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An evaluation of Ireland’s water fluoridation policy
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Date
2024
Authors
Cronin, Jodi
Journal Title
Journal ISSN
Volume Title
Publisher
University College Cork
Published Version
Abstract
Introduction
Community water fluoridation (CWF), the controlled addition of fluoride to the water supply, is an approved preventive oral health intervention to reduce the prevalence and severity of dental caries (dental decay). Celebrated for its role in reducing dental caries, it is recognised as one of the ten great public health promotion measures of the 20th century. Today, 60 years since fluoride was first added to the public water supply in Dublin, 71% of the Irish population have access to fluoridated water, emphasising the lasting influence of CWF as a fundamental aspect of public health in Ireland. This thesis aims to comprehensively assess the economic and oral health implications of Ireland’s CWF policy within the context of the nation’s hybrid oral healthcare system. This system, operating in parallel to the main healthcare system, combines public and private service provision, with most individuals paying out-of-pocket fees to independent dental practitioners.
Methods
The thesis explores historical, contextual, and methodological landscapes to provide a comprehensive understanding of the Ireland’s CWF policy and its implications for public health policy. To address the gaps in the evidence relating to CWF in the Irish setting, three studies were undertaken. The first study described in Chapter 6, critically appraises the methodological conduct and reporting quality of economic evaluations (EEs) of CWF. Guided by established principles for reviewing economic evidence, the study assesses the economic evidence using reliable quality appraisal instruments, specifically the Consensus on Health Economic Criteria list (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards statement (CHEERS). Chapter 7, presents an economic evaluation of CWF for schoolchildren, the first formal assessment of its cost-effectiveness in the Irish setting since the adoption of the policy in 1964. Following traditional economic evaluation methods and using epidemiological data from a representative sample of schoolchildren with and without lifetime exposure to CWF, a cost-effectiveness analysis (CEA) is performed from the health-payer perspective. The third study, presented in Chapter 8, examines the long-term effects of exposure to the Ireland’s CWF policy on dental caries among adults. The study uses epidemiological, demographic, and sociological data from adult residents of the Republic of Ireland (Ireland) with lifelong exposure to a CWF policy and adults in Northern Ireland without exposure to CWF. Negative binomial regressions are employed to estimate the relative risks of various explanatory variables, including CWF exposure, on dental caries experience among adults.
Results
Collectively, the results of these three studies provide a more comprehensive understanding of the effects of Ireland’s CWF policy on oral health outcomes. Chapter 6, highlights persistent misunderstandings in valuing consequences within cost-benefit analyses of CWF. The study also identifies shortcomings in the measurement and valuation of costs and outcomes across all evaluation types. Moreover, it reveals methodological subtleties that may not be discerned by the quality assessment instruments, such as accurately estimating the impact of fluoridation and the inclusion of treatment savings within cost estimates. This chapter provides valuable insights into the existing economic evidence of CWF, helping policymakers effectively leverage it to inform resource allocation decisions. Additionally, it may serve as a resource for researchers, facilitating improvements in the methodological rigor and reporting standards of future EEs of CWF. In Chapter 7, compelling economic evidence highlights the imperative of maintaining public provision of CWF for schoolchildren despite the current environment of multiple fluoride sources. CWF as a health intervention provides a reduction in the national disease burden and offers cost-savings to the health-payer, which in Ireland, is often the private individual. The findings presented by the analysis in Chapter 8, reveals that adults, exposed to a CWF policy for most of their lives, show a significantly reduced dental caries experience compared to individuals of similar age with no exposure. Furthermore, exposure to the CWF policy emerges as the most influential variable affecting caries outcomes when compared to the other variables examined in the study.
Conclusions
The mandatory legislation surrounding CWF in the Irish context has been instrumental in ensuring widespread access to the benefits of this preventive measure. The findings of this thesis affirm that Ireland’s CWF policy has not only been the cornerstone of its preventive oral healthcare strategy but also a steadfast pillar of the publicly funded oral healthcare service. Despite the challenges posed by a fragmented and underfunded oral healthcare system that has yet to be fully integrated into the broader healthcare agenda, the CWF policy has reliably maintained the population’s oral health since its introduction in 1964. This highlights the policy’s critical role in mitigating the negative impacts of systemic shortcomings while also demonstrating its capacity to drive enhancements in oral health outcomes for all members of the community.
By providing a consistent and accessible source of fluoride through the public water supply (PWS), CWF offers a cost-effective and broad-reaching intervention to improve oral health outcomes. The findings of this thesis emphasise the significance of CWF as a public health measure in reducing the prevalence of dental caries and health inequalities, supporting its continued implementation as a public health strategy.
Description
Keywords
Community water fluoridation , Economic evaluation , Public health , Oral health
Citation
Cronin, J. 2024. An evaluation of Ireland’s water fluoridation policy. PhD Thesis, University College Cork.