Anda di halaman 1dari 57

The Equity & Social determinants of NCD (Cardiovascular disease, 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:


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

Social Determinant (Marmot)

Social gradient Unemployment Stress Social support Early life Addiction Social exclusion Food Work and Transport

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 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 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.

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.

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, multidimensional 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.

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.

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.

Penentu Sosial Kesehatan (WHO)

Penghasilan Status sosial Pendidikan


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


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 , kematian dan beban sakit CVD

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

Conceptual framework for understanding health inequities, pathways and entry-points

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 Economic development, urbanization, globalizationa Social stratificationa

Differential exposure

Social devripationa Unemployment Literacy Deprived neighbourhoods Adverse intrauterine life

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

Less access to: Health services Early detection Healthy foodb

Differential outcomes

Higher incidence, frequent recurrences, higher case fatality, comorbiditiesb

Povertyb Overcrowding Poor housing

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

Rheumatic heart disease chagas disease

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

Main patterns of social gradients associated with CVD

Main Patterns Changing direction of gradient Examples 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)


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)


Main patterns of social gradients associated with CVD

Main Patterns Top-end Examples 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) 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) 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)

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

Social determinants and pathways

Social status Education Occupation Poverty Parents social class Ageing of populations Poor governance

Main entry-points



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

Social determinants and pathways

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

Main entrypoints



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

Priority public health conditions level Differential vulnerability

Social determinants and pathways

Main entrypoints



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

Priority public health conditio ns level

Differential health care outcomes

Social determinants and pathways

Main entrypoints



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

Priority public health conditio ns level Differen tial consequ ences

Social determinants and pathways

Main entry- Interventions points


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

Prevention and Control of NCD : public health model


Estimasi jumlah penderita Diabetes di negara maju & berkembang

Prevalensi Komplikasi Diabetes

Social stratification

Industrialization, urbanization and globalization

Overview of diabetesrelated pathways

Ageing Population Social Context

Obesogenic environment
Social norms Local food environments Urban infrastructures

Environments Promoting Tobacco use

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


Diabetes incidence, glucose control, blood pressure control and lipid control

Diabetes complications and premature mortality

Differential care outcome

Costs for health And social care

Quality of life

Loss of income

Differential consequences


Prevalensi Perokok berdasarkan WHO region

Status ekonomi dan risiko kematian di ` beberapa negara

` Tobacco Consumption in ASEAN

Viet Nam 14.11%

Brunei 0.04%

Cambodia 2.07%

Thailand 7.74% Singapore 0.39%

Indonesia 46.16%

Philippines 16.62%

3rd in the world

Myanmar 8.73% Malaysia 2.90%

Lao PDR 1.23%

Indonesia is 3rd rank the worlds leading tobacco consuming nations with
146.860.000 population is smoker

Smoking prevalence `` in Indonesia

Year 1995* Male 53.9 Female 1.7 Total 27.2

2004* 2007** 2010***

63.0 65.3 65.9

5.0 5.1 4.2

35.0 35.4 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)

Keluarga miskin pemilik kartu sehat
Status merokok: - Tidak - Ya Keluarga miskin yang TIDAK memiliki kartu sehat

Keluarga miskin pemilik kartu sehat
Keluarga miskin yang TIDAK memiliki kartu sehat





80,00 20,00

82,11 17,89



Pernah merokok - Tidak - Ya

Merokok di dalam rumah - Tidak - Ya Rata-rata mulai merokok

Mayoritas perokok adalah keluarga miskin Umur mulai merokok semakin muda Jumlah rokok yang dihisap berkurang

4,92 95,08 18,67 10,05

5,83 94,17 18,58 10,14

15.33 84,67 17,34 8,32

14,78 85.22 17,61 8,37

Rata-rata jumlah rokok yang dihisap perhari

Susenas 2001 & 2004*

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
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






Susenas 2001 & 2004*

Prevalensi Perokok Remaja Pelajar SMP dan SMA Kota Yogyakarta tahun 2000-2009

Yayi Suryo Prabandari dan Arika Dewi Fakultas Kedokteran Universitas Gadjah Mada Yogyakarta

`` Rokok dan Remaja Indonesia

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

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

Laki-laki % 39 57 4 41 15 44 2 Perempuan % 54 43 3 34 23 43 1

Rp. 2000,- -Rp. 5000,> Rp. 5000,-





Hasil Penelitian : Prevalensi Perokok ` Pelajar di Kota Yogya

Non perokok 35 Perokok eksperimen 30 Perokok teratur 35

Non perokok 68 Perokok eksperimen 10 Perokok teratur 22

Non perokok 77 Perokok eksperimen 30 Perokok teratur 6

Non perokok 96 Perokok eksperimen 2 Perokok teratur 2

Teman non perokok: 10

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

Teman perokok 1/ > 1: Ayah perokok : 65

Ibu perokok : 8 Kakak laki-laki perokok:



Teman non perokok: 26 Teman perokok 1/>1: 74 Ayah perokok : 65 Ibu perokok: 6 Kakak laki-laki perokok: 38

` Hasil Penelitian : Smoker Social Network

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

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

Faktor penyebab ` remaja merokok

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

` 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

Structural interventions addressing ` socioeconomic context and position in society

a. b. c.

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)

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

Structural interventions addressing ` differential vulnerability

a. b. c. 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

Prevention starts with cure


Reaching the poor ` with effective curative interventions

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

Weak and inequitable economic Social and environmental policy

Globalization, migration, Urbanization, demographic transition

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

High-level contact with infectious droplets

Impaired host defence



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

` 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

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;

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

Terima kasih atas perhatiannya`