Community-Wide Campaigns to Promote the Use of Folic Acid Supplements

 

Social & Behavioral Foundations of Public Health – HPRB 7010

Part I. Community Guide Update and Rationale for Intervention

1. Summarize the recent evidence for or against the intervention strategy in a table. (20 points)

Author & Year	Intervention Setting, Description, and Comparison Group(s)	Study Population Description and Sample Size	Effect Measure (Variables)	Results including Test Statistics and Significance	Follow-up Time
Jiang, B., Ding, C., Yao, G., Yao, C., Zhang, Y., Ge, J., & Qiu, E. (2014).	Adult patients with hyperhomocysteinemiaa in China were divided into a control group and an intervention group, which was given 5mg of folic acid every day.	120 patients with VCIND were randomly selected.	The concentration of folic acid, vitamin B12, and Hey levels were measured three times at 4, 12, and 24 weeks.	Prior to treatment there was no noticeable difference in levels measured in the study. However, after the study the levels of folic acid were significantly higher in the intervention group and levels of Hey decreased. Hey levels for the intervention group (n=60) were 12.13 at 24 weeks and 23.28 for the control group (n=60)	The follow up time was 24 weeks from baseline visit to final evaluation.
de Smit, D. J., Weinreich, S. S., & Cornel, M. C. (2015).	Dutch women visiting the doctor for their youngest child’s 6mo check up with the intention to get pregnant within 12 months. Half of women were instructed on the benefits of folic acid supplement use during pregnancy, while the other half received a normal checkup	198 women were part of the intervention group, while 215 women were part of the control group	Outcome measures included were a woman’s intention to use folic acid supplements in her next pregnancy	The intervention group showed a 65% inclination to use folic acid (n=49) and a 42% inclination in the control group (n=43)	The follow up time frame included the initial study period of 11 months and then a questionnaire response at the conclusion of the trial.
Ashorn, P., Alho, L., Ashorn, U., Yin Bun, C., Dewey, K. G., Harjunmaa, U., & … Maleta, K. (2015).	Women with a healthy pregnancy for greater than 20 weeks in rural Malawi were entered into a randomized control trial. There were three interventions: one of standard care, one of folic acid plus malaria care, and the final consisted of intermittent care.	1391 women visiting 3 Malawi sites were enrolled with an average of 371 women per group.	The three control groups each represented different levels of vitamin supplements, including varying concentration of folic acid. The birth weight of the baby was recorded along with quantitative data regarding the number of tablets not consumed.	The study did not conclusively support the use of folic acid supplementation, but the study also examined vitamin use in general so it is hard to establish folic acid as a singular indicator.	The follow up period extended from the time of entering the study, where women were enrolled at less than 20 weeks gestation, to 6 weeks after delivery of the infant.

 

2. Explicitly state the updated recommendation(s) for the selected strategy(ies). You should have a statement declaring whether the strategy is Strongly Recommended, Recommended, Not Recommended or there is Insufficient Evidence to make a recommendation. (5 points)

The US Public Health Service currently recommends women of childbearing age take a folic acid supplement throughout the years they are most likely to become pregnant in order to reduce birth defects (Preventing, 2004). This recommendation is based off of 16 studies conducted prior to 2004, each with varying results that support folic acid supplementation, but do not present strong enough evidence to strongly recommend the intervention. Therefore, the intervention strategy of folic acid supplements is recommended.

3. Justify your recommendation. Identify whether there were any changes to the recommendations. For example, did you change one of the recommendations from “insufficient evidence” to “recommended”? Explain why or why not based on the evidence. (10 points)

After reviewing three intervention studies of pregnant women’s propensity to take supplements and the health outcome in regards to the health of their newborn infant, I stand behind the previous recommendation as none of the studies presented causative data to upgrade the recommendation; however, no studies presented data that contradicted previous evidence and would lead to a down grade of recommendation status.

The three studies examined represent different types of studies with a self report study, a prospective interview study, and a randomized control trial. The studies presented varying levels of strength of association as the Zheng et al (2016) reported some success, the Smit et al (2015) reported a large degree of success, and the Ashorn et al (2015) portrayed inconclusive evidence. Therefore, with previous studies in mind, the recommendation remains the same due to consistent evidence for the benefit of folic acid supplements both prior to and during pregnancy.

The three studies examined to make this recommendation come from a wide variety of backgrounds, such as racial and geographic diversity. Women in China, the Netherlands, and Malawi each showed improvements in various health outcomes after undergoing folic acid supplementation. The patients in the China trial exhibited significant improvement in their Hcy levels, in which elevated levels contribute to increased symptoms from hyperhomocysteinemia. Women in Malawi who underwent a regiment of vitamin supplements showed some positive health outcomes, but the magnitude was not significant enough to provide conclusive evidence.

The studies examined are similar to previous task force studies examined, as previous task force studies were of rural and urban areas, each represented in the new studies. The task force found a median decrease 4% for neural tube defects, the new studies examined looked at health outcomes when women were supplied the supplements and found the folic acid supplements were beneficial for hyperhomocysteinemia (p<.05). When women were educated in Malawi on how to take the supplements, there was a 65% increase in willingness to take the supplements.

 

Part II. Theoretical Framework/Model

4. Briefly describe in text the theory you selected, including each of the constructs, and why. You may reference evidence from your table above or other sources. (20 points)

 

The Transtheoretical model (TTM) or Stages of Change is an individual level theory that combines elements of many other individual behavioral theories, with a specific emphasis on the propensity of a behavior to be fluid. This theory was chosen in regards to folic acid supplementation of pregnant women because it is a woman’s choice to begin and maintain a supplementation regiment in order to improve the health of the individual and her unborn child. Most women are motivated to begin behaviors that will aid in the development of their child as an evolutionary response to promote the best possible outcomes for their offspring; thus the stages of change model accommodates a woman’s process to begin engaging in behavior such as adding a folic acid supplement.

 

The primary constructs of the TTM include the stages of change that an individual goes through in order to enact a certain behavior. An individual may move through Precontemplation, Contemplation, Preparation, Action, Maintenance, and Termination in a linear fashion or they may cycle through, revert, or skip certain steps. However, in addition to the stages of change there are ten processes of change which are experiential. TTM is comprised of many other theory’s constructs and incorporates thoughts such as external influences, which can change the behavior of the individual.

 

The stages of behavior commence at Precontemplation where the individual is not considering any action and may not be aware of the proposed beneficial behavior. Contemplation follows where the individual may become aware of the behavior, perhaps due to a doctor’s intervention or community wide campaign and this step is typically in the time frame of six months. Following, an individual will prepare to commence the behavior and take the necessary steps to enact the behavior, typically within a month. An individual then moves into the Action stage and begins to physically participate in the behavior. Finally maintenance is achieved after the behavior has lasted five years. A new stage is proposed called Termination where the behavior has occurred long enough that a negative behavior is no longer tempting.

 

A main concept throughout this model is the capacity of steps to regress through relapse or reversion to previous steps. This can be due to an individual no longer valuing the benefits of the behavior or an inability to participate in the behavior.

 

For folic acid supplementation in the Transtheoretical model of change, a woman may enter precontemplation where she is not aware of the importance of folic acid supplementation, then she may move on to contemplation where a doctor has discussed the relevance and possible benefits of beginning a supplementation regimen. Then as she begins to understand and believe in the importance of folic acid, she will move into preparation where she may take the necessary steps to purchase folic acid and have a plan made to take the supplements. Finally, she will enter the action and maintenance stage where she is actively taking the supplements and continuing to take the supplements for an extended period of time.

 

5. Draw a diagram to illustrate your conceptual model, making sure to include an indication of the hypothesized direction of the relation (positive or inverse) between the constructs. You may use plus or minus signs, up and down arrows, or another method as long as it is clear. Do not create a logic model. (15 points)

Part III. Logic Model, Causal and Intervention Hypotheses, and Intervention Strategies

6. Briefly describe the target population and program setting for your intervention. Think about the course materials and discussion of health disparities. Provide evidence for why your target population is a health disparate group. This can include, but is not limited to, description of greater risk or prevalence of disease or risk factors, being in a minority group or low-resource geographic area. Provide citations as appropriate. (5 points)

 

The target population is comprised of women planning to become pregnant in the next 12 months and women in the first trimester of their pregnancy within Athens Clarke County. They may be of any race or socioeconomic status, but due to the general population that comprises Athens Clarke County, they will most likely be of lower socioeconomic status. Approximately 36% of the country is considered impoverished; thus, the women are more likely to lack access to information regarding supplements during pregnancy (US Census, 2010).

 

The program will be implemented within doctor’s offices and clinics that serve impoverished women in the county. Clinics such as Mercy Clinic and Athens Nurses Clinic are the most significant targets, in order to impact the most at risk population.

7. Explicitly state the Intervention Methods for the program, the theory from which they are derived, and a brief description of how they align with that theory. Use the Table template below. (10 points)

 

8. Explicitly state the Intervention Strategies for the program and explain which strategy will be used with each method. Enter this information into the table below. (15 points)

Intervention Method	Alignment with Theory	Intervention Strategy
Physician discusses benefit of folic acid supplements with women planning to become pregnant (Consciousness Raising, Dramatic Relief)	The women may not be aware that folic acid supplements can reduce their child’s potential propensity for fetal malformations. Initially there may be some fear that they have caused irreversible harm by not taking supplements for previous pregnancies, but the doctor can alleviate these concerns and promote new positive behaviors.	Health Education: Doctors and nurses will undergo a training process to ensure they are well informed on the benefits of folic acid and prepared to discuss those benefits with their patients. When women enter the clinic and mention their intention to become pregnant or are pregnant, the doctor should immediately begin to discuss the benefits.
Physician engages in a continued discussion with the women to ensure they understand the benefits and will continue the behavior (Environmental Reevaluation, Self-Reevaluation)	The experiential process dictates that women must become aware that their actions are directly impacting their fetus in a positive or negative manner and then form a new image of themselves in order to ensure the behavior will continue.	Health Communication: As the conversation begins between doctor and patient, the doctor should address the patient’s concerns and show images of the potential harms that can arise without a folic acid supplementation. The doctor should help the patient process the new health addition and ensure it remains in their lifestyle.
Physician supplies folic acid supplements to ensure women have access to necessary supplements (Helping Relationships)	A woman must have a strong positive support system and a physician that is ready to provide her with both emotional support and physically supplying the supplements will provide her with the necessary requisites to continue the supplementation.	Through the program, we will provide supplements to the intervention group randomly selected to receive the supplements.
A physician continues to have contact with the patient after she has her child to ensure she will continue the supplementation if she has another child (Reinforcement Management)	In order for a behavior to enter the maintenance stage, it must be continued for five years and although a woman may not take the supplements continuously for five years, she should be aware of the pressing nature of taking folic acid supplements.	As a woman continues to encounter her physician for the course of five years, the physician should continue to promote the benefits of folic acid supplementation throughout the course of their relationship.

 

9. Provide the logic model for the program as a schematic. (24 points)

Inputs/Resources	Activities	Outputs	Short-term Outcomes	Intermediate Outcomes	Long-term Outcomes
For example, funding sources, space, personnel   Funding: governmental grants to improve community health   Personnel: trainer for the doctors, doctors   Facilities: Access within Mercy Healthcare and Athens Nurses Clinic	This column should include your Intervention Strategies from Table 2.   Train the doctors to appropriately converse with patients and encourage them to change behavior.   The doctor engages in a discussion with the patient and provides incentives to begin taking supplements.   The supplements will be provided to the women to relieve some of the financial stress of purchasing the supplements.	For example, # of brochures or pamphlets distributed, # of educational sessions, # of lay health outreach workers trained     Ideally this program will impact any woman entering the clinics due to it’s low cost. Every doctor and nurse should undergo seminar training that shouldn’t last more than an hour as a one time event.	This should link to your theoretical model. For example, if you selected Theory of Planned Behavior, you should want to change attitudes, subjective norms, and perceived behavioral control in addition to any other short-term outcomes   The women will go through the appropriate stages of behavior to ultimately reach the conclusion that folic acid supplements are beneficial to both their health and their future child’s health.	Your health behavior(s) of interest   The women will begin taking the supplements.   The women will continue taking folic acid supplements through the course of their childbearing years.   (deleted doctor’s awareness)	The mortality, infectious or chronic disease outcomes associated with the health behavior(s) of interest; may also include quality of life indicators   Measurements of neonatal health will reflect the folic acid supplements benefits. In addition the mother will be healthy due to an increased availability of nutrients.

 

10. Explicitly state the causal and intervention hypotheses. You should have an intervention hypothesis linking each item in your activities to one or more short-term outcomes, and a causal hypothesis linking each item in short-term outcomes to at least one intermediate or long-term outcome. (12 points)

Intervention hypothesis example format: [Intervention activities] will lead to increases/decreases/improvements in [health behavior].

Causal hypothesis example format: Increases/Decreases/Improvements in [short-term outcome] will increase/decrease/improve [intermediate or long-term outcome].

 

Intervention hypothesis:

Training the doctor in appropriate ways to converse with the patient will encourage the woman to begin considering folic acid supplementation. The conversation with the woman by a well respected physician will encourage her to pass the pre-contemplation and contemplation stage and move into action.

The presence of an intimate doctor patient conversation regarding the importance of folic acid supplementation lead to increases in the prevalence of folic acid supplementation in women.

The doctor’s conversations will encourage a woman to continue the course of her folic acid supplementation throughout her childbearing years.

Causal hypothesis:

The female’s tendency to consider folic acid supplementation will lead to an increase in females taking folic acid supplements.

Increases in women taking the folic acid supplements will improve the overall health of the mother and child.

The change of mindset from pre-contemplation to contemplation to action, through the stages of change, will encourage an increase in taking folic acid supplements.

 

11. State the SMART outcome objectives for your program. At minimum you should have a SMART objective for each outcome in your short-term outcomes and your health behavior(s) of interest from your logic model. Your SMART outcome objectives should link back to the theoretical construct/behavior/risk factor you want to change with your intervention strategies in Item 8. (10 points)

A woman considers the importance of folic acid supplements and begins the process of adding them to her life.

Objective 1: 75% of the females encountered by a medical professional agree to consider the idea of taking the supplements.

Objective 2: 75% woman can express the importance of taking folic acid supplements while pregnant or attempting to get pregnant.

A woman takes the folic acid supplements regularly until they are no longer necessary.

Objective 1: 75% of women encountered by the medical professionals begin to take the supplements due to their changed thinking which accommodates the importance of taking the supplements.

 

 

Part IV. Evaluation Design and Measures

12. State the major stakeholders of your project, evaluation questions each stakeholder may want answered about the project, and how each group of stakeholders might be affected by the evaluation outcomes? Be sure to consider any individual or group who you list on your Inputs column of your logic model. (16 points)

Stakeholder	Role in Intervention	Evaluation Questions from Stakeholder	Effect on Stakeholder of a Successful Program	Effect on Stakeholder of an Unsuccessful Program
Doctor/Nurse/Physician	Providing appropriate conversations, encouraging women to take folic acid supplements	How will I best serve my patients through this conversation? What will sway the women to believe the folic acid supplements are necessary?	Women will be healthier and have healthier babies, reducing the future burden on healthcare providers	Women and neonate may suffer adverse health effects and require extensive health care
Woman and Child taking folic acid supplements	Taking the supplements	Will the folic acid supplements aid in my health? Will the supplements harm my future child? What is the cost associated with the supplements?	The woman will feel accomplished in aiding in the health of her future child and will experience positive health effects.	The woman may feel discouraged or less self satisfied if she does not complete the program.
Funding sources	Provide funding for training and supplements	Will the addition of these funds contribute to a noticeable change in the health of the community? Will the women actually participate and achieve the purpose the of intervention?	The overall health of the community has been improved with minimal effort and funding required.	The health of the community may be adversely affected and funding may be more difficult to come by
Trainers for doctors	Train physicians to have appropriate conversations	How do I best communicate my knowledge to the physicians in order to allow them to communicate most effectively to their patients?	The women’s health has improved and the training methods are successful.	Their communication methods are lacking and did not provide the proper communication to produce a positive effect.

 

13. Provide the outcome evaluation design(s) name and the scientific notation (Xs and Os). Name the major threats to internal validity for your evaluation, briefly describe why they are a threat, and discuss how your study design or other methods (e.g., incentives) will attenuate these threats. (20 points)

The study will utilize a randomized control trial as this provides the most internal validity and generalizability. There will be three groups, with one serving as a control group and each group evaluated on a pre-test, post-test informational survey.

R O1 X O2 O3 (Intervention group 1)

R 01 X O2 O3 (Intervention group 2)

R O1 O2 O3 (Control group)

[O1 = pre-test, O2 = post-test at 4 months, O3 = post-test at 12 months]

Group 1 will receive both doctor’s advisement and supplements physically handed to them by the doctor. Group 2 will receive a physician advisement with the strong suggestion to take folic acid supplements and a pamphlet of where to purchase them. Finally, the control group will experience a typical doctor’s visit with no mention of folic acid supplementation. Both the pre and post tests will be two part tests with a urine analysis for the presence of folic acid and a self survey indicating whether or not the women took folic acid supplements on a regular basis.

The greatest threat to the study is inherent within the population being studied as many are transients and may not remain in the study for an extended period of time. In addition, some women in the control group may have previously been exposed to the benefits of folic acid supplementation which may skew their tendency to take the supplements. By requiring a test at the beginning of the study, the women are made aware of the primary objective, though this may be hidden by asking a multitude of unrelated questions.

By identifying the threats to internal validity, we are attempting to create a study design that will reduce these threats and increase our ability to draw a relationship between folic acid supplementation and positive health outcomes. A woman’s history with folic acid supplements may negatively influence her propensity to take the supplements, but randomizing the groups should accommodate for the vast majority of these problems. However, the history threat is not entirely relevant in this study due to the two group design. The selection of the groups should be fairly equal and increase internal validity because they are randomly assigned once identified as a candidate for the study. The testing on the groups should be relatively equal as they are both submitting a blood sample at the beginning; although some problems may arise due to the use of questionnaires that require the women to be able to read, though this can be addressed by the physician giving the test aloud.

Mortality and Attrition

Mortality and attrition are both fears when completing a trial with such a transient population group, as many of the women will move or cease visiting their physicians. This cannot be avoided but can be reduced by follow up phone calls. In addition there may be an uneven distribution of drop out rate for the control or intervention group, but a large sample size can help reduce some of this threat to internal validity.

Testing

One threat to internal validity that is present even in a randomized control trial stems from testing the women initially and then testing them throughout the process so they are aware of the purpose of the trial and may mediate their answers to what they believe will placate the physician.

Recall bias

Recall bias is an important threat to validity within this study because the women are asked to recall how often they perceive they took folic acid supplements. This threat is mediated by blood testing for the level of folate in the body.

 

14. You are putting together a survey to answer these outcome evaluation questions. Use the table to describe the variables you will measure and how. Be sure to include information on the validity and reliability of the instruments. You may see reliability reported as test-retest reliability or internal consistency (AKA: Cronbach’s alpha). Validity may be reported as face or content validity or construct validity (e.g., factor loadings). (20 points)

 

Short-term or Intermediate Outcome Variable	Scale, Questionnaire, Assessment Method	Brief Description of Instrument	Example item (for surveys, scales, or questionnaires)	Reliability and/or Validity Description
Thoughts regarding folic acid supplements	University of Rhode Island Change Assessment Scale (DiClement, 2004)	The instrument is used to predict someone’s readiness to change and propensity to engage in the expected behavior.	Do you believe folic acid supplementation is useful to your health or your future child’s health? Does the thought of adding a supplement to your regular diet seem attainable?	Internal consistency and validity of content, criterion, and construct have been done all indicating the test is valid and reliable. A study examining the reliability found internal consistency between .76 and .89 indicating it is valid and reliable (Khali, 2011).
Behavior regarding folic acid supplements	Rapid Dietary assessment (FIT) Folate Intake tool (Hickling, 2005)	A fasting blood serum sample is taken to determine the level of folate in the blood. Folate levels can be measured in blood samples (Hickling, 2005).	Each patient will provide a blood sample before the test begins, at 4 months, and 12 months.	FIT-A r=0.75; FIT-B r=0.68 Both types of measurement were found to be a valid and reliable tool to assess intake of folic acid.

 

 

Part V. Process Evaluation and Data Collection Forms

15. Provide the following data collection forms for monitoring the program process. More than one form may be submitted for a given category, but all forms must be clearly labeled. (18 points)
    1. Recruitment and enrollment – how will you track who you invite to participate in your intervention and who actually takes part?
    2. Attrition – how will you know if participants complete all of the observations (O’s from your study design) and all of the intervention components (from your Outputs column of your logic model)?
    3. Fidelity of the program – how will you know if the intervention was implemented as you had planned? This should match your Outputs column of your logic model.
16. Recruitment and Enrollment

All women planning to become pregnant or in their first trimester of pregnancy encountering a physician at Mercy West or Athen’s Nurses Clinic are invited to participate. The physician will be given a form to track the number of women eligible for the study and the number of women who actually enter the study.

 

Physician Training Form

Dear Physician,

The University of Georgia is partnering with your location of employment to encourage the use of folic acid supplementation. If you are willing to participate please fill out the attached form and sign indicating your willingness.

Name:

Location of Employment:

Contact Information:

Questions:

What do you know about folic acid supplementation?

Are you willing to undergo a training seminar to explain the importance of folic acid and then implement the knowledge in daily conversations with women?

 

Signature ____________________________________

 

 

Doctor’s Form when first engaging with patient

Name:

Willingness to Participate:

Contact Information:

Answers to Questions

Are you planning to become pregnant in the next 12 months?

What do you know about folic acid?

Are you willing to take supplements for an extended period of time?

Do you believe folic acid is beneficial?

 

1. Attrition

The participants will be contacted via phone call at the 3 month and 12 month mark and encouraged to submit a blood sample at the 12 month mark. An excel document will be completed for each participant recording their responses to the initial questionnaire, phone interviews and results for blood tests prior to the start of the trial and at the 12 month mark.

Column1	Column2	Column3	Column4	Column5	Column6	Column7
Name	Date of Birth	Contact Information	3 month participation	12 month participation	Blood Pre-Trial	Blood Post-Trial

 

Physician Training Attrition

The physicians will sign in on an attendance sheet at the training seminar, in order to ensure they receive the proper training and are fully prepared to guide the women through the process of change.

Physician Name	Completed the Training (Y/N)	Comments

 

 

1. Fidelity of the Program

The women will be interviewed at the 3 month and 12 month mark in order to confirm their participation in the program. In addition they will be contacted according to the contact information on the initial forms filled out a year and two years after their entry in the program. The mother will submit a blood sample at the 12 month mark to establish her overall health, as compared to her blood sample prior to entering the program. In addition, the health of her newborn will be recorded via qualitative descriptions and quantitative data from the hospital.

	Woman 1	Woman 2	Woman 3	Woman 4	Woman 5	Etc
Did the women complete the study to the 3 month check?
Did the woman complete the study to the 12 month check?
Did the doctor feel confident the woman was responsive to early conversations?
Did the woman’s blood sample reflect her reported intake of folic acid supplements?
Does the physician believe the woman progressed through the stages of change?
Does the woman feel like the folic acid supplements are beneficial?
Comments and concerns

 

 

Fidelity of Physician Training

The physicians will fill out a form indicating their perception of the training and the impact they believe their conversations had on each woman.

 

Physician name	Do you believe the training was beneficial to your patients?	Do you believe the women completed the program and will take folic acid supplements regularly?	Would you change anything regarding the training to improve it?	Did the training provide accurate and pertinent information to equip you to appropriately converse with your patients?	Additional Comments

 

References:

Ashorn, P., Alho, L., Ashorn, U., Yin Bun, C., Dewey, K. G., Harjunmaa, U., & … Maleta, K. (2015). The impact of lipid-based nutrient supplement provision to pregnant women on newborn size in rural Malawi: a randomized controlled trial. American Journal Of Clinical Nutrition, 101(2), 387-397.

DiClemente, C.C., Schlundt, D., & Gemmell, L. (2004). Readiness and stages of change in addiction treatment. The American Journal on Addictions, 13, 103-119.

de Smit, D. J., Weinreich, S. S., & Cornel, M. C. (2015). Effects of a simple educational intervention in well-baby clinics on women’s knowledge about and intake of folic acid supplements in the periconceptional period: a controlled trial. Public Health Nutrition, 18(6), 1119-1126 8p.

Hickling, S., Knuiman, M., Jamrozik, K., & Hung, J. (2005). A rapid dietary assessment tool to determine intake of folate was developed and validated. Journal of Clinical Epidemiology, 58(8), 802-808.

Jiang, B., Ding, C., Yao, G., Yao, C., Zhang, Y., Ge, J., & Qiu, E. (2014). Intervention effect of folic acid and vitamin B12 on vascular cognitive impairment complicated with hyperhomocysteinemia. Journal Of Medical Biochemistry, 33(2), 169-174.

Khali, M. (2011). Reliability and Confirmatory Factor Analysis of the University of Rhode Island Change Assessment (URICA). Alcohol and Alcoholism. 46 (2) 138-142.

Oluka, O., Shaofa, N., Sun, Y., (2014). Quality Assessment of TPB-Based Questionnaires: A Systematic Review.

Preventing Birth Defects: Community-Wide Campaigns to Promote the Use of Folic Acid Supplements. (2004, June). Retrieved June 07, 2016, from http://www.thecommunityguide.org/birthdefects/community.html

US Census (2010). Demographics. Retrieved from https://athensclarkecounty.com/105/Demographics