Understanding mental health and its determinants from the perspective of adolescents: A qualitative study across diverse social settings in Indonesia.

Poor mental health is a leading contributor to the burden of disease experienced by adolescents, including in resource constrained settings. However, little is known about how adolescents in these countries conceptualise mental health and its determinants which is essential to informing effective responses. This study aimed to explore how adolescents in Indonesia (a populous and rapidly developing country) conceptualise mental health and what they identify as important determinants. Eight focus group discussions (FGDs) were conducted with 86 Indonesian adolescents (aged 16-18 years), sampled from schools and community settings from Jakarta and South Sulawesi. FGDs were recorded, transcribed, translated and thematically analysed. Mental health was recognised as a significant concern by adolescents in Indonesia. Good mental health was conceptualised as emotional wellbeing and happiness. By contrast, poor mental health was predominantly described in terms of substantial mental illness manifesting as behavioural and physical disturbance. Further, poor mental health only happened to 'other' people, with stigmatising views prevalent. Absent from the discussions were common symptoms of poor mental health (stress, loneliness, poor sleep) and common mental disorders (e.g. depression, anxiety) or a conceptualisation that reflected poor mental health to be a normal human experience. Discussions around determinants of poor mental health suggested that family connections (particularly with parents), school pressures, and adverse exposures on social media were important drivers of poor mental health, with religion also surfacing as an important determinant. In highlighting mental health as an important issue for Indonesian adolescents, this study provides a foundation for targeted responses.

Direct assessment of mental health and metabolic syndrome amongst Indonesian adolescents: a study design for a mixed-methods study sampled from school and community settings.

Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality globally, with the burden largely borne by people living in low- and middle-income countries. Adolescents are central to NCD control through the potential to modify risks and alter the trajectory of these diseases across the life-course. However, an absence of epidemiological data has contributed to the relative exclusion of adolescents from policies and responses. This paper documents the design of a study to measure the burden of metabolic syndrome (a key risk for NCDs) and poor mental health (a key outcome) amongst Indonesian adolescents. Using a mixed-method design, we sampled 16-18-year-old adolescents from schools and community-based settings across Jakarta and South Sulawesi. Initial formative qualitative enquiry used focus group discussions to understand how young people conceptualise mental health and body weight (separately); what they perceive as determinants of these NCDs; and what responses to these NCDs should involve. These findings informed the design of a quantitative survey that adolescents self-completed electronically. Mental health was measured using the Centre for Epidemiologic Studies Depression Scale-Revised (CESD-R) and Kessler-10 (both validated against formal psychiatric interview in a subsample), with the metabolic syndrome measured using biomarkers and anthropometry. The survey also included scales relating to victimisation, connectedness, self-efficacy, body image and quality of life. Adolescents were sampled from schools using a multistage cluster design, and from the community using respondent-driven sampling (RDS). This study will substantially advance the field of NCD measurement amongst adolescents, especially in settings like Indonesia. It demonstrates that high quality, objective measurement is acceptable and feasible, including the collection of biomarkers in a school-based setting. It demonstrates how comparable data can be collected across both in-school and out of school adolescents, allowing a more comprehensive measure of NCD burden, risk and correlates.

Screening for depressive and anxiety disorders among adolescents in Indonesia: Formal validation of the centre for epidemiologic studies depression scale - revised and the Kessler psychological distress scale.

BACKGROUND: This study aimed to culturally verify and examine the empirical psychometric properties of the Indonesian versions of the Centre for Epidemiologic Studies Depression Scale - Revised (CESD-R), the Kessler Psychological Distress Scale - 10 items (K10) and a subset of 6 items of the K10, the K6 to detect depressive and anxiety disorders among older adolescents in Indonesia. METHODS: The empirical psychometric properties were examined formally among students aged 16-18 years attending high schools in Jakarta. The scales were validated against the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-Kid) modules for major depressive episode, dysthymia, panic disorder, separation anxiety disorder, and generalized anxiety disorder. RESULTS: In total, 196 students contributed complete data. All of the scales had Cronbach's alpha >0.8. The areas under the ROC Curve of CESD-R against MINI depressive disorders and K10/K6 against MINI depressive and anxiety disorders were at moderate to high accuracy levels (0.78 to 0.86). The optimal cut-off value of CESD-R (scores ranging: 0-60) to screen for any depressive disorder is ≥20 (sensitivity 75.0%; specificity 79.9%). The optimal cut-off value of K10 to detect any depressive/anxiety disorders is ≥18 (sensitivity 85.7%; specificity 74.7%); and K6 is ≥12 (sensitivity 81.0%; specificity 76.6%); LIMITATIONS: The school-based sample limits the generalisability of the findings to this group. CONCLUSIONS: This study suggests that the CESD-R I is a useful tool for screening for depressive disorders and both the K10 I and K6 I are useful for screening for any depressive or anxiety disorders among Indonesian adolescents.

Incidence of unintended pregnancy among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis.

OBJECTIVES: To determine the incidence of unintended pregnancy among female sex workers (FSWs) in low-income and middle-income countries (LMICs). DESIGN: We searched MEDLINE, PsychInfo, Embase and Popline for papers published in English between January 2000 and January 2016, and Web of Science and Proquest for conference abstracts. Meta-analysis was performed on the primary outcomes using random effects models, with subgroup analysis used to explore heterogeneity. PARTICIPANTS: Eligible studies targeted FSWs aged 15-49 years living or working in an LMIC. OUTCOME MEASURES: Studies were eligible if they provided data on one of two primary outcomes: incidence of unintended pregnancy and incidence of pregnancy where intention is undefined. Secondary outcomes were also extracted when they were reported in included studies: incidence of induced abortion; incidence of birth; and correlates/predictors of pregnancy or unintended pregnancy. RESULTS: Twenty-five eligible studies were identified from 3866 articles. Methodological quality was low overall. Unintended pregnancy incidence showed high heterogeneity (I²>95%), ranging from 7.2 to 59.6 per 100 person-years across 10 studies. Study design and duration were found to account for heterogeneity. On subgroup analysis, the three cohort studies in which no intervention was introduced had a pooled incidence of 27.1 per 100 person-years (95% CI 24.4 to 29.8; I2=0%). Incidence of pregnancy (intention undefined) was also highly heterogeneous, ranging from 2.0 to 23.4 per 100 person-years (15 studies). CONCLUSIONS: Of the many studies examining FSWs' sexual and reproductive health in LMICs, very few measured pregnancy and fewer assessed pregnancy intention. Incidence varied widely, likely due to differences in study design, duration and baseline population risk, but was high in most studies, representing a considerable concern for this key population. Evidence-based approaches that place greater importance on unintended pregnancy prevention need to be incorporated into existing sexual and reproductive health programmes for FSWs. PROSPERO REGISTRATION NUMBER: CRD42016029185.

Economic evaluation of a randomized controlled trial of an intervention to reduce office workers' sitting time: the "Stand Up Victoria" trial.

Objectives This study aimed to assess the economic credentials of a workplace-delivered intervention to reduce sitting time among desk-based workers. Methods We performed within-trial cost-efficacy analysis and long-term cost-effectiveness analysis (CEA) and recruited 231 desk-based workers, aged 24-65 years, across 14 worksites of one organization. Multicomponent workplace-delivered intervention was compared to usual practice. Main outcome measures including total device-measured workplace sitting time, body mass index (BMI), self-reported health-related quality of life (Assessment of Quality of Life-8D, AQoL-8D), and absenteeism measured at 12 months. Results Compared to usual practice, the intervention was associated with greater cost (AU$431/person), benefits in terms of reduced workplace sitting time [-46.8 minutes/8-hour workday, 95% confidence interval (CI): -69.9- -23.7] and increased workplace standing time (42.2 minutes/8-hour workday, 95% CI 23.8-60.6). However, there were no significant benefits for BMI [0.148 kg/m 2(95% CI-1.407-1.703)], QoL-8D [-0.006 (95% CI -0.074-0.063)] and absenteeism [2.12 days (95% CI -2.01-6.26)]. The incremental cost-efficacy ratios (ICER) ranged from AU$9.94 cost/minute reduction in workplace sitting time to AU$13.37/minute reduction in overall sitting time. CEA showed the intervention contributed to higher life year (LY) gains [0.01 (95% CI 0.009-0.011)], higher health-adjusted life year (HALY) gains [0.012 (95% CI 0.0105 - 0.0135)], and higher net costs [AU$344 (95% CI $331-358)], with corresponding ICER of AU$34 443/LY and AU$28 703/HALY if the intervention effects were to be sustained for five-years. CEA results were sensitive to assumptions surrounding intervention-effect decay rate and discount rate. Conclusions The intervention was cost-effective over the lifetime of the cohort when scaled up to the national workforce and provides important.

Associations of occupational standing with musculoskeletal symptoms: a systematic review with meta-analysis.

OBJECTIVE: Given the high exposure to occupational standing in specific occupations, and recent initiatives to encourage intermittent standing among white-collar workers, a better understanding of the potential health consequences of occupational standing is required. We aimed to review and quantify the epidemiological evidence on associations of occupational standing with musculoskeletal symptoms. DESIGN: A systematic review was performed. Data from included articles were extracted and described, and meta-analyses conducted when data were sufficiently homogeneous. DATA SOURCES: Electronic databases were systematically searched. ELIGIBILITY CRITERIA: Peer-reviewed articles on occupational standing and musculoskeletal symptoms from epidemiological studies were identified. RESULTS: Of the 11 750 articles screened, 50 articles reporting 49 studies were included (45 cross-sectional and 5 longitudinal; n=88 158 participants) describing the associations of occupational standing with musculoskeletal symptoms, including low-back (39 articles), lower extremity (14 articles) and upper extremity (18 articles) symptoms. In the meta-analysis, 'substantial' (>4 hours/workday) occupational standing was associated with the occurrence of low-back symptoms (pooled OR (95% CI) 1.31 (1.10 to 1.56)). Evidence on lower and upper extremity symptoms was too heterogeneous for meta-analyses. The majority of included studies reported statistically significant detrimental associations of occupational standing with lower extremity, but not with upper extremity symptoms. CONCLUSIONS: The evidence suggests that substantial occupational standing is associated with the occurrence of low-back and (inconclusively) lower extremity symptoms, but there may not be such an association with upper extremity symptoms. However, these conclusions are tentative as only limited evidence was found from high-quality, longitudinal studies with fully adjusted models using objective measures of standing.

The experiences of patients with advanced cancer and caregivers presenting to Emergency Departments: A qualitative study.

BACKGROUND: Despite being a common event in the course of an advanced cancer illness, there is little understanding of patients' perceptions of hospital Emergency Department presentations. AIM: To explore the experiences and perceptions of Emergency Departments held by patients with advanced cancer and their informal caregivers. DESIGN: Cross-sectional study involving semi-structured interviews with advanced cancer patients and their informal caregivers. Qualitative data analysis was underpinned by a phenomenological approach utilising a data-driven inductive thematic frame. SETTING/PARTICIPANTS: In total, 19 patients with advanced cancer who presented to Emergency Departments in the previous 6 months and 10 informal caregivers from an Australian public hospital and community palliative care service were interviewed. RESULTS: Patients reported that Emergency Department presentations were largely prompted by worsening symptoms or were a means to expedite hospital admission, with many instructed to attend by their health care provider. The experience in the Emergency Department was described as a time of anxiety and uncertainty with concerns over communication, the general environment and delays in the symptom management highlighted. Long waits were common. Despite this, patients described relief at receiving care. While the Emergency Department was viewed as a safety net for the health system, many believed advanced cancer patients should have alternative options. CONCLUSION: Relatively simple changes of regular communication updates and early symptom relief would improve patient experience of Emergency Department care. However, since an Emergency Department presentation is frequently serving as a default to access medical care, a significant re-orientation of the health care system is required to meet patient needs.

Associations of prolonged standing with musculoskeletal symptoms-A systematic review of laboratory studies.

While prolonged standing has shown to be detrimentally associated with musculoskeletal symptoms, exposure limits and underlying mechanisms are not well understood. We systematically reviewed evidence from laboratory studies on musculoskeletal symptom development during prolonged (≥20min) uninterrupted standing, quantified acute dose-response associations and described underlying mechanisms. Peer-reviewed articles were systematically searched for. Data from included articles were tabulated, and dose-response associations were statistically pooled. A linear interpolation of pooled dose-response associations was performed to estimate the duration of prolonged standing associated with musculoskeletal symptoms with a clinically relevant intensity of ≥9 (out of 100). We included 26 articles (from 25 studies with 591 participants), of which the majority examined associations of prolonged standing with low back and lower extremity symptoms. Evidence on other (e.g., upper limb) symptoms was limited and inconsistent. Pooled dose-response associations showed that clinically relevant levels of low back symptoms were reached after 71min of prolonged standing, with this shortened to 42min in those considered pain developers. Regarding standing-related low back symptoms, consistent evidence was found for postural mechanisms (i.e., trunk flexion and lumbar curvature), but not for mechanisms of muscle fatigue and/or variation in movement. Blood pooling was the most consistently reported mechanism for standing-related lower extremity symptoms. Evidence suggests a detrimental association of prolonged standing with low back and lower extremity symptoms. To avoid musculoskeletal symptoms (without having a-priori knowledge on whether someone will develop symptoms or not), dose-response evidence from this study suggests a recommendation to refrain from standing for prolonged periods >40min. Interventions should also focus on underlying pain mechanisms.

Reducing occupational sitting: Workers' perspectives on participation in a multi-component intervention.

BACKGROUND: Office workers spend much of their time sitting, which is now understood to be a risk factor for several chronic diseases. This qualitative study examined participants' perspectives following their involvement in a cluster randomised controlled trial of a multi-component intervention targeting prolonged workplace sitting (Stand Up Victoria). The intervention incorporated a sit-stand workstation, individual health coaching and organisational support strategies. The aim of the study was to explore the acceptability of the intervention, barriers and facilitators to reducing workplace sitting, and perceived effects of the intervention on workplace culture, productivity and health-related outcomes. METHODS: Semi-structured interviews (n = 21 participants) and two focus groups (n = 7) were conducted with intervention participants at the conclusion of the 12 month trial and thematic analysis was used to analyse the data. Questions covered intervention acceptability, overall impact, barriers and facilitators to reducing workplace sitting, and perceived impact on productivity and workplace culture. RESULTS: Overall, participants had positive intervention experiences, perceiving that reductions in workplace sitting were associated with improved health and well-being with limited negative impact on work performance. While sit-stand workstations appeared to be the primary drivers of change, workstation design and limited suitability of standing for some job tasks and situations were perceived as barriers to their use. Social support from team leaders and other participants was perceived to facilitate behavioural changes and a shift in norms towards increased acceptance of standing in the workplace. CONCLUSIONS: Multi-component interventions to reduce workplace sitting, incorporating sit-stand workstations, are acceptable and feasible; however, supportive social and environmental conditions are required to support participant engagement. Best practice approaches to reduce workplace sitting should address the multiple levels of influence on behaviour, including factors that may act as barriers to behavioural change.

Effectiveness of an Integrated Community- and Clinic-Based Intervention on HIV Testing, HIV Knowledge, and Sexual Risk Behavior of Young Men Who Have Sex With Men in Myanmar.

PURPOSE: Young men who have sex with men (YMSM) in Myanmar are disproportionately affected by HIV, with prevalence five times that of the general population. The Link Up project implemented an intervention using peer education and outreach providing education and counseling on health seeking around sexually transmitted infections and reproductive health, combined with focused clinic capacity building to improve the sexual and reproductive health of YMSM. This study aimed to evaluate the effectiveness and acceptability of the intervention. METHODS: Using a mixed-methods approach, and employing a quasi-experimental design, we conducted two quantitative repeat cross-sectional surveys in purposively selected control (no intervention) and intervention townships, before and after implementation of the Link Up intervention. Respondent-driven sampling was used to recruit YMSM aged 15-24 years, and study participants were administered a structured questionnaire assessing intervention exposure, health service access, knowledge of HIV, and sexual risk behavior. Focus group discussions were held to elicit perspectives on the use and acceptability of the health services and peer outreach. RESULTS: At baseline, 314 YMSM were recruited in the intervention townships and 309 YMSM in the control townships. At end line, 267 (intervention) and 318 (control) YMSM were recruited. Coverage of the program was relatively low, with one-third of participants in the intervention townships having heard of the Link Up program by the end line. Comparing changes between baseline and end line, a greater proportion of HIV-negative or unknown status YMSM accessed HIV testing in the past 3 months in intervention townships (from 45.0% to 57.1%) compared with those in control townships (remained at 29.0%); however, this difference in the effect over time was not statistically significant in multivariate modeling (adjusted odds ratio: 1.45; 95% confidence interval: .66-3.17). Qualitative findings showed that the intervention was acceptable to YMSM. CONCLUSIONS: Overall, the intervention was perceived as acceptable. Although not statistically significant, results showed some trends toward improvements among YMSM in accessing HIV testing services and HIV-related knowledge. The modest coverage and short time frame of the evaluation likely limits the ability for any significant behavioral improvements.

Corrigendum to "Office workers' objectively assessed total and prolonged sitting time: Individual-level correlates and worksite variations" [Prev. Med. Rep. 4 (2016) 184-191].

[This corrects the article DOI: 10.1016/j.pmedr.2016.06.011.].

A Cluster Randomized Controlled Trial to Reduce Office Workers' Sitting Time: Effect on Activity Outcomes.

PURPOSE: This study aimed to evaluate the initial and long-term effectiveness of a workplace intervention compared with usual practice, targeting the reduction of sitting on activity outcomes. METHODS: Office worksites (≥1 km apart) from a single organization in Victoria, Australia, were cluster randomized to intervention (n = 7) or control (n = 7). Participants were 231 desk-based office workers (5-39 participants per worksite) working at least 0.6 full-time equivalent. The workplace-delivered intervention addressed organizational, physical environment, and individual behavioral changes to reduce sitting time. Assessments occurred at baseline, 3 months, and 12 months, with the primary outcome participants' objectively measured (activPAL3 device) workplace sitting time (minutes per 8-h workday). Secondary activity outcomes were workplace time spent standing, stepping (light, moderate to vigorous, and total), and in prolonged (≥30 min) sitting bouts (hours per 8-h workday); usual duration of workplace sitting bouts; and overall sitting, standing, and stepping time (minutes per 16-h day). Analysis was by linear mixed models, accounting for repeated-measures and clustering and adjusting for baseline values and potential confounders. RESULTS: At baseline, on average, participants (68% women; mean ± SD age = 45.6 ± 9.4 yr) sat, stood, and stepped for 78.8% ± 9.5%, 14.3% ± 8.2%, and 6.9% ± 2.9% of work hours, respectively. Workplace sitting time was significantly reduced in the intervention group compared with the controls at 3 months (-99.1 [95% confidence interval = -116.3 to -81.8] min per 8-h workday) and 12 months (-45.4 [-64.6 to -26.2] min per 8-h workday). Significant intervention effects (all favoring intervention) were observed for standing, prolonged sitting, and usual sitting bout duration at work, as well as overall sitting and standing time, with no significant or meaningful effects observed for stepping. CONCLUSIONS: This workplace-delivered multicomponent intervention was successful at reducing workplace and overall daily sitting time in both the short term and the long term.

Office workers' objectively assessed total and prolonged sitting time: Individual-level correlates and worksite variations.

Sedentary behavior is highly prevalent in office-based workplaces; however, few studies have assessed the attributes associated with this health risk factor in the workplace setting. This study aimed to identify the correlates of office workers' objectively-assessed total and prolonged (≥ 30 min bouts) workplace sitting time. Participants were 231 Australian office workers recruited from 14 sites of a single government employer in 2012-13. Potential socio-demographic, work-related, health-related and cognitive-social correlates were measured through a self-administered survey and anthropometric measurements. Associations with total and prolonged workplace sitting time (measured with the activPAL3) were tested using linear mixed models. Worksites varied significantly in total workplace sitting time (overall mean [SD]: 79% [10%] of work hours) and prolonged workplace sitting time (42% [19%]), after adjusting for socio-demographic and work-related characteristics. Organisational tenure of 3-5 years (compared to tenure > 5 years) was associated with more time spent in total and prolonged workplace sitting time, while having a BMI categorised as obese (compared to a healthy BMI) was associated with less time spent in total and prolonged workplace sitting time. Significant variations in sitting time were observed across different worksites of the same employer and the variation remained after adjusting for individual-level factors. Only BMI and organisational tenure were identified as correlates of total and prolonged workplace sitting time. Additional studies are needed to confirm the present findings across diverse organisations and occupations.

Toward a systematic approach to assessment and care planning in palliative care: A practical review of clinical tools.

OBJECTIVE: Ensuring a consistent and systematic approach to the delivery of care for people with advanced disease is a priority for palliative care services worldwide. Many clinical tools are available to aid in this process; however, they are often used sporadically, and implementation of a routine set of clinical tools to guide care planning in the specialist palliative care sector in Australia has not been achieved. This study sought to recommend key clinical tools that may assist with the assessment and care planning of specialist palliative care provision for patients and family caregivers admitted to specialist palliative care settings (home, hospital, and hospice). METHOD: A mixed-methods sequential approach over four phases was employed, involving: (1) a palliative care sector survey, (2) a systematic literature review, (3) an appraisal of identified clinical tools, and (4) a focus group with an expert panel who critiqued and endorsed a final suite of clinical tools recommended for specialist palliative care. RESULTS: Twelve tools with practical relevance were recommended for use across settings of care. SIGNIFICANCE OF RESULTS: Palliative services should review current practices and seek to implement this recommended suite of tools to enhance assessment and guide care delivery across care settings. Subsequent evaluation should also occur.

A pre-test and post-test study of the physical and psychological effects of out-of-home respite care on caregivers of children with life-threatening conditions.

BACKGROUND: Respite services are recommended as an important support for caregivers of children with life-threatening conditions. However, the benefits of respite have not been convincingly demonstrated through quantitative research. AIM: To determine the impact of out-of home respite care on levels of fatigue, psychological adjustment, quality of life and relationship satisfaction among caregivers of children with life-threatening conditions. DESIGN: A mixed-methods, pre-test and post-test study SETTING/PARTICIPANTS: A consecutive sample of 58 parental caregivers whose children were admitted to a children's hospice for out-of-home respite over an average of 4 days. RESULTS: Caregivers had below-standard levels of quality of life compared to normative populations. Paired t-tests demonstrated that caregivers' average psychological adjustment scores significantly improved from pre-respite (mean = 13.9, standard error = 0.71) to post-respite (mean = 10.7, standard error = 1); p < 0.001, 95% confidence interval: 1.25-5.11). Furthermore, caregivers' average fatigue scores significantly improved from pre-respite (mean = 14.3, standard error = 0.85) to post-respite (mean = 10.9, standard error = 1.01; p < 0.001, 95% confidence interval: 1.69-7.94), and caregivers' average mental health quality of life scores significantly improved from pre-respite (mean = 44.2, standard error = 1.8) to post-respite (mean = 49.1, standard error = 1.6; p < 0.01, 95% confidence interval: -9.56 to 0.36). Qualitative data showed caregivers sought respite for relief from intensive care provision and believed this was essential to their well-being. CONCLUSION: Findings indicate the effectiveness of out-of-home respite care in improving the fatigue and psychological adjustment of caregivers of children with life-threatening conditions. Study outcomes inform service provision and future research efforts in paediatric palliative care.

The association between mammographic density measures and aspirin or other NSAID use.

There is evidence that aspirin use reduces the risk of breast cancer. Increased mammographic density is known to be associated with increased breast cancer risk. Little is known about the association between mammographic density and aspirin or other non-steroidal anti-inflammatory drug (NSAID) use, but it is possible that the association between aspirin use and breast cancer risk might be due to the effect of aspirin on mammographic density. Multiple linear regression was used to investigate the association between measures of mammographic density and the use, frequency, and duration of aspirin and other NSAIDs such as paracetamol (acetaminophen), arthritis medication, and other over-the-counter or doctor-prescribed pain medications in 3286 women from the Australian Mammographic Density Twins and Sisters Study and the Genes Behind Endometriosis Study. We found no association between either dense area or percent dense area with any of the NSAIDs examined (all P > 0.06). If aspirin is reducing the breast cancer risk in women, it is likely doing so via a different pathway other than mammographic density measures that predict breast cancer risk.

The effect of financial incentives on the quality of health care provided by primary care physicians.

BACKGROUND: The use of blended payment schemes in primary care, including the use of financial incentives to directly reward 'performance' and 'quality' is increasing in a number of countries. There are many examples in the US, and the Quality and Outcomes Framework (QoF) for general practitioners (GPs) in the UK is an example of a major system-wide reform. Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care. OBJECTIVES: The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians (PCPs) and to identify:i) the different types of financial incentives that have improved quality;ii) the characteristics of patient populations for whom quality of care has been improved by financial incentives; andiii) the characteristics of PCPs who have responded to financial incentives. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), MEDLINE, HealthSTAR, EMBASE, CINAHL, PsychLIT, and ECONLIT. Searches of Internet-based economics and health economics working paper collections were also conducted. Finally, studies were identified through the reference lists of retrieved articles, websites of key organisations, and from direct contact with key authors in the field. Articles were included if they were published from 2000 to August 2009. SELECTION CRITERIA: Randomised controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series analyses (ITS) evaluating the impact of different financial interventions on the quality of care delivered by primary healthcare physicians (PCPs). Quality of care was defined as patient reported outcome measures, clinical behaviours, and intermediate clinical and physiological measures. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed study quality, in consultation with two other review authors where there was disagreement. For each included study, we reported the estimated effect sizes and confidence intervals. MAIN RESULTS: Seven studies were included in this review. Three of the studies evaluated single-threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups' performance (tournament-based pay), one study examined a mix of tournament-based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment. Three cluster RCTs examined smoking cessation; one CBA examined patients' assessment of the quality of care; one CBA examined cervical screening, mammography screening, and HbA1c; one ITS focused on four outcomes in diabetes; and one controlled ITS (a difference-in-difference design) examined cervical screening, mammography screening, HbA1c, childhood immunisation, chlamydia screening, and appropriate asthma medication. Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. One study found no effect on quality of care. Poor study design led to substantial risk of bias in most studies. In particular, none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme or health plan. AUTHORS' CONCLUSIONS: The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. In addition to basing incentive design more on theory, there is a large literature discussing experiences with these schemes that can be used to draw out a number of lessons that can be learned and that could be used to influence or modify the design of incentive schemes. More rigorous study designs need to be used to account for the selection of physicians into incentive schemes. The use of instrumental variable techniques should be considered to assist with the identification of treatment effects in the presence of selection bias and other sources of unobserved heterogeneity. In randomised trials, care must be taken in using the correct unit of analysis and more attention should be paid to blinding. Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. Studies should more consistently describe i) the type of payment scheme at baseline or in the control group, ii) how payments to medical groups were used and distributed within the groups, and iii) the size of the new payments as a percentage of total revenue. Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.

Increasing school playground physical activity: a mixed methods study combining environmental measures and children's perspectives.

Schools are integral settings in which children can participate in moderate and vigorous physical activity. This study reports on the relationship between playground characteristics and child activity levels using a combination of quantitative and qualitative methods. The aim of the study is to increase understanding of how children respond to their school playground environments. Twenty-three primary schools located in a predominantly low socio-economic area of Melbourne, Australia were involved. SOPLAY (System for Observing Play and Leisure Activity in Youth) was administered in all 23 schools to measure the levels of student physical activity and playground environmental factors such as equipment provision. In 12 of the 23 schools, a sample of 9-11-year-old students participated in focus group discussions exploring perceptions of their school playgrounds using a photo ordering technique. A larger proportion of students participated in VPA when loose equipment (60% vs. 52%; p<0.001) and teacher supervision (62% vs. 52%; p<0.001) were present in activity settings, compared to when they were unavailable. Fixed play equipment and bitumen with court/play-line markings were seen by children as settings inviting active play but only had the greatest impact on moderate activity (fixed play equipment: 35% vs. 20%, p<0.001; court markings/goals: 62% vs. 52%, p<0.001; play-line markings: 25% vs. 20%, p=0.04). The mixed method design provided a greater understanding of the potential influence of environmental characteristics on children's lunch time activity levels and their perceptions of play areas. The findings indicate that relatively simple changes such as the provision of loose equipment, painting of court and play-line markings, and increased teacher presence on the playground, are likely to provide opportunities for increased physical activity.