Social determinant of healthSocial Epidemiology dan pendekatan sosioekologi

Charles Surjadi

FK Unika Atmajaya

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 200853 policy recommendation

http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

6 prinsip pendekatan socioecological

1. identifikasi phenomena sbg problem social2. Melihat masalah dari pelbagai level dengan berbagai cara

metode analisi3. menggunakan perspektiv teori diversitas4. mengenal interaksi lingkungan dan manusia sebagai hal

yang dinamis dan aktip5. 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 live2. Stress, 3. Early life, 4. Social exclusion5. Working conditions, 6. Unemployment7. Social support, 8. Addiction, 9. Healthy food10. Transport policy

Influenced by all MDGsMDG 3

MDGs 2 and 3

MDG 1

MDGs 1, 8, 7 & others

MDG 7

MDGs 4, 5, 6, 8

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.

MDG 7

MDG 1 MDG 1

MDG interlinkages: action on health determinants as part of a human rights approach to health

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 EpidemiologySource: M. Susser. Am J Public Health 1996;86:674-7.

Era Paradigm Analytic approach

Prevention

Sanitary Miasma theory Clustering of mortality

Sanitation

Infectious disease

Germ theory Laboratory Vaccination

Chronic disease

Black box Risk ratios Host, agent, environment

Eco-epidemiology

Integrated and multilevel

Determinants at many levels

Contextual to 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

•

PUBLIC POLICY

COMMUNITY

ORGANIZATIONAL

INTERPERSONAL

INDIVIDUAL

Social-Ecological Model

Structures, Policies, SystemsLocal, state, federal policies and laws to

regulate/support healthy actions

InstitutionsRules, regulations, policies &

informal structures

CommunitySocial Networks, Norms, Standards

InterpersonalFamily, peers, social networks,

associations

IndividualKnowledge, attitudes,

beliefs

Levels of Influence in the Social-Ecological Model

Behavior changeinfluenced at all levels

Social-Ecological Model

Broad Conditions and Policies

Living and Working Conditions

Social, Family, and Community Networks

Individuals

Broad Conditions and Policies

Broad social, economic, cultural,

health, and environmental

conditions and policies at the global, national, state and local levels

Broad social, economic, cultural,

health, and environmental

conditions and policies at the global, national, state and local levels

Broad Conditions and Policies

Social conditions include, but are not limited to: economic inequality,

urbanization, mobility, cultural values, attitudes and policies related to discrimination and intolerance on the basis of race, gender, and other

differences.

Social conditions include, but are not limited to: economic inequality,

urbanization, mobility, cultural values, attitudes and policies related to discrimination and intolerance on the basis of race, gender, and other

differences.

Broad Conditions and Policies

O

•Other conditions at the national level might include major sociopolitical shifts, such as recession, war, and governmental collapse.•The built environment includes transportation, water and sanitation, housing, and other dimensions of urban planning.

•Other conditions at the national level might include major sociopolitical shifts, such as recession, war, and governmental collapse.•The built environment includes transportation, water and sanitation, housing, and other dimensions of urban planning.

Living and Working Conditions

May include:•Psychosocial factors•Employment status and occupational factors•Socioeconomic status (income, education, occupation, wealth)•The natural and built environments•Public health services•Health care services

May include:•Psychosocial factors•Employment status and occupational factors•Socioeconomic status (income, education, occupation, wealth)•The natural and built environments•Public health services•Health care services

Social, Family, Community Networks

Social Connectedness:•Social networks•Social support•Social integration•Social engagement

Social Connectedness:•Social networks•Social support•Social integration•Social engagement

Social, Family, Community Networks

Social network pathways of influence on health:•Health behaviors•Health care•Access to material resources – jobs, etc.•Direct physiological responses leading to disease development and prognosis

Social network pathways of influence on health:•Health behaviors•Health care•Access to material resources – jobs, etc.•Direct physiological responses leading to disease development and prognosis

Individuals

•Innate biological factors•Health behaviors•Psychological factors•Physiological influences

•Innate biological factors•Health behaviors•Psychological factors•Physiological 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)

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

ENVIRONM ENTAL CHANGE

DEM OGRAPHIC AND SOCIAL

TRADE TRAVEL M IGRATION

HUM AN ANIM AL RELATIONSHIP

TECHNOLOGY

WAR CONQUEST

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

•

Most Public Health Interventions

Health Outcomes

Most Health Care

Political Social Cultural Economic Spiritual Ecological Technological

ForcesNation-States

Regions

(Urban Entities)

Neighborhoods / Communities

Families / Couples / Households

Lifecourse of Individuals

Population Health Framework

Biological Endowment

Gene-Environment Interactions

Physical & Social Environmental Exposures

27

Peran dr kesmas ; link individu.keluarga

population dan kebijakan

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