Peer-reviewed article
Adherence and Attrition in Public Fluoride Varnish Programs: A Mixed-Methods Systematic Review.
Zeyang-Liu N, Gupta R, Chiang J, Aleksejuniene J ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This systematic review examined why children drop out of public fluoride varnish programs used to prevent tooth decay in high-income countries. The researchers found that children's behavior and sensory discomfort, family capacity and health literacy, staff shortages and training gaps, and unequal access to services all contributed to poor adherence. About 23% of children stop attending these programs. The review suggests that culturally sensitive approaches, community-based delivery, and better coordination between schools and health services can improve retention.
Key points
- Pooled attrition rate across programs was 23% (95% CI 8%-43%, n = 14,455)
- Child-level barriers included behavioral distress, sensory aversion, and temporary medical exclusions
- Family-level barriers included caregiver capacity, health literacy, and mobility constraints
- Provider-level barriers included workforce constraints, training gaps, and weak school/community coordination
- Facilitators included culturally safe engagement, task-sharing, school/community-based delivery, and active follow-up systems
Limitations
The review does not identify which barriers or facilitators are most impactful or whether interventions to address them actually improve retention. The focus on high-income countries limits generalizability to lower-resource settings.
Abstract
Background Public fluoride varnish (FV) programs, often delivered as part of a multi-component oral preventive package, rely on the patient's continued participation. However, continued adherence is often poor in real-world settings. Aim To synthesize child, family, provider, and systemic level barriers and facilitators influencing adherence and attrition in public FV programs for children < 18 years in multi-ethnic high-income countries. Design Systematic review was conducted in accordance with PRISMA 2020. Six databases were searched for studies reporting barriers and facilitators to repeated FV applications. Results From 3616 records, 22 studies were included. Child-level barriers included behavioral distress, sensory aversion, and temporary medical exclusions. Family-level barriers included caregiver capacity, health literacy, and mobility. Provider-level barriers included workforce constraints, training, role boundaries limiting task-sharing, and weak school/community coordination. System-level barriers included inequitable reach to high-risk groups and geographic constraints. Facilitators included culturally safe, relationship-based engagement, task-sharing, school/community-based delivery with active follow-up systems, and child-centered engagement strategies. Meta-analysis demonstrated a pooled attrition rate of 23% (95% CI 8%-43%, n = 14 455). Conclusion Adherence and attrition in public FV programs are shaped by interacting determinants across child, family, provider, and system levels. Retention should be considered when designing and implementing these programs. Trial registration CRD420251044425 (PROSPERO).