew the role, optimal timing, and dose of FA needed for NTD prevention; however some HCPs did not have a thorough understanding of NTDs or FA. Barriers to FA counseling included no incentives to increase preconception counseling and FA's low prioritization during well-woman visits. Factors affecting prioritization included time constraints, differing patient priorities, and competing topics. Providers also mentioned barriers that affected women's ability to comply with the recommendation of FA supplement use. These included limited access to (or poor utilization of) well-woman visits and lack of support, including lifestyle, financial, and social support. HCPs cited several strategies to increase FA use: providing tactical support (electronic medical records, printed checklists, or office champions), printed materials (posters and handouts) and free supplement distribution. Providers also mentioned education initiatives for HCPs, generating buy-in among organizations that influence large populations, and promoting other benefits of FA beyond birth defects prevention.

Conclusion and implications for practice:
Increasing the use of folic acid among childbearing age women will require a multifaceted approach, which includes educating HCPs, developing materials and practice-based aides, promoting FA's other benefits, and utilizing social marketing strategies.