Exploring the process of restoring psychological needs after incidences of frustration and need unfulfillment.

Background: Research on psychological need restoration after incidences of need frustration holds promise for deepening our understanding of the dynamic nature of psychological needs proposed by self-determination theory. We aimed to extend this work by exploring differences in the process of restoring psychological needs after indences of frustration versus need unfulfillment. Methods: In-depth semi-structured interviews were conducted with 42 Danish adults varying in age, gender, and physical activity levels. Data were analyzed using the Framework Method. Results: We identified four distinct yet interconnected phases in the need restoration process: Discrepancies between Actual and Desired Need States, Experiencing Negative Emotions, Initiating Plans for Action, and Action Stage. These stages offer a comprehensive framework for understanding how individuals restore their needs. Discussion: We discerned contrasting approaches to need restoration depending on prior experiences of need frustration due to external contingencies versus need frustration due to internal factors and need unfulfillment. Need frustration due to external contingencies prompts withdrawal, aligning with the avoidance strategies identified in the literature. Conversely, unfulfilled needs and need frustration due to internal factors lead to proactive engagement, highlighting a distinct 'fight' response. These insights extend existing research, providing a nuanced understanding of the dynamic processes of need restoration.

Exploring basic psychological needs within and across domains of physical activity.

PURPOSE: This study explored variations in adults' experience of satisfaction, unfulfilment and frustration of basic psychological needs within and across four domains of physical activity: Transport, household, occupation, and recreation. METHODS: We utilized a qualitative approach, conducting semi-structured interviews with a diverse group of 42 Danish adults. The participants ranged in age from 16 to 79 years (mean age 49 years, SD 21 years), gender (45% men, 55% women), and physical activity levels (38% low, 33% average, 29% high). Data were analysed using a thematic analysis, applying Self-Determination Theory as the guiding framework. RESULTS: In the Transport domain, while most activities were seen as utilitarian necessities, autonomy satisfaction emerged for some through control over their means of transport. In Household domain, tasks were generally viewed as obligatory; however, activities with personal significance led to autonomy satisfaction and skill development. Occupation-wise, physical activity satisfaction varied, with the nature of the job impacting feelings of autonomy and competence. For Recreation domain, personal choice dictated autonomy satisfaction, with competence and relatedness varying according to goal achievement and social interactions. CONCLUSION: The variations in the findings across domains indicate the effectiveness of applying strategies tailored to specific domains for enhancing need satisfaction.

Motives for leisure-time physical activity participation: an analysis of their prevalence, consistency and associations with activity type and social background.

BACKGROUND: Studies argue that knowledge about motives for physical activity participation can inform activities, initiatives and interventions to promote physical activity. However, most of these studies are based on small sample sizes and only include participants within a few selected types of PA. Further, they have not examined the consistency of individuals' motives across different activity types. As a result, this article examines RQ1: the most prevalent motives, RQ2: the association of motives with activity type and social background characteristics, and RQ3: the consistency of motives across different activity types. METHODS: We utilised data from a survey of physical activity participation among 163,000 adult Danes (aged 15 + years). In the survey, the participants were asked about their participation in thirteen activity types and about their motives for practising the activity types they reported to do at least weekly. The motive items were operationalised based on the eight dimensions in the Physical Activity and Leisure Motivation Scale (PALMS). We conducted analyses of mean values and standard deviations as well as multilevel regression analyses. RESULTS: We identified large differences in the importance of different motives for physical activity participation. The three most important motives were psychological condition (M = 4.54), physical condition (M = 4.48) and enjoyment (M = 4.36). We also found significant associations between motives and activity types in particular, but also between motives and social background characteristics (gender, age and educational level). For instance, we found that compared to running, physical condition was a much less important motive in outdoor activities (b = -3.01), activities on water (b = -2.44) and street sports (b = -2.38). Finally, our analysis showed how individuals' motives are not consistent across different activity types. CONCLUSIONS: Our study contributes to the literature on motives for physical activity participation by using a large sample of individuals and by differentiating motives according to a wide range of activity types. The results underline the need to study motives in relation to activity types, as there are large differences in the prevalence of different motives. Our findings suggest that motives are not consistent across activity types, but rather they develop in an interplay between the individual and the activity type practised.

Motives and Barriers Related to Physical Activity within Different Types of Built Environments: Implications for Health Promotion.

Studies have identified individuals' motives and barriers as main predictors of physical-activity behaviour, while other studies found physical-activity behaviour to be related to characteristics of the built environment. However, studies that have a combined focus on motives and barriers and the built environment are less common. This scoping review aims to provide knowledge about motives and barriers related to physical activity within different types of built environments to mitigate this knowledge gap. A systematic literature search was performed in four scientific databases and yielded 2734 articles, of which 31 articles met the inclusion criteria. The review identified four types of built environments within which motives and barriers were studied, including walkability, cyclist infrastructure, neighbourhood parks and open spaces and sports facilities. Several common motives recur across all four types of built environments, especially easy accessibility and good facility conditions. Conversely, poor accessibility and inadequate facility conditions are common barriers. Our review also showed how some motives and barriers seem to be more context-specific because they were only identified within a few types of built environments. This knowledge may help target future health-promotion initiatives in relation to urban planning and the importance of the environment on physical activity.

Implementation strategies, and barriers and facilitators for implementation of physical activity at work: a scoping review.

Background: Inactivity and sedentary lifestyle have led experts to recommend an increase in structured, workplace-based physical activity (PA) initiatives. Previous studies on workplace-based PA have only shown moderate and short-term effects. This has been attributed to the lack of clear implementation strategies and understanding of factors that may hinder or enable uptake of PA. To ensure long-term, sustainable outcomes, there is a need for a better understanding of implementation strategies, and barriers and facilitators to workplace-based PA. Method: A scoping review of studies investigating implementation approaches and factors affecting uptake of workplace-based PA was conducted. Qualitative and quantitative articles published in MEDLINE, Embase, Scopus, or PsycINFO between 2008 and 2018 evaluating the implementation of PA were included. Data on study characteristics, evaluation, and implementation methods applied were systematically extracted. Two reviewers extracted, coded, and organised factors affecting uptake using the Theoretical Domains Framework (TDF). Results: After dual, blinded screening of titles and abstracts, 16 articles reporting on eight studies were included in the review. Several different methods of implementation were applied, including information meeting, kick-off events, and "change agents" as the most common. A total of 109 factors influencing implementation were identified, consisting of 57 barriers and 52 facilitators. Barriers most often related to the TDF domains Environmental Context and Resources (n = 34, 36.2%), Social influences (n = 13, 13.8%), and Social/Professional Role and Identity (n = 8, 8.5%). Likewise, facilitators most often related to the TDF domains Social influences (n = 17, 19.5%), Environmental Context and Resources (n = 16, 18.4%), and Social/Professional Role and Identity (n = 9, 10.3%). Conclusion: Our review has highlighted the multilevel factors affecting the uptake of workplace-based PA and underpins the complexities in implementation of such initiatives. The published literature predominantly provides details from the employees' perspectives on factors that need to be addressed and a lack of attention to these factors will cause them to hamper uptake of PA. The analysis of barriers and facilitators provides a theoretical foundation to guide future intervention design. However, further research is needed to fully understand the success or failure of implementation processes.

Implementation of a successful long-term school based physical education intervention: Exploring provider and programme characteristics.

There is an ongoing need for research focusing on how to implement physical activity programmes into a school setting. This includes documentation of the extent to which programmes are compatible with the basic views of providers and their local practices. The present study explores the Svendborgproject - a programme tripling the amount of physical education in six public schools, sustaining it for 10-years and documenting a decreased incidence of overweight, obesity and cardiovascular risk factors. The aim was to analyse provider and programme characteristics of the Svendborgproject to gain insights into providers motives for adopting, implementing, and maintaining the programme. Six school heads and six teachers were interviewed to explore how they perceived programme compatibility to their school's practice and their own role as providers. Both teachers and school heads found the additional lessons a valuable asset that fitted existing school values and priorities. Additionally, physical education teachers participated in a course providing new perspectives and teaching methods that aided the implementation of the programme. Lastly, school heads stressed that implementation fidelity was heavily dependent on the dedication of physical education teachers and on having simple programme requirements that made it clear what could be expected of the programme.

Attendance barriers experienced by female health care workers voluntarily participating in a multi-component health promotion programme at the workplace.

BACKGROUND: Studies have shown that Workplace Health Promoting Programmes (WHPP) can facilitate healthier behaviour. Despite the benefits achieved from participating in a WHPP, a systematic review showed that only 10-50% of the employees participated and a challenge was lack of participation. Previous studies stress that understanding the barriers that prevent participants from attending WHPPs are important for designing highly effective interventions. To exploit the potential of a WHPP, it requires a deep insight into the attendance barriers experienced by the participants who voluntarily sign-up for a WHPP; and particularly those who want to stay in the programme but are prevented from participating in it regularly. Thus, the aim of this study was to identify and explore attendance barriers experienced by female Health Care Workers (HCWs) who voluntarily participated in a weekly one-hour multi-component training session, within a WHPP, over a one-year period. METHODS: This study was carried out within a RCT named FRIDOM (FRamed Intervention to Decrease Occupational Muscle pain) and was designed as a single-case study with an inductive approach for analysing the content of in-depth semi-structured qualitative interviews. Data was collected at two home care workplaces and two retirement homes in Denmark. Nine HCWs from the intervention group were selected as participants in the present study. RESULTS: The attendance barriers identified, consisted of three main themes and six related sub-themes: 1) organizational factors (work inflexibility, lack of support from team leaders), 2) intervention factors (training sessions organized outside normal work hours, incongruence between information received and reality, content and intensity of the program) and 3) individual factors (personal factors). CONCLUSION: Organizational and intervention factors are the two most important attendance barriers in future WHPPs. To overcome these barriers; training sessions should be organized within or in connection with work hours, support should be secured from team management and work shifts should be planned to enable attendance for all participants. Furthermore, the attendance barriers may be minimized by including participants in the decision-making process. This relates to both the content and intensity of the intervention, not only in the planning stage but throughout the intervention process. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02843269 - 06.27.2016 - retrospectively registered.

Using the RE-AIM framework to evaluate a school-based municipal programme tripling time spent on PE.

Documenting the implementation of effective real-world programmes is considered an important step to support the translation of evidence into practice. Thus, the aim of this study was to identify factors influencing the adoption, implementation and maintenance of the Svendborgproject (SP) - an effective real-world programme comprising schools to implement triple the amount of physical education (PE) in pre-school to sixth grade in six primary schools in the municipality of Svendborg, Denmark. SP has been maintained for ten years and scaled up to all municipal schools since it was initiated in 2008. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework (RE-AIM) was applied as an analytic tool through a convergent mixed method triangulation design. Results show that SP has been implemented with high fidelity and become an established part of the municipality and school identity. The successful implementation and dissemination of the programme has been enabled through the introduction of a predominantly bottom-up approach combined with simple non-negotiable requirements. The results show that this combination has led to a better fit of programmes to the individual school context while still obtaining high implementation fidelity. Finally, the early integration of research has legitimated and benefitted the programme.

Understanding and scaffolding Danish schoolteachers' motivation for using classroom-based physical activity: study protocol for a mixed methods study.

INTRODUCTION: The benefits of physical activity for children's health, both mental and physical, and its positive effects on academic achievement are well established. Research also emphasises that schools could provide a natural setting for regular physical activity. There is, however, a limited amount of knowledge about teachers' views when it comes to integrating physical activity as part of teaching. The aim of this study is to understand teachers' motivation for integrating physical activity as part of teaching and to assess their need for guidance and support. METHODS AND ANALYSIS: The study uses an explanatory sequential mixed-methods design. Schools from across Denmark are included in the sample. The design comprises two separated phases-a quantitative and qualitative phase. The quantitative phase is guided by the self-determination theory where teachers' motivation will be measured using the Work Task Motivation Scale for Teachers. The theory of scaffolding guides the qualitative phase, which consists of in-depth interviews with participants selected from the quantitative phase based on levels of motivation and on demographic information. In accordance with the study aims, the analysis of data will identify teachers' internal and external levels of motivation. The purpose of the qualitative phase is to enhance understanding of teachers' motivation and of their need for support in the use of physical activity in teaching. ETHICS AND DISSEMINATION: All relevant ethics approvals have been acquired. All participants in this study will provide written informed consent prior to data collection. All data emerging from the quantitative and qualitative phase will be anonymised for analysis. Ethics approval was requested from the Regional Committee on Health Research Ethics for Southern Denmark approval ID S-20162000-40 and the Danish Data Protection Agency approval ID 16/15491). The study was deemed not notifiable by both authorities. TRIAL REGISTRATION NUMBER: NCT02894346; Pre-results.

Background, design and conceptual model of the cluster randomized multiple-component workplace study: FRamed Intervention to Decrease Occupational Muscle pain - "FRIDOM".

BACKGROUND: Several RCT studies have aimed to reduce either musculoskeletal disorders, sickness presenteeism, sickness absenteeism or a combination of these among females with high physical work demands. These studies have provided evidence that workplace health promotion (WHP) interventions are effective, but long-term effects are still uncertain. These studies either lack to succeed in maintaining intervention effects or lack to document if effects are maintained past a one-year period. This paper describes the background, design and conceptual model of the FRIDOM (FRamed Intervention to Decrease Occupational Muscle pain) WHP program among health care workers. A job group characterized by having high physical work demands, musculoskeletal disorders, high sickness presenteeism - and absenteeism. METHODS: FRIDOM aimed to reduce neck and shoulder pain. Secondary aims were to decrease sickness presenteeism, sickness absenteeism and lifestyle-diseases such as other musculoskeletal disorders as well as metabolic-, and cardiovascular disorders - and to maintain participation to regular physical exercise training, after a one year intervention period. The entire concept was tailored to a population of female health care workers. This was done through a multi-component intervention including 1) intelligent physical exercise training (IPET), dietary advice and weight loss (DAW) and cognitive behavioural training (CBT). DISCUSSION: The FRIDOM program has the potential to provide evidence-based knowledge of the pain reducing effect of a multi component WHP among a female group of employees with a high prevalence of musculoskeletal disorders and in a long term perspective evaluate the effects on sickness presenteeism and absenteeism as well as risk of life-style diseases. TRIAL REGISTRATION: NCT02843269 , 06.27.2016 - retrospectively registered.

Improving the well-being of children and youths: a randomized multicomponent, school-based, physical activity intervention.

BACKGROUND: The benefits of physical activity for the mental health and well-being of children and young people are well-established. Increased physical activity during school hours is associated with better physical, psychological and social health and well-being. Unfortunately many children and young people exercise insufficiently to benefit from positive factors like well-being. The main aim of this study is to develop, implement and evaluate a multi-component, school-based, physical activity intervention to improve psychosocial well-being among school-aged children and youths from the 4th to the 6th grade (10-13 years). METHODS: A four-phased intervention - design, pilot, RCT, evaluation - is carried out for the development, implementation and evaluation of the intervention which are guided by The Medical Research Council framework for the development of complex interventions. 24 schools have been randomized and the total study population consists of 3124 children (baseline), who are followed over a period of 9 months. Outcome measure data at the pupil level are collected using an online questionnaire at baseline and at follow-up, 9 months later with instruments for measuring primary (general physical self-worth) and secondary outcomes (self-perceived sport competences, body attractiveness, scholastic competences, social competences and global self-worth; enjoyment of PA; self-efficacy; and general well-being) that are both valid and manageable in setting-based research. The RE-AIM framework is applied as an overall instrument to guide the evaluation. DISCUSSION: The intervention focuses on the mental benefits of physical activity at school, which has been a rather neglected theme in health promotion research during recent decades. This is unfortunate as mental health has been proclaimed as one of the most important health concerns of the 21st century. Applying a cluster RCT study design, evaluating the real-world effectiveness of the intervention, this study is one of the largest physical activity intervention projects promoting psychosocial well-being among children and youths. Through a comprehensive effectiveness evaluation and a similar substantial process evaluation, this study is designed to gain knowledge on a broad variety of implementation issues and give detailed information on project delivery and challenges at the school level - among other things to better inform future practice. TRIAL REGISTRATION: Date of registration: 24 April 2015 retrospectively registered at Current Controlled Trials with study ID ISRCTN12496336.

When Intervention Meets Organisation, a Qualitative Study of Motivation and Barriers to Physical Exercise at the Workplace.

OBJECTIVE: To provide a comprehensive understanding of the motivational factors and barriers that are important for compliance with high-intensity workplace physical exercise that is aimed at reducing musculoskeletal disorders. METHOD: The present study, which used semideductive, thematic, and structured in-depth interviews, was nested in a 20-week cluster randomised controlled trial among office workers. Interviews were conducted with 18 informants with diverse fields of sedentary office work who participated in strength training at the workplace for 20 minutes, three times per week. Organisational, implementational, and individual motives and barriers were explored. RESULTS & DISCUSSION: The results show that attention should be given to the interaction between the management, the employees, and the intervention, as the main barrier to compliance was the internal working culture. The results emphasised the need for a clear connection between the management's implementational intentions and the actual implementation. The results emphasise the importance of ensuring the legitimacy of the intervention among managers, participants, and colleagues. Moreover, it is important to centrally organise, structure, and ensure flexibility in the working day to free time for participants to attend the intervention. Recommendations from this study suggest that a thorough intervention mapping process should be performed to analyse organisational and implementational factors before initiating workplace physical exercise training.

Does training frequency and supervision affect compliance, performance and muscular health? A cluster randomized controlled trial.

The aim was to determine the effect of one weekly hour of specific strength training within working hours, performed with the same total training volume but with different training frequencies and durations, or with different levels of supervision, on compliance, muscle health and performance, behavior and work performance. In total, 573 office workers were cluster-randomized to: 1 WS: one 60-min supervised session/week, 3 WS: three 20-min supervised sessions/week, 9 WS: nine 7-min supervised sessions/week, 3 MS: three 20-min sessions/week with minimal supervision, or REF: a reference group without training. Outcomes were diary-based compliance, total training volume, muscle performance and questionnaire-based health, behavior and work performance. Comparisons were made among the WS training groups and between 3 WS and 3 MS. If no difference, training groups were collapsed (TG) and compared with REF. Results demonstrated similar degrees of compliance, mean(range) of 39(33-44)%, and total training volume, 13.266(11.977-15.096)kg. Musculoskeletal pain in neck and shoulders were reduced with approx. 50% in TG, which was significant compared with REF. Only the training groups improved significantly their muscle strength 8(4-13)% and endurance 27(12-37)%, both being significant compared with REF. No change in workability, productivity or self-rated health was demonstrated. Secondary analysis showed exercise self-efficacy to be a significant predictor of compliance. Regardless of training schedule and supervision, similar degrees of compliance were shown together with reduced musculoskeletal pain and improved muscle performance. These findings provide evidence that a great degree of flexibility is legitimate for companies in planning future implementation of physical exercise programs at the workplace. ClinicalTrials.gov, number NCT01027390.

Effect of training supervision on effectiveness of strength training for reducing neck/shoulder pain and headache in office workers: cluster randomized controlled trial.

OBJECTIVE: To investigate the effect of workplace neck/shoulder strength training with and without regular supervision on neck/shoulder pain and headache among office workers. METHOD: A 20-week cluster randomized controlled trial among 351 office workers was randomized into three groups: two training groups with the same total amount of planned exercises three times per week (1) with supervision (3WS) throughout the intervention period, (2) with minimal supervision (3MS) only initially, and (3) a reference group (REF). Main outcome is self-reported pain intensity in neck and shoulder (scale 0-9) and headache (scale 0-10). RESULTS: Intention-to-treat analyses showed a significant decrease in neck pain intensity the last 7 days in 3MS compared with REF: -0.5 ± 0.2 (P < 0.02) and a tendency for 3WS versus REF: -0.4 ± 0.2 (P < 0.07). Intensity of headache the last month decreased in both training groups: 3WS versus REF: -1.1 ± 0.2 (P < 0.001) and 3MS versus REF: -1.1 ± 0.2 (P < 0.001). Additionally, days of headache decreased 1.0 ± 0.5 in 3WS and 1.3 ± 0.5 in 3MS versus REF. There were no differences between the two training groups for any of the variables. CONCLUSION: Neck/shoulder training at the workplace reduced neck pain and headache among office workers independently of the extent of supervision. This finding has important practical implications for future workplace interventions.

Influence of self-efficacy on compliance to workplace exercise.

BACKGROUND: Continuous neck and shoulder pain is a common musculoskeletal complaint. Physical exercise can reduce pain symptoms, but compliance to exercise is a challenge. Exercise-specific self-efficacy has been found to be a predictor of participation in preplanned exercise. Little is known about the influence of exercise-specific self-efficacy on compliance to workplace physical exercise. PURPOSE: To determine the influence of exercise-specific self-efficacy on compliance to specific strength exercises during working hours for laboratory technicians. METHODS: We performed a cluster-randomized controlled trial, including laboratory technicians from two industrial production units in Copenhagen, Denmark. The participants were randomized to supervised specific strength exercises for the neck and shoulder muscles for 20 minutes three times a week (n = 282) or to a reference group (n = 255). The participants answered baseline and follow-up questions regarding self-efficacy and registered all exercises in a diary. RESULTS: Overall compliance to exercises was 45 %. Compliance in company A (private sector) differed significantly between the three self-efficacy groups after 20 weeks. The odds ratio of compliance was 2.37 for moderate versus low self-efficacy, and 2.93 for high versus low self-efficacy. No significant difference was found in company B (public sector) or in the intervention group as a whole. CONCLUSION: We did not find self-efficacy to be a general statistically significant predictor of compliance to exercises during 20 weeks, but found self-efficacy to be a predictor of compliance in a private sector setting. Workplace-specific differences might be present and should be taken into account.

Exercise on prescription: changes in physical activity and health-related quality of life in five Danish programmes.

BACKGROUND: Exercise prescribed by the general practitioner may be an important health-improving intervention for inactive individuals with lifestyle diseases. The objective was to analyse changes in physical activity and health-related quality of life among participants in five similar 'Exercise on Prescription' (EoP) programmes. METHODS: The analysis was based on self-reported information in a follow-up design without a control group. The intervention comprised group training twice weekly in the first 2 months and once weekly in the following 2 months (24 sessions in all) combined with four to five sessions of motivational counselling. Self-report questionnaires were administered at the first contact and again after 4, 10 and 16 months. Outcome measures were changes in self-reported activity levels converted to metabolic equivalents and health-related quality of life measured by standard instruments (SF-12v2 and EQ-5D). RESULTS: 449 individuals (59% women, mean age 57 years) agreed to participate in the study. Dropout was considerable [123 (27%); 231 (52%) 297 (66%) after 4, 10 and 16 months]. Participants increased their physical activity level and health-related quality of life from baseline to 4 months and maintained improvement throughout the observation period. One in three to six participants increased their physical activity level and one in 4-10 achieved improvements in health-related quality of life. CONCLUSION: Exercise on prescription can contribute to improvements in physical activity level and health-related quality of life in physically inactive patients with or at increased risk of developing lifestyle diseases. An acceptable number of participants achieved and maintained improvements in physical activity level and health-related quality of life.

Exercise on Prescription. Effect of attendance on participants' psychological factors in a Danish version of Exercise on Prescription: a study protocol.

BACKGROUND: In many countries exercise prescriptions are used to facilitate physical activity in a sedentary population with or in risk of developing lifestyle diseases. Some studies show a positive effect of exercise prescription on specific lifestyle diseases. Others only show moderately positive or no effect on physical activity level. Furthermore, the challenge is adherence of participants to a physically active lifestyle on a long term basis after intervention. Therefore, it is essential for offering successful prescribed interventions aiming towards behaviour change to focus on psychological and social issues as well as physiological issues. The aim of this study is to assess the short and long term development of psychological conditions in two different Exercise on Prescription groups; The Treatment Perspective and The Preventive Perspective behaviour. Thus, the aim of this paper is to describe the design used. METHODS/DESIGN: The Treatment Perspective involves a 16 week supervised training intervention including motivational counselling. The Preventive Perspective only involves motivational counselling. The study is an evaluation of best practice and is accomplished by the use of a combination of quantitative (collected by questionnaires) and qualitative (collected by the use of semi structured interviews) measures. Comparison of The Treatment Perspective and The Preventive Perspective are performed at baseline and after 16 months. Development within the groups is measured at 4, 10, and 16 months. Self-reported measures describe physical activity, health-related quality of life, compliance with national guidelines for physical activity, physical fitness, self-efficacy, readiness to change, decisional balance, and processes of change. To elaborate self-efficacy, readiness to change, decisional balance, and processes of change, these issues were elucidated by interviews. DISCUSSION: This study of best practice is designed to provide information about important psychological concepts in relation to behaviour change and physical activity. The study is part of a health technology assessment of Exercise on Prescription, which apart from the psychological concepts (the patient's perspective) covers the effectiveness, the organization, and the health economy.