Study design, participants and setting
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 intervention
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 [8,9,10,11, 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.
Procedures
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.
Theoretical framework and measures
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 analysis
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.