Presentation on theme: "The Equity & Social determinants of NCD (Cardiovascular disease, Diabetics), Tobacco case and TB* Referensi utama: Blas, E., & Kurup, A.S. 2010. Equity,"— Presentation transcript:
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: WHODisampaikan oleh:Yayi Suryo PrabandariProdi S2 IKMFK 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 danKasus penggunaan tembakau
3 Social Determinant (Marmot) Social gradientUnemploymentStressSocial supportEarly lifeAddictionSocial exclusionFoodWork andTransport
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) PenghasilanStatus sosialPendidikanPelayanan kesehatanPekerjaan dan lingkungan kerjaKeterampilan personal dan penyesuaianLingkunganGenetik - genderJejaring dukungan sosialSTATUS SEHATBudayaWhat 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.
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 majuDALYs = Disability Adjusted Life YearsThe 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 AgeEconomic development, urbanization, globalizationaSocial stratificationaSocial contextLifetime exposure to advertising of fast foods, tobacco, vehicle use,disposable income, urban infrastructure, physical inactivity, highcalorie intake, high salt intake, high saturated fat diet, tobacco use.lack of control over life and work, high deprivation neighbourhoodsSocial devripationaUnemploymentLiteracyDeprived neighbourhoodsAdverse intrauterine lifeDifferentialexposureRaised cholesterol, raised blood sugar, raised bloodpressure, overweight, obesityb, lack of access to healthinformation, health services, social support and welfareassistance, poor health care-seeking behaviourLess access to:Health servicesEarly detectionHealthy foodbDifferentialvulnerabilityHigher incidence, frequent recurrences,higher case fatality, comorbiditiesbPovertybOvercrowdingPoor housingDifferentialoutcomesHigh out-of-pocket expenditure, poor adherence, lower survival, lossof employment, loss of productivity and income, social and financialconsequences, entrenchment in poverty, disability, poor quality of lifebRheumatic heartdiseasechagas diseaseDifferentialconsequences
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, foodb. Health policies at macro, health system and micro levelsc. Individual, household and community factors: use of health services, dietary practices, lifestyle
17 Main patterns of social gradients associated with CVD ExamplesChanging direction of gradientIn 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)MonotonousThe 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-endPeople 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 ExamplesTop-endIn 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)ThresholdSome 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)ClusteringIn 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)DichotomousIn 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 needsPriority public health conditions levelSocial determinants and pathwaysMain entry-pointsInterventionsMeasurementSocio-economic contextand position(entry-points andIntervention are commonTo other areas of healthSocial statusEducationOccupationPovertyParents’ social classAgeing of populationsPoor governanceDefine, institutionalizeProtect, and enforce human rights to education, employment, living conditions and healthRedistribution of power and resources in populationsUniversal primary educationProgrammes to alleviate undernutrition in women of childbearing age and pregnant womenTax-financed public services, including education and healthMultifaceted poverty reduction strategies at country level, including employment opportunityAccess to employment opportunities, poverty alleviation schemes and educationLevel 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 needsPriority public health conditions levelSocial determinants and pathwaysMain entry-pointsInterventionsMeasurementDifferential exposurePoor living conditions in childhoodCommunity structuresControl over life and workAttitudes towards healthMarketingTelevision exposurePsychosocial and work stressUnemploymentHigh-deprivation health servicesHealth-related behavioursResidence:urban/ruralStrengthen positive and counteract negative health effects of modernizationCommunity infrastructure developmentReduce affordability of harmful productsIncrease availability of and accessibility to health foodInternational trade agreements that promote availability and affordability of healthy foodsInternational agreements on marketing of food to childrenUse tobacco tax for promotion of health of the populationDevelop urban infrastructures to facilitate physical activityGovernment legislation and regulation, e.g. tobacco advertising and pricingVoluntary agreement with industry, e.g. trans fats and salt in processed foodUser-friendly food labelling to help customers to make healthy food choicesInformation 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 behaviourMeasurement of gaps in implementation of policies and legislative and regulatory frameworks
21 Priority public health conditions level Social determinants and pathwaysMain entry-pointsInterventionsMeasurementDifferen-tial vulnera-bilityAccess to educationComorbidityLack of social supportAccess to welfare assistanceHealth care-seeking behavioursAccessibility of health servicesUndernutritionPhysical inactivityAccess to health educationGenderSubsidize healthy items to make healthy choices easy choicesCompensate for lack of opportunitiesEmpower peopleProvide healthy meals free or subsidize to schoolchildrenSubsidize fruits and vegetables in worksite canteens and restaurantsFacilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milkImprove early case detection of individuals with diabetes and hypertension by targeting vulnerable groups, e.g. deprived neighbourhoods, slum dwellersImprove population access to health promotion by targeting vulnerable groups in health education programmesCombine poverty reduction strategies with incentives utilization of preventive services, e.g. conditional cash transfers, vouchersProvide social insurance and fee examinations for basic preventive and curative health interventionsEducation and employment opportunities for womenAccess to media, e.g. print, radio and television and health education programmes broadcast through these mediaAffordability of fruits. vegetables and low-fat food itemsPopulation coverage of screening and early detection of high-risk groupsAccess 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 pathwaysMain entry-pointsInterventionsMeasurementDifferen-tial health care out-comesCost to appropriate carDifferential utilization by patientsPrescription practices not based on evidencePoor adherenceDiscriminating servicesPoor access to essential medicinesFrequent recurrences and hospitalizationsLife stress and social isolationLack of educationComorbidityMedical ProceduresProvider practices: compensate for differential outcomesIncrease awareness among providers of ethical norms and patient rightsProvide 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 groupsProvide dedicated services for particular groups, e.g. smoking cessation programmes for people in deprived neighbourhoodsAccess to essential medicines and basic technologies in primary health careLevels of population coverage related to essential CVD interventionsSupport for smoking cessation for high-risk groups among low socioeconomic segments of the population
23 Priority public health conditions level Social determinants and pathwaysMain entry-pointsInterventionsMeasurementDifferential consequencesLower survival and worse outcomesLoss of employmentSocial and financial consequencesLack of access to welfare assistanceHeavy health expenditureLack of safety netsSocial and physical accessPolicies and environments in worksites to reduce differential consequencesIncrease access of services for people with specific health conditions, e.g. cardiac rehabilitationImprove referral links to social welfare and health education servicesSocial and economic effects of health outcomesAccess to cardiac rehabilitationPolicies for linking health and social welfare
24 Prevention and Control of NCD : public health model
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 ASEAN3rd in the world
33 Smoking prevalence in Indonesia ``Indonesia is 3rd rank the world’s leading tobacco consuming nations withpopulation is smokerSmoking prevalence in IndonesiaYearMaleFemaleTotal1995*53.91.727.22001*62.91.431.82004*63.05.035.02007**184.108.40.206010***220.127.116.11*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 sehatStatus merokok:TidakYa35,8864,1235,4864,5232,8867,1236,2563,75Pernah merokok80,0020,0082,1117,89-Merokok di dalam rumah4,9295,085,8394,1715.3384,6714,7885.22Rata-rata mulai merokok18,6718,5817,3417,61Rata-rata jumlah rokok yang dihisap perhari10,0510,148,328,37Mayoritas perokok adalah keluarga miskinUmur mulai merokok semakin mudaJumlah rokok yang dihisap berkurangSusenas 2001 & 2004*
35 Persentase Perokok Indonesia 64,12 64,52 67,12 63,75 No Propinsi 2001 2004Keluarga miskin pemilik kartu sehatKeluarga miskin yang TIDAK memiliki kartu sehat1NADN.A66,4060,622Sumut60,0062,9658,3360,083Sumbar83,3367,6847,0655,614Riau100,0075,6125,0050,005Jambi77,7866,2833,3366,676Sumsel44,4467,3364,7178,617Bengkulu78,5767,3052,6374,518Lampung76,0974,9086,0975,159Kep.Babel65,0030,5610DKI Jkt55,000,0011Jabar56,0472,2562,7969,8412Jateng69,5962,4365,8762,6913DI Yogya54,5550,3162,0756,3414Jatim58,6763,9764,8563,9915Banten78,9246,1570,42Indonesia64,1264,5267,1263,75Susenas 2001 & 2004*
36 Prevalensi Perokok Remaja Pelajar SMP dan SMA Kota Yogyakarta tahunYayi Suryo Prabandaridan Arika DewiFakultas 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
41 Tobacco use initiation during adolescence `Ability to resist peer pressureAdequate awareness of tobacco’s harmsScepticism about smoking preventionPrevalence of social problemsCo-occurring psychological or psychiatricSchool performance
42 Tobacco use initiation during adolescence `Tobacco use initiation during adolescenceDifferential 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 usePrevalence of peer smokingAvailability of tobacco productsTargeted advertising and promotionPaucity of environments supportive of being tobacco free
44 Tobacco use cessation or continuation during adulthood `Tobacco use cessation or continuation during adulthoodHigher levels of nicotine additionLow self-efficacy and greater perceived barriers to quittingHigher levels of stressCo-occurring health and other problemsWorking conditions
45 Differential exposure `Differential exposureSocial norms permissive to smokingLack of social and instrumental support to quitAvailability 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 approachWhile 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 groupsFew countries, even in the developed world, have fully implemented the range of tobacco control measures outlined in the Convention, including mechanisms to enforce complianceIn 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 productsPrice 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 goodEntry-point: enhancing accessibility to tobacco control
48 Structural interventions addressing differential exposure `Entry-point: increasing the availability of environments supportive of tobacco controlEntry-point: reducing the social acceptability of tobacco useBanning 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 modelsEntry-point: regulating tobacco product disclosuresEntry-point: increasing accessibility to cessation support
49 Structural interventions addressing differential vulnerability `Structural interventions addressing differential vulnerabilityEntry-point: increasing availability of informationEntry-point: reducing the acceptability of tobacco use within populationsEntry-point: tying tobacco control interventions into community development and and empowerment initiativesIntervention 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 interventionsAccess barriersBarriers to successful treatmentThe social and economic burden of TBStrategic 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 economicSocial and environmental policyGlobalization, migration,Urbanization, demographic transitionUpstreamWeak healthsystem, poor accessPoverty, low socioeconomicstatus, low educationInappropriatehealth seekingInappropriatehealth seekingActive TBcases incommunityCrowding,PoorventilationTobaccosmoke, airpopulationHIV, malnutrition, lungdiseases, diabetes,alcoholism, etcAge. Sexand geneticfactorsDownstreamHigh-level contact withinfectious dropletsImpaired hostdefenceExposureConsequencesInfectionActive diseaseIndicates where the current global TB control strategy has its main focusIndicates entry-point for interventions outside the health systemIndicates 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 riskGender differentiation in TB incidence and risk factor profileUrbanization and povertyDemographic changesChanging lifestylesPoor physical environmentFragmented 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 TBbasic 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 TBanalysis 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