Dentists’ perceptions and usability testing toward the implementation of the ISAC, a comprehensive oral cancer intervention in dental practices: a qualitative study in Jazan region, Saudi Arabia

We followed in this qualitative cross-sectional study we followed the Consolidated Criteria for Reporting Qualitative Research Checklist (COREQ) [17]. For the present study we included participants from dental interns, clinical director, intern supervisor as well as staff from community Dentistry Division (CDD). All participants were invited to participate through an internal channel (e-mails). The adopters and implementers were purposively invited to participate in the study as they were the qualified individuals in the Jazan Dental School (JDS) who can decide to adopt and implement the intervention. We selected the JDS setting because it is the major dental institution in Jazan region that provides dental services in different specialties with approximately 80 annual graduates. Thousands of patients across different Jazan governorates are receiving their free dental care in JDS. Further, graduates of JDS are now serving most public and private dental practices across the region. Therefore, it is viewed as the most suitable setting in this stage of intervention mapping focusing on pre-testing the evidence-based intervention design and components. We included the four individuals who were responsible for the adoption and implementation of the ISAC in the JDS setting (100% the population included). With regard to the target group, we included six out of 80 dental interns (7.5% of the population included). We believe six interns is adequate at the current stage of the intervention, as it yielded varied enough information to proceed on to the first trial of the ISAC. Furthermore, the hallmark of qualitative research is the particularity rather than generalizability of findings [14].

The ISAC stands for: I = inform patient of OC screening; S = screen for OC; A = advice and educate patient of OC and quit its associated risk factors; and C = connect high-risk patients and suspicious cases to specialized centers. Guided by the Intervention Mapping Approach (IMA), the ISAC intervention was developed in a systematic and an iterative process by a multidisciplinary team of researchers, stakeholders and representatives from the target group [14]. IMA is a planning model that utilizes theory and evidence-based methods to develop and evaluate health interventions to promote behavioral and environmental health conducive changes [14]. The ISAC rests on relevant evidence from comprehensive needs’ assessments including participants from dental students, dental interns, college dean, academic staff and dental patients [8‐11, 18]. In our context, intervention adopters are the clinical director and the intern supervisor as they are the authority in charge of dental interns and dental clinics management. Staff of the CDD are the intervention implementers and dental interns are the target group of the intervention.

The ISAC intervention comprised the following two sessions: a theoretical session and a practical session. The theoretical session covered 1- Introduction to the ISAC, its relevance and its development; 2- General and local OC epidemiology and risk factors; 3- Full OC screening protocol; 4- Importance of patient education practice; 5- Tobacco counseling by dentists; 6- Patient communication skills; and 7- patient connection to necessary services and centers. While the practical session was constructed as the following: 1- Actual modeling of the ISAC by change agents: inform patient of OC examination, screen for OC, educate and provide brief tobacco counseling and connect patient to specialized tobacco cessation/oncology centers if needed; 2- Second group observing first group performing the ISAC; 3- First group observing second group performing the ISAC.

To answer the first research question (What are the first thoughts, feelings or impressions of dental interns while practicing the ISAC?): we utilized the think-aloud approach during which participating dental interns were instructed on how to think aloud during their modeling of the ISAC intervention on patient-actors [19]. Our role as researchers in the thinking-aloud was to record the expression elicited by the dental interns while they were performing the ISAC sub-behaviors and to prompt them if required (if staying silent). Further, to encourage dental interns through positive reinforcement “you are providing relevant information, good job”. The adopters’ role in the think-aloud was to have the chance to experience the full trialability of the intervention that they decided to adopt in their organization and then express their thoughts and perceptions toward its implementation and potential barriers and facilitators. The implementers’ role was to experience the trialability of intervention they committed to implement (deliver) to dental interns and reflect on their thoughts and perceived difficulties toward its implementation in the JDS. After the thinking-aloud, a focus group discussion was conducted among the participating dental interns to express their thoughts and opinions away from the influence of adopters and implementers. Adopters and implementers were not part of the focus group discussion that was conducted among the dental interns to allow dental interns express their opinions comfortably. The fact that a think-aloud method will always exclude some thought processes that are not held long enough to be expressed in working memory, a follow up interview is commonly recommended to add in-depth information of participants thought processes and to allow interviewees to validate researchers’ interpretation of their think-aloud utterances [20]. Individual one-to-one semi structured qualitative interviews were conducted for the adopters and implementers to reflect on their perceptions toward the ISAC intervention (see Additional file 1). The interviews lasted between 30 and 45 min. While the focus group discussion lasted approximately 50 min. The interviews and FGD were meant to answer the second research question: What are the adopters, implementers and dental interns’ perceptions toward the ISAC intervention? The interviews and FGD were audio-recorded and verbatim transcribed into Arabic language and then converted into the English language and reviewed by bilingual speakers.

The semi-structured guide was developed and guided by the Fleuren framework for determinants of innovation within health care organizations [15]. In 2004, Fleuren and her colleagues have identified 50 potentially relevant determinants of implementation based on a Delphi study and literature review [15]. The list of 50 determinants was subsequently reduced to include 29 determinants [21]. In Fleuren’s framework, the potential determinants were classified according to the following categories: 1) the innovation: compatibility, observability, complexity; 2) the potential user: knowledge, attitude, self-efficacy; 3) the organization: available time, resources, staff capacity; and 4) the socio-political context such as the regulation [15, 21].

Therefore, the semi-structured interview guide covered ten themes in regard to the second research question as the following: knowledge, attitude, barriers, facilitators, change beliefs, motivators, the ISAC development process, intervention characteristics, organizational factors and socio-political factors.

Data was processed using NVivo software version 12. Framework analysis (FA) was the followed principle in the data analysis [22]. We have utilized this analysis because it is suitable particularly for studies that have a defined sample and predetermined themes, as was the case in the present study. FA also enables the emergence of novel themes. Data analysis included familiarizing with the data through listening to the records and re-reading the transcripts by the first author and the last author, identifying recurrent themes and sub-themes in an iterative process with mutual discussion which included checking the consistency of coding as well as developing and refining the thematic framework. Finally, illustrative quotes for each theme were created. In addition, we’ve utilized a member checking strategy to further enhance the validity of the findings [23]. Therefore, we contacted a subsample of the participants to review the results after the initial themes were identified. They were asked to comment if they felt that their views were fully represented and if they agreed with the interpretation of their quotes. Participants stated that they agreed with the authors interpretation.

Ten participants of both genders participated in the study: six dental interns, two adopters and two implementers. Four individual face-to-face interviews and one focus group discussion was conducted after the thinking-aloud procedure. Table 1 describes participant characteristics and provides more information on data collection method.

The identified themes were as the following: seven themes were identified on adopting person determinants level, four themes were identified on innovation determinants level, three themes were identified on organization determinants level, two themes on socio-political context level and one theme was developed focusing on recommendation and areas for re-adaptation (please insert Table 2 here). The identified themes were explained in line with the Fleuren framework and summarized as the following (please insert Table 3 here for detailed description of themes and illustrative quotes):

Participants have accurately captured the model and the aim of the ISAC intervention as follows: a comprehensive and evidence-based intervention that fills a gap in dentist practice toward oral cancer and aims to enhance oral cancer early detection.

Participants perceived the ISAC as an excellent, successful intervention and the right project at the right time. Further, they perceived the ISAC as an intervention that targets the needs in the country. Regret of having been unfair to patients before, high confidence and awareness, more organized patient examination and professionalism were the feelings reported by participating dental interns.

Participants anticipated that the ISAC will create positive changes in terms of dentists’ skills, confidence and early detection of OC.

“…the ISAC is going to help us from the perspective of early detection and from the perspective of the skills and abilities gained from ISAC” – Implementer1

Two participants believed that gender of both patient and dentist can be a possible barrier to practice the ISAC intervention outside JDS.

“…I don’t think all females would be satisfied that males examine them especially in the neck region and behind the neck.” – Adopter1

Other participants believed that it might appear as a barrier in research more than in the actual dental practice in the region. Also, they believed that with increasing dentists and patients’ awareness as well as dentist-patient communication skills, gender would no longer be a potential barrier of practicing ISAC.

Participants mentioned some potential facilitators for the ISAC implementation in JDS including gender-concordance, supportive environment, use of regional trainers, standard examination forms as well as collaboration with the Ministry of Health (MOH).

Participating adopters believed that increasing dentist’s awareness about the impact of OC on patients will motivate them to practice the ISAC. Further, participating implementers believed that giving dental interns certificates for performing the ISAC can motivate dental interns to practice the ISAC. Some of participating dental interns have shared a similar point but mentioned that having a certificate for performing the ISAC is not the main reason that would motivate them. Many participants found that the ISAC intervention is already appealing for them and few participants mentioned the fact that the ISAC has built their confidence is one of the things that made the ISAC attractive to them. Others mentioned that feeling satisfaction in following religious teaching is what motivates them to practice ISAC. Some participating dental interns believed that making advertisement for the ISAC can increase the attraction to the intervention. Many participants mentioned that the program provider himself was a motivator for them to practice the ISAC.

All participants shared favorable perceptions toward the transparency/clarity of the ISAC development and developer credibility. Among the points that were mentioned in relation to objectivity and clarity was the use of a scientific approach as well as the engagement of different groups in the ISAC development and planning process such as students and dental interns.

Participants perceived that the ISAC has a superior advantage in comparison to the previous program, which is the fact that ISAC is targeting oral healthcare providers. Whereas previous programs targeted people in the community with unknown characteristics. Participants mentioned that there was no previous program that included an intervention like the ISAC and those previous implemented programs were focused only on raising awareness about the negative health effects of using Shammah. Two participants believed that the ISAC developers have raised the attention to OC in the Jazan region because of the ISAC development process and subsequently the organization of two international and national conferences.

“But we know that these conferences were the result of the ISAC founders’ efforts to the problem.”- Adopter2

Majority of participants believed that the ISAC has well-defined objectives that makes it superior to previous programs related to OC. Dental interns favored that ISAC was built on relevant information and data in relation to the dental field and Jazan culture. For example, including dental interns like them in the first stages of the needs assessments and using their output in the development of the ISAC.

Majority of participants believed that the ISAC is easy to be practiced. Some participants mentioned that the ISAC is not difficult but requires training. Others mentioned that they may suffer difficulty in practicing the ISAC outside JDS as they may have very limited clinical time in a future dental daily practice as compared to the situation in JDS context. Two participants stated that the variation in the examination forms between JDS and other clinics might make it difficult to practice the intervention.

Majority of participants believed that the results from the ISAC intervention will be very visible to others. Others believed that the visibility of the results will depend on the effect measurement.

All participants found the ISAC intervention very compatible with the norms and beliefs in the society.

“I see that it is 100% compatible because it arises from the community needs.” – Adopter2

Participating dental interns stated that they could easily memorize the main four steps of the ISAC in general. But they struggle to remember all the sub-behaviors related to each step. They have stated it would be very helpful if they had the ISAC clinical chart/protocol with the steps they need to follow. Further, they felt they need more practice on patient education and preferred to receive separate training on patient communication and tobacco counseling before the ISAC comprehensive training. In addition, they preferred to have the ISAC materials given in Arabic language.

This study was done on the major dental organization in the Jazan region; thus, it would be interesting to explore other dental organizations perceptions, opinions and possible challenges toward the implementation of the ISAC intervention in their daily practice. In line with other studies, the study findings support the idea that following a co-participatory approach throughout the project, enhances intervention compatibility, perceived relevance and engagement of the target group. This study included dental interns’ perceptions of potentially embedding factors for implementing and practicing a comprehensive OC examination in dental organizations other than JDS. The significant feedback from the participating dental interns should give current dental interns practicing outside JDS confidence to negotiate and push their organization leaders’ focus of attention from focusing only on patient complaint to include a serious community issue as OC and to facilitate the use of an evidence-based intervention that tackles the disease. Dental interns and other oral health providers should advocate for the active practice of OC examination and consider the ramification of dentists’ passive behavior on patient quality of life and OC burden on the community. Leaders and directors of dental organizations should take their responsibility toward the OC issue, facilitate and embolden OC examination in their clinical practice. Finally, participants feeling of immediate intervention changes on their confidence and skills has motivated them to continue practicing ISAC in their daily clinical practice. Intervention developers should pay attention to combining long-term change with short-term visible changes that can enhance participants’ adherence to the intervention. The ISAC intervention was meant to eliminate the observed barriers and challenges in dental interns’ awareness, confidence, and skills toward the practice of OC examination and patient education. Dental internship is the first stage when graduates of dental school independently practice in the clinics (with zero to minimal interfere from senior dentists) and they are considered practicing dentists. Practicing dentists with considerable years of experience can benefit from practicing the intervention after receiving the necessary education and training on the ISAC. To apply the ISAC for instance on a national level of Saudi Arabia, where all dentists would be practicing the intervention, we may need further exploration of the needs, facilitators, and barriers perceived by practicing dentists in relation to further implementation of the ISAC.