Post on 01-Apr-2015
The Equity & Social determinants of NCD (Cardiovascular disease, Diabetics), Tobacco case and TB*
Disampaikan oleh:Yayi Suryo PrabandariProdi S2 IKMFK UGM
• Referensi utama:Blas, E., & Kurup, A.S. 2010. Equity,
social determinants and public health programmes. Switzerlands: WHO
LO – learning objectives
Setelah mengikuti sesi ini mahasiswa akan mampu memahami dan mengidentifikasi beban sakit, determinan sosial dan equity:-PTM (Penyakit kardiovaskular dan diabetes), -TB dan -Kasus penggunaan tembakau
Social Determinant (Marmot)
• Social gradient• Unemployment• Stress• Social support• Early life• Addiction• Social exclusion• Food• Work and • Transport
What is meant by social gradient?• The poorest of the poor, around the world, have the worst health. Within
countries, the evidence shows that in general the lower an individual’s socioeconomic position the worse their health. There is a social gradient in health that runs from top to bottom of the socioeconomic spectrum. This is a global phenomenon, seen in low, middle and high income countries.
• The social gradient in health means that health inequities affect everyone.• For example, if you look at under-5 mortality rates by levels of household
wealth you see that within counties the relation between socioeconomic level and health is graded. The poorest have the highest under-5 mortality rates, and people in the second highest quintile of household wealth have higher mortality in their offspring than those in the highest quintile. This is the social gradient in health.
The Meaning of social exclusion
Social exclusion (Sociology):
•the failure of society to provide certain individuals and groups with those rights and benefits normally available to its members, such as employment, adequate housing, health care, education and training, etc.
The Meaning of social exclusion
The report draws attention to an important distinction between ‘social exclusion’ used to describe a state experienced by particular groups of people (common in policy discourse) as opposed to the relational approach adopted by the SEKN. From this perspective exclusion is viewed as a dynamic, multi-dimensional process driven by unequal power relationships. In the SEKN conceptual model exclusionary processes operate along and interact across four main dimensions - economic, political, social and cultural - and at different levels including individual, household, group, community, country and global regional levels. These exclusionary processes create a continuum of inclusion/exclusion characterised by an unjust distribution of resources and unequal access to the capabilities and rights required to: • Create conditions necessary for entire populations to meet and go beyond basic needs. • Enable participatory and cohesive social systems. • Value diversity. • Guarantee peace and human rights. • Sustain environmental systems.
Health inequality and inequity
• Health inequalities can be defined as differences in health status or in the distribution of health determinants between different population groups.
• For example, differences in mobility between elderly people and younger populations or differences in mortality rates between people from different social classes. It is important to distinguish between inequality in health and inequity.
• Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions mainly outside the control of the individuals concerned.
Health inequality and inequity
• In the first case it may be impossible or ethically or ideologically unacceptable to change the health determinants and so the health inequalities are unavoidable.
• In the second, the uneven distribution may be unnecessary and avoidable as well as unjust and unfair, so that the resulting health inequalities also lead to inequity in health.
Penentu Sosial Kesehatan (WHO)
Budaya
STATUS SEHAT
What are the social 'determinants' of health?The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.
Penyakit Kardiovaskular
CVD
Perbandingan trend kematian NCD/PTM dan Penyakit Infeksi di Low dan Middle Income Country
DALYs = Disability Adjusted Life Years
The sum of years of potential life lost due to prematuremortality and the years of productive life lost due to disability.
Beban Sakit Mayor (10 penyakit dan injuries) di Negara berkembang dng kematian tinggi dan rendah serta negara maju
Status perkem-bangan ekonomi , kematian dan beban sakit CVD
Status perkembangan ekonomi dan prevalensi faktor risiko CVD di WHO sub region
Conceptual framework for understanding health inequities, pathways and entry-points
Age Economic development, urbanization, globalizationa
Lifetime exposure to advertising of fast foods, tobacco, vehicle use, disposable income, urban infrastructure, physical inactivity, high
calorie intake, high salt intake, high saturated fat diet, tobacco use.lack of control over life and work, high deprivation neighbourhoods
Raised cholesterol, raised blood sugar, raised blood pressure, overweight, obesityb, lack of access to healthinformation, health services, social support and welfare
assistance, poor health care-seeking behaviour
Higher incidence, frequent recurrences, higher case fatality, comorbiditiesb
High out-of-pocket expenditure, poor adherence, lower survival, lossof employment, loss of productivity and income, social and financial
consequences, entrenchment in poverty, disability, poor quality of lifeb
Social context
Differential exposure
Differential vulnerability
Differential outcomes
Differential consequences
Social stratificationa
Social devripationa
Unemployment Literacy
Deprived neighbourhoodsAdverse intrauterine life
Less access to:• Health services• Early detection• Healthy foodb
Povertyb
Overcrowding Poor housing
Rheumatic heart diseasechagas disease
Determinants of the economic development and summary prevalence of cardiovascular risk factors in WHO sub regions:
a. Government policies: Influencing social capital, infrastructure, transport, agriculture, food
b. Health policies at macro, health system and micro levels
c. Individual, household and community factors: use of health services, dietary practices, lifestyle
Main patterns of social gradients associated with CVD
Main Patterns Examples
Changing direction of gradient
In the past CVD was considered to be a disease of affluent countries and the affluent in low-income countries. While CVD trends are declining in development countries, the impact of urbanization and mechanization has resulted in rising trends of CVD in developing countries. With economic development the prevalence of cardiovascular risk factors will shift from higher socioeconomic groups in these countries to lower socioeconomic groups, as has been the case in developed countries (94)
Monotonous The risk of late detection of CVD and cardiovascular risk factors and consequent worse health outcomes is higher among people from low socioeconomic groups due to poor access to health care. This gradient exists in both rich and poor countries (95, 96)
Bottom-end People with coronary heart disease of a lower socioeconomic status are more likely to be smokers and more likely to be obese than others. They usually have higher levels of comorbidity and depression and lower self-efficacy expectations, and are less likely to participate in cardiac rehabilitation programmes (97)
Main patterns of social gradients associated with CVD
Main Patterns
Examples
Top-end In some countries, upper-class people gain preferential access to services even within publicly-funded health care systems compared to those with lower incomes or less education (98)
Threshold Some types of CVD, such as chagas disease and rheumatic heart disease, are associated with extreme poverty due to poor housing, malnutrition and overcrowding (5, 6)
Clustering In low-and middle-income countries cardiovascular risk profiles are more unhealthy in urban in rural populations because of the cumulative effects of higher exposure to tobacco promotion, unhealthy food and fewer opportunities for physical activity due to urban infrastructure (2.32)
Dichotomous
In some populations women are much less exposed to certain cardiovascular risk factors, such as tobacco, due to cultural inhibitions (99)
Inequity and CVD : social determinants and pathways, entry-points for interventions, and information needs
Priority public health
conditions level
Social determinants
and pathways
Main entry-points Interventions Measurement
Socio-economic context
and position
(entry-points and
Intervention are common
To other areas of health
Social status
Education
Occupation
Poverty
Parents’ social class
Ageing of populations
Poor governance
Define, institutionalize
Protect, and enforce human rights to education, employment, living conditions and health
Redistribution of power and resources in populations
Universal primary education
Programmes to alleviate undernutrition in women of childbearing age and pregnant women
Tax-financed public services, including education and health
Multifaceted poverty reduction strategies at country level, including employment opportunity
Access to employment opportunities, poverty alleviation schemes and education
Level of investment in interventions that improve health (including cardiovascular health) that lie outside the health sector
Inequity and CVD : social determinants and pathways, entry-points for interventions, and information needs
Priority public health
conditions level
Social determinants and pathways
Main entry-points
Interventions Measurement
Differential exposure
Poor living conditions in childhood Community structures Control over life and work Attitudes towards health Marketing Television exposure Psychosocial and work stressUnemployment High-deprivation health services Health-related behavioursResidence:urban/rural
Strengthen positive and counteract negative health effects of modernization Community infrastructure development Reduce affordability of harmful products Increase availability of and accessibility to health food
International trade agreements that promote availability and affordability of healthy foodsInternational agreements on marketing of food to children Use tobacco tax for promotion of health of the population Develop urban infrastructures to facilitate physical activity Government legislation and regulation, e.g. tobacco advertising and pricing Voluntary agreement with industry, e.g. trans fats and salt in processed food User-friendly food labelling to help customers to make healthy food choices
Information on policies and structural environment measures conducive to healthy behaviour, e.g. tobacco cessation, consumption of fruits and vegetables, reduce salt in processed food, regular physical activityInformation on legislative and regulatory frameworks to support healthy behaviour Measurement of gaps in implementation of policies and legislative and regulatory frameworks
Priority public health conditions level
Social determinants and pathways
Main entry-points
Interventions Measurement
Differen-tial vulnera-bility
Access to education
Comorbidity
Lack of social support
Access to welfare assistance
Health care-seeking behaviours
Accessibility of health services
Undernutrition
Physical inactivity
Access to health education
Gender
Subsidize healthy items to make healthy choices easy choices
Compensate for lack of opportunities
Empower people
Provide healthy meals free or subsidize to schoolchildren
Subsidize fruits and vegetables in worksite canteens and restaurants
Facilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milk
Improve early case detection of individuals with diabetes and hypertension by targeting vulnerable groups, e.g. deprived neighbourhoods, slum dwellers
Improve population access to health promotion by targeting vulnerable groups in health education programmes
Combine poverty reduction strategies with incentives utilization of preventive services, e.g. conditional cash transfers, vouchers
Provide social insurance and fee examinations for basic preventive and curative health interventions
Education and employment opportunities for women
Access to media, e.g. print, radio and television and health education programmes broadcast through these media
Affordability of fruits. vegetables and low-fat food items
Population coverage of screening and early detection of high-risk groups
Access to treatment and follow-up including to essential drugs, basic technologies and special interventions, e.g. bypass surgery
Priority public health conditions level
Social determinants and pathways
Main entry-points
Interventions Measurement
Differen-tial health care out-comes
Cost to appropriate car Differential utilization by patients Prescription practices not based on evidence Poor adherence Discriminating services Poor access to essential medicinesFrequent recurrences and hospitalizations Life stress and social isolation Lack of education Comorbidity
Medical Procedures Provider practices: compensate for differential outcomes
Increase awareness among providers of ethical norms and patient rights Provide universal access to a package of essential CVD interventions through a primary health care approachProvide incentives within public and private health systems to increase equity in outcomes, e.g. fees and bonuses for disadvantaged groups Provide dedicated services for particular groups, e.g. smoking cessation programmes for people in deprived neighbourhoods
Access to essential medicines and basic technologies in primary health care Levels of population coverage related to essential CVD interventions Support for smoking cessation for high-risk groups among low socioeconomic segments of the population
Priority public health conditions level
Social determinants and pathways
Main entry-points
Interventions Measurement
Differential consequences
Lower survival and worse outcomes Loss of employment Social and financial consequences Lack of access to welfare assistance Heavy health expenditure Lack of safety nets
Social and physical access
Policies and environments in worksites to reduce differential consequences Increase access of services for people with specific health conditions, e.g. cardiac rehabilitation Improve referral links to social welfare and health education services
Social and economic effects of health outcomes Access to cardiac rehabilitation Policies for linking health and social welfare
Prevention and Control of NCD : public health model
Diabetes
Estimasi jumlah penderita Diabetes di negara maju & berkembang
Prevalensi Komplikasi Diabetes
Overview of diabetes-related pathways Social
stratification
Industrialization,urbanization
and globalization
Social norms
Local foodenvironments
Urbaninfrastructures
Environments Promoting
Tobacco use
Ageing Population
Social Context
Differential exposure
Access to and type ofhealth care, including
Self-management
Excess caloriesand poor diet
Physical inactivity
Genes andearly life
experience Smoking Old age
Diabetes incidence,glucose control,
blood pressure controland lipid control
Diabetes complicationsand premature mortality
Differential vulnerability
Differential consequences
Differential care outcome
Costs for healthAnd social care
Quality of life
Loss of income
Obesity
‘Obesogenic’ environment
TOBACCO CASE
Prevalensi Perokok berdasarkan WHO region
`Status ekonomi dan risiko kematian di beberapa negara
`Tobacco Consumption in ASEAN
3rd in the world
``Smoking prevalence
in Indonesia
*Kosen, Aryastami, Usman, Karyana, Konas Presentation IAKMI XI, 2010 ** Ministry of Health, Basic Health Research, 2007 ( prevalence of > 10 years old)*** Ministry of Health, Basic Health Research, 2010 (prevalence of > 15 years old)
Year Male Female Total
1995* 53.9 1.7 27.2
2001* 62.9 1.4 31.8
2004* 63.0 5.0 35.0
2007** 65.3 5.1 35.4
2010*** 65.9 4.2 34.7
Indonesia is 3rd rank the world’s leading tobacco consuming nations with
146.860.000 population is smoker
2001 2004Keluarga miskin pemilik kartu sehat
Keluarga miskin yang TIDAK memiliki kartu sehat
Keluarga miskin pemilik kartu sehat
Keluarga miskin yang TIDAK memiliki kartu sehat
Status merokok:-Tidak-Ya
35,88 64,12
35,48
64,52
32,88 67,12
36,25 63,75
Pernah merokok-Tidak-Ya
80,0020,00
82,11
17,89
-
-Merokok di dalam rumah-Tidak-Ya
4,92 95,08
5,8394,17
15.33 84,67
14,78 85.22
Rata-rata mulai merokok
18,67
18,58
17,34
17,61
Rata-rata jumlah rokok yang dihisap perhari
10,05
10,14
8,32
8,37
Mayoritas perokok adalah keluarga miskin
Umur mulai merokok semakin muda
Jumlah rokok yang dihisap berkurang
Susenas 2001 & 2004*
No Propinsi Persentase Perokok2001 2004Keluarga miskin pemilik kartu sehat
Keluarga miskin yang TIDAK memiliki kartu sehat
Keluarga miskin pemilik kartu sehat
Keluarga miskin yang TIDAK memiliki kartu sehat
1 NAD N.A N.A 66,40 60,622 Sumut 60,00 62,96 58,33 60,083 Sumbar 83,33 67,68 47,06 55,614 Riau 100,00 75,61 25,00 50,005 Jambi 77,78 66,28 33,33 66,676 Sumsel 44,44 67,33 64,71 78,617 Bengkulu 78,57 67,30 52,63 74,518 Lampung 76,09 74,90 86,09 75,159 Kep.Babel 100,00 65,00 100,00 30,5610 DKI Jkt 100,00 55,00 0,00 33,3311 Jabar 56,04 72,25 62,79 69,8412 Jateng 69,59 62,43 65,87 62,6913 DI Yogya 54,55 50,31 62,07 56,3414 Jatim 58,67 63,97 64,85 63,9915 Banten 25,00 78,92 46,15 70,42 Indonesia 64,12 64,52 67,12 63,75
Susenas 2001 & 2004*
Yayi Suryo Prabandari dan Arika Dewi
Fakultas Kedokteran Universitas Gadjah Mada Yogyakarta
Prevalensi Perokok Remaja Pelajar SMP dan SMA Kota Yogyakarta tahun 2000-2009
``Rokok dan Remaja Indonesia 1986: perokok usia 10-14 tahun dan 15-19 tahun sebesar
0.6% dan 13.2% 1995: prevalensinya menjadi 1.1% dan 22.6% pada usia
yang sama* Riset Kesehatan Dasar pada tahun 2007 dan dilanjutkan
Riskesdas 2010 menunjukkan peningkatan perokok usia 15-24 tahun, dari 24.6% menjadi 26.6%
Perokok pemula di Indonesia juga semakin muda, dari rata-rata 17,4 tahun menjadi 14-15 tahun
(*Suhardi, 1997; **Riskesdas, 2007;Riskesdas 2010)
`
2000 2009Laki-laki
%Perem-puan %
Laki-laki %
Perem-puan %
Status sekolah
Negeri 45 56 39 54
Swasta disamakan/Akreditasi A
33 27 57 43
Swasta diakui/Akreditasi B
22 17 4 3
Umur < 14 tahun 9 13 41 34
15 tahun 55 65 15 23
> 16 tahun 36 22 44 43
Uang saku
< Rp. 2000,- 54 48 2 1
Rp. 2000,- --Rp. 5000,-
44 49 53 53
> Rp. 5000,- 2 3 45 46
Karakteristik sampel
`Hasil Penelitian : Prevalensi Perokok Pelajar di Kota Yogya
`Hasil Penelitian : Smoker Social Network
`Tobacco use initiation during
adolescence
• Ability to resist peer pressure• Adequate awareness of tobacco’s harms• Scepticism about smoking prevention • Prevalence of social problems• Co-occurring psychological or psychiatric • School performance
Differential exposure. These vulnerabilities are compounded by the differential exposure of disadvantage young people to pressures within the physical and social environment that encourage the uptake of tobacco use and discourage successful quitting. These include:•Preponderance of adults who model tobacco use •Prevalence of peer smoking •Availability of tobacco products •Targeted advertising and promotion•Paucity of environments supportive of being tobacco free
`Tobacco use initiation during adolescence
`Faktor penyebab remaja merokok
`Tobacco use cessation or continuation
during adulthood
• Higher levels of nicotine addition • Low self-efficacy and greater perceived
barriers to quitting • Higher levels of stress• Co-occurring health and other problems• Working conditions
`Differential exposure
• Social norms permissive to smoking
• Lack of social and instrumental support to quit
• Availability of cigarettes, and advertising where allowed (see above)
• Barriers to affordable cessation services
`Strengthening implementation of the WHO Framework
Convention on Tobacco Control with a Social determinants approach
• While overall prevalence of tobacco use has reduced significantly in much of the developed word, this is not evidenced across all population subgroups, including young people and lower socioeconomic groups
• Few countries, even in the developed world, have fully implemented the range of tobacco control measures outlined in the Convention, including mechanisms to enforce compliance
• In many developing countries, where implementation to tobacco control measures lags behind the developed world, tobacco use is actually increasing
`Structural interventions addressing socioeconomic context and position in society
a. Entry-point: reducing availability of tobacco and tobacco products
a. Price and tax measures to reduce the demand for tobacco (Article 6 of the WHO Framework Convention on Tobacco Control)
b. Elimination of illicit trade in tobacco products (article 15 of FCTC)
c. Prohibition of sales to minors (Article 6 of the WHO Framework Convention on Tobacco Control)
b. Entry-point: increasing the acceptability of tobacco control as a global public good
c. Entry-point: enhancing accessibility to tobacco control
`Structural interventions addressing differential exposure
Entry-point: increasing the availability of environments supportive of tobacco control
Entry-point: reducing the social acceptability of tobacco use Banning tobacco adversiting, promotion and sponsorship
(article 13 of FCTC)Packaging and labelling of tobacco products (Article II of the
WHO Framework Convention on Tobacco Control)Other interventions to reduce the acceptability of tobacco
use: promoting tobacco-free role models Entry-point: regulating tobacco product disclosures Entry-point: increasing accessibility to cessation support
`
a. Entry-point: increasing availability of information
b. Entry-point: reducing the acceptability of tobacco use within populations
c. Entry-point: tying tobacco control interventions into community development and and empowerment initiatives
Intervention addressing differential health care outcomes and consequences:
provision of cessation services
`Structural interventions addressing differential vulnerability
CURRENT GLOBAL TB CONTROL STRATEGY TARGETS
“Prevention starts with cure”
a. Access barriers
b. Barriers to successful treatment
c. The social and economic burden of TB
d. Strategic response to address access and adherence barriers
`Reaching the poor with effective curative interventions
`Framework for downstream risk factors and upstream determinants of TB, and related entry-points for interventions
Weak and inequitable economicSocial and environmental policy
Globalization, migration,Urbanization, demographic transition
Weak healthsystem, poor access
Inappropriatehealth seeking
Poverty, low socioeconomicstatus, low education
Inappropriatehealth seeking
Active TBcases in
community
Crowding, Poor
ventilation
Tobaccosmoke, airpopulation
HIV, malnutrition, lung diseases, diabetes,
alcoholism, etc
Age. Sexand genetic
factors
High-level contact withinfectious droplets
Impaired hostdefence
Exposure Infection Active disease Consequences
Indicates where national TB programmes could intervene jointly with other Disease control programmes within the general health care system Indicates entry-point for interventions outside the health system Indicates where the current global TB control strategy has its main focus
Do
wn
stre
am
U
pst
rea
m
`Upstream determinants
• Causal pathways linking socioeconomic status and TB risk
• Gender differentiation in TB incidence and risk factor profile
• Urbanization and poverty– Demographic changes– Changing lifestyles– Poor physical environment– Fragmented health system
`Relative risk, prevalence and population attributable fraction of selected downstream risk factors for TB in 22 High TB Burden Countries
`Area riset yg
direkomendasikan untuk TB• basic epidemiological research to further
establish association and causality of TB risk factors, including interactions between the risk factors;
• refined and country-specific analyses of population attributable fractions of different risk factors, accounting for interaction and heterogeneity across countries;
• multilevel analysis to explain causal pathways linking low socioeconomic status with higher risk of TB;
• analysis of factors determining variations in TB burden and historical change in TB burden across countries and across geographical areas within countries;
• modelling of impact on future TB burden of different scenarios for socioeconomic change and change in risk factor exposure in population
`Area riset yg direkomendasikan untuk TB
Terima kasih atas perhatiannya`