Deprived areas and community water fluoridation: a multilevel approach for refocusing the public policy.

Objectives to determine whether characteristics of geographic location, socioeconomic status, infant mortality, mortality from diarrheal disease in health regions are associated with the provision of community water fluoridation (CWF) in Brazilian municipalities. Methods Multi-level ecological study 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 Observation units comprised 5,565 municipalities clustered in 438 health regions within the country. The lack of CWF provision was positively associated with the following municipal characteristics: proportion below the median of inhabitants covered by the sewage network, average and low/very low human development index, below-median per capita Gross domestic product and above-median percentage of expenditure on sanitation. In relation to the health regions, the chance of lack of provision was greater in the municipalities belonging to the health regions located in the Brazilian Northern and Northeastern areas and where the child mortality, that due to acute diarrheal disease and the proportion of people with low income were higher adjusted by municipal indicators. Conclusion The information on the associated characteristics with CWF provision constitutes important input directed to the refocusing the public policy for reducing inequalities among Brazilian municipalities and health regions. It may help policymakers to understand the challenges for its expansion in low, middle and high-income countries.