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Franklin Barbosa da Silva 1 Article
Deprived areas and community water fluoridation in Brazil: a multilevel approach for refocusing public policy
Franklin Barbosa da Silva, José Leopoldo Ferreira Antunes, Paulo Frazão
Epidemiol Health. 2021;43:e2021031.   Published online May 1, 2021
DOI: https://doi.org/10.4178/epih.e2021031
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Abstract
OBJECTIVES
The aim of this study was to determine whether geographic location, socioeconomic status, infant mortality, and mortality from diarrheal disease in health regions are associated with the provision of community water fluoridation (CWF) in Brazilian municipalities.
METHODS
A multilevel ecological study was conducted based on data from the National Survey of Basic Sanitation and Human Development Atlas. A multilevel analysis was carried out considering Brazilian municipalities as the first level and health regions as the second level, comprising sanitation, demographic, socioeconomic, and health characteristics.
RESULTS
The observation units comprised 5,565 municipalities clustered in 438 health regions in Brazil. The lack of CWF provision was positively associated with the following municipal characteristics: a below-median proportion of inhabitants covered by the sewage network, medium to very low human development index, below-median per capita gross domestic product, and an above-median percentage of expenditures on sanitation. In relation to the health regions, the likelihood of a lack of CWF provision was greater in the municipalities belonging to the health regions located in the Northern and Northeastern areas of Brazil and in those where child mortality due to acute diarrheal disease and the proportion of people with low income were higher when adjusted by municipal indicators.
CONCLUSIONS
Information on the characteristics associated with CWF provision constitutes important input for refocusing public policy to reduce inequalities among Brazilian municipalities and health regions. These findings may help policy-makers to understand the challenges facing CWF expansion in low-, middle-, and high-income countries.
Summary
Korean summary
Key Message
Just as the challenges for CWF's expansion in Brazil's most vulnerable areas require firm leadership for refocusing public policy, expansion in low- and middle-income countries demands a continued global collaborative effort.

Epidemiol Health : Epidemiology and Health