Patients’ E-Readiness to use E-Health technologies for oral health

Introduction Scientific evidence highlights the importance of E-Readiness in the adoption and implementation of E-Oral Health technologies. However, to our knowledge, there is no study investigating the perspective of patients in this regard. Therefore, the objective of this study was to explore patients’ E-Readiness in the field of dentistry. Materials and methods A qualitative study was conducted using interpretive descriptive methodology. Purposeful sampling with maximum variation and snowball techniques were used to recruit the study participants via McGill University dental clinics and affiliated hospitals, as well as private or public dental care organizations. A total of 15 face-to-face, semi-structured and 60 to 90-minute audio recorded interviews were conducted. Data collection and analyses were performed concurrently, and interviews were continued until saturation was reached. Activity theory was used as the conceptual framework, and thematic analysis was used to analyze data. Data analysis was conducted both manually and with the use of “ATLAS-ti” software. Results Four major themes emerged from the study; unlocking barriers, E-Oral Health awareness, inquisitiveness for E-Oral Health technology and enduring oral health benefits. These themes correspond with all three types of readiness (core, engagement and structural). Conclusion The study results suggest that dental patients consider E-Oral Health as a facilitator to access to care, and they are ready to learn and use E-Oral Health technology. There is a need to implement and support E-Oral Health technologies to improve patient care.

Introduction clinical practice generating clinical practice-based knowledge [17]. It goes beyond the theoretical description of the phenomenon and offers more practical forms of the interpretation [17].

Study setting, participants, and data collection
The study participants were recruited from dental clinics and affiliated hospitals at McGill University, as well as other private or public health care clinics. The participants were seeking oral health care for themselves, their children or other family members. All participants or their family members from various cultural, educational and socio-economic backgrounds were eligible to be included in the study. A semi-structured interview guide was designed based on the study framework. A purposeful sampling with maximum variation, as well as a snowball sampling technique were used to recruit the study participants [18]. This approach allowed us to collect "information-rich" data and capture the perspectives of a wide range of people, regardless of their backgrounds [18]. By using snowball sampling, the recruited participants were asked to identify other participants who might be interested in participating in the study. Data were collected using in-depth, face-to-face, audio-recorded and 60 to 90-minute interviews. The inclusion criteria to participate in study were age above 18 years, Montreal resident and ability to speak and understand English. The exclusion criteria were the non-willingness of the participant to provide consent. These interviews were conducted by a postgraduate student (AKJ) trained in qualitative research and at a place suited to the interviewee. Data collection and analysis were performed concurrently, and interviews were continued until saturation was reached [19].

Data analysis
Analysis included transcription, debriefing, codification, data display, inductive-deductive thematic analysis and interpretation [20,21]. Data were coded manually, then analyzed using "ATLAS.ti" version 8 to facilitate the analysis. The first coding round used the principles of text interpretation developed by Strauss and Corbin (1998). This method involved cutting the transcript into significant sections [22]. We used an initial list of codes inspired by the type of E-Readiness and, throughout the coding, we refined the list. Then, the codes and their respective texts were examined and grouped into broad themes (Table 1. Development of Categories). The preliminary interpretations were reviewed during research team meetings, and themes were elaborated collectively.

Conceptual framework
The Activity Theory framework adopted for E-Health readiness assessment was used as the conceptual framework for this study, as shown in Fig 1 [23,24]. The Activity Theory offers a philosophical structure for studying the developmental processes that interlink individuals and society [25]. This sophisticated tool has potential to provide a rich, systematic and more structured description of human activities in any complex and dynamic environment [26].
It provides a helpful paradigm to understanding the meaning of technology for people, including human experience, needs, environment, motivations, complexities and efficiency of emerging technologies [25]. As shown in Table 2, this framework was used in the development of the interview guide, in understanding user behavior and associated broader contextual problems on E-Health technology usability and in analysing the data [23].

Results
The profile of the study participants is shown in Table 3. Data saturation was reached after the 10th interview; however, data collection continued up to the 15th interview to ensure the it will be helpful for old age people too and international people also, but we cannot implement it hundred percent right now. In future this is going to be the best thing.

Engagement readiness
Affordability Understand E-Oral Health advantages and disadvantages it is same thing like a taxi, you know where you reach for taxi and do you have the number you have on the Cybernet where to reach for taxi or the or for your breakfast, first it will be same way good and I think it's additional advantage.
It assesses the degree to which a community member is exposed to the concept of E-Health and actively discusses its potential benefits and negative effects. It also includes assessing the ability and willingness of members of a community to accept E-Health training.

Inquisitiveness of E-Oral Health technology
Willingness to be trained you know, as a mother if you ask any mother to this (E-Oral Health) she will say yes, because that's the kind of very handy so I can easily access, I can talk to maybe I can text them this is a problem and what should be the next step (Continued ) saturation level. A total of four themes emerged from the analysis: unlocking barriers, E-Oral Health awareness, inquisitiveness for E-Oral Health technology and enduring oral health benefits. These themes cover all three types of readiness; core, engagement and structural readiness.

Unlocking barriers
This theme covers core readiness, as participants expressed their needs for E-Oral Health services by expressing dissatisfaction with the current oral health care system. The need for E-Oral Health services emerged from participants' previous experiences of oral health services and the challenges that they faced in accessing dental care. Most of the participants identified multiple barriers, such as being recent immigrants, lack of familiarity with the health care system, lack of information, language barriers, financial challenges, not having dental insurance coverage, long waiting hours to see a dentist in the public setting and lack of transportation.
"Waiting to see Dentist is always been concern in Canada, ever since I am here, I faced so many problems like speaking French" (Participant 6, Interview).

E-Oral health awareness
This theme covers engagement and patient readiness as participants were exposed to the concept of E-Health. Participants actively debated the perceived benefits of E-Oral Health, as well as its disadvantages. They consider its benefits as immediate, providing easy access to information and health care services, as well as being affordable. Participants also deem E-Oral Health Interestingly, most participants were aware of E-Oral Health and considered it to be an interesting technology.
"To be honest with you, I haven't heard about that before, but it seems like a good idea" (Participant 1, Interview).

Inquisitiveness to learn and use E-Oral health technology
This theme covers engagement and structural readiness, as participants shared their views of learning E-Oral Health technology and its perceived advantages. Participants were optimistic about obtaining E-Oral Health applications and were ready to pay for such applications because they believe that it would be cost-effective. They thought that this technology is the future of oral health care and expressed their interest, primarily in active learning.
"If something like that is there which is specifically prepared for the e-dentistry, I would be happy to learn about that" (Participant 8, Interview).

"As a mother if you ask any mother to this (E-Oral Health training) she will say yes, because that's the kind of very handy, so I can easily access, I can talk to maybe I can text them that this is a problem and what should be the next step" (Participant 5, Interview).
"I mean most app-like ranges and for Apple there $1 each or whatever, $2, even if it goes up to $10, as long as it does the job, people will pay for it" (Participant 7, Interview).

Enduring oral health benefits
This theme covers core readiness, as participants considered E-Health to be a solution to reducing health care challenges and expressed their beliefs in its long-term benefits.
Participants anticipated that this technology would be promising in reducing oral health inequalities, especially for vulnerable populations including immigrants, refugees and those living in rural and remote areas. They considered it as a technology that can potentially improve oral health literacy and users' satisfaction at both individual and wider societal level.
"I think to have more access to the E appraisal of healthcare or Cybernet will be really it will be too good stead for benefits to the society" (Participant 2, Interview).
"It would help everyone in rural remote all the people living in any areas" (Participant 13, Interview).

Discussion
A better understanding of e-health is of public health importance since it could lead to the implementation of effective policies based on patients' perceptions and needs [27,28]. Various E-Health Readiness frameworks have been developed to understand readiness from different stakeholders' perspectives, especially those of health care providers and health organizations [13,[28][29][30][31]. Only one among those frameworks included the patients' perspective on E-Health Readiness [13]. Moreover, most of those frameworks lack credible evaluation and validation [28]. To our knowledge, this study is the first to explore the patient-perspective on E-Readiness in the field of oral health. Study results indicate that participants demonstrated their core, engagement and structural readiness for adoption and implementation of E-Oral Health technology within the Canadian health system. They considered this technology effective, not only for themselves and their families, but also for the society at large; however, they also revealed a few barriers that might need to be considered.
Various concepts have been used to elucidate E-Health technology and its readiness, such as Theory of Change and Innovation Diffusion Theory [32]. Among these, the use of Activity Theory in our study was influenced by a previous study that suggested using Activity Theory as a framework for E-Health Readiness assessment in health care institutions [32]. Activity Theory is popular not only in health research, but also in various fields, including information system, education, culture, psychology, management and human technology interaction research [26,33]. The available literature suggests that Activity Theory is pertinent in cases of understanding and solving problems related to e-readiness and e-learning and their associated environments [26,32]. Moreover, this theory is coherent with qualitative research methodology due to its holistic and conceptual nature of exploring human activities, such as E-Oral Health technology in this study [26].
Based on our data and elements of activity theory, the activity system of this research work is illustrated by Fig 2. Activity when using E-Oral Health technology to report the result on E-Readiness. The Activity Theory allowed us to understand the patients' E-Oral Health Readiness by exploring ongoing activities in different types of readiness at every stage of the study. As per the elements of Activity Theory, the results of this study suggest that E-Oral Health technology, being a central activity tool, prompted dental patients to be ready to use this technology. Their readiness was influenced by various mediating factors, such as their dissatisfaction with the oral health care system, awareness of E-Oral Health and motivation to use this technology.
Patient participation is imperative even earlier in order to effectively design, implement and utilize E-Health technology. A deep understanding of patient needs regarding the use of E-Health and E-Oral Health will aid in these efforts [34]. Patient perspectives on E-Oral Health have been measured among a wide range of patients utilizing the health services in both developed and developing nations, such as in general private and public health services, primary health care services, rehabilitation services and services for multi-morbid chronic diseases [3,[34][35][36][37][38]. Our results are in line with available evidence on patient perspective for E-Health technology in other health disciplines relative to its positive impact on access, treatment adherence, cost-effectiveness, health outcomes, satisfaction, empowerment and quality of life [34,[37][38][39][40][41][42]. Moreover, these studies on e-health also reported patients' willingness to use and learn such technology, also similar to this present study [3, 34-36, 40, 41]. Furthermore, patients' concerns regarding E-Oral Health were also consistent with that of E-Health technology in terms of lack of human contact and personal data privacy [34,43].
The results of this study will create a platform in dentistry to develop and validate E-Oral Health readiness instruments for future oral health research. Various recommendations are suggested to optimize the use of technology in oral healthcare practices. For example, the development of E-oral Health technology training programs for its users as well as the creation of E-Oral based applications such as oral health education-based application for children and adults, oral health care access related applications, oral health digital service management, Econsultations. Dentist should recommend such technology to their patients in order to facilitate its use. Simultaneously, detailed policies and legislations should be developed to protect patients' privacy, access and sharing of E-Oral Health related data.
The results of this study can be generalized only to similar settings; further research is necessary to determine whether the results identified in this study are relevant to other populations. Another possible limitation was conducting the interviews only in the English language in Montreal, which is primarily a French-speaking city. This criterion excluded the perceptions of Francophone people. Similarly, another language-based limitation was the inclusion of non-native English speakers who may have had difficulty in expressing their views in the English language. Lastly, the lack of prior awareness of E-Oral Health among the participants suggests the need to introduce and create more E-Oral Health awareness in the public education system. This study prepares the ground for future studies aimed to understand multistakeholders' perspectives on E-Oral Health in both developed and developing nations.

Conclusion
The study results suggest that dental patients consider E-Oral Health to be a facilitator to access to care, and they were ready to learn and use E-Oral Health technology. Implementation of and support for E-Oral Health technologies are needed to improve access to care for many populations.