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Referensi utama:
Blas, E., & Kurup, A.S. 2010. Equity,
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
STATUS SEHAT
What are the social 'determinants' of health? The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.
Penyakit Kardiovaskular
CVD
Perbandingan trend kematian NCD/PTM dan Penyakit Infeksi di Low dan Middle Income Country
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.
Status perkembangan ekonomi dan prevalensi faktor risiko CVD di WHO sub region
Differential exposure
Differential vulnerability
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
Differential outcomes
Differential consequences
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
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
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)
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)
Bottom-end
Threshold
Clustering
Dichotomous In some populations women are much less exposed to certain cardiovascular risk factors, such as tobacco, due to cultural inhibitions (99)
Inequity and CVD : social determinants and pathways, entry-points for interventions, and information needs
Priority public health conditions level
Socioeconomic context and position (entry-points and Intervention are common To other areas of health
Main entry-points
Interventions
Measurement
Define, institutionalize Protect, and enforce human rights to education, employment, living conditions and health Redistribution of power and resources in populations
Universal primary education Programmes to alleviate undernutrition in women of childbearing age and pregnant women Tax-financed public services, including education and health Multifaceted poverty reduction strategies at country level, including employment opportunity
Access to employment opportunities, poverty alleviation schemes and education Level of investment in interventions that improve health (including cardiovascular health) that lie outside the health sector
Inequity and CVD : social determinants and pathways, entry-points for interventions, and information needs
Priority public health conditions level
Differential exposure
Main entrypoints
Interventions
Measurement
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
Main entrypoints
Interventions
Measurement
Access to education Comorbidity Lack of social support Access to welfare assistance Health careseeking 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 highrisk groups Access to treatment and follow-up including to essential drugs, basic technologies and special interventions, e.g. bypass surgery
Main entrypoints
Interventions
Measurement
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
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
Measurement
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
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
Diabetes
Social stratification
Obesogenic environment
Social norms Local food environments Urban infrastructures
Differential exposure
Differential vulnerability Access to and type of health care, including Self-management Excess calories and poor diet Physical inactivity Genes and early life experience Smoking Old age
Obesity
Diabetes incidence, glucose control, blood pressure control and lipid control
Quality of life
Loss of income
Differential consequences
TOBACCO CASE
Brunei 0.04%
Cambodia 2.07%
Indonesia 46.16%
Philippines 16.62%
Indonesia is 3rd rank the worlds leading tobacco consuming nations with
146.860.000 population is smoker
2001*
2004* 2007** 2010***
62.9
63.0 65.3 65.9
1.4
5.0 5.1 4.2
31.8
35.0 35.4 34.7
2001
Keluarga miskin pemilik kartu sehat
Status merokok: - Tidak - Ya Keluarga miskin yang TIDAK memiliki kartu sehat
2004
Keluarga miskin pemilik kartu sehat
Keluarga miskin yang TIDAK memiliki kartu sehat
35,88
35,48
32,88
36,25
64,12
80,00 20,00
64,52
82,11 17,89
67,12
-
63,75
-
Mayoritas perokok adalah keluarga miskin Umur mulai merokok semakin muda Jumlah rokok yang dihisap berkurang
No Propinsi 2001 Keluarga miskin pemilik kartu sehat 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 NAD Sumut Sumbar Riau Jambi Sumsel Bengkulu Lampung Kep.Babel DKI Jkt Jabar Jateng DI Yogya Jatim Banten N.A 60,00 83,33 100,00 77,78 44,44 78,57 76,09 100,00 100,00 56,04 69,59 54,55 58,67 25,00
Persentase Perokok
2004
Keluarga miskin Keluarga yang TIDAK miskin memiliki kartu pemilik sehat Keluarga miskin yang TIDAK memiliki kartu sehat
kartu sehat
N.A 62,96 67,68 75,61 66,28 67,33 67,30 74,90 65,00 55,00 72,25 62,43 50,31 63,97 78,92
66,40 58,33 47,06 25,00 33,33 64,71 52,63 86,09 100,00 0,00 62,79 65,87 62,07 64,85 46,15
60,62 60,08 55,61 50,00 66,67 78,61 74,51 75,15 30,56 33,33 69,84 62,69 56,34 63,99 70,42
Indonesia
64,12
64,52
67,12
63,75
Prevalensi Perokok Remaja Pelajar SMP dan SMA Kota Yogyakarta tahun 2000-2009
Yayi Suryo Prabandari dan Arika Dewi Fakultas Kedokteran Universitas Gadjah Mada Yogyakarta
1986: perokok usia 10-14 tahun dan 15-19 tahun sebesar 0.6% dan 13.2% 1995: prevalensinya menjadi 1.1% dan 22.6% pada usia yang sama* Riset Kesehatan Dasar pada tahun 2007 dan dilanjutkan Riskesdas 2010 menunjukkan peningkatan perokok usia 15-24 tahun, dari 24.6% menjadi 26.6% Perokok pemula di Indonesia juga semakin muda, dari rata-rata 17,4 tahun menjadi 14-15 tahun
(*Suhardi, 1997; **Riskesdas, 2007;Riskesdas 2010)
` Karakteristik sampel
2000
Laki-laki % Status sekolah Negeri Swasta disamakan/ Akreditasi A Swasta diakui/ Akreditasi B Umur < 14 tahun 15 tahun > 16 tahun Uang saku < Rp. 2000,45 33 22 9 55 36 54 Perempuan % 56 27 17 13 65 22 48
2009
Laki-laki % 39 57 4 41 15 44 2 Perempuan % 54 43 3 34 23 43 1
44
2
49
3
53
45
53
46
2000
(%)
Non perokok 35 Perokok eksperimen 30 Perokok teratur 35
2009
(%)
Non perokok 68 Perokok eksperimen 10 Perokok teratur 22
2000
(%)
Teman non perokok: 10
2009
(%)
Teman non perokok: 17 Teman perokok 1/ > 1: 75 Ayah perokok: 78 Ibu perokok: 4 Kakak laki-laki perokok: 31 Teman non perokok: 33 Teman perokok 1 / >1: 61 Ayah perokok: 82 Ibu perokok: 2 Kakak laki-laki perokok: 36
90
43
Teman non perokok: 26 Teman perokok 1/>1: 74 Ayah perokok : 65 Ibu perokok: 6 Kakak laki-laki perokok: 38
` Differential exposure
Social norms permissive to smoking Lack of social and instrumental support to quit Availability of cigarettes, and advertising where allowed (see above) Barriers to affordable cessation services
Strengthening implementation of the WHO Framework ` with a Social determinants Convention on Tobacco Control 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
b. c.
Entry-point: increasing the acceptability of tobacco control as a global public good Entry-point: enhancing accessibility to tobacco control
Structural interventions addressing ` differential exposure Entry-point: increasing the availability of environments supportive of tobacco control Entry-point: reducing the social acceptability of tobacco use
Banning tobacco adversiting, promotion and sponsorship (article 13 of FCTC) Packaging and labelling of tobacco products (Article II of the WHO Framework Convention on Tobacco Control) Other interventions to reduce the acceptability of tobacco use: promoting tobacco-free role models
Entry-point: regulating tobacco product disclosures Entry-point: increasing accessibility to cessation support
Intervention addressing differential health care ` outcomes and consequences: provision of cessation services
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
` Framework for downstream risk factors and upstream determinants of TB, and related entry-points for interventions
Upstream
Downstream
Exposure
Infection
Active disease
Consequences
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
` Upstream determinants
Causal pathways linking socioeconomic status and TB risk Gender differentiation in TB incidence and risk factor profile Urbanization and poverty
Demographic changes Changing lifestyles Poor physical environment Fragmented health system
Relative risk, prevalence and population attributable fraction of selected ` downstream risk factors for TB in 22 High TB Burden Countries