Evidence-based research to impact health policy and practice: Interview with Research Associate, Penny Lun

GERI has convened the Advance Care Planning (ACP) Quality Implementation (AQI) Knowledge Exchange Platform, in collaboration with the Agency of Integrated Care (AIC), to explore ways of adopting research evidence to enhance the implementation of ACP in Singapore.

Together with practitioners from three regional healthcare clusters, the community care and long-term care sector, and the Ministry of Health (MOH), the team is developing a framework and set of quality indicators aimed at raising standards and enabling quality implementation of ACP in real-world settings.

In this two-part feature series, Associate Professor James Low (Knowledge Translation Lead and Joint Faculty, GERI) and Penny Lun (Research Associate, GERI) share their insider insights on working on the AQI project, as well as closing the research-to-practice gap through knowledge translation and implementation research strategies. Read part two of this story below.​

GERI: In supporting the AQI workgroup, how have you tapped on your know-how as a researcher, to help your collaborators make sense of the barriers when it comes to ACP implementation in Singapore?

Penny Lun: I became interested when I learnt that the team was using the Theoretical Domains Framework (TDF) to map barriers found in implementing ACP in Singapore. The TDF is a synthesis of 33 theories of behaviour and behaviour change organised into 14 domains. It is useful in systematically identifying influences that encourage or hinder behaviours, in order to point us to targeted, evidence-based implementation strategies and bring about behaviour change.​

It was very helpful in a previous GERI intervention development project I was on, related to addressing potentially inappropriate prescribing among older adults with multimorbidity, and I wanted to be part of the AQI team to contribute to the knowledge and learning.

The AQI project aims to improve the quality of implementing ACP in Singapore, which could improve the uptake of ACP. I was working with AIC colleagues to map the barriers, which was a challenging process due to the sheer number of barriers identified. It was a learning process, as we needed to contextualise the TDF domains from an ACP implementation angle. I drew on the experience I had as well as knowledge in the literature to understand and differentiate the concepts in each domain.

Fortunately, our AIC colleagues' expertise in the subject matter complemented interpretations of the domains in context. This greatly helped in narrowing down the many barriers identified, which then enabled us to formulate a national survey for ACP facilitators and administrators that was detailed but yet manageable.

Could you share some reflections on your experience working with diverse stakeholders (hospital and community care partners, healthcare practitioners) and engaging with the workgroup?

I have enjoyed being part of the workgroup and meeting various stakeholders in the process. There were many opportunities to share the Knowledge Translation (KT) methodology adopted and our results with the core group, workgroup, and during an ACP Continuous Learning and Networking meeting. I also helped facilitate group discussions with a diverse community of ACP practitioners during a World Café* event organised by AIC, which exposed me to a new methodology that is both exploratory and engaging. All these experiences have enriched my journey as a researcher, especially on how to share complex or technical information with an audience with limited research backgrounds. One important point I have learned is the need to focus on the group goal(s) and to understand expectations of the stakeholders early on.

* A World Café is a conversation that encourages participants to engage in constructive dialogue around critical questions through a participatory engagement process (Fouché & Light 2011).

In parallel, you have also been working with KT expert Dr Sharon E. Straus (​GERI Adjunct Faculty and Director of the Knowledge Translation Program, St Michael's Hospital, Canada​) to apply KT principles to the AQI project. What has this been like, and what are some insights you have gained about knowledge translation in Singapore’s context?

Working with Dr Straus has been a delight; she is generous with sharing her vast experience and expertise in implementation science. For the AQI project, we adopted the Knowledge-To-Action (KTA) model in the framework development process.

KT involves working with relevant knowledge users when implementing a change, such as in adopting an evidence-based practice. It is especially important that knowledge users are involved from the beginning during the problem identification phase, and through to finding the appropriate solution or implementation strategy. This way, they are invested in the problem and are also in the best position to judge if a strategy is feasible and sustainable in the long run, if implemented. In addition, operationalising a specified strategy will also require their knowledge in context.

That said, changing practice is not an easy task. The healthcare professionals that I have had the privilege to work with are passionate about their work, wanting to do their best to improve patient care. However, many system- and organisation-level barriers exist, which would impact the feasibility and sustainability of an individual-level implementation strategy, should those barriers remain unaddressed. Nevertheless, giving knowledge users a voice in the change process today could be a first step to influencing higher-level changes in the future.​

Another translation and evidence-centric project that you were also involved in was a rapid review​ to identify brief screening tools for possible dementia in the community, of which the results informed Singapore’s policy strategy for dementia screening. How did you support the multi-institution team in this project, and why do you think rapid reviews are a good way to help people make sense of pressing health challenges?

For this project, the domain experts are geriatricians from across the three healthcare clusters, including GERI faculty, of which three were the reviewers. I played a supporting role by coordinating collaborations between the domain experts and the methodology experts (from the Singapore Clinical Research Institute). Together with another colleague, we provided administrative support and facilitated the review process. For example, we reviewed relevant literature and drafted the first search strategy, as well as the protocol for circulation, with the study team for their input. We also helped to summarise some data and drafted part of the presentation deck. All this was completed in a relatively short amount of time.

As this project was intended to answer a crucial and timely question that could impact policy decision-making, the rapid review is a good methodology to use. The rapid review is a systematic review condensed to accommodate the need for quicker evidence, without compromising on rigour. Under normal circumstances, a systematic review that typically takes a year to complete might be the preferred method. However, when a pressing issue emerges that has wider implications, such as COVID-19, a rapid review is helpful—when evidence is required within a short time frame for evidence-informed decision making, or in addressing a pressing health policy challenge.​

Read the first part of this story here​, where we speak to our Knowledge Translation Lead, Associate Professor James Alvin Low, on his experiences as Core Group member of GERI’s first knowledge exchange platform bringing together leaders and practitioners in Advance Care Planning across Singapore.