Application of the integrated multilevel conceptual model using water fluoridation as an example
| Type of uncertainty | Definition | Example: Fluoride debate—Israel water fluoridation case45 46 |
| Micro level | ||
| Personal | Uncertainty experienced individually by all stakeholders in the healthcare system due to their personal beliefs, values, fears, previous experiences, risk perceptions and tolerance level. | People against water fluoridation are reluctant to voice out their views against the decision made by the government due to personal fears. Personal uncertainty is also caused by the fear of chronic fluoride toxicity causing cancer especially to those with history of losing near ones due to cancer. |
| Meso level | ||
| Clinical | Uncertainty experienced during patient–physician encounters in a clinical setting when confronted with the dilemmas relating to diagnosis, treatment and prognosis. | Parents from water fluoridated areas often consult dentists regarding the white spots on the developing dentition of their children and the possible influence of fluoridated water. It is difficult for the clinicians to confirm the aetiology of the hypoplastic lesions and ascertain the role of fluoridated water. |
| Relational | Uncertainty arising from interpersonal relations and interactions among the various stakeholders in the healthcare team. | In the Israel fluoridation case, two groups were created: For and Against. Controversies and debates between all the involved stakeholders created another level of uncertainty due to interpersonal relationships. |
| Knowledge exchange | Uncertainty around how knowledge is communicated and exchanged. | To create a sense of certainty (despite uncertainty), policymakers and health professionals withhold information and provide ‘ready-made meal’ for providing convenient information to the public. (Israel water fluoridation case). Misleading information exchange leads to uncertainty. |
| Macro level | ||
| Healthcare system | Uncertainty emerging from the manner in which services and systems are structured and organised, while involving the navigation of the patient in the complexities of the healthcare delivery. | Water fluoridation is not usually part of the health system and hence in many contexts, it does not add a direct uncertainty to these decisions. However, there are other systems, for example, water system in countries that introduce uncertainty in these decisions. For example, certain cities might have mutual water systems where one city may agree for water fluoridation while the other does not. It introduces uncertainty whether we can implement water fluoridation considering where the water comes from, who is responsible for it and how many communities share the same water system and what other water sources are contaminated through this system. |
| Public health | Uncertainty focuses on issues that affect the health of the population of a particular country or community or society, which are within the realms of national boundaries. | A typical example is the Israeli case of water fluoridation where in order to establish mandatory regulation, health ministry officials expressed information in an unbalanced format, promoting the topic of fluoridation by framing it in exclusively positive terms creating public level uncertainty. |
| Global | Uncertainty related to health issues that evade, undermine or go beyond the territorial and political boundaries, and are thus beyond the capacity of individual countries to resolve. | Despite the contradicting evidence, Centres for Disease Control and Prevention and American Dental Association support mandatory water fluoridation and call oppositions against it as ‘myths’ while referring to arguments in favour of fluoridation as ‘facts’. |
| Uncertainty across all three levels | ||
| Epistemic | Uncertainty related to quantity and quality of knowledge. | Cochrane’s systematic review of water fluoridation concluded that there is very little evidence indicating that fluoridation reduces dental caries. In spite of lack of evidence, water fluoridation is done globally highlighting its benefits creating uncertainty. |
| Aleatoric | Uncertainty that is inherent in healthcare due to unpredictability of events. | Effect of fluoride on individuals may vary and it is difficult to predict the adverse outcomes with certainty. |
| Parametric | Uncertainty due to lack of estimate of uncertainties or uncertainties in the model underlying the cause-effect relation or it might be lack of inclusion of these quantitative information in official updated clinical guidelines used by the clinician. | The current example did not use a modelling of data to inform their decision-making due to the nature of studies around fluoride for example, clinical studies along with biomedical studies. If in other contexts, decision-makers use a model of clinical and pre-clinical studies to make these decisions. Then uncertainty can arise from the existence or lack of estimate of uncertainty in these models. |
| Ethical | Uncertainty that arises due to inability to determine the right course of moral action in a given situation. | The main ethical arguments against water fluoridation are infringement of personal freedom of consuming water without fluoride, infringement of personal freedom of consuming ‘natural’ water without additives and coercing people to consume the water as supplied. |