Targeting the poorest in a performance-based financing programme in northern Cameroon.

Performance-Based Financing (PBF) is a promising approach to improve health system performance in developing countries, but there are concerns that it may inadequately address inequalities in access to care. Incentives for reaching the poor may prove beneficial, but evidence remains limited. We evaluated a system of targeting the poorest of society ('indigents') in a PBF programme in Cameroon, examining (under)coverage, leakage and perceived positive and negative effects. We conducted a documentation review, 59 key informant interviews and 33 focus group discussions with community members (poor and vulnerable people-registered as indigents and those not registered as such). We found that community health workers were able to identify very poor and vulnerable people with a minimal chance of leakage to non-poor people. Nevertheless, the targeting system only reached a tiny proportion (≤1%) of the catchment population, and other poor and vulnerable people were missed. Low a priori set objectives and implementation problems-including a focus on easily identifiable groups (elderly, orphans), unclarity about pre-defined criteria, lack of transport for identification and insufficient motivation of community health workers-are likely to explain the low coverage. Registered indigents perceived improvements in access, quality and promptness of care, and improvements in economic status and less financial worries. However, lack of transport and insufficient knowledge about the targeting benefits, remained barriers for health care use. Negative effects of the system as experienced by indigents included negative reactions (e.g. jealousy) of community members. In conclusion, a system of targeting the poorest of society in PBF programmes may help reduce inequalities in health care use, but only when design and implementation problems leading to substantial under-coverage are addressed. Furthermore, remaining barriers to health care use (e.g. transport) and negative reactions of other community members towards indigents deserve attention.

Participatory approaches to promote healthy lifestyles among Turkish and Moroccan women in Amsterdam.

Although it is recognized that community health promotion succeeds or fails by level of participation, effectiveness and benefits of community programs are underestimated, because participation is seldom monitored and evaluated. In the Dutch "Healthy Lifestyle Westerpark" program in Amsterdam, participation was both the main working principle and the main goal.Between 2003 and 2006, the Municipal Health Service (MHS) carried out a qualitative study on the background of overweight in Turkish and Moroccan women aged 25 to 45 years and on possibilities for promoting health with and for the target group. The aim of the program was to increase the women's participation and to evaluate participation levels in all phases. The research aim of this paper is to contribute to the development of participatory methods.Needs assessment and intervention development phases resulted in implementation of aerobic lessons and nutrition interventions. In the evaluation phase, participation levels were measured using Pretty's typology in focus groups.Results show that women appreciate participating in the program. Increase in physical activity was not measured. Women's knowledge about healthy food increased, women changed behavior by buying healthier food ingredients and women continued to participate.Participatory approaches facilitate participation at the desired level in the different phases of the program. Participatory approaches are time-consuming but worthwhile. Pretty's typology is useful to measure degree of participation, although methods can be improved and the meaning of participation should be reconsidered.The added value of this article is twofold: 1. it demonstrates that participatory methods and tools both facilitate and evaluate participation, and 2. it shows how to evaluate the degree of participation.

Beliefs of South Africans regarding food and cardiovascular health.

OBJECTIVES: To investigate the beliefs of South African metropolitan adults regarding the importance of influencing cardiovascular health by eating certain food types, and to compare these beliefs between different race, living standards, age and gender groups. DESIGN: Randomised cross-sectional study. Trained fieldworkers administered questionnaires by conducting face-to-face interviews with consumers. SUBJECTS: Two thousand South Africans (16 years and older) were randomly selected from metropolitan areas in South Africa. The data were weighted to be representative of the total South African metropolitan population (N = 10695000) based on gender, age and race distribution. RESULTS: The majority (94%) of the population indicated that it is important to influence cardiovascular risk-related health issues by eating certain food types, especially the higher LSM (Living Standard Measure) groups within the different race groups. Weight loss was considered the least important (61% indicated that it is important) compared with cholesterol lowering (80%), blood pressure (89%), diabetes (86%) and healthy blood vessels (89%). In the higher LSM groups (7-10) higher proportions of respondents agreed than in the lower LSM groups (2 and 3). No differences were seen in responses between different gender, race and age groups. CONCLUSIONS AND RECOMMENDATIONS: This study shows that the metropolitan South African adult population considers the influence on cardiovascular health by eating certain food types to be important. However, modifying weight loss by eating certain food types was considered less important.

Determinants of non-home-prepared food consumption in two low-income areas in Nairobi.

OBJECTIVE: Street foods are an important source of nutrients for poor urban residents. This study aimed to identify determinants of the proportion of daily energy provided by non-home-prepared foods. METHODS: A survey was conducted in a slum and a low- to middle-income area of Nairobi. The survey included 241 men and 254 women. Through a structured questionnaire, data on demographic and socioeconomic factors were collected and food intake was assessed with three standardized 24-hour recalls. A measure of socioeconomic status was constructed with principal component analysis. RESULTS: For women in the slum area, the presence of school-age children and distance to work were determinants of non-home-prepared food consumption, whereas employment status and distance to work were determinants for men in the slum area (P < 0.05). Having their own income and, for those employed, employment status were determinants for women in the low- to middle-income area, whereas socioeconomic status was the determinant for the men (P < 0.05). In the slum area, most non-home-prepared foods were derived from street foods, whereas in the low- to middle-income area, both kiosks and street foods were important sources of non-home-prepared foods. CONCLUSIONS: In the determinants of non-home-prepared energy consumption, we discerned a pattern from rather basic determinants to determinants of a more complicated nature with increasing socioeconomic level of the groups. Furthermore, a shift from street foods to kiosks as the main source of non-home-prepared foods consumed appeared with increasing socioeconomic levels.

Non-home prepared foods: contribution to energy and nutrient intake of consumers living in two low-income areas in Nairobi.

OBJECTIVE: : To determine the nutritional importance of non-home prepared foods for men, women and schoolchildren living in two low-income residential areas of Nairobi, and the sources of these non-home prepared foods. DESIGN, SETTING AND SUBJECTS: : A survey was conducted in Korogocho, a slum area, and Dandora, a low-middle-income residential area. Some 241 men, 254 women and 146 children aged 9 to 14 years were included in the study. Food intake was measured using three 24-hour recalls per individual, with special attention on the sources of all foods consumed. RESULTS: : The median proportion of daily energy intake of consumers provided by non-home prepared foods ranged from 13% for schoolchildren in Korogocho to 36% for men in Dandora. The median contribution to fat intake was higher than to energy, but the contributions to iron and vitamin A intakes were lower than to energy intake. Men consumed more non-home prepared foods on weekdays than at the weekend. Intakes of energy and most nutrients were below Kenyan Recommended Daily Intakes in all groups, but similar for consumers and non-consumers. In Korogocho, street foods were the main source of non-home prepared foods. In Dandora, both kiosks and street foods were major sources. CONCLUSIONS: : Non-home prepared foods are an important source of energy and nutrients for men, women and schoolchildren in Nairobi. In Korogocho, street foods, and in Dandora, both kiosks and street foods are the main sources of non-home prepared foods. The adequacy of energy and nutrient intakes does not differ between consumers and non-consumers of non-home prepared foods.