Impact case study database

Our REF2014 impact case study detailed the piloting and roll-out of Childsmile across Scotland. Since August 2013, Childsmile has been the leading exemplar for development, implementation and evaluation of child oral health improvement programmes internationally ( impact 1), and in England ( impact 2). UofG research has also continued to influence Scottish child oral health policy during this period ( impact 3).

Impact 1. Expansion of Childsmile internationally

The 2019 Global Burden of Disease Study found that more than 520 million children worldwide had experienced dental caries, with immediate and longer-term economic and public health implications. Considerable international recognition for Childsmile has occurred via dissemination of UofG research [3.1–3.5] at numerous public engagement and knowledge exchange activities and events with key stakeholders, including the ‘ ChildsmileEvaluation’ Twitter feed ( @UoGChildsmile). Since August 2013, UofG researchers have hosted colleagues from Australia, Brazil, Chile, Israel, Malawi, the Netherlands, Nigeria, Saudi Arabia, countries in Southeastern Europe and Thailand, interested in the development and evaluation of national child oral health improvement programmes. In addition, they have given invited presentations and workshops in Chile, China, Croatia, Ireland, Poland, Serbia and South Africa (2014–2019). In 2018, UofG researchers hosted an international Childsmile symposium with speakers including the World Health Organization (WHO) global oral health lead, and government representatives from Chile and Israel. Subsequently, UofG researchers were asked to submit Childsmile as a case study for the WHO Oral Health Country/Area Profile website (hosted by the WHO Collaborating Centre at Malmö University, Sweden) [5.A]. In 2019, the European Commission adopted the Childsmile methodology as best practice to tackle United Nations Sustainable Development Goals for noncommunicable diseases, with Childsmile the only oral health improvement programme on this electronic platform [5.A].

An Israeli implementation of Childsmile began in 2014 [5.B], after a survey showed that only 38% of Israeli 6-year-olds were free from dental caries. Use of the Childsmile approach by this country was in response to the UofG cost analysis [3.3]. Nurseries participating in supervised toothbrushing rose in number from 627 in 2015 to 2,200 in 2018 [5.B]. The Ministry of Health subsequently adopted nursery supervised toothbrushing as part of the national dental service for children in disadvantaged towns and cities across Israel (2018) [5.B].

Childhood dental caries is also a major health challenge in Chile, with high prevalence and wide socioeconomic inequalities [5.C]. In 2015, the Chilean Ministry of Health established the Sembrando Sonrisas child oral health improvement programme with Conway, Macpherson and McMahon advising the Sembrando Sonrisas team. UofG researchers are continuing to support the ongoing evaluation and development of this programme [5.C]. Sembrando Sonrisas delivers supervised toothbrushing and FVA to over 400,000 nursery school children each year, with improvements in oral health observed among all age groups (3–6 years) since implementation; for example, the percentage of 5-year-olds with dental caries reduced from 58% in 2015 to 53% in 2019 [5.C]. The Ministry of Health highlights that support from UofG was crucial for implementation and evaluation of Sembrando Sonrisas as “ the guidelines and objectives [of Childsmile], despite coming from a different sociocultural context, were aligned with the objectives expected in our country, i.e. likely to reduce inequity, be cost-effective, multisectoral and focused on prevention and education” [5.C].

In 2017, UofG researchers and WHO oral health leads gave a workshop explaining the Childsmile approach and appropriate strategies for Southeastern European countries where poor child oral health is rife. The workshop, sponsored by UK oral health charity The Borrow Foundation, was held in Glasgow (2018), and attended by senior policy representatives from Albania, Bulgaria, Croatia, Romania, Serbia and Slovenia [5.D]. Conway and Macpherson then led a workshop in Croatia (2018), and supported the development and initiation of a pilot nursery supervised toothbrushing programme in 2019 [5.D]. Following this workshop, Romania and Serbia have conducted baseline national child oral health surveys as a first stage, and this, together with ongoing UofG researcher input, is informing national policy development [5.D].

The Borrow Foundation also funded the development of a child oral health improvement strategy in Malawi [5.D], involving collaboration between UofG, the Malawi Ministry of Health, the University of Malawi, and the WHO Country and Regional Office for Africa. In February 2020, Macpherson and Prof Jeremy Bagg (Head of the UofG Dental School) participated in a Malawi Ministry of Health workshop to discuss the development of the first oral health policy for this country [5.D]. They are now members of a multi-agency Government Taskforce to develop and implement this policy, with Childsmile principles and the child oral health improvement work forming major components. According to the Acting Principal of the College of Medicine (COM), University of Malawi: “ It was very obvious to the COM team that Malawi would benefit more if the country’s oral health strategy followed a prevention model rather than treatment, partly due to the large deficiency of dentists. As such, the team concluded that Malawi needed to adopt and contextualise the Childsmile model to suit our local setting” [5.D]. Consequently, “ the task force has so far resolved that prevention of dental disease in children will be the central concept of the development of the policy. Thus, the research work of the Childsmile programme in Scotland will be valuable in the formulation of Malawi’s oral health policy” [5.D].

Other countries that have adopted Childsmile components include the Netherlands and Vanuatu. Macpherson and Conway participated in workshops with Dutch stakeholders (2018) which, along with UofG research [3.5], contributed to the development of Gezonde Peutermonden, a pilot programme adopting DHSW-related elements of Childsmile into well-baby clinics in the Netherlands [5.E]. In 2018, the UofG team was contacted by a dental volunteer from a non-governmental organisation working in Vanuatu. A survey had revealed low rates of toothbrushing among children aged 5–7 years, and the volunteer felt that the Childsmile model would be appropriate for use in this country. Policy for a school-based programme based on Childsmile (‘ Gudfala Tut Skul’) was ratified by the Vanuatu Ministry of Health in 2019 [5.E]. The Childsmile evidence base [3.1, 3.3] was used in funding bids and, by February 2020, 32 schools were involved in supervised toothbrushing, with expansion to an additional 40 schools planned. FVA was adopted by 22 schools, also with plans for expansion.

Impact 2. Expansion of Childsmile to England

An overview of Childsmile was presented as one of two expert papers supporting the 2014 National Institute for Health and Care Excellence (NICE) formulation of guidelines on oral health (PH55). This guideline recommended the implementation of supervised toothbrushing schemes for children, with the advisory committee noting that “ lessons can be learnt from existing programmes such as Childsmile” [5.F].

UofG research has also informed the development of child oral health policy recommendations by Public Health England (PHE) [5.G]. Macpherson was a member of the Steering Group developing a 2014 PHE evidence-based toolkit for local authorities, responsible for commissioning better oral health of children and young people. The toolkit recommended nursery supervised toothbrushing and FVA, with reference made to the UofG cost analysis model [3.3] and wider Childsmile approach [5.H]. In 2016, PHE commissioned a rapid review of the cost-effectiveness evidence for oral health interventions among children aged up to 5 years, and a bespoke return on investment (ROI) tool from the York Health Economics Consortium [5.H]. The ROI tool was designed to inform local authorities on investment in oral health programmes. UofG research [3.3] provided the only good-quality evidence on the cost-effectiveness of nursery supervised toothbrushing. In 2016, PHE published a further toolkit, based on evidence from NICE PH55 [5.F] and the ROI, to support supervised toothbrushing programmes in early years and school settings in England [5.H]. Together, these PHE documents supported the 153 upper-tier English local authorities to make the case for commissioning child oral health improvement programmes [5.G]. A PHE audit published in 2018 found that 74 of 145 local authorities surveyed (51%) had implemented nursery supervised toothbrushing [5.H].

In 2019, the UK Government promised to consult on the roll-out of a preschool and school toothbrushing scheme in its Parliamentary Green Paper, ‘ Advancing our health: prevention in the 2020s’ [5.I], to reach the most socioeconomically disadvantaged children aged 3–5 years across England. A nursery supervised toothbrushing programme Steering Group, led by PHE and the UK Department of Health and Social Care, was formed to co-ordinate and advise on taking this commitment forward. Macpherson is a member of the Steering Group, and UofG research [3.1–3.3] provides the main evidence base [5.I].

Impact 3. Further development of Childsmile within Scotland

Between 2014 and 2020, dental caries among 5-year-olds in Scotland declined from 32% to 26%, with a 43% reduction overall since the initiation of Childsmile in 2006 (data source: National Dental Inspection Programme reports). UofG research showed that the nursery supervised toothbrushing programme has provided greater impact among children from the most socially disadvantaged areas [3.2]. In addition, Childsmile has influenced Scottish Government and NHS Scotland policy:

• In 2016, the Scottish Government committed to expanding its FVA programme in more deprived areas of Scotland [5.J] as a result of UofG findings on the limited reach into these communities of the targeted FVA component of Childsmile [3.4].

• The cost analysis of nursery supervised toothbrushing [3.3] was used in both the Scottish Government’s 2016 national clinical strategy and the Chief Medical Officer’s 2016–2017 annual report to evidence the effectiveness of preventive expenditure in improving health and reducing NHS Scotland treatment costs [5.K].

• Childsmile interventions were incorporated into the Scottish Intercollegiate Guidelines Network 2014 clinical guidelines (SIGN 138) [5.L] and the Scottish Dental Clinical Effectiveness Programme (2018) 5.M], with Childsmile considered the key implementation vehicle for delivering the recommendations.