Abstract
BackgroundChildsmile School adopts a directed-population approach to target fluoride varnish applications to 20% of the primary one (P1) population in priority schools selected on the basis of the proportion of enrolled children considered to be at increased-risk of developing dental caries. The study sought to compare the effectiveness of four different methods for identifying individuals most in need when a directed-population approach is taken.MethodsThe 2008 Basic National Dental Inspection Programme (BNDIP) cross-sectional P1 Scottish epidemiological survey dataset was used to model four methods and test three definitions of increased-risk. Effectiveness was determined by the positive predictive value (PPV) and explored in relation to 1-sensitivity and 1-specificity.ResultsComplete data was available on 43470 children (87% of the survey). At the Scotland level, at least half (50%) of the children targeted were at increased-risk irrespective of the method used to target or the definition of increased-risk. There was no one method across all definitions of increased-risk that maximised PPV. Instead, PPV was highest when the targeting method complimented the definition of increased-risk. There was a higher percentage of children at increased-risk who were not targeted (1-sensitivity) when caries experience (rather than deprivation) was used to define increased-risk, irrespective of the method used for targeting. Over all three definitions of increased-risk, there was no one method that minimised (1-sensitivity) although this was lowest when the method and definition of increased-risk were complimentary. The false positive rate (1-specificity) for all methods and all definitions of increased-risk was consistently low (<20%), again being lowest when the method and definition of increased-risk were complimentary.ConclusionDeveloping a method to reach all (or even the vast majority) of individuals at increased-risk defined by either caries experience or deprivation is difficult using a directed-population approach at a group level. There is a need for a wider debate between politicians and public health experts to decide how best to reach those most at need of intervention to improve health and reduce inequalities.
Highlights
Childsmile School adopts a directed-population approach to target fluoride varnish applications to 20% of the primary one (P1) population in priority schools selected on the basis of the proportion of enrolled children considered to be at increased-risk of developing dental caries
The most recent National Dental Inspection Programme (NDIP), which monitors the oral health of Scottish primary school children, found that overall, 33% of 5 year old primary 1 (P1) children had caries experience, and in the most deprived areas of Scotland, this figure rose to 49.5% [14]
The highest proportion of P1 children with obvious caries experience is concentrated in the West of Scotland Health Boards of Greater Glasgow & Clyde, Lanarkshire, Dumfries & Galloway and Ayrshire & Arran
Summary
Childsmile School adopts a directed-population approach to target fluoride varnish applications to 20% of the primary one (P1) population in priority schools selected on the basis of the proportion of enrolled children considered to be at increased-risk of developing dental caries. Notwithstanding the above, it is recognised that a combination of approaches is often the most appropriate option for strategies aimed at health improvement and reductions in health inequality. This is in keeping with the Marmot Review [13] of 2010 which introduced the concept of “proportionate universalism”, whereby to reduce the steepness of the social gradient in health, interventions must be universal but with a scale and intensity that is proportionate to the level of disadvantage faced. Despite recent improvements in the oral health of children in Scotland, dental caries remains a highly prevalent disease with persisting inequalities. In addition it has been established that the incidence of new cavities is much higher in children with caries than those free of caries, and there is an imperative to prevent the development of caries in high-risk caries free children [15]
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