Universal and targeted policy to achieve health equity: a critical analysis of the example of community water fluoridation cessation in Calgary, Canada in 2011

Community water fluoride cessation and rate of caries-related pediatric dental treatments under general anesthesia in Alberta, Canada

OBJECTIVE

This study examined the rate of caries-related dental treatments under general anesthesia (GA) in fluoridated and non-fluoridated communities in Alberta, Canada, between 2010 and 2019.

METHODS

This retrospective, population-based study included all children ( < 12 years of age) living in Calgary (non-fluoridated) and Edmonton (fluoridated) who underwent caries-related dental treatments under GA at publicly funded facilities. Demographics and dental data were extracted from health administrative databases for three time periods of 2010/11 (pre-cessation), 2014/15, and 2018/19 (post-cessation).

RESULTS

Among 2659 children receiving caries-related treatments under GA, the mean (SD) and median (IQR) age were 4.8 (2.3) and 4 (3-6) years, respectively, and 65% resided in the non-fluoridated area. The analysis revealed that the cessation of water fluoridation was significantly associated with an increased rate of caries-related GA events per 10,000 children in both age groups (0-5 and 6-11 years), with a more pronounced effect in 0-5-year-olds in non-fluoridated areas. The risk of dental treatments under GA was also positively associated with post-cessation time.

CONCLUSION

Discontinuing water fluoridation appears to negatively affect young children's oral health, potentially leading to a significant increase in caries-related dental treatments under GA and oral health disparities in this pediatric population.

Associations between school-based fluoride mouth-rinse program, medical-dental expense subsidy policy, and children's oral health in Japan: an ecological study

BACKGROUND

Dental caries are a common non-communicable disease among children. As a public health measure at the prefectural level, school-based fluoride mouth-rinse (S-FMR) program, medical/dental expense subsidy policies, and other factors may reduce the incidence of dental caries and tooth loss. Prefectures focusing on promoting oral health policies may promote both, but the interaction effect of implementing both subsidy policies and S-FMR at the prefectural level on caries prevention has not yet been examined.

METHODS

We conducted an ecological study using two-wave panel data, prefecture-level aggregated data in Japan for 2016 and 2018. Coefficient and 95% confidence intervals (CI) were calculated for the dependent variables for oral health using mixed-effects linear regression analysis adjusted for possible confounders. Two dependent variables were used; the standardized claim ratio (SCR) of deciduous tooth extraction and 12-year-olds' decayed, missing, or filled permanent teeth (DMFT). Four independent variables were S-FMR, the SCR of dental sealants, prefectural income per person, and subsidy policy in three models: co-payment until children enter elementary school (n = 23), no co-payment until children enter elementary school (n = 7), and co-payment continuing beyond elementary school (n = 17). The effects of six interaction terms, each representing a unique pairing from the four independent variables, were individually calculated.

RESULTS

S-FMR was negatively associated with the SCR of deciduous tooth extractions and DMFT (coefficient = -0.11, 95% CI -0.20; -0.01 and coefficient = -0.003, 95% CI -0.005; -0.001, respectively). No co-payment until children enter elementary school was positively associated with the SCR of deciduous tooth extraction compared to co-payment until children enter elementary school(coefficient = 11.42, 95% CI 3.29; 19.55). SCR of dental sealants was positively associated with the SCR of deciduous tooth extractions (coefficient = 0.12, 95% CI 0.06; 0.19) but negatively associated with DMFT (coefficient = -0.001, 95% CI -0.003; -0.0001). Per capita prefectural income was positively associated with the SCR of deciduous tooth extractions(coefficient = 0.01, 95% CI 0.001; 0.02). No interaction was found between S-FMR and the subsidy policy at both outcomes.

CONCLUSION

High S-FMR utilization and no co-payment until children enter elementary school were associated with fewer deciduous tooth extractions. Also, S-FMR and dental sealant were associated with decreased DMFT.

Transforming Intractable Policy Conflicts: A Qualitative Study Examining the Novel Application of Facilitated Discourse (Track Two Diplomacy) to Community Water Fluoridation in Calgary, Canada

Governments face challenges in resolving complex health and social policy conflicts, such as the community water fluoridation (CWF) impasse in Calgary. Track Two diplomacy, informal dialogues facilitated by an impartial third party, is proposed to address these issues amid epistemic conflict and declining public trust in fellow citizens, science, and government. This study examined Track Two diplomacy's application in Calgary's CWF policy conflict. Collaborating with policymakers and community partners, the research team explored a Track Two-CWF process and conducted 21 semi-structured interviews with policymakers, scholars, practitioners, observers, and civil society representatives. Data interpretation explored contextual factors, conflict transformation potential, and design features for a Track Two process. A conflict map revealed factors contributing to impasse: the polarizing nature of a binary policy question on fluoridation; disciplinary silos; failed public engagement; societal populism; societal lack of disposition to dialogue; individual factors (adverse impact of conflict on stakeholders, adherence to extreme positions, issue fatigue, apathy, and lack of humility); together with policy-making factors (perceived lack of leadership, lack of forum to dialogue, polarization and silos). Participants suggested reframing the issue as nonbinary, involving a skilled facilitator, convening academics, and considering multiple dialogue tracks for a Track Two process. The first theory of change would focus on personal attitudes, relationships, and culture. Participants expressed cautious optimism about Track Two diplomacy's potential. Track Two diplomacy offers a promising approach to reframe intractable public health policy conflicts by moving stakeholders from adversarial positions to jointly assessing and solving problems. Further empirical evidence is needed to test the suggested process.

Exploring what progress is being made in the development of health promotion material for vascular dementia: A systematic review of the evidence

A systematic review conducted by Price and Keady (Journal of Nursing and Healthcare of Chronic Illness, 2, 88 and 2010) demonstrated that there was a dearth of health-promoting literature available for people diagnosed with vascular dementia. The correlation between health behavior and the onset of cardiovascular change that can lead to vascular dementia had demonstrated a need for health education and health-promoting information to be made accessible to vulnerable populations to ameliorate the risk of cognitive decline because of cardiovascular disease. Dementia is a progressive and life-limiting condition and with limited treatment options and a lack of progress in identifying a way to delay onset or even cure the condition. Focus must be targeted towards risk reduction strategies that serve to reduce onset and decline and limit the global burden on not only the individual with the condition and their carers but also to the health and social care economy. To identify the progress that has been made in developing health-promoting literature and patient education guidance since 2010 a systematic literature review was undertaken. Using thematic analysis, CINAHL, MEDLINE, and psych INFO databases were accessed and following PRISMA guidelines an inclusion and exclusion criteria was developed in order to locate peer-reviewed articles. Titles and abstracts were reviewed to identify a match with key terms, and from 133 screened abstracts eight studies met the inclusion requirements. From the eight studies, thematic analysis was implemented to identify shared understanding of experiences relating to health promotion in vascular dementia. The methodology for the study was replicated from the authors' previous systematic review in 2010. Five key themes were identified in the literature (Healthy heart healthy brain; Risk factors; Risk reduction/modification; Interventions; Absence of targeted health promotion). From what little evidence was available to review the thematic analysis has demonstrated developments in knowledge into the link between the onset of cognitive impairment and vascular dementia because of compromised cardiovascular health. Modifying health behavior has become essential in ameliorating the risk of vascular cognitive decline. With these developments the synthesis of the literature demonstrates that even with these insights there continues to be a lack of targeted material that individuals can access to understand the link between cardiovascular health and cognitive decline. It is recognized that maximizing cardiovascular health has the potential to lessen the risk of vascular cognitive impairment and vascular dementia developing and progressing yet targeted health promoting material remains lacking. With the developments in understanding the causal links between poor cardiovascular health, vascular cognitive impairment, and vascular dementia progress now needs to be made in developing targeted health promotion material for individuals to access to share this knowledge to reduce the potential onset and subsequent burden of dementia.

Fluoridation cessation and oral health equity: a 7-year post-cessation study of Grade 2 schoolchildren in Alberta, Canada

OBJECTIVE

Community water fluoridation, because of its universal scope and passive mechanism of uptake, is one component of a multifaceted approach to promoting equity in dental health. The objective of this study was to examine social inequities in children's dental health in the Canadian cities of Calgary (fluoridation cessation in 2011) and Edmonton (still fluoridated).

METHODS

We analyzed data from surveys of population-based samples of Grade 2 (approx. age 7) children in Calgary in 2009/2010 (pre-cessation; n=557) and in both Calgary and Edmonton in 2013/2014 (Calgary, n=3230; Edmonton, n=2304) and 2018/2019 (Calgary, n=2649; Edmonton, n=2600) (post-cessation). We estimated associations between several socioeconomic indicators and dental caries indicators (i.e., dental caries experience [deft, DMFT] and untreated decay in two or more teeth [untreated decay]) using zero-inflated Poisson, binary logistic regression, and the concentration index of inequality. We compared those associations over time (between survey waves) and between cities at post-cessation.

RESULTS

Persistent social inequities in deft and untreated decay were evident; for example, having no dental insurance was significantly associated with higher odds of untreated decay across city and survey wave. In most (but not all) cases, differences between cities and survey waves were consistent with an adverse effect of fluoridation cessation on dental health inequities. For example, the association between no dental insurance and higher odds of untreated decay in Calgary was greater in 2018/2019 (later post-cessation) than in 2009/2010 (pre-cessation; odds ratio [OR] for comparison of coefficients = 1.89 [1.36-2.63], p<0.001) and 2013/2014 (early post-cessation; OR for comparison of coefficients = 1.67 [1.22-2.28], p=0.001); that same association in 2018/2019 was greater in Calgary (fluoridation cessation) than in Edmonton (still fluoridated) (OR for comparison of coefficients = 1.44 [1.03-2.02], p=0.033).

CONCLUSION

Social inequities in dental caries were present in both Calgary and Edmonton. Those inequities tended to be worse in Calgary where fluoridation was ceased. Our findings may be relevant to other settings where income inequality is high, dental services are costly, and dental public health infrastructure is limited.

The Impact of Water Fluoridation on Medicaid-Eligible Children and Adolescents in Alaska

Juneau, Alaska, ceased community water fluoridation (CWF) in 2007, and previous research found a substantial increase in dental caries-related procedures and treatment costs for children from low-income families in Juneau between 2003 and 2012. We collected comparable dental caries-related procedures and treatment cost data for the same years for children in Anchorage, Alaska, where CWF has been continuously maintained. This retrospective study analyzed all Medicaid dental claims records in two separate years for caries-related procedures and associated costs among children (aged 0 to 18 years) residing in Anchorage's 99502 zip code and compared these records to data from Juneau. We obtained descriptive statistics and conducted bivariate analyses and binomial logistic regression. Between 2003 and 2012, children in Anchorage experienced a nonsignificant modest decrease in the mean number of caries-related procedures and only small, statistically nonsignificant changes to the mean inflation-adjusted service costs of caries-related restorative care. The lack of significant change in child dental caries-related procedures and treatment costs in Anchorage between 2003 and 2012 contrasted with the substantial increase in caries-related procedures and treatment costs over the same period in Juneau. Our results are consistent with previous research that has demonstrated a significant protective effect of CWF against dental caries.

A Qualitative Exploration of Indicators of Health Equity Embeddedness Among Public Health Policy Advocacy Campaigns

There are socioeconomic and racial/ethnic health disparities that warrant policy change to advance health equity. The purpose of this qualitative study was to elucidate primary activities and/or tangible characteristics that indicate that a policy advocacy campaign has an embedded health equity focus. Researchers interviewed policy advocacy experts (n = 13) and campaign leaders (n = 9), transcribed audio recordings of interviews, and conducted a thematic analysis to examine health-equity-related processes within policy campaigns. Based on experiences of policy advocacy experts and campaign leaders, mostly within the Voices for Healthy Kids initiative, several objective aspects and activities were identified that indicate that a policy campaign, and the coalition that conducts the campaign, has an embedded health equity focus. It should be stressed that these activities are not intended to represent the extent of all campaign activities, only the subset of activities and aspects of a campaign that indicate a health equity orientation. Broadly, aspects identified were related to what had the campaign done to engage with the community, who in the community was providing input about direction of the campaign, and how had that community input been used. Authentic Community engagement was seen as the foundation of a campaign's health equity focus. A model synthesizing these findings is included in the results. A major strength of this study is that factors associated with health equity in campaign functioning are not typically assessed. These findings support identification of associated constructs to inform measurement development, and can help guide organizations, campaigns, and researchers working to advance health equity.

Why public health matters today and tomorrow: the role of applied public health research

Public health is critical to a healthy, fair, and sustainable society. Realizing this vision requires imagining a public health community that can maintain its foundational core while adapting and responding to contemporary imperatives such as entrenched inequities and ecological degradation. In this commentary, we reflect on what tomorrow's public health might look like, from the point of view of our collective experiences as researchers in Canada who are part of an Applied Public Health Chairs program designed to support "innovative population health research that improves health equity for citizens in Canada and around the world." We view applied public health research as sitting at the intersection of core principles for population and public health: namely sustainability, equity, and effectiveness. We further identify three attributes of a robust applied public health research community that we argue are necessary to permit contribution to those principles: researcher autonomy, sustained intersectoral research capacity, and a critical perspective on the research-practice-policy interface. Our intention is to catalyze further discussion and debate about why and how public health matters today and tomorrow, and the role of applied public health research therein.

In defense of a population-level approach to prevention: why public health matters today

A focus on populations, and a corresponding population-level approach to intervention, is a foundation of public health and is one reason why public health matters today. Yet, there are indications that this foundation is being challenged. In some policy and practice domains, and alongside growing concern about the social determinants of health and health equity, there has been a shift from a population-level or universal approach to intervention, to a targeted approach focusing on those experiencing social or economic vulnerability. More than 30 years ago, Geoffrey Rose articulated strengths and limitations of population-level and high-risk approaches to prevention. In light of a strong analogy between "high risk" and "targeted" approaches, it seems timely, in a forum on why public health matters today, to revisit Rose's points. Focusing on points of overlap between strengths and limitations of the two approaches as described in public health (population-level; high-risk) and social policy (universal; targeted), I illustrate strengths of a population-level approach from the point of view of health equity. Although different circumstances call for different intervention approaches, recent discourse about the weakening of public health suggests that there is value in discussing foundations of the field, such as the population-level approach, that we as a community may wish to defend.

Sociodemographic Variation in Consumption Patterns of Sustainable and Nutritious Seafood in Australia

National dietary guidelines (DGs) consistently recommend consuming seafood for health benefits, however, the sustainability of increasing seafood consumption is often challenged. Seafood products vary in environmental performance as well as health benefits, yet there is no information integrating the health and ecological impacts of different seafood choices. The first step in optimising improved health and environmental outcomes is to examine more closely the types of seafood being consumed at population and individual levels, to develop the means to increase the intake of seafood that is optimal for human health and the environment. The purpose of this analysis was to better understand the specific types and amounts of seafood consumed by the Australian population, and by socioeconomic subgroups within the population, to determine the relative nutritional content and sustainability of seafood consumed by these groups. Secondary analysis of the Australian Health Survey (AHS) (2011-2013), which reached 32,000 people (25,000 households) was undertaken. The majority of respondents (83%) did not consume any seafood on the day of the survey. Results indicated the proportion of seafood consumers was lowest among adults who were unemployed, had the least education and were the most socio-economically disadvantaged. Crustaceans and farmed fish with low omega 3-content, such as basa and tilapia, were identified as the least nutritious and least sustainable seafood categories. These two categories constituted a substantial amount of total seafood intake for the lowest socio-economic consumers, and over 50% for unemployed consumers. In contrast, consumers in the highest socio-demographic group consumed mainly high trophic level fish (moderate nutrition and sustainability) and farmed fish with high omega-3 content (high nutrition, moderate sustainability). Fewer than 1% of adults or children reported eating seafood identified as both more nutritious and less resource intensive, such as small pelagics or molluscs. Opportunities exist to increase seafood intakes to improve health outcomes by varying current seafood consumption patterns to maximise nutritional outcomes and minimise environmental impacts. Initiatives to promote the health and environmental benefits of seafood should be promoted at the population level, with targeted interventions for specific groups, and should encourage consumption of highly nutritious low resource intensive types of seafood.