Full text of DOI:10.1038/sj.bdj.4800521a

RESEARCH
public health policy
How much do the general public want
to be involved in decisions on
implementing water fluoridation?
1
2
3
R. J. Lowry, B. Thompson, M. A. Lennon,
Objective Test general public view about how much they wish
to be involved in water fluoridation implementation decisions.
Design Qualitative research using focus group discussions led
by an experienced moderator.
enshrined in public policy, it is important to discover the public’s
own view of its role. The objective of the study was to test the
view of the general public about how much they wish to be
involved in water fluoridation implementation decisions.
Setting Among the general public living in three non-
fluoridated areas in England.
Methods
Subjects Members of the public more than 20 years of age and
by social class.
Results General public wish to be informed of water
fluoridation plans but do not see themselves as being the
appropriate implementation arbiters.
The research adopted a qualitative, focus group methodology.
This method is commonly used in market research, and increas-
ingly in medical and dental research.5,6 It is particularly suitable
for identifying, exploring and explaining complex attitudes and
emotions, for example the public’s views of priority setting,7
ConclusionsIn the public’s eyes, it would be inappropriate and and can overcome some of the disadvantages of quantitative
unwelcome to delegate to them the decision about whether to
fluoridate the public water supply.
methods, especially non-sampling error such as the superficial-
ity of response.
Focus group discussions involve bringing together, in an infor-
mal setting, groups of six to eight subjects who are carefully
selected in social demographic terms, and asking them to discuss
Establishment support for water fluoridation in the United King- areas of interest under the direction of a group moderator.8 The
dom remains high: well-respected commentators on public health moderator encourages interaction and synergy between group
recommend further implementation to reduce inequalities in members and ensures that all the issues are explored in depth.
dental health,1 and the Government recognises this intervention as Members of the public were recruited to take part in one of six
an important route to improving the health of sections of society. focus groups in three non-fluoridated areas in England according
Nevertheless, how to involve the public in the decision-making to social class and age (Table 1). Subjects were recruited by
process when implementing new water fluoridation schemes trained and experienced market research interviewers according
remains an issue.2
to a strict code of conduct.9 Potential recruits who expressed
Under current legislation, before any new water fluoridation strong views for or against water fluoridation were excluded from
schemes are implemented, the public have to be informed the study groups. The groups were not made aware that fluorida-
(though not formally consulted),3 and in an increasingly con- tion was the core subject for discussion; water fluoridation was
sumer-conscious health service, their views are likely to be given but one of a number of issues for discussion about public involve-
even greater importance. Although, according to regular, rigor- ment in matters of local interest (Table 2). Focus group discus-
ously-conducted public opinion surveys, public support for sions lasting 1.5 hours were held at a central location (for
water fluoridation remains high, evidence is now emerging on example, a hotel), and subjects were paid a standard fee for par-
how the public feels about the role they might be ascribed in the ticipating. The moderator (who conducted and analysed all
implementation of water fluoridation.4 More needs to be under- groups) used a standardised discussion guide and each group was
stood about what the public knows, understands and feels about recorded on audio tape for later analysis. High profile media
water fluoridation; the role, if any, they want and feel able to play reporting of fluoridation issues was noted if it occurred before
in decision making about its implementation and the informa- any group discussion.
tion and other needs they have to discharge this role. Before a
greater public involvement in the decision-making process is
Table 1 Focus group composition by age, socio-economic
group (SEG) and location
1
Senior Lecturer in Dental Public Health/Consultant in Public Health Medicine,
Department of Child Dental Health, Dental School, University of Newcastle upon
Group
Age
SEG
Location
2
Tyne NE2 4BW; Senior Research Consultant, Flat 1a, 89 East Hill, Wandsworth,
London SW18 2QD (Formerly: Senior Research Executive, NOP Consumer,
3
Ludgate House, 245 Blackfriars Road, London SE1 9UL); Professor of Dental
1
2
3
4
5
6
20–35
36–50
50+
36–50
20–35
50+
C1,C2
C2,D,E
C1,C2
B,C1
C1,C2
B,C1
Hounslow
Hounslow
Leeds
Public Health, Department of Clinical Dental Sciences, The University of
Liverpool L69 3BX
Correspondence to: R J Lowry
REFEREED PAPER
Received 05.08.99; accepted 04.11.99
© British Dental Journal 2000; 188: 500–502
Leeds
Oldham
Oldham
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BRITISH DENTAL JOURNAL VOLUME 188. NO. 9 MAY 13 2000

RESEARCH
public health policy
Results
Table 3 Degree of public involvement in decision-making by issue
Awareness of water fluoridation
Always wish to be involved
Closure of local hospital
Closure of casualty facility
Relocation of schools
Sometimes wish to be involved
Relocation of well baby clinic
Public transport
The topic of water fluoridation was easy to explore in all groups
and it did not become the dominant topic of conversation even
in groups which took place following an emotive report in a
popular television consumer series. Although most group par-
ticipants were aware of water fluoridation, there were miscon-
ceptions: for example, some people mistakenly thought that
their water supplies were already fluoridated at the appropriate
level. There was little detailed understanding of water fluorida-
tion and confusion surrounding the benefits or possible objec-
tions, even in an area where a formal publicity and consultation
exercise had been undertaken.
Building a new hospital
Opening of psychiatric home
Drug issues
Area redevelopment
New road planning
Food fortification
Water fluoridation
Sex education
Relocation of old peoples homes
Relocation of dental clinic
information and accessibility were expressed, together with the
view that the local community is usually made aware of issues well
Being involved in decisions
After an initial discussion, the public’s involvement in decision- after decisions have been finalised.
making processes was explored in a dynamic fashion. At first, the
‘They don’t ask you what you want, they just do things their own
groups would only talk about the relative importance of services way to suit themselves.’ (Leeds, 50+, C1,C2)
and issues that directly concerned them (for example, local traffic
Indeed subjects only saw real public involvement when it was
problems) or those that are high profile within the community initiated by the community in opposition to a decision strongly
(such as hospital closures).
opposed.
To overcome this, a wide range of issues including fluoridation
‘It was the community, if a group of people want to do some-
was presented (Table 2), so that they could rank them in relation thing, they would take it upon themselves to set something up on
to their desire to be part of the decision-making process. Groups their own.’ (Oldham, 20-35, C1,C2)
were divided into sub-groups of two or three people and were
Subjects were receptive to being involved in decision making but
given a set of cards on which were written the issues (Table 2), felt the initiative to inform the public and seek participation should
and a board on which the cards could be freely displayed. Each be taken by some authority (for example the local council, the
board was marked with a scale with ‘definitely would like to be health authority).
involved with the decision-making process’ at one end and ‘defi-
‘I think a lot should come down to the council, being proactive,
nitely would not like to be involved with the decision-making you know the council, poking us and saying sit up, wake up, this is
process’ at the other. The cards were given to the sub-groups and going to happen, what do you think? It is down to them to do that,
they were asked to place the individual cards along the scale shouldn’t be down to us to find out what they are doing.’ (Leeds,
according to their preferred degree of involvement in the deci- 50+, C1 C2)
sion-making process. Each card was placed independently so
that no hierarchy was implied.10
‘It is a new concept that we could perhaps affect some of these
decisions, I don’t know how we can.’ (Leeds, 50+, C1 C2)
This procedure was confusing for participants initially. The very
The groups considered a number of ways public opinion might
first group started to place all cards on the ‘definitely want to be be assessed, including referenda, citizen’s juries, citizen’s panels and
involved’ end because they assumed ‘being involved’ meant ‘being (the most popular) question and answer sessions in the local coun-
informed’. After being told to assume that they would have all the cil. Citizen’s panels and juries were well received as ideas, but refer-
information they desired and just to concentrate on the involve- enda, although inviolable and all-embracing, were not.
ment in decision-making, they (and all subsequent sub-groups)
‘The problem with referendums is always unfortunately, you get
were able to place the cards along the scale of involvement to reflect everybody putting in their two pennies and a lot of the opinion and
their intended views. Water fluoridation was consistently among therefore the vote is totally uninformed.’ (Oldham, 50+, BC1)
the issues which members of the group placed as warranting a low
level of involvement (Table 3).
Opinion surveys were seen as a good way to get a representative
sample of the views of a large number of people.
On the subject of information/consultation about water fluo-
ridation, the groups agreed that a package of measures was the
The mechanics of ‘consultation’
The groups showed a general lack of knowledge about public ‘con- best: ways in which citizens could be involved and informed
sultation’ on local issues: feelings of lack of trust, communication, combined with quantitative methods to gauge the opinion of a
greater number of the public.
Table 2 Local issues for discussion in
The decision to fluoridate
focus groups
The groups agreed that they did not want to be involved in final
• Water fluoridation
decisions about the implementation of water fluoridation
schemes and that this particular issue was best left to professionals
provided that information was available to the public from an
independent body:
‘It depends on how major the decision is, like you said you don’t
want to be pestered all the time, but at the moment I don’t feel
involved in anything.’ (Hounslow. 20-35)
‘However the community gets their opinions into the frame, you
have still got to have some body which will arbitrate and make the
final decision otherwise you would never get a decision made and
nothing will ever happen.’ (Oldham, 50+)
‘I agree a decision which involves a particular knowledge or a par-
ticular skill which Joe Public doesn’t have, the big decisions should
• Food fortification
• Closure of local hospital
• Closure of casualty facility
• Relocation of well baby clinic
• Relocation of dental clinic
• Relocation of schools
• Area redevelopment
• New road planning
• Public transport
• Drug issues
• Sex education
• Relocation of old peoples homes
• Building a new hospital
• Opening of psychiatric home
BRITISH DENTAL JOURNAL VOLUME 188. NO. 9 MAY 13 2000
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RESEARCH
public health policy
be made by the professionals. But it would be nice to be advised responsibility (public health bodies, politicians) off the hook. In
beforehand as to what they think they should do.’ (Oldham, 50+)
‘But I think we should be informed about it, to be told that it is public (for example in a referendum) will be seen by the public as
happening.’ (Leeds, 50+) the government avoiding responsibility. Second, even after all
other words, passing the buck by leaving the final say to the
The groups also thought that water fluoridation implementation the years of the so-called ‘fluoridation controversy’, the public in
decisions should not be solely a local matter; to proceed with the UK and elsewhere has remained resolutely apathetic.12
implementation required national government/expert endorse- Third, as water fluoridation is still urgently needed in some parts
ment .
‘You have to have someone who has the intelligence — as you
of the UK, there is nothing to be gained by waiting for the public
ve to ‘rise up’ and demand fluoridation either spontaneously or
’
found out none of us really know much about water fluoridation. after an awareness-raising campaign. There is never likely to be a
Maybe if we were educated in that department then, yes, we would national outcry for fluoridation, and it is ducking responsibility
be able to speak up, but because we don’t, we have to leave it to to assert otherwise.
someone out there.’ (Hounslow, 20-35)
‘Surely the experts ought to get together and decide if it’s a good eral public wish to be informed about water fluoridation plans,
thing or a bad thing.’ (Leeds, 36-50) but do not see themselves as the decision makers. The public
‘But surely this is a medical issue, it should be decided by medical expect experts (such as health authorities) to take the decisions —
people, not by politicians.’ (Leeds, 36-50) and when the decision is made to implement new schemes, it
There are a number of implications for policy makers. The gen-
‘They should have an independent medical committee that says should be simpler for this to happen.
that water should have fluoride then they should inform the gov-
ernment and the government tells the water companies, it’s done
on independent advice, I would trust that.’ (Hounslow, 20-25)
‘I would say with something like water fluoridation, an indepen-
dent board should be set up to make that decision, independent of
the water company.’ (Oldham, 20-35)
1
Acheson D. Independent Inquiry into Inequalities in Health Report. 1998.
HMSO, London.
Our Healthier Nation. London: HMSO, 1998.
2
3
4
Water Fluoridation Bill. London: HMSO, 1985.
Hastings G B, Hughes K, Lawther S, Lowry R. The role of the public in
water fluoridation: public health champions or anti-fluoridation freedom
fighters? Br Dent J 1998; 184: 39-41.
5
Hastings G B, Lawther S, Eadie D R, Haywood A, Lowry R, Evans D.
General anaesthesia: who decides and why? Br Dent J 1994; 177:
332-336.
Hastings G, Hughes K, Lowry R. Promoting sugar-free medicines: parents
views. Br J Roy Coll Gen Practit 1997; 47: 823-824.
Dolan P, Cookson R, Ferguson B. Effect of discussion and deliberation on
the public’s views of priority setting in health care: focus group study. BMJ
1999; 318: 916-919.
Discussion
Public awareness of fluoridation has not improved over the years;
as shown in this study, there is still a widespread lack of knowledge
of the availability of water fluoridation. The public support the ini-
tiative, wish to be informed about water fluoridation plans but
expect experts to carry the burden when it comes to final decisions,
and national experts at that. It is interesting to note that, no matter
what new sophisticated ways we can devise to involve the public in
decision making,11 experts are still expected to take most of the
responsibility for these sometimes controversial decisions.
There are policy issues raised by this and similar studies. First,
the public are unwilling (and/or unable) to make decisions on
complex issues such as water fluoridation, and no amount of
involvement or ‘consultation’ will let those in positions of
6
7
8
9
Kitzinger J. Introducing focus groups. BMJ 1995; 311: 299-302.
Code of conduct. In The Market Research Society Yearbook. pp62-76.
London: Market Research Society, 1996.
10 Kitzinger J. Introducing focus groups. BMJ 1995; 311: 299-302.
11 Summers A, McKeown K. Local voices: evolving a realistic strategy on
public consultation. Public Health 1996; 110: 145-150.
12 Levallois P. Knowledge, perception and behaviour of the general public
concerning the addition of fluoride to drinking water. Can J Public Health
1998; 89: 162-165.
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