Presented By:
Shivaun M. Nestor, MA
San Francisco Department of Public Health
Kitty Ha, MPHc
San Jose State University
Disclosure
 The Go Folic! Project was funded by a grant from the
California Vitamin Cases Consumer Settlement Fund
created as a result of an antitrust class action. One of
the purposes of the Fund is to improve the health and
nutrition of California consumers.
Agenda
 Introduction
 Marketing Research: Creating the message
 Social Marketing Campaign Overview
 Evaluation
 Results
 Conclusions
 Implications
What is GO FOLIC?
 In 2008, DPH received funding for the Go Folic! Women’s
Nutrition Project to promote and increase folic acid
supplementation among reproductive-age women (14 to 44) in
San Francisco
 Primary Focus Populations among San Francisco Women:
Adolescents and transition age youth, ages 14-26; 2) AfricanAmericans; 3) Latinas - recently immigrated and earlier
generations; 4) Chinese immigrants - monolingual and English
speaking
 Modeled on the March of Dimes Florida Chapter VitaGrant Project,
which included social marketing and vitamin distribution components
(Lefebvre, R. Craig; June A. Flora (1988)
Introduction
 In 1992, the U.S. Public Health Service recommended that all
women of childbearing age in the U.S. capable of becoming
pregnant consume 400 µg of folic acid daily to reduce their risk
for having a pregnancy affected by NTDs (Morbidity and
Mortality Weekly Report, 1992: 41: 001)
 A 2005 March of Dimes survey found that only one-third of
women of child-bearing age took a multivitamin daily containing
100% of the RDA for folic acid (MMRW, 2005: 54(38): 955)
Introduction, continued
 In 2007, the San Francisco Department of Public Family
Planning Program formed a “Pre/Interconception Health
Advisory Group” to develop recommendations for
incorporating preconception health into family planning
 Among the Advisory Group’s primary recommendations
was incorporating distribution of multi-vitamins with 400
µg of folic acid into routine family planning care at DPH
and DPH-funded community clinics
Go Folic! Intervention
Timeline of Project
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Project Year 1 (Jul – Dec 2008)
 Conduct baseline research/assessment to document current clinic activities and staff concerns
 Recruit initial clinics and design clinic intervention
Project Year 1 (Jan – Jun 2009)
 Train clinic staff/initiate clinic distribution program
 Hire marketing firm
 Conduct social marketing research
Project Year 2 (Jul – Dec 2009)
 Design and field test marketing messages
 Hire culturally and linguistically competent outreach staff
 Design and launch marketing campaign
 Expand vitamin distribution to additional clinics/DPH programs
Project Year 2 (Jan 2010-June 2010)
 Conduct mid-project evaluation of both components
 Use findings to hone messages, materials and interventions
Project Year 3 (July 2010-June 2011)
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Continue/expand project activities & final evaluation
Creating the Marketing
Campaign - Concerns
 Cultural considerations- how to respond to a diverse
population in terms of both age and ethnicity/culture
in a linguistically and culturally competent manner
with a small marketing budget
 Previous research finds that younger women do not
relate to pregnancy or neural tube defect prevention
messages, but might respond better to “beauty
messaging” (Lindsey et al, 2007)
Marketing research
 Written surveys (English and Spanish) completed by 64 adult women
(African American, A/PI, Latina and White), ages 21-54, at two community
health events targeting low-income residents
 One-on-one interviews with 14 clients (African American, A/PI and
Latina), ages 13-24, at two clinics serving primarily low-income youth
 Focus groups (recruited @ DPH Clinics and CBOs and via Internet):
 Group 1: 6 African American women, ages 22-54
 Group 2: 10 Latina women, ages 18-44 (conducted in English and
Spanish)
 Group 3: 18 Chinese women between the ages of 18 and 44 (conducted in
Cantonese)
 Group 4: 12 high-school age women (Asian/Pacific Islander, African
American, Latina, white)
Findings – Product & Benefits
 Needed to define “folic acid” – concern with term
 Most younger women had not heard of folic acid
 Older women had only heard of it in context of pregnancy
and not before they conceived
 Concern about side effects
 Preconception health benefits were very important but
shouldn’t be the first message – would “shut out” women who
were not in contemplation phase
 Beauty benefits important for all groups – hair, skin and nails
(some youth were already taking prenatals for this reason)
Findings – Pricing/Features
 Vitamins could be expensive –important to emphasize
that they were available for free
 Taste, size and smell of the pill (all groups)
 Easy accessibility– alternative locations for women
who were not DPH clients; alternative times for
women with rigid work schedules
 Provide alternative for women who didn’t like pills
(African American) – fortified cereal was acceptable
 Labels should be appealing and easy to read
Findings - Promotion
 Short, catchy tag-lines:
 Multi-generational (except for teens)
 Multi-ethnic – no group wanted to be singled out
as “having a problem”
 Women of various sizes and shapes
 No men or celebrities
 Emphasize beauty and general health benefits
 Simple, clear information
 Clear call to action
Messaging: Clinic Intervention
and Social Marketing
 Primary: Folic acid is “good for hair, skin, and nails”
 Secondary: A daily multivitamin is good for your
health
 Third Message: A daily multivitamin with folic acid
helps build a stronger body for future pregnancies and
can help to prevent some serious birth defects
Go Folic! PSA
Locations (resources & findings)
 Posters at public clinics and community centers
 Radio PSAs on KMEL (youth-oriented Hip-Hop & R&B) &
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KDYA (African-American Gospel Station)
Social Marketing– web site, blog, Facebook, MySpace,
Flicker, YouTube, Twitter
Ads - Voter Pamphlets & high school newspapers
News Coverage: KTSF Channel 26 (Chinese) & KDYA
Outreached at health fairs, cultural events, church revivals,
and high school functions
Evaluation
 Surveyed women who received multivitamins and provided
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written agreement to participate in the evaluation process.
Three to six months after women are given free vitamins,
we surveyed their behavior, and knowledge about taking a
daily multivitamin with folic acid.
Surveys were conducted online using SurveyMonkey and
over the phone.
Surveys were available in English, Spanish, and Chinese.
We invited 411 women to participate and 95 responded –
roughly 25%.
Results
 Only 26% of women reported taking a multivitamin before
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being introduced to the project.
Over 89% of women reported that they started to take a
multivitamin after they got free multivitamins through the
project.
Over 60% reported that they started taking a multivitamin
because it was “good for the skin, hair, and nails.”
Over 65% reported that they continue to consistently take a
multivitamin, at the time of the survey.
Only 31% reported that women should start taking folic
acid 3 months before getting pregnant.
Limitations
 Respondents may be biased positively toward the Go
Folic! Project since the evaluation only captured
women who signed up for the project.
 Respondents are not randomly selected, therefore, do
not represent the general population.
 The study was unable to control women’s exposure to
other folic acid messages.
Conclusions
 The majority of women who responded to the survey
did not know about the benefits of folic acid before the
project, which effectively increased women’s
knowledge and intake of folic acid through “beauty
messaging,” patient education, and free multivitamin
distribution.
Implications
 Results suggest that a folic acid vitamin distribution
project that focuses on beauty-related outcomes
increase low-income women’s knowledge and intake of
folic acid
 Upon the results to this study the intervention and
campaign materials have been improved.
References
 Lefebvre, R. Craig; June A. Flora (1988). “March of Dimes Florida Chapter
VitaGrant Project”. “Social marketing and public health intervention.” Health
Education Quarterly (John Wiley & Sons) 15 (3): 300, 301.
 “Centers for Disease Control and Prevention. Recommendations for the use of
folic acid to reduce the number of cases of spina bifida and other neural tube
defects.” Morbidity and Mortality Weekly Report, 1992: 41: 001.
 “Use of dietary supplements containing folic acid among women of
childbearing age — United States, 2005.” MMRW, 2005: 54(38): 955
 Lindsey LL, Hamner HC, Prue CE, et al.(2007) “Understanding optimal
nutrition among women of childbearing age in the United States and Puerto
Rico: employing formative research to lay the foundation for national birth
defect prevention campaigns.” J Health Commun 2007;12:733--57.
 Prue, Cristine E. and Daniel, Katherine Lyon (2006). “Social marketing: planning
before conceiving preconception care.” Matern Child Health J 10:S79–S84
Questions?
Thank you!
Contact Information
Shivaun M. Nestor, MA
San Francisco Department of Public Health
30 Van Ness Avenue
San Francisco, CA. 94102
Telephone: (415) 575-5677
Email: Shivaun.Nestor@sfdph.org