Diagnosa Komunitas

dr. Regina Satya W, MSc

FKUAJ

What do we mean by ethics?

• Doing no harm • Respecting people's as ends, not means • Respecting participant's ability to play a role on what

they need • Respect everyone's human, civil, and legal rights. • Doing what is best for everyone • Not abusing your position

Common situations in medicine

• Patient-Provider interactions

• Uses of new technologies

• Beginning and end of life

• Distribution of health care

Key principles in medical ethics

• Autonomy: the right of a person to govern himself or herself; the right not to be coerced. The autonomy of the patient is the key concern here; protecting the patient from abuse by the clinician who has the most power in the patient-provider interaction.

• Nonmaleficence: the absence of an intent to do harm. Again, this is an intent or attitude to be had by the clinician when interacting with a patient. hey are

• Beneficence: to seek the best interests or benefit of the patient.

• Justice

Common situations in public health

• Institutional action

• To prevent disease or disability

• In populations and communities

Common situations

• Policies and practices affecting a population are typically designed and implemented by a government agency or some other organization such as a health department.

• In contrast to medicine where the primary moral agent is the clinician, in public health, government agencies and other institutions dominate the moral landscape. Affect whole populations

Common situations

• Primary : Avoidance of illness or disability

• Secondary : Treatment of a curable condition

• Tertiary : Postponing progression of an incurable condition

Key Principles in Public Health Ethics

• Values and Beliefs Underlying the Code : key assumptions inherent to a public health perspective. They underlie the 12 Principles of the Ethical Practice of Public Health

Key Principles in Public Health Ethics

Health

• Humans have a right to the resources necessary for health (“Everyone has the right to a standard of living adequate for the health and well-being of himself and his family…” )

Community

• Humans are inherently social and interdependent. Positive relationships = healthy community. Each person’s actions affect other people.

• 4.

Key Principles in Public Health Ethics Community • The effectiveness of institutions depends on the public’s trust.

Factors : communication; truth telling; transparency ; accountability; reliability; and reciprocity (listening to as well as speaking with the community).

• Collaboration is of agencies and professional disciplines. New collaborations will be needed for new PH challenges.

• People and their physical environment are interdependent. Damaged or unbalanced natural environment/ poor design or poor condition of environment adverse health effect of people. Conversely, consumption of resources and generation of waste bad effect for environment.

•

Key Principles in Public Health Ethics

Community • Each person in a community should have an opportunity to

contribute to public discourse; through a direct or a representative system of government. (i.e in developing and evaluating policy)

• Identifying and promoting the fundamental requirements for health in a community are of primary concern to public health. Community’s health reflects how structured the society is. PH concern about the underlying structural aspects, causes and prevention addressing the fundamental causes rather than more proximal causes is more truly preventive.

Key Principles in Public Health Ethics

Bases for Action

• Knowledge is important and powerful research knowledge sharing information ie. active and informed participation in policy-making processes need access to relevant information. If information provided in confidence, there is an obligation to protect information.

• Science is the basis for much of PH knowledge the scientific method and tools relatively objective means of identifying the factors for population’s health, evaluating policies and programs to protect and promote health.

Key Principles in Public Health Ethics

Bases for Action

• Public health should seek to translate available information into timely action. Often, the action required is research to fill in the gaps of what we don’t know.

• Action is not based on information alone. In many instances, action is required in the absence of all the information one would like. In other instances, policies are demanded by the fundamental value and dignity of each human being, even if implementing them is not calculated to be optimally efficient or cost-beneficial. In both of these situations, values inform the application of information or the action in the absence of information.

Principles of the Ethical Practice of Public Health

1. Address fundamental causes of disease and requirements for health, to prevent adverse health outcomes.

2. Achieve community health in a way that respects the rights of individuals in the community.

3. Policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

4. Advocate and work for the empowerment of disenfranchised community members, to ensure that basic resources and conditions are accessible to all.

5. Seek information needed to implement effective policies and programs that protect and promote health.

6. Institutions should provide the information on policies or programs, to obtain community’s consent for implementation.

Principles of the Ethical Practice of Public Health

7. Institutions should act in a timely manner on the information about the resources and on the mandate given by the public.

8. Programs and policies should incorporate approaches, to anticipate and respect values, beliefs, and cultures in the community.

9. Programs and policies should be implemented in a manner that most enhances the physical and social environment.

10. Institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions: high likelihood of significant harm to others.

11. Institutions ensure the professional competence of employees.

12. Institutions and employees should engage in collaborations and affiliations, to build the public’s trust and the institution’s effectiveness.

Definisi Komunitas

• Sekelompok orang dengan karakteristik yang sama (misalnya lokasi geografi, pekerjaan, etnis, sosial ekonomi, kondisi rumah, dll)

• Biasanya tinggal bersama

• Biasanya berada dalam suatu komunitas yang lebih besar masyarakat.

• Mempunyai fungsi tertentu dalam sebagai bagian yang saling berkaitan dengan kelompok masyarakat lainnya.

Definisi Diagnosa Komunitas

• Proses identifikasi dan pengukuran dari masalah-masalah kesehatan di dalam masyarakat, dan sumber daya yang ada di masyarakat.

• Bertujuan untuk mengidentifikasi kelompok masyarakat yang memiliki risiko dan membutuhkan pelayanan kesehatan.

• Tujuan globalnya adalah untuk meningkatkan dan mempromosikan kesehatan dari anggota masyarakat.

Tujuan Diagnosa Komunitas

• Menganalisa status kesehatan masyarakat • Mengevaluasi sumber data kesehatan, pelayanan

dan sistem yang ada dalam masyarakat • Menilai perilaku masyarakat terhadap pelayanan

kesehatan dan masalah perilaku yang ada • Menentukan prioritas, tujuan dan tindakan yang

akan dilakukan untuk meningkatkan status kesehatan masyarakat

• Membuat dasar pengukuran epidemiologis yang dapat digunakan untuk mengukur kemajuan dari waktu ke waktu.

Karakteristik Diagnosa Komunitas Yang Baik

• Dapat menemukan masalah kesehatan yang dapat dikontrol

• Dapat mengidentifikasi sebagian target dari masalah kesehatan

• Menampakkan perubahan dari waktu ke waktu • Definisi jelas untuk populasi, pengumpulan data, alur

data, analisa data, interpretasi dan umpan balik • Terorientasi kepada tindakan yang dapat dilakukan • Melibatkan partisipasi masyarakat, tidak terlalu rumit,

sensitif, dapat dilakukan dalam waktu yang tersedia dan sesuai dana yang tersedia.

Kerangka Diagnosa Komunitas

• Tentukan definisi komunitas

• Melakukan analisa komunitas

• Membuat prioritas

• Mendesign program

• Mengevaluasi program

1. Menentukan Definisi Komunitas

• Dapat berupa suatu negara, provinsi, atau secara geografis (seperti kota) atau sosial (seperti kelompok miskin, kelompok rentan).

• Definisi dari komunitas harus cukup luas supaya dalam mencakup sub grup yang dibutuhkan untuk menilai status kesehatan, untuk menjamin equity dari kesehatan.

Equity

• The absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.

• Health inequities involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes.

• Equity also entails a failure to avoid or overcome inequalities that infringe on fairness and human rights norms.

2. Analisa Komunitas

• Proses pengolahan data untuk menentukan kebutuhan, kekuatan, hambatan, kesempatan, kesiapan dan sumber daya “community profile”.

Determinant of population health, as presented in the US Federal report “Sharing vision of health statistics for 21st century (2002)”.(3)

2. Analisa Komunitas

• Untuk memudahkan dalam menganalisa data, biasanya data dikelompokkan dalam:

– Demografi

– Lingkungan

– Socioekonomi

– Sumber data pelayanan kesehatan

– Kebijakan kesehatan

– Penelitian dari masyarakat terkait

Indikator Kesehatan

2.a. Indikator Kesehatan

• Adalah variabel yang digunakan untuk menilai status kesehatan masyarakat

• Syarat indikator: – Valid: mengukur apa yang harus diukur – Reliable and objective: jawaban harus sama bila diukur

oleh orang yang berbeda atau dalam waktu yang berbeda – Sensitive: sensitif untuk mengukur perubahan yang terjadi – Specific: menggambarkan perubahan situasi yang

diinginkan – Feasible: data yang dibutuhkan tersedia – Relevant: berkontribusi dalam pengertian fenomena yang

dipelajari

2.a. Classification of health Indicators

• Positive: Indicators of quality of life limitations for developing countries (lower hopes among poorer people).

• Negative: mortality, morbidity, disability rates, nutritional status indicators

• Other indicators: Health care delivery indicators, utilization rates, indicators of social and mental health, environmental indicators, socio-economic indicators, health policy indicators

2.b. Sumber Informasi Untuk Indikator

• Laporan rutin pelayanan kesehatan

• Surveillance (aktif, pasif dan sentinel)

• Screening

• Special survey

• Rapid survey

• Contact tracing

• Combination

2.c. Melakukan Analisa Trend

• Yaitu menganalisa perubahan indikator situasi kesehatan, beban kesehatan, perilaku beresiko dari waktu ke waktu

• Transisi demografi, urbanisasi, pengembangan pendidikan, perubahan kemandirian wanita, kemajuan ekonomi, politik, inovasi teknologi, global intervention/international tranfer of risk (polusi, pemanasan global, epidemi global).

Membuat Prioritas

• Preparatory work ( 5 point)

• Deciding on priorities ( 2 point)

• After priorities has been set (2 point)

Preparatory work Context

• Contextual factors underpin the process: resources available, focus of the exercise (i.e. what is the exercise about and who is it for), underlying values or principles, health, research and political environment in which the process will take place

Use of a comprehensive approach

• Decide if use of a comprehensive approach is appropriate, or if development of own methods is the preferred choice.

• These approaches provide structured, detailed, step-by-step guidance for health research priority setting processes from beginning to end.

Preparatory work

Inclusiveness • Who should be involved in setting the health research priorities and

why. (Include appropriate representation of expertise, balanced gender, regional participation, important health sectors and other constituencies)

Information gathering • Information should be gathered, such as literature reviews,

collection of technical data (e.g. burden of disease or cost-effectiveness data), assessment of broader stakeholder views, reviews or impact analyses of previous priority setting exercises or exercises from other geographical levels.

Planning for implementation • Establish plans for translation of the priorities to actual research

(via policies and funding) as a priority at the beginning of the process. Who will implement the research priorities? And how?

Deciding on priorities

Criteria

• Select relevant criteria to focus discussion around setting priorities.

Methods for deciding on priorities

• Choose a method for deciding on priorities. Decide whether to use a consensus based approach or a metrics based approach (pooling individual rankings), or a combination.

After priorities have been set

Evaluation

• Define when and how evaluation of the established priorities and the priority setting process will take place. Health research priority setting should not be a one-time exercise!

Transparency

• Write a clear report that discusses the approach used: Who set the priorities? How exactly were the priorities set?

Why is ethical behavior important in community interventions?

• Program effectiveness

• Standing in the community

• Moral credibility and leadership

• Professional and legal issues

What are the ethical issues that need to be considered, and how do they play out

in community interventions?

1. Confidentiality

Program possibilities: • No one will have access to records of a participant without

her permission • Information may be shared among staff members for

purposes of consultation • Information may be shared with other programs in which

the participant is involved • Information is submitted to funding sources as

documentation of services provided • Information is not confidential

2. Consent

• Consent to sharing of information

• Informed consent for services, treatment, research, or program conditions

• Community consent

3. Disclosure

• Disclosure to participants of the conditions of the program they're in

• Disclosure of participant information to other individuals, agencies, etc

• Disclosure of any conflict of interest

4. Competence

• The organization can accomplish its goals under reasonable circumstances

5. Conflict of interest

• Point it out to whoever needs to know

• Eliminate the conflict situation

6. Grossly unethical behavior

• Sexual relationships, exploit, fraud, discrimination, criminal behavior, etc

7. General ethical responsibilities

• to funders

• to staff members

• to participants

• to the community

Steps in addressing an ethical issue

• Clarify the facts • Identify the ethical questions • Identify the stakeholders • Consider various ethical perspectives (human right dignity,

protection from accidental death; right- utilitarian benefits to the majority, Majority benefits from work of minority, inexpensive intervention)

• Apply ethics tools (law, codes of ethics, prior or parallel instances) • Identify possible courses of action ( i.e. pamphlets,

resident caretakers, emergency responder visits) • Select one course • Evaluate the decision (fund, personnel, time, follow through)

Tugas

• Ringkaslah materi yang diberikan dalam bentuk power point yang dapat dipresentasikan dalam waktu 15 menit.

• Hand out di print ( 2 slides dalam 1 halaman), untuk diberikan kepada dosen).