Sealant Program Targeting Decision
A school district of 6,500 elementary students asks a health department to place sealants. Screening data show: 22% of children have untreated decay; 48% of first molars are sealed among children whose parents have private insurance, versus 12% among Medicaid-enrolled children. The department can seal approximately 900 children per year with current staffing. Two targeting options are proposed: (A) seal all second-graders in the 3 schools with the highest free/reduced-lunch eligibility; (B) seal only children who screen positive for deep pits/fissures or incipient caries on first molars. Option A reaches about 750 children in year one; Option B reaches about 400 children but with higher per-child need. The state Medicaid program pays $32 per sealant and requires parental consent.
1. Which targeting option should the department choose, and on what criteria?
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Choose Option A (school-level targeting), with refinement.
Criteria and reasoning:
- Reach and equity: Option A reaches ~750 children vs ~400, and the gap in sealant prevalence (48% vs 12%) is a clear inequity signal. School-level targeting by lunch eligibility efficiently concentrates on the underserved population.
- Effectiveness: sealants are most effective when applied to caries-free or incipient surfaces; restricting to children who screen positive (Option B) misses the preventive benefit for at-risk but currently sound molars and is harder to operationalize.
- Cost/throughput: at $32 per sealant, Option A generates more revenue and covers more children per staffing hour; Option B's higher need per child does not offset the halved reach.
- Practical: Option A is simpler to consent and schedule at the school level.
Refinement: within the 3 schools, prioritize children with no private dental insurance and no existing sealants, and include a small screen-and-refer component. This captures Option B's logic without sacrificing reach.
2. Consent is required. What consent strategy maximizes participation without compromising ethics?
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Use an opt-out (passive) consent model only if state law permits; otherwise use an active consent with strong follow-up.
- Active consent typically yields 30–60% return in low-income schools, which would undercut the equity goal. Passive consent raises participation to 80–90% but requires legal authority and clear parent information.
- If active consent is required: send forms in the family's home language, use multiple reminders (paper, text, phone), allow verbal consent documented by staff, and set a firm return deadline with a second distribution.
- Never seal a child without valid consent, and never imply consent from non-response where law requires active consent.
- Provide a clear opt-out for parents who prefer their own dentist, and offer referral information.
- Track consent return by school and demographic group to detect differential exclusion - if Medicaid-enrolled children are less likely to return consent, the program will reproduce the very inequity it aims to fix.
3. How should the department evaluate whether the program reduced inequity, not just caries?
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Measure the gap, not just the mean.
- Primary equity metric: difference in sealant prevalence between Medicaid-enrolled and privately insured children at 1 and 3 years. Success = narrowing gap, not just rising overall sealant rates.
- Coverage metrics: proportion of eligible children sealed, stratified by insurance, language, and school.
- Outcome metrics: new caries in sealed vs unsealed molars (sealant retention and effectiveness), and untreated decay prevalence at follow-up screening.
- Process metrics: consent return rates by group (to detect differential exclusion), referral completion for children with decay.
- Design: compare the 3 targeted schools to matched non-targeted schools, or use a pre/post with a comparison group; account for sealant retention (lost sealants should be repaired, not counted as failures of the program).
Report the gap explicitly to the school board and Medicaid; a program that raises overall sealant rates while leaving the 48% vs 12% gap unchanged has not met its equity objective.