social determinants and risk factors of tb: how countries

Working Group on SD and risk factors

13th NTP Managers’ Meeting

27-29 Jun 2015, The Hague

Social determinants and risk factors of TB:

how countries do monitor and tackle them?

Pierpaolo de Colombani, WHO Regional Office for Europe, Copenhagen

Wouter Arrazola de Oñate, BELTA, Brussels

Members of the Working Group on Social Determinants of TB and Drug Resistant TB:

Pierpaolo de Colombani (Copenhagen, Denmark), Wouter Arrazola de Oñate (Brussels,

Belgium), Liliana Domente (Chisinau, Republic of Moldova), Araksya Hovhannesyan

(Yerevan, Armenia), Aaron Reeves (Oxford, UK), Alena Skrahina (Minsk, Belarus), Sarah

Simpson (Montluel, France)




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Composition and terms of reference finalized in Sep 2013

Working Group on SD of TB and DR-TB

Six objectives:

1. Map social determinants (SD) + risk factors (RF) collected at

national level through surveillance/survey

2. Recommend on how to improve TB recording/reporting

3. Document past and present interventions for improving the SD

of TB

4. Recommend for addressing SD of TB and ensuring social

protection

5. Produce a paper for possible publication

6. Develop an operational research age

7. Develop an agenda for ACSM

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Survey on how NTPs monitor SD/RF (1/3)

Pretested semi-structured questionnaire, English/Russian; e-mailed

to national TB surveillance correspondents

Responses from 47/53 (89%) countries: 28 EU/EEA, 19 non-

EU/EEA, 17 TB high-priority countries (HPC) (no response: Austria,

Israel, San Marino, Slovenia, Turkmenistan)

EU/EEA (%) non-EU/EEA (%) HPC (%)

Requested by ECDC/WHO for reporting:

Nationality/citizenship 96% 95% 88%

Status of imprisonment 54% 79% 76%

Not requested by ECDC/WHO for reporting:

Occupation/employment 68% 89% 88%

Homelessness 57% 79% 71%

Urban/rural 46% 89% 94%

Refugee/displaced/asylum 50% 58% 41%

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EU/EEA (%) non-EU/EEA (%) HPC (%)

Requested by ECDC/WHO for reporting:

Age 100% 100% 100%

Sex 100% 100% 100%

HIV infection 82% 89% 100%

Not requested by ECDC/WHO for reporting:

Diabetes mellitus 54% 63% 59%

Use of alcohol 54% 58% 59%




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Case Case variables and definitions

Occupation Employed: individual receiving an income from a

employer or a self-employment job

Unemployed: individual without work but available for

and seeking work

Homelessness Individual without stable, permanent, appropriate

housing, or the immediate prospect, means and ability

of acquiring it.

Diabetes

mellitus

Presence of fasting plasma glucose ≥ 7.0mmol/l

(126mg/dl) or 2–h plasma glucose ≥ 11.1mmol/l

(200mg/dl).

(Harmful) use

of alcohol

Intake of 5 or more drinks (60g pure alcohol) on one

occasion monthly or more often during the past 12

months




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2nd Survey: interventions SD

Open-ended question to all national TB focal points

“Describe any non-medical intervention by any actor, past or recent ... “

Qualitative analysis PPHCKN* framework: socioeconomic context (society); differential

exposure (social and physical environment); differential vulnerability (population groups); differential health

outcomes (individual); and differential consequences (individual)

Participation of 12/53 (23%) countries: 7 EU/EEA (Belgium, Latvia, Malta, Netherlands,

Norway, Slovakia, United Kingdom), 5 non-EU/EEA (Armenia, Belarus, FYR Macedonia, Serbia, Ukraine), 3 TB

high-priority countries (Armenia, Belarus, Ukraine)

14 respondents (2 from Belgium and Serbia):

7 top managers of national TB institutes,

4 senior staff in the Ministry of Health and public health institutes

3 were senior staff of nongovernmental organizations

* Priority Public Health Conditions Knowledge Network (PPHCKN)




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To complement survey

• secondary data

• countries of respondents

• case studies on actions addressing poverty and social exclusion

• WHO. Poverty and social exclusion in the WHO European Region: health

systems respond. Copenhagen: WHO, 2010

• European Observatory on Health Systems and Policies. Health system reviews

published on the following countries:

– Armenia (2013), Belarus (2013), Belgium (2010), The former Yugoslav

Republic of Macedonia (2006), Latvia (2012), Malta (2014), Netherlands

(2010), Norway (2013), Slovakia (2011), Ukraine (2010), England (2011),

Northern Ireland (2012), Scotland (2012) and Wales (2012)




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Examples of responses on survey

• Armenia: “Under the Soviet Union, each TB patient received an apartment,

which increased the treatment success and decreased TB transmission”

• Belarus: “rehabilitation centres for former prisoners: i) medical screening and

care; ii) free accommodation and meals; iii) temporary registration and

document recovery; iv) legal assistance; v) social rehabilitation and job

opportunities”

• Latvia : “municipality of Riga provides financial support (public transport,

purchase of food) to patients coming for DOT”

• Norway: “improve socioeconomic conditions: labor laws ensuring fair salaries

and working conditions, progressive taxation, social housing, nutrition program

in schools, health insurance for all, etc.”

• Slovakia: “Health Support Programme for Disadvantaged Roma Community”

• UK: “Health and social care act 2012” duty to local governments ... to reduce

health inequities”

• Norway: taxing alcohol + earmarked to TB control activities




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2nd Survey: Conclusions

Questionnaire design + awareness

Scarce documentation of interventions at the first 2-3 levels of PPHCKN the

framework

Further work needed to systematically document existing social protection

interventions in relation to people with TB

Addressing social determinants and risk factors of TB is priority under

Health 2020 European policy and strategy

End TB Strategy

TB Action Plan 2016-2020 for Europe




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1. Should the working group continue its work?

2. Should it continue along with the current TOR (i.e. develop an

operational research agenda and an ACSM agenda) or differently?

3. New members, more members?

4. Duplication with other initiatives? How to link with them?

5. Questionnaire fatigue in countries?

Questions for discussion

social determinants and risk factors of tb: how countries

Documents