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

Public Health. 2018 Aug:161:83-89. doi: 10.1016/j.puhe.2018.04.009. Epub 2018 Jun 21.


Objectives: Preconception 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 design: A 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.

Methods: Data 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.

Results: Uptake 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.

Conclusions: High 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.

Keywords: Migrant; Myanmar; Neural tube defects; Preconception folic acid; Refugee; Thailand.

MeSH terms

  • Adolescent
  • Adult
  • Clinical Competence
  • Community-Based Participatory Research
  • Dietary Supplements*
  • Female
  • Focus Groups
  • Folic Acid / administration & dosage*
  • Follow-Up Studies
  • Health Personnel
  • Humans
  • Incidence
  • Middle Aged
  • Myanmar / epidemiology
  • Neural Tube Defects / epidemiology
  • Neural Tube Defects / prevention & control*
  • Pregnancy
  • Program Evaluation
  • Refugees / statistics & numerical data*
  • Surveys and Questionnaires
  • Thailand / epidemiology
  • Transients and Migrants / statistics & numerical data*
  • Young Adult


  • Folic Acid