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The Equity & Social determinants of NCD (Cardiovascular disease, Diabetics), Tobacco case and TB* Referensi utama: Blas, E., & Kurup, A.S. 2010. Equity,

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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: 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


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`

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