Social Determinant and NCD

8/13/2019 Social Determinant and NCD

1/57

The Equity & Socialdeterminants of NCD(Cardiovasculardisease, Diabetics),Tobacco case and TB*

Disampaikan oleh:

Yayi Suryo Prabandari

Prodi S2 IKM

FK UGM

Referensi utama:

Blas, E., & Kurup, A.S. 2010. Equity,

social determinants and public

health programmes. Switzerlands:

WHO


2/57

LO learning objectives

Setelah mengikuti sesi ini mahasiswa akan

mampu memahami dan mengidentifikasi

beban sakit, determinan sosial dan equity:

- PTM (Penyakit kardiovaskular dandiabetes),

- TB dan

- Kasus penggunaan tembakau


3/57

Social Determinant

(Marmot) Social gradient

Unemployment

Stress

Social support Early life

Addiction

Social exclusion

Food

Work and

Transport


4/57

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 thelower an individuals 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 relationbetween 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.


5/57

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.


6/57

The Meaning of social exclusionThe 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.


7/57

Health inequality and inequity

Health inequalities can be defined as differences inhealth 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 inmortality rates between people from different social

classes. It is important to distinguish between inequality

in health and inequity.

Some health inequalities are attributable to biologicalvariations or free choice and others are attributable to

the external environment and conditions mainly outside

the control of the individuals concerned.


8/57

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.


9/57

Penentu Sosial Kesehatan (WHO)

Penghasilan

Status sosialPendidikan

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.


10/57

PenyakitKardiovaskular

CVD


11/57

Perbandingan trend kematianNCD/PTM dan Penyakit Infeksi di

Low dan Middle Income Country


12/57

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.

Beban SakitMayor (10penyakit dan

injuries) diNegaraberkembangdng kematiantinggi dan

rendah sertanegara maju


13/57

Statusperkem-bangan

ekonomi ,kematiandanbebansakit

CVD

i i


14/57

Status perkembangan ekonomi dan prevalensi faktorrisiko CVD di WHO sub region


15/57

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, loss

of employment, loss of productivity and income, social and financial

consequences, entrenchment in poverty, disability, poor quality of life

b

Social context

Differential

exposure

Differentialvulnerability

Differential

outcomes

Differential

consequences

Social stratificationa

Social devripationa

Unemployment

Literacy

Deprived neighbourhoods

Adverse intrauterine life

Less access to:

Health services

Early detection

Healthy foodb

Povertyb

OvercrowdingPoor housing

Rheumatic heart

disease

chagas disease


16/57

Determinants of the economic developmentand summary prevalence ofcardiovascular risk factors in WHO subregions:

a. Government policies: Influencing socialcapital, infrastructure, transport,agriculture, food

b. Health policies at macro, health system

and micro levelsc. Individual, household and community

factors: use of health services, dietarypractices, lifestyle


17/57

Main patterns of social gradientsassociated with CVDMain 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)


18/57

Main patterns o socia gra ientsassociated with CVDMain

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 andrheumatic 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 populationsbecause 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 tocultural inhibitions (99)


19/57

Inequity and CVD : social determinants and pathwaysentry-points for interventions and information needsPriority public

health

conditionslevel

Social

determinants

and pathways

Main entry-points Interventions Measurement

Socio-

economic

context

and position

(entry-pointsand

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 toeducation,

employment,

living conditions

and health

Redistribution of

power andresources in

populations

Universal primary

education

Programmes to

alleviate

undernutrition inwomen of

childbearing age and

pregnant women

Tax-financed public

services, including

education and healthMultifaceted poverty

reduction strategies

at country level,

including

employment

opportunity

Access to

employment

opportunities,

poverty alleviation

schemes andeducation

Level of

investment in

interventions that

improve health

(including

cardiovascular

health) that lie

outside the health

sector


20/57

Inequity and CVD : social determinants and pathwaysentry-points for interventions and information needsPriority

public

health

conditions

level

Social

determinantsand pathways

Main entry-

points

Interventions Measurement

Differential

exposure

Poor living conditions

in childhood

Community structures

Control over life andwork

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 onmarketing 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. tobaccoadvertising 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 andregulatory frameworks

to support healthy

behaviour

Measurement of gaps in

implementation of

policies and legislative

and regulatoryframeworks

Priority Social Main entry Interventions Measurement


21/57

Priority

public

health

conditions

level

Social

determinants and

pathways

Main entry-

points


Differen-

tial

vulnera-

bility

Access to

education

Comorbidity

Lack of social

support

Access to welfare

assistance

Health care-

seeking behavioursAccessibility 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 andhypertension 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 employmentopportunities 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 fooditems

Population

coverage of

screening and early

detection of high-

risk groups

Access to treatmentand follow-up

including to

essential drugs,

basic technologies

and special

interventions, e.g.

bypass surgery


22/57

Priority

public

health

conditio

ns level

Social determinants

and pathways

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

medicines

Frequent recurrences

and hospitalizationsLife stress and social

isolation

Lack of education

Comorbidity

Medical

Procedures

Provider

practices:

compensate

fordifferential

outcomes

Increase awareness among

providers of ethical norms and

patient rights

Provide universal access to a

package of essential CVD

interventions through a primaryhealth care approach

Provide 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

neighbourhoods

Access to essential

medicines and

basic technologies

in primary health

care

Levels ofpopulation

coverage related

to essential CVD

interventions

Support for

smoking cessationfor high-risk

groups among low

socioeconomic

segments of the

population


23/57

Priority

public

healthconditio

ns level

Social determinants

and pathways

Main entry-

points


Differen

tial

consequ

ences

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 healtheducation services

Social and

economic

effects of health

outcomes

Access to

cardiac

rehabilitation

Policies for

linking healthand social

welfare


24/57

Prevention and Control of NCD :public health model


25/57

Diabetes


26/57

Estimasi jumlah penderita Diabetes

di negara maju & berkembang


27/57

Prevalensi Komplikasi Diabetes

Overview of diabetes-


28/57

Overview of diabetesrelated pathwaysSocial

stratification

Industrialization,

urbanization

and globalization

Social

norms

Local food

environments

Urban

infrastructuresEnvironments

Promoting

Tobacco use

Ageing

Population

Social

Context

Differential

exposure

Access to and type of

health care, including

Self-management

Excess calories

and poor diet

Physical

inactivity

Genes andearly life

experienceSmoking Old age

Diabetes incidence,

glucose control,

blood pressure control

and lipid control

Diabetes complications

and premature mortality

Differential

vulnerability

Differential

consequences

Differential

care outcome

Costs for health

And social care

Qualityof life

Loss ofincome

Obesity

Obesogenic environment


29/57

TOB CCOC SE


30/57

Prevalensi Perokok berdasarkan WHO region

St tus ekonomi d n isiko kem ti n di


31/57

`Status ekonomi dan risiko kematian dibeberapa negara


32/57

`

Malaysia

2.90%

Indonesia

46.16%

Myanmar

8.73%

Philippines

16.62%

Singapore

0.39%

Thailand

7.74%

Viet Nam

14.11%

Lao PDR

1.23%

Brunei

0.04%Cambodia

2.07%

Tobacco Consumption in ASEAN

3rdin the world

S ki l


33/57

``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 theworlds

leading

tobacco

consuming

nations with

146.860.000

population is

smoker

2001 2004


34/57

2001 2004Keluarga

miskin

pemilik

kartu sehat

Keluarga

miskin yang

TIDAK

memiliki

kartu sehat

Keluarga

miskin

pemilik

kartu sehat

Keluarga

miskin yang

TIDAK

memiliki

kartu sehatStatus merokok:

- Tidak

- Ya 35,8864,1235,48

64,5232,88

67,12 36,2563,75Pernah merokok

- Tidak

- Ya 80,0020,00 82,1117,89 - -Merokok di

dalam rumah

- Tidak

- Ya4,92

95,08

5,83

94,17

15.33

84,67

14,78

85.22Rata-rata mulaimerokok 18,67 18,58 17,34 17,61Rata-rata jumlah

rokok yang

dihisap perhari10,05 10,14 8,32 8,37

Mayoritas

perokok adalah

keluarga miskin

Umur mulai

merokok semakin

muda

Jumlah rokok

yang dihisap

berkurang

Susenas 2001 & 2004*

N P i i P t P k k


35/57

No Propinsi Persentase Perokok2001 2004Keluarga

miskin

pemilik

kartu sehat

Keluarga miskin

yang TIDAK

memiliki kartu

sehat

Keluarga

miskin

pemilik

kartu sehat

Keluarga miskin

yang TIDAK

memiliki kartu

sehat1 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 63,75Susenas 2001 & 2004*


36/57


37/57

``Rokok dan Remaja Indonesia

1986: perokok usia 10-14 tahun

dan 15-19 tahun sebesar 0.6% dan13.2%

1995: prevalensinya menjadi 1.1%

dan 22.6% pada usia yang sama*

Riset Kesehatan Dasar pada tahun2007 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)

K kt i tik l


38/57

`

2000 2009

Laki-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


39/57

2000(%)

2009(%)

Non perokok 35

Perokok eksperimen 30Perokok teratur 35

Non perokok 68


Non perokok 77Perokok eksperimen 30Perokok teratur 6

Non perokok 96


`Hasil Penelitian Prevalensi PerokokPelajar di Kota Yogya


40/57

2000(%)

2009(%)

Teman non perokok: 10

Teman perokok 1/ > 1: 90Ayah perokok : 65

Ibu perokok : 8Kakak laki-laki perokok: 43


Teman perokok 1/ > 1: 75

Ayah perokok: 78

Ibu perokok:4Kakak laki-laki perokok: 31


Teman perokok 1/>1: 74

Ayah perokok : 65Ibu perokok: 6

Kakak laki-laki perokok: 38


Teman perokok 1 / >1: 61Ayah perokok:82

Ibu perokok: 2

Kakak laki-laki perokok:36

`Hasil Penelitian : Smoker Social etwork


41/57

`Tobacco use initiation during

adolescence

Ability to resist peer pressure

Adequate awareness of tobaccos harms

Scepticism about smoking prevention

Prevalence of social problems

Co-occurring psychological or psychiatric

School performance


42/57

Differential exposure. These vulnerabilities arecompounded by the differential exposure ofdisadvantage young people to pressures withinthe physical and social environment thatencourage the uptake of tobacco use anddiscourage successful quitting. These include:

Preponderance of adults who model tobaccouse

Prevalence of peer smoking

Availability of tobacco products

Targeted advertising and promotion

Paucity of environments supportive of beingtobacco free

`Tobacco use initiation during

adolescence


43/57

`Faktor penyebab

remaja merokok


44/57

`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


45/57

`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


46/57

`

Strengthening implementation of the WHO Framework

Convention on Tobacco Control with a Social determinants

approach

While overall prevalence of tobacco use hasreduced significantly in much of the developedword, this is not evidenced across all populationsubgroups, including young people and lower

socioeconomic groups Few countries, even in the developed world, have

fully implemented the range of tobacco controlmeasures outlined in the Convention, includingmechanisms to enforce compliance

In many developing countries, whereimplementation to tobacco control measures lagsbehind the developed world, tobacco use isactually increasing

S l i i dd i


47/57

`Structural interventions addressing

socioeconomic context and position in society

a. Entry-point: reducing availability of tobacco andtobacco productsa. Price and tax measures to reduce the demand for

tobacco (Article 6 of the WHO Framework Conventionon 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 oftobacco control as a global public good

c. Entry-point: enhancing accessibility to tobaccocontrol

St t l i t ti dd i


48/57

`Structural interventions addressing

differential exposure

Entry-point: increasing the availability ofenvironments supportive of tobacco control

Entry-point: reducing the social acceptability oftobacco use

Banning tobacco adversiting, promotion andsponsorship (article 13 of FCTC)

Packaging and labelling of tobacco products (Article IIof the WHO Framework Convention on TobaccoControl)

Other interventions to reduce the acceptability oftobacco use: promoting tobacco-free role models

Entry-point: regulating tobacco productdisclosures

Entry-point: increasing accessibility to cessationsupport


49/57

`

a. Entry-point: increasing availability ofinformation

b. Entry-point: reducing the acceptability oftobacco use within populations

c. Entry-point: tying tobacco control interventionsinto community development and andempowerment initiatives

Intervention addressing differential health careoutcomes and consequences:

provision of cessation services

`Structural interventions addressingdifferential vulnerability


50/57

CURRENT GLOBAL TB CONTROL

STRATEGY TARGETS

Prevention starts with cure


51/57

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 effectivecurative interventions

`

Framework for downstream risk factors and upstream determinants of TB, and related entry-points for interventions


52/57

Weak and inequitable economic

Social and environmental policy

Globalization, migration,

Urbanization, demographic transition

Weak healthsystem, poor access

Inappropriate

health seeking

Poverty, low socioeconomicstatus, low education

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

High-level contact with

infectious droplets

Impaired host

defence

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

Downstream

Upstream


53/57

`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


54/57

downstream risk factors for TB in 22 High TB Burden Countries

Area riset yg


55/57

`Area riset yg

direkomendasikan untuk TB

basic epidemiological research to furtherestablish association and causality of TB riskfactors, including interactions between the riskfactors;

refined and country-specific analyses of

population attributable fractions of different riskfactors, accounting for interaction andheterogeneity across countries;

multilevel analysis to explain causal pathwayslinking low socioeconomic status with higher

risk of TB;

A i t yg di kom d ik


56/57

analysis of factors determining variations in TBburden and historical change in TB burdenacross countries and across geographicalareas within countries;

modelling of impact on future TB burden of

different scenarios for socioeconomic changeand change in risk factor exposure inpopulation

`Area riset yg direkomendasikanuntuk TB


57/57

Terima kasih atas perhatiannya`

Documents

Social Determinant and NCD