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Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 221-226

Role of pharmacist's counseling on folate compliance

Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia

Date of Submission01-Jun-2020
Date of Decision22-Jul-2020
Date of Acceptance30-Jul-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Tahani S Alenazi
Faculty of Pharmacy, University of Tabuk, Tabuk
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_121_20

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Background: Pregnant women's compliance with a regimen of folate supplementation is an important factor in decreasing incidence of neural tube defects (NTDs). Because effective medication counseling can be used to enhance women's compliance with folate intake, pharmacists can help ensure good pregnancy outcomes by improving women's compliance through such counseling. Objectives: To determine the effect of medication counseling delivered by pharmacists on compliance among pregnant women in Tabuk, Saudi Arabia. Materials and Methods: A cross-sectional analytical study was conducted of 360 pregnant women who attended antenatal care clinics at primary health-care centers in 2018. A well-designed questionnaire was used for data collection. The data were analyzed using descriptive statistics and the Chi-squared test. Results: About half of the study participants began consuming folic acid after becoming pregnant (55.8%) and only 28.6% reported preconceptional intake. The most common reason for noncompliance was forgetfulness (64.40%). Almost two-thirds of women knew the importance of taking folate in pregnancy to prevent NTDs (64.2%). Their main sources of knowledge about folic acid were doctors (35.8%) and pharmacists (25%). A significant association was found between regular folate intake and pharmacist counseling as a source of folate information. Conclusion: Almost half of pregnant women complied with their folate supplementation regimen. However, lower preconceptional intake was observed. Participants' level of awareness of the importance of folic acid supplementation for pregnant women, though adequate, was not sufficient to ensure good pregnancy outcomes. Pharmacists were identified as a valuable source of information about folic acid, with their provision of medication counseling significantly associated with regularity of folate intake.

Keywords: Compliance, counseling, folic acid, pharmacist, pregnancy, Tabuk

How to cite this article:
Prabahar KK, Alenazi TS. Role of pharmacist's counseling on folate compliance. Saudi J Health Sci 2020;9:221-6

How to cite this URL:
Prabahar KK, Alenazi TS. Role of pharmacist's counseling on folate compliance. Saudi J Health Sci [serial online] 2020 [cited 2021 Jun 13];9:221-6. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/221/300286

  Introduction Top

Folic acid supplementation is important during and before pregnancy because of its role in preventing the development of serious birth defects such as neural tube defects (NTDs).[1] Accordingly, the World Health Organization (WHO) advises that all women who are trying to conceive take 0.4 mg of folic acid daily until their 12th week of pregnancy.[2] Folate deficiency is common among pregnant women because of increased placental and fetal demand and can increase the risk of NTDs.[3],[4],[5] Although in 1978 Saudi Arabia adopted a food fortification strategy, NTDs are still prevalent, according to a national cohort study published in 2015.[6],[7]

Noncompliance with folic acid supplements is a significant factor in folate deficiency among pregnant Saudis, chiefly as a result of forgetfulness.[8] Saudi women who have inadequate knowledge about the importance of folic acid are, however, more likely to be noncompliant.[9] Furthermore, women's awareness can be increased by effective delivery of medication counseling.[10]

A previous study has reported that sources of such information range from doctors and nurses to the media, family members, and friends. However, the significance of pharmacist counseling as a source of such information has not yet been ascertained,[11] even though several studies in different countries have examined pharmacists' role in counseling women to use folic acid during pregnancy.[12],[13] Despite pharmacist medication counseling's potentially crucial role in improving patient compliance with medication regimens, no study has focused on pharmacists' role in encouraging folic acid compliance among pregnant Saudis.[14]

The primary objective of this study was to investigate the role of pharmacists in proper medication counseling on women's compliance with a folate supplementation regimen in Tabuk, Saudi Arabia. Secondary objectives include assessing compliance with folic acid supplement among pregnant women, identifying factors contributing to noncompliance, with a view to promoting maternal and neonatal health in Tabuk, and assessing pregnant women's knowledge about folic acid's role in preventing congenital defects.

  Materials and Methods Top

For this cross-sectional analytical study, the data were collected for 2 months (June–July 2019) from pregnant women attending antenatal care clinics at primary health-care centers, with the ethical approval of the Research Ethics Committee (UT-68-04-2019). All pregnant women who visited the antenatal care clinics were eligible for inclusion in the study; no exclusion criteria were established. All pregnant women who were willing to participate in the study were asked to sign the informed consent form. Considering that 6,259 pregnant women attended antenatal care clinics in Tabuk in 2017, in establishing our sample size, we took the impact of pharmacist medication counseling to be 50% and the level of significance to be 0.05 (type 1 error), with a confidence interval of 95%, figures that indicated a needed sample size of 360.

We used a questionnaire that was prepared by a researcher and then revised by two physicians. It addressed women's compliance, factors associated with noncompliance, and women's knowledge about the importance of folic acid when evaluating the effect of pharmacists' medication counseling on compliance with a folic acid regimen. The questionnaire's 16 questions were written in simple Arabic and were introduced by a cover letter explaining the study's objectives and assuring participants of confidentiality. The questionnaire was back translated by a bilingual professional. A pilot study was conducted to ensure the questionnaire's validity before beginning data collection. Knowledge about folic acid benefits was defined as possessing sufficient information about folic acid's role in preventing birth defects prevention and knowing that folic acid should be taken before and during the first trimester. Compliance was defined as adherence to the doctor's prescribed regimen of 0.4 mg daily before pregnancy and during the first trimester.[15],[16] To assess compliance, women were asked about their timing of taking folic acid and their number of tablets consumed per day. Based on their responses, their folic acid consumption was described as regular (daily during the prescribed period), irregular (on most days during the prescribed period), rarely, or never.

Study variables were age, education level, job, and number of pregnancies. The outcome variables were participants' answers related to knowledge about and compliance with a folic acid regimen in addition to the effect of a pharmacist's medication counseling. The data were analyzed using the the Statistical Package for the Social Sciences (SPSS) 18.0 statistical suite. Descriptive statistics, including mean, standard deviation, and percentage, was used to describe the study's characteristics. Analytic statistics, including Chi-squared test, was used to test for an association between categorical study and outcome variables. P < 0.05 was considered statistically significant.

  Results Top

The current study was intended to identify the effects of pharmacists' counseling regarding compliance with a folic acid supplementation regimen among pregnant women in Tabuk, Saudi Arabia. All 360 participants answered the questionnaire in full, with no omissions of data. [Table 1] shows the demographics of the study participants. Most women were aged 18–25 years (50.8%), and most had completed a university or postgraduate level of education (32.5% and 32.8%, respectively). Most were homemakers (39.7%), and first-order pregnancies predominated (36.9%). [Table 2] shows participants' level of compliance with their folic acid supplement regimen, with most taking only one tablet daily (80.6%). About half of women began taking folic acid after becoming pregnant (55.8%), and only 28.6% reported preconceptional intake. Regular intake of folic acid was the most commonly identified pattern of behavior (57.2%). Participants' understanding of the importance of folic acid supplementation is shown in [Table 2]; 64.2% of women knew about folic acid's role in preventing NTDs and most agreed on the importance of taking folic acid before pregnancy (70%). [Figure 1] shows obstacle to nonadherence to a folic acid supplement regimen: the most commonly identified reason was forgetfulness (64.4%) followed by lack of knowledge about such a regimen's importance (15.6%). [Table 3] shows participants' sources of knowledge about folic acid; doctors were the predominant source (35.8%) followed by pharmacists (25%). About 52.5% of women reported that their pharmacist gave them information about folic acid supplementation during the dispensing processing, and most (80%) saw pharmacists as playing a role in counseling about folic acid, although (84.7%) indicated that pregnant women in Tabuk need more education about maternal health. [Table 4] shows the association between folic acid intake behavior and the pharmacist role's in medication counseling (P < 0.05), with women who had sources of knowledge about folic acid beyond pharmacists showing more regular intake of folic acid. Accordingly, pharmacists should offer more effective counseling.
Table 1: Sociodemographic characteristics of the participants

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Table 2: Compliance and knowledge evaluation of pregnant women toward folic acid supplement

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Figure 1: Reasons for nonadherence to folic acid supplements

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Table 3: Evaluation of pharmacist's role in the counseling of pregnant women about the importance of folic acid

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Table 4: Association between the folic acid intake and pharmacist role in medication counseling

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  Discussion Top

This study was intended to assess compliance with a folic acid regimen in pregnant women. Almost 55.8% of participants took folic acid during pregnancy, whereas only 28.6% took it before pregnancy. Finding of lower preconceptional intake was consistent with results reported in, Nigeria, Israel, and Nepal.[17],[18],[19] However, we found higher compliance than in AL Riyadh's study, which reported figures of 14.2% and 9.5% during and before pregnancy, respectively.[20] Moreover, a high percentage of compliance with folate consumption was found among pregnant women in a Sudanese study, which found that 92% of women took folate during pregnancy and that more than 50% did so before pregnancy.[21] These differences in outcomes may correspond to differences between the study populations in question. In general, women in Tabuk seemed to show less compliance with folate intake. Our findings indicated that the major contributing causes of noncompliance were forgetfulness and lack of sufficient knowledge, with fear of side effects which was the least common cause. These results are consistent with those of earlier study.[22] However, side effects of taking folate were a major challenge for pregnant women in Egypt, Iran,[23],[24] perhaps because doctors and pharmacists counseled this study's participants in the management of folate side effects. To overcome forgetfulness, as a pharmacist, it is highly encouraged to provide effective patient counseling and written instruction presented simply and attractively. The use of technology to remind patients about their medication regimen is recommended including mobile phone and text message. Pharmacist can further use some adherence aids such as pill reminder charts and alarms.

In the current study, doctors were women's most commonly reported source of knowledge about the importance of folic acid intake, followed by pharmacists, social media, family members, and friends. Similar results were reported in studies in Japan and Korea.[25],[26] In other studies, however, doctors were the only major source of information[27],[28] perhaps because most pregnant women spend long periods with their treating doctor during prenatal care visits. Pharmacists' delivery of counseling on folate's role was higher in this study (52.5%) than in a previous study (26.7%),[29] this is an indication of the improved attitudes toward pharmacists' contribution as providers of medication information. Women's degree of knowledge in the current study was lower than in Western and Asian studies.[30-32] A study in Malaysia,moreover, found that 75% of women had at least heard of or read about folic acid.[33] However, participants' knowledge in this study (64%)was higher than in previously conducted study in Tabuk (54.5%).[34] This indicates pharmacists' delivery of counseling when dispensing folate during this study.

This study's findings indicated a positive effect of pharmacist counseling on compliance, with regular folate intake significantly associated with women who reported their pharmacist as an information source (P < 0.05). So far, as we know, our study is the first to have specifically investigated the practice of pharmacist counseling on compliance with a folate intake regimen among pregnant women in Saudi Arabia. Compared with limited local studies, this study's results support the findings of a study conducted in Jeddah and indicates a significant association between increased folate intake and education given by health-care providers generally.[35] Moreover, they broadly support the findings of other studies in this area by linking pharmacist-delivered counseling with women's knowledge about the importance of folic acid intake.[36],[37]

Because the study sample comprised pregnant women in one city (Tabuk), the study's findings cannot be generalized to all Saudi women. Moreover, the primary care centers are not representative of all antenatal care clinics. Accordingly, further studies are required to address maternal and neonatal health problems in all Saudi cities. Health-care professionals should educate women effectively on the importance of complying with a folate supplementation regimen to avoid serious morbidity.

  Conclusion Top

The findings of this study showed that almost half of pregnant women complied with their folate supplementation regimen. However, most had inadequate preconceptional intake. Participants' level of awareness of the importance of folic acid supplementation for pregnant women, though adequate, was not sufficient to ensure good pregnancy outcomes. Pharmacists were identified as a valuable source of information about folic acid, with their provision of medication counseling significantly associated with regularity of folate intake.


Our sincere gratitude for the administrators and the physicians in antenatal care clinics at primary health-care centers, Tabuk, Saudi Arabia, for permitting to avail the facilities.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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