This study is part of a broader study on global readiness for digital oral health, and it focuses on presenting the results regarding facilitators of and barriers to global digital oral health. The reporting of this study adheres to the GRAMMS (Good Reporting of A Mixed Methods Study) guidelines [21]. The GRAMMS checklist is available in Multimedia Appendix 1.

An explanatory sequential mixed methods [22] study was conducted in 2 phases. The initial phase used a quantitative approach. Subsequently, a qualitative phase was undertaken aimed at contextualizing and elaborating on the quantitative findings [23]. This design is valuable for gaining an in-depth understanding of the context of the study and supports policy implementation. The quantitative and qualitative data were collected sequentially from April 2022 to May 2023 but were analyzed simultaneously and in an iterative way to validate and confirm the results (triangulation) [24].

The technology acceptance model [25] and the eHealth readiness assessment tool by Khoja et al [17] were used as conceptual frameworks for the qualitative study. The technology acceptance model is a well-known theory widely used in research on health IT, explaining how factors such as perceived ease of use, perceived usefulness, and behavioral intention influence technology acceptance. The eHealth readiness assessment tool evaluates e-readiness among managers and health care providers across the categories of core, societal, and policy readiness, as well as technological readiness and learning readiness.

The potential study participants were invited through a collaboration with the WHO. One of the study team members (NG), who acts as a WHO expert in digital health, facilitated the communication with CDOs via email. The invitation email included an informative letter summarizing the study objectives and methods, including the anonymous online survey. The email addresses we contacted were valid as none of the messages were returned as undeliverable.

The eligibility criteria were being a CDO or the responsible oral health officer in the ministry of health of countries that were WHO members and represented the 6 WHO regions. The 6 WHO regions encompass the African Region, the Region of the Americas, the Eastern Mediterranean Region, the European Region, the South-East Asia Region, and the Western Pacific Region. These countries varied with regard to income level and included high, upper-middle, lower-middle, and low income levels. The income level was defined using the World Development Indicators database gross national income per capita, which categorizes economies based on their gross national income per capita into different income groups [26]. The invitation was sent only to 144 CDOs or responsible officers from 6 WHO regions and 194 WHO member countries. The FDI World Dental Federation maintains a section dedicated to CDOs and dental public health worldwide.

Ethics approval for this study was granted by the institutional review board (A04-E17-21A) of McGill University. Participation in the study was completely voluntary, and informed consent was obtained from all participants. Participants were clearly informed that any data collected during both the quantitative and qualitative phases would be deidentified to maintain confidentiality and ensure anonymity. No monetary or other forms of compensation were provided for participation.

The online survey was received by all 144 invited CDOs or responsible officers, of whom 101 (70.1%) returned the questionnaires. Approximately 17.8% (18/101) of the filled-out questionnaires had incomplete responses and were excluded from the analysis, leaving 83 questionnaires for the final analysis.

The mean age of the participants was 50.7 (SD 9.3) years. The majority of the participants were female (48/80, 60%). Approximately 69.9% (n=58) spoke English, 19.3% (n=16) spoke French, 9.6% (n=8) spoke Spanish, and 1.2% (n=1) spoke Russian. In total, 93% (n=77) worked full-time as CDOs or WHO associate members.

Of the 83 participants, 38.6% (n=32) were representatives of the African Region, 8.4% (n=7) were representatives of the Eastern Mediterranean Region, 13.3% (n=11) were representatives of the Region of the Americas, 16.9% (n=14) were representatives of the European Region, 8.4% (n=7) were representatives of the South-East Asia Region, and 14.5% (n=12) were representatives of the Western Pacific Region. The participants were from high-income (n=25, 30.1%), upper-middle–income (n=23, 27.7%), lower-middle–income (n=23, 27.7%), and low-income countries (n=12, 14.5%). More than three-quarters of the respondents (80/83, 84.3%) used a computer to complete the survey. Smartphones were mostly used by respondents from low- or lower-middle–income countries, whereas those from high-income countries (HICs) predominantly used computers.

For the qualitative study, interviews were conducted with 15 participants (n=14, 93.3% female) aged between 34 and 69 years, representing countries of all income levels: 2 (13.3%) from HICs, 3 (20%) from upper-middle–income countries, 6 (40%) from lower-middle–income countries, and 4 (26.7%) from low-income countries. Data saturation was reached after the 10th interview; however, we continued data collection to achieve diversity and at least one representative from all WHO regions.

This study identified key factors influencing the adoption of digital oral health in countries belonging to the 6 WHO regions from the decision-makers’ perspective. The key enablers identified were the presence of national eHealth policies, availability of funding for infrastructure and technology, and health care provider willingness. On the other hand, the barriers identified were the lack of governmental support for digital health, lack of partnerships, neglected oral health programs, lack of infrastructure and funding, and inadequate human resources. This study revealed that the frequency of these barriers was higher in low- and middle-income countries (LMICs), where policy gaps, competing health care priorities, and limited resources often exacerbate these issues compared to HICs.

Our findings are in agreement with those of previous systematic reviews [35,36] that have pointed to insufficient infrastructure, outdated equipment, technology gaps, and human resource challenges as major barriers to mHealth implementation in LMICs. Additionally, health care executives in Ethiopia have emphasized further challenges, including economic inflation, low digital literacy, and a lack of system interoperability as significant challenges to the adoption of mHealth solutions [37]. These barriers collectively pose significant threats to the performance of the health workforce, undermining their efforts to deliver high-quality care and further perpetuating health disparities.

Underuse and slow progression of digital health initiatives and mHealth programs despite the growing adoption of mobile phones and recognition of their potential benefits was a finding in LMICs. One key factor contributing to this issue could be the low mobile internet penetration in these regions, which stands at 69% and only 48% when China is excluded despite an estimated 2.9 billion current users of mobile phones [38,39]. This is in sharp contrast to 87% mobile internet penetration in HICs [39]. The lack of mobile internet access can prevent the effective use of mHealth tools that depend on real-time communication, data transmission, and access to digital health platforms. Consequently, the government’s role is crucial to improve the telecommunications infrastructure and enhance mobile internet access by making it more affordable through low costs of mobile devices and data services [40].

Digital technology offers an opportunity to enhance education, incentives, aid, supervision, and support for universal health coverage [41]. However, these efforts require adequate funding, the lack of which was reported as a significant barrier in our study and has also been reported as a barrier in other research [35,36], affecting both HICs and LMICs. The successful implementation of digital health interventions requires investment not only in technology but also in operational costs; training for dental health care providers; and the development of health care workflows, including data management and security systems. Securing sustained support from the government and relevant local funders and institutions is crucial for the success of digital interventions [42]. Moreover, to facilitate both scaling up and financial sustainability, diverse funding sources, such as private sector investments and public-private partnerships, should be sought rather than relying on a single source [40,43].

In addition to funding, proactive government engagement and the development of clear policies are essential, with well-defined roles and responsibilities at all levels, from government bodies to health care managers and dental health care providers [35]. Engaging local stakeholders and collaborating with mobile technology developers early in the design phase can help ensure that the interventions are both suitable and embraced [35]. Furthermore, strong partnerships between the national and local governments, nongovernmental organizations, private entities, and global organizations such as the WHO must be established for active leadership toward the successful implementation and long-term sustainability of the programs [40]. Within routine dental practices, ensuring successful implementation of digital health would require reforms in dental education toward the development of relevant competencies, positive attitudes, and behavioral intentions, ensuring easy access to digital technologies and establishing supportive policies and regulatory frameworks [44,45].

To our knowledge, this is the first study conducted in partnership with the WHO on global e–oral health readiness that involved participants from many countries working in different settings and with various profiles. The results of this study provide a basis for comparison and future planning. The mixed methods design used in this study enabled the combination of 2 complementary datasets to generate meaningful information and gain a strong understanding of factors that can be considered in developing a global strategic plan and improving the success of mOral Health implementation. However, this study has some limitations. First, while the participation rate was acceptable, the survey was self-administered, which may have resulted in an over- or underestimation of information. Second, many surveys were incomplete, resulting in the impossibility of analyzing nonrespondents. However, the purposeful sampling technique for the qualitative study provided rich data due to the inclusion of diverse participants from the 6 WHO regions. Third, the participants in this study represented WHO member countries from the 6 WHO regions. Therefore, the results may not be generalizable to nonmember countries, whose national health and digital health policies might differ from those of the countries included in our study.

This study identified key barriers to and enablers of implementing digital oral health programs in WHO member states through an e-readiness assessment across multiple levels. The analysis revealed gaps in funding support, the establishment of norms and regulations, and the availability of robust infrastructure. As readiness is essential for the successful adoption of new policies, practices, and technologies, its systematic assessment is crucial for integrating digital oral health into oral health care systems and practice to advance global oral health outcomes. Governments play a central role in this process by developing concrete policies, investing in infrastructure, and allocating adequate budgets for e–oral health technologies to overcome the limitations of traditional health care delivery models.