Report. Equality Impact Assessment of a proposed water fluoridation scheme in Southampton and parts of Hampshire

Transcription

1 Report Equality Impact Assessment of a proposed water fluoridation scheme in Southampton and parts of Hampshire February 2009

2 Glossary BASCD British Association for the Study of Community Dentistry BFS British Fluoridation Society dmfs - decayed, missing or filled surfaces in primary dentition DMFS - decayed, missing or filled surfaces in permanent dentition dmft /DMFT - decayed, missing or filled teeth in primary/permanent dentition EqIA Equality Impact Assessment GOSE Government Office for the South East JSNA Joint Strategic Needs Assessment MRC Medical Research Council NHMRC National Health Medical Research Council (Australia) NHS South Central the collective term used to refer to all the NHS organisations in the South Central area. NPWA - National Pure Water Association ONS Office of National Statistics PCT Primary Care Trust SCSHA South Central Strategic Health Authority SOA - Super Output Area. SOAs are small areas specifically introduced to improve the reporting and comparison of local statistics. Within England and Wales there is a Lower Layer (minimum population 1000) and a Middle Layer (minimum population 5000). Unlike electoral wards, these SOA layers are of consistent size across the country and are not subjected to regular boundary change. (Source: Office for National Statistics). Statistical terms CI Confidence Interval: Provides a specified degree of probability (e.g. 95%) that the true underlying value of a variable is contained within the interval stated.

3 Table of Contents 1 Executive Summary Methods Summary of findings Conclusions and recommendations Background Context Water fluoridation Equality Impact Assessment Screening assessment Overview of the screening assessment Rationale for the conclusions of the screening assessment Conclusion from the assessment process Scope of Equality Impact Assessment The proposal (scheme) to be assessed Population focus Geographical area Elements of the scheme to be considered Principles behind the EqIA Definitions Supporting documentation Data used in the EqIA How the evidence is used Demography Ethnicity Disability Age distribution Religion and belief Sexual orientation Socioeconomic Deprivation Deprivation in relation to proposed fluoridation coverage Epidemiology Dental health in England Dental health in South Central SHA Dental health in Southampton and Hampshire PCTs Page 1 of 72

4 6.4 Dental health inequalities (Socioeconomic) Evidence review Potential benefits and harms Evidence for inequalities Assessment of equality impacts Method for appraising equality impacts Equality impacts Summary of impacts and supporting evidence used in the Equality Impact Assessment References Table of Tables Table 1: Overview of the conculusions of the screening assessment Table 2: Standardised morbidity rate Table 3: Self reported health (ONS) Table 4: Improvements in dental health. Data source: Choosing Better Oral Health Table 5: Mean dmft and presence of any dmft. South Central SHA PCTs Table of Figures Figure 1: Ethnic background in Southampton Figure 2: Southampton PCT central locality (Bevois, Bargate, Freemantle) Figure 3: Southampton North locality (Portswood, Swaythling, Basset) Figure 4: Southampton South Locality (Woolston, Sholing, Peartree) Figure 5: Southampton West Locality (Redbridge, Shirley, Coxford) Figure 6: Southampton West Locality (Redbridge, Shirley, Coxford) Figure 7: Southampton East locality (Harefield, Bitterne, Bitterne Park) Table 8: Coverage of the scheme. Priority neighbourhoods, electoral wards and schools Figure 9: Average dmft/dmft per child in England Figure 10: Adults in England with no teeth Figure 11: Decay experience of 5-year-old children in English SHAs and in Scotland and Wales, Figure 12: Average dmft in 5 year-olds, PCTs in South Central SHA Page 2 of 72

5 Figure 13: Proportion of caries-free 5 year old children Figure 14: Average dmft score for schools in Southampton Figure 15: Percentage of pupils with any dmft 1997/98 to 2005/ Figure 16: dmft levels in 5 year old children by social class Figure 17: Percentages of adults with no teeth (English regions) Page 3 of 72

6 1 Executive Summary In 2005, following a review of its existing oral health promotion initiatives, the Southampton City Primary Care Trust (PCT), examined different options to improve oral health. The PCT asked the then Hampshire and Isle of Wight Strategic Health Authority 1 (SHA) to investigate the feasibility and cost of a water fluoridation scheme in Southampton. An independent technical feasibility study was commissioned by South Central SHA. This identified two technically feasible water supplies for a fluoridation scheme across Southampton and parts of south west Hampshire. A public consultation was completed in December 2008 on this scheme. South Central SHA will decide whether to implement the fluoridation scheme at a Board Meeting on 26th February This Equality Impact Assessment (EqIA) aims to inform that decision. EqIA is a systematic way of identifying potential favourable and unfavourable impacts of a proposal or scheme on equality for a specified population. Equality is considered in relation to the six strands of diversity: ethnicity, disability, gender, sexual orientation, age and religion or belief. It should be noted that vulnerable groups in the area not explicitly considered in the EqIA include refugees and asylum seekers, people who are homeless and people who are institutionalized (e.g. prisoners). The EqIA adheres to the following principles 2, identified by Department of Health guidance (2008): Eliminating unlawful/unjustifiable discrimination; Promoting equality; Promoting positive attitudes towards disabled people and taking account of someone s disabilities even where that involves treating them more favourably than other people. 1.1 Methods The Public Health Resource Unit (PHRU) 3 carried out the EqIA in line with DH guidance. This includes: An initial screening assessment to identify potential equality issues (both favourable and unfavourable) in the proposed scheme. Identifying the scope for the EqIA. A review of published evidence pertaining to issues identified by the assessment screening. An outline demographic profile, including mapping the geographical coverage of the proposed schemes in relation to local demography. A brief review of the epidemiology of oral and dental health in Southampton, based on existing profiles. 1 Hampshire and Isle of Wight SHA merged with Thames Valley SHA in October 2006 to form NHS South Central. 2 Note that this EqIA does not address social cohesion or involvement, which are also principles of EqIA. It is unlikely that the scheme will have any impact on community cohesion as far as the relevant population groups are concerned. Involvement has been addressed elsewhere: formal public consultation to assess the level of local support for the proposed scheme took place between 8th September and 19th December An EqIA was carried out on the public consultation. 3 PHRU is a not-for-profit NHS Public Health consultancy based in Oxford and hosted by Milton Keynes PCT. Page 4 of 72

7 An appraisal of potential equality impacts in the light of available evidence. Providing suggestions for mitigating potential negative equality impacts. The main evidence sources for the population impacts of water fluoridation were two systematic reviews one carried out by NHS Centre for Reviews and Dissemination, University of York (McDonagh 2000) in 2000 and one by the Australian National Health and Medical Research Council (2007). In addition PHRU searched for evidence relevant to equality issues in dental health and dental services for the six population groups addressed in the EqIA. 1.2 Summary of findings Potential consequences of fluoridation that might affect certain groups differently from others and therefore have an impact on equity ( equality impacts ) were identified from the evidence review. PHRU designed a simple subjective rating scale which was used to assess, a) the probability of potential impacts actually occurring (based on the strength and certainty of the available evidence) and, b) the proportion of the population of interest likely to be affected (extent of impact). The rating scale is described in Section The report includes a summary of the research evidence accessed for each potential impact Potential favourable impacts on equality Favourable equality impacts were assessed by addressing two key questions: 1. Will the scheme contribute to promoting equality of opportunity for dental health promotion and protection? 2. Will the scheme contribute to eliminating discrimination in terms of dental health promotion and protection? The following impacts were rated definite or probable: Population subgroup / diversity strand Potential equality impact Probability of occurrence Proportion of population likely to be affected Ethnicity E1: water fluoridation will reduce existing inequalities in access to, and uptake of, dental health protection between people from different ethnic groups. definite high E2: there will be a reduction in inequalities in dental caries prevalence between people from different ethnic groups. probable moderate Disability D1: water fluoridation will reduce existing inequalities in access to, and uptake of, dental health protection for people with disabilities. definite high D2: there will be a greater improvement in dental caries levels for people with disabilities relative to the population as a whole as this group probably experience a higher baseline prevalence of caries. probable high Page 5 of 72

8 Gender G1: water fluoridation will reduce existing genderbased inequalities in access to, and uptake of, dental health protection. definite moderate G2: there will be a reduction in inequalities in dental caries prevalence between people of different genders. definite moderate Age A1: water fluoridation will reduce existing agebased inequalities in access to, and uptake of, dental health promotion and protection. definite high Religion or belief RB1: water fluoridation will reduce existing inequalities in access to dental health promotion and protection for people of different faiths. probable moderate The following potential impacts were rated speculative as the available evidence was indirect i.e. deduced from a range of related but not direct evidence: Population subgroup / diversity strand Potential equality impact Probability of occurrence Proportion of population likely to be affected Sexual orientation SO1: water fluoridation will reduce existing inequalities in access to dental health promotion and protection. speculative low SO2: there will be a reduction in inequalities in dental caries levels among people of different sexual orientations. speculative low Religion or belief RB3: there will be a reduction in inequalities in dental caries levels for people of different faiths. speculative unknown Potential unfavourable impacts on equality Unfavourable equality impacts were assessed by addressing three key questions: 1. Will the scheme present any problems or barriers for any particular group? 2. Will any group of people be excluded from the suggested benefits of the scheme? 3. Does the scheme have the potential to worsen existing discrimination and inequality? Page 6 of 72

9 The following impacts were rated definite or probable: Population subgroup / diversity strand Potential equality impact Probability of occurrence Proportion of population likely to be affected Ethnicity E3: there will be ethnically based differences in babies uptake of fluoride in the water-fluoridated areas associated with differences in feeding practices. probable moderate E4: there will be ethnicity-based exclusions where minority ethnic groups are outside the scope of the scheme. The non-white minority ethnic population appears to be higher in the central and north of Southampton. Some of these areas, (Swaythling and Bassett) may not be covered by the proposed schemes. n/a moderate E5: where there is socio-economic deprivation, people from minority ethnic groups receiving state benefits will gain financially less than others from dental health improvements. definite moderate Disability D3: people with disabilities who receive non-oral fluids and nutrition may be excluded from the scheme or receive non-optimal amounts of fluoride. definite low D4: some people may wish to seek cosmetic dental treatment for fluorosis 4 for aesthetic reasons. This will impact more on people with disabilities because at an aggregate level they are socioeconomically disadvantaged. definite low D5: people with disabilities will experience fewer financial savings than the general population as a result of reduced need for dental care because as a group they have higher rates of socioeconomic disadvantage and state benefits. definite low Age A2: child poverty rates are greater than adult poverty rates across all ethnic groups. There are potential inequalities for children who might wish to seek (private) cosmetic treatment for fluorosis of aesthetic concern. definite low A3: there will be age-based exclusions if certain age groups are clustered in areas that are geographically outside the scheme e.g. students. probable unknown 4 Fluorosis is a change in the composition of the tooth enamel that shows up as a speckling or mottling of the teeth and is associated with exposure to fluoride. It ranges from a mild flecking to more obvious forms of staining and discoloration. Page 7 of 72

10 The following potential impacts were rated speculative: Population subgroup / diversity strand Potential equality impact Probability of occurrence Proportion of population likely to be affected Ethnicity E6: people from some minority ethnic groups will have relatively higher incidence of fluorosis after water fluoridation, due to dietary differences. speculative low E7: some people may wish to seek cosmetic dental treatment for fluorosis of aesthetic concern. This will impact on some groups more than others due to socioeconomic inequalities associated with ethnicity. speculative low E8: there will be ethnically based exclusions if certain minority ethnic groups are clustered in areas that are geographically outside the scheme speculative unknown Disability D6: the impact of fluorosis may disproportionately affect people who have poorer mental health, reduced wellbeing or low self-image associated with disability-based discrimination. speculative low D7: Some people may wish to seek cosmetic dental treatment for fluorosis of aesthetic concern. This will impact on the disabled population more than others due to socioeconomic inequalities associated with ethnicity. speculative low D8: people with disabilities will be excluded if they are geographically clustered outside the areas covered by the scheme (e.g. in residential settings). speculative unknown Sexual orientation SO3: the impact of fluorosis will disproportionately affect people who have poorer mental health, reduced wellbeing or low self-image associated with discrimination. speculative low Age A5: children might wish to seek cosmetic treatment for fluorosis of aesthetic concern may be unable to pay for treatment child given that poverty rates are greater than adult poverty rates across all ethnic groups. speculative low Page 8 of 72

11 1.3 Conclusions and recommendations Equality Impact Assessment: Southampton Fluoridation Scheme Whilst the scheme is likely to have a favourable impact on inequalities in access to improved dental health protection for most strands of diversity, some potential unfavourable equality impacts have been identified. The following suggested actions aim to mitigate these: Suggested actions Where there are ethnically based inequalities in fluorosis due to diet (e.g. brick tea): Fluorosis from this source can be avoided by using low fluoride varieties. Advise community groups / community leaders. Where there are potential ethnically based inequalities in babies uptake (due to differences in breastfeeding prevalence): At a national level, develop public information on the issues for feeding babies in water fluoridated areas. Advocate for a review of fluoride content of infant formula feeds. Promote breastfeeding locally and provide culturally sensitive information on fluoride in breast milk, formula milk and supplements / toothpaste for infants and children across all ethnic groups. Joint action by dental, public health, maternity and paediatric services, NGOs and user groups. For geographical areas are not covered by the fluoridated water scheme: Small area profile of ethnic diversity to inform targeted community oral and dental services. Focused dental health needs assessment and targeted dental health promotion for students in the main student areas of the city that are not covered by the scheme. For people with disabilities who receive non-oral fluids and nutrition (equality impact depends on fluoride content of feeds and absorption characteristics of fluoride). Advocate for reviewed fluoride content of feeds and disseminate appropriate guidance. Small-population monitoring and targeted oral care for this group locally. Where there are age-based inequalities Qualitative research to enhance understanding of age differences in experience and response to caries. This should aim to inform guidance on treatment approaches. Research (possibly secondary research) into bioavailability of fluoride in relation to variables such as age, body mass, duration of exposure, age-related nutritional patterns Monitoring and evaluation It will be important to implement monitoring and evaluation of the impact of the water fluoridation scheme on inequalities in dental health and caries experience. Page 9 of 72

12 2 Background 2.1 Context PCTs have a responsibility to assess the oral health needs of their local population and to deliver a strategy for addressing local needs (DH 2008). In May 2005, Southampton City Primary Care Trust (PCT) asked the then Strategic Health Authority 5 (Hampshire and Isle of Wight) to investigate the feasibility and costs of adjusting the level of fluoride in the water supplied to the Southampton area to address their finding that children in Southampton have some of the poorest dental health across the NHS South Central region and in the country 6. An independent technical feasibility study was commissioned by South Central Strategic Health Authority (SHA). This identified two feasible water supplies for a fluoridation scheme across Southampton and parts of south west Hampshire. A public consultation on this scheme was completed in December In January 2009 South Central SHA commissioned the Public Health Resource Unit to undertake this Equality Impact Assessment (EqIA). 2.2 Water fluoridation Water fluoridation is: The addition of a controlled amount of fluoride to a public water supply with the intent to prevent dental caries in the population (Pizzo et al 2007). The first fluoride programme was implemented in Michigan, USA, in Some areas of the UK were fluoridated between the 1960 s and mid 1980s. The West Midlands is the most extensively fluoridated area in the UK, followed by parts of the North East of England (DH/BASCD 2007) Fluoride is widely believed to be effective in the prevention of dental caries. A major systematic review 7 (McDonagh et al 2000, York University) concluded that: The best available evidence suggests that fluoridation of drinking water supplies does reduce caries prevalence, both as measured by the proportion of children who are caries free and by the mean change in dmft/dmft 8 score. The studies were of moderate quality (level B), but of limited quantity. The degree to which caries is reduced, however, is not clear from the data available. The technical feasibility study for water fluoridation in Southampton identified two viable schemes. Together they would supply approx 160,000 residents (67%) of the population of SCPCT. In addition 36,000 residents of Hampshire PCT would receive fluoridated water (NHS South Central Board paper HA 08/ ). The areas that would be covered are: Central 5 Strategic Health Authorities (or, in Wales, the National Assembly) are the authorizing bodies for arrangements with water undertakers with respect to water fluoridation. Together, SHAs and PCTs aim to identify feasible options which most cost-effectively address the high need populations in their areas (DH 2008a). 6 In October 2006 the Hampshire & Isle of Wight and Thames Valley (Buckinghamshire, Berkshire, Oxfordshire) SHAs merged to form South Central SHA. 7 Hereafter referred to as the York review 8 Decayed, missing or filled teeth. Throughout this text, dmft denotes primary (child) dentition; DMFT denotes permanent (adult) dentition. Page 10 of 72

13 Southampton, Lordshill, Freemantle, Polygon, Totton, parts of Eastleigh, Weston, Shirley, Portswood, St Denys, Netley, Aldermoor, Millbrook, Bassett and Woolston. 2.3 Equality Impact Assessment Equality Impact Assessment (EqIA) is a systematic way of addressing the question of whether an existing or proposed function or policy is likely to affect people from certain groups differently or disproportionately. It addresses both impacts that are potentially favourable and those that are potentially unfavourable with respect to equality. Public organizations have a legal duty 9 to: promote equality and eliminate discrimination; foster positive relationships between different groups of people; involve people in decisions regarding their health and social care and their access to services. Equality Impact Assessment (EqIA), together with the Single Equality Scheme (DH 2007) seeks to eliminate discrimination and reduce health inequalities. The six strands of equality to be addressed in EqIA are ethnicity, disability, gender, sexual orientation, age, religion and belief (DH 2008b). Throughout the report these six strands are addressed in the same order for ease of reading. The report presents an initial screening assessment (Section 3) followed by the scope of the review (4), the demography of the area (5), epidemiology (6), the evidence review (7) and the potential impacts (8). The report concludes with a brief summary and recommendations (9) In addition an appendix (11) presents a tabulated summary of the impacts and supporting evidence. 9 Section 71(1) of the Race Relations Act 1976, which came into force on 2 April 2001; Section 49A of the Disability Discrimination Act 1995, which came into force on 4 December 2006; Section 76A of the Sex Discrimination Act 1975, which came into force for these purposes on 6 April Page 11 of 72

14 3 Screening assessment 3.1 Overview of the screening assessment The screening assessment aims to identify whether the proposed scheme is likely to have implications for equality on the grounds of ethnicity, disability, gender, sexual orientation or religion and belief. It forms the basis for deciding whether to carry out an EqIA. It identifies specific questions for the EqIA and informs the scope. The screening process does not constitute evidence or assessment of equality impacts: it simply identifies potential issues for consideration based on the questions defined by the Department of Health for EqIA. Table 1: Overview of the conclusions of the screening assessment Do different groups have different needs, experiences, issues and priorities with reference to the proposed water fluoridation scheme? Is there public concern (including media, academic, voluntary or sector specific interest) about actual, perceived or potential discrimination against particular groups in relation to the water fluoridation scheme? Potentially unfavourable impacts Will the scheme present any problems or barriers for any particular group? ethnicity disability gender sexual orientation age Y Y Y Y Y Y N Y N N Y N N Y N N Y N Will any group of people be excluded? N Y N N N N religion Does the scheme have the potential to worsen existing discrimination and inequality? Will the scheme have a negative effect on community relations with regard to the six strands of diversity? Potential favourable impacts Promoting equality of opportunity for dental health and prevention of dental caries? Eliminating discrimination in terms of access to dental health promotion and prevention of dental caries? N N N N Not known N N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Eliminating harassment? N N N N N N Promoting good community relations? N N N N N N N Page 12 of 72

15 3.2 Rationale for the conclusions of the screening assessment Ethnicity At a population level, people from certain minority ethnic groups may experience dental and oral health status, protection and promotion differently. Studies of specific minority ethnic groups have found lower use or receipt of care from dental services by some groups compared with the general population. Uptake of health promotion and education services in general is anecdotally perceived to be low among minority ethnic groups (Gill et al 2007). Different ethnic groups appear to have different dmft/dmft rates when adjustments are made for socioeconomic variation (Dugmore and Rock 2005). Water fluoridation is not dependent on access to or receipt of health promotion messages or professional services. It is therefore likely to contribute to equality of opportunity and reduced discrimination for people from minority ethnic groups. Different rates and forms of poverty are found amongst people from different ethnic groups (Gill et al 2007). Therefore any economic implications of the scheme (Board Paper HA08/046) will impact differently on people according to ethnically-based socioeconomic differences. It is unlikely that any particular ethnic groups living within the geographical area for the scheme will be excluded. There may be unintended exclusions if any particular minority ethnic group is geographically clustered outside the coverage of the proposed schemes Disability People with disabilities have different experiences of dental and oral health care and prevention. They may: have higher levels of oral and dental health risk factors (DH 2007), have difficulty maintaining their own oral care (Kelly & Watts 2006, Griffiths et al 2007, Jin et al 2003, Selwitz et al 2007), find dental surgeries inaccessible or inadequate (lo Rosso et al 2008). People with disabilities are more likely to be socio-economically disadvantaged compared with the population as a whole (Parckar 2008). Any financial implications of the scheme might therefore have equality impacts in relation to disability. Because of their potentially higher oral and dental health need, people with disabilities are likely to have a relatively high gain from a universal oral health promotion scheme if there is evidence that the scheme is beneficial in the general population. The proposed water fluoridation scheme is not dependent on accessing a professional service and in most cases (but see next paragraph) does not require any additional carer support. Thus it is likely to contribute to equality of opportunity and reduced discrimination. Within this population are groups who have specific nutritional needs for example, those with dysphagia (swallowing impairments) who receive fluids and nutrition by a non-oral route may Page 13 of 72

16 not receive the same exposure to fluoride as the general population 10. This impact would be mitigated if non-oral feeds contained fluoride or were reconstituted with fluoridated water. The National Pure Water Association (NPWA) has raised concerns that above average water drinkers, diabetics, people with poor kidney function may consume more than the average daily intake of fluoride of the general population (NWPA 2008) Gender There are differences in receipt or uptake of professional services and in dental caries outcomes between men and women (ONS 2008). A scheme that does not depend on access to professional support would therefore promote gender equality. Researchers have investigated the possibility of associations between exposure to fluoride and a range of long-term health conditions. There might be gender differences in the risk of some of these conditions (for example, bone conditions, certain types of cancer). There is currently no clear evidence of an association between fluoride levels of 1ppm and any of these conditions except for fluorosis 11 (for which there is no known gender association) (McDonagh et al 2000, Au Gov review 2007), but the possibility that an association might be found in the future cannot be ruled out.. It is unlikely that anyone living in the proposed area would be excluded from the scheme because of their gender Sexual orientation Lesbian, gay and bisexual people may have different oral health promotion needs because: Age health education messages may be unsuccessful in targeting them (ONS 2008), they are at higher risk of poor mental health than heterosexual people (DH 2007b). People of different ages may have different experiences of dental and oral health care and health promotion associated with: different physiological stages of dentition at the time of exposure to fluoride, which might affect its effectiveness as a protective measure and also the risk of fluorosis: - Fluoride exposure whilst the teeth are forming (before they erupt) is sometimes associated with fluorosis: The World Health Organisation (WHO 1994) cited in MRC (2002) states that fluoride content of tooth tissues reflects the biologically available fluoride at the time of tooth formation after which time, except for the outermost layer of the enamel, fluoride levels remain constant (WHO1994). - There appears to be uncertainty about how long the protective effect of fluoride lasts. A recent U.S. meta-analysis of twenty studies [Griffin] found that fluoride was effective in preventing caries in adults aged 20+ and aged 40+,. 10 Absorption through the gastrointestinal tract is the main mechanism for the caries-protective effect of fluoride (MRC DATE). 11 Fluorosis is a change in the composition of the tooth enamel that shows up as a speckling or mottling of the teeth and is associated with exposure to fluoride. It ranges from a mild flecking to more obvious forms of staining and discoloration. Ref: MRC Page 14 of 72

17 different risk factors for caries. For example children may have more risk factors for caries if they consume more sugar than other age groups, different fluoride concentration requirements are associated with differences in body size: For example, the National Pure Water Association (2008) states that The average daily intakes* of fluoride associated with many [of these] adverse effects are reached by some people consuming water at the concentration levels now used for fluoridation, especially small children.* "Daily intake" takes into account the exposed individual s bodyweight and is measured in mg. of fluoride per kilogram bodyweight, nutritional and dietary differences: The British Fluoridation Society website cites American studies which raised the possibility that infants could receive a greater than optimal amount of fluoride from reconstituted baby formula, differences in ease of access to professional dental services, differences in receipt of and response to oral health promotion messages, differences in personal independence and self-care, differences in financial opportunities. In the longer term, once the scheme has been operational for a number of years, people of different ages will have different lifetime exposures to water fluoridation. Future generations may have different experiences of dental and oral health and fluoride exposure. In this respect, children and young people may have different lifetime needs Religion or belief People of different faiths may have different risk factors and prevalence of caries independent of their ethnic identity. For example, children from Muslim Asian families have been found to have higher rates of caries than those from non-muslim Asian families (Dugmore and Rock 2005). 3.3 Conclusion from the assessment process Following this assessment process the EqIA concluded that a full EqIA was appropriate. Page 15 of 72

18 4 Scope of Equality Impact Assessment 4.1 The proposal (scheme) to be assessed This EqIA addresses the water fluoridation scheme as described by South Central SHA in the Board Paper HA08/046, May Population focus The EqIA addresses potential impacts (favourable and unfavourable) on equality for the six strands of diversity identified by the Department of Health. EqIA has a population focus it draws on information about specific groups of people. There is likely to be substantial sub-group and individual variation within the groups addressed. The following groups are considered: minority and majority ethnic groups; people with disabilities; men, women and transgender people; gay, lesbian and bisexual people; babies, children, young people and older people; people with different religions and beliefs. Socioeconomic disadvantage is not included per se, but is considered where it has a potential relevance to some or all of these groups. Vulnerable groups in the area that are not explicitly considered in the EqIA include refugees and asylum seekers, people who are homeless and people who are institutionalised (e.g. care homes, prisoners). 4.3 Geographical area Equality impacts are considered for communities in Southampton PCT, Eastleigh, Totton and Netley. The EqIA focuses on population groups. It does not explicitly address geographically based differences between populations of fluoridated and non-fluoridated communities. 4.4 Elements of the scheme to be considered The EqIA considers such elements of the scheme as effectiveness, safety, value, implementation characteristics and scientific basis only as they relate to equality for the six strands of diversity. NHS South Central has previously undertaken a technical feasibility study, economic analysis and a review of the scientific evidence regarding the health risks and benefits and ethical considerations. For the purposes of the EqIA, the generic 12 risks and benefits are taken to be those presented by the authors of two major systematic reviews (York 2000, Australia 2007). The EqIA considers the implications of those conclusions for the six population groups. The EqIA does not attempt to compare the scheme with any other schemes that have similar objectives (for example, topical application of fluoride; fluoride in milk, salt, food or toothpaste; or other oral health promotion schemes). 4.5 Principles behind the EqIA EqIA as described by the Department of Health adheres to the following principles: 12 That is, the conclusions that these authors have drawn for a general population, without particular consideration of the specific population sub-groups addressed in the EqIA. Page 16 of 72

19 eliminating unlawful/unjustifiable discrimination, promoting equality, fostering positive relationships between different groups of people, thereby improving community cohesion, promoting positive attitudes towards disabled people and taking account of someone s disabilities even where that involves treating them more favourably than other people, Involving people in decisions regarding their health and social care and their access to services. This EqIA addresses the first two and the fourth of these principles. It is unlikely that the scheme will have any impact on community cohesion as far as the relevant population groups are concerned Involvement This EqIA does not address involvement. Formal public consultation to assess the level of local support for the proposed scheme took place between 8th September and 19th December An EqIA was carried out for the process of the public consultation. The South Central SHA July 2008 Board paper states: The consultation process ensures that no sections of the community who may live or work in Southampton or South West Hampshire are excluded from accessing all supporting information and making their views known through a variety of mechanisms. The consultation plan and consultation document are fully compliant with internal Equality Impact Assessment processes Human rights Human rights issues other than those relating to equality are not addressed here. The SHA July 2008 Board Paper stated: Following questions raised by a member of the public at the previous board meeting regarding the impact of water fluoridation on human rights legislation, legal advice has been sought and adjusting the level of fluoride in water supplies is not considered a breach of human rights having previously been tested at the European Court of Justice. 4.6 Definitions Ethnicity Ethnicity implies self-identification with a group that has shared origins or social background, culture and traditions that are distinctive. Smaller or minority ethnic groups may experience discrimination in a majority culture (Gill et al 2007) Page 17 of 72

20 Disability Disabilities include physical, sensory and cognitive impairments (for example, learning disability or cognitive impairment following brain injury) and mental health problems. The social model of disability emphasizes the role of social barriers in failing to accommodate people with particular impairments. EqIA aims to identify and address unintentional barriers that a policy or scheme may create. 4.7 Supporting documentation The following documents are used for background technical information and initial identification of potential equality impacts. These documents do not constitute evidence for the EqIA: Choosing better oral health an oral health plan for England (DH 2005) The Chief Dental Officer s Guidance on water fluoridation (2008a) Valuing people s oral health (DH 2007a) Delivering better oral health (DH 2007c) Water fluoridation and health (Medical Research Council, 2002) South Central SHA Board Paper, May 2008 Briefing paper submitted by Dr. Andrew Mortimore to Southampton City Council Overview and Scrutiny Committee. Item 11, Appendix Data used in the EqIA Demography The population profile used for this EqIA is based on existing profiles collated for the Southampton Joint Strategic Needs Assessment (JSNA) and some data from the supporting documentation listed above. Comparisons are limited because data are available at different levels depending on topic area (e.g. PCT locality, school catchment area, Local Authority administrative boundaries). There is an extensive dataset in Hampshire s Local Health Comparisons for readers seeking further information 13. Geographical inequalities per se do not fall within the remit of this EqIA. Where the JSNA data indicates a strong demographic feature (for example, particular age or ethnic groups) clustered in a particular part of the city that may not be covered by the scheme we have highlighted this as a potential exclusion. However, we cannot discount the possibility that other population groups covered by the EqIA may be relatively excluded from the scheme because of their geographical clustering outside the proposed fluoridation areas Epidemiology Section 5 (Epidemiology) uses existing profiles prepared by the PCT and SHA. The main sources are: surveys conducted by the British Association for Community Dentistry, information provided for the JSNA, information provided for the May 2008 NHS South Central Board Meeting Page 18 of 72

21 4.9 How the evidence is used The main evidence source for the EqIA is the comprehensive and rigorous systematic review carried out by the York Centre for Reviews and Dissemination in 2000 (McDonagh 2000) and a subsequent systematic review by the Australian Government National Health and Medical Research Council (2007). An additional literature review conducted for this EqIA aimed to identify key evidence in relevant research pertaining to the equality issues identified in the screening assessment. Snowballing methods were used for this search 14. PHRU developed a simple rating scale (adapted from the Merseyside Health Impact Assessment Guidelines) to assess the weight of the evidence in relation to the equality impacts identified. The rating scale is described in Section 8 of this report. 14 Greenhalgh & Peacock (2005) identify snowballing as a method of pursuing references of references and electronic citation tracking [which is] especially powerful for identifying high quality sources in obscure locations Page 19 of 72

22 5 Demography This section draws on the Southampton PCT Joint Strategic Needs Assessment (JSNA). It aims to describe the local population, and in particular to identify the size and nature of the subgroups to be considered in this EqIA. 5.1 Ethnicity Non-white minority ethnic groups are more prevalent in the central and north localities of Southampton: Figure 1: Ethnic background in Southampton % of total population Proportion of Population from an Ethnic Background other than White - Southampton PCT Localities: 2001 Locality SC PCT Average 0 Central East North South West Source: 2001 Census - Key Statistics, Ethnic Group Table KS06, ONS Neighbourhood Statistics, Crow n Copyright. From Local Health Comparisons 15 data it appears that the two wards with the highest proportions of Asian / Asian British people are Bevois (Bangladeshi: 2.64%; Pakistani 7.8%; Other 1.29%) and Portswood wards (Bangladeshi 0.56%; Pakistani 1.69%; other, 0.77%) People of mixed white and black Caribbean identity are also greater in number (as a percentage of the total population) in Bevois (0.78%) compared with all the other Southampton wards. 5.2 Disability Southampton Southampton has a high Standardised Morbidity Rate for Limiting Long Term Illness compared with the rest of the South East and with England as a whole [JSNA Document 4]: 15 Page 20 of 72

23 Table 2: Standardised morbidity rate Area Southampton South East 82.4 England & Wales Standardised morbidity rate In 2001, 14.7% of Southampton s under 15 year-olds self assessed their general health as not good, compared with an England average of 11.6%. In , compared with 15 neighbouring areas, Southampton had the 16 : highest rate per 1000 of over 65 year-olds with mental health problems receiving services. fourth highest rate per 1000 of under 65 year-olds with mental health problems receiving services. sixth-highest rate per 1000 of over 65 year-olds with a learning disability receiving services lowest rate per 1000 of over 65 year-olds with a learning disability living in the community second-lowest rate per 1000 of under 65 year olds with a learning disability receiving services Hampshire wards For Hampshire, standardised morbidity was only available for Totton (73.3). ONS Neighbourhood Statistics provides the following information (based on 2001 census data): Table 3: Self reported health (ONS) Self-reported good health % Self-reported not good health % Limiting long term illness % Eastleigh Central Eastleigh North Eastleigh South Eastleigh West Totton Central Totton East JSNA Social Services data document 6 Page 21 of 72

24 Totton North Totton West Totton South Netley, Copythorne South and Netley Marsh Burlesdon and Old Netley Netley Abbey Netley Marsh From this self-reported data, Eastleigh South, Netley, Copythorne South and Netley Marsh, Netley Abbey and Totton East appear to have more concerns about health and to be experiencing more limiting long term illness. 5.3 Age distribution As part of its JSNA, the PCT estimated 2006 population age distribution pyramids for the five PCT sectors. Figure 2: Southampton PCT central locality (Bevois, Bargate, Freemantle) Southampton PCT - Central Locality Resident population in 2006 estimated to be Age group Male Female % 15% 5% 5% 15% 25% % Resident population Source: Hampshire County Environment Department's 2006-based Small Area Population Forecasts Southampton City central locality is characterised by a large student population. Population estimates for 2006 show a very high proportion of year-olds. From the greatest population growth is expected in the 65+ age group. Page 22 of 72

25 Figure 3: Southampton North locality (Portswood, Swaythling, Basset). Southampton PCT - North Locality Resident population in 2006 estimated to be Age group Male Female % 15% 5% 5% 15% 25% % Resident population Source: Hampshire County Environment Department's 2006-based Small Area Population Forecasts Figure 4: Southampton South Locality (Woolston, Sholing, Peartree) Southampton PCT - South Locality Resident population in 2006 estimated to be Age group Male Female % 10% 5% 0% 5% 10% 15% % Resident population Source: Hampshire County Environment Department's 2006-based Small Area Population Forecasts Page 23 of 72

26 Figure 5: Southampton West Locality (Redbridge, Shirley, Coxford) Southampton PCT - West Locality Resident population in 2006 estimated to be Age group Male Female % 10% 5% 0% 5% 10% 15% % Resident population Source: Hampshire County Environment Department's 2006-based Small Area Population Forecasts Figure 6: Southampton West Locality (Redbridge, Shirley, Coxford) Southampton PCT - West Locality Resident population in 2006 estimated to be Age group Male Female % 10% 5% 0% 5% 10% 15% % Resident population Source: Hampshire County Environment Department's 2006-based Small Area Population Forecasts Page 24 of 72

27 Figure 7: Southampton East locality (Harefield, Bitterne, Bitterne Park). Southampton PCT - East Locality Resident population in 2006 estimated to be Age group Male Female % 10% 5% 0% 5% 10% 15% % Resident population Source: Hampshire County Environment Department's 2006-based Small Area Population Forecasts Local Health Comparisons 2006 for the former South West Hampshire PCT stated outside of the New Forest, Southampton East and Test Valley South have relatively older population profiles Religion and belief Data for England based on the 2001 census indicate that Muslims, and particularly Muslim women, have higher rates of self-reported not good health and higher rates of limiting long term illness compared with other faith groups. England % Southampton UA % Great Britain agestandardized self-reported not good health rates (%) Great Britain Age standardized limiting long term illness or disability (%) Men Women men women Christian Buddhist Hindu Jewish Muslim Sikh Other No religion Not stated Page 25 of 72

28 5.5 Sexual orientation A review of 10 UK surveys by the Office for National Statistics estimated that the proportion of the population self-identifying as lesbian, gay or bisexual (LGB) ranged from 0.3 per cent to 3 per cent (ONS 2008). Local data for Southampton and Hampshire are not available. 5.6 Socioeconomic Deprivation A recent assessment by the Audit Commission concluded that: Deprivation is dispersed throughout the population with concentration in specific wards which also have the greatest level of health inequalities. Poverty levels in Southampton are higher than the England average with 10,900 children living in low-income households and 30,000 people dependent on means tested benefits. Life expectancy is increasing but there are significant differences between income groups (Southampton PCT 2008) The JSNA states that: 28.4 % of Southampton s children are living in families receiving means-tested benefits compared with an average of 22.4% for England. This places the region in the worst 25% nationally for this indicator. Southampton District Council and PCT have identified eleven Priority neighbourhoods. These neighbourhoods each include Super Output Areas (SOAs) that are in the most deprived quintiles for the District on various sub-domains of the Index of Multiple Deprivation (These data are reported in the JSNA). 5.7 Deprivation in relation to proposed fluoridation coverage A technical feasibility study for water fluoridation in Southampton identified two viable schemes. Together, these would supply fluoridated water to approximately 196,000 residents - 160,000 in Southampton (67% of the population of Southampton PCT) and 36,000 in Hampshire PCT. [May 2008 Board paper]. The areas that would be covered are: Central Southampton, Lordshill, Freemantle, Polygon, Totton, parts of Eastleigh, Weston, Shirley, Portswood, St Denys, Netley, Aldermoor, Millbrook, Bassett and Woolston. The majority of the proposed fluoridation area falls within Southampton PCT, Eastleigh, Totton and Netley are in Hampshire PCT. From visual inspection of the maps provided in the SHA Board Paper (HA08/046) it appears that the Southampton wards that would have least coverage are Peartree, Sholing, (PCT South Locality), parts of Bitterne Park, Swaythling (East locality) and parts of Bassett and Coxford (North locality). The table below maps the proposed water fluoridation scheme coverage against Priority Neighbourhoods, administrative boundaries, schools and school dmft levels (2006 survey of 5 year-olds). It should be noted that these are approximations. Administrative boundaries are artificial constructs and do not have a direct correspondence with communities or neighbourhoods. Similarly, GP practice and school catchment areas may cross more than one boundary. For this analysis, schools were mapped to wards by postcode. Page 26 of 72

29 Table 8: Coverage of the scheme. Priority neighbourhoods, electoral wards and schools. JSNA priority areas Electoral Ward / approximate PCT locality Proposed coverage by the two viable schemes Schools with mean dmft > Bevois and Bargate Bevois 2. Portswood and St. Denys Bargate (Central) Portswood (North) 3. Thornhill Bitterne (East) 4. Outer Shirley Redbridge / Shirley (West) 5. Weston Woolston (South) 6. Lordshill Coxford 7. Flower Roads, Hampton Park and Mansbridge 8.Freemantle and Polygon (West) Swaythling (North) Freemantle (Central) 9. Townhill Park Harefiled / Bitterne Park (East) 10. Harefield Harefield (East) 11. Shirley Estate Shirley (West) Central Southampton Portswood St. Denys NOT COVERED Shirley Weston Lordshill PARTIALLY COVERED Freemantle Polygon NOT COVERED NOT COVERED Shirley Maytree infants St. John s Infants Bevois Town Primary St. Mary s St. Denys Primary Kaneshill Primary Newlands Primary Redbridge Primary Mason Moor Primary Weston Park infants Sinclair infants Fairisle Swaythling Mansbridge Primary Banister infants Town Hill Infants Shirley Warren Primary Millbrook Bassett Bassett Bassett Green Infants (North) Coxford Aldemoor Redbridge (Hampshire PCT) Totton No data (Hampshire PCT) Netley No data (Hampshire PCT) Eastleigh No data This assessment suggests that Kaneshill Primary, Swaythling, Townhill infants and Bassett Green schools are in the relatively high dmft range and children attending them may not be covered by the proposed fluoridation scheme, depending on their precise catchment areas. Page 27 of 72

30 6 Epidemiology 6.1 Dental health in England Children Two of the most frequently used outcome measures for dental health in children are mean (average) dmft/dmft 18 and percentage of children who are caries-free. Both of these outcomes have shown a substantial improvement in recent decades. The Department of Health, in Choosing Better Oral Health (2005) reports that 12 year-old children in England now have the best dental health in Europe. Table 4: Improvements in dental health. Data source: Choosing Better Oral Health Outcome measure Early 1970s 2003 Children with no experience of tooth decay on starting school 30% 59% 12 year-old children with tooth decay 93% 30% Average DMFT, 12 year-olds However, epidemiological data also shows that children s dental health as measured by mean dmft /DMFT is now starting to plateau. See Figure 1. Figure 9: Average dmft/dmft per child in England Source: Data from National Children s Dental Health Surveys 1973 to Harker R and Morris J (2005). Office for National Statistics, London 18 Decayed, missing or filled teeth. Throughout this text, dmft denotes primary (child) dentition; DMFT denotes permanent (adult) dentition. Page 28 of 72

31 6.1.2 Adults In adults, changes in dental health have been demonstrated for the outcome proportion of adults with no natural teeth. There has been a progressive improvement in this outcome since 1968 although the Department of Health (2005) reports that England performs poorly on this outcome compared with some other European countries: Figure 10: Adults in England with no teeth Source: Choosing Better Oral Health 6.2 Dental health in South Central SHA South Central SHA ranks fifth of eleven SHAs for overall dmft in 5 year-old children (2006 BASCD survey). The following section draws on this survey unless otherwise stated. Page 29 of 72

32 Figure 11: Decay experience of 5-year-old children in English SHAs and in Scotland and Wales, Source: NHS South Central Board Paper May 2008 HA08/046 Decision to consult on proposal for water fluoridation in Southampton 6.3 Dental health in Southampton and Hampshire PCTs Mean dmft in 5 year-olds 2006 Five year-olds within the South Central SHA region, Southampton PCT have the highest estimated mean number of missing teeth of all 9 PCTs. The SHA is ranked eighth for estimated mean overall dmft. Hampshire and Oxfordshire are the two PCTs with the lowest mean dmft: Page 30 of 72

33 Figure 12: Average dmft in 5 year-olds, PCTs in South Central SHA Source: NHS South Central May 2008 Board Paper HA08/046 (Original data: BASCD 2006 Survey). The mean number of dmft per child at age 5 in Southampton was 1.76 in , compared with an England mean of 1.47 and a South Central mean of Presence of caries Forty two percent of Southampton PCT children had some dmft compared with 38% for England and 35.7% for NHS South Central; Hampshire had the lowest percentage of children with any dmft across the nine South Central PCTs: Table 5: Mean dmft and presence of any dmft. South Central SHA PCTs. Health geography Mean (average) dmft England South Central SHA Berkshire East Berkshire west Buckinghamshire Hampshire Isle of Wight Milton Keynes Oxfordshire Portsmouth Southampton Percent of children with no Dmft Source: BASCD 2006 survey of dental caries in 5 year-olds. BASCD 2006 Survey Page 31 of 72

34 6.4 Dental health inequalities (Socioeconomic) England Equality Impact Assessment: Southampton Fluoridation Scheme Data from the National Children s Dental Health Surveys showed that 5 year-old children in less socio-economically advantaged groups had a consistently higher chance of having some dmft/caries. Choosing Better Oral Health (2005) notes that in the 2003 survey, the probability of having obvious decay experience of the primary teeth was about 50% higher in the lowest social group than in the highest social group. Among 15 year olds from managerial and professional backgrounds, 47% had obvious decay experience compared with 65% from routine and manual socio-economic backgrounds. Among adults, people in social classes III, IV and V were three times more likely to have lost all their teeth than those in social classes I and II. Figure 13: Proportion of caries-free 5 year old children Source: National Children s Dental Surveys, cited in Choosing Better Oral Health Southampton The mean (average) dmft for 5 year olds by school tends to be higher in schools in the more deprived areas of the city. Figure Page 32 of 72

35 Figure 14 on the next page shows mean dmft mapped to the eleven priority areas (See Demography section). Page 33 of 72

36 Figure 14: Average dmft score for schools in Southampton Source: Briefing Paper submitted to Southampton City council Health Overview and Scrutiny Committee. Item 9 Appendix 1. Dr. Andrew Mortimore. Surveys from the last ten years indicate that the percentage of children with dmft /DMFT has remained consistently higher in the eleven priority neighbourhood schools compared with other schools. Figure 15: Percentage of pupils with any dmft 1997/98 to 2005/06 Source: Briefing Paper submitted to Southampton City council Health Overview and Scrutiny Committee. Item 9 Appendix 1. Dr. Andrew Mortimore. Page 34 of 72

37 In summary, although there has been an improvement in dental health over the last 30 years, people who live in deprived areas have benefited less that those in more prosperous areas. In Southampton this means that, overall, residents experience more caries and damaged, missing or filled teeth Community dental services A community dental and oral health programme has been implemented across the city. Five schools in high risk areas were specifically targeted for support (JSNA). In 2004, as part of their Health and Wellbeing Strategy Southampton City PCT set targets to achieve: an average of less than one decayed, missing or filled teeth at the age of 5, 70% of children with no dental decay, A 25% reduction in inequalities between priority areas. Their overall aim is for Southampton s children [to be] enjoying some of the best dental health in England. The PCT is planning additional oral health promotion initiatives for those priority neighbourhoods not covered by the proposed fluoridation scheme. Page 35 of 72

38 7 Evidence review 7.1 Potential benefits and harms The evidence for this section is taken from two systematic reviews the York Review (McDonagh 2000) and the Australian NHMRC review (AU Gov 2007). A systematic review is considered to be the highest quality form of evidence available. The York systematic review was based on a thorough and systematic search for primary sources (original research), with strict pre-determined criteria for inclusion or exclusion of studies. This methodology minimises the possibility of selection bias in the choice of studies reported and ensures a minimum standard of research. The reviewers carried out some meta-analysis 19, including only studies that were similar with respect to important variables. The NHMRC review sought to build on the York review. Both studies used a lower threshold 20 for inclusion of studies examining possible harms. Because the two papers primarily addressed dental caries outcomes in children, we used an additional systematic review (Griffin 2007) to examine evidence relating to adults. This section reports the reviewers conclusions on benefits and harms in the general population that is, not with particular reference to any of the six groups to be addressed in the EqIA. The evidence for potential economic impacts is taken from the NHS South Central Board paper (May 2008 HA08/046). It should be noted that where this EqIA report states that there is no evidence of association, this does not exclude the possibility that a link may be found in the future Water fluoridation and prevention of dental caries Babies The two systematic reviews used for the EqIA did not describe any differences in outcome for children who had been exposed to fluoride as babies, compared with people who had been exposed only at later ages Children The York systematic review (McDonagh 2000) analysed data from 25 research studies in children at various ages from 5 to 14 (in addition one study looked at fluoridation effects in adults). Out of thirty analyses 21, 20 showed a statistically significant change, with a greater proportion of caries-free children in the fluoridated area (one found a statistically significant greater decrease in the proportion of caries-free children). The remaining 10 analyses did not detect a statistically significant difference. The median (average) difference between the percentage of caries-free children before and after fluoridation was 14.6%. The review concluded that fluoridation is effective in preventing caries in children. They stated that the large differences observed were unlikely to have been accounted for by confounders. The cariesprotective effect appears to be progressive: 19 Analyses that combine the results of a number of studies, using statistical techniques to control for the variability among the original studies. 20 That is, they were less stringent in their criteria for inclusion, so that a wider possible range of studies would be included, thus reducing the risk of missing important findings. 21 One research study may report more than one data analysis. Page 36 of 72

39 For both [these] outcome measurements, increased duration of follow up was associated with a greater difference in the change in caries measurement from baseline to final examination in the fluoridated compared with the control group. The authors calculated that for one extra person to be caries-free, six people need to receive fluoridated water Adults A 2007 U.S. systematic review (Griffin 2007) conducted secondary analysis of findings from studies of the effects of water fluoridation on adults at ages 20+ years and 40+ years. From a summary based on analysis of five post-1979 studies, the reviewers concluded that water fluoridation improved DMFT scores by 27.2% in adults. Further robust reviews of UK data would be beneficial to confirm the effect of water fluoridation in adults in this country Water fluoridation and fluorosis Dental fluorosis is a mottling of the teeth associated with fluoride intake. The York review (McDonagh 2000) looked at 88 studies from around the world, predominantly of children. They found statistically significant differences in fluorosis prevalence at 1ppm fluoride concentration compared with a reference level of 0.4ppm. With this magnitude of increase in fluoride concentration (similar to that implemented in most water fluoridation schemes), six people would need to be exposed to the water for one extra person to have any fluorosis. The risk is higher in permanent than in primary teeth and the prevalence of fluorosis increases with increasing concentrations of fluoride in water (i.e. a dose-response relationship exists). The authors state that there is evidence that very mild fluorosis is not concerning to people and some people found the appearance of mild fluorosis more attractive than no fluorosis. They therefore carried out a second analysis of fluorosis of aesthetic concern (as judged by children, using a published index) and state that 22 people would need to be exposed to the water for one person to have fluorosis severe enough to cause concern. The finding was supported by the Australian NHMRC (2007) review, which concluded that metaanalysis of additional original studies provides results consistent with those seen in the existing systematic reviews Fluoride and bone health The York review (McDonagh 2000) analysed 27 primary research studies of potential positive and negative impacts of fluoride on bone fracture and bone development problems. Various fracture sites, predominantly in adults (18 studies included hip fracture) were considered. Studies were included of both naturally occurring and artificial fluoridation. Findings from individual studies were mixed. Most showed no association; 5/30 analyses of hip fracture showed a significant positive (protective) effect; 4/30 showed a significant negative (harmful) effect. Meta-regression analysis of pooled data found no evidence of an association between water fluoridation and fracture incidence. Relevant to this EqIA, the York review (McDonagh 2000) found: Factors which would be expected to show an association with fracture incidence, such as fracture site, age and sex, were not associated with water fluoride at the 5% significance level in either the univariate or multivariate models. The later Australian NHMRC review (2007) considered three additional studies. Two of these looked at levels of water fluoridation of 4ppm (much higher than the 1ppm that is usually implemented). The third (Chinese) study found that, compared with a reference level of Page 37 of 72

40 ppm, the odds ratios for bone fractures increased both for lower and higher concentration levels of naturally occurring fluoride in water. The NHMRC authors interpreted this as indicative (weak evidence) of a possible protective effect of optimum concentrations of fluoride of approximately 1ppm. The data for hip fracture alone are less convincing than for all types of fracture combined. Findings from this study would require replication to support the NHMRC authors inferences with regard to a possible protective effect. If an association between longer term exposure and bone health were found (positive or negative) this would have implications for inequalities for people as they grow older. Neither of the systematic reviews specifically addressed this question. There is a suggestion in the York review that for bone health, the protective effect becomes stronger as the duration of follow-up increases (that is, the longer the time-lapse since the beginning of the study, the fewer the fractures observed): Cancers A statistically significant positive association was seen in studies that lasted for longer than 10 years, meaning that fewer fractures occur in fluoridated areas compared to nonfluoridated areas if they are studied longer than 10 years. The York review (McDonagh 2000) analysed 26 studies of potential associations between cancer incidence and water fluoridation. The reviewers concluded: The findings of cancer studies were mixed, with small variations on either side of no effect... Overall, from the research evidence presented no association was detected between fluoridation and mortality from any cancer, or from bone or thyroid cancers specifically. The NHMRC review (2007) identified four further studies. They reported that three of these had substantial methodological difficulties. The findings of a fourth study suggested an increased risk of osteosarcoma in young males, but the authors of the primary research had been unable to replicate the finding. If a gender-related difference were found in the future, this would have implications for inequalities Other potential negative effects Researchers have investigated potential associations between water fluoridation and a wide range of other effects, including Down s syndrome, goitre, and dementia. However, the York review found insufficient research to establish conclusions about any particular effects. Additional studies were reviewed by the NHMRC in These authors concluded that the research reviewed did not suggest an increased risk of other adverse events from 1ppm water fluoridation Socioeconomic variation and fluoridation The York Review addressed the question: Does fluoridation result in a reduction of caries across social groups and between geographical locations? The NHMRC did not specifically address socioeconomic variation in outcomes from fluoridation Prevalence of caries The York review pooled data from several studies. Their analysis showed that in 5-year-old children: Page 38 of 72

41 in both fluoridated and non-fluoridated areas the proportion of caries free children is significantly lower in those from socioeconomically disadvantaged groups relative to other groups at 95% confidence intervals. This finding was demonstrated in all four included studies of five year old children. in both fluoridated and non-fluoridated areas dmft levels are higher in children from socioeconomically disadvantaged groups relative to other groups. whether disease is measured in terms of caries-free or dmft levels, a social gradient effect was demonstrated for five-year old children: Prevalence of caries and mean (average) dmft levels increase with increasing social disadvantage. The gradient is steeper for dmft levels than for the proportion of children who are cariesfree. The evidence was weaker for older children where fewer studies have been conducted and/or confidence intervals were not provided Impact of fluoridation on socioeconomic variation in dental health The York Review pooled data from studies of dental caries experience in children stratified according to the Registrar General s Classification of Social Class 22. Pooled data from four studies showed that for five-year old children the dmft social class gradient is reduced in waterfluoridated areas. There was insufficient evidence to demonstrate this effect in other age groups. The review did not find evidence that fluoridation influences the social gradient for caries in children. Figure 16: dmft levels in 5 year old children by social class Source: York review (McDonagh 2000) Data pooled from four studies. Regression analyses included in the York systematic review showed that the effect size of water fluoridation on dmft levels in five year olds (two studies) and twelve-year olds (one study) increased in groups where social disadvantage is greater. The studies provide evidence that water fluoridation is effective for all socioeconomic groups and that the impact is strongest for more disadvantaged groups The Registrar General s Classification of Social Class is based on occupation and was widely used until Page 39 of 72

42 Individual financial impacts of the proposed scheme Based on the health economic analysis, South Central Strategic Health Authority reports (May Board Paper): Patients have to pay part of the cost of NHS treatment of tooth decay and therefore stand to benefit financially from prevention of tooth decay. The cost of treatment depends on the type of work carried out by the dentist and there would be no saving for patients who are exempt from dental charges, such as children and those on benefits.. There are poor data on the average costs of private dental care, but costs and therefore potential savings would be higher for patients treated in the private sector. Thus wealthier people stand to benefit more from cost savings associated with fluoridation. 7.2 Evidence for inequalities The evidence for this section is based on an initial search for dental or oral + health in the population groups of interest. The search spanned the National Library for Health (NLH) databases, the BASCD and the British Dental Association websites and the Office for National Statistics. Snowballing methods (Greenhalgh & Peacock 2005) were used to find evidence of inequalities in the pathways to dental health (the determinants of dental health). These included socioeconomic inequality, differences in nutritional patterns and differences in access to health services. The data accessed are predominantly from surveys or reviews of surveys Ethnicity Ethnicity and socioeconomic variation A review of research since 2001 for the Joseph Rowntree Foundation (Platt 2007) identified higher than average rates of poverty in all minority groups studied. The highest poverty rates were observed for Bangladeshi, Pakistani and Black African people. Bangladeshi people were identified as having the greatest poverty and the reviewers noted that poverty for this group also appeared to be severer and more long-lasting than that experienced by other groups. Caribbean, Indian and Chinese people also demonstrated rates above average. The review noted wide variation in poverty levels and the experience of poverty within groups, and a diversity of underlying reasons for poverty. They noted that even though those from White groups were least likely to be in poverty, among those White British claiming means tested benefits, low-income persistence was found to be greatest. Differences in socioeconomic status are associated with different prevalence of dmft/dmft and response to water fluoridation Ethnicity and oral/dental health An editorial (2007) in the British Dental Journal reported that a link has been found between country of origin and oral health Rates of tooth decay and periodontal disease can be linked to ethnicity and country of origin even among immigrants who have lived for many years in the United States, according to a New York University (NYU) College of Dentistry research team. For Southampton, where the ethnic mix is different, this constitutes indirect evidence of potential differences in biological risk. Studies of children s dental health from the UK present a complex picture. In a study of 5-year olds in Glasgow, Pakistani children had significantly higher prevalence of caries than other ethnic groups after adjusting for socioeconomic variation (Conway et al 2007) Page 40 of 72

43 A survey of 12 year-old children from Leicestershire and Rutland found that the overall prevalence of caries was greater in White than Asian children, but varied at different levels of deprivation and amongst different Asian religious groups. Among White children there was a significant positive association between caries and deprivation (more caries in children living with higher levels of deprivation), but the trend was reversed in non-muslim Asians (less caries with higher levels of deprivation). Muslim children had higher levels of caries than non-muslim Asian children (Dugmore & Rock 2005). Another study from Dudley compared the dental health of 5 year olds from similarly deprived South Asian and White communities living in a fluoridated area. This study found a significantly higher prevalence of dental caries in South Asian children and suggests that fluoridation does not eliminate ethnic differences in caries levels (Gray et al 2000). An earlier study from Leeds (Prendergast et al 1997) which also attempted to tease out the effects of deprivation and ethnicity concluded that ethnic differences in children s dental health were independent of deprivation. This study found that Asian children from the most deprived districts had significantly worse dental health than White Caucasian or Afro-Caribbean children. Like the Rutland study, it found that Muslim Asians had significantly more caries than non- Muslim Asians (controlling for deprivation). Thus Children from certain ethnic groups (especially Muslim Asians) have a higher prevalence of caries (mean dmft/dmft) and there is some evidence that this difference persists in fluoridated areas. However, the differences between minority ethnic groups are also significant, and the available studies offer piecemeal evidence. Different ethnic groups also seem differently susceptible to the effects of deprivation (as outlined above), suggesting that a range of factors play a part in the observed ethnic differences Ethnicity and access, uptake and receipt of services Surveys indicate that uptake of many health promotion and education services is lower in some minority groups, particularly Pakistani and Bangladeshi. Studies have consistently reported under-use of GP services by the Chinese population. However, uptake of services is highly variable within groups and across different types of service (Aspinall & Jacobson 2004, Gill et al 2007). Studies of specific minority ethnic groups have found lower use or receipt of care from dental services by some groups compared with the majority population (Gill et al 2007). For example, there is some survey evidence of under-use of dental services by Bangladeshi groups (Platt 2007). Qualitative research indicates that different ethnic groups have different cultural and lifestyle patterns that predict their uptake and receipt of dental services (Newton et al 2001, Kwan et al 2000). Interviews and focus groups with gypsy and traveler communities 23 indicate that these groups have lower uptake or receipt of services. Many experience difficulty accessing a range of primary health care services. New Roma gypsy and traveling communities mainly from Eastern Europe face additional challenges since services may not have built up contacts with these groups and they remain hidden (Aslam et al 2007) This research was carried out in the East Midlands. Local variations will apply but as these communities by definition move to other parts of the country, the research has much relevance for traveler communities throughout England. Page 41 of 72

44 Ethnicity, diet and nutrition Some studies indicate that in the UK there are lower breastfeeding initiation and continuation rates among white women compared with other ethnic groups (Kelly & Watts 2006, Griffiths et al 2007). The MRC cites previous research by the NHMRC which indicates that different infant feeding choices are associated with different fluoride absorption and fluorosis outcomes: The conclusions of the NHMRC were that breast-fed infants under six months in fluoridated and non-fluoridated areas are likely to have sub-optimal intakes of fluoride. The same is true of breast-fed infants of any age in fluoridated areas, who do not use fluoridated toothpaste. Individuals most likely to have supra-optimal fluoride intakes are formula-fed infants in fluoridated areas, infants in non-fluoridated areas fed on high fluoride containing formula, and individuals with excessive toothpaste use and ingestion. Relatively high concentrations of fluoride and relatively high prevalence of fluorosis has been associated with Brick tea in some countries and with Trona (a salt) in some parts of Tanzania (Jin et al 2003). We found no evidence of consumption of brick tea by particular ethnic groups in the UK. However, the possibility that this or other dietary variations occur in small minority ethnic groups cannot be ruled out. Fluorosis from this cause can be prevented by replacement with low-fluoride variants (Jin et al 2003) Ethnicity and disability The Joseph Rowntree review (Platt 2007) found higher rates of sickness and disability among Bangladeshi households compared with other ethnic groups. At a population level any impacts of the fluoridation scheme associated with disability may have a larger impact on some minority ethnic groups than on the general population Ethnicity and mental health Aspinall (2004) reported that rates of common mental disorders (such as depression, anxiety, panic disorders and obsessive compulsive disorder) were high in Irish men and Pakistani women but the differences between groups for these disorders were not marked Disability Disability and socioeconomic variation Disabled people are twice as likely to live in poverty as non-disabled people, where poverty is defined as living in a household with income of less than 60% of median (average) national income. A recent report estimates that around 30% of disabled people live below this income line, compared to around 16% of non-disabled people (Parckar 2007) Disability and oral /dental health At a population level people with disabilities or long term conditions have more risk factors for dental caries. Risk factors include inadequate salivary flow and composition, high numbers of cariogenic bacteria, insufficient fluoride exposure, gingival recession, immunological components, a need for special health care and genetic factors (Selwitz 2007). Increased oral health care need and / or difficulties with independent tooth cleaning or oral care have been documented for a range of disabilities. These include disability following stroke (Hunter et al 2006), visual impairment (Mahoney 2004, Nzegwo 2004), dementia (Hilton & Simons 2003, Australian Centre for Evidence Based Residential Aged Care, 2004), multiple Page 42 of 72

45 sclerosis (Baird et al 2002), eating disorders (lo Rosso 2008, Dougall & Fiske 2008) and many mental health problems (Griffiths et al 2000). Some medications contain sugar or are associated with increased oral and dental health risk factors. For example the effects of antidepressants and antipsychotics include decreased saliva flow, dry mouth, dyskinesia (abnormal movements) associated with grinding of teeth and a higher prevalence of oral mucosal lesions (Australian Centre for Evidence Based Residential Aged Care 2004) Disability and access, uptake and receipt services There is evidence that people with disabilities experience barriers in accessing services; for primary care in general and for dental surgeries specifically. Twenty-four per cent of deaf or hearing impaired people miss appointments and 19% miss more than five appointments, because of poor communication such as not being able to hear staff calling out their name (RNID 2004). People with disabilities are four times more likely than the general population to find dental surgeries inaccessible or inadequate, and twice as many find their doctors surgery inaccessible (Leonard Cheshire 2002). Forty per cent of visually impaired people believe that their GP is not fully aware of their needs, rising to 60% for other surgery staff. Many visually impaired people cite low staff awareness and a lack of accessible information (Nzegwu 2004). A survey in Leicestershire indicated that, despite the challenges of physical access to dentists buildings, people with Multiple Sclerosis had higher registration and routine attendance levels than a national sample 24. This level of access is at least partially relative to need, since the study sample also demonstrated increased oral health needs (Baird et al 2007). Similarly, a UK study found that children with Down s syndrome have high levels of registration with a dentist and are more likely to attend regularly than children who do not have Down s syndrome. However, the study found that the Down s syndrome children received minimal levels of preventive therapy such as fluoride treatments and fissure sealing (Kaye et al 2005). The following extract from the Department of Health s Valuing People s Oral Health (DH 2007a) illustrates the difficulties faced in providing oral and dental care for people with severe disabilities: Delivering a quality service to children and adults who may have poor understanding, uncontrolled movements, limited mouth opening, poor posture or limited mobility, who may experience tiredness during treatment or have medical problems, presents a range of difficulties and barriers. For some people with disabilities, oral health care and access to professional services may depend partly on how and where they are cared for. In a South Australian survey, differences were associated with the extent of carer contact, amount of oral assistance provided and the context for care. People cared for in family homes accessed professional services less frequently than those cared for in institutions It should be noted however that the two surveys had different aims and methodologies and were conducted at different times. Page 43 of 72

46 Disability, diet and nutrition People with disabilities are at higher risk for dysphagia (swallowing disorders) and nutritional problems. The exact prevalence of dysphagia in people with disabilities is not known. Estimates vary with diagnostic methods and vary according to the type of disability. One study reported a 37% - 78% incidence of dysphagia following stroke (Foley et al 2005). A local audit in the West Midlands reported dysphagia prevalence of 29% in adults with profound learning disabilities (Gittins & Rosem 2008). A proportion of people with dysphagia receive fluids and nutrition by a non-oral route, and this group may not receive the same exposure to, and therefore bioavailability of, fluoride as the general population 25. This impact would be mitigated if non-oral feeds contain fluoride or are reconstituted with fluoridated water. Variation in fluid uptake and absorption associated with specific long term conditions may impact on the effectiveness of water fluoridation for people with these conditions. There is continuing debate about variation in fluoride intake, absorption and bioavailability. Factors that may affect absorption include individual variation, the type of fluoride compound present and qualities of the water such as water hardness/softness (Maguire et al 2005) Mental health, self esteem and discrimination Associations between stigma, discrimination, self esteem and wellbeing are receiving increasing attention as public health issues. In one survey of people with disabilities in London, 34% said they faced discrimination on a regular basis (London Development Agency). Some psychiatric disorders may be associated with heightened concerns about appearance and requirement for cosmetic dentistry (De Jongh et al 2004). Therefore it is possible that people with some types of mental health problem may experience fluorosis (see below) more negatively than the general population. The EqIA did not find any direct research evidence of this Gender Gender and socioeconomic variation In 2008 the ONS reported that women receive lower incomes than men on all measures of employment income (ONS 2008) Gender and oral /dental health The 1998 adult dental health survey (ONS 2008) found more dental caries in men: Teeth which had unrestorable decay were more likely to be found among dentate men than women (11% compared with 5%) Gender and access to services In the same adult dental health survey, women were more likely than men to report seeking regular dental check-ups (66% of women compared with 52% of men). Boys have a higher rate of permanent exclusions from school than girls [24]. This would make them more vulnerable to missing dental health services provided in schools. 25 Absorption through the gastrointestinal tract is the main mechanism for the caries-protective effect of fluoride (MRC 2002) Page 44 of 72

47 Gender and disability / long term conditions The incidence of hip fracture is strongly associated with age and gender. Bone health may also be associated with ethnicity (York Review, McDonagh 2000). Therefore, any associations between fluoridation and bone health (favourable or unfavourable) would have differential impacts on these groups Sexual orientation Sexual orientation and access, uptake and receipt services There is some evidence that lesbian women may experience differences in receipt of preventive services (Hutchinson 2006, Jorm et al 2002). A report by Stonewall for the Department of Health provides illustrative examples of how health promotion messages may fail to reach gay/lesbian women, gay men and bisexual people (Hunt & Minsky 2006) Sexual orientation, disability and mental health Several surveys from different geographical communities around the world have found evidence of higher levels of psychological distress and risk of mental health disorders among gay/lesbian women, gay and bisexual men (Balsam et al 2005, King et al 2004, Jorm et al 2002, Cochran & Mays 2007) Age Age and socioeconomic variation The extensive review for the Joseph Rowntree foundation (Platt 2007) concluded that child poverty rates are greater than adult poverty rates across all ethnic groups Age and dental health (see also Section 5 Epidemiology). When considering equality implications for different age groups it is important to bear in mind that norms and expectations and also treatment practices are likely to change across generations. Consequently, it is not possible to say that differences in outcome between people of different ages result from age inequalities per se. Outcomes that can be attributed to age differences are therefore qualitative and relative to need for example, there may be differences in the way people of different ages experience pain or social embarrassment from dental health issues Children According to the most recent BASCD survey ( ), 39.4% of 5 year-old children in Great Britain had dentinal caries. Young children may have a different subjective response to the impacts of caries (e.g. pain, oral function, confidence) compared with older children (Nuttall et al 2003). Page 45 of 72

48 Young people In 2003 the UK Children s Dental Health Survey found that 10% of 12 year-olds and 9% of 15 year-olds sampled felt their oral health had affected their self confidence, compared with 4% of five year olds 26. The BASCD survey found a mean (average) of 33% of 11 year-olds with dental caries. The authors emphasized the importance of protecting teeth in the early stages of permanent dentition (BASCD 2004/05): The condition of the permanent teeth in the pre-teen years will, to a large extent, determine the future dental health of emerging population cohorts of young adults Adults Caries remains a significant problem for adults. Figure 17: Percentages of adults with no teeth (English regions). Source: Choosing Better Oral Health. Although advances in treatment and prevention mean that more adults are retaining their teeth, missing teeth remains a significant problem for older people. Within the older population there is significant regional variation for this dental outcome. Griffin (2007) points out that as the proportion of older people in the population increases, so the number of teeth at risk of decay increases. Subsequently, in terms of numbers of people or numbers of teeth protected the effects of whole-population interventions are potentially larger for older people relative to other age groups The questionnaires were completed by parents and confidence intervals are not given for the results. The study is presented as illustrative of potential variation in impact of dental health for people of different ages. Page 46 of 72