The Equity & Social determinants of NCD (Cardiovascular disease, Diabetics), Tobacco case and TB*...

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


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


Main entry-points


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



Main entry-points


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



Main entry-points



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


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 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


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 pemilik 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

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`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`

The Equity & Social determinants of NCD (Cardiovascular disease, Diabetics), Tobacco case and TB*...

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