Evaluation of international case studies within ‘Live.Learn.Laugh.’: a unique global public-private partnership to promote oral health

Abstract

The partnership between the Féderation Dentaire International (FDI), and Unilever Oral Care, aims to raise awareness of oral health globally; to enable FDI member associations to promote oral health; and to increase the visibility of the FDI and authority of Unilever oral care brands worldwide. Country Projects between National Dental Associations (NDAs), the member associations of FDI, and Unilever Oral Care local companies have been established as a key strand of the partnership. Aim: This paper reports on the evaluation of an in-depth sample of Country Projects (n = 5) to determine their potential to impact on oral health. Method: Five country sites were selected as being indicative of different programme delivery types. Each site received a two-day visit during Spring-Summer 2009, which enabled the evaluators to audit what was delivered in practice compared with the original written project briefs and to undertake interviews of study site staff. Results: 39 projects in 36 countries have been initiated. In those examined by site visits, clear evidence was found of capacity building to deliver oral health. In some countries, widespread population reach had been prioritised. Effectiveness of partnership working varied depending on the strength of the relationship between the NDA and local Unilever Oral Care representatives and alignment with national marketing strategy. The quality of internal evaluation varied considerably. Conclusions: Over a million people had been reached directly by Country Projects and this public-private partnership has made a successful start. To move towards improving oral health rather than only awareness raising; future Country Projects would benefit from being limited to certain evidence-based intervention designs, and using an agreed core indicator set in order to allow cross-country comparison of intervention outcomes.

INTRODUCTION

The World Health Organisation¹ acknowledges that global promotion of oral health remains a significant challenge. The burden of oral disease is particularly high among disadvantaged population groups in both developing and developed countries. The risk of oral disease is related to living conditions, lifestyles, environmental factors, and the availability and accessibility of oral health services. Availability of preventive oral health programmes is varied. WHO¹ state that “It is expected that the incidence of dental caries will increase in the near future in many of these countries as a result of growing consumption of sugars and inadequate exposure to fluorides”.

The partnership between the Féderation Dentaire International (FDI) and Unilever Oral Care, to promote oral health worldwide through the Live.Learn.Laugh. programme (LLL) completed its first phase at the end of 2009. The partnership had three main goals:

• •To raise awareness of oral health globally
• •To enable and support FDI member associations in promoting good oral health
• •To increase the visibility of the FDI and authority of Unilever Oral Care brands worldwide.

The partnership consists of three main strands of work

• •The FDI granting the right to use the FDI logo on Unilever oral care products together with a supportive health message
• •Programmes (known as Country Projects) between FDI and its member, National Dental Associations (NDAs) and Unilever local companies to promote oral health, funded through the partnership
• •Global Projects: activities of the FDI to promote oral health worldwide, funded through the partnership.

Country based oral health partnerships are common², however this partnership is recognised as being the first, global public-private partnership aiming to promote oral public health, of its kind3., 4.. Effectiveness of joint working in this public-private partnership included assessment of the recognition of the pre-requisites for successful delivery of shared agendas; and understanding and overcoming barriers to delivery, against the stated aims. The companion paper describes the partnership in further details, the aims and methods of the evaluation and general results⁴. This paper details the part of the externally commissioned evaluation of the partnership that had the agreed aim of determining the potential of Country Projects to impact on oral health. The partners also requested that the Evaluation Team seek to determine, where possible, the potential of Country Projects, to achieve the behaviour of twice daily brushing with fluoridated toothpaste. This paper describes the evaluation, in-depth, of a sample of Country Projects; this was an important part of the whole evaluation, since as Danzon⁵ stated: “The requirement for evidence-based health promotion pertains to public health practice in general from designing an intervention through evaluating its impact”.

METHODS

The evaluation of the partnership would have been significantly comprised without triangulating⁶ the information in written project specifications with direct observation of a selection of ‘active’ projects⁷. In discussion with FDI and Unilever, a classification (Table 1, in the companion paper⁴) was developed and Country Projects were selected to be visited for the evaluation. Programmes were categorised into one of four types as follows, providing a sampling framework for site selection.:

• A.Multi-objective public health programmes (oral health is one component)
• B.Directly delivered by the dental team
• C.Indirectly delivered via trainers
• D.Dental treatment provided in addition to health promotion.

Inclusion for selection required a site to have been active for more than a year and active during the evaluation period, with completed reports. In agreement with the commissioners of the evaluation, FDI and Unilever Oral Care, the following sites were chosen to be case studies for the evaluation:

• A.Philippines, Poland (chosen in addition for its whole country coverage)
• B.No active site
• C.Indonesia
• D.Nigeria (and Kenya).

Each site received a two-day visit during Spring-Summer 2009, by one member of the Evaluation Team. The itineraries were determined by the Country Project in question with the brief to enable access for the evaluators to see the project being implemented i.e. ‘in action’. In-depth data were collected in order to verify the paper-based records which already formed part of the ongoing internal monitoring process of the project.

Typically the evaluators would meet and interview the project lead (who was usually from the local NDA), key partners, observe sites where the project was delivered, observe and speak to some participants and recipients of the project intervention from the general public and interview political leaders using a portfolio approach as advocated by WHO⁸. Data were collected in the form of observations of sites, formal interviews which were audio-taped and transcribed verbatim at a later date, informal conversations with groups of people and participants during the visit and some photographic recording ⁹.

The questions below provide a sample of those that were used to review the Country Projects:

• •What has been the reach and impact of the project?
• •What aspects/ways of working were effective and why? ¹⁰
• •Can best practice be identified?
• •What should continue and why?
• •What capacity has been developed?
• •What resource model was used to deliver the project, i.e. what monies were levered from elsewhere or contributions in kind?

Data were analysed using a thematic content analysis framework¹¹.

RESULTS AND ANALYSIS

Country Project Type A. Multi-objective public health programmes (oral health is one component): Philippines - Training day care workers to deliver oral health promotion as part of a hygiene routine in day care centres in urban and rural locations.

This programme involved pre-school children (aged 2–4 years) in a holistic routine of hand washing, tooth brushing, eating a healthy diet, mass de-worming and waste management (recycling), in day care centres. The project existed prior to LLL however, LLL monies allowed the programme to become fully integrated and developed further in terms of the training provision for day care centre administrators through a capacity building seminar series implemented by the project lead. The programme has extensive political support from the local authorities and politicians. Parental involvement was strongly encouraged especially in helping to supervise hand washing and tooth brushing on site, and in the preparation of a healthy meal for the children whilst at the centre. Health education with the parents was an ongoing process in order to establish habits such as the provision of healthy (rather than sugary) snacks and water only for drinking. Another important part of the project has been to establish hand washing and tooth brushing facilities within the day care centres, which were often in remote locations.

Analysis

This is a well established project with a ten year development history hence the developed infrastructure and especially the level of political support being provided. The project lead noted: “My personal experience communicating…with the leaders is very crucial, with those who make it happen. I found out that there are key people you have to talk to because they are the people who make it happen.”

The project lead has an extensive track record of carrying out community-based, oral health promotion projects and showed comprehensive understanding of how to design and deliver a high quality programme.

There were tensions between the marketing strategy of Unilever in the Philippines as their target market was teenagers and the LLL project which was targeting pre-school children. This and some other communication problems seemed to have led to this project not being signed off by the key partners at country level even though there was extensive political support and sign up to the process. Within the partnership it became clear that the understanding of the governance structures of the project at country level, had been unclear. This led to misunderstanding about lines of accountability between project leads, the NDA and Unilever Local, where and how monies were to be drawn down, and who was involved in the decision making process regarding resources.

The lack of local support and lack of consistent help with appropriate supplies of toothpaste and brushes had created barriers within the partnership. Although the partnership at country level was somewhat difficult, the perception of the partnership with Unilever at an international level was excellent and much valued in terms of the support given and the opportunities which had been provided through the project e.g. by project members attending regional workshops.

One of the benefits from the LLL programme was how it had enabled oral health promotion and behaviour to be integrated as part of optimal general health behaviour with all the different components, (hand washing, tooth brushing, eating a healthy diet, mass de-worming and waste management [recycling]), being integrated into a single package for delivery. This was particularly important in more rural areas where oral health problems were extreme and inequalities more marked.

It was also evident that the capacity building seminars designed to raise awareness of oral health and train the day care centre administrators were only effective if followed up with advice on how to implement these procedures within the day care centre e.g. with respect to hand washing correctly for example: “My capacity building seminars, …I just tell them ‘you just wash your hands’ but when you visit the community, they’re not doing it right. It’s a problem of providing running water…we are coming up with effective solutions on how to address the [need for] running water, and of course the health of the community.”

This project employed two evaluators to visit day care centres and check that the processes of hand washing, tooth brushing and healthy dietary guidance were being followed appropriately. The evaluators would visit with little or no prior warning so that they could see the reality of practice within the centres. They would complete a checklist to ensure procedures were being implemented correctly and if necessary would give some constructive feedback to the day care administrators if any procedures needed amending. The day care centre administrators said it normally took three to four weeks to get the healthy habits embedded in parental routines, and about a week for the children to learn the hand washing and tooth brushing routines. In some of the centres, tooth brushing record cards had been set up by the day care centre administrators so that a record was maintained of every day a child was present and brushed their teeth. This was cross-referenced with a regular oral health check conducted by a local community dentist. The dentist said she had seen improvements in the oral health status of children in the centres where the LLL project was being implemented although she could not guarantee that parents were replicating the healthy dietary habits in the home environment.

Overall, this project was well planned and organised and had a sound theoretical and practical rationale. The project had a clear preventative focus being aimed at the 2–4 year age group and their parents, and as the model was being implemented through a ‘training the trainers’ model then it was potentially sustainable in the longer term. The site visit gave clear evidence that the infrastructure for hand washing and tooth brushing had been established in a sample of the day centres and that this was a part of the daily routine of these children. Parents were also clearly involved especially in producing healthy meals.

The training for day care centre assistants was being implemented with confidence in the day care centres and was an ongoing process, not a single event. Innovative developments of facilities for hand washing and tooth brushing had been built in or alongside many of the centres to ensure running water was available for hand washing and a trough or sink so tooth brushing could also be accomplished. Integrating project monitoring was a way of ensuring implementation of the project was being achieved. Some evidence of health outcomes was evident in some of the centres but this is at an early stage of development and comparing outcomes between centres has not yet been possible. It is clear that children across at least 89 centres are being reached through this programme and the longer term plan is to roll this out more widely. A manual which encompasses all the above health components for pre-school sites has already been developed for roll-out on a larger scale across the Philippines allied to the programme developed for elementary schoolchildren¹².

Country Project Type A. Multi-objective public health programmes (oral health is one component): Poland - Implementing a dental education programme for parents-to-be in order to improve infant oral health.

Although pre-natal health education is common practice in Poland, currently programmes do not cover oral health information for mothers-to-be (during and after their pregnancy) and their infants. The rationale was therefore to prepare and introduce a pre-natal oral health education programme to be delivered within childbirth and parenting classes. It was developed by academic dentists with prior experience in prenatal education: “In our department, we have quite a long tradition of pre-natal education because it was 80 years ago, we had such a local programme for pregnant women. It involved pre-dental treatment for pregnant woman, and also education.”

The first year of the project entailed the development of educational materials and identifying childbirth and parenting schools willing to cooperate. The next two years involved distribution of education packs to the educators both dental and general health professionals and implementation of the parenting classes. The site visit gave clear evidence of the professional infrastructure for delivering the childbirth classes however it was not possible to see these classes being implemented which was a limitation of this site visit.

Analysis

There appeared to be some partnership difficulties and lack of clarity regarding support from the local Unilever office hence, the project team decided to focus efforts on producing educational materials. At one point the cooperation between the project lead within the local NDA and Unilever local had been very good but then the Unilever representative had moved on and re-establishing the relationship had been difficult. Political support from top level was limited although the Polish Ministry of Health was aware of the project. Local level political support through the regional mayor was much stronger and clearly in evidence. The development of appropriate educational materials including over 5,000 brochures was a fundamental part of the development phase of this project, which was followed up with their distribution to all dental practitioners who could utilise them in parenting and childbirth classes. Much of the educational process focused on trying to change parental behaviour towards feeding and drinking habits of the child such as not putting sugar in drinks as a soother during the teething process: “…mostly because of the teething, during the night, with some sweet milk, or tea …the kids just fall asleep with the beaker and that is the way to make them [babies] sleep and it’s how it [tooth decay] starts.”

Little systematic evaluation of the materials appeared to have been carried out. Assessment of the efficacy was to be achieved by checking the oral health knowledge of the parents at the end of the childbirth classes by test and questionnaire, however the project had not proceeded this far. The dental leads believed the programme was starting to make a difference to parental behaviour.

There was interest expressed from other health professionals in Poland regarding the project: “Our project, we think it was the inspiration for some people from other cities because as we know, they started to organise some training for nurses and midwives.”

Dentists involved were also incorporating the content and learning from the LLL project into the educational classes with trainee dentists and were using the educational materials to inform relevant professionals such as midwives and doctors. Dentists involved in the LLL project were obviously prioritising prophylaxis and inter-professional education regarding oral health, in order to inform parents early: “I think what we learnt from the project, what is most important is to educate parents and some other professions, like paediatricians.”

The project had a clear preventative focus being aimed at parents prior to birth, however to date the main phase of implementation has been to distribute educational materials (over 5,000 brochures plus posters) regarding oral health to dental and other health professionals - so the reach and impact of the project on parents was not possible to assess. Also, it was not possible to comment on the quality and use of the oral health education materials as the evaluator was not able to see them being used in a typical setting. Project monitoring did not appear to be systematic or integrated into the project, possibly due to the focus being mainly on the development and roll-out of the educational materials rather than their effectiveness. A future plan was to make the oral health educational materials web-based.

Country Project Type C. Indirectly delivered via trainers: Indonesia - Training of dental health educators in local communities.

There are over 130 million people in Indonesia and a shortage of dentists and dental nurses. Enhancing capacity within the community, by engaging local people about oral health issues and training them to supervise tooth brushing with fluoride toothpaste in schools, was seen as a key way forward in promoting oral health, and in primary prevention of dental caries in a country with limited access to dental care, especially for those in less advantaged areas.

The project lead developed a short training programme to become a ‘dental kader’ and implemented this with support from dentists, members of the Indonesian Dental Association. She trained volunteers from the local community to work in schools to deliver the oral health programme (Training the Trainer model), and followed up with visits to the schools to check on progress and delivery and evaluate changes in knowledge and reported behaviour of the children.

Unilever Indonesia has a school oral health programme, which began in 1995, and hence has significant experience of working in schools to deliver oral health promotion. However, it became clear that the original programme was run separately to LLL and therefore, this local expertise was not being harnessed.

Analysis

More than 12,000 children have been reached by the LLL programme in Indonesia. There was excellent collaboration between the NDA and local Unilever. “We cannot do this programme by ourselves we need help of the local Unilever company.”

Changes were implemented after Year 1 of the programme, following advice from one of the FDI Public Health Committee members. It was suggested that the programme should be expanded to include screening and simple treatment; recommendations which were adopted. There are a number of good practice elements to this programme e.g. members of the local education and health department attended the oral health training session, an important aspect for access and sustainability of programmes. Also the programme developed from significant local research undertaken by the programme lead.

Established partnership working, between local Unilever and the NDA, was built on longstanding links between individual members of the NDA and the fact that several dentists had, at times, worked for the company. There was trust that Unilever was seeking to do good and improve dental health in Indonesia. It was recognised that trust takes years to build. In parts of the country, there was suspicion about the motivation of some multinationals as they appeared to be entirely profit-based regardless of the local community; but, this was not the perception in relation to Unilever, which was highly trusted by the professional dental community.

The training programme was based on sound principles, however, the content was complex covering: dental development; the role of dental plaque; dental caries; benefit of tooth brushing; role of sugar with examples of sugary foods and drinks; challenges in establishing brushing as a daily habit; aspects of behaviour change. The trainer was an engaging dentist with postgraduate qualifications, clearly deeply committed to the community work; the delivery was well-paced and interactive. Those in the community attending the training ranged from experienced teachers to local grandparents. It was recognised that some of the training had been condensed for the visit, however, delivery of this range of content and complexity of concepts in a single training session was likely to result in only partial understanding and retention particularly of local volunteers; although teachers in the audience would have some familiarity with aspects. The training session could benefit from being simplified and delivered over two sessions with follow-up checks and support in the schools once the ‘kaders’ have completed their initial training sessions. It is understood this happened initially when the programme was being developed. In future, baseline assessment of knowledge, attitudes and behaviours of the volunteers would be helpful. This would enable training to be more tailored with checks on understanding and gain in knowledge from sessions.

Country Project Type D. Dental treatment provided in addition to health promotion: Kenya - Oral health intervention programme for needy children.

The aim of the Kenya project was to bring oral care to disadvantaged children, to raise awareness of oral health and to organise tooth brushing in varied settings e.g. residential homes for disadvantaged, mentally handicapped and abandoned children. The children’s parents were either deceased or living in the local community and some were disabled through the effects of HIV/Aids.

The site visited was a feeding centre in a disadvantaged area of Nairobi run by a pastor of a nearby church. The church was supported by a charity. The visit to the centre was organised in conjunction with an LLL workshop in Nairobi, in spring 2009. The visit was organised to show the project to the President of the FDI and a number of additional dignitaries who accompanied him on the visit, including the Chief Dental Officer of Kenya, therefore the visit was mainly ceremonial; as a site visit, it had not been separately organised by the Evaluation Team and, consequently, it had some limitations for that purpose.

Analysis

The site visited comprised a single building with an office area in which a wooden board was affixed with holes cut in and numbered. In preparation for the visit, new toothbrushes were in each of the approximately 50 holes. In the office there were also new unopened boxes of a Unilever Oral Care toothpaste. In discussions with the dentists, it became clear that some of them had been released from Government health centres to provide care in the mobile van, and that the LLL funding had provided an additional honorarium for this activity. Some of the dentists, notably the academics, involved in the project, had volunteered to provide care and attended on weekends. The project team had struggled to get supplies of toothpaste and brushes from Unilever, and this had caused some discontent within the local LLL project team. Unlike other sites visited, there was no significant previous partnership working between the NDA and Unilever Oral Care local offices. Despite some difficulties, the commitment of all the NDA team to provide care for these disadvantaged communities was very evident. There were evident links to the Ministry of Health and the LLL project had brought dental treatment to a number of children who would not otherwise have been able to access dental care; overall, by this stage, at least 300 children in several centres had been reached and many provided with treatment and preventive advice.

Country Project Type D. Dental treatment provided in addition to health promotion: Nigeria - Oral health awareness and assessment of a targeted population

The aim of this major programme was to raise awareness, promote regular oral health habits, notably twice daily tooth brushing and distribute samples of toothbrushes and toothpaste, as well as to provide simple treatment from a mobile dental van on school grounds. From the outset the programme was designed to involve local and state level decision makers in health and education. In Nigeria, all dentists are members of the National Dental Association which is strong and well respected by its members. This is the first large-scale preventive project that has been conducted by the NDA. One of the features of working across different areas of the country on LLL has been that it has encouraged the establishment of new chapters of the NDA.

The dental team in Nigeria identified a very long, trusted relationship between Unilever and the dental community that has been in place for many years. Therefore, the LLL project was a welcome addition. In addition, the most popular brand of toothpaste in Nigeria is a Unilever product. The company had started a new night and day brushing campaign and, as a further example of the ongoing trusted relationship, the lead for the LLL project was also working on the new programme. It became evident that the local Unilever Oral Care company supplemented the funding from the international partnership.

At the outset, the project lead set up training programmes for the dentists who would be involved in asking people to complete a questionnaire and doing a dental examination recording oral health indices, e.g. plaque measurements. In 2006, a Mobile Dental Unit was donated by Unilever, which acted as a physical focal point attracting people in the community, many of whom had never had dental care. At this site visit, there were two people from the supporting company and they were involved in giving out a brush and sachet of fluoride toothpaste to each participant on presentation of a completed questionnaire and dental chart.

Analysis

The programme has reached over 20,000 people in states across the country, and is raising awareness of oral health. It has resulted in many people with dental problems being referred for care. When the dental bus was operational some immediate treatment had been provided. Due to the vast numbers of people reached, sites had been visited only once. Therefore, despite commendable efforts, this model of intervention is unlikely to lead to behaviour change as there is no ongoing reinforcement of the educational messages and practise of the behaviour. Providing sample sachets of toothpaste could have increased purchases of fluoride toothpaste in the markets. The project lead reported that most local education and health authorities had been supportive and very helpful but some were not as committed. The local administration changes every four years and the people in charge are elected, therefore, access and support needs regular work. This is where a local agent can be helpful in doing the ground work to get the local community out and the dental bus is usually an attraction.

A direct outcome of the programme has occurred in Lagos state. A dental component has now been added to the School Health programme for the first time and a new dental mobile purchased. The LLL project has raised the profile of dentistry and dentists as engaging with the community and highlighted the relevance of dental health as a key part of health. In addition, it was clear that the personal development for the senior dentists involved had been important. Some had been involved in an international project for the first time; been invited to attend an international meeting with other African colleagues and established a network of contacts of like-minded people in other countries.

The co-ordinator of the programme, the project lead, considered that there had been four main benefits of the programme, namely: raising awareness within the local communities; making FDI relevant to local dentists, opening new NDA chapters within Nigeria and encouraging more people to attend the FDI World Congress and participate.

DISCUSSION

The projects had reached many thousands of people who have been exposed to oral health issues and, or, have had dental treatment. Capacity building had clearly taken place to deliver oral health promotion projects amongst dentists whose previous experience had largely been confined to clinical matters. There was considerable evidence of the personal development of dentists who had taken part in LLL projects and an increased commitment to a preventive philosophy.

However, in some cases an evidence-based approach to project design had not been taken, resulting in interventions which could succeed in raising awareness but not in changing oral health behaviour e.g. mobile buses which reached vast numbers but had no follow-up and reinforcement of the health message. This reflects the early first phase of the partnership where projects had not been given specific designs to follow and the focus had been on encouraging engagement of NDAs, getting projects off the ground and raising awareness of oral health rather than, necessarily, impacting on oral health. In order to take future projects to a level of potential to impact on health, there is a clear need for training of project staff in evidence-based planning and design for public health interventions and their evaluation. Projects had often instigated evaluation too late in the project cycle thus making pre-post evaluation impossible due to lack of a baseline against which improvements could be measured.

Both well developed political partnerships and a history of prior partnership working were indicators of success within the projects seen in this evaluation. As Labonte¹³ observed:

“As most health promoters have long known, ‘healthy public policy’ usually arises from the entwined efforts of those who provide as much evidence as possible and those who then lobby its importance”.

In several countries there were excellent relationships between Unilever Local and the local NDA. These links had been established around a wide range of activities including longstanding collaborations with dental schools and continuing education programmes. In addition, in these countries there were often well established oral health programmes already receiving substantial funding from Unilever. Sustainability and future roll-out of effective interventions requires a strong partnership structure to be built at country level where the project is well integrated into ongoing activity. In terms of the two partners working together it is evident that much has been achieved on a global scale in a relatively short time scale and this has resulted in benefits to both organisations.

RECOMMENDATIONS

Emerging from this evaluation are some principles on which future Country Projects could be designed to maximise their potential to bring health gain. They should be limited to evidence-based designs, with an agreed core indicator set14., 15. within the evaluation framework of the design. Core indicator sets would allow cross-country comparison of intervention outcomes and would allow a more in-depth understanding and capacity to be built up across the partnership in being able to say ‘what works’ and ‘why’¹³. This would enhance the potential learning from these public health interventions across the partnership globally and allow both parties to quantify benefits to oral health. Site visits are an important part of the process of auditing project implementation and effectiveness.

To increase the chances of successful projects in this partnership, which rely on joint working between local Unilever and NDAs, ideally projects should be aligned with the business. Evaluation must be in the design from the outset. Many Country Projects produced dental health promotion material and it is recommended that a generic set of materials are used that could be adapted for local use with central support. Allowance should be made for training workshops before new projects are implemented and both local Unilever Oral Care and NDA members should be involved working together. In some cases, other organisations outside of the NDA were part of the project, e.g. charities or non-governmental organisations, it is recommended that this needs to be explicit and assessed to ensure appropriateness for both partners at the international level of the partnership.

In summary, Country Projects have been a major expression of the Live Laugh Learn partnership between the FDI and Unilever Oral Care; 39 projects in 36 countries have resulted in over one million people being reached directly in oral health promotion activities; capacity of many local dental practitioners to engage in community projects has increased. The Evaluation Team commends the vision and hard work of those people at the international level in both organisations who were involved in establishing this partnership and making it work. Addressing the issues found will make delivery easier in the future and strengthen the potential of the partnership to make a major impact on oral health around the world.

ACKNOWLEDGEMENTS

The Evaluation Team gratefully acknowledge all the individuals who contributed to the evaluation. The authors express particular thanks to the LLL project team in each site, with particular thanks to team leaders: Dr Noel Vallesteros Executive Director, Paediatric Dentistry Center, Phillipines; Dr Tri Erri Astoeti, Vice-Dean, Faculty of Dentistry IV, Trisakti University, Jakarta, Indonesia; Prof A.O. Olusile, Nigerian Dental Association; Dr Susan Maina, Kenya Dental Association and Dr Tamara Pawlaczyk-Kamieńska, Polish Dental Society.

Limitations of the evaluation and declarations of interest by the authors

Limitations of this evaluation are similar to any project evaluation; namely constraints on the time allowed and on the budget available. However, within both of these a comprehensive review has been completed. It is noted here that evaluation of the effect of the FDI logo and LLL brand, is limited. In order to undertake a comprehensive review including general practitioners and consumers, additional survey work would be required. The Principal Investigator, Professor Pine is not employed by either organisation but, in common with many senior research colleagues, has undertaken advisory work for different oral care companies including Unilever Oral Care and, her employing university has previously received funding for a clinical trial. However, she has not been involved in any of the Country Projects or Global Projects. Professor Pine is a member of the British Dental Association. Professor Dugdill, co-investigator and Professor in Public Health is not a dentist and has no previous experience with either organisation.