This study was conducted to assess awareness of folic acid, awareness of existence of folic acid fortified flour in community, consumption of folic acid-fortified flour, and factors influencing intake among WRA in Ifakara, Morogoro region, Tanzania. Two third of participants reported consumption of folic acid fortified flour despite low awareness of its existence. Being employed, having fewer than five children, and folic acid awareness were independent factors associated with intake. These findings provide a snapshot of the level of folic acid fortified flour intake among WRA after initiation of a fortification program in Ifakara.
Folic acid awareness was low, far less than awareness reported in other studies done in Nepal, Honduras, Europe, USA, and New Zealand where awareness ranged from 40 to 98% [10,11,12,13,14]. Furthermore, our study found that only five (10.1%) respondents who were aware of folic acid knew that folic acid can prevent some birth defects. This is low compared to studies from Europe, New Zealand, and Honduras [12, 14, 15]. The low awareness could be due to the fact that in Tanzania, during antenatal visits folic acid is provided in combination with iron in a formulation known as “FEFO”, typically with health education on the prevention of anaemia alone.
Awareness of folic acid fortified flour was low as well, but higher than a report from a Northern Ugandan study where no woman was aware of existence of fortified foods [16]. The low level of awareness among WRA in Ifakara could be attributed to the fact that the fortification policy is relatively new in Tanzania, having been in practice for only 4 years. The fortification program was officially launched in 2013 involving various local and international actors and stakeholders [17, 18].
In our study, self-reported intake of folic acid fortified flour among WRA was 63.3%. Intake of commercially-produced folic acid fortified wheat flour was higher than folic acid fortified maize flour. This could be explained by the fact that all wheat flour brands available in the council were fortified, widely used for breakfast snacks, and produced by big industries, as opposed to maize flour which is milled by local small-scale millers within the district. Although all small-scale millers are encouraged to fortify maize flour, only a few do. In some parts of Tanzania, including Ifakara, an organization named “SANKU” provides fortification dosifiers, premix, and technical assistance to selected small- or medium-scale mills [19]. Currently there are three small-scale mills in Ifakara under this support. Therefore, we found only a few brands of folic acid fortified maize flour, one of which was predominant in the market. Other maize flour brands were available but not fortified.
This study revealed that employed women were almost two times as likely to have consumed folic acid fortified flour compared to unemployed women. The lower intake by unemployed persons in our study could either be due to low purchasing power that would not allow buying commercial foods, or due to the fact that they use self-produced foods in their home rather than commercial foods. In addition, employed women are more likely to be educated compared to unemployed women [20,21,22] and may be better positioned financially (stable income).
Another independent factor that influenced intake of folic acid fortified flour among WRA in Ifakara was parity (being nulliparous or having fewer than 5 children). This observation was contrary to our expectation, as we thought exposure would be high in multiparous women and would correspond with high intake of folic acid fortified flour. However, nulliparous women might be younger, more educated, and more financially sound than women with many children, and thus likely to consume fortified foods. Also women with fewer children are more likely to have small family size hence more chance of fortified flour intake through ability to manage and feed the small family.
Strength of this study is that it was conducted at the community level, and the relatively large sample size could be representative of the community. The other strength is high response rate.
However, the study had some limitations, including possible recall bias. We attempted to reduce this by collecting information on intake of folic acid-fortified flour within 7 days before the interview. Furthermore the study was cross-sectional whose results can not establish causality. Also respondents in the same cluster may assume similar characteristics which could have overestimated or underestimated intake or associations. This was encountered by adjusting for clustering effect during analysis. The study did not measure quantity of folic acid consumed in fortified flour products.