Adherence and Attrition in Public Fluoride Varnish Programs: A Mixed-Methods Systematic Review.
Nathan Zeyang-Liu, Rahul Gupta, Joseph Chiang et al.
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In 30 seconds
This mixed-methods systematic review examined barriers and facilitators to repeated fluoride varnish (FV) applications in public programs for children under 18 in multi-ethnic high-income countries. It included 22 studies identified from 3616 records. Barriers spanned child, family, provider, and system levels, while facilitators included culturally safe engagement, task-sharing, community-based delivery, active follow-up, and child-centered approaches. Meta-analysis of 14 455 participants found a pooled attrition rate of 23% (95% CI 8%-43%). The authors conclude that retention should be considered in program design and implementation.
Key findings
- Meta-analysis found a pooled attrition rate of 23% (95% CI 8%-43%, n = 14 455).
- Child-level barriers included behavioral distress, sensory aversion, and temporary medical exclusions.
- Family, provider, and system barriers included caregiver capacity, workforce constraints, weak coordination, inequitable reach, and geographic limitations.
- Facilitators included culturally safe engagement, task-sharing, school/community delivery with active follow-up, and child-centered strategies.
Why it matters
The review indicates that continued participation in public FV programs is influenced by interacting factors rather than a single obstacle. Recognizing barriers across children, families, providers, and delivery systems can help program planners identify where retention may falter and consider supportive approaches. The pooled attrition estimate also highlights that loss to follow-up is a substantial implementation concern in the included settings.
What to keep in mind
The review synthesizes studies across varied settings and methods; the pooled attrition estimate has a wide 95% CI of 8%-43%.