Evans et al.

Health Research Policy and Systems 2011, 9:42

http://www.health-policy-systems.com/content/9/1/42

RESEARCH

Open Access

Activating the knowledge-to-action cycle for

geriatric care in India
Jenna M Evans1*, Pretesh R Kiran2 and Onil K Bhattacharyya1,3

Abstract
Despite a rapidly aging population, geriatrics - the branch of medicine that focuses on healthcare of the elderly - is
relatively new in India, with many practicing physicians having little knowledge of the clinical and functional
implications of aging. Negative attitudes and limited awareness, knowledge or acceptance of geriatrics as a
legitimate discipline contribute to inaccessible and poor quality care for Indias old. The aim of this paper is to
argue that knowledge translation is a potentially effective tool for engaging Indian healthcare providers in the
delivery of high quality geriatric care. The paper describes Indias context, including demographics, challenges and
current policies, summarizes evidence on provider behaviour change, and integrates the two in order to propose
an action plan for promoting improvements in geriatric care.
Introduction: an aging India
The size of Indias older adult population is greater than
the total population of many developed and developing
countries. According to World Health Statistics 2011, 83
million persons in India are 60 years of age and older,
representing over 7% of the nations total population [1].
Over the next four decades, Indias demographic structure is expected to shift dramatically from a young to an
aging population resulting in 316 million elderly persons
by 2050 [2]. The aging population is a sign of successful
development in medical sciences and technology, living
standards, and education, but the elderly also raise
unique social, economic, and clinical challenges, including a growing demand for increasingly complex healthcare services. Chronic diseases now constitute the
leading cause of death and disability among Indias old
in both urban and rural areas [3,4].
Despite an aging population, geriatrics - the branch of
medicine that focuses on healthcare of the elderly - is
relatively new in India with many practicing physicians
having little knowledge of the clinical and functional
implications of aging [5,6]. According to the World
Health Organizations (WHO) multi-country study, Integrated Response of Health Systems to Rapidly Ageing
Populations, Indias old, their caregivers, and healthcare
* Correspondence: jenna.evans@utoronto.ca
1
Institute of Health Policy, Management and Evaluation, University of
Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6, Canada
Full list of author information is available at the end of the article

providers passively accept ill-health as part of old age

[7]. In fact, healthcare providers often view elderly
patients in a negative and mechanistic fashion [6].
Condemnatory attitudes and limited awareness, knowledge or acceptance of geriatrics as a legitimate discipline
can manifest in inaccessible or poor quality care. For
example, elderly persons in India often die from preventable conditions like bronchitis, asthma, and pneumonia
[8]. Indias old are hospitalized for an average of 32
days, often due to inadequate community-based health
and social support rather than ongoing acute needs [9].
This population takes an average of six prescription
drugs concurrently [10,11] and often suffer from adverse
drug reactions [12,13]. An absence of human and institutional capacity for geriatric care in the Indian healthcare system contributes to variations in morbidity and
access to care based on gender, location, and socioeconomic status [14].
Attitudes and practices that fail the elderly may be
reinforced by cultural values that reject long-term hospitalization of the old because it is viewed as a sign of disrespect; traditionally younger family members tend to
the needs of their elderly relatives. In a study of bedridden elderly patients in northern India, 82% of the primary caregivers were relatives and untrained hired help
was frequently sought [15]. Preventable medical complications like urinary tract infection and pressure ulcers
occurred in over 39% of patients, and caregivers
reported burn-out and need for respite [15]. Changes to

2011 Evans et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

Evans et al. Health Research Policy and Systems 2011, 9:42

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Indias economy are influencing the availability of informal care for the elderly. Urbanization and industrialization have resulted in increased migration of the young
to urban areas, improved female employment opportunities, and a shift in values towards commercialism and
individualism, all of which have contributed to lower
fertility rates, a breakdown in social support networks,
disintegration of families, and in turn fewer informal
caregivers [16,17]. At least 5% of elderly persons in both
urban and rural areas live alone [18]; some reports suggest that as many as 30% either have no family to live
with or are unable to reside with family members for
various reasons [19].
Dramatic demographic, social, and economic shifts in
India have created an urgent need for good quality medical and social care for the nations elders. However,
meeting the needs of an aging population in a resourceconstrained environment characterized by limited
awareness, knowledge, and research in geriatrics is challenging. Improved research production and knowledge
uptake - processes referred to collectively as knowledge
translation - can help determine how best to intervene.
Knowledge translation is defined as a dynamic and iterative process that involves the synthesis, dissemination,
exchange, and application of knowledge to improve
health status, provide more effective services, and
strengthen the healthcare system [20]. The aim of this
paper is to argue that knowledge translation is a potentially effective tool for engaging healthcare providers in
the delivery of accessible, high quality geriatric care in
India. The paper is divided into three sections: (1) Geriatric care in India, which describes the context, including demographics, challenges, and current policies and
perspectives; (2) Knowledge translation: a way forward?, which summarizes research on changing the
behaviour of healthcare providers from both general and
geriatric-specific viewpoints; and (3) Towards a knowledge translation action plan for India, which integrates
what we know about geriatric care in India with what
the literature on knowledge translation recommends.
The purpose of this paper is not to advocate for a specific intervention, but rather to argue for the potential
benefits of utilizing knowledge translation theories and
strategies to address the problem of poor quality geriatric care in India.

Geriatric care in India

India is a lower-middle income country with a gross
domestic product (GDP) per capita of $2,930 at purchasing power parity [21]. In recent years, health expenditure as a percentage of GDP has hovered around 4.2%
[21]. Private health spending accounts for more than
70% of all health spending, the majority of which is outof-pocket at the point of service [22]. Even though

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community-based health insurance schemes show promise, less than 20% of Indians have some form of health
insurance; nevertheless, a large portion of the population
choose to bypass free public services to pay out-ofpocket in private institutions [23-25]. Accessibility plays
a role in the preference for private care: most facilities
and providers operate in the private sector and public
health infrastructure is not evenly distributed across
Indias states. Both sectors face critical challenges. A
lack of staff, drugs, and equipment plague the public
system, while the private sector is largely unregulated
with serious complaints regarding poor quality of care
and unethical behaviour [24]. At least 36 million people
in India fall below the poverty line each year as a result
of healthcare costs [26]. Due to their financial dependence, elderly persons are among the most vulnerable.
Within the context of these issues, the country carries a
double disease burden of both non-communicable and
infectious illnesses [14]. However, government health
expenditure is slated to increase by 1% of GDP over the
next 5 years, which will provide additional resources to
address both sets of healthcare needs [27].
Although this paper adopts a broad perspective in
examining the status of geriatric care in India, the
nation consists of twenty-eight states and seven union
territories with considerable heterogeneity in demographics, disease burden, and healthcare coverage [2,28].
A state-specific discussion is beyond the scope of this
paper, but our analysis and recommendations incorporate consideration for local and regional differences.
Many aging faces

Indias elders, aged 60 and over, make important contributions to society not only via the formal workforce
(primarily in agriculture), but also in raising grandchildren, volunteering, caring for the sick, resolving conflict
and offering counsel, and translating experience, culture,
and religious heritage [7]. However, delivering quality
healthcare services to this population has proved challenging for a number of reasons. The elderly in India
are a heterogeneous population with variations in morbidity across several dimensions, gender, location and
socioeconomic status in particular, as well as great
diversity in cultures, religions, and languages. At least
65% of Indias old live in rural areas and are illiterate
and economically dependent [5,18]. Cardiovascular diseases, respiratory disorders, hearing and visual impairments, depression, and infections such as tuberculosis
are common [8]. Furthermore, this population is characterized by irregular utilization of healthcare services due
to inaccessibility, immobility, misconceptions, and poverty [14]. While some choose to self-medicate or use
home remedies, the majority report that they do not
seek treatment because their ailment is not serious

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(32-50%) or because of financial constraints (20-28%)

[18]. Healthcare utilization is greater among older adults
with higher levels of education, among those living in
urban rather than rural areas, and among those seeking
treatment for communicable rather than non-communicable diseases [18,28]. Non-compliance with treatment
plans and drug regimens is also an impediment to
managing the health of this population, resulting in an
estimated 8% of hospital admissions; the most commonly cited reasons for non-compliance include cost,
inadequate instruction, and switch to non-conventional
treatment [13]. The influence of cost constraints on
decisions to seek or continue treatment, as noted above,
highlights the fundamental role poverty plays in shaping
the health of Indias aging population. Any attempt to
improve the quality of geriatric care and outcomes in
India must address or account for these financial barriers to access. In fact, planners and policymakers
should take note of signs of gradual change, such as
increasing literacy levels and intergenerational distance
in interactions; in the future the elderly will demand
more financial, social and healthcare services than the
present generation [29].
Geriatric health services and providers

Although aging research in India is relatively new, the

Geriatric Society of India, the Indian Academy of Geriatrics, and the Association of Gerontology are established
institutions dedicated to the cause [30]. Unfortunately,
most members lack formal training in geriatrics [21].
Non-governmental organizations (NGOs) include HelpAge India, the Agewell Foundation, and the Dignity
Foundation, among others [7]. Government and social
policies for the elderly in India are also growing and
include old age pensions, the National Policy for Older
Persons (1999), the National Initiative on Care for the
Elderly (2004), and the Maintenance and Welfare of
Parents and Senior Citizens Act (2007). Despite the
importance of these initiatives in directing attention
towards the needs of the elderly, criticisms and challenges to implementation abound. Efforts across NGOs,
government, and provider organizations tend to be
uncoordinated, rely heavily on NGOs even though they
are not evenly distributed across India, and have been
described as wish lists that do not incorporate financial considerations or mechanisms for monitoring performance [31-33]. Others highlight the lack of attention
to gender differences and biases towards the needs of
those residing in urban areas and retiring from the formal work sector [33].
The most recent national policy effort is the National
Programme for the Health Care of the Elderly
(NPHCE), released in early 2011. Until now, healthcare
delivery options for geriatric care and associated

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knowledge and skill requirements have not been

accorded due attention. Health service organizations and
individual providers often fail to prioritize elderly
patients, do not provide continuity of care, and have
limited human and material resources to manage
chronic conditions [7]. Few facilities are dedicated
exclusively to geriatric care; those that are tend to be
concentrated in urban areas and are prohibitively expensive [6]. General hospitals lack the capacity to deliver
comprehensive geriatric care to the elderly [6] and
although some hospitals provide geriatric outpatient services, there are very few geriatric inpatient units even
though the Indian Council of Medical Research (ICMR)
states that the special needs of the elderly are best dealt
with by a geriatric unit with trained geriatricians and
nursing staff [34]. Furthermore, old-age homes, day-care
centres, and mobile medicare units number in the hundreds. These facilities are managed by NGOs or funded
partially by government, but tend to be urban based,
expensive, or focused on tertiary as opposed to primary
care, leaving many of Indias 83 million seniors without
appropriate healthcare [14,35]. Several indigenous systems of medicine also operate amidst the formal public
and private systems, and offer treatments which may be
more accessible, affordable or acceptable to the rural
elderly [36,37]. However, a recent study suggests that
graduates of indigenous medical programs often lack the
clinical training required to utilize diagnostic tools, conduct basic procedures, and handle primary care emergencies [38].
Indian researchers and experts, including the ICMR,
have reached consensus on the need to educate and
train healthcare providers in geriatrics, and to develop
gender-sensitive and rural-based geriatric services that
operate through the existing primary healthcare system
[5,7,14,29,39,40]. With a network of at least 2,000 community health centres and 22,000 primary health centres
in rural India, the infrastructure needed to deliver geriatric care exists, but the required human resource capacity does not. A WHO India project series on
community-based healthcare for the elderly confirms
this point [41]. The total number of physicians and
nurses in India is less than half the WHO benchmark of
25 workers per 10,000 population [42]. Many community-based facilities lack medical and paramedical personnel; for example 18% of primary health centres
function without a doctor and 16% without a pharmacist
[22]. Healthcare workers are unevenly distributed with
more workers practicing in southern states and in urban
areas than in northern states and rural areas [42]. Many
healthcare workers - both informal and formal - have
no medical training [42]. In order to improve geriatric
care, India needs a national human resource policy to
address issues of provider shortages, distribution,

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education, and quality [42] as well as training opportunities to sensitize healthcare workers to the aging process [7,40]. Community volunteers and medical,
paramedical, and indigenous providers must be trained
to identify issues common among elderly patients, to
conduct comprehensive surveys of morbidity and functional status, and to engage in capacity-building of geriatric services in local communities [5,41]. In hospitals,
collaborative training among physicians, psychiatrists,
nurses, dentists, urologists, and other professionals can
foster multi-disciplinary approaches to geriatric care [5].
Unfortunately, there are few opportunities for geriatric
knowledge-building and formal training in India. Only
one of the countrys 206 medical colleges, Madras Medical College, has a full-time geriatric MD program. Indira
Gandhi National Open University offers a one-year parttime Post-Graduate Diploma in Geriatric Medicine with
4-weeks of practical training to doctors working in different streams of medicine. Increasing the availability of
specialized education and training opportunities in geriatrics is important considering the inadequacy of general healthcare programs in raising awareness of issues
related to healthy aging. In a recent study of senior-level
students from medical, nursing, and social work colleges
in India, about 50% were unaware of policies relating to
the health and well-being of the elderly and none of the
students demonstrated recognition of the clinical and
functional implications of aging [43].
The NPHCE seeks to address many of the identified
gaps in institutional and human capacity for the provision of good quality geriatric care. Compared to previous policy-driven attempts at change - most notably
the National Policy on Older Persons - the NPHCE is
more action and results-oriented. The program aims to
provide accessible, affordable, and high-quality long
term, comprehensive and dedicated services to an aging
population by (1) expanding infrastructure to include
Regional Geriatric Centres, geriatric units in district
hospitals, and community-based geriatric clinics; (2)
establishing specialized geriatric training programs and
research institutes; and (3) utilizing mass media to educate the public [44]. The NPHCE outlines the source,
purpose, and flow of funds; the responsibilities and
inter-dependencies of various players at the national,
regional, and local levels; and requirements for staff mix
as well as data collection and reporting. In accordance
with expert opinion, the program also promotes strong
inter-organizational linkages and referral mechanisms as
well as training and support for informal caregivers [7].
The level of detail promotes a standardized approach to
implementation which will help improve the consistency
of service availability and quality. However, the NPHCE
may also be viewed negatively as a top-down initiative
that leaves little room for adaptation based on local

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needs and preferences [45]. That being said, states will

have the flexibility to shift up to 10% of allocated funds,
and will take over responsibility from the central government once units are fully functional. The program is
being implemented in phases beginning with 100 districts in 21 of Indias 28 states.
Summary

The literature on geriatric care in India summarizes

demographic trends, the medical and socioeconomic
problems among the elderly, general provider characteristics, contextual considerations, and suggestions for
improvement with a particular emphasis on education
and training as well as building on Indias existing primary healthcare system. In general, the literature
reviewed adequately answers the what and the why
of aging and poor geriatric care in India, but more
research is needed to understand how to instigate
improvements. For example, while many papers contain
descriptive or normative discussions from knowledgeable authors, little empirical research exists to support
their recommendations.

Knowledge translation: a way forward?

Knowledge Translation (KT) is the scientific study of the
methods for closing the knowledge-to-practice gap and
the analysis of barriers and facilitators inherent in this
process. KT is based on the premise that quality of care
and patient outcomes improve when research findings
are translated into practice. However, KT is not only
about translating and utilizing evidence, but also about
the process of producing knowledge. Graham et al.s
[20] conceptual framework for KT synthesizes several
international frameworks and was adopted by the Canadian Institutes for Health Research. The defining feature
of the framework is that it captures both the knowledge
creation and action components of the knowledge-toaction cycle. Knowledge creation consists of research
inquiry, the synthesis of evidence, and the production of
knowledge-based tools and products, such as clinical
practice guidelines. The action cycle consists of problem
identification, adaptation of the knowledge to the context, implementation of the intervention, evaluation, and
sustaining changes. KT differs from continuing medical
education (CME) in that CME focuses on enhancing
clinical competence and maintaining certification,
whereas KT involves broader activities and goals including behaviour change and improved health outcomes
[46]. KT can also involve other stakeholders including
policymakers, researchers, community members, managers, and patients, in addition to clinicians.
While Graham et al.s [20] framework provides an
overview of KT, a model designed by Farkas et al. [47]
provides an examination of specific KT strategies aimed

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at improving elder care. Interventions operate at four

levels: the individual health professional, healthcare
teams, organizations providing healthcare, and healthcare systems. Farkas and her colleagues are interested in
instigating change at the individual level. As such they
identify three target populations: researchers, providers
and administrators, and consumer and families. They
outline four strategies and their corresponding goals: (1)
exposure (to increase knowledge), (2) experience (to
increase knowledge and positive attitudes), (3) expertise
(to increase competence) and (4) embedding (to increase
utilization over time). Under each strategy are a variety
of KT interventions that can be used to achieve the corresponding goals depending on the audience of interest.
Exposure strategies are the most passive methods of dissemination and for providers include activities like reading publications, participating in conferences, and
accessing web-based resources. The strategies become
increasingly complex from experience to embedding and
involve provider-centered KT interventions such as
mentorship, practice visits, training programs, supervision, technical assistance, and feedback tools. The
micro-level perspective of the Farkas et al. framework,
which helps us identify problems, clarify goals, and
select appropriate interventions complements the
broader knowledge-to-action framework presented by
Graham and colleagues, which outlines the steps we
need to take to introduce and sustain change [20,47].
State of the evidence

Most developed countries are farther along in the demographic transition than developing countries; this creates
a practical learning opportunity for countries slated to
become aging nations like India and China. Even in
the US few opportunities exist for medical students and
physicians to receive geriatric training; as a result many
professionals are poorly skilled in caring for older adults
unique needs [48]. Physicians in the US experience difficulty in caring for the elderly because of administrative
burden, medical complexity, and interpersonal challenges; researchers suggest that changes in the care
delivery system and medical education are required [49].
KT can help facilitate evidence-based change across various systems grappling with the problem of poor geriatric care.
There is a wide range of KT interventions targeting
providers, organizations and health systems, such as
interactive educational sessions, audit and feedback,
reminders, and pay for performance. In addition, interventions can be patient or family mediated, technology
enabled, or multi-faceted, combining 2 or more modalities. Reviews of KT interventions consistently demonstrate moderate improvements in care in high, middle,
and low-income settings [50-54]. For example, in a

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systematic review of 102 interventions, practice visits,

patient-mediated interventions, and multi-faceted interventions were effective; audit and feedback and reminders produced mixed results; and educational materials,
conferences, and workshops had no impact [53]. Similarly, in low-resource settings the simple dissemination
of written guidelines is often ineffective, but audit and
feedback as well as multifaceted interventions are generally effective [55]. Although reviews from developing
countries sometimes reach different conclusions from
reviews of studies in wealthier settings [55], performance
feedback and educating patients were also successful in
changing the knowledge, attitudes, and/or behaviours of
providers in the US [56]. In general, these studies suggest that single methods with no additional follow-up
fail to effect change.
Unfortunately very few KT papers address geriatric
care; those that do hail from the developed world and
tend to focus exclusively on CME [47,56,57]. A recent
scoping review found a scarcity of KT literature pertaining to geriatric care; out of 53 systematic reviews of KT
research, only two focused on KT in the care of older
adults [58]. These two reviews found that KT can influence physician behaviour and patient outcomes particularly when multifaceted interventions are utilized.
KT research and practice is often narrow in scope,
targeting a specific clinical setting or group of providers.
However, KT can also be an effective tool for promoting
changes on a larger scale. In fact there is increasing support for KT at international and national levels. Two
examples include the WHOs Evidence-Informed Policy
Networks (EVIPNET) currently active in Asia, Africa,
and the Americas, and the Regional East African Community Health (REACH) Policy Initiative [59,60]. Collaborative KT interventions that involve multiple
stakeholders, such as these, enhance the probability of
large-scale evidence-informed changes in low-resource
settings [61,62].
KT for geriatric care in India

There are five key reasons why KT may be an effective

tool for improving the quality of geriatric care in India.
First, as demonstrated above, evidence suggests that KT
can improve quality of care, in part, by changing the
behaviors of providers. Despite a lack of geriatric KT
research within India, unpublished data reveal an
increase in physician confidence in elder care after a
one-year geriatric training program at the Indira Gandhi
National Open University [31]. Second, local evidence
suggests gaps in the production, translation, and uptake
of knowledge. For example, several authors advocate for
the development of geriatric education, training, and
research programs in India [5,30,39,63]. It has also been
reported that research findings with implications for the

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welfare of the elderly never reach Indian healthcare providers, caregivers, or policymakers [30]. Therefore, one
of the many barriers to improvements in geriatric care
in India appears to be a lack of adequate KT. Third, a
KT approach aligns with expert consensus in India by
including geriatric education and training efforts. However, KT also goes beyond these traditional methods of
instigating change from within the classroom. This is
important because poor performance is not always the
result of a lack of knowledge or skills [64]. For example,
providers often feel pressure from patients and communities to provide inappropriate treatments. KT acknowledges these contextual factors and promotes the
targeting of multiple stakeholders. Furthermore, some
scholars advocate for an elder care model that emphasizes a family and community care system [16,65]. A KT
perspective is in line with this proposition. Successful
KT requires attention to all relevant stakeholders; in
India, both formal and informal caregivers are of interest. In a resource-constrained, family-oriented environment, the role of informal caregivers cannot be
overlooked. Fourth, a geriatric KT strategy can
strengthen and extend the recently initiated NPHCE.
Previous national efforts to improve elder care have
been criticized for not being implemented universally or
effectively. Considering that much of the NPHCE
focuses on capacity-building through education, training,
and research, KT frameworks and methods are relevant
and may increase the probability of successful implementation and sustainable improvements. Finally, in the
near future the case for shifting more resources to geriatric care and chronic disease will intensify. According to

Users: Healthcare Providers

Objective(s)
Exposure
Experience
Expertise
Embedding

9 Private or public sector

9 Geriatric knowledge and skills
9 Attitudes and beliefs towards elderly
9 Expectations/perception of elder needs
9 Work habits
9 Peer influence
9 Access to resources
9 Perceptions of constraints
9 Intention/motivation to change

the Disease Control Priorities Project in India, it is estimated that 1 million lives could be saved using interventions targeted at non-communicable illnesses like
cardiovascular disease and cancer [27]. The costs associated with addressing these growing needs are within
the projected increases in health spending planned by
the Indian government [27]. As the number of elderly
persons continues to increase and as India experiences
unprecedented economic growth the demand for high
quality geriatric care, including chronic disease management, will escalate.

Towards a knowledge translation action plan for

India
Five key questions must be addressed in order to initiate
action in KT [12]: (1) What should be disseminated?, (2)
To whom?, (3) By whom?, (4) How should it be disseminated?, and (5) What is the potential impact? Figure 1
illustrates the answers to many of these questions and
depicts areas where more research is needed (symbolized by question marks) as well as the pathway from
objectives to anticipated outcomes.
What should be disseminated?

Research evidence from the fields of geriatrics and gerontology need to be disseminated to Indias healthcare
providers. Geriatrics is the study of health and disease
in later life and emphasizes comprehensive care for
older persons as well as the well-being of their caregivers. Gerontology is the study of the aging process
and involves the study of the physical, mental, and social
changes that occur as people age. The production,

Knowledge Translation
Interventions

Audit and Feedback (control)

Remuneration (operant conditioning)
Self-Evaluation (control)

Delivery Context: India

9 Bimodal mortality profile
9 Low-income, high rates of poverty
9 Heterogeneous elder population
9 High illiteracy rates among elderly
9 Indigenous health systems
9 Preference for private healthcare
9 Traditional family values
9 Disparities based on socioeconomic status,
gender, age and location
9 Little monitoring and regulatory
enforcement capacity
9 National Programme for the Health Care
of the Elderly (2011)

Supervision and Practice Visits (social

cognitive, control)
Education and Training (social cognitive,
information motivation behavioral skills
(IMBS), etc.)
Job Aids (operant conditioning)
Community of Practice
(social comparison, social support)

Patient/Family-Mediated Interventions
(reasoned action, planned behavior, IMBS)
Combination of Interventions

Figure 1 Towards an Action Plan for Geriatric Knowledge Translation in India.

Anticipated Outcome(s)
Reaction
Learning
Behavior
Impact

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dissemination and sharing of knowledge from both fields

are required in order for healthcare providers to deliver
high quality services to Indias elderly. In the context of
a poverty-stricken population, best practices must be
identified and applied with consideration for financial
barriers that may prevent some elderly patients from
seeking and complying with treatment, lifestyle, and
medication regimens.
In planning dissemination efforts, it is important to
begin by clarifying goals. As described above and
depicted in Figure 1, exposure, experience, expertise, and
embedding constitute four distinct and increasingly complex KT objectives [47]. Considering reports that suggest
low knowledge and awareness of the clinical and functional implications of aging among Indias providers, it is
appropriate to initiate KT work in the areas of exposure
and experience, but to build a plan for incorporating
more complex strategies associated with expertise and
embedding, such as providing performance feedback and
developing communities of practice. Furthermore, the
variability in cost and effect of KT interventions and our
lack of data on overall cost-effectiveness make an incremental approach with an initial focus on exposure and
experience strategies a prudent first step.
To whom should it be disseminated?

Although the target recipients of KT efforts can span

multiple stakeholder groups, this paper focuses primarily
on formal healthcare providers, which includes doctors,
nurses, community workers like home health assistants
and paramedicals, and even those with formal training in
traditional systems of medicine such as Ayuverda, Yoga,
Unani, Sidda, and Homeopathy (AYUSH). Figure 1 outlines some of the user group characteristics that we need
to better understand as well as contextual factors. Models
of provider behaviour can be used as a supplement;
Brugha and Zwi [64], for example, outline considerations
regarding national context; needs, expectations, and
social environment; provider knowledge and attitudes;
and patient-provider interactions as well as potential KT
interventions at the community and policy levels.
By whom should it be disseminated?

Indias geriatric KT initiatives can be planned, organized,

and implemented jointly by national and state governments using the structures and relationships established
through the NPHCE. For example, the NPHCE calls for
the appointment of liaisons to manage relationships
among various layers of government and service organizations. These individuals could take on responsibilities
similar to those of a knowledge broker by facilitating
information flow and awareness of relevant research evidence across multiple stakeholder groups [62]. Other
entities involved in elder care such as the Geriatric

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Society of India, the Indian Academy of Geriatrics, the

Association of Gerontology, the ICMR, and NGOs such
as HelpAge India should also be included in KT efforts;
their expertise, networks, and resources can be used to
support KT across organizational, professional, and political boundaries.
Considering the heterogeneity in demographics, disease burden, and healthcare coverage across states, there
will be no one size fits all intervention for geriatric
care improvement. Therefore collaborative approaches
that promote a balance between standardization of KT
methods and content, and flexibility for local adaptation
are essential. A national human resource policy to
improve the availability, distribution, education, and
quality of healthcare providers is fundamental to the
success and sustainability of these efforts.
How should it be disseminated?

Many methods exist for transferring knowledge; the

most common are listed in Figure 1 along with their
associated theories [66]. It is important to link methods
with theory so that interventions can be designed
around an existing body of knowledge. We lack information regarding which factors influence the effectiveness of different interventions; the use of theory in the
development and implementation of KT interventions
will allow for more accurate interpretations of why certain methods have positive or negative effects [67,68].
Based on the available evidence, education and training
methods must be used in combination with KT strategies that promote active-mode learning and application
[50-53,55-57]. In particular, social interaction methods,
such as communities of practice and frequent contact
with a supervisor, mentor, knowledge broker, or opinion
leader show promise. However, most behavioural interventions have been developed for use with individuals
motivated to seek help [67]; thus, for healthcare providers lacking the desire to change, KT strategies that target the patient and caregiver or broader organizational
or system environment may also be required. Both
options are already underway in India. The NPHCE
details several organizational and system-level changes
to healthcare delivery, and incorporates education efforts
via mass media and home visits to build capacity for
informal and self care. These strategies address the problem of limited knowledge and awareness from multiple
perspectives, and can help support provider behaviour
change.
The targeted healthcare providers will have varied
levels of knowledge and skill in geriatrics and gerontology, and potentially divergent views of elder care,
depending on their role, setting, training, and past
experiences [67]. KT is a user-focused endeavour in
which both the content and the method must be

Evans et al. Health Research Policy and Systems 2011, 9:42

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tailored to the needs, capabilities, and contexts of different stakeholder groups. In order to undertake this process effectively, the geriatric-related knowledge, skills,
attitudes, beliefs, and perceptions of various healthcare
providers in India need to be better understood, as
depicted in Figure 1. In addition to being developed
with consideration for provider characteristics and the
factors that influence provider behaviour, KT interventions to improve geriatric care in India must also be
context-specific and inexpensive in order to offer sustainable benefits to patients and their families.
With what effect should it be disseminated?

Expected outcomes of KT interventions are divided into

four levels of evaluation [69]: (1) Reactions are measures
of participant views of the intervention, including satisfaction, level of participation, attitude, and confidence;
(2) Learnings are measures of what the participants have
learned from the intervention, including intention to
apply learning or change practice; (3) Behaviours are
measures of whether new knowledge is being applied in
practice; and (4) Impacts are measures of change in
individual or organizational performance measures, and/
or change in patient outcomes. Although measurement
and reporting requirements are included in the NPHCE,
the focus is on monitoring implementation in terms of
physical progress and financial targets. Systematically
collecting information using a set of indicators from
each of the four levels of evaluation outlined above will
offer additional insights into whether the program is
having the desired impact on human capacity and
patient outcomes. Successful infrastructure development
and program implementation are not ends in themselves; they are means to an end. Performance measurement must therefore reflect other outcomes such as
provider behaviour change and the ultimate goal of
improved quality of care for the elderly.
Knowledge Production

Although KT research often focuses on the action cycle,

the knowledge creation cycle precedes action and
requires particular attention in India. Proven techniques
and approaches can be borrowed from around the
world, but their value in India is questionable. There is
a need for more research on cost-effective approaches
to elder care from within the Indian context [5,16].
India has already reduced the cost of heart and cataract
surgeries to 10% of the cost in the US [70]; similar frugal innovations may make geriatric care more broadly
available, affordable, and appropriate.
The NPHCE proposes the establishment of Regional
Geriatric Centres (RGCs) at each of the eight existing
Regional Medical Institutes in India. In addition to providing tertiary services, the RGCs will offer continuing

Page 8 of 10

education and training programs, and will conduct

research in geriatrics and gerontology to develop evidence-based service and treatment protocols. Funds for
these activities are available from a grant under the
NPHCE as well as from national and international
agencies.
Areas of elder research that have been well-covered in
India include caregiving, social supports, demographic
changes, widowhood, and intergenerational interactions
whereas mental health, elder abuse, health behaviours,
and human resource issues require further attention
[30]. The three basic functions of aging research are: (1)
to provide basic data on the overall status and needs of
the elderly, (2) to understand what constitutes good
quality of life for the elderly, and (3) to formulate, execute, and evaluate appropriate interventions to improve
elder care [30]. Evaluation is of particular importance
because KT intervention evaluations in low-and-middle
income countries tend to be less rigorous [64] and
because the ability to pay for KT efforts is lower in
these contexts, their value must be demonstrated. Many
initiatives in India have potential for widespread use, or
at the very least can contribute to learning, but they
need to be systematically documented, monitored, and
assessed. A systematic approach to knowledge production and translation requires a common language and
understanding of the purpose and process of KT among
designers, adopters, and reviewers. A common framework and language is important because they help
researchers replicate studies and determine how intervention content influences effectiveness. Ideally
researchers should report on all of the following aspects
of any given intervention: content or elements of the
intervention, characteristics of those delivering the intervention, characteristics of the recipients, the setting, the
mode of delivery, the intensity and duration of the intervention, and adherence to the delivery protocols [66].

Conclusions
As a result of dramatic demographic, social, and economic shifts, Indias growing elderly population needs
high quality medical and social care. However, current
literature suggest that negative attitudes, and limited
awareness, knowledge, and acceptance of geriatrics as a
legitimate discipline result in inaccessible and poor quality care for Indias old. Competing demands, the large
numbers requiring support, and resource availability
remain important challenges. Improved research production and knowledge uptake in geriatrics and gerontology are required. KT is a promising tool for engaging
healthcare providers in the delivery of high quality geriatric care.
Indias NPCHE sets the foundation for a comprehensive, long-term geriatric KT strategy. Many of the

Evans et al. Health Research Policy and Systems 2011, 9:42

http://www.health-policy-systems.com/content/9/1/42

necessary building blocks for effective KT are now in

development, including the expansion of infrastructure,
education and training of healthcare providers and
informal caregivers, and the development of geriatric
research institutes. The NPHCE offers an unprecedented
opportunity in India to improve elder care and prepare
for the future needs of an aging population. This paper
argues that we can enhance the probability of success
and impact of the NPHCE through the development of
a geriatric KT action plan that incorporates and applies
theories, frameworks, and evidence for activating the
knowledge-to-action cycle.

Page 9 of 10

12.

13.

14.
15.

16.
17.

Acknowledgements
Jenna M. Evans holds a Vanier Canada Graduate Scholarship and is a Fellow
with the Health System Performance Research Network.

18.

19.
Author details
1
Institute of Health Policy, Management and Evaluation, University of
Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6, Canada.
2
Department of Community Health, St. Johns Medical College, Sarjapur
Road, Bangalore 560034, India. 3Li Ka Shing Knowledge Institute, 30 Bond
Street, First Floor, Toronto, ON M5B 1W8, Canada.

20.

21.
22.

Authors contributions
JE constructed the first draft of the manuscript with subsequent inputs and
revisions from OB and PK. All authors read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.

23.

24.
25.

Received: 24 January 2011 Accepted: 2 December 2011

Published: 2 December 2011
26.
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doi:10.1186/1478-4505-9-42
Cite this article as: Evans et al.: Activating the knowledge-to-action
cycle for geriatric care in India. Health Research Policy and Systems 2011
9:42.

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