Returning to Malawi: co-designing and piloting a supervised toothbrushing programme

This is a guest post by Anna Smith, who will be well known to regular readers of this blog.

In 2025, between Years 4 and 5 of her BDS course at the University of Birmingham, Anna spent a month in Blantyre undertaking an elective project. Her very positive experiences were recounted in an earlier post which you can view here. In addition, Anna made a documentary about her findings which can be watched via a link in this post. Finally, Anna and her friend Mutoni Bisetso, at the time a BDS student at Kamuzu University of Health Sciences (KUHeS), participated in the Student Leadership in Oral Health Class of 2026, run by the Alliance for Oral Health Across Borders in the USA, described in this further post.

This fourth post by Anna describes a recent return visit she has made to Malawi and her experiences establishing a supervised toothbrushing programme at the Beehive Centre for Social Enterprise at Chilomoni, just outside Blantyre City.

Introduction

Following my Community Engagement and Involvement (CEI) paediatric oral health needs assessment in Blantyre in 2025, I returned to Malawi in 2026 with a new focus: exploring supervised toothbrushing as a community-informed preventive intervention.

My previous work highlighted the extensive oral health needs among children, limited access to toothbrushes and toothpaste, and the need for accessible oral health information that supports prevention.

This year, with support from Prof Jeremy Bagg, Dr Vahid Ravaghi and Prof Lorna Macpherson, we began planning a follow-up co-designed feasibility pilot.

The University of Birmingham and Dr Ravaghi kindly supported me with toothbrushes, toothpaste and my flight to Malawi, while family and friends helped me raise additional funds for stationery and incentives.

Just one week after graduating with my BDS from the University of Birmingham …

… I was heading back to Malawi, this time with a suitcase full of toothbrushes, toothpaste and supplies!

Starting with the community

Before beginning the main pilot, I visited one of the Joshua Early Childhood Development Centres in Chilaweni.

I met with children and caregivers, observed existing practices and explored supervised toothbrushing alongside their education and porridge-feeding programme:

Speaking with caregivers was particularly valuable in understanding what could make a future intervention practical and acceptable:

I then visited Beehive Centre for Social Enterprise, where the main pilot would take place alongside their feeding programme. After meeting with the staff, many of whom I already knew from my visit in 2025, the next step was recruiting volunteers.

Working with the BDS 5 team

A group of BDS 5 students from Kamuzu University of Health Sciences, Grace, Hopeson, Nellie, Patrick and Wezzie, quickly became an essential part of the project.

They did far more than volunteer. They helped co-design activities, translate and adapt ideas, engage with the children and bring so much energy and creativity to the sessions.

Establishing the supervised toothbrushing programme

Before starting, consent forms were kindly translated by Dr Benjamin Williams, a former KUHeS BDS 5 student:

Patrick then helped begin the sessions with oral health information and demonstrations:

I had arrived with a plan, but co-design and flexibility were central to the pilot. The intervention needed to work for the community, not simply follow what had been planned on paper.

Making toothbrushing fun

Our first session began with introductions, games and dancing before splitting into smaller groups.

The children decorated their own cups for storage of their toothbrushes…

… while we introduced them to our lion with teeth, who was quickly named Miji:

We decorated our own cups too and demonstrated toothbrushing ourselves, helping to make the activity feel comfortable and fun:

Then it was time for the children to brush. Once the children began brushing, the room became very quiet, so we put some music on! The atmosphere completely changed.

By the end of the first session, caregivers were already helping to lead the intervention and give instructions:

Listening to the children

As the sessions continued, the children became increasingly confident asking questions about their oral health.

We talked about fluoride, toothpaste, brushing techniques and what they used to clean their teeth at home.

Some children told us they brushed with soda or salt, while others spoke about bleeding gums. These conversations gave us an opportunity to correct misinformation and create a space where children felt comfortable talking about their oral health.

One of the most important things I learnt was how much access influences behaviour.

Several children explained that they could not always brush because they did not have toothpaste at home, or had to ration what they had.

This reinforced why preventive interventions need to consider not only knowledge, but also whether children have the resources to act on that knowledge.

Learning through play

A huge part of the intervention was dancing, games and creativity.

The children created songs about what they had learnt, shared poems and dances, and took part in activities throughout the sessions.

They were brilliant.

At the end, all 35 children completed anonymous feedback. It was amazing to see that every child had something to share.

We finished with a celebration of games, dancing and toothbrushing, alongside distributing stationery and school supplies.

Listening beyond the children

The children’s voices were only one part of the pilot. I also held a focus group with caregivers and met again with mothers I had spoken to during my previous visit. Their perspectives helped me understand concerns around supervised toothbrushing and how it might fit within existing family practices.

These conversations were a reminder that successful prevention needs to involve children, caregivers and the wider community.

Beyond the pilot

There was, of course, plenty of time to experience Malawi outside the project too! I visited the Beehive new porridge factory, explored Liwonde National Park and Mangochi with my good friend Mutoni Bisetso, visited Williams Falls in Zomba, and went hiking in Chikwawa with Jeremy and Nelson. There were also plenty of memorable meals and conversations with friends and colleagues along the way.

Looking ahead

There is so much more I could share about this trip, but overall, the pilot was an incredibly valuable and informative experience.

I arrived with a plan, but the intervention evolved through the voices of the children, caregivers, Beehive staff and student volunteers.

Most importantly, it showed me again that oral health interventions must represent the community that they are meant to serve and this requires listening and consulting with the people affected.

I am incredibly grateful to Professor Jeremy Bagg, Dr Vahid Ravaghi, Professor Lorna Macpherson, the University of Birmingham, Kamuzu University of Health Sciences, the Beehive team, Sue Cabon (Joshua), and Ruthie Markus (AMECA). Finally, very special thanks to Grace, Hopeson, Nellie, Patrick and Wezzie, the KUHeS BDS 5 students who made this pilot possible.

In the next MalDent Project blog post, the BDS 5 students will share their own experiences of volunteering in the intervention.

Looking forward to speaking to you soon :).