Bilardi et al. BMC Public Health 2010, 10:70 http://www.biomedcentral.com/1471-2458/10/70 Lastly, female GPs and part time GPs were over-repre- sented in the sample compared with the Australian GP population and therefore it is possible that the results of our study may not be generalizable to the wider population. While it appears that a small financial incentive did not motivate behaviour change in GPs, large financial incentives have shown to be effective in other settings. In the UK, as part of the 1999/2000 pilot chlamydia testing program undertaken in two healthcare authori- ties, financial incentives of up to £25 pounds (approxi- mately $AUD50) were offered to practices for the opportunistic chlamydia testing of young women aged 16 to 24 years. General practices comprised a high proportion of participating health sites (72%), from which an effective screening rate (ESR) of 46% in the target female population was achieved in the Ports- mouth authority, where testing was fully implemented from the beginning of the program [19]. However, since the introduction of the National Chlamydia Test- ing Program (NCSP) in 2003, when financial incentives were discontinued, the ESR dropped significantly in general practice to around 10% [34]. Santer et al [35], in a similar study examining opportunistic chlamydia testing in primary care among women, reported an ESR of 30% in women attending for a cervical smear and 23% for contraception, however conceded it was unlikely higher rates could be achieved among teenage women (23%) without the use of a financial incentive scheme and an education campaign to raise public and professional awareness [35]. In recent Australian stu- dies, in which GPs have been asked about how best to facilitate increased testing in general practice, the need for financial incentives has been stressed [13,15]. The size of the financial incentive offered in this study may have been insufficient to motivate GPs to offer increased testing. Systematic reviews have shown small financial incentives have mixed results in improving the quality of physician care [17,18,28]. Town et al [18], in a systematic review of the rando- mized trials examining the effect of financial incentives on provider preventative care (n = 8), deduced that small rewards did not appear to induce change in doc- tors preventative care practices. A higher incentive payment or different incentive scheme i.e. target screening rate bonuses or practice level incentives, may have proved more effective however, a cost-effec- tiveness analysis would need to be undertaken to com- pare alternative strategies to increase testing [36]. Payments in the UK pilot chlamydia testing program were considerably higher than those offered here and were offered to the practice, not the GP, however they were not sustained as part of the NCSP. In stating this, there has been evidence to suggest that small incentive Page 7 of 9 payments to GPs, as part of a multi-faceted package including regular feedback, have increased childhood immunization rates in Australia [5]. The lack of reminders may have also have had a nega- tive impact on the uptake of testing by GPs. Reminders are generally accepted as an effective way to promote behaviour change [37,38] and reviews have shown that computer based alerts can be effective in increasing GPs preventative care practices [39-41]. In a recent Austra- lian RCT, in which intervention group GPs received a computer generated alert to remind them to test young women for chlamydia, a 27% greater increase in chlamy- dia testing was evident in the intervention group [10]. The authors concluded that while the computer alert increased chlamydia testing, the reminder alone would not be sufficient to increase testing to the levels required; however, it would be useful as part of a multi- faceted intervention [10]. Conclusions Our study suggests that a small financial incentive alone does not increase chlamydia testing in general practice. Given the limitations of the study, it is possible that small incentives with regular feedback or reminders may increase chlamydia testing in general practice; however higher financial incentives may also be required. Further research is required to determine if financial incentives can increase testing in Australian general practice, the type and level of financial scheme required and whether incentives need to be part of a multi-faceted package. A cost-effective analysis would need to be undertaken to evaluate the economic viability of alternative incentive schemes versus other possible interventions to increase chlamydia testing in general practice. Acknowledgements We would like to thank GPs and staff at the participating general practices for their assistance with the study. Author details 1Sexual Health Unit, Melbourne School of Population Health, The University of Melbourne, Carlton, Victoria 3053, Australia. 2Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria 3053, Australia. 3Primary Care Research Unit, Department of General Practice, The University of Melbourne, Carlton, Victoria 3053, Australia. 4Family Planning Victoria, Box Hill, Victoria 3128, Australia. 5Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, Melbourne School of Population Health, The University of Melbourne, Carlton, Victoria 3053, Australia. 6Centre for Population Health, Burnet Institute, Melbourne, Victoria 3004, Australia. 7General Practice Divisions Victoria, 458 Swanston Street, Carlton, Victoria 3053, Australia. 8Centre for Women’s Health, Gender and Society, Melbourne School of Population Health, The University of Melbourne, Carlton, Victoria 3053, Australia. Authors’ contributions JB was responsible for the recruitment of practices, data collection, questionnaire data analysis and preparation of the first draft of the manuscript; CF contributed to the conception, design and planning of this study and the writing, editing and approval of the manuscript; MTS