Background

F1000Research

2046-1402

F1000 Research Limited

London, UK

10.12688/f1000research.172444.1

Study Protocol

Articles

Oral Health Policy Assessment in the WHO Eastern Mediterranean Region: A Scoping Review Protocol

[version 1; peer review: 1 approved]

Alalyani

Abdullah

Conceptualization Investigation Methodology Project Administration Supervision Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0009-0008-1893-1424 1 Urquhart

Olivia

Conceptualization Methodology Validation Writing – Review & Editing 1 Bhosale

Ankita Shashikant

Conceptualization Methodology Validation Writing – Review & Editing https://orcid.org/0009-0005-6791-9403 1 O'Brien

Kelly K.

Conceptualization Methodology Resources Writing – Review & Editing https://orcid.org/0000-0003-0135-1657 2 Pimentel

Julia

Conceptualization Methodology Validation Writing – Review & Editing https://orcid.org/0009-0002-0440-0530 1 Glick

Michael

Conceptualization Investigation Methodology Resources Validation Writing – Review & Editing https://orcid.org/0000-0003-4236-5385 a 1 Carrasco-Labra

Alonso

Conceptualization Investigation Methodology Resources Supervision Validation Writing – Review & Editing https://orcid.org/0000-0003-3546-3526 1 1Center for Integrative Global Oral Health, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, 19104, USA 2Library & Archives, American Dental Association, Chicago, Illinois, 60611, USA

a glickmi@upenn.edu

No competing interests were disclosed.

7 11 2025

2025

1229

31 10 2025

2025

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background

Although preventable and treatable, oral diseases affect nearly half of the world’s population, driven by limited accessibility and equity in oral healthcare services, and lack of integration of oral health into noncommunicable diseases (NCDs) and universal health coverage (UHC) agendas. The World Health Organization (WHO) Global Strategy and Action Plan on Oral Health 2023–2030 (WHOOH) emphasizes the importance of embedding oral health in national health systems and policies. Evidence-informed oral health policies (OHPs) can help reduce disease burden, improve access, and address inequalities. However, in the WHO Eastern Mediterranean Region (WHO EMR) (hereafter, EMR), current policies have not achieved meaningful impact, constrained by barriers that require comprehensive analysis and systematic evaluation. This review aims to systematically identify and assess OHPs and barriers and facilitators influencing their creation, dissemination, implementation, monitoring, and evaluation (CDIM&E).

Methods

A systematic search was developed for Ovid MEDLINE, and also used to search Embase, Cochrane Library, and Epistemonikos. It will also be applied to global and regional databases, covering January 2014 to December 2024 without language restrictions. Additional searches will be conducted on government websites (e.g., ministries of health) to capture OHPs. Eligible documents will include official and up-to-date national OHPs, and research or policy-related documents reporting barriers to and facilitators for the CDIM&E of OHPs. Independent reviewers will perform screening and data extraction using DistillerSR. Quantitative data will be analyzed in R Studio using descriptive statistics, while qualitative data will undergo thematic analysis in NVivo.

Discussion

Advancing evidence-informed OHPs in the EMR requires mapping existing national policies, evaluating their alignment with WHOOH targets, and understanding the barriers and facilitators for their CDIM&E. This review’s findings may help and support ministries of health, chief dental officers, academic institutions, and regional interest-holders to inform policy dialogue and support collective efforts to achieve the WHOOH targets.

Registration

The protocol is registered with the Open Science Framework (OSF): https://doi.org/10.17605/OSF.IO/DQ6E4.

Oral Health Policy Eastern Mediterranean Region Scoping Review Barriers and Facilitators.

The author(s) declared that no grants were involved in supporting this work.

Introduction

Oral health and specifically interventions for oral diseases have been neglected for a long time on global, regional, and national levels. ¹ The vast majority of oral diseases are preventable and can be successfully treated, but the lack of oral health services programs among communities, and the lack of accessibility and equity have increased the oral disease burden, with nearly half of the world’s population suffering from oral diseases. Although oral diseases share common risk factors with other NCDs, oral health remains insufficiently integrated into NCD and UHC agendas. ²

The WHOOH prioritized each member state’s national OHPs, ³ emphasizing the importance of including oral health in NCDs and UHC policies. Evidence-informed health policies, including OHPs, are one of the most powerful tools to produce system-level changes that directly impact the health and well-being of nations and entire regions. ³ Thus, OHPs informed by high-quality evidence syntheses and relevant research can potentially reduce the burden of oral diseases, improve access to oral health services, and reduce inequality in health systems. However, current policies have not been able to create such an impact in the EMR. It is important to understand the factors and barriers influencing the CDIM&E of OHPs.

The EMR is culturally and ethnically diverse, with each province (i.e., division of a country, such as a state or county) having unique characteristics, which means that successful OHPs need to be contextualized to accommodate varying cultural, social, and economic characteristics. To understand if OHPs are attentive to these diverse characteristics, a deep understanding of current regional and national OHPs is needed. To advance OHPs in the EMR, this scoping review aims to identify OHPs in the EMR, assess their alignment with the WHOOH targets, and determine the barriers and facilitators to the CDIM&E of OHPs in the EMR.

Oral health definitions

The WHO defines oral health as “… the state of the mouth, teeth and orofacial structures that enables individuals to perform essential functions, such as eating, breathing, and speaking, and encompasses psychosocial dimensions, such as self-confidence, well-being and the ability to socialize and work without pain, discomfort and embarrassment. Oral health varies over the life course from early life to old age, is integral to general health and supports individuals in participating in society and achieving their potential.” ⁴

The FDI World Dental Federation defines oral health as “… multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex (head, face, and oral cavity).” ⁵

Health policy definitions

Health policy is defined as “… decisions, plans, and actions that are undertaken to achieve specific health care goals within a society.” ⁶

Public health policy is defined as “… the laws, regulations, actions, and decisions implemented within society in order to promote wellness and ensure that specific health goals are met.” ⁷

Objectives

Systematically identify OHPs in the EMR.

Assess the alignment of national EMR OHPs with the WHOOH targets.

Determine the barriers to and facilitators for the CDIM&E of OHPs in the EMR.

Protocol

The reporting of this protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) ^{8,
9} and the findings will be reported using the PRISMA-ScR extension for Scoping Reviews. ¹⁰

Eligibility criteria

Inclusion criteria

For national OHPs (objectives 1 & 2)

Official and most up-to-date national OHPs for each country in the EMR will be included.

Type of document

OHP documents that regulate oral health systems at national levels will be included. The documents should be published or posted by a governmental organization in a website or archive and should be using a national scope.

Setting

OHPs published by a government organization in any of the following EMR countries: Afghanistan, Bahrain, Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen will be included. ¹¹

For the barriers to and facilitators for the CDIM&E of OHPs (objective 3)

Research articles and policy-related documents that provide quantitative or qualitative data related to barriers or facilitators to the CDIM&E of OHPs in the EMR between 2014 and 2024 will be included. ¹²

Type of document

Research articles and policy-related documents that describe the perspectives and experiences of interest-holder groups defined as “… groups with legitimate interests in the health issue under consideration. The interests arise and draw their legitimacy from the fact that people from these groups are responsible for or affected by health-related decisions that can be informed by research evidence”, ¹³ including policymakers, organizational leaders, healthcare managers and administrators, healthcare professionals and providers, researchers, and citizens (including all members of society, e.g., patients, parents, workers, community leaders, caregivers) will be included.

Setting

Research articles and policy-related documents pertaining to any of the EMR countries will be included.

Evidence type 1.

Research articles (primary studies, scoping reviews, systematic reviews, and umbrella reviews).

Research articles assessing or measuring barriers to and facilitators for the CDIM&E of OHPs at the EMR’s regional, national, and sub-national levels.

Research articles addressing oral healthcare services (accessibility, affordability, availability). The articles could focus on attitudes, perspectives, perceptions, knowledge, or experiences.

Research articles related to specific interventions for oral health disease. The articles could be about attitudes, perspectives, perceptions, knowledge, or experiences of interest-holders. Articles will be included if the intervention relates to an OHP or government program.

Policy-related documents assessing barriers to and facilitators for the CDIM&E of OHPs in the EMR (regional, national, and sub-national policies, strategies and plans, clinical practice and public health guidelines, and policy briefs and policy analysis).

Exclusion criteria

For national OHPs (objectives 1 & 2)

OHPs with the following characteristics will be excluded: -

Regional policies including a country-based approach

Previous versions of a current policy

For the barriers to and facilitators for the CDIM&E of OHPs (objective 3)

Research articles and OHP-related documents with the following characteristics will be excluded: -

Editorials, protocols, and conference abstracts.

Articles that assess disease burden, prevalence, epidemiological data related to oral disease, and risk and protection factors.

Articles that evaluate effectiveness and safety of interventions to prevent, diagnose, or treat oral diseases.

Articles that report collected data regarding barriers and facilitators of OHPs from multiple countries in and outside the EMR, where only aggregated data is reported.

Information sources and search strategy

An informationist developed a search strategy for Ovid MEDLINE ¹⁴ that included thematic concepts related to OHPs, EMR countries, and barriers and facilitators. This strategy was also translated and applied to other databases, including Embase, ¹⁵ Cochrane Library, ¹⁶ Epistemonikos, ¹⁷ and is available in the extended data section. ¹⁸ A date limit of January 1 ^st, 2014 - December 31 ^st, 2024, was applied, with no language restrictions. In addition, the search strategy will be used for both global and Eastern Mediterranean-specific electronic journal databases (e.g., African Journals Online, ¹⁹ Eastern Mediterranean Region Index Medicus, ²⁰ and KAUST Repository ²¹), and ProQuest Dissertations & Theses Global. ²² All search results will be exported to EndNote. The EndNote library will be imported into DistillerSR, ²³ where the DistillerSR’s de-duplication tool will be used to remove duplicates, leaving unique citations. The search will continue to be updated as needed.

To capture national OHP documents not available in traditional electronic biomedical databases, additional searches will be conducted using EMR and government websites (e.g., ministries of health and dental associations), again, with no language restrictions.

Document selection

Document selection will be completed by pairs of independent reviewers in DistillerSR. Titles and abstracts will screen against predefined eligibility criteria. Retrieved research articles and OHP documents published in Arabic, French, Urdu, Pashto, Persian, Somali, and Dari will be assigned to research team members who are native-level speakers of the respective languages. Any disagreement regarding study eligibility will be resolved through consultation with a third reviewer.

Data extraction

For national OHPs (objectives 1 & 2)

Pairs of independent reviewers will use an assessment sheet to evaluate the included national OHPs ( Table 1). The assessment sheet will be refined iteratively throughout the review process, and modifications will be documented in the Methods section of this scoping review.

Table 1. National OHP assessment sheet.

National OHP
Variable	Sub-variable
Country name	▪ The existence of OHPs. ▪ Title of the policy. ▪ Year of policy. ▪ National OHPs and systems alignment with the WHOOH targets (proportions against targets).
The WHOOH objectives and targets: Strategic objective 1: Oral health governance. • Global target 1.1: National leadership for oral health. (By 2030, 80% of countries have an operational national OHP, strategy or action plan and dedicated staff for oral health at the Ministry of Health or other national governmental health agency). • Global target 1.2: Environmentally sound oral health care (By 2030, 90% of countries have implemented measures to phase down the use of dental amalgam as stipulated in the Minamata Convention on Mercury or have phased it out). Strategic objective 2: Oral health promotion and oral disease prevention. • Global target 2.1: Policies to reduce free sugars intake (By 2030, 50% of countries implement policy measures aiming to reduce free sugars intake). • Global target 2.2: Optimal fluoride for population oral health (By 2030, 50% of countries have national guidance on optimal fluoride delivery for oral health of the population). Strategic objective 3: Health workforce. • Global target 3: Innovative workforce model for oral health (By 2030, 50% of countries have an operational national health workforce policy, plan or strategy that includes workforce trained to respond to population oral health needs). Strategic objective 4: Oral health care. • Global target 4.1: Integration of oral health in primary care (By 2030, 80% of countries have oral health care services generally available in primary health care facilities). • Global target 4.2: Availability of essential dental medicines (By 2030, 50% of countries include dental preparations listed in the WHO Model Lists of Essential Medicines in their national essential medicines list). Strategic objective 5: Oral health information systems. • Global target 5: Monitoring implementation of the national OHP (By 2030, 80% of countries have a monitoring framework for the national OHP, strategy or action plan). Strategic objective 6: Oral health research agendas. • Global target 6: Research in the public interest (By 2030, 50% of countries have a national oral health research agenda focused on public health and population-based interventions).
OHP: Oral Health Policy, WHO: World Health Organization, WHOOH: WHO Global Strategy and Action Plan on Oral Health 2023–2030.

For the barriers to and facilitators for the CDIM&E of OHPs (objective 3)

Pairs of independent reviewers will use a data extraction sheet to collect information from the included documents ( Table 2). Evidence related to interest-holders’ perceptions and experiences will be extracted, including quantitative, qualitative, or mixed data. The extraction sheet will be refined iteratively throughout the extraction process, and any modification will be documented in the Methods of this scoping review.

Table 2. Research articles and health policy documents extraction sheet.

Research articles and health policy documents
Variable	Sub-variable	Note
Reference ID
PMID
Publication Year
Last and corresponding authors	▪ Name ▪ Affiliation
Title
Abstract
Type of article	▪ Research article ▪ Policy document
Country of origin of the study	▪ Country name	Step 1. Identification of the primary location of the study (i.e., the location of the center recruiting participants). If more than one country is reported, all locations will be extracted. Step 2. If no description about the primary location of the study was provided based on step 1, the affiliation of the last and the corresponding author will be extracted. When these two authors have different affiliations, the location for the corresponding author will be the primary location of the study.
Interest-holder groups	▪ Policymakers ▪ Organizational leaders ▪ Healthcare managers and administrators ▪ Healthcare professionals and providers ▪ Researchers ▪ Citizens ▪ Multi-interest-holder	Policymakers refer to “(… elected officials, political staff or civil servants) in the national government and/or in sub-national governments.” ³¹ Organizational leaders refer to non-governmental organizational leaders. ²⁷ Healthcare managers and administrators refer to those who provide leadership, management, and direction to healthcare units to ensure the best delivery of available healthcare services. ³² Healthcare professionals and providers refer to oral healthcare workers, including dentists, oral hygienists, dental nurses, dental therapists, and dental assistants. ²⁷ Researchers refer to those who conduct research, and the resulting evidence may be used by policy-makers. ³³ Citizens refer to “all members of society, including patients and caregivers, service users, parents, voters, community leaders, and workers.” ²⁷ Multi-interest-holder refers to reported data from the perspective of mixed populations (e.g., policymakers and citizens). ²⁷
Stage of policy process	▪ Creation ▪ Dissemination ▪ Implementation ▪ Monitoring ▪ Evaluation	Creation: refers to “How the policy was developed, already in place elsewhere and adopted in a new setting, or adapted for citizens, healthcare personnel, institutions, or organizations” ²⁷ in the EMR. Dissemination: refers to “Any plans for sharing or promoting the content of the OHP widely to the intended target audiences” ²⁷ Implementation, Monitoring, and Evaluation: refer to “How an OHP is applied at a subnational, national, or regional level, whether an OHP changes health organizations; behaviors of healthcare professionals, patients, or caregivers; or utilization of healthcare services” ²⁷
Characteristics	▪ Type of evidence ▪ Evidence method ▪ Assessment tool ▪ Category level to which the policy directed (e.g., regional, national, or subnational) ▪ Scope of OHP
Barriers and facilitators of the creation	▪ Barriers ▪ Facilitators	Barrier: refers to “Any problem—whether practical, political, financial, or technical—that obstructed the creation, dissemination, implementation, monitoring, or evaluation of an OHP” ²⁷ Facilitator: refers to “Any entity, process, social movement, technology, legislation, or organizational structure that promoted or optimized any creation, dissemination, implementation, monitoring, or evaluation of an OHP” ²⁷
barriers and facilitators of the dissemination	▪ Barriers ▪ Facilitators
Barriers and facilitators of the implementation, monitoring, and evaluation	▪ Barriers ▪ Facilitators

PMID: PubMed Identifier, OHP: Oral Health Policy, EMR: Eastern Mediterranean Region.

Data analysis and synthesis

R Studio will be used to conduct a descriptive statistical analysis, including measures of central tendency and dispersion (e.g., mean and standard deviation, frequencies, proportions, and interquartile ranges for quantitative data). ²⁴ For qualitative analysis, NVivo software ²⁵ will be used to conduct a descriptive content analysis and thematic coding. ²⁶ The current version of the available national OHPs for each of the EMR countries will be identified and analyzed. The WHOOH targets will be used to assess the existing OHPs in the EMR. To analyze the barriers to and facilitators for the CDIM&E of OHPs in the EMR, a taxonomy informed by previous systematic and scoping reviews, addressing health policy issues, will be created. ²⁷ This taxonomy will incorporate levels of resources and capabilities based on the policy capacity matrix at the individual, organizational, and systemic levels. ²⁸ The taxonomy will be refined based on statements reported in the included studies. Pairs of independent reviewers will define and apply coding to the data from the included documents, with a third reviewer consulted to resolve any coding disagreements. The coded data identifying barriers and facilitators will be synthesized and summarized, and presented in tables and figures (e.g., Sankey chart). ²⁹

Discussion

To enhance evidence-informed OHPs in the EMR, it is necessary to identify each country’s national OHPs, assess their alignment with the WHOOH targets, and understand the barriers and facilitators influencing their development. This scoping review will systematically map OHPs across the EMR and evaluate their alignment with the WHOOH targets. In addition, it will capture research evidence and interest-holder perspectives on the barriers and facilitators related to the CDIM&E of OHPs in the EMR. The findings will provide valuable insights for policymakers and interest-holders, guiding evidence-informed policy development and supporting EMR countries in progressing toward the WHOOH targets.

Although the review will employ comprehensive search strategies across databases, grey literature sources, and government websites, some limitations are expected. Variations in policy definitions, limited access to unpublished or non-digitized policy documents, cultural differences, economic and political status, and linguistic diversity may pose challenges to the identification, synthesis, and comparative analysis of OHPs across the EMR. Nevertheless, involving multilingual reviewers and implementing a systematic, transparent methodology will help mitigate these limitations.

Dissemination

The findings of this scoping review will be disseminated through presentations at international conferences and regional meetings, publication in peer-reviewed journals, and circulated to key regional interest-holders (e.g., chief dental officers, researchers, and deans of dental schools or academic institutions in the EMR countries). These country-level interest-holders will help communicate the project’s findings within their networks, constituencies, and relevant colleagues.

Study status

The search strategy has been developed in Ovid MEDLINE and is expected to be completed by December 2025. Data collection is expected to begin by April 2026, and data analysis by July 2026.

Ethical consideration

Ethical approval is not required for this project since it does not involve human subjects.

Patient consent for publication

Not applicable.

Data availability Underlying data

No data is associated with this article.

Reporting guidelines

Figshare: PRISMA-P Checklist OHP, https://doi.org/10.6084/m9.figshare.30300235. ⁹

This project contains the following underlying data: •

PRISMA-P Checklist

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC BY 4.0).

Extended data

Figshare: Search strategy: Oral Health Policy Assessment in the WHO Eastern Mediterranean Region, https://doi.org/10.6084/m9.figshare.30223426. ¹⁸

This project contains the following underlying data: •

Search strategy - Oral Health Policy Assessment in the WHO Eastern Mediterranean Region

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC BY 4.0).

OSF: Oral Health Policy Assessment in the WHO Eastern Mediterranean Region: A Scoping Review Protocol, https://doi.org/10.17605/OSF.IO/DQ6E4. ³⁰

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Reviewer response for version 1

Singh

Abhinav

1 2 Referee https://orcid.org/0000-0002-8830-9955 1All India Institute of Medical Sciences, New Delhi, Delhi, India 2All India Institute of Medical Science - Bhopal (Ringgold ID: 390706), Bhopal, Madhya Pradesh, India

Competing interests: No competing interests were disclosed.

30 12 2025

2025

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

approve

Overall assessment

The protocol addresses a timely and important public health issue, namely oral health policy development and implementation in the WHO Eastern Mediterranean Region (EMR).

The objectives are clearly stated, methodologically sound, and appropriate for a scoping review.

Overall, the protocol is well designed, transparent, and aligned with established scoping review standards.

Minor comments and suggestions

Clarification needed on how the “most up-to-date” national oral health policy will be identified if multiple policy versions or revisions exist. or the website of concerned agencies have not been updated.

The qualitative analysis approach could be clarified by explicitly stating whether thematic coding will be inductive, deductive, or a hybrid approach.

Conclusion

This is a high-quality scoping review protocol with strong methodological rigour and policy relevance.

Only minor clarifications are required; addressing these would further strengthen the protocol.

Is the study design appropriate for the research question?

Yes

Is the rationale for, and objectives of, the study clearly described?

Yes

Are sufficient details of the methods provided to allow replication by others?

Yes

Are the datasets clearly presented in a useable and accessible format?

Not applicable

Reviewer Expertise:

Dental Public Health specifically focussing on policy perspectives.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.