The results of the needs assessment revealed the following:
A total of 237 individuals participated (72 students, 68 dental interns, and 88 faculty members of different nationalities) in which 55.1% were males and 44.9% were females. The average knowledge of OC and its risk factors among last year students, interns, and faculty members was at a moderate level; 20.2 ± 3.6 out of 35. The questions regarding the risk factors of OC among females in particular were answered correctly by only 28% of dentists. Majority of the participants had a high level of knowledge about how to preform OC examination but a low level of knowledge regarding the sites and clinical manifestation of the disease as well as it epidemiology.
Dentists’ Perceptions Toward OC 
FGDs revealed the following themes representing participants’ thoughts about OC: (1) OC in Jazan region as a public health issue; (2) behavioral and cultural related risk factors attributed to tobacco consumption; (3) impact of JDS curriculum on OC recent and future dental practice; (4) clinicians’ behavior toward OC; and (5) challenges and barriers toward OC clinical practice.
Direct Clinical Observation 
Ninety-five examiners (final-year students, dental interns, and faculty members) and 32 patients participated in the study. A total of 70% of examiners investigated the systemic diseases and < 30% investigated tobacco use and oral hygiene practices. A total of 90% of the examiners assessed patients’ dentations and < 50% assessed lymph nodes of the neck, lip, check, tongue, palate, or floor of the mouth. Only three female final-year dental students had requested specialist consultations, as well as only 11 provided advice to the patients. A significant difference between examiner groups was found in favor of faculty members (p = 0.007 95% CI: 3.08–23.53). Twenty-three participants participated in the two follow-up FGDs to discuss the factors possibly associated with the observed items’ scores. Dependence on previous dental examination was elicited to be generally related to the low-score items in the checklist. Other factors included lack of confidence to identify oral precancerous/cancerous lesion, to provide tailored risk factor education or to provide tobacco counseling as they lacked formal training on these skills. Participants linked the cultural and religious unacceptability of alcohol use to the observed low score in asking about it. For items related to tobacco and advice on OC risk factors, female students and interns had higher scores than males and it was justified as related to the fact that female students/interns are vigilant to the oral changes associated with tobacco as they are used to examine mainly female patients who are usually non-smokers. However, female participants had given tobacco advice to the patients based on their personal beliefs as they did not receive formal training on tobacco cessation. Dental interns revealed two factors related to their general low score in comparison to students and faculty members: they rely on the other dentists whom the patient will be referred to in the next appointment, and because they have a busy clinical schedule with a high number of patients, and therefore they cannot perform full oral screening on each patient.
Dental Patients’ Perceptions and Needs Concerning OC Information, Examination, Prevention and Behavior 
The qualitative analysis of interviews showed three major themes: knowledge regarding OC and its associated aspects, perception of OC and its related aspects, and patients’ behavior and their dentists’ behavior regarding OC self-examination and clinical procedures. Several participants indicated that they had no idea of what oral cancer could mean and other participants thought that OC could be the result of some type of bacterial or fungal infection. Most of participants did not know the risk factors of OC. Several participants were not aware of the preventive measures they could take to avoid OC. Other participants thought that regular dental check-ups could prevent oral cancer.
The follow-up quantitative study included 315 patients. The mean participant age was 31 ± 11 years (range of 12–70). Among the 313 participants who reported their gender, 41.2% were males and 58.8% were females. Majority were Saudis (85.9%). Participants reported their levels of education as follows: 4.4% were uneducated, 7.9% had primary education, 15.6% had intermediate education, 24.1% had secondary education, and 47.2% had university education. The study findings revealed that patients’ OC knowledge levels were adequate, but most reported that their dentist had never examined them for OC. Furthermore, they had never performed self-examinations for OC, nor were they aware of the possibility of doing so. Participants showed a preference for being examined and educated by their dentist about oral cancer and believed it would help early detection. Patients felt a need for more attention to be paid to OC examinations, preventive measures, and targeted information on OC risk factors.
Key Findings of Steps 1 and 2
The findings from the needs’ assessments in addition to group brainstorming sessions revealed a gap that exists between knowledge and practice of OC examination among JDS dentists [3, 11,12,13,14]. The main determinants that were found to be related to the personal contributing behaviors were as follows: low awareness of OC status in Jazan, dentists’ lack of experience, skills and self-efficacy, and the negative descriptive norms regarding oral cancer practices in JDS [3, 11,12,13]. The determinants of the environmental behaviors were interns lacking exposure to OC patients and having clinical guidelines that do not include OC. The logic model of the problem shows a detailed description of the OC problem and the relationships between the factors associated with it (See Fig. 1).
The agreed expected outcomes were as follows: (a) all dental interns performing complete OC practices (examination and patient education) at JDS clinics within 1 year of implementation and (b) Clinical Director including the complete OC practice in the clinical guidelines and adding OC centers to the interns’ training schedule at JDS clinics within 1 year of implementation.
Dental interns were the target group because they are the first to see the patients in JDS-clinics and they had the lowest score in terms of performing OC examination and patient education . The intervention period was specified as 1 year due to the structure of JDS interns’ rotations, as all interns must practice at JDS within their 1-year internship. The clinical director was chosen because he is the main person in charge of internships in JDS. After formulating the outcome, we have specified the performance objectives for behavioral and environmental agents which are the exact actions needed to be carried out by individuals to achieve the behavioral change outcome . The performance objectives for dental interns included the following: (a) dentists inform their patients of OC screening; (b) dentists perform full OC screenings on their patients; (c) dentists advising their OC and high-risk patients; and (d) dentists connecting their OC and high-risk patients with specialized clinics and counseling centers. While the performance objectives of the clinical director included the following: (a) Clinical Director includes OC practices, e.g., ISAC into the clinical guidelines and (b) Clinical Director increases interns’ exposure to OC patients by adding OC centers to their interns’ training rotations.
Subsequently, the matrices of change objectives were formulated which symbolize the pathways for the most immediate changes in the targeted determinants, which influence the individual and environmental agent’s behavior . Based on current literature, experiences and findings from needs assessments, the main behavioral determinants that need to be modified to achieve the performance objectives for dental interns, were awareness, skills, self-efficacy, and descriptive norms. These determinants were evaluated according to its importance and changeability in literature. A detailed description of the change objectives’ matrices and determinants of change is accessible on https://osf.io/epnwx/. Finally, the logic model of change was constructed to illustrate the potential relations between theory and evidence-based methods, influencing determinants, and behavioral and environmental outcome (See Fig. 2).
ISAC was determined as the intervention theme. ISAC is an acronym for a new evidence-based intervention for comprehensive OC dental practices, which stands for I = Inform (verbally and documentation): dental interns will inform their patients about performing OC examinations as part of the routine dental examination practice and include the action of informing of this in the clinical examination documentation; S = Screen, with two main parts: the first part is taking medical history, according to the clinical guidelines as well as including asking about the local risk factors, such as smokeless tobacco use and water-pipe smoking. The second part is a clinical examination according to the clinical guidelines, which includes screening for OC; A = Advice: patients at high risk (e.g., users of smokeless tobacco) will be counseled to aid cessation, using clear and tailored language to deliver health messages; and C = Connect, with two dimensions: the first dimension is to connect the patient that has any suspicious lesions with specialized centers that are qualified in dealing with OC cases, such as Prince Mohammed Bin Nasser Hospital (PMBN) in the Jazan region. The second dimension is to connect tobacco users with a designated service to stop using tobacco products.
Potential Adopters and Implementers
The potential adopter of ISAC intervention in JDS is the clinical director. The implementers of ISAC will be the Community Dentistry Division (CDD). The expected outcome of the implementation plan is as follows: All faculty members in CDD at JDS will implement ISAC with high fidelity and completeness within 1 year. In order to reach the performance objectives, certain determinants were identified and evaluated according to their importance and changeability in the literature [15, 16]: knowledge, attitude, self-efficacy, and skills toward ISAC.
ISAI Intervention Delivery, Implementation and Evaluation
ISAC will be delivered as a workshop that targets JDS dental interns and consists of didactic and practical components. Table 1 provides a detailed description of each component. The selected theory and evidence-based behavior change methods for dental interns and the Clinical Director were as follows: consciousness raising, guided practice, information on the approval of others, and persuasive communication (Table 1). Additional information is accessible on < https://osf.io/6g9pd/ > . ISAC intervention components and materials will be pre-tested using thinking-aloud, expert evaluation, and questionnaire piloting, in order to optimize the content and execution. The objectives of the pre-test were based on the change method parameters < https://osf.io/j9e28/ > , to test the concept (dental interns, CDD), readability (dental interns), message execution (dental interns), and the implementation factors to determine the perceptions of the Clinical Director and the CDD of ISAC’s complexity, trialability, relative advantage, and to predict possible problems with implementation < https://osf.io/fapc3/ > .
The effect-evaluation questions on health, quality of life, behavior, and environment as well as the methodological design for conducting the effect and the process evaluations are described in detail in < https://osf.io/38dy6/ > .