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Communicating risk for issues that involve 'uncertainty bias': what can the Israeli case of water fluoridation teach us?

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Abstract

Water fluoridation is a controversial issue in public health. Despite the uncertainty regarding its efficacy and safety, health officials continue to communicate it as 'unequivocally' safe and effective. Our focus is on how health officials and policy-makers in Israel frame the issue of water fluoridation in terms of certainty while promoting a mandatory fluoridation policy. According to van Asselt and Vos, the uncertainty paradox describes situations in which uncertainty is acknowledged, but the role of science is framed as providing certainty. Our study is an analysis of documents and media articles emphasizing the paradoxical language used by official representatives on the controversial topic of fluoridation. A central contribution of this study is that we coin the term 'uncertainty bias,' in which policy-makers do exactly what they accuse laypeople of doing, framing uncertainty in biased terms. We found that 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. This study does not focus on the practice of water fluoridation per se, and is not intended to decide for or against it, but rather, to explore how the debate regarding it is communicated. Understanding this particular case can shed light on how other controversial topics are transformed into health policy that is characterized in equivocal terms.

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... Since its inception, this pattern of bias has been de rigeur in the handful of the primarily English speaking countries that practice fluoridation. Emphasis on poor quality science is part of this pattern, a pattern that is continuing in the 21st century [1,10,46,[49][50][51][52]. ...
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Municipal fluoridation was a mid-twentieth century innovation based on the medical hypothesis that consuming low doses of fluoride when young provided protection against cavities with only a small risk of mild dental fluorosis, a cosmetic effect. In the 21st century, more than half of American teens are afflicted by dental fluorosis with approximately one in five having moderate to severe dental fluorosis in at least two teeth. Scientific literature since the 1990s has found that even low doses of fluoride adversely affect cognitive-behavioral development and that deficits are correlated with the severity of dental fluorosis in afflicted individuals. Evidence of neurotoxic impact from low dose systemic exposure to fluoride prompted an investigation by a branch of the governmental agency that has promoted fluoridation policy since its 1940′s inception. This review identifies ten significant flaws in the design of an animal experiment conducted by the U.S. National Toxicology Program as part of that investigation into the neurotoxic impact of systemic prenatal and postnatal fluoride exposure. The authors hypothesize that organizational bias can and does compromise the integrity of fluoride research.
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Within a neoliberal environment that prioritizes the individual over the community, understanding challenges associated with advancing population-level or universal interventions is important if public health is to remain a relevant collective institution. As a case example, we considered a controversial public health intervention – community water fluoridation – and undertook focus groups with dental hygienists in Calgary, Alberta, Canada, to explore ways that fluoridation (a population-level intervention) is understood and discussed in their day-to-day clinical interactions as frontline cavity prevention experts. The overarching theme in our data centered around a key public health conundrum – that is, the difficulties reconciling individual and community- or population-level responsibility for health. Dental hygienists wrestled with the transdisciplinary nature of population-level public health interventions; acknowledged changing roles and relationships between themselves and their patients; and revealed dissonance in their own beliefs about individualism and collectivism in health. Our findings shed light on communication challenges where public health information delivery intersects with clinical encounters, in the context of empowered and knowledgeable health consumers. A challenge for the public health community is to reflect on how to better address a contemporary public’s reasonable information requests and negotiate the clash between individualism and collectivism more effectively.
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Background Iodine deficiency disorders (IDD) and their attendant effects on human development, perinatal mortality and intellectual dysfunction are a major nutrition and public health problem worldwide, with Ethiopia counted among the top iodine-deficient countries. Despite the passing of new legislation in 2011 under the National Nutrition Programme and subsequent increase in the availability of iodized salt, the eradication of IDD in Ethiopia remains a significant challenge. This paper critically reviews the recent published data on iodine-status in Ethiopia as a basis for formulating future research and policy initiatives. Methods We performed a structural search for IDD studies in Ethiopia for all population groups published after the year 2000. Results Twenty four studies reported national and regional data giving a national total goiter rate above 35.8 % in women, with rates close to 60 % in four regional states, and an estimated prevalence of IDD ranging from 0.4 to 66.3 % depending on region. The prevalence of goiter in children was 35 %, but was as high as 71 % in the South Nations Nationalities and Peoples Region. The problem persists despite the widespread availability of iodized salt. Conclusions Eradicating IDD in Ethiopia will require concerted efforts including the close evaluation of intervention programs through regular, nation-wide monitoring of IDD and salt-iodization coverage. Salt iodization became mandatory in Ethiopia in 2011 and despite significant progress, the current level of eradicating IDD could be improved. Prospective and controlled intervention studies to evaluate biomarkers of thyroid function and cognitive outcomes will help to monitor and improve eradication efforts. Ascertaining and improving health and development in the most vulnerable populations of women and children is a priority that may be advanced through a greater investment in outreach and education.
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Background Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation was initiated in the USA in 1945 and is currently practised in about 25 countries around the world; health authorities consider it to be a key strategy for preventing dental caries. Given the continued interest in this topic from health professionals, policy makers and the public, it is important to update and maintain a systematic review that reflects contemporary evidence. Objectives To evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries. To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. Search methods We searched the following electronic databases: The Cochrane Oral Health Group's Trials Register (to 19 February 2015); The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2015); MEDLINE via OVID (1946 to 19 February 2015); EMBASE via OVID (1980 to 19 February 2015); Proquest (to 19 February 2015); Web of Science Conference Proceedings (1990 to 19 February 2015); ZETOC Conference Proceedings (1993 to 19 February 2015). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization's WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language of publication or publication status in the searches of the electronic databases. Selection criteria For caries data, we included only prospective studies with a concurrent control that compared at least two populations - one receiving fluoridated water and the other non-fluoridated water - with outcome(s) evaluated at at least two points in time. For the assessment of fluorosis, we included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. We included populations of all ages that received fluoridated water (naturally or artificially fluoridated) or non-fluoridated water. Data collection and analysis We used an adaptation of the Cochrane 'Risk of bias' tool to assess risk of bias in the included studies. We included the following caries indices in the analyses: decayed, missing and filled teeth (dmft (deciduous dentition) and DMFT (permanent dentition)), and proportion caries free in both dentitions. For dmft and DMFT analyses we calculated the difference in mean change scores between the fluoridated and control groups. For the proportion caries free we calculated the difference in the proportion caries free between the fluoridated and control groups. For fluorosis data we calculated the log odds and presented them as probabilities for interpretation. Main results A total of 155 studies met the inclusion criteria; 107 studies provided sufficient data for quantitative synthesis. The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste. There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels. There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels. No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria. With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation. Authors' conclusions There is very little contemporary evidence, meeting the review's inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries. The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population's oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review's inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults. There is insufficient information to determine the effect on caries levels of stopping water fluoridation programmes. There is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.
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Risk communication helps companies, governments and institutions minimise disputes, resolve issues and anticipate problems before they result in an irreversible breakdown in communications. Without good risk communication and good risk management, policy makers have no roadmap to guide them through unforeseen problems, which frequently derails the best policies and results in a breakdown in communications and a loss of trust on behalf of those they are trying hardest to persuade. Most policy makers still use outdated methods - developed at a time before health scares like BSE, genetically modified organisms and dioxin in Belgian chicken feed eroded public confidence in industry and government - to communicate policies and achieve their objectives. Good risk communication is still possible, however. In this book, through the use of a host of case studies from four countries, the author identifies a series of methods that are set to work in a post trust society. © Ragnar E. Löfstedt 2005. Foreword George Cvetkovich 2005. All rights reserved.
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Water fluoridation is one of the most effective public health programs of the past century. However, efforts to extend water fluoridation into currently non-fluoridated areas are often thwarted. Despite considerable evidence regarding the effectiveness of water fluoridation at an individual level, published national community-based studies are rare. This study compared children's decay experience and prevalence between areas with and without water fluoridation in Australia.
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While previous research has suggested that there is an association between fluoride ingestion and the incidence of hypothyroidism, few population level studies have been undertaken. In England, approximately 10% of the population live in areas with community fluoridation schemes and hypothyroidism prevalence can be assessed from general practice data. This observational study examines the association between levels of fluoride in water supplies with practice level hypothyroidism prevalence. We used a cross-sectional study design using secondary data to develop binary logistic regression models of predictive factors for hypothyroidism prevalence at practice level using 2012 data on fluoride levels in drinking water, 2012/2013 Quality and Outcomes Framework (QOF) diagnosed hypothyroidism prevalence data, 2013 General Practitioner registered patient numbers and 2012 practice level Index of Multiple Deprivation scores. We found that higher levels of fluoride in drinking water provide a useful contribution for predicting prevalence of hypothyroidism. We found that practices located in the West Midlands (a wholly fluoridated area) are nearly twice as likely to report high hypothyroidism prevalence in comparison to Greater Manchester (non-fluoridated area). In many areas of the world, hypothyroidism is a major health concern and in addition to other factors-such as iodine deficiency-fluoride exposure should be considered as a contributing factor. The findings of the study raise particular concerns about the validity of community fluoridation as a safe public health measure. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Article
Controversy persists concerning the impact of community water fluoridation on bone health in adults, and few studies have assessed relationships with bone at younger ages. Ecological studies of fluoride's effects showed some increase in bone mineral density of adolescents and young adults in areas with fluoridated water compared with non-fluoridated areas. However, none had individual fluoride exposure measures. To avoid ecological fallacy and reduce bias, we assessed associations of average daily fluoride intake from birth to age 15 yr for Iowa Bone Development Study cohort members with age 15 yr dual-energy x-ray absorptiometry (DXA) bone outcomes (whole body, lumbar spine, and hip), controlling for known determinants (including daily calcium intake, average daily time spent in moderate-to-vigorous intensity physical activity, and physical maturity). Mean (SD) daily fluoride intake was 0.66 mg (0.24) for females and 0.78 mg (0.30) for males. We found no significant relationships between daily fluoride intake and adolescents' bone measures in adjusted models (for 183 females, all p values ≥ .10 and all partial R(2) ≤ 0.02; for 175 males, all p values ≥ .34 and all partial R(2) ≤ 0.01). The findings suggest that fluoride exposures at the typical levels for most US adolescents in fluoridated areas do not have significant effects on bone mineral measures.
The aim of this study was to evaluate the systemic effect of water fluoridation on dental caries prevalence and experience in Cheongju, South Korea, where water fluoridation ceased 7 years previously. A cross-sectional survey was employed at two schools where water fluoridation had ceased (WF-ceased area) and at two schools where the water had never been fluoridated (non-WF area). The schools in the non-WF area were of a similar population size to the schools in the WF-ceased area. Children of three age groups were examined in both areas: aged 6 (n = 505), 8 (n = 513), and 11 years (n = 467). The differences in the mean number of decayed or filled primary teeth (dft) and the mean number of decayed, missing, or filled permanent teeth (DMFT) scores between areas after adjusting for oral health behaviors and socio-demographic factors were analyzed by a Poisson regression model. The regression model showed that the DMFT ratio for children aged 11 years in the WF-ceased area was 0.581 (95% CI 0.450-0.751). In contrast, the dft ratio for age 6 in the WF-ceased area was 1.158 (95% CI 1.004-1.335). Only the DMFT ratio for age 8 (0.924, 95% CI 0.625-1.368) was not significant. While 6-year-old children who had not ingested fluoridated water showed higher dft in the WF-ceased area than in the non-WF area, 11-year-old children in the WF-ceased area who had ingested fluoridated water for approximately 4 years after birth showed significantly lower DMFT than those in the non-WF area. This suggests that the systemic effect of fluoride intake through water fluoridation could be important for the prevention of dental caries.
Article
Images of group panic and collective chaos are ubiquitous in Hollywood movies, mainstream media and the rhetoric of politicians. But, contrary to these popular portrayals, group panic is relatively rare. In disasters people are often models of civility and cooperation.
Article
Over the past number of years the reporting of food scares, particularly in European context, have grown in prevalence. These scares are more often than not amplified by the media leading to greater pressure on regulators, industry and other stakeholders to communicate the actual risks associated with the food issue in question accurately. The aims of this paper is three fold: firstly, provide a brief background on the history of risk communication itself. Secondly, to summarise some of the main theoretical avenues that are presently favoured by the wider academic (risk) community. The final section of the paper provides research ideas regarding what academics working in the food risk communication area may wish to look at now. Among the issues highlighted include addressing the issue of media amplification, rebuilding public trust, and better communicating uncertainty.
Article
The author considers the implications for current assumptions about scientific knowledge and environmental policy raised by the preventive approach and the associated Precautionary Principle. He offers a critical examination of approaches to characterizing different kinds of uncertainty in policy knowledge, especially in relation to decision making upstream from environmental effects. Via the key dimension of unrecognized indeterminacy in scientific knowledge, the author argues that shifting the normative principles applied to policy use of science is not merely an external shift in relation to the same body of 'natural' knowledge, but also involves the possible reshaping of the 'natural' knowledge itself.
Book
"This book provides step-by-step instructions on how to analyze text generated from in-depth interviews and focus groups - i.e., transcripts. The book is primarily designed for research studies with an applied focus, but is also useful for theoretically oriented qualitative research. The book covers all aspects of the qualitative data analysis process including planning, data preparation, identification of themes, codebook development and code application, reliability and inter-coder agreement, data reduction techniques, comparative techniques, integration with quantitative data, and software considerations. The book describes what the authors call "applied thematic analysis", because it is the approach predominantly used in applied qualitative studies (and increasingly in academic contexts). The method employs a phenomenological approach to data analysis which has a primary aim of describing the experiences and perceptions of research participants. The approach presented is similar to Grounded Theory - in that it is inductive, content-driven, and searches for themes within textual data - and is complementary to Grounded Theory on many levels. However, within an applied context a phenomenological approach is primarily concerned with characterizing and summarizing perceptions and lived experiences and applying the results to a particular research problem, rather than building and assessing theoretical models"--
Article
Dealing with uncertain risks is an important challenge. Uncertain risks need to be sharply distinguished from traditional, simple risks which can be calculated by means of statistics. Arguably current governance of uncertain risks tends to erode into organized irresponsibility, i.e., society's ill‐preparedness and inability to deal with surprises, negative consequences and/or long‐term impacts which are associated with uncertain risks, notwithstanding all institutions and procedures in place. In such cases, a particular pattern in risk regulation can be identified, the uncertainty paradox, which is an umbrella term for situations in which uncertainty is acknowledged, but the role of science is framed as one of providing certainty. This article highlights the need to further understand the uncertainty paradox by investigating actual decision‐making processes. Through case‐study research on EU GMO regulation this article examines how various actors actually deal with science, knowledge and uncertainty. Four mechanisms sustaining the uncertainty paradox are inferred: 1) uncertainty intolerance; 2) boundary work; 3) the inclination to equate uncertainty with risk; and 4) technocratic provisions. In conclusion, some suggestions are advanced as to how to break through the uncertainty paradox.
Article
Proposes a descriptive model of how people make judgments under ambiguity that assumes an anchoring-and-adjustment process in which an initial estimate provides the anchor, and adjustments are made for what might be. The latter is modeled as the result of a mental simulation process that reflects not only the amount of ambiguity, which affects the size of the simulation but also one's attitude toward ambiguity, which affects the differential weighting of imagined probabilities. A 2-parameter model of this process is shown to be consistent with D. Ellsberg's (1961) original paradox, the nonadditivity of complementary probabilities, current psychological theories of risk, and J. M. Keynes's (1921) idea of the "weight of evidence." Four experiments were conducted to test the model. In Exps I and II, each with 32 volunteers, the model accurately predicted inferential judgments; in Exp III, with 20 Ss, the model predicted choices between gambles; and in Exp IV, with 112 masters of business students, it showed how buying and selling prices for insurance are influenced by one's attitude toward ambiguity. Results are discussed with respect to the importance of ambiguity in assessing uncertainty, the use of cognitive strategies in judgments under ambiguity, the role of ambiguity in risky choice, and extensions of the model. Further explanations of specific facets of the model are appended. (62 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
One of the main themes that has emerged from behavioral decision research during the past 2 decades is the view that people's preferences are often constructed in the process of elicitation. This concept is derived in part from studies demonstrating that normatively equivalent methods of elicitation often give rise to systematically different responses. These "preference reversals" violate the principle of procedure invariance that is fundamental to theories of rational choice and raise difficult questions about the nature of human values. If different elicitation procedures produce different orderings of options, how can preferences be defined and in what sense do they exist? Describing and explaining such failures of invariance will require choice models of far greater complexity than the traditional models. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Salt iodization has been introduced in many countries to control iodine deficiency. The two most commonly used approaches to assessing iodine nutrition on the population level are estimation of the household penetration of adequately iodized salt (HHIS) and measurement of urinary iodine concentrations (UICs). The aim of this review is to assess global and regional iodine status in 2012 by using each of these indicators. The most recent national data on HHIS were obtained from UNICEF. The most recent data on UICs, primarily national data in school-age children, were obtained from a systematic literature search, the International Council for the Control of Iodine Deficiency Disorders and the WHO Micronutrients Database. The median UIC was used to classify national iodine status and the UIC distribution to estimate the number of individuals with low iodine intakes. Thirty-two countries are iodine deficient based on the national median UIC. Globally, 29.8% of school-age children (246 million) are estimated to have insufficient iodine intake. Out of 128 countries with HHIS data, 37 countries have salt iodization coverage that meets the international goal of at least 90% of households consuming adequately iodized salt and 39 countries have coverage rates of less than 50%. Overall, ≈70% of households worldwide have access to iodized salt. Iodized salt programs need to be strengthened and extended to reach nearly one-third of the global population that still has inadequate iodine intakes.
Article
Risk perception is sometimes measured by means of judgments about worry, sometimes as perceived risk more directly. However, perceived level of risk calls for a more intellectual judgment and worry tends to refer to emotional reactions. These two are therefore not the same and need not be strongly correlated. Results reported here show that perceived risk and worry are indeed weakly correlated, both for generalized worry and for more specific measures of worry matched with the same hazard as risk ratings. A distinction is suggested between cognitive, abstract hazards and concrete, sensory hazards, with implications for the worry-perceived risk relationship. It was furthermore found by means of cluster analysis that there were groups of subject displaying different dynamics of risk and worry.
Article
Scientific experts (drawn from scientific institutions, universities, industry, and government) were interviewed about how they thought the general public might handle information about uncertainty associated with risk analysis. It was found that, for many people within the scientific community, there was a widespread belief that the general public were unable to conceptualize uncertainties associated with risk management processes. Many scientists thought that providing the public with information about uncertainty would increase distrust in science and scientific institutions, as well as cause panic and confusion regarding the extent and impact of a particular hazard. It was concluded that scientists still appear to be subscribing to the deficit model of science communication, and it is vital that effective mechanisms for communicating about risk uncertainty with the public must be developed as a matter of urgency, particularly as increased transparency in risk management processes means that scientific uncertainties associated with risk analysis become more likely to be the subject of public scrutiny and debate.
Article
The "optimal" intake of fluoride has been widely accepted for decades as between 0.05 and 0.07 mg fluoride per kilogram of body weight (mg F/kg bw) but is based on limited scientific evidence. The purpose of this paper is to present longitudinal fluoride intake data for children free of dental fluorosis in the early-erupting permanent dentition and free of dental caries in both the primary and early-erupting permanent teeth as an estimate of optimal fluoride intake. Data on fluoride ingestion were obtained from parents of 602 Iowa Fluoride Study children through periodic questionnaires at the ages of 6 weeks; 3, 6, 9, 12, 16, 20, 24, 28, 32, and 36 months; and then at 6-month intervals thereafter. Estimates of total fluoride intake at each time point were made by summing amounts from water, dentifrice, and supplements, as well as other foods and beverages made with, or containing, water. Caries data were obtained from examinations of children at ages 5 and 9 years, whereas fluorosis data were obtained from examinations of children only at age 9 years. The estimated mean daily fluoride intake for those children with no caries history and no fluorosis at age 9 years was at, or below, 0.05 mg F/kg bw for nearly all time points through the first 48 months of life, and this level declined thereafter. Children with caries had generally slightly less intakes, whereas those with fluorosis generally had slightly higher intakes. Given the overlap among caries/fluorosis groups in mean fluoride intake and extreme variability in individual fluoride intakes, firmly recommending an "optimal" fluoride intake is problematic.
Article
We articulate a model that focuses on characteristics of individuals that might predispose them to seek and process information about health in different ways. Specifically, the model proposes that seven factors-(1) individual characteristics, (2) perceived hazard characteristics, (3) affective response to the risk, (4) felt social pressures to possess relevant information, (5) information sufficiency, (6) one's personal capacity to learn, (7) beliefs about the usefulness of information in various channels-will influence the extent to which a person will seek out this risk information in both routine and nonroutine channels and the extent to which he or she will spend time and effort analyzing the risk information critically. By adapting and synthesizing aspects of Eagly and Chaiken's Heuristic-Systematic Model and Ajzen's Theory of Planned Behavior, we also expect that people who engage in more effortful information seeking and processing are more likely to develop risk-related cognitions, attitudes, and behaviors that are more stable (i.e., less changeable or volatile) over time. Since most forms of health information campaigns attempt to get people to adopt habitual or lifestyle changes, factors leading to the stability or volatility of those behavioral changes are essential concerns.
Article
Water fluoridation in Israel was initially introduced on a municipal level in 1981. Legislation in favor of national water fluoridation was approved in 1998. Over the last year an increasing campaign against the fluoridation project has become more and more evident. The material published by the opponents to fluoridation, distributed in pamphlets, daily journals and mass media resources, illustrate as in the USA, an endless and unrestrained "duel" between opponents and supporters of fluoridation. In Israel, in contrast to the USA, referenda are unprecedented, therefore, the political "battle field" is transferred to the municipal authorities and the Knesset. The pivotal component of the Israeli opponents to fluoridation regards the public's health and safety. Unscientific publications appear regularly in the daily journals and electronic mass media with no reference of supporting studies ever mentioned. The inevitable question addressed in this article is what are the best ways of action to be taken by the supporters of fluoridation is Israel. The main and most important mode of action against this campaign is, undoubtedly, continuous persuasion. Nevertheless, the continuous daily struggle of the supporters must be in a world-wide frame and be adjusted to the different target groups of the public. An effective confrontation should include nation-wide available publications (internet, daily papers and multimedia) with special emphasis on the important subjects (e.g. evidence based care, significance of toxic doses and the value of social justice), in a format comprehensible to the public and its leaders. The American experience helps us to understand that the opposition to water fluoridation will not diminished but, on the contrary, is expected to strengthen. We must look forward with no illusions and establish ways of action and cooperation by learning from past experience and from that of our collaborators. This will serve as the basis for the ongoing frank and persuasive efforts, derived from a deep and honest belief in the justice of our way.
Article
This article explores the use of the precautionary principle in situations of intermingled uncertainty and risk. It analyses how the so-called uncertainty paradox works out by examining the Pfizer case. It reveals regulatory complexities that result from contradictions in precautionary thinking. In conclusion, a plea is made for embedment of uncertainty information, while stressing the need to rethink regulatory reform in the broader sense.
December TIM Poll: Goggle Continue to Lead
  • D Avraham
Avraham, D. 2013. "December TIM Poll: Goggle Continue to Lead." Walla, January 14 [July 24, 2015]. http://b.walla.co.il/item/2606671
Petition against Health Minister's Decision to Stop Water Fluoridation in Israel Submitted to the Supreme Court
  • Doctorsonly Desk
DoctorsOnly Desk. 2014. "Petition against Health Minister's Decision to Stop Water Fluoridation in Israel Submitted to the Supreme Court." DoctorsOnly, October 7 July 24, 2015. http://doctorsonly.co.il/2014/10/85419/
Litzmann Reverses German's Decision and Restores Fluoride to Drinking Water
  • I Efrati
  • Z Rinat
Efrati, I., and Z. Rinat. 2015. "Litzmann Reverses German's Decision and Restores Fluoride to Drinking Water." Haaertz, May 31 [July 24, 2015].
The Role of Uncertainty Intolerance in European Risk Governance
  • T Fox
Fox, T. 2009. "The Role of Uncertainty Intolerance in European Risk Governance." Paper read at Risk Research Symposium, King's College London, London.