Local authorities
By improving options for cycling (cycle-ways, bike-parking racks) and
for pedestrians (footpaths, accessways and malls), local authorities
enhance opportunities for physical activity. Some local authorities
have greatly enhanced options for recreational walking and mountain
biking in urban areas. Restrictions on inner-city parking may also
encourage walking. Local authorities are also involved with Healthy
Cities and Safer Community programmes.
Department of
Conservation
The Department of Conservation provides for a wide range of recreational opportunities involving physical activity.
Target revision
The Hillary Commission has noted in Moving a Nation 1997–2000 that the target for physical
activity may be revised when the data from the 1997 full-year Sport and Physical Activity
Survey become available.
Fluoride and Oral Health
Water fluoridation
Key points
• In communities with reticulated water supplies, water fluoridation is the most effective
and efficient way of reducing the prevalence of dental caries.
• Fifty-six percent of New Zealanders receiving reticulated water had their water
fluoridated in 1998.
• Water supplies serving a total of half a million people will need to commence fluoridation
if the target is to be met. This is unlikely to be achieved by the year 2000.
TARGET
To increase the size of the population receiving fluoridated water to 70 percent of the
population on reticulated water supplies by the year 2000.
Target derivation
The Public Health Commission included the water fluoridation target in its policy paper
Fluoride and Oral Health: The Public Health Commission’s advice to the Minister of Health 1995
(PHC 1995b). At that time it was estimated that 63 percent of the population connected to
reticulated water supplies had its water fluoridated, and a target of 70 percent appeared
feasible. More accurate recent data suggest that 63 percent was an overestimation.
Indicator
Size of population receiving fluoridated water, as a percentage of the population on
reticulated water supplies.
48
Progress on Health Outcome Targets 1998
Data source
Information on all public drinking-water supplies is collected by local public health services
and is held in the Water Information New Zealand (WINZ) database, maintained by the
Institute of Environmental Science and Research Limited (ESR) on behalf of the Ministry of
Health. WINZ includes data on the number of people served by each supply and the
supply’s fluoridation status.
Related targets
• Dental caries
• Fluoride toothpastes
• Sucrose and other free sugars (food and nutrition target)
Health impact
For communities receiving reticulated water, adjustment of fluoride in water to between 0.7
and 1.0 parts per million is the most effective and efficient way of preventing dental caries
(WHO 1994).
A review of research in New Zealand as well as the US, Australia, Britain, Canada and
Ireland concluded that water fluoridation reduces caries prevalence:
• by 30–60 percent in primary teeth in children
• by 20–40 percent in the mixed dentition in children aged 8–12 years
• by 15–30 percent in adolescents aged 14–17 years
• by 15–30 percent in adults (Newbrun 1989).
In New Zealand, the lifetime benefit of drinking fluoridated water is estimated to be
prevention of between 2.4 and 12.0 decayed, missing or filled teeth per person (PHC 1994n).
The benefits of water fluoridation appear to be greatest for people most at risk of dental
caries, including Mäori and lower socioeconomic groups (Treasure and Dever 1992). Thus
water fluoridation contributes to equity of health outcomes (PHC 1995b).
Water fluoridation also benefits persons living in areas not supplied with fluoridated water
who consume products prepared with fluoridated water content.
Progress towards the target
In February 1998, 83 percent of New Zealanders received their water from a reticulated
supply included on the WINZ database. Of these, 56 percent had their water fluoridated
(Figure 18). This is similar to the 1996 estimate of 55 percent (Ministry of Health 1997l).
GOAL: Social and Physical Environment
49
Figure 18: Percentage of population on reticulated water supply and receiving
fluoridated water, 1998
Population receiving reticulated
fluoridated water*
17%
47%
36%
Population receiving reticulated
non-fluoridated water
Population not receiving
reticulated water
Source of data: ESR 1998.
* This corresponds to 56 percent of the total population receiving reticulated water.
Assessment
Data quality
Both the quality and usefulness of data about fluoridated water supplies in New Zealand
have improved in recent years, through the replacement of earlier databases with the WINZ
database system. Beginning in 1996, this database has provided reliable estimates of the
target indicator, and a time series is being developed.
Limitations of indicator
The target indicator does not capture use of fluoride among populations without reticulated
water supplies, ie, those with private supplies or with very small community supplies –
approximately 17 percent of the total population. The indicator also does not capture
discretionary use of fluoride at the household level, in the form of tablets added to water, in
areas supplied with non-fluoridated water.
Interpretation of trend
WINZ includes data on many small community supplies that were not previously included.
Thus, although the 1996 and 1998 estimates of 55 and 56 percent fluoridation of reticulated
supplies are significantly lower than earlier estimates, they are considered to be more
reliable.
Fluoridation of supplies serving about half a million people is required to meet the target.
This figure represents one-third of the population currently receiving reticulated but nonfluoridated drinking-water. The target level appears very unlikely to be achieved by the year
2000, given that very few large supplies have changed fluoridation practice in recent years.
Strategies
See Strategies section under dental caries target.
50
Progress on Health Outcome Targets 1998
Target revision
The Ministry of Health is investigating whether the target indicator can be focused more
accurately on water supplies where fluoridation is a realistic option. In general, these are
larger supplies, in which fluoridation is more cost-effective. In future, the target may only
include supplies serving greater than a certain number of people. Revision of the target level
will be held until that investigation has been completed.
Fluoride toothpaste
Key points
• Regular use of fluoride toothpaste reduces tooth decay.
• 94.8 percent of toothpaste sold in early 1998 contained fluoride.
• The target of at least 97 percent market share by toothpastes containing fluoride by the
year 2000 appears likely to be achieved.
TARGET
To increase the percentage of fluoride toothpaste out of all toothpaste sold in New
Zealand to 97 percent or more by the year 2000.
Target derivation
The fluoride toothpaste target was included in the policy paper Fluoride and Oral Health: The
Public Health Commission’s advice to the Minister of Health 1995 (PHC 1995b). At that stage it
was estimated that 97 percent of toothpaste sold was fluoridated, and maintenance of at least
this level until the year 2000 was adopted as the target.
Indicator
Percentage (by volume) of toothpaste sold that contains fluoride.
Data source
The percentage of toothpaste sold that contains fluoride is calculated by matching the
Ministry of Health’s data on fluoride content of toothpastes with data on sales, obtained
from a market research company (AC Nielsen Ltd).
Related targets
• Dental caries
• Sucrose and other free sugars (food and nutrition target)
• Water fluoridation
Health impact
Regular use of fluoride toothpaste is an effective method of reducing dental caries. For
people whose drinking-water is fluoridated, regular use of fluoride toothpaste provides an
additional degree of protection against tooth decay. In non-fluoridated areas it is the prime
GOAL: Social and Physical Environment
51
method of preventing decay (Murray et al 1991; Ministry of Health 1998a). Fluoride toothpaste use in children is associated with average caries prevention of 25 percent after two to
three years. The preventive effect applies both to children (WHO 1994) and adults (Thomson
1997).
Excessive exposure to fluoride from swallowing toothpaste can contribute to dental fluorosis.
This is a risk for young children because they are prone to, and should be discouraged from,
swallowing toothpaste. However, in most cases fluorosis is of no or only minor cosmetic
significance (PHC 1994n).
Progress toward the target
The estimated percentage of toothpaste sold that contains fluoride increased to 95 percent in
the 26 weeks to mid-April 1998, up from between 85 and 92 percent in 1991–96 (Figure 19).
However, estimates prior to 1997 were probably too low, due to incomplete information on
which brands of toothpaste contained fluoride.
Figure 19: Percentage (by volume) of toothpaste sold that contains fluoride, 1991–98
Percentage
100
Target
2000
95
90
85
80
75
0
1991
1992
1993
1994
1995
1996
1998
2000
Source of data: Ministry of Health
Note: Data for 1997 were not available.
Assessment
Data quality
Sales data used in this target refer only to sales through supermarkets. Some toothpastes,
especially non-fluoride brands, are sold through pharmacies and health product shops or by
52
Progress on Health Outcome Targets 1998
direct distribution. For this reason the true consumption of fluoride toothpastes is probably
overestimated to some extent. However, supermarkets still account for the vast majority of
sales, and these data are of sufficiently high quality for monitoring trends from year to year.
Limitations of indicator
The percentage of toothpaste sold that contains fluoride is a good indicator of exposure to
fluoride from toothpaste for the whole population. However, significant proportions of some
age groups do not use any toothpaste on a regular basis (Hunter et al 1992).
Interpretation of trend
As mentioned above, the market share of fluoride toothpastes was most likely underestimated in the period 1991– 96. The latest estimate (1998) is the most reliable thus far and
indicates the target level has nearly been achieved.
Strategies
See Strategies section under Dental caries target.
Target revision
Despite the intention stated in last year’s report (Ministry of Health 1997l) to revise the target
level, the improved data now indicate that target revision is not required. Maintenance of the
market share of fluoride toothpastes at 97 percent or more remains a target that is
challenging, yet achievable.
Dental caries
Key points
• Form Two MFT scores appeared to worsen in 1994–96, ending a sustained period of
improvement.
• An improvement of 10 percent per year is required to meet the target for all children.
• An improvement of 9 percent per year is required to meet the target for Mäori children.
TARGETS
To reduce the average number of missing or filled permanent teeth in Form Two children
to one per child or less by the year 2000.
To reduce the average number of missing or filled permanent teeth in Form Two Mäori
children to 1.4 per child or less by the year 2000.
Target derivation
The Public Health Commission advised the Minister of Health in 1995 that dental caries
(tooth decay) severity in Form Two children would be a useful indicator for monitoring oral
health in New Zealand (PHC 1995b). A consistent set of nationwide data has been available
annually for many years. Extrapolation of the consistently falling average number of missing
or filled permanent teeth (MFT) indicated a target of one per child by the year 2000 would be
feasible, with continuation of the strategies in place. Progress towards this target has since
GOAL: Social and Physical Environment
53
been monitored (PHC 1995h; Ministry of Health 1996j, 1997l). A separate target for Mäori
children was added in 1997, as data for Mäori children in some regions became available in
that year.
Indicator
The average number of MFT in Form Two children.
Data source
Information on the number of missing and filled teeth (MFT) for children at age five years
and in Form Two (approximately age 12 years) is collected by HHS school dental services.
The most recent available data are for 1996.
Related targets
• Fluoride toothpastes
• Sucrose and other free sugars (food and nutrition target)
• Water fluoridation
Health impact
At a microscopic level, very early decay of tooth surfaces can be stopped and reversed.
However, once cavities have occurred, treatment and restorative dental procedures are
required. Good dental care is essential for health, self-esteem and pain-free living. Poor oral
health can lead to problems in eating and talking. Serious and persistent dental problems can
disrupt work and social life. Untreated caries can result in the need for admission to hospital
for acute medical conditions.
The prevalence of caries in children has decreased markedly in most industrialised
countries, including New Zealand, over the past quarter century (Newbrun 1992; Bjarnason
et al 1993; Li et al 1993; Downer 1995; Nadanovsky and Sheiham 1995). However, caries
continues to be the main reason for tooth loss among children and young adults. In New
Zealand the prevalence of caries in children is higher among Mäori, lower socioeconomic
groups, and in areas without fluoridated water (PHC 1994n).
Progress toward the target
The average number of MFT in Form Two children decreased from 5.1 in 1980 to a low of
1.33 in 1994. In the following two years the MFT score rose to 1.53 (Figure 20).
54
Progress on Health Outcome Targets 1998
Figure 20: Average number of missing or filled permanent teeth, Form Two children,
1980–96; Mäori Form Two children, 1995–96
Number
6
5
4
3
2
Targets
2000
1
0
1980
1982
1984
Mäori children
1986
1988
1990
Year
1992
1994
1996
1998
2000
All children
Note: Data for Mäori children are available only from 1995 (not all regions)
Source of data: Ministry of Health
Assessment
Data quality
Information provided from school dental services on the dental health status of children is of
high quality. About 95 percent of Form Two children are seen by school dental services.
Separate data for Mäori children have only been reported for some regions (different regions
for 1995 and 1996). The MFT score for all Mäori children is estimated from these limited data.
Limitations of indicator
The indicator used for this target, MFT (missing or filled permanent teeth), does not include
decayed unfilled teeth, since data for these are not available.
Interpretation of trend
MFT scores improved consistently through the 1980s. The rate of improvement slowed in the
early 1990s and has now reversed. An improvement of 10 percent each year for the period
1997–2000 is required to meet the target of one MFT per child. A similar rate of decrease, 9
percent per year, is required to meet the target of 1.4 for Mäori children.
In recent years there has been greater use of radiography in school dental services, which has
enhanced sensitivity for detecting caries. This is likely to be at least a partial explanation of
the small rise in MFT scores in 1995. If this is the case, the downward trend may possibly
resume, albeit from a higher baseline level, though it is too soon to tell. An alternative
GOAL: Social and Physical Environment
55
hypothesis is that socioeconomic marginalisation of substantial sections of the New Zealand
population has caused Form Two MFT scores to worsen (Thomson 1994).
With the target indicator tracking in the wrong direction, the target for all Form Two
children appears unlikely to be met. Whether the target for Mäori children is likely to be met
cannot be properly assessed at this stage because a sufficient time series does not exist.
Strategies
Water fluoridation
Public education
Fluoridation of water supplies is promoted by public health services,
the New Zealand Dental Association and the New Zealand Dental
Health Foundation. Promotion strategies focus on raising awareness in
the community of the benefits of water fluoridation.
Ministry of Health
The Ministry of Health has produced a pamphlet (code 7003)
explaining the benefits of water fluoridation and has developed a
poster (code 7016) with the same theme. The Ministry also responds to
requests for information from the media, the public, and local
government.
Health Funding Authority Strategies used by the HFA and public health services to promote
water fluoridation include the development and distribution of health
education material, attendance at public meetings, media statements
and advertisements, responses to media reports, letters to editors,
interviews, provision of information in libraries and to councillors and
council staff, and replies to public queries.
New Zealand
Dental Association
The New Zealand Dental Association has produced an information
pamphlet. Representatives have been interviewed and have provided
media releases. Local dentists and dental therapists have been active in
raising community awareness and in attending meetings.
Fluoride toothpastes
Few specific strategies for this target have been implemented since the policy paper was
released in 1995. Oral health professionals (dentists and dental therapists), industry
marketing campaigns and health education resources promote the use of fluoride
toothpastes.
Dental caries
Promotion of oral health
The HFA purchases the promotion of oral health and the delivery of
primary prevention strategies through the public health and
community dental services provided by HHSs, including school dental
services. This covers advice and information on oral hygiene (including
the use of fluoride toothpastes), appropriate diets, and water
fluoridation. It also includes support and information for parents about
breastfeeding, which may reduce the prevalence of ‘bottle caries’. The
New Zealand Dental Association and the New Zealand Dental Health
Foundation also promote oral health through patient education and the
promotion of water fluoridation.
Provision of fluoridated
public water supplies.
See Water fluoridation target.
continued/. . .
56
Progress on Health Outcome Targets 1998
School dental services
Early detection and treatment, using techniques such as topical
fluoride treatments and fissure sealants, reduce the need for fillings
and extractions due to dental caries. These services are provided by
school dental services, HHS community dental services, and private
dentists.
Dietary sugar intake
See Foods and Nutrients targets.
Target revision
No revision of the dental caries target is required at this stage. However, the target level for
Mäori children may need revising in 1999, as more complete baseline and trend data become
available.
Hazardous Substances (Poisonings)
Key points
• Hospitalisation rates for childhood poisoning decreased in 1997 to 300 per 100 000 for all
children aged under five years. Rates were lower for Mäori (234 per 100 000) and Pacific
children (80 per 100 000).
• To meet the target, rates must decrease by 9 percent per year in the period 1998–2000.
TARGET
To reduce the unintentional poisoning hospitalisation rate among children aged under
five years to 230 per 100 000 or less by the year 2000.
Target derivation
A target for poisonings was first set in 1994 by the Public Health Commission (PHC 1994e).
The target indicator included only unintentional poisoning from drugs, medicinal
substances and other biological substances (ICD-9-CM codes E850–E858). The target
indicator was revised in 1997 to include unintentional poisoning from other solid and liquid
substances, gases and vapours (codes E860–E869) (Ministry of Health 1997l). The new target
level for all unintentional poisonings was based on the same proportionate decrease that was
set for the original target.
A separate target for Mäori children was set in 1997, but this is no longer relevant. From
1996, when a new definition of Mäori ethnicity was used in calculation of rates (see
discussion in Use of Ethnicity Data section), the poisoning hospitalisation rate for Mäori
children has been lower than the rate for all children.
Indicator
The hospitalisation rate for unintentional poisoning (ICD-9-CM codes E850–E869) in the
0–4-years age group.
GOAL: Social and Physical Environment
57