social determinant and ncd
TRANSCRIPT
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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
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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
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Social Determinant
(Marmot) Social gradient
Unemployment
Stress
Social support Early life
Addiction
Social exclusion
Food
Work and
Transport
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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.
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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.
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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.
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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.
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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.
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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.
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PenyakitKardiovaskular
CVD
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Perbandingan trend kematianNCD/PTM dan Penyakit Infeksi di
Low dan Middle Income Country
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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
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Statusperkem-bangan
ekonomi ,kematiandanbebansakit
CVD
i i
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Status perkembangan ekonomi dan prevalensi faktorrisiko CVD di WHO sub region
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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
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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
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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)
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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)
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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
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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
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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 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
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Priority
public
health
conditio
ns 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 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
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Priority
public
healthconditio
ns level
Social determinants
and pathways
Main entry-
points
Interventions Measurement
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
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Prevention and Control of NCD :public health model
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Diabetes
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Estimasi jumlah penderita Diabetes
di negara maju & berkembang
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Prevalensi Komplikasi Diabetes
Overview of diabetes-
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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
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TOB CCOC SE
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Prevalensi Perokok berdasarkan WHO region
St tus ekonomi d n isiko kem ti n di
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`Status ekonomi dan risiko kematian dibeberapa negara
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`
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
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``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
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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
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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*
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``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
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`
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
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2000(%)
2009(%)
Non perokok 35
Perokok eksperimen 30Perokok teratur 35
Non perokok 68
Perokok eksperimen 10Perokok teratur 22
Non perokok 77Perokok eksperimen 30Perokok teratur 6
Non perokok 96
Perokok eksperimen 2Perokok teratur 2
`Hasil Penelitian Prevalensi PerokokPelajar di Kota Yogya
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2000(%)
2009(%)
Teman non perokok: 10
Teman perokok 1/ > 1: 90Ayah perokok : 65
Ibu perokok : 8Kakak laki-laki perokok: 43
Teman non perokok: 17
Teman perokok 1/ > 1: 75
Ayah perokok: 78
Ibu perokok:4Kakak laki-laki perokok: 31
Teman non perokok: 26
Teman perokok 1/>1: 74
Ayah perokok : 65Ibu perokok: 6
Kakak laki-laki perokok: 38
Teman non perokok: 33
Teman perokok 1 / >1: 61Ayah perokok:82
Ibu perokok: 2
Kakak laki-laki perokok:36
`Hasil Penelitian : Smoker Social etwork
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`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
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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
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`Faktor penyebab
remaja merokok
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`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
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`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
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`
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
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`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
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`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
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`
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
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CURRENT GLOBAL TB CONTROL
STRATEGY TARGETS
Prevention starts with cure
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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
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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
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`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
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downstream risk factors for TB in 22 High TB Burden Countries
Area riset yg
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`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
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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
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Terima kasih atas perhatiannya`