Part I. Community Guide Update and Rationale for Intervention
| 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 |
| This cross-sectional survey used a natural experiment to assess the impact of community water fluoridation. The study used 6, 8, and 11-year-old children in the Cheongju and Seongnam areas. Eleven-year-old children from the Cheongju area had consumed water four years before water fluoridation was discontinued in December 2003. The Cheongju children were of comparable socioeconomic standing as the children of Seongnam, South Korea, who had not consumed fluoridated water. Researchers compared these two groups seven year after stopping water fluoridation in Cheongju, to ascertain if the water fluoridation program had increased resistance to dental caries in early childhood and if resistance to tooth decay would continue after the removal of the community’s water fluoridation program. | There were 125 6-year-olds, 106 8-year-olds, and 104 11-year-olds from Cheongju, where water fluoridation was discontinued. There were 192 6-year-olds, 226 8-year-olds, and 171 11-year-olds from Seongnam, where water fluoridation had never been implemented. | Numbers of filled tooth surfaces were used to assess the tooth decay of the children. The statistical modeling controlled for the confounding effects of sex, monthly family income, diet, and dental care. | The 11-year-old children from Cheongju, where fluoridation was discontinued, retained a protective effect of fluoridation as they had a 0.581 (95% CI 0.450-0.751; p<0.001) lower risk of filled permanent teeth surfaces compared 11-year-olds from Seongnam. Furthermore, 6 year old children in Cheongju, who had been born after water fluoridation stopped, had a 1.158 (95% CI 1.004-1.335; p=0.044) higher risk of filled tooth surfaces compared to 11-year-olds in the same area who had consumed fluoridated water earlier in their childhood. | This study occurred 7 years after stopping water fluoridation in Cheongju, South Korea. | |
| Do, Loc and Spencer, John 2014 | This cross sectional survey examines the impact of water fluoridation in Queensland, Australia before the 2011 fluoridation of all municipal water for the area. It used the Queensland community of Townsville, a fluoridated community, and compared it to Queensland communities without water fluoridation. | There were 2,214 children 5-8 years of age and 3,186 children 9-14 years of age were used in the analysis. These children resided in Queensland, Australia | Study design and analytical modeling controlled for the confounding of socio-demographic and economic status of their family. Effect modification of sugar consumption and was built into their final model. The exposure of interest was community fluoridated water with the outcome being measured tooth decay of the individual children. | After controlling for the confounding effects of SES, children in the community with fluoridated water had a 0.61 (95% CI 0.44-0.82; p<0.05) risk of developing tooth decay in deciduous teeth compared to children who did not live in communities with a water fluoridation program. Furthermore, the children residing in the community with fluoridated water had a 0.60 (95% CI 0.42-0.88; p<0.05) risk of developing tooth decay in permanent teeth compared to children who did not live in communities with a water fluoridation program. | This study compared a Queensland community who had begun water fluoridation in 1965 to the remainder of the Queensland area before their adoption of water fluoridation in 2011. |
| McLaren, Lindsay et al. 2016 |
This longitudinal study examines the impact on childhood caries after Calgary, Canada halted water fluoridation by comparing the number of caries in second grade students before the stoppage of water fluoridation (2009/2010) to that after stopping fluoridation (2013/2014). | This study compared second graders in both the public and catholic school systems in Calgary, Canada. For 2009/2010, 1,108 teeth were examined. For 2013/2014, 6,412 teeth were examined. | Presence of a dental cavity was the outcome of interest and stratified by the child’s dental insurance status. | In 2013/2014, 2nd graders without dental insurance were 1.56 (95% CI 1.05-2.33; p=0.03) higher risk for dental caries than 2nd graders with dental insurance. No statistically significant difference was noted for the 2009/2010 2nd graders. | Followup occurred 4 years after stopping water fluoridation |
In an effort to prevent tooth decay, the Community Preventive Services Task Force currently recommends community water fluoridation. Fluoride, whether coming from tooth paste, mouth rinse, or water, helps stop the weakening effects of enamel demineralization. The Department of Health and Human Services recommends municipal potable water fluoride levels at 0.7 mg/L (Centers for Disease Control and Prevention, 2013).
I have reviewed three studies completed since the Task Force’s recommendation and found that there continues to be strong evidence to make a recommendation for community water fluoridation. I propose community water fluoridation be strongly recommended. This is in line with a body of evidence spanning over 60 years and arguably one of the Centers for Disease Control and Prevention’s (CDC) greatest public health successes.
The CDC states community fluoridation has benefits across all socioeconomic strata (Centers for Disease Control and Prevention, 2013). My literature review went one step further and revealed oral health disparities among children who have dental insurance and those without (McLaren, et al., 2016). The McLaren study took advantage of a natural experiment when the leadership of Calgary, Canada stopped water fluoridation. The researchers examined trends in second grader’s dental caries stratified by having or not having dental insurance. Their findings showed the in 2013/2014, when water fluoridation had stopped, second graders without dental insurance were 1.56 (95% CI 1.05-2.33; p=0.03) higher risk for dental caries than second graders with dental insurance. No statistically significant difference in risk was noted among insured and uninsured second graders when the water was fluoridated in 2009/2010 (McLaren, et al., 2016). This highlights the disproportionate impact discontinuation of water fluoridation has on children without dental insurance, and in turn the financial burden on their families.
The Queensland, Australia study of 2015 compared the risk of tooth decay among 5-8 year old and 9-14 year olds in a Queensland community with longtime water fluoridation to those without fluoridation. This study was conducted in 2011 before the greater area of Queensland enacted water fluoridation in all communities. After controlling for the confounding effects of socio-demographic and economic status, children from the fluoridated community of Townsville had a lower risk of dental decay than those of unfluoridated Queensland communities. Children in the community with fluoridated water had a 0.61 (95% CI 0.44-0.82; p<0.05) risk of developing tooth decay in deciduous teeth compared to children who did not live in communities with a water fluoridation program. Furthermore, the children residing in the community with fluoridated water had a 0.60 (95% CI 0.42-0.88; p<0.05) risk of developing tooth decay in permanent teeth compared to children who did not live in communities with a water fluoridation program (Do & Spencer, 2015). This study highlights the benefits to decreasing the risk of dental caries in communities who enact community water fluoridation.
To underscore the importance of community water fluoridation to caries prevention in children, I reviewed a South Korean study looking into the risk of oral disease among 6, 8, and 11-year-old children who consumed fluoridated water at an early age and then had the community fluoridation program removed for a period of seven years prior to the study (Cho, et al., 2014). This study, like the previously mentioned Canadian study, used a natural experiment to assess the impact of community water fluoridation. Eleven-year-old children from the Cheongju area had consumed water four years before water fluoridation was discontinued in December 2003. The Cheongju children were of comparable socioeconomic standing as the children of Seongnam, South Korea, who had not consumed fluoridated water. Researchers compared these two groups seven year after stopping water fluoridation in Cheongju, to ascertain if the water fluoridation program had increased resistance to dental caries in early childhood and if resistance to tooth decay would continue after the removal of the community’s water fluoridation program. There were 125 6-year-olds, 106 8-year-olds, and 104 11-year-olds from Cheongju, where water fluoridation was discontinued. There were 192 6-year-olds, 226 8-year-olds, and 171 11-year-olds from Seongnam, where water fluoridation had never been implemented. The statistical analysis controlled for the confounding effects of sex, monthly family income, diet, and dental care. Only children who had been born and reared in their respective areas for the entirety of their lives were included in the analyzed population. The 11-year-old children from Cheongju, where fluoridation was discontinued, retained a protective effect of fluoridation as they had a 0.581 (95% CI 0.450-0.751; p<0.001) lower risk of filled permanent teeth surfaces compared 11-year-olds from Seongnam. Furthermore, 6 year old children in Cheongju, who had been born after water fluoridation stopped, had a 1.158 (95% CI 1.004-1.335; p=0.044) higher risk of filled tooth surfaces compared to 11-year-olds in the same area who had consumed fluoridated water earlier in their childhood (Cho, et al., 2014). This study highlights the beneficial impact of community water fluoridation on tooth decay prevention during childhood, and the protective effects of fluoridation retained by the tooth’s enamel for years after fluoridated water is discontinued. Furthermore, if the protective effect is carried for years after exposure to fluoridated water, the burden of increased risks of tooth decay associated with non-fluoridated water are also carried.
The reviewed studies provide sufficient evidence to determine fluoridation interventions coordinated with community water services to reduce dental caries is effective. It is worth noting among the studies reviewed for this assessment, all were conducted in different parts of the world, with differing populations, but all nations involved were medium to high income (as determined by the World Bank criteria) compared to other parts of the world. Furthermore, the studies primarily assessed the impacts of water fluoridation on children.
From analysis of these materials, community water fluoridation is a safe, efficient way to decrease the risk of tooth decay. No peer reviewed articles, dating from the most current 2013 Community Preventive Services Task Force recommendation, could be found demonstrating a danger or increased risk for adverse health effects from community water fluoridation. Moreover, the opposite was found. For communities who discontinue water fluoridation, the risk of tooth decay increases. From the Vietnam study, there is a lasting, protective effect to water fluoridation for children who consumed fluoridated water even after a fluoridation program is discontinued. From the Canadian study we see non-fluoridated water disproportionately impacts people of low SES, children, and those without dental insurance. Finally, from the Australian study, we identify the benefits of tooth decay prevention in communities with water fluoridation compared to those without. The community water fluoridation program has proven safety, efficacy, and long term benefits against dental caries and worth considering for strong recommendation.
References:
Centers for Disease Control and Prevention. (2013, April). Preventing Dental Caries: Community Water Fluoridation. Task Force Finding and Rationale Statement. Retrieved from http://www.thecommunityguide.org/oral/supportingmaterials/RRfluoridation.html
Cho, H., Jin, B., Park, D., Jung, S., Lee, H., Paik, D., & Bae, K. (2014). Systemic effect of water fluoridation on dental caries prevalence. Community Dentistry and Oral Epidemiology, 42(4), 341-348.
Do, L., & Spencer, J. (2015). Contemporary multilevel analysis of the effectiveness of water fluoridation in Australia. Australian and New Zealand Journal of Public Health, 39, 44-50.
McLaren, L., McNeil, D. A., Potestio, M., Patterson, S., Thawer, S., Faris, P., . . . Shwart, L. (2016). Equity in children’s dental caries before and after cessation of community water fluoridation: differential impact by dental insurance status and geographic material deprivation. International Journal for Equity in Health, 15, 1-9. doi:10.1186/s12939-016-0312-1
McLeroy, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An Ecological Perspective on Health Promotion Programs. In Health Education and Behavior (Vol. 15, pp. 351-377).
Ran, T., & Chattopadhyay, S. K. (2016). Economic Evaluation of Community Water Fluoridation: A Community Guide Systematic Review. American Journal of Preventive Medicine, 50(6), 790-796.
Tuan, H. L., Chin, C., & Shieh, S. (2005). The development of a questionnaire to measure students’ motivation towards science learning. International Journal of Science Education, 27(6), 639-654.
Witherspoon, D., Horowitz, A., & Kleinman, D. (2016). Maryland Physicians’ Knowledge, Opinions, and Practices Related to Dental Caries Etiology and Prevention in Children. Pediatric Dentistry, 38(1), 61-67.
Part II. Theoretical Framework/Model
The fluoridation of community water program takes place at a municipal water treatment facility with a goal to provide potable water to members of the community who have access and utilize this water for consumption. The community public health goal is to improve resistance to dental caries (tooth decay). Key individuals involved in this process may be at a state or local level and may include, but in no way are not limited to, community members, public health officials, dentists, dental hygienists, healthcare workers, elected/government officials, water treatment personnel, educators, and advocacy groups. To encompass these groups, the Ecological Model for Health Promotion, also known as the Social Ecological Model, was used to describe this public health intervention (McLeroy et al., 1988). In order to fluoridate a municipal water source, community, social groups, and ultimately the individual consumer must understand and appreciate the public health benefits offered by implementation of the policy. Different levels have different elements influencing the success or failure of the fluoridation objective. Elements leading to adoption of community fluoridation are detailed under each level.
Individual Level:The individual level represents a person who may or may not have knowledge or opinions on water fluoridation. Increasing awareness within the individual, in turn influencing their opinion, is achieved through: education regarding the causes of tooth decay, the populations at risk (especially children and those without dental insurance), the costs of fluoridation, the benefits, and documented risks. Making sure the individual has access to the pertinent information and highlighting the decades of successes across numerous other communities, is key to successful education of an individual.
Interpersonal Level:This level, encompassing the individual level, represents the opportunities to educate at the healthcare level. Interactions dentists, dental hygienists, and other healthcare workers have with patients is key to facilitating their understanding of the topic and how they can participate. Making sure a provider is able to address this educational opportunity, at each meeting, in addition to dispelling any misconceptions, elevates levels of understanding regarding fluoridation. Furthermore, serving underserved or uninsured populations is essential. These populations are most impacted from water fluoridation (McLaren, et al., 2016).
Institutional Level:Educational material, public service announcements, and guidelines adopted by organizations like the American Dental Association, American Dental Hygienist Association, Centers for Disease Control and Prevention, and Department of Health and Human Services all represent institutional level sources to promote community water fluoridation. These established organizations help guide providers, who in turn provide guidance to patients and community leaders.
Community Level:Activities at this level may involve elected officials, government counsel hearings, open public forums, and/or meeting with advocacy groups in an effort to expand communication of water fluoridation into the community’s consciousness. In an effort to highlight the importance of the program, individuals, healthcare providers, or representatives from leading organizations may participate to educate and promote community water fluoridation.
Policy Level:This level involves the drafting, revision, adoption, execution, and monitoring of legislation. For community water fluoridation, this level can encompass local, state, and federal legislation and numerous agencies. Ensuring a collaborative, cooperative environment where opinions are considered and decisions are clearly outlined in policy is key to successful legislation.
Part III. Logic Model, Causal and Intervention Hypotheses, and Intervention Strategies
The target population for community water fluoridation are persons living in communities currently consuming potable, unfluoridated municipal water. Communities with the greatest financial benefits from water fluoridation are cities with over 10,000 people (Ran & Chattopadhyay, 2016). Cities with a robust preschool, elementary, and middle-school populations in addition to all racial demographics without dental insurance are desirable communities for municipal water fluoridation (McLaren, et al., 2016). An eligible community would be Mount Clemens, Michigan. With a population over 16,000, this suburb of the metro-Detroit area provides high quality potable water but does not fluoridate the water. This community, and its elected officials, are appropriately suited for the focus of a community water fluoridation initiative.
| Intervention Method | Alignment with Theory | Intervention Strategy |
| Increase individual awareness of the benefits of water fluoridation, including the under-served, vulnerable populations | At the core of the Ecological Model for Health Promotion is the individual. The knowledge and opinions of the individual are shaped most directly by the Interpersonal level, but the beliefs of an individual ultimately determine the success or failure of this intervention. Education, through different formats, will enlighten an individual to the causes of tooth decay, the consequences to their health, and methods of prevention. The intersection of Individual level and Interpersonal level with a dentist, dental hygienist, nurse, or medical provider can increase knowledge and foster enlightened opinions regarding water fluoridation. | Using school Health class in grade 1-12 to educate children on tooth decay and water fluoridation.
Deliver public service announcements via radio, newspaper, and television addressing the benefits of water fluoridation. These strategies can be delivered to a classroom or chair-side, but all aim to educate and provide immediate feedback to questions or concerns regarding fluoride and water fluoridation. |
| Increase dental professional awareness of benefits associated with community water fluoridation | Dissemination of Institutional ADA, ADHA, CDC, and HHS guidelines to health professionals. | Enrolling local dental professionals and healthcare providers in a continuing education meeting highlighting the beneficial effects of fluoride and the proven successes of community water fluoridation. |
| Increase favorable opinions of elected officials on enacting local water fluoridation policy |
The Policy level of the Ecological Model for Health Promotion is the goal for community water fluoridation. Growing from the individual level through the Interpersonal, Institutional, and Community levels and culminating in a policy to fluoridate the municipal water is the objective for this strategy of dental caries prevention. | Meet individually with public officials and solicit support of elected officials to garner support and foster a pro-water fluoridation policy. |
| Inputs/Resources | Activities | Outputs | Short-term Outcomes | Intermediate Outcomes | Long-term Outcomes |
| Individuals paying for municipal water,
Dental Professionals, Community Leadership, Local / State Governments, Municipal Water Supplier treating the water |
*Health Class focused on oral health and fluoridation
*Provide CE for local dental professionals and healthcare providers *Provide information via public service announcements, news coverage, and public forums for the public, and personal meetings with community officials
|
*Educated individuals, dental professionals, and healthcare providers
*Provide two CE meetings to dentists and dental hygienists *Have grades 1-12 school health classes provide 1 hour of class time focused on caries prevention and benefits of water fluoridation. *Deliver 1 daily public service announcement, 4 news reports, and 4 public forums to provide information regarding the impact of community water fluoridation to all community members. Considerations for language, reading level, and access to municipally sourced water should be made when preparing and presenting these materials. *Meet with each city council member and elected officials to discuss benefits and concerns associated with water fluoridation. |
*Increase dental professional awareness of benefits associated with community water fluoridation
*Increase individual awareness of the benefits of water fluoridation, including the under-served, vulnerable populations *Increase favorable opinions of elected officials on enacting local water fluoridation policy |
*Enact a community water fluoridation policy, fluoridate municipal water, and monitor fluoridation levels | *Decreased dental caries among community members, with the largest benefits to uninsured and children |
Using the health class of grades 1-12 to highlight tooth decay prevention and water fluoridation will increase awareness and education among school age children.
Using continuing education meetings will increase awareness of community water fluoridation benefits , in addition to identification of tooth decay and strategies of prevention among dentists, dental hygienists, and healthcare providers. This will increase their support for community water fluoridation.
Using public service announcements, news media coverage, and public forums will increase awareness and in turn support for community water fluoridation among community members and politicians.
Using meetings with elected officials and fostering a dialogue with city leadership will increase favorability and support of water fluoridation policy.
Using the Ecological Model for Health Promotion as a guide, increased dental professional awareness of the benefits associated with community dental fluoridation, through continuing education, increases patient care and awareness of the benefits of dental fluoridation. Education of school children, coupled with a media campaign focused on benefits of water fluoridation, increases awareness among community members. Furthermore, meeting with elected officials fosters public involvement and increases awareness and efforts of local government to dialogue on enacting local water fluoridation policy. This will lead to enacting a community water fluoridation policy, fluoridation of municipal water, and monitoring fluoridation levels. These changes will lead to decreased risk of tooth decay among community members.
Goal #1: Increase dental professional awareness of benefits associated with community water fluoridation
- Objective #1: After the continuing education meeting, 80% of dental professionals are aware of the benefits of community water fluoridation, up from 50% at baseline.
Goal #2: Increase individual awareness of the benefits of water fluoridation
- Objective #1: After the school Health class, 70% of students are aware of the benefits of community water fluoridation, up from 5% at baseline.
- Objective #2: After the public service announcements, news reports, and public forums, 60% of Mount Clemens community members are aware of the benefits of community water fluoridation, up from 5% at baseline.
Goal #3: Increase favorable opinions of elected officials to enact local water fluoridation policy
- Objective #1: After the individual meetings, 75% of politicians are aware of the benefits and support community water fluoridation, up from 50% at baseline.
Part IV. Evaluation Design and Measures
| Stakeholder | Role in Intervention | Evaluation Questions from Stakeholder | Effect on Stakeholder of a Successful Program | Effect on Stakeholder of an Unsuccessful Program |
| Community Members | Consumers of municipal water | Why is fluoridation beneficial and what are the risks?
How much will it cost me? |
Decreased risk for tooth decay, especially among uninsured and children.
Increased awareness of oral health. |
Unchanged, elevated risk for dental caries. |
| Dental Professionals | Educate Public and help guide policy | How many people with this benefit in my community?
Will this cost me lost revenue? |
Patients with less tooth decay.
Community outreach.
|
Unchanged to increased patient tooth decay. |
| Elected Officials / Government | Development of Policy and monitoring | What will this cost the community?
How many people will it impact? |
Decreased community tooth decay. | Unfavorable public opinion regarding failed public health initiative. |
| Municipal Water Management | Fluoridation of the water | How much will it cost for equipment upgrades, fluoride sourcing, and upkeep?
How many jobs will it create? |
Increased number of employees.
Modernized equipment. |
No change to operations |
The body of evidence supporting community water fluoridation spans 60 years and the feasibility of randomization of Mount Clemens, MI community members to fluoridated and non-fluoridated water delivery to their homes is logistically impossible and fraught with ethical shortfalls. In addition, literature evaluating the benefit or detriment to dental caries risk after implementing or eliminating a community water fluoridation program occurs between 5 to 10 years after implementation or cessation, making measurement of the long-term goal of reduced numbers of dental caries infeasible. For these reasons, examination of the short-term outcomes of interest using a quasi-experimental design will be used for evaluation of dental professional understanding of water fluoridation, understanding of water fluoridation among community members, and support of community water fluoridation policy among the law makers of Mount Clemens, MI. Although the temporal nature of a pre-post evaluation allow for accurate assessment of understanding, awareness, and opinions after an educational or face-to-face meeting intervention to the group of dental professionals, politicians, or community members, it lacks randomization and generalizability to other communities.
For evaluation of dental professional awareness of benefits associated with community water fluoridation after the intervention of a continuing education meeting focused on community water fluoridation, we will use a quasi-experimental design as the attendees will serve as their own controls. A pre-test of understanding and post-test of key topics of discussion during the CE will be administered. This awareness measurement to a questionnaire can be compared to their pre-test. Notation is represented below.
O1 x O2
To evaluate individual awareness of individuals regarding the benefits of community water fluoridation, we will evaluate the overall awareness of water fluoridation and public support of Mount Clemens community members. We will use a quasi-experimental design as the community members will serve as their own controls. A pre-test and post-test of of tooth decay and water fluoridation awareness will be administered for school children during Health class. Assessment of the general public will rely on public polling conducted via random digit dialing both before and after television & radio public service announcements, news reports, and public forums. Notation is represented below.
O1 x O2
To evaluate favorable opinions of elected officials, and water treatment facility management, on enacting local water fluoridation policy after individual meetings, public hearings, and town hall meetings, a quasi-experimental design will be used. A pre-poll of lawmaker opinions will be conducted and a post-poll to assess their commitment to policy change. Notation is represented below.
O1 x O2 O3
O2 is measurement at meeting conclusion, O3 is measurement at 6 months post meeting
Threats to Internal Validity:
Due to the quasi-experimental nature of this study, strains to the internal validity are inevitable. Preexisting opinions and knowledge regarding water fluoridation are likely present within the Mount Clemens community. This could skew favorability data making education and public relations materials look more influential. To address this issue and accurately measure public favor, we are using pre-polling of the population before implementing public relation and educational campaigns. Post-polls after education and public relations events will monitor the trends for or against community water fluoridation.
Selection bias for polling participation is another area for internal validity. Selecting primarily one group of individuals could influence the measures of public opinions or knowledge regarding community water fluoridation. To minimize this effect, we are planning to utilize random digit dialing to contact households in Mount Clemens. This will reduce the probability of polling people who do not live in the community or do not have municipal water service and consume Mount Clemens water.
In addition to the opinions of the public, awareness and opinions of medical providers and dental professionals will be assessed. These individuals are subject to response bias, as they may practice differently than their knowledge base dictates. This could be the result of a patient’s dental insurance status, training of staff, or personal opinions of the provider. In addition, in attempting to increase their knowledge regarding the issues of tooth decay and water fluoridation, we seek to accurately measure the effect of the continuing education. To accomplish this, we are conducting a pre-test and post-test to measure if the CE has enhanced their awareness, knowledge, and/or favorably influenced their opinions of community water fluoridation.
Ultimately, the success or failure of the program is in the ability to reduce cavities. As discussed earlier, the internal validity of this study relies on measuring other, short-term outcomes rather than the overall objective. This long-term morbidity data will not be assessed in this intervention and left to others to examine at a later time. This is in part to the time needed to strengthen or decay teeth. To measure the overarching impact of water fluoridation on Mount Clemens, incidence data can be used pre-water fluoridation and then several years after implementation. This community can serve as its own control.
A historical threat to the internal validity would be other initiatives to increase oral health within the community. One such program, run by the Michigan Department of Health and Human Services, serves persons of low income without dental insurance. Although not likely to dramatically impact public opinions of the issue of water fluoridation, the access of this this program to eligible persons in Mount Clemens should be identified and addressed when long-term outcomes of dental caries is evaluated in future studies.
| 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 |
| Dental professional’s awareness of benefits associated with community water fluoridation | 30-question survey covers knowledge of the formation and prevention of dental caries (Witherspoon, Horowitz, & Kleinman, 2016). | We would adapt this newly developed 30 question survey (uses a 5 point Likert-scale) to assess the awareness of healthcare providers regarding benefits of community water fluoridation. | Fluoride mechanism of action: “The most important mechanism of action of fluoride is the re-mineralization of incipient decay”
Opinion regarding awareness of Community Water Fluoridation: Using the 5 point Likert-scale of “not aware” to “very aware” |
This newly developed tool is to measure the opinions and beliefs of the individual being examined. It has content validity as a measurement tool. Regarding reproducability, this survey was consistent with a previous study regarding opinions and beliefs of healthcare providers regarding caries but was limited generalizability due to study design (Witherspoon, Horowitz, & Kleinman, 2016). |
| Individual and Politician’s awareness of benefits associated with community water fluoridation | Questionnaire used to measure attitudes of individuals (Tuan et al, 2005) | We would adapt and modify this questionnaire and conduct a public poll to assess the awareness of individuals about community water fluoridation and their support of water fluoridation policy based on their knowledge. | Using a 5 point Likert-scale [from “strongly disagree” to “strongly agree”]:
I am aware water fluoridation is important to preventing cavities in teeth. I am aware of and support a policy to implement community water fluoridation in Mount Clemens. |
Cronbach’s alpha reliability ranged from 0.70 to 0.89. A positive attitude toward the goal behavior has a correlation (r=0.41) to an individual’s knowledge/awareness (Tuan et al, 2005). |
Part V. Process Evaluation and Data Collection Forms
The groups of interest for this initiative include: schools, community members, dental professionals, and politicians. Information regarding community water fluoridation will be made directly available to school children, dental professionals, and politicians. Because of this, they are provided participation recruitment letters, and their attrition from the program will be monitored. As community members will be provided with information about community water fluoridation through public service announcements, news articles, and public forums, they will not directly be recruited and their attrition cannot be followed. The fidelity for each will be monitored.
Recruitment Letter to School Participants:
Dear (Enter Name of School):
The University of Georgia’s Health Promotion Program would like to invite your school to participate in cavity prevention and water fluoridation education initiative. Your participation is voluntary and consists of emphasizing the importance of good oral hygiene for 1 hour during health class. At the completion of the course, a quiz to assess the student’s understanding of what tooth decay is and methods to prevention. The number of students participating and the number successfully passing the exam should be reported. Please consider participation in this important initiative to improve the community’s oral health.
If you are interested in enrolling, please return the below section to our team coordinator:
[ ] Our school is interested in participating
[ ] Our school is not interested in participating
Respectfully,
(Health Promotion Team – Coordinator Information)
Attrition for School Participants:
Health Class Attendance Tracker
School Name:
Number Enrolled:
| Name | Class Attended | Pre Education | Post Education | Comments |
Instructor Signature: _________________________
Date: __________________
Fidelity for School Participation:
| Checklist | Yes | No | Not Applicable | Comments |
| Were all available schools contacted? | ||||
| Were all available grades, within each school, enrolled in the program? | ||||
| Was classroom information communicated clearly? | ||||
| Was information verbally communicated in a language the child understands? | ||||
| Were medical terms explained in understandable language? | ||||
| Was the presenter familiar with oral healthcare? | ||||
| Was the presenter familiar with public water fluoridation? | ||||
| Was the class 1 hour in duration? | ||||
| Were class materials available for children to review? | ||||
| Were class materials available in a language the child understands? | ||||
| Were pre-tests completed before the class? | ||||
| Were enough pre-tests available? | ||||
| Were post-tests completed after the class? | ||||
| Were enough post-tests available? | ||||
| Were tests available in a language the child understands? | ||||
| Were more than 10% of the class absent? | ||||
| Were absent children offered an opportunity to make-up the class? | ||||
| Were absent children offered an opportunity to make-up the pre-test? | ||||
| Were absent children offered an opportunity to make-up the pre-test? | ||||
| Were all questions answered? |
Additional comments or observations:
Instructor Signature: _________________________
Date: __________________
Recruitment Letter to Healthcare Professionals:
Dear (Enter Name of Healthcare Professional):
The University of Georgia’s Health Promotion Program would like to invite you to participate in cavity prevention and water fluoridation continuing education dinner. Your participation is voluntary and consists of attending one of our two CE meetings. At the beginning and at the completion of the course, a short survey will be given to assess the quality of the meeting. This meeting is accredited for 1 hours of contact continuing education. Please consider participation in this important initiative to improve the community’s oral health.
If you are interested in attending one of our two CE meetings, please return the below section to our team coordinator:
[ ] I am interested in attending the first CE meeting (date TBD)
[ ] I am interested in attending the second CE meeting (date TBD)
[ ] I am not interested in attending the CE meeting
[ ] I need special accommodations for the CE meeting: (explain: language, accessibility, etc.) _________________________
Respectfully,
(Health Promotion Team – Coordinator Information)
Attrition for Dental Professionals:
CE Meeting Attendance Tracker
CE Meeting Date:
Title of CE Meeting:
Number Enrolled:
| Participant Name | Title: MD, DDS, RDH, etc. | Pre CE Meeting | Post CE Meeting | Comments |
Health Promotion Team Instructor’s Signature: _________________________
Date: __________________
Fidelity for Healthcare Professionals:
| Checklist | Yes | No | Not Applicable | Comments |
| Were all available healthcare professionals contacted? | ||||
| Was the venue reserved for both CE meetings? | ||||
| Were CE meeting materials submitted for accreditation approval? | ||||
| Was accreditation confirmation received prior to the meeting? | ||||
| Was the presenter familiar with oral healthcare? | ||||
| Was the presenter familiar with public water fluoridation? | ||||
| Were healthcare professionals provided accurate time, date, and location information for the CE meeting? | ||||
| Were topics to be covered clearly identified? | ||||
| Were all topics to be communicated covered? | ||||
| Did the CE meeting’s minutes meet requirements for accreditation? | ||||
| Was information verbally communicated in a language the participant understands? | ||||
| Were medical terms explained (if not understood)? | ||||
| Were materials available for review? | ||||
| Were materials available in a language the participant understands? | ||||
| Were pre-tests completed before the CE meeting? | ||||
| Were enough pre-tests available? | ||||
| Were post-tests completed after the CE meeting? | ||||
| Were enough post-tests available? | ||||
| Were tests available in a language the participant understands? | ||||
| Were more than 25% of the registered participants absent? | ||||
| Were absent participants offered an opportunity to make-up the CE course? | ||||
| Were absent participants offered an opportunity to make-up the pre-test? | ||||
| Were absent participants offered an opportunity to make-up the pre-test? | ||||
| Were all questions answered? | ||||
| Were CE completion certificates given to all participants? |
Additional comments or observations:
CE Meeting Instructor’s Signature: _________________________
Date: __________________
Recruitment Letter to Elected Officials/Politicians:
Dear (Enter Name of elected Official/Politician):
The University of Georgia’s Health Promotion Program would like to invite you to a private meeting about the prevention of tooth decay and water fluoridation. Your participation is voluntary and consists of a face-to-face meeting, available at your earliest convenience. At the beginning and end of the meeting, a short survey will be given to assess the quality of our message. Please consider participation in this important initiative to improve the community’s oral health.
If you are interested in a meeting, please return the below section to our team coordinator:
[ ] I am interested in scheduling a meeting.
Location: ______________ Time: ______________
[ ] I am unable to scheduling a meeting at this time but would like a follow-up in the future.
Respectfully,
(Health Promotion Team – Coordinator Information)
Attrition for Politicians:
Meeting Attendance Tracker
| Politician Name | Position | Pre Meeting | Post Meeting | Comments |
Health Promotion Team Coordinator’s Signature: _________________________
Date: __________________
Fidelity for Healthcare Professionals:
| Checklist | Yes | No | Not Applicable | Comments |
| Were all available public officials/politicians contacted? | ||||
| Was a venue reserved for the meetings? | ||||
| Were officials requesting a follow-up, contacted again? | ||||
| Were meeting times, dates, and locations confirmed? | ||||
| Were meetings cancelled? | ||||
| If cancelled, were meetings rescheduled? | ||||
| Was the presenter familiar with oral healthcare? | ||||
| Was the presenter familiar with public water fluoridation? | ||||
| Were all topics to be communicated covered? | ||||
| Was information verbally communicated in a language the participant understands? | ||||
| Were medical terms explained (if not understood)? | ||||
| Were materials available for review? | ||||
| Were materials available in a language the participant understands? | ||||
| Was a pre-meeting questionnaire completed? | ||||
| Was a post-meeting questionnaire completed? | ||||
| Was a 6-month post-meeting questionnaire completed? | ||||
| Were questionnaires available in a language the participant understands? | ||||
| Were all questions answered? | ||||
| Were follow-up meetings requested? |
Additional comments or observations:
Meeting Coordinator’s Signature: _________________________
Date: __________________
Fidelity for Public Service Announcements, News Articles, and Public Forums:
| Public Service Announcements | ||||
| Checklist | Yes | No | Not Applicable | Comments |
| Were PSAs messages approved by the public affairs officer or attorney? | ||||
| Did the message cover the importance of community water fluoridation? | ||||
| Were medical terms explained? | ||||
| Were all available radio carriers contacted? | ||||
| Were radio messages played on all available radio stations? | ||||
| Were radio messages in the language listeners understand? | ||||
| Were radio messages played once per day? | ||||
| Was the radio carrier contacted with any questions/concerns from listeners? | ||||
| Were all available television carriers contacted? | ||||
| Were television messages played on all available stations? | ||||
| Were television messages in the language listeners understand? | ||||
| Were television messages played once per day? | ||||
| Was the television carrier contacted with any questions/concerns from listeners? | ||||
| News Reports | ||||
| Checklist | Yes | No | Not Applicable | Comments |
| Did the message cover the importance of community water fluoridation? | ||||
| Were medical terms explained? | ||||
| Were all available news carriers contacted? | ||||
| Were messages published on print (paper) format? | ||||
| Were messages published on digital (on-line) format? | ||||
| Were articles available in different languages? | ||||
| Were four articles about the benefits of community water fluoridation published? | ||||
| Was the news provider contacted with any questions/concerns from readers? | ||||
| Public Forums | ||||
| Checklist | Yes | No | Not Applicable | Comments |
| Were announcements of the public forum made in advance? | ||||
| Was the venue reserved for the forums? | ||||
| Were the presenters familiar with oral healthcare? | ||||
| Were the presenters familiar with public water fluoridation? | ||||
| Were topics to be covered clearly identified? | ||||
| Were all topics to be communicated covered? | ||||
| Was information verbally communicated in a language the participant understands? | ||||
| Were medical terms explained (if not understood)? | ||||
| Were materials available for review? | ||||
| Were materials available in a language the participant understands? | ||||
| Were all questions answered? | ||||
| Were all four public forums offered? | ||||
Additional comments or observations about Public Service Announcements:
Additional comments or observations about News Coverage:
Additional comments or observations about Public Forums:
Health Promotion Team Coordinator’s Signature: _________________________
Date: __________________