DETERMINAN SOSIAL

KESEHATAN DAN
PENDEKATAN
SOSIOEKOLOGI
Perkembangan strategi pendekatan kesmas
WHO ( 1948-2008)
 Social determinant of health
(SDH)
Bagian terbesar masalah kesehatan dan kesakitan terjadi
karena kondisi sosial pada masyarakat hidup dan bekerja
dikemukakan dalam laporan Bridging the gap
:1. Kesenjangan yg terjadi kaena keadaan kehidupan sehari hari pada
saat kelahirah, pertumbuhan, hidup dan bekerja dan usia tua
mngakibatkan kesenjangan kesehatan di dalam negara serta antar
negara;
2. Keadaan kehidupan sehari hari itu dipengaruhi oleh keadaan struktural
karena kesenjangan keuangan, sumber daya dan kekuasaan.
3. Ada Kebutuhan untuk memperluas dan menyebarkan pengetahuan
tentang social determinants of health dan mengevaluasi program dan
aksi yang dilakukan secara kritis disamping melakukan pelatihan tentang
SDH

Ada kebutuhan untuk merumuskan hal itu menjadi agenda kesmas yang
pragmatis
 SDH report 2008
53 policy recommendation
http://www.who.int/social_determinants/thecommission/finalreport/en/index.html
 6 prinsip pendekatan socioecological
1. identifikasi phenomena sbg problem social
2. Melihat masalah dari pelbagai level dengan berbagai cara
metode analisi
3. menggunakan perspektiv teori diversitas
4. mengenal interaksi lingkungan dan manusia sebagai hal
yang dinamis dan aktip
5. memperhatikan tatanan/konteks social, histories, cultural
dan institusional dari interaksi masyarakat dan lingkungan
6. Mengerti kehidupan masyarakat sehari hari dalam
kesederhanaannya

• "...most public health challenges...are too complex to be

understood adequately from single levels of analysis and, instead,
require more comprehensive approaches that integrate
psychologic, organizational, cultural, community planning, and
regulatory perspectives."
• Stokols, D. (1996). "Translating Social Ecological Theory into Guidelines for Community Health
Promotion." American Journal of Health Promotion, 10(4), 282-293.
But what are they? - The top ten*
1. The social gradient ,- What you do
- How much you earn, - Who you are, - Where you
live
2. Stress, 3. Early life, 4. Social exclusion
5. Working conditions, 6. Unemployment
7. Social support, 8. Addiction, 9. Healthy food
10. Transport policy
 MDG interlinkages: action on health determinants
as part of a human rights approach to health
MDGs 1, 8, 7 & others

MDG 1 MDG 1

MDG 7
MDGs 2 and 3

MDGs 4, 5, 6, 8

MDG 1

MDG 7

MDG 3 Influenced by all MDGs

Figure source: Rainbow on the social determinants of health, Dahlgren and Whitehead 1991, further elaborated by Theadora Koller, Technical
Officer, Social Determinants, WHO Regional Office for Europe, June 2010.
 Social Epidemiology
• Social Epidemiology has been defined as
the branch of epidemiology that studies
the social distribution and social
determinants of health (Berkman and
Kawachi 2000)..
• Faktor sosioekologi yang berkaitan dengan
penyakit dan kesehatan Social and environmental
risk factors in the emergence of infectious diseases
• Robin A Weiss1 & Anthony J McMichael Nature
Medicine 10, S70 - S76 (2004
 Susser’s Eras in Epidemiology
Source: M. Susser. Am J Public Health 1996;86:674-7.

Era Paradigm Analytic Prevention

approach
Sanitary Miasma theory Clustering of Sanitation
mortality

Infectious Germ theory Laboratory Vaccination

disease

Chronic Black box Risk ratios Host, agent,

disease environment

Eco- Integrated and Determinants Contextual to

epidemiology multilevel at many levels molecular / life
course
• Ikatan yg kuat antara epidemiology dan ilmu social
menfasilitasi kebutuhan analisa health determinants,
dari faktor micro level pada mana keadaan biologis
individu bekerja ke faktor macro yang di ekspresikan
oleh kondisi sosial pda mana komunitas hidup,
pendekatan ini dikenal sebagai “social epidemiology.”
• The principal concern is the study of how society and
different forms of social organization include structure/policy
influence the health and well-being of individuals and
populations..
• Social epidemiology di dasarkan atas 3 dasar teori
(1) psychosocial,
(2) social production of disease and/or political
economy of health, and
(3) ecosocial theory and related multi-level
frameworks.

• Epidemiological Bulletin, Vol. 23 No. 1, March 2002 Krieger Theories for social
epidemiology in the 21st century: an ecosocial perspective
•
Social-Ecological Model

PUBLIC POLICY

COMMUNITY

ORGANIZATIONAL

INTERPERSONAL

INDIVIDUAL
Levels of Influence in the Social-Ecological Model
Behavior
Structures, Policies, Systems change
Local, state, federal policies and laws to influenced at
regulate/support healthy actions all levels

Institutions
Rules, regulations, policies &
informal structures

Community
Social Networks, Norms, Standards

Interpersonal
Family, peers, social networks, associations

Individual
Knowledge, attitudes,
beliefs
Social-Ecological Model

Individuals

Social, Family, and Community

Networks

Living and Working

Conditions
Broad Conditions and Policies
Broad Conditions and Policies

Broad
Broadsocial,
social,economic,
economic,
cultural,
cultural,health,
health,and
and
environmental
environmental
conditions
conditionsandandpolicies
policies
at
atthe
theglobal,
global,national,
national,
state
stateand
andlocal
locallevels
levels
Broad Conditions and Policies

Social
Social conditions
conditionsinclude,
include,but
but are
are
not
notlimited
limitedto:
to:economic
economicinequality,
inequality,
urbanization,
urbanization, mobility,
mobility, cultural
cultural
values,
values, attitudes
attitudesand
andpolicies
policiesrelated
related
to
to discrimination
discriminationand andintolerance
intoleranceon on
the
thebasis
basisofof race,
race,gender,
gender,and
andother
other
differences.
differences.
Broad Conditions and Policies

••Other
Other conditions
conditions at
at the
thenational
national level
level
might
might include
include major sociopolitical
O major sociopolitical
shifts,
shifts, such
suchas
as recession,
recession, war,
war,and
and
governmental
governmentalcollapse.
collapse.
••The
Thebuilt
builtenvironment
environmentincludes
includes
transportation,
transportation,water
water and
andsanitation,
sanitation,
housing,
housing,andandother
other dimensions
dimensionsof of
urban
urban planning.
planning.
Living and Working Conditions
May
Mayinclude:
include:
••Psychosocial
Psychosocialfactors
factors
••Employment
Employment status
statusand
and
occupational
occupational factors
factors
••Socioeconomic
Socioeconomicstatus
status
(income,
(income, education,
education,
occupation,
occupation, wealth)
wealth)
••The
The natural
natural and
and built
built
environments
environments
••Public
Public health
health services
services
••Health
Health care
careservices
services
Social, Family, Community Networks

Social
Social Connectedness:
Connectedness:
••Social
Social networks
networks
••Social
Social support
support
••Social
Social integration
integration
••Social
Social engagement
engagement
Social, Family, Community Networks

Social
Socialnetwork
networkpathways
pathwaysof of
influence
influenceononhealth:
health:
••Health
Healthbehaviors
behaviors
••Health
Healthcare
care
••Access
Accessto tomaterial
material
resources
resources––jobs,
jobs,etc.
etc.
••Direct
Directphysiological
physiological
responses
responsesleading
leadingtoto
disease
diseasedevelopment
developmentand and
prognosis
prognosis
 Individuals

••Innate
Innatebiological
biological
factors
factors
••Health
Healthbehaviors
behaviors
••Psychological
Psychologicalfactors
factors
••Physiological
Physiological
influences
influences
Uraian dari 5 faktor dlm kaitan kes indivdu dan populasi

Incl institusi
 Berkaitan dengan promosi kesehatan dalam
praktek kedokteran dan kesmas

• ... the health-promotive capacity of an environment must

be defined in terms of the multiple health outcomes
resulting from people-environment transactions over a
specified time interval. Thus, for any environmental
context of behavior, it is important to specify key
environmental resources or constraints that are likely to
influence personal and collective well-being among
members of the setting (Stokols, 1992, ).
 
 
• Daniel Stokols "Establishing and Maintaining Healthy Environments: Toward
a Social Ecology of Health Promotion" American Psychologist January
1992, Vol. 47, No. 1, pp. 6-22.)
Perubahan interaksi
Agent-Host-
Environment dan
perubahan iklim
mengubah siklus hidup
vektor penyakit dan
keadaan lingkungan dan
perilaku manusia
Mengakibatkan adanya
usul klasifikasi penyakit
menjadi empat golongan
utama
1,
 ENVIRONMENT AND SOCIAL INFLUENCES ON
EMERGING INF DISEASES (McMichael 2004)

WAR CONQUEST

TECHNOLOGY

HUM AN ANIM AL RELATIONSHIP

TRADE TRAVEL M IGRATION

DEM OGRAPHIC AND SOCIAL

ENVIRONM ENTAL CHANGE

0% 10% 20% 30% 40% 50% 60%

 Praktek kedokteran traditional
Orientasi individu . Dengan alat penyembuh adalah
obat, vaksin dan dukungan lingkungan dan keluarga
serta kebijakan pemerintah

Penyakit disebabkan karena

1. Agent , intervensi mengobati penyakit untuk
membunuh kuman penyakit
2. Host Melakukan pencegahan dengan vaksinasi
dalam rangka peningkatan kekebalan
3. Lingkungan , pengadaan lingkungan sehat dan
bersih agar kuman penyakit dan penyebab
masalah tidak ada di lingkungan kehidupan
 Keadaan kehidupan
• Agent penyakit selalu ada karena keadaan
sosial ( hidup di udara tercemar, lingkungan
kumuh yang berdempetan ,perilaku tidak sehat/
perokok,air tergenang dengan jentik dll )
• Host acapkali tanpa kebijakan dan legalitas
individu dan keluarga tak mampu melakukan
tindakan pencegahan dan upaya peningkatan
kesehatan
• Lingkungan , tak dapat di ubah pasien dan
keluarganya karena kedudukan nya di
masyarakat dan keluarga
•
 Population Health Framework
Political
Social Cultural
Economic
Forces
Health
Spiritual Nation-States Outcomes
Ecological
Technological Regions
(Urban Entities)

Neighborhoods / Communities Most

Health Care
Families / Couples / Households

Lifecourse of Individuals
Peran dr
kesmas ;
link
individu.
keluarga Biological Physical & Social
Endowment Environmental Exposures

population
dan Gene-Environment Interactions
kebijakan
Most Public Health Interventions
27
Tbc control program
 Berkaitan dengan case study
• Bgmn dgn perilaku hidup sehat di padang
• Kota sehat di bitung dikaitkan dengan
penanggulangan hiv/aids
• Pasar sehat dikaitkan dengan flu burung
• IPKM dikaitkan dengan health inequity dan
partisipasi pimpinan daerah / lokal dan
pusat kesehatan dan non kesehatan