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Using Intervention Mapping to Develop ISAC, a Comprehensive Intervention for Early Detection and Prevention of Oral Cancer in Saudi Arabia

Using Intervention Mapping to Develop ISAC, a Comprehensive Intervention for Early Detection and... Oral cancer forms a major public health issue. In Saudi Arabia, Jazan region has the highest rate of oral cancer; > 35% of total cases. Furthermore, dentists’ engagement in oral cancer screening and patient education in Jazan region is limited. This paper aimed to describe the process used to develop a comprehensive oral cancer (OC) practice intervention to be implemented in dental clinics. The intervention was informed by the six steps of intervention mapping (IM). Steps 1–3 included mixed methods approach of reviewing relevant existing literature, focus group discussions, observations, one-on-one interviews, and questionnaires utilizing the community participatory approach. Step 4 used information form steps 1–3 to develop the intervention components and its associated tools to facilitate its delivery. Steps 5 and 6 specified the prospective plans for implementation and evaluation. ISAC is the developed intervention that comprises the following: Informing dental patients about performing routine OC screenings, Screenings for OC, Advising patients, and Connecting patients to the required ser- vices. ISAC practical applications were clustered into two components: (a) didactical session covering aspects related to OC practices and introducing ISAC and (b) practical session that included a step-by-step modeling of the intervention. Using IM facilitated the systematic planning of the ISAC intervention that covers the main issues revealed by the need’s assessments. Working towards developing the ISAC required extensive work in assessing dental public health issues in a specific context with limited data — and this constituted a great challenge. The development of the ISAC was a lesson that casts light on the advantages of engaging multidisciplinary expertise to tackle serious public health issue like OC. Keywords Oral cancer · Intervention mapping · Methods · Program development · Prevention · Early detection · Dental practice · Oral health · Behavior change Background (compared to men) [1]. A strong association was found between these diagnosed cases and the use of smokeless Oral cancer (OC), and particularly squamous cell carci- tobacco [2]. The form of smokeless tobacco that is com- noma, is one of the most prevalent cancers in Saudi Ara- monly used in the Jazan region is known as Shammah. bia [1]. In comparison to other regions of Saudi Arabia, the Despite the disease being so prevalent in Saudi Arabia, and Jazan region carried the heaviest burden of the disease, as particularly in the Jazan region, there has been limited effort it had more than 35% of the registered diagnosed cases at to prevent its risk factors or to screen for it in clinics [3]. an advanced stage, with a slightly higher rate in females Evidence had shown that oral cancer can be prevented by eliminating its risk factors [4]. Moreover, it was found that early detection of OC can lead to a better prognosis for the * Mohammed Jafer recovery from the disease [5]. Due to this, dentists screening m.jafer@maastrichtuniversity.nl for OC and educating patients on its risk factors is highly Dental Public Health, Department of Preventive Dental recommended [6]. However, these recommendations are not Science, College of Dentistry, Jazan University, Jazan, usually met by dentists [7]. Similarly, in the Jazan region, Saudi Arabia dentists’ engagement in OC screening and patient education Department of Health Promotion, Maastricht has been found to be limited [3]. Several factors were sug- University/CAPHRI, P.O. Box 616, Maastricht 6200 MD, gested as contributing factors towards this kind of behavior The Netherlands Vol.:(0123456789) 1 3 Journal of Cancer Education by dentists — for example, limited exposure to OC cases, a dental practices by four calibrated dentists (the observers lack of OC screening skills, and a lack of skill in educating who received calibration trainings to improve their scoring patients [3]. Therefore, it is essential to have an intervention accuracy and consistency) [13]; (d) an exploratory sequen- that aims to improve OC practices in the Jazan region. The tial mixed methods design to investigate dental patients’ objective of this paper was to report on the development of a behavior, thoughts, opinions, and needs for oral cancer comprehensive intervention for OC practices (ISAC), using information, and dentists’ behavior regarding prevention the Intervention Mapping approach [8]. and examination of oral cancer [14]; and (e) an assessment and evaluation of JDS organization context factors [12–14]. Methods Step 2: Program Outcomes, Objectives, and Logic Model of Change We have utilized the findings from step 1 to deter - We believe that Intervention Mapping (IM) was the most mine who and what needs to be changed in order to increase appropriate approach because it addresses this challenge the early detection and prevention of OC. We’ve formulated from different perspectives. [8 ]. IM is a systematic frame- the desired outcomes using SMART objectives, which work that is characterized by three aspects: (1) application of stands for Specific, Measurable, Achievable, Realistic, and a social ecological model that views the individual behavior Time, and we finally created the logic model of change. as an outcome of the interaction of the individual with physi- cal, social, and organization environments; (2) community Steps 3 and 4: Program design and Program Production We broad participation to enhance the relevance, acceptability, have defined the intervention theme, components, scope, and and cultural suitability; (3) utilizes theory and evidence as sequence. Additionally, we have identified the behavioral foundations in order to assess and develop effective inter - change methods targeting the relevant determinants. These ventions for behavior and environmental changes that are determinants were translated into practical applications con- conducive to health. IM entails six steps: (1) Logic model sidering their parameters for use to optimize effectiveness. of problem; (2) logic model of change; (3) program design; Aside from this, the intervention channel/vehicle, materials, (4) program production; (5) implementation plan; and (6) length, quality, and feasibility were distinguished for each evaluation plan [8]. Each of these steps involves several component. Finally, the intervention material resources were tasks and build in an iterative and a cumulative process [8]. prepared in collaboration with experts in oral cancer, digital The research team with representation from dental public design, health education, and promotion. health, patients’ education, behavior change, and technology have established the planning group. This planning group Steps 5 and 6: Program Implementation and Evaluation included all potential intervention implementers of essen- Plan We have written the evaluation questions (process/ tial value — including the Dean and the Head of the Com- effect) considering the intervention logic models, goals, munity Dentistry Division (CDD) of Jazan Dental School objectives, and matrices. Effect evaluation investigates (JDS) [9]. Moreover, a bottom-up community empower- whether the behavior, environmental outcomes, and objec- ment approach sought to include the target group: dentists, tives change because of the intervention [8, 15], while the dental interns, and dental patients of JDS (from both male process evaluation assesses the intervention implementation and female branches) to create a compatible intervention and delivery [8]. Following this, indicators and measures that ensured dental best practices and ultimately improve were determined to assess the formulated questions on the patient quality of life [8, 10]. All the research team mem- effect and process evaluation. Finally, we have specified the bers are experienced with Intervention Mapping (IM). The methodological design for conducting process and effect team has followed the six steps of IM for the development, evaluation. implementation, and evaluation of the intervention. This paper describes the process of intervention development, intervention protocol for implementation, and evaluation in Results steps 1 to 6 of IM. The results of the needs assessment revealed the following: Step 1: Logic Model of the Problem We have conducted needs assessments that involved the following: (a) Evidence Knowledge [11] A total of 237 individuals participated (72 reviews of existing data on OC problem at Jazan region; students, 68 dental interns, and 88 faculty members of dif- (b) a quantitative study to assess dentists’ knowledge of OC ferent nationalities) in which 55.1% were males and 44.9% [11]; a qualitative study to explore dentists’ perspectives were females. The average knowledge of OC and its risk fac- related to OC utilizing the grounded theory approach [12]; tors among last year students, interns, and faculty members (c) direct clinical observation of dentists in their routine was at a moderate level; 20.2 ± 3.6 out of 35. The questions 1 3 Journal of Cancer Education regarding the risk factors of OC among females in particular Dental Patients’ Perceptions and Needs Concerning OC Infor- were answered correctly by only 28% of dentists. Majority mation, Examination, Prevention and Behavior [14] The of the participants had a high level of knowledge about how qualitative analysis of interviews showed three major to preform OC examination but a low level of knowledge themes: knowledge regarding OC and its associated aspects, regarding the sites and clinical manifestation of the disease perception of OC and its related aspects, and patients’ as well as it epidemiology. behavior and their dentists’ behavior regarding OC self- examination and clinical procedures. Several participants Dentists’ Perceptions Toward OC [12] FGDs revealed the fol- indicated that they had no idea of what oral cancer could lowing themes representing participants’ thoughts about OC: mean and other participants thought that OC could be the (1) OC in Jazan region as a public health issue; (2) behavio- result of some type of bacterial or fungal infection. Most ral and cultural related risk factors attributed to tobacco con- of participants did not know the risk factors of OC. Several sumption; (3) impact of JDS curriculum on OC recent and participants were not aware of the preventive measures they future dental practice; (4) clinicians’ behavior toward OC; could take to avoid OC. Other participants thought that regu- and (5) challenges and barriers toward OC clinical practice. lar dental check-ups could prevent oral cancer. Direct Clinical Observation [13] Ninety-five examiners The follow-up quantitative study included 315 patients. (final-year students, dental interns, and faculty members) The mean participant age was 31 ± 11  years (range of and 32 patients participated in the study. A total of 70% 12–70). Among the 313 participants who reported their of examiners investigated the systemic diseases and < 30% gender, 41.2% were males and 58.8% were females. Major- investigated tobacco use and oral hygiene practices. A ity were Saudis (85.9%). Participants reported their levels of total of 90% of the examiners assessed patients’ dentations education as follows: 4.4% were uneducated, 7.9% had pri- and < 50% assessed lymph nodes of the neck, lip, check, mary education, 15.6% had intermediate education, 24.1% tongue, palate, or floor of the mouth. Only three female had secondary education, and 47.2% had university educa- final-year dental students had requested specialist consulta- tion. The study findings revealed that patients’ OC knowl- tions, as well as only 11 provided advice to the patients. A edge levels were adequate, but most reported that their den- significant difference between examiner groups was found tist had never examined them for OC. Furthermore, they had in favor of faculty members (p = 0.007 95% CI: 3.08–23.53). never performed self-examinations for OC, nor were they Twenty-three participants participated in the two follow-up aware of the possibility of doing so. Participants showed a FGDs to discuss the factors possibly associated with the preference for being examined and educated by their dentist observed items’ scores. Dependence on previous dental about oral cancer and believed it would help early detec- examination was elicited to be generally related to the low- tion. Patients felt a need for more attention to be paid to OC score items in the checklist. Other factors included lack of examinations, preventive measures, and targeted information cond fi ence to identify oral precancerous/cancerous lesion, to on OC risk factors. provide tailored risk factor education or to provide tobacco counseling as they lacked formal training on these skills. Key Findings of Steps 1 and 2 The findings from the needs’ Participants linked the cultural and religious unaccept- assessments in addition to group brainstorming sessions ability of alcohol use to the observed low score in asking revealed a gap that exists between knowledge and practice of about it. For items related to tobacco and advice on OC risk OC examination among JDS dentists [3, 11–14]. The main factors, female students and interns had higher scores than determinants that were found to be related to the personal males and it was justified as related to the fact that female contributing behaviors were as follows: low awareness of students/interns are vigilant to the oral changes associated OC status in Jazan, dentists’ lack of experience, skills and with tobacco as they are used to examine mainly female self-efficacy, and the negative descriptive norms regarding patients who are usually non-smokers. However, female par- oral cancer practices in JDS [3, 11–13]. The determinants ticipants had given tobacco advice to the patients based on of the environmental behaviors were interns lacking expo- their personal beliefs as they did not receive formal training sure to OC patients and having clinical guidelines that do on tobacco cessation. Dental interns revealed two factors not include OC. The logic model of the problem shows a related to their general low score in comparison to students detailed description of the OC problem and the relationships and faculty members: they rely on the other dentists whom between the factors associated with it (See Fig. 1). the patient will be referred to in the next appointment, and The agreed expected outcomes were as follows: (a) all because they have a busy clinical schedule with a high num- dental interns performing complete OC practices (exami- ber of patients, and therefore they cannot perform full oral nation and patient education) at JDS clinics within 1 year screening on each patient. of implementation and (b) Clinical Director including the complete OC practice in the clinical guidelines and adding 1 3 Journal of Cancer Education Fig. 1 Logic model of the problem OC centers to the interns’ training schedule at JDS clinics immediate changes in the targeted determinants, which within 1 year of implementation. influence the individual and environmental agent’s behav - ior [8]. Based on current literature, experiences and findings Dental interns were the target group because they are the from needs assessments, the main behavioral determinants first to see the patients in JDS-clinics and they had the lowest that need to be modified to achieve the performance objec- score in terms of performing OC examination and patient tives for dental interns, were awareness, skills, self-efficacy, education [13]. The intervention period was specified as and descriptive norms. These determinants were evaluated 1 year due to the structure of JDS interns’ rotations, as all according to its importance and changeability in literature. interns must practice at JDS within their 1-year internship. A detailed description of the change objectives’ matrices The clinical director was chosen because he is the main per- and determinants of change is accessible on https:// osf. io/ son in charge of internships in JDS. After formulating the epnwx/. Finally, the logic model of change was constructed outcome, we have specified the performance objectives for to illustrate the potential relations between theory and evi- behavioral and environmental agents which are the exact dence-based methods, influencing determinants, and behav - actions needed to be carried out by individuals to achieve ioral and environmental outcome (See Fig. 2). the behavioral change outcome [8]. The performance objec- tives for dental interns included the following: (a) dentists The Intervention ISAC was determined as the interven- inform their patients of OC screening; (b) dentists perform tion theme. ISAC is an acronym for a new evidence-based full OC screenings on their patients; (c) dentists advising intervention for comprehensive OC dental practices, which their OC and high-risk patients; and (d) dentists connect- stands for I = Inform (verbally and documentation): den- ing their OC and high-risk patients with specialized clinics tal interns will inform their patients about performing OC and counseling centers. While the performance objectives examinations as part of the routine dental examination of the clinical director included the following: (a) Clinical practice and include the action of informing of this in the Director includes OC practices, e.g., ISAC into the clinical clinical examination documentation; S = Screen, with two guidelines and (b) Clinical Director increases interns’ expo- main parts: the first part is taking medical history, according sure to OC patients by adding OC centers to their interns’ to the clinical guidelines as well as including asking about training rotations. the local risk factors, such as smokeless tobacco use and Subsequently, the matrices of change objectives were water-pipe smoking. The second part is a clinical exami- formulated which symbolize the pathways for the most nation according to the clinical guidelines, which includes 1 3 Journal of Cancer Education Fig. 2 Logic model of change screening for OC; A = Advice: patients at high risk (e.g., dental interns and consists of didactic and practical compo- users of smokeless tobacco) will be counseled to aid ces- nents. Table 1 provides a detailed description of each com- sation, using clear and tailored language to deliver health ponent. The selected theory and evidence-based behavior messages; and C = Connect, with two dimensions: the first change methods for dental interns and the Clinical Direc- dimension is to connect the patient that has any suspicious tor were as follows: consciousness raising, guided practice, lesions with specialized centers that are qualified in dealing information on the approval of others, and persuasive com- with OC cases, such as Prince Mohammed Bin Nasser Hos- munication (Table 1). Additional information is accessible pital (PMBN) in the Jazan region. The second dimension is on < https://osf. io/ 6g9pd/ > . ISAC intervention components to connect tobacco users with a designated service to stop and materials will be pre-tested using thinking-aloud, expert using tobacco products. evaluation, and questionnaire piloting, in order to optimize the content and execution. The objectives of the pre-test Potential Adopters and Implementers The potential adopter were based on the change method parameters < https://os f. of ISAC intervention in JDS is the clinical director. The io/j9e28/ > , to test the concept (dental interns, CDD), read- implementers of ISAC will be the Community Dentistry ability (dental interns), message execution (dental interns), Division (CDD). The expected outcome of the implementa- and the implementation factors to determine the perceptions tion plan is as follows: All faculty members in CDD at JDS of the Clinical Director and the CDD of ISAC’s complex- will implement ISAC with high fidelity and completeness ity, trialability, relative advantage, and to predict possible within 1 year. In order to reach the performance objectives, problems with implementation < https:// osf. io/ fapc3/ > [9]. certain determinants were identified and evaluated accord- ing to their importance and changeability in the literature The effect-evaluation questions on health, quality of [15, 16]: knowledge, attitude, self-efficacy, and skills toward life, behavior, and environment as well as the methodolog- ISAC. ical design for conducting the effect and the process evalu- ations are described in detail in < https:// osf. io/ 38dy6/ > . ISAI Intervention Delivery, Implementation and Evalua- tion ISAC will be delivered as a workshop that targets JDS 1 3 Journal of Cancer Education 1 3 Table 1 Change objective for dental interns — methods and application Determinants and change objective Methods Parameters Applications for JDS Channel for JDS Awareness Acknowledge the importance of Consciousness raising Feedback and confrontation; The trainer gives a lecture Lecture communicating with patients raising awareness must be fol- addressing: general/local oral lowed by self-efficacy cancer epidemiology, general/ Acknowledge the importance of local oral cancer risk factors full oral cancer screening and their affects, full oral can- Acknowledge the importance of cer screenings, the importance advising their patients of patient education and its List the specialized centers and applications, introducing the counseling services ISAC method, introducing tobacco-cessation services Self-efficacy and Skills Express confidence and dem- Guided Practice (reinforcement, Subskill demonstration, Instruc- First: interns have a session with Group communication onstrate ability in informing vicarious learning) tion, and enactment with trainer who models practice and mutual support their patients of oral cancer individual feedback; requires ISAC screening supervision by an experienced Second: interns engage in a role- person play where they apply ISAC Express confidence and demon- in two groups; practicing and strate ability in performing full observing oral cancer screening Third: they give feedback to Express confidence and demon- each other under supervision strate ability in advising their of trainer and receive positive patients regarding their oral comments from the supervi- cancer status or regarding oral sors and each other cancer risk factors Fourth: workshop certificate Express confidence and demon- signed by the JDS Dean strate ability in referring oral cancer patients Descriptive norms Recognize that other dentists Information about others’ Positive expectations are avail- Informing interns that all JDS In both lectures, group com- inform their patients of oral approval able in the environment clinicians will be engaging in munication and mutual cancer ISAC practice support Recognize that other dentists perform full oral cancer screenings for their patients Recognize that other dentists advise their patients regard- ing their oral cancer status or regarding oral cancer risk factors Recognize that other dentists connect their patients to tobacco-quitting services Journal of Cancer Education enhanced the credibility of the findings [20]. Moreover, Discussion patients’ opinions and advice regarding the best method and approach to enhance the OC examinations practice In Jazan, where the prevalence of OC and its risk factors in Jazan region and the possible facilitators and barriers is high [2], there are urgent efforts needed to control the toward OC interventions were incorporated in the inter- disease in the region. There had only been limited attempts vention design. However, as described in our evaluation to raise awareness of OC by a few dental-students’ volun- plan summary, the dissemination of the intervention find- teers [3]. Therefore, the research team took the initiative to ings will target relevant stakeholders including research challenge OC burden and its risk factors in the region from team, scientific literature, JDS, policymakers, health pro- different approaches. One of these approaches was through moters and dental schools in areas that share the similar utilizing intervention mapping, which engaged stakehold- burden of oral cancer high rate, e.g., Sudan and Yemen. ers, oral healthcare providers, and citizens in Jazan. As a result, the current developed intervention (ISAC) aimed to improve OC practices at Jazan University by preparing its dental graduates to perform full OC clinical examinations Conclusions and patient education, which will lead to early detection and prevention of OC. Using IM facilitated in planning and designing the current The needs assessment, at both the level of dentists and developed intervention for the early detection and preven- patients, has revealed major issues relating to dentists’ tion of OC. Working towards developing ISAC required behavior toward OC practice and educating patients — extensive work in assessing dental public health issues in for example, not informing patients of OC examinations, a specific context with limited data — and this constituted not performing full OC examinations, and not educating a great challenge. However, it enriched the research team’s their patients on the risk factors, if needed, or referring understanding of OC in the Jazan region and its local risk them to tobacco-cessation services [3, 11, 13]. Those factors — for example, the use of Shammah — through major issues were covered in the main pillars of ISAC. investing effort to investigate the issue from different Furthermore, upon assessing the contextual character- angles, including its clinical practice by oral healthcare istics of JDS, several factors were found to be positive providers. Furthermore, the development of ISAC was, in in the progress toward implementing the interventions. itself, a lesson that casts light on the advantages of engag- An interesting example of one of these factors was the ing multidisciplinary expertise to tackle a dental public implementation climate (dentists’ shared perceptions of health issue like OC. These advantages can be seen clearly the importance of intervention implementation within the when deciding what behavioral and environmental deter- JDS that results from dentists’ shared experiences, obser- minants need to be targeted and when weighing these vations of and their information about JDS implementa- determinants based on their importance and changeabil- tion policies) which will provide a supportive context for ity using theoretical and empirical evidence. In addition, implementing ISAC. The effect of this strategic climate is the fact that ISAC was a response to JDS administration’s believed to be most proximal to the effective implementa- request to develop an intervention that targets OC and its tion of the intervention [17, 18]. Moreover, it reflects oral related health risk behaviors would aid in its successful healthcare providers’ perceptions toward the priorities of implementation [18]. JDS, from what they learned as a shared assumption from JDS policies, procedures, and communications (formal and Abbreviations OC: Oral cancer; IM: Intervention mapping; JDS: Jazan informal) with JDS leaders [18, 19]. Dental School; CDD: Community Dentistry Division; ISAC: Inform, It should be noted that patients’ engagement in the screen, advise and connect present protocol was not tokenistic participation, but rather, patients had a significant contribution to the pro- cess of developing the intervention protocol. In addition Author Contribution Jafer M., Crutzen R. and Borne B. contributed to dentists’ (faculty member, intern, and students) role, to the design and the conception of the research. Jafer M. and Moafa I. patients’ knowledge, opinions, perceptions, and practice were involved in data acquisition. All authors had substantial contribu- regarding OC and OC examinations have added signifi- tion in data analysis and interpretation as well as in manuscript prepa- cant input to the intervention development as it brought ration and drafting. Jafer M., Crutzen R., and Borne B have critically reviewed the manuscript. While the final version of the manuscript was innovative insights toward OC practices in the region of approved for the publication by all authors. All authors contributed to Jazan. Furthermore, patients provided an indirect objective the design and the conception of the protocol. MJ, IM, and BB are still assessment for dentists’ practice of OC examinations and contributing to the implementation of the intervention. All authors patient education based on patients’ real experience which have critically reviewed the manuscript for intellectual content and have approved the final version of the manuscript for the publication. 1 3 Journal of Cancer Education to screening for mucosal lesions and to counselling patients Declarations on tobacco and alcohol use: baseline data from 1991. Oral Dis 5(1):10–14 Ethics Approval The present intervention protocol was performed 8. Bartholomew Eldredge LK, Markham C, Ruiter R, Fernández M, according to the ethical standards of the institutional research com- Kok G, Parcel G (2016) Planning health promotion programs: an mittee, as well as the 1964 Helsinki Declaration. The whole project intervention mapping approach, 4th edn. Jossey-Bass & Pfeiffer received ethical approval from Jazan University; Registry no. [CDREC- Imprints, Wiley, San Francisco 06], dated 21 December 2016. 9. Bonham CA, Sommerfeld D, Willging C, Aarons GA (2014) Organizational factors influencing implementation of evidence- Consent to Participate Not Applicable. based practices for integrated treatment in behavioral health agen- cies. Psychiatry J 2014:9. https:// doi. org/ 10. 1155/ 2014/ 802983 Consent for Publication Not Applicable. 10. Minkler M, Wallerstein N, Wilson N. Improving health through community organization and community building. Health Educ Conflicts of Interest The authors declare no competing interests. Behav. 2008; 287–312. 11. Jafer M, Crutzen R, Jafer A, Van Den Borne B (2018) What do dental college clinicians know about oral cancer and its risk fac- Open Access This article is licensed under a Creative Commons Attri- tors? An assessment among final year students, interns and fac- bution 4.0 International License, which permits use, sharing, adapta- ulty members in saudi arabia. J Clin Exp Dent 10(9):e908–e913. tion, distribution and reproduction in any medium or format, as long https:// doi. org/ 10. 4317/ jced. 55168 as you give appropriate credit to the original author(s) and the source, 12. Jafer M, Crutzen R, Moafa I, van den Borne B (2021) What do provide a link to the Creative Commons licence, and indicate if changes dentists and dental students think of oral cancer and its control and were made. The images or other third party material in this article are prevention strategies? A qualitative study in Jazan Dental School. included in the article's Creative Commons licence, unless indicated J Canc Educ 36(1):134–142 otherwise in a credit line to the material. If material is not included in 13. Jafer M, Crutzen R, Halboub E, Moafa I, Van Den Borne B, the article's Creative Commons licence and your intended use is not Bajonaid A (2020) Dentists behavioral factors influencing early permitted by statutory regulation or exceeds the permitted use, you will detection of oral cancer: a direct clinical observational study. J need to obtain permission directly from the copyright holder. To view a Canc Educ. https:// doi. org/ 10. 1007/ s13187- 020- 01903-1 copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . 14. Jafer M, Crutzen R, Ibrahim A, Moafa I, Zaylaee H, Ajeely M, van den Borne B, Zanza A, Testarelli L, Patil S (2021) Using the exploratory sequential mixed methods design to investigate dental References patients’ perceptions and needs concerning oral cancer informa- tion, examination, prevention and behavior. Int J Environ Res Public Health 18:7562. https:// doi. org/ 10. 3390/ ijerp h1814 7562 1. Saudi Cancer Registry. 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Using Intervention Mapping to Develop ISAC, a Comprehensive Intervention for Early Detection and Prevention of Oral Cancer in Saudi Arabia

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Springer Journals
Copyright
Copyright © The Author(s) 2022
ISSN
0885-8195
eISSN
1543-0154
DOI
10.1007/s13187-022-02146-y
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Abstract

Oral cancer forms a major public health issue. In Saudi Arabia, Jazan region has the highest rate of oral cancer; > 35% of total cases. Furthermore, dentists’ engagement in oral cancer screening and patient education in Jazan region is limited. This paper aimed to describe the process used to develop a comprehensive oral cancer (OC) practice intervention to be implemented in dental clinics. The intervention was informed by the six steps of intervention mapping (IM). Steps 1–3 included mixed methods approach of reviewing relevant existing literature, focus group discussions, observations, one-on-one interviews, and questionnaires utilizing the community participatory approach. Step 4 used information form steps 1–3 to develop the intervention components and its associated tools to facilitate its delivery. Steps 5 and 6 specified the prospective plans for implementation and evaluation. ISAC is the developed intervention that comprises the following: Informing dental patients about performing routine OC screenings, Screenings for OC, Advising patients, and Connecting patients to the required ser- vices. ISAC practical applications were clustered into two components: (a) didactical session covering aspects related to OC practices and introducing ISAC and (b) practical session that included a step-by-step modeling of the intervention. Using IM facilitated the systematic planning of the ISAC intervention that covers the main issues revealed by the need’s assessments. Working towards developing the ISAC required extensive work in assessing dental public health issues in a specific context with limited data — and this constituted a great challenge. The development of the ISAC was a lesson that casts light on the advantages of engaging multidisciplinary expertise to tackle serious public health issue like OC. Keywords Oral cancer · Intervention mapping · Methods · Program development · Prevention · Early detection · Dental practice · Oral health · Behavior change Background (compared to men) [1]. A strong association was found between these diagnosed cases and the use of smokeless Oral cancer (OC), and particularly squamous cell carci- tobacco [2]. The form of smokeless tobacco that is com- noma, is one of the most prevalent cancers in Saudi Ara- monly used in the Jazan region is known as Shammah. bia [1]. In comparison to other regions of Saudi Arabia, the Despite the disease being so prevalent in Saudi Arabia, and Jazan region carried the heaviest burden of the disease, as particularly in the Jazan region, there has been limited effort it had more than 35% of the registered diagnosed cases at to prevent its risk factors or to screen for it in clinics [3]. an advanced stage, with a slightly higher rate in females Evidence had shown that oral cancer can be prevented by eliminating its risk factors [4]. Moreover, it was found that early detection of OC can lead to a better prognosis for the * Mohammed Jafer recovery from the disease [5]. Due to this, dentists screening m.jafer@maastrichtuniversity.nl for OC and educating patients on its risk factors is highly Dental Public Health, Department of Preventive Dental recommended [6]. However, these recommendations are not Science, College of Dentistry, Jazan University, Jazan, usually met by dentists [7]. Similarly, in the Jazan region, Saudi Arabia dentists’ engagement in OC screening and patient education Department of Health Promotion, Maastricht has been found to be limited [3]. Several factors were sug- University/CAPHRI, P.O. Box 616, Maastricht 6200 MD, gested as contributing factors towards this kind of behavior The Netherlands Vol.:(0123456789) 1 3 Journal of Cancer Education by dentists — for example, limited exposure to OC cases, a dental practices by four calibrated dentists (the observers lack of OC screening skills, and a lack of skill in educating who received calibration trainings to improve their scoring patients [3]. Therefore, it is essential to have an intervention accuracy and consistency) [13]; (d) an exploratory sequen- that aims to improve OC practices in the Jazan region. The tial mixed methods design to investigate dental patients’ objective of this paper was to report on the development of a behavior, thoughts, opinions, and needs for oral cancer comprehensive intervention for OC practices (ISAC), using information, and dentists’ behavior regarding prevention the Intervention Mapping approach [8]. and examination of oral cancer [14]; and (e) an assessment and evaluation of JDS organization context factors [12–14]. Methods Step 2: Program Outcomes, Objectives, and Logic Model of Change We have utilized the findings from step 1 to deter - We believe that Intervention Mapping (IM) was the most mine who and what needs to be changed in order to increase appropriate approach because it addresses this challenge the early detection and prevention of OC. We’ve formulated from different perspectives. [8 ]. IM is a systematic frame- the desired outcomes using SMART objectives, which work that is characterized by three aspects: (1) application of stands for Specific, Measurable, Achievable, Realistic, and a social ecological model that views the individual behavior Time, and we finally created the logic model of change. as an outcome of the interaction of the individual with physi- cal, social, and organization environments; (2) community Steps 3 and 4: Program design and Program Production We broad participation to enhance the relevance, acceptability, have defined the intervention theme, components, scope, and and cultural suitability; (3) utilizes theory and evidence as sequence. Additionally, we have identified the behavioral foundations in order to assess and develop effective inter - change methods targeting the relevant determinants. These ventions for behavior and environmental changes that are determinants were translated into practical applications con- conducive to health. IM entails six steps: (1) Logic model sidering their parameters for use to optimize effectiveness. of problem; (2) logic model of change; (3) program design; Aside from this, the intervention channel/vehicle, materials, (4) program production; (5) implementation plan; and (6) length, quality, and feasibility were distinguished for each evaluation plan [8]. Each of these steps involves several component. Finally, the intervention material resources were tasks and build in an iterative and a cumulative process [8]. prepared in collaboration with experts in oral cancer, digital The research team with representation from dental public design, health education, and promotion. health, patients’ education, behavior change, and technology have established the planning group. This planning group Steps 5 and 6: Program Implementation and Evaluation included all potential intervention implementers of essen- Plan We have written the evaluation questions (process/ tial value — including the Dean and the Head of the Com- effect) considering the intervention logic models, goals, munity Dentistry Division (CDD) of Jazan Dental School objectives, and matrices. Effect evaluation investigates (JDS) [9]. Moreover, a bottom-up community empower- whether the behavior, environmental outcomes, and objec- ment approach sought to include the target group: dentists, tives change because of the intervention [8, 15], while the dental interns, and dental patients of JDS (from both male process evaluation assesses the intervention implementation and female branches) to create a compatible intervention and delivery [8]. Following this, indicators and measures that ensured dental best practices and ultimately improve were determined to assess the formulated questions on the patient quality of life [8, 10]. All the research team mem- effect and process evaluation. Finally, we have specified the bers are experienced with Intervention Mapping (IM). The methodological design for conducting process and effect team has followed the six steps of IM for the development, evaluation. implementation, and evaluation of the intervention. This paper describes the process of intervention development, intervention protocol for implementation, and evaluation in Results steps 1 to 6 of IM. The results of the needs assessment revealed the following: Step 1: Logic Model of the Problem We have conducted needs assessments that involved the following: (a) Evidence Knowledge [11] A total of 237 individuals participated (72 reviews of existing data on OC problem at Jazan region; students, 68 dental interns, and 88 faculty members of dif- (b) a quantitative study to assess dentists’ knowledge of OC ferent nationalities) in which 55.1% were males and 44.9% [11]; a qualitative study to explore dentists’ perspectives were females. The average knowledge of OC and its risk fac- related to OC utilizing the grounded theory approach [12]; tors among last year students, interns, and faculty members (c) direct clinical observation of dentists in their routine was at a moderate level; 20.2 ± 3.6 out of 35. The questions 1 3 Journal of Cancer Education regarding the risk factors of OC among females in particular Dental Patients’ Perceptions and Needs Concerning OC Infor- were answered correctly by only 28% of dentists. Majority mation, Examination, Prevention and Behavior [14] The of the participants had a high level of knowledge about how qualitative analysis of interviews showed three major to preform OC examination but a low level of knowledge themes: knowledge regarding OC and its associated aspects, regarding the sites and clinical manifestation of the disease perception of OC and its related aspects, and patients’ as well as it epidemiology. behavior and their dentists’ behavior regarding OC self- examination and clinical procedures. Several participants Dentists’ Perceptions Toward OC [12] FGDs revealed the fol- indicated that they had no idea of what oral cancer could lowing themes representing participants’ thoughts about OC: mean and other participants thought that OC could be the (1) OC in Jazan region as a public health issue; (2) behavio- result of some type of bacterial or fungal infection. Most ral and cultural related risk factors attributed to tobacco con- of participants did not know the risk factors of OC. Several sumption; (3) impact of JDS curriculum on OC recent and participants were not aware of the preventive measures they future dental practice; (4) clinicians’ behavior toward OC; could take to avoid OC. Other participants thought that regu- and (5) challenges and barriers toward OC clinical practice. lar dental check-ups could prevent oral cancer. Direct Clinical Observation [13] Ninety-five examiners The follow-up quantitative study included 315 patients. (final-year students, dental interns, and faculty members) The mean participant age was 31 ± 11  years (range of and 32 patients participated in the study. A total of 70% 12–70). Among the 313 participants who reported their of examiners investigated the systemic diseases and < 30% gender, 41.2% were males and 58.8% were females. Major- investigated tobacco use and oral hygiene practices. A ity were Saudis (85.9%). Participants reported their levels of total of 90% of the examiners assessed patients’ dentations education as follows: 4.4% were uneducated, 7.9% had pri- and < 50% assessed lymph nodes of the neck, lip, check, mary education, 15.6% had intermediate education, 24.1% tongue, palate, or floor of the mouth. Only three female had secondary education, and 47.2% had university educa- final-year dental students had requested specialist consulta- tion. The study findings revealed that patients’ OC knowl- tions, as well as only 11 provided advice to the patients. A edge levels were adequate, but most reported that their den- significant difference between examiner groups was found tist had never examined them for OC. Furthermore, they had in favor of faculty members (p = 0.007 95% CI: 3.08–23.53). never performed self-examinations for OC, nor were they Twenty-three participants participated in the two follow-up aware of the possibility of doing so. Participants showed a FGDs to discuss the factors possibly associated with the preference for being examined and educated by their dentist observed items’ scores. Dependence on previous dental about oral cancer and believed it would help early detec- examination was elicited to be generally related to the low- tion. Patients felt a need for more attention to be paid to OC score items in the checklist. Other factors included lack of examinations, preventive measures, and targeted information cond fi ence to identify oral precancerous/cancerous lesion, to on OC risk factors. provide tailored risk factor education or to provide tobacco counseling as they lacked formal training on these skills. Key Findings of Steps 1 and 2 The findings from the needs’ Participants linked the cultural and religious unaccept- assessments in addition to group brainstorming sessions ability of alcohol use to the observed low score in asking revealed a gap that exists between knowledge and practice of about it. For items related to tobacco and advice on OC risk OC examination among JDS dentists [3, 11–14]. The main factors, female students and interns had higher scores than determinants that were found to be related to the personal males and it was justified as related to the fact that female contributing behaviors were as follows: low awareness of students/interns are vigilant to the oral changes associated OC status in Jazan, dentists’ lack of experience, skills and with tobacco as they are used to examine mainly female self-efficacy, and the negative descriptive norms regarding patients who are usually non-smokers. However, female par- oral cancer practices in JDS [3, 11–13]. The determinants ticipants had given tobacco advice to the patients based on of the environmental behaviors were interns lacking expo- their personal beliefs as they did not receive formal training sure to OC patients and having clinical guidelines that do on tobacco cessation. Dental interns revealed two factors not include OC. The logic model of the problem shows a related to their general low score in comparison to students detailed description of the OC problem and the relationships and faculty members: they rely on the other dentists whom between the factors associated with it (See Fig. 1). the patient will be referred to in the next appointment, and The agreed expected outcomes were as follows: (a) all because they have a busy clinical schedule with a high num- dental interns performing complete OC practices (exami- ber of patients, and therefore they cannot perform full oral nation and patient education) at JDS clinics within 1 year screening on each patient. of implementation and (b) Clinical Director including the complete OC practice in the clinical guidelines and adding 1 3 Journal of Cancer Education Fig. 1 Logic model of the problem OC centers to the interns’ training schedule at JDS clinics immediate changes in the targeted determinants, which within 1 year of implementation. influence the individual and environmental agent’s behav - ior [8]. Based on current literature, experiences and findings Dental interns were the target group because they are the from needs assessments, the main behavioral determinants first to see the patients in JDS-clinics and they had the lowest that need to be modified to achieve the performance objec- score in terms of performing OC examination and patient tives for dental interns, were awareness, skills, self-efficacy, education [13]. The intervention period was specified as and descriptive norms. These determinants were evaluated 1 year due to the structure of JDS interns’ rotations, as all according to its importance and changeability in literature. interns must practice at JDS within their 1-year internship. A detailed description of the change objectives’ matrices The clinical director was chosen because he is the main per- and determinants of change is accessible on https:// osf. io/ son in charge of internships in JDS. After formulating the epnwx/. Finally, the logic model of change was constructed outcome, we have specified the performance objectives for to illustrate the potential relations between theory and evi- behavioral and environmental agents which are the exact dence-based methods, influencing determinants, and behav - actions needed to be carried out by individuals to achieve ioral and environmental outcome (See Fig. 2). the behavioral change outcome [8]. The performance objec- tives for dental interns included the following: (a) dentists The Intervention ISAC was determined as the interven- inform their patients of OC screening; (b) dentists perform tion theme. ISAC is an acronym for a new evidence-based full OC screenings on their patients; (c) dentists advising intervention for comprehensive OC dental practices, which their OC and high-risk patients; and (d) dentists connect- stands for I = Inform (verbally and documentation): den- ing their OC and high-risk patients with specialized clinics tal interns will inform their patients about performing OC and counseling centers. While the performance objectives examinations as part of the routine dental examination of the clinical director included the following: (a) Clinical practice and include the action of informing of this in the Director includes OC practices, e.g., ISAC into the clinical clinical examination documentation; S = Screen, with two guidelines and (b) Clinical Director increases interns’ expo- main parts: the first part is taking medical history, according sure to OC patients by adding OC centers to their interns’ to the clinical guidelines as well as including asking about training rotations. the local risk factors, such as smokeless tobacco use and Subsequently, the matrices of change objectives were water-pipe smoking. The second part is a clinical exami- formulated which symbolize the pathways for the most nation according to the clinical guidelines, which includes 1 3 Journal of Cancer Education Fig. 2 Logic model of change screening for OC; A = Advice: patients at high risk (e.g., dental interns and consists of didactic and practical compo- users of smokeless tobacco) will be counseled to aid ces- nents. Table 1 provides a detailed description of each com- sation, using clear and tailored language to deliver health ponent. The selected theory and evidence-based behavior messages; and C = Connect, with two dimensions: the first change methods for dental interns and the Clinical Direc- dimension is to connect the patient that has any suspicious tor were as follows: consciousness raising, guided practice, lesions with specialized centers that are qualified in dealing information on the approval of others, and persuasive com- with OC cases, such as Prince Mohammed Bin Nasser Hos- munication (Table 1). Additional information is accessible pital (PMBN) in the Jazan region. The second dimension is on < https://osf. io/ 6g9pd/ > . ISAC intervention components to connect tobacco users with a designated service to stop and materials will be pre-tested using thinking-aloud, expert using tobacco products. evaluation, and questionnaire piloting, in order to optimize the content and execution. The objectives of the pre-test Potential Adopters and Implementers The potential adopter were based on the change method parameters < https://os f. of ISAC intervention in JDS is the clinical director. The io/j9e28/ > , to test the concept (dental interns, CDD), read- implementers of ISAC will be the Community Dentistry ability (dental interns), message execution (dental interns), Division (CDD). The expected outcome of the implementa- and the implementation factors to determine the perceptions tion plan is as follows: All faculty members in CDD at JDS of the Clinical Director and the CDD of ISAC’s complex- will implement ISAC with high fidelity and completeness ity, trialability, relative advantage, and to predict possible within 1 year. In order to reach the performance objectives, problems with implementation < https:// osf. io/ fapc3/ > [9]. certain determinants were identified and evaluated accord- ing to their importance and changeability in the literature The effect-evaluation questions on health, quality of [15, 16]: knowledge, attitude, self-efficacy, and skills toward life, behavior, and environment as well as the methodolog- ISAC. ical design for conducting the effect and the process evalu- ations are described in detail in < https:// osf. io/ 38dy6/ > . ISAI Intervention Delivery, Implementation and Evalua- tion ISAC will be delivered as a workshop that targets JDS 1 3 Journal of Cancer Education 1 3 Table 1 Change objective for dental interns — methods and application Determinants and change objective Methods Parameters Applications for JDS Channel for JDS Awareness Acknowledge the importance of Consciousness raising Feedback and confrontation; The trainer gives a lecture Lecture communicating with patients raising awareness must be fol- addressing: general/local oral lowed by self-efficacy cancer epidemiology, general/ Acknowledge the importance of local oral cancer risk factors full oral cancer screening and their affects, full oral can- Acknowledge the importance of cer screenings, the importance advising their patients of patient education and its List the specialized centers and applications, introducing the counseling services ISAC method, introducing tobacco-cessation services Self-efficacy and Skills Express confidence and dem- Guided Practice (reinforcement, Subskill demonstration, Instruc- First: interns have a session with Group communication onstrate ability in informing vicarious learning) tion, and enactment with trainer who models practice and mutual support their patients of oral cancer individual feedback; requires ISAC screening supervision by an experienced Second: interns engage in a role- person play where they apply ISAC Express confidence and demon- in two groups; practicing and strate ability in performing full observing oral cancer screening Third: they give feedback to Express confidence and demon- each other under supervision strate ability in advising their of trainer and receive positive patients regarding their oral comments from the supervi- cancer status or regarding oral sors and each other cancer risk factors Fourth: workshop certificate Express confidence and demon- signed by the JDS Dean strate ability in referring oral cancer patients Descriptive norms Recognize that other dentists Information about others’ Positive expectations are avail- Informing interns that all JDS In both lectures, group com- inform their patients of oral approval able in the environment clinicians will be engaging in munication and mutual cancer ISAC practice support Recognize that other dentists perform full oral cancer screenings for their patients Recognize that other dentists advise their patients regard- ing their oral cancer status or regarding oral cancer risk factors Recognize that other dentists connect their patients to tobacco-quitting services Journal of Cancer Education enhanced the credibility of the findings [20]. Moreover, Discussion patients’ opinions and advice regarding the best method and approach to enhance the OC examinations practice In Jazan, where the prevalence of OC and its risk factors in Jazan region and the possible facilitators and barriers is high [2], there are urgent efforts needed to control the toward OC interventions were incorporated in the inter- disease in the region. There had only been limited attempts vention design. However, as described in our evaluation to raise awareness of OC by a few dental-students’ volun- plan summary, the dissemination of the intervention find- teers [3]. Therefore, the research team took the initiative to ings will target relevant stakeholders including research challenge OC burden and its risk factors in the region from team, scientific literature, JDS, policymakers, health pro- different approaches. One of these approaches was through moters and dental schools in areas that share the similar utilizing intervention mapping, which engaged stakehold- burden of oral cancer high rate, e.g., Sudan and Yemen. ers, oral healthcare providers, and citizens in Jazan. As a result, the current developed intervention (ISAC) aimed to improve OC practices at Jazan University by preparing its dental graduates to perform full OC clinical examinations Conclusions and patient education, which will lead to early detection and prevention of OC. Using IM facilitated in planning and designing the current The needs assessment, at both the level of dentists and developed intervention for the early detection and preven- patients, has revealed major issues relating to dentists’ tion of OC. Working towards developing ISAC required behavior toward OC practice and educating patients — extensive work in assessing dental public health issues in for example, not informing patients of OC examinations, a specific context with limited data — and this constituted not performing full OC examinations, and not educating a great challenge. However, it enriched the research team’s their patients on the risk factors, if needed, or referring understanding of OC in the Jazan region and its local risk them to tobacco-cessation services [3, 11, 13]. Those factors — for example, the use of Shammah — through major issues were covered in the main pillars of ISAC. investing effort to investigate the issue from different Furthermore, upon assessing the contextual character- angles, including its clinical practice by oral healthcare istics of JDS, several factors were found to be positive providers. Furthermore, the development of ISAC was, in in the progress toward implementing the interventions. itself, a lesson that casts light on the advantages of engag- An interesting example of one of these factors was the ing multidisciplinary expertise to tackle a dental public implementation climate (dentists’ shared perceptions of health issue like OC. These advantages can be seen clearly the importance of intervention implementation within the when deciding what behavioral and environmental deter- JDS that results from dentists’ shared experiences, obser- minants need to be targeted and when weighing these vations of and their information about JDS implementa- determinants based on their importance and changeabil- tion policies) which will provide a supportive context for ity using theoretical and empirical evidence. In addition, implementing ISAC. The effect of this strategic climate is the fact that ISAC was a response to JDS administration’s believed to be most proximal to the effective implementa- request to develop an intervention that targets OC and its tion of the intervention [17, 18]. Moreover, it reflects oral related health risk behaviors would aid in its successful healthcare providers’ perceptions toward the priorities of implementation [18]. JDS, from what they learned as a shared assumption from JDS policies, procedures, and communications (formal and Abbreviations OC: Oral cancer; IM: Intervention mapping; JDS: Jazan informal) with JDS leaders [18, 19]. Dental School; CDD: Community Dentistry Division; ISAC: Inform, It should be noted that patients’ engagement in the screen, advise and connect present protocol was not tokenistic participation, but rather, patients had a significant contribution to the pro- cess of developing the intervention protocol. In addition Author Contribution Jafer M., Crutzen R. and Borne B. contributed to dentists’ (faculty member, intern, and students) role, to the design and the conception of the research. Jafer M. and Moafa I. patients’ knowledge, opinions, perceptions, and practice were involved in data acquisition. All authors had substantial contribu- regarding OC and OC examinations have added signifi- tion in data analysis and interpretation as well as in manuscript prepa- cant input to the intervention development as it brought ration and drafting. Jafer M., Crutzen R., and Borne B have critically reviewed the manuscript. While the final version of the manuscript was innovative insights toward OC practices in the region of approved for the publication by all authors. All authors contributed to Jazan. Furthermore, patients provided an indirect objective the design and the conception of the protocol. MJ, IM, and BB are still assessment for dentists’ practice of OC examinations and contributing to the implementation of the intervention. All authors patient education based on patients’ real experience which have critically reviewed the manuscript for intellectual content and have approved the final version of the manuscript for the publication. 1 3 Journal of Cancer Education to screening for mucosal lesions and to counselling patients Declarations on tobacco and alcohol use: baseline data from 1991. Oral Dis 5(1):10–14 Ethics Approval The present intervention protocol was performed 8. Bartholomew Eldredge LK, Markham C, Ruiter R, Fernández M, according to the ethical standards of the institutional research com- Kok G, Parcel G (2016) Planning health promotion programs: an mittee, as well as the 1964 Helsinki Declaration. The whole project intervention mapping approach, 4th edn. Jossey-Bass & Pfeiffer received ethical approval from Jazan University; Registry no. 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Journal

Journal of Cancer EducationSpringer Journals

Published: Apr 1, 2023

Keywords: Oral cancer; Intervention mapping; Methods; Program development; Prevention; Early detection; Dental practice; Oral health; Behavior change

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