1. The Equity & Social determinants of NCD (Cardiovascular disease, Diabetics), Tobacco case and TB*
Referensi utama:
Blas, E., & Kurup, A.S Equity, social determinants and public health programmes. Switzerlands: WHO
Disampaikan oleh:
Yayi Suryo Prabandari
Prodi S2 IKM
FK UGM

2. 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

3. Social Determinant (Marmot)
Social gradient
Unemployment
Stress
Social support
Early life
Addiction
Social exclusion
Food
Work and
Transport

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. Penentu Sosial Kesehatan (WHO)
Penghasilan
Status sosial
Pendidikan
Pelayanan kesehatan
Pekerjaan dan lingkungan kerja
Keterampilan personal dan penyesuaian
Lingkungan
Genetik - gender
Jejaring dukungan sosial
STATUS SEHAT
Budaya
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.

10. Penyakit Kardiovaskular CVD

11. Perbandingan trend kematian NCD/PTM dan Penyakit Infeksi di Low dan Middle Income Country

12. Beban Sakit Mayor (10 penyakit dan injuries) di Negara berkembang dng kematian tinggi dan rendah serta negara maju
DALYs = Disability Adjusted Life Years
The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.

13. Status perkem-bangan ekonomi , kematian dan beban sakit CVD

14. Status perkembangan ekonomi dan prevalensi faktor risiko CVD di WHO sub region

15. Conceptual framework for understanding health inequities, pathways and entry-points
Age
Economic development, urbanization, globalizationa
Social stratificationa
Social context
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
Social devripationa
Unemployment
Literacy
Deprived neighbourhoods
Adverse intrauterine life
Differential
exposure
Raised cholesterol, raised blood sugar, raised blood
pressure, overweight, obesityb, lack of access to health
information, health services, social support and welfare
assistance, poor health care-seeking behaviour
Less access to:
Health services
Early detection
Healthy foodb
Differential
vulnerability
Higher incidence, frequent recurrences,
higher case fatality, comorbiditiesb
Povertyb
Overcrowding
Poor housing
Differential
outcomes
High out-of-pocket expenditure, poor adherence, lower survival, loss
of employment, loss of productivity and income, social and financial
consequences, entrenchment in poverty, disability, poor quality of lifeb
Rheumatic heart
disease
chagas disease
Differential
consequences

16. 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

17. Main patterns of social gradients associated with CVD
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)

18. Main patterns of social gradients associated with CVD
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)

19. 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

20. Social determinants and pathways Main entry-points Interventions
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 stress
Unemployment
High-deprivation health services
Health-related behaviours
Residence: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 foods
International 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 activity
Information on legislative and regulatory frameworks to support healthy behaviour
Measurement of gaps in implementation of policies and legislative and regulatory frameworks

21. 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

22. 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 medicines
Frequent 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 approach
Provide 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

23. 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

24. Prevention and Control of NCD :
public health model

25. Diabetes

26. Estimasi jumlah penderita Diabetes di negara maju & berkembang

27. Prevalensi Komplikasi Diabetes

28. Overview of diabetes-related pathways
Social
stratification
Industrialization,
urbanization
and globalization
Ageing
Population
Social
Context
‘Obesogenic’ environment
Social
norms
Local food
environments
Urban
infrastructures
Environments
Promoting
Tobacco use
Differential
exposure
Access to and type of
health care, including
Self-management
Differential
vulnerability
Genes and
early life
experience
Excess calories
and poor diet
Physical
inactivity
Smoking
Old age
Obesity
Diabetes incidence,
glucose control,
blood pressure control
and lipid control
Differential
care outcome
Diabetes complications
and premature mortality
Differential
consequences
Costs for health
And social care
Quality
of life
Loss of
income

29. TOBACCO CASE

30. Prevalensi Perokok berdasarkan WHO region

31. Status ekonomi dan risiko kematian di beberapa negara`
Status ekonomi dan risiko kematian di beberapa negara

32. Tobacco Consumption in ASEAN`
Tobacco Consumption in ASEAN
3rd in the world

33. Smoking prevalence in Indonesia``
Indonesia is 3rd rank the world’s leading tobacco consuming nations with
population is smoker
Smoking prevalence in Indonesia
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
*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)

34. 2001 2004 64,52 Keluarga miskin pemilik kartu sehat 35,88 64,12 35,48
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
80,00
20,00
82,11
17,89 -
Merokok di dalam rumah
4,92
95,08
5,83
94,17
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*

35. Persentase Perokok Indonesia 64,12 64,52 67,12 63,75 No Propinsi 2001
2004
Keluarga miskin pemilik kartu sehat
Keluarga miskin yang TIDAK memiliki kartu sehat 1
NAD
N.A
66,40
60,62 2
Sumut
60,00
62,96
58,33
60,08 3
Sumbar
83,33
67,68
47,06
55,61 4
Riau
100,00
75,61
25,00
50,00 5
Jambi
77,78
66,28
33,33
66,67 6
Sumsel
44,44
67,33
64,71
78,61 7
Bengkulu
78,57
67,30
52,63
74,51 8
Lampung
76,09
74,90
86,09
75,15 9
Kep.Babel
65,00
30,56 10
DKI Jkt
55,00
0,00 11
Jabar
56,04
72,25
62,79
69,84 12
Jateng
69,59
62,43
65,87
62,69 13
DI Yogya
54,55
50,31
62,07
56,34 14
Jatim
58,67
63,97
64,85
63,99 15
Banten
78,92
46,15
70,42
Indonesia
64,12
64,52
67,12
63,75
Susenas 2001 & 2004*

36. Prevalensi Perokok Remaja Pelajar SMP dan SMA
Kota Yogyakarta tahun
Yayi Suryo Prabandari
dan Arika Dewi
Fakultas Kedokteran Universitas Gadjah Mada Yogyakarta

37. Rokok dan Remaja Indonesia``
1986: perokok usia tahun dan 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 tahun, dari 24.6% menjadi 26.6%
Perokok pemula di Indonesia juga semakin muda, dari rata-rata 17,4 tahun menjadi tahun
(*Suhardi, 1997; **Riskesdas, 2007;Riskesdas 2010) 37

38. Karakteristik sampel 2000 2009 ` 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 44
Uang saku
< Rp. 2000,- 48 2 1
Rp. 2000,- --
Rp. 5000,- 49 53
> Rp. 5000,- 46

39. Perokok eksperimen 2 Perokok teratur 2`
Hasil Penelitian : Prevalensi Perokok Pelajar di Kota Yogya
2000
(%)
2009
Non perokok 35
Perokok eksperimen 30
Perokok teratur 35
Non perokok 68
Perokok eksperimen 10
Perokok teratur 22
Non perokok 77
Perokok teratur 6
Non perokok 96
Perokok eksperimen 2 Perokok teratur 2

40. Kakak laki-laki perokok: 43 Kakak laki-laki perokok: 31
2000
(%)
2009
Teman non perokok: 10
Teman perokok 1/ > 1: 90
Ayah perokok : 65
Ibu perokok : 8
Kakak laki-laki perokok: 43
Teman non perokok: 17
Teman perokok 1/ > 1: 75
Ayah perokok: 78
Ibu perokok: 4
Kakak laki-laki perokok: 31
Teman non perokok: 26
Teman perokok 1/>1: 74
Ibu perokok: 6
Kakak laki-laki perokok: 38
Teman non perokok: 33
Teman perokok 1 / >1: 61 Ayah perokok: 82
Ibu perokok: 2
Kakak laki-laki perokok: 36 `
Hasil Penelitian : Smoker Social Network

41. 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

42. Tobacco use initiation during adolescence`
Tobacco use initiation during adolescence
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

43. Faktor penyebab remaja merokok`
Faktor penyebab remaja merokok

44. Tobacco use cessation or continuation during adulthood`
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

45. Differential exposure`
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

46. `
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

47. Structural interventions addressing socioeconomic context and position in society`
Entry-point: reducing availability of tobacco and tobacco products
Price and tax measures to reduce the demand for tobacco (Article 6 of the WHO Framework Convention on Tobacco Control)
Elimination of illicit trade in tobacco products (article 15 of FCTC)
Prohibition of sales to minors (Article 6 of the WHO Framework Convention on Tobacco Control)
Entry-point: increasing the acceptability of tobacco control as a global public good
Entry-point: enhancing accessibility to tobacco control

48. 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

49. Structural interventions addressing differential vulnerability`
Structural interventions addressing differential vulnerability
Entry-point: increasing availability of information
Entry-point: reducing the acceptability of tobacco use within populations
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 `

50. Current global TB control strategy targets
“Prevention starts with cure”
Current global TB control strategy targets

51. Barriers to successful treatment The social and economic burden of TB `
Reaching the poor with effective curative interventions
Access barriers
Barriers to successful treatment
The social and economic burden of TB
Strategic response to address access and adherence barriers

52. Framework for downstream risk factors and upstream determinants of TB, and related entry-points for interventions `
Weak and inequitable economic
Social and environmental policy
Globalization, migration,
Urbanization, demographic transition
Upstream
Weak health
system, poor access
Poverty, low socioeconomic
status, low education
Inappropriate
health seeking
Inappropriate
health seeking
Active TB
cases in
community
Crowding,
Poor
ventilation
Tobacco
smoke, air
population
HIV, malnutrition, lung
diseases, diabetes,
alcoholism, etc
Age. Sex
and genetic
factors
Downstream
High-level contact with
infectious droplets
Impaired host
defence
Exposure
Consequences
Infection
Active disease
Indicates where the current global TB control strategy has its main focus
Indicates entry-point for interventions outside the health system
Indicates where national TB programmes could intervene jointly with other Disease control programmes within the general health care system

53. 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

54. `
Relative risk, prevalence and population attributable fraction of selected downstream risk factors for TB in 22 High TB Burden Countries

55. Area riset yg direkomendasikan untuk TB`
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;

56. Area riset yg direkomendasikan untuk TB`
Area riset yg direkomendasikan untuk 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

57. Terima kasih atas perhatiannya`