Preparación y respuesta ante emergencias sensibles a poblaciones migrantes en Chile: perspectivas postpandémicas / Emergency preparedness and response sensitive of migrant populations in Chile: post-pandemic perspectives

El 31 de agosto de 2023, el Gobierno de Chile puso fin a la alerta sanitaria por COVID-19. Este hito invita a reflexionar sobre lecciones aprendidas respecto a la preparación y respuesta ante emergencias, que sean sensibles e informadas sobre la experiencia de la población migrante de nuestro país. En este marco, se presentan tres perspectivas. La primera se centra en evitar la responsabilización individual en el incumplimiento de las medidas de prevención del contagio, ya que este enfoque ignora las inequidades estructurales e históricas. Las recomendaciones de emergencia se deben construir bajo un abordaje colectivo y con la consideración de los diversos contextos socioculturales y políticos. La segunda perspectiva llama a tomar en cuenta y abordar la migración como determinante social de la salud de la población en la preparación y respuesta ante emergencias. Durante la pandemia, los cambios en la gobernanza de la migración en todo el mundo precarizaron los procesos migratorios, con riesgos para la salud física y mental de las personas que migran. Esto requiere una mejor planificación y decisiones informadas en evidencia científica para futuras pandemias. La tercera perspectiva se enfoca en promover la interculturalidad, dado que la comunicación de los riesgos de contagio y de las medidas preventivas se vio dificultada entre poblaciones migrantes con diversas cosmovisiones e interpretaciones de los procesos de salud y enfermedad. Asimismo, el responder a las necesidades de aquellas comunidades históricamente marginadas, requiere establecer modos de vida que respeten la diversidad en las narrativas y las prácticas cotidianas. Los gobiernos y sistemas sanitarios deben incorporar la migración a sus estrategias de preparación y respuesta ante emergencias, con la construcción de las condiciones para su cumplimiento óptimo.

On August 31, 2023, the Chilean government ended the health alert for COVID-19. This milestone invites us to reflect on lessons learned in emergency preparedness and response regarding migrant populations in the country. In this context, three perspectives are presented. The first focuses on avoiding pointing to individual responsibility for non-compliance with prevention measures, as this approach ignores structural and historical inequities. Emergency recommendations should be constructed considering a collective approach and diverse sociocultural and political contexts. The second perspective calls for considering and addressing migration as a social determinant of health. During the pandemic, changes in the governance of migration around the world made migration processes more precarious, with risks to the physical and mental health of migrants, which needs better planning and evidence-based decision-making in future pandemics. The third perspective focuses on promoting intercultural health, as effective communication of contagion risks and preventive measures were hampered among migrant populations with diverse worldviews and interpretations of health and disease processes. Responding to the needs of historically marginalized communities requires establishing ways of life that respect diversity in narratives and everyday practices. Governments and health systems must incorporate migration into their emergency preparedness and response strategies, creating the conditions for optimal compliance.

The socioeconomic distribution of life expectancy and healthy life expectancy in Chile.

BACKGROUND: Life expectancy (LE) has usually been used as a metric to monitor population health. In the last few years, metrics such as Quality-Adjusted-Life-Expectancy (QALE) and Health-Adjusted-Life- Expectancy (HALE) have gained popularity in health research, given their capacity to capture health related quality of life, providing a more comprehensive approach to the health concept. We aimed to estimate the distribution of the LE, QALEs and HALEs across Socioeconomic Status in the Chilean population. METHODS: Based on life tables constructed using Chiang II´s method, we estimated the LE of the population in Chile by age strata. Probabilities of dying were estimated from mortality data obtained from national registries. Then, life tables were stratified into five socioeconomic quintiles, based on age-adjusted years of education (pre-school, early years to year 1, primary level, secondary level, technical or university). Quality weights (utilities) were estimated for age strata and SES, using the National Health Survey (ENS 2017). Utilities were calculated using the EQ-5D data of the ENS 2017 and the validated value set for Chile. We applied Sullivan´s method to adjust years lived and convert them into QALEs and HALEs. RESULTS: LE at birth for Chile was estimated in 80.4 years, which is consistent with demographic national data. QALE and HALE at birth were 69.8 and 62.4 respectively. Men are expected to live 6.1% less than women. However, this trend is reversed when looking at QALEs and HALEs, indicating the concentration of higher morbidity in women compared to men. The distribution of all these metrics across SES showed a clear gradient in favour of a better-off population-based on education quintiles. The absolute and relative gaps between the lowest and highest quintile were 15.24 years and 1.21 for LE; 18.57 HALYs and 1.38 for HALEs; and 21.92 QALYs and 1.41 for QALEs. More pronounced gradients and higher gaps were observed at younger age intervals. CONCLUSION: The distribution of LE, QALE and HALEs in Chile shows a clear gradient favouring better-off populations that decreases over people´s lives. Differences in LE favouring women contrast with differences in HALEs and QALEs which favour men, suggesting the need of implementing gender-focused policies to address the case-mix complexity. The magnitude of inequalities is greater than in other high-income countries and can be explained by structural social inequalities and inequalities in access to healthcare.

The social and health protection of migrants in Chile: qualitative analysis of civil society proposals for constitutional change.

BACKGROUND: A sustained period of social, economic, and political unrest took place during October of 2019 in Chile. As an institutional solution, the "Agreement for Social Peace and the New Constitution" was signed. In this document, most political parties committed to reestablishing peace and public order in Chile, agreeing on the initiation of a constitutional process. To promote participation of civil society actors, the "Popular Initiative for Norms" was enabled. This was a platform where civilians could submit proposals for constitutional norms to be discussed by the Constitutional Convention. We aimed to analyze proposals related to migrants and migrant health. METHODS: We conducted a qualitative thematic analysis of the proposals. Sixteen of them were related to migrants, and we analyzed their association to health. We also evaluated their link to the Health Goals 2030 set out by the Chilean Ministry of Health and the Global Action Plan 2019-2023 for Promoting the Health of Refugees and Migrants by the World Health Organization. RESULTS: Four main thematic categories were identified: 1) Humans rights of migrants, refugees, and asylum seekers; 2) Nationality and regularization of migrants and refugees; 3) Political participation and cultural integration of migrants and refugees; and 4) Specific regulations on slavery and human trafficking. These resonated with broader frameworks established in the Health Goals 2030 (Chile) and the Global Action Plan 2019-2023 for Promoting the Health of Refugees and Migrants by the World Health Organization. CONCLUSIONS: The 'Popular Initiative for Norms' was a non-binding participatory mechanism. Although the proposals sent through were not guaranteed to be included in the constitutional draft-and despite the final draft being rejected last September 2022-the platform allowed to gain insights into civilian opinions. Our findings showed that there is an incipient yet weak recognition of the rights and situation of migrants in Chile. There was no direct mention of health nor an explicit contemplation of social determinants of health. Despite there being an urgent need to define strategies for migrants' health in Chile, this study demonstrated that civil awareness and interest are still insufficient.

Inequalities in infant vaccination coverage during the COVID-19 pandemic: A population-based study in Peru.

OBJECTIVE: To identify the associated factors and assess the inequalities of full vaccination coverage (FVC) among Peruvian infants aged 12-23 months during the COVID-19 pandemic in a nationally representative sample. METHODS: We carried out a population-based cross-sectional study based on a secondary data analysis using the 2021 Peruvian Demographic Health Survey (DHS) in infants aged 12 to 23 months. The sampling design was probabilistic, multistage, stratified, and independent at both departmental and area of residence levels. FVC was defined according to the WHO definition. We performed generalized linear models (GLM) Poisson family log link function to estimate crude (aPR) and adjusted prevalence ratios (aPR). Also, for inequality assessment, we calculated the concentration curve (CC), concentration index (CI), and Erreygers normalized concentration index (ECI). RESULTS: We included 4,189 infants in our analysis. Nationwide, the prevalence of FVC was 66.19% (95% CI: 64.33-68). Being younger, having a mother with no education or primary education, belonging to a large family, having no access to mass media, having had six or fewer ANC visits, and having a mother whose age was under 20 at first delivery were inversely associated with FVC. Meanwhile, living in the Highlands or on the rest of the coast, and living in rural areas were directly associated with FVC. We found a pro-rich inequality in FVC based on wealth-ranked households (CI: 0.0066; ECI: 0.0175). CONCLUSION: FVC has dropped among Peruvian infants aged between 12 and 23 months. There were several factors associated with FVC. It was more concentrated among the better-off infants, although in low magnitude.

The legal path for priority setting in Chile: a critical analysis to improve health planning and stewardship.

Health systems have committed their path to universal health coverage using health planning to accomplish their goals of efficiency, equity and sustainability. Chile, a high-income country with a public-private mix health system, has made significant progress through several successive health policies implemented in the last 20 years which have been consistent with this approach. However, in the last 5 years, the national congress has produced several disease-specific laws, which have been mainly promoted by the civil society. These laws indicate the actions the health authority must perform to tackle the needs of the affected population, which ultimately determine the priorities of the health system. We argue that this legal pattern has become an alternative path to priority-setting, as opposed to health planning. We claim this "legal path" is a mechanism used by civil society in a context where the health authority fails to implement a robust and legitimate prioritization process. Although these laws have brought benefits to patients suffering the corresponding conditions, we highlight this approach does not guarantee improvements in equity, efficiency and health system performance. Instead, we advocate for taking back the control of the priority-setting based on health planning, through a new institutionalization of health technology assessment and quality of care.

Access to health services for international migrants during the COVID-19 pandemic: a qualitative study / Acesso a serviços de saúde para migrantes internacionais durante a pandemia de COVID-19: estudo qualitativo / Acceso a servicios de salud para personas migrantes internacionales durante la pandemia por COVID-19: estudio cualitativo

ABSTRACT Objective: To explore the experience and perception of international migrants in Chile regarding access to health services during the pandemic. Method: Collective case study following the qualitative paradigm. Forty semi-structured interviews were carried out with 30 migrants from different countries in Latin America and the Caribbean and 10 key actors from the health or social sector in November and December 2020. The interviews were analyzed thematically. Results: Perceived facilitators for general access to health services are related to formal work, support networks, and good treatment, while barriers are linked to immigration status, information gaps, discrimination, lack of cross-cultural skills, and personal limits of the system. In the context of access to COVID-19 diagnosis and treatment, the main barriers identified are: cultural approach to the disease, communication gaps, experiences of discrimination, costs, and lack of support networks. Conclusion: Access to health services is related to social vulnerability and violation of international migrants rights.

RESUMO Objetivo: Explorar a experiência e a percepção dos migrantes internacionais no Chile sobre o acesso aos serviços de saúde durante a pandemia. Método: Estudo de caso coletivo sob o paradigma qualitativo. Foram realizadas 40 entrevistas semiestruturadas com 30 migrantes de diferentes países da América Latina e Caribe e 10 atores-chave do setor de saúde ou social em novembro e dezembro de 2020. As entrevistas foram analisadas tematicamente. Resultados: Os facilitadores percebidos para o acesso geral aos serviços de saúde estão relacionados ao trabalho formal, redes de apoio e bom tratamento, enquanto as barreiras estão ligadas ao status de imigração, lacunas de informação, discriminação, falta de habilidades interculturais e limites próprios do sistema. No contexto do acesso ao diagnóstico e tratamento da COVID-19, identificam-se principalmente barreiras: abordagem cultural da doença, lacunas de comunicação, vivências de discriminação, custos e falta de redes de apoio. Conclusão: O acesso aos serviços de saúde está vinculado à vulnerabilidade social e à violação dos direitos dos migrantes internacionais.

RESUMEN Objetivo: Explorar la experiencia y percepción de las personas migrantes internacionales en Chile en torno al acceso a servicios de salud durante la pandemia. Método: Estudio de caso colectivo bajo el paradigma cualitativo. Se llevaron a cabo 40 entrevistas semi-estructuradas con 30 personas migrantes provenientes de diferentes países de América Latina y el Caribe y 10 actores clave del sector salud o social en noviembre y diciembre 2020. Se analizaron las entrevistas temáticamente. Resultados: Los facilitadores percibidos para el acceso general a servicios de salud se relacionan con el trabajo formal, las redes de apoyo y el buen trato, mientras que las barreras se vinculan con situación migratoria, brechas de información, discriminación, falta de competencias interculturales y límites propios del sistema. En contexto de acceso a diagnóstico y tratamiento de COVID-19, se identifican principalmente barreras: abordaje cultural de la enfermedad, brechas comunicacionales, experiencias de discriminación, costos y faltas de redes de apoyo. Conclusión: El acceso a servicios de salud se vincula con vulnerabilidad social y vulneración de derechos de las personas migrantes internacionales.

Health in Chile's Recent Constitutional Process: A Qualitative Thematic Analysis of Civil Proposals.

(1) Background: In response to the recent political crisis in Chile, the "Agreement for Social Peace and the New Constitution'' was approved. We aimed to analyze the health-related civil proposals uploaded to the official website for popular participation in the new constitution in Chile. (2) Methods: We carried out a qualitative thematic analysis of 126 health-related valid proposals. Moreover, we analyzed their link to the Health Goals 2030, established by the Ministry of Health of Chile and to the Sustainable Development Goals (SDGs). (3) Results: Sixteen main categories were reached. In all, they were organized into four main areas: (i) the right to health and the establishment of a universal health system; (ii) effective access to selected healthcare services; (iii) improving health outcomes for all and for the relevant subgroups; and (iv) the social determinants of health, health in all the policies, and community health. We found that these four areas were strongly linked to the Health Goals 2030 for Chile and to the SDGs. (4) Conclusions: Despite the fact that the new constitutional proposal was rejected in September 2022, the civil health-related proposals and the areas of health and healthcare were of interest to the citizens as the request showed a strong demand from the population for participation in matters of health, healthcare, and public health.

Health-related quality of life by household income in Chile: a concentration index decomposition analysis.

BACKGROUND: Health inequities have a profound impact on all dimensions of people's lives, with invariably worse results among the most disadvantaged, transforming them into a more fragile and vulnerable population. These unfair inequalities also affect dimensions focused on subjectivity, such as health-related quality of life (HRQoL), which has been positioned, in recent decades, as an important outcome in health decision-making. The main objective of this study is to estimate socioeconomic inequality in HRQoL of Chilean by household income.  METHODS: Secondary analysis of the National Health Survey (ENS 2016-2017, Chile). This survey includes a nationally representative, stratified, and multistage household sample of people aged 15 and above. Socioeconomic inequality in HRQoL (EQ5D) is estimated by the concentration index (CI) ranked by household income. Decomposition analysis is conducted to examine potential explanatory sociodemographic factors.  RESULTS: The CI for household income inequality in HRQoL was -0.063. The lower the household income, the worse the HRQoL reported by in Chile. The decomposition analysis revealed that socioeconomic position contributes 75,7% to inequality in the quality of life, followed by educational level (21.8%), female gender (17.3%), and type of Health Insurance (15%), age (-19.7%) and residence (-10.8%). Less than 1% corresponds to the unexplained residual component. CONCLUSIONS: Our findings suggest the existence of a disproportionate concentration of worse HRQoL in the most disadvantaged socioeconomic groups in Chile. This inequality is largely, yet not completely, associated with household income. Other significant factors associated with this inequality are education, gender, and healthcare insurance. These results suggest the need of strengthening efforts to reducing socioeconomic gaps in health outcomes in Chile, as a means to achieve social justice and equity in health and healthcare.

Perceptions of Health Needs among Venezuelan Women Crossing the Border in Northern Chile during the COVID-19 Pandemic.

In parallel to the COVID-19 pandemic, Chile has experienced a significant influx of international migrants, many of whom are Venezuelan women who have entered the country through unauthorized crossing points. In this context, gender and migration intersect as the social determinants of health, leading to their experiencing a range of adverse events. This poses important challenges in terms of short- and long-term health outcomes, the social determinants of health, and access to healthcare. This study aims at describing Venezuelan women's perceptions of their health needs as they migrate to Chile via an unauthorized crossing point, with a focus on adverse events throughout the migration cycle, self-reported health needs, and responses. A qualitative case study was carried out with 22 participants in the Antofagasta region of Chile, including Venezuelan migrant women, healthcare professionals, and social workers from the public healthcare system, stakeholders from non-governmental and international organizations, and local government officials. The semi-structured, individual interviews were analyzed thematically. The results show that Venezuelan women face a range of adverse events throughout the migration cycle. The perceived health needs that are reported are sometimes linked to these adverse events or existed prior to migration and were exacerbated throughout the migratory cycle. Addressing these physical and mental health needs is essential for short- and long-term individual and public health; however, despite substantial efforts to ameliorate the situation, persisting gaps in access to care are reported.

Disparities in scientific research activity between doctors and nurses working in the Peruvian health care system: Analysis of a nationally representative sample.

AIM: To evaluate disparities in the frequency of scientific activity between medical doctors and nurses in Peru. METHODS: We carried out a secondary data analysis of the National Health Services Users' Satisfaction Survey (ENSUSALUD), 2016. This nationally representative survey evaluates doctors and nurses working in clinical settings. We defined scientific activity as i) having published an original article (journal indexed in Web of Science, Scopus or Medline); and ii) having authored an abstract in a national or international conference. We estimated crude and adjusted disparities prevalence ratios (aDPR) and 95% confidence intervals (95%CI). RESULTS: We included 2025 doctors and 2877 nurses in the analysis; 71% of doctors doctor were male, and 93% of nurses were female (p<0.001). Among doctors, 13.9% had published an article, and 8.4% presented an abstract at a conference in the last two years, while these proportions were 0.6% and 2.5% for nurses, respectively. The adjusted models showed that doctors, when compared to nurses, were approximately 27 times likely to have published a paper (aDPR = 27.86; 95% CI 10.46 to 74.19) and twice as likely to have authored a conference abstract (aDPR = 2.51; 95% CI 1.39 to 4.53). CONCLUSIONS: There are important disparities in scientific activity between doctors and nurses working in clinical settings in Peru. Disparities are more significant for article publication than for authoring in conference abstracts. We suggest public policies that promote research dissemination between health professionals, with emphasis on nurses.

Recursos y vulnerabilidades de comunidades migrantes en Chile para enfrentar la pandemia SARS-CoV-2

Objetivo Conocer, en contexto de la pandemia por SARS-CoV-2, las vulnerabilidades psicosociales y socioeconómicas de la población migrante internacional en Chile y los recursos y capitales sociales reportados desde la propia comunidad. Métodos Estudio cualitativo descriptivo. Se realizaron 40 entrevistas semiestructuradas a migrantes (N=30) e informantes claves (N=10), ejecutadas virtualmente durante el 2020. El material fue analizado mediante análisis temático. El proyecto fue aprobado por el Comité de Ética Científico de la Facultad de Medicina de la Universidad del Desarrollo. Resultados Como principales vulnerabilidades enfrentadas por parte de personas migrantes en pandemia se identifican: hacinamiento, precariedad laboral y necesidades económicas, uso del transporte público, desinformación y creencias en torno al COVID-19, discriminación, falta de redes de apoyo, y estatus migratorio. Como recursos se reconocen: contar con redes de apoyo, posibilidad de teletrabajo o salir a trabajar, acceso a información y a la red asistencial y municipal, apoyo gubernamental y de la sociedad civil. Adicionalmente, se reportan experiencias de diagnóstico de COVID-19, identificando dificultades en acceso a PCR y adaptaciones familiares y laborales como cambios en los hábitos de vida dentro y fuera del hogar. Discusión El estudio entrega información relevante e inédita para la construcción de políticas en salud para migrantes internacionales con foco en crisis sanitarias. Se destaca la necesidad de fortalecer adecuaciones interculturales en las estrategias de prevención del contagio y de promoción de la salud y aumentar la disponibilidad de respuesta en el acceso a salud en el marco de la pandemia, mitigando así la vulnerabilidad social en migrantes y potenciando sus recursos de afrontamiento.

Objective To know, in the context of the SARS-CoV-2 pandemic, the psychosocial and socioeconomic vulnerabilities experienced by the international migrant population in Chile, as well as the resources and social capital reported from the community itself and its support networks, and to analyze the reception and implementation of the measures recommended by the health authorities in the different stages of the pandemic in the country. Methods Descriptive qualitative study. The information was collected through 40 semi-structured individual interviews with migrants (N=30) and key informants (N=10), carried out through online communication platforms during 2020. A thematic analysis of the material was carried out. The project was approved by the Scientific Ethics Committee of the Faculty of Medicine of the Universidad del Desarrollo. Results The main vulnerabilities experienced by migrants in the context of the pandemic include overcrowding, job insecurity and economic needs, use of public transport, misinformation and beliefs about COVID-19, experiences of discrimination and xenophobia, lack of support networks, and migratory status. The main resources are support networks, the possibility of working remotely or going out to work, access to information, access to the assistance and municipal network, and government support and civil society. In addition, experiences of diagnosis of COVID-19 are reported, identifying difficulties in accessing PCR testing, and family and work adaptations such as changes in lifestyle habits inside and outside the home. Discussion The study provides relevant and unpublished information for the construction of health policies for international migrants with a focus on sanitary crises. It highlights the need to strengthen cross-cultural strategies for the prevention of infection and health promotion, and to improve access to health in the context of the pandemic and beyond, thereby mitigating the social vulnerability experienced by migrants and enhancing their coping resources.

A comparative analysis of health status of international migrants and local population in Chile: a population-based, cross-sectional analysis from a social determinants of health perspective.

BACKGROUND: During recent decades intraregional migration has increased in Latin America. Chile became one of the main receiving countries and hosted diverse international migrant groups. Evidence have suggested a healthy migrant effect (HME) on health status, but it remains scarce, controversial and needs to be updated. This study performed a comprehensive analysis verifying the existence of HME and its association with social determinants of health (SDH). METHODS: We analyzed data from the Chilean National Socioeconomic Characterization Survey (CASEN, version 2017). Unadjusted prevalence of health status indicators such as negative self-perceived health, chronic morbidity, disability, and activity limitations were described in both international migrants and local population. Adjusted associations between these outcomes and sets of demographics, socioeconomic, access to healthcare, psychosocial and migration-related SDH were tested using multivariate logistic regression in each population. The HME for each health outcome was also tested using multivariate logistic regression and sequentially adjusting for each set of SDH (ref = Chilean). RESULTS: International migrants had lower unadjusted prevalence of all health indicators compared to Chileans. That is, unadjusted analysis revealed an apparent HME in all health outcomes. Age, unemployment, and health care system affiliation were associated with health outcomes in both populations. Psychosocial determinants were both risk and protective for the analysed health outcomes. After adjustment for each set of SDH, the immigrant health advantage was only significant for chronic morbidity. Being migrant was associated with 39% lower odds of having chronic diseases compared to locals (OR: 0.61; 95% CI: 0.44-0.84; P = 0.0003). For all other outcomes, HME disappeared after adjusting by SDH, particularly unemployment, type of health system and psychosocial factors. CONCLUSIONS: Testing the HME in Chile revealed an advantage for chronic morbidities that remained significant after adjustment for SDH. This analysis shed light on health disparities between international migrants and local population in the Latin American region, with special relevance of unemployment, type of health system and psychosocial SDH. It also informed about differential exposures faced during migration process that could dissolve the HME over time. Evidence from this analytical approach is useful for informing health planning and intersectoral solutions from a SDH perspective.

Posición social y obesidad en población chilena: mediadores y moderadores psicológicos / Social position and obesity in Chilean population: Psychological mediators and moderators

Resumen Introducción: la obesidad es un problema de salud mundial que ha sido vinculada con la posición social de las personas. Si bien la evidencia que relaciona estas variables es clara, se ha puesto menos atención a los mecanismos por medio de los cuales estas variables pueden asociarse. El objetivo de este estudio fue determinar si la posición social se relacionaba directamente con obesidad abdominal e indirectamente vía percepción de discriminación, afectividad negativa y calidad de la dieta, y el rol moderador del apoyo social. Método: 420 funcionarios de una universidad chilena. Se midió el perímetro de cintura como proxy de obesidad, se utilizaron instrumentos de autorreporte para variables psicológicas y conductuales. Resultados: análisis de ecuaciones estructurales revelaron que la posición social no se asoció directamente con obesidad abdominal, pero sí a través de una secuencia de mediación que incluyó la percepción de discriminación, afectividad negativa y calidad de la dieta. El apoyo social no moderó estas relaciones. Conclusión: se identifican mecanismos que median el nexo entre posición social y obesidad abdominal. Se destaca la relevancia de considerar variables psicológicas y conductuales subyacentes en esta relación.

Abstract Introduction: Obesity is a health problem worldwide that has been linked to social position. Although the evidence linking these variables is sound, little attention has been paid to the mechanisms by which these variables can be associated. We sought to determine whether social position is directly related to abdominal obesity and indirectly via perceived discrimination, negative affectivity and diet quality, and the moderating role of social support. Method: Four hundred and twenty participants from a Chilean University were selected. Obesity was measured through waist circumference and self-reported measures were used to asses psychological and behavioral variables. Results: Structural equation modeling allowed us to estimate that social position was not directly related to abdominal obesity, but indirectly via a sequenced mechanism that included perceived discrimination, negative affectivity and diet quality. Social support did not moderate these associations. Conclusion: We identified underlying mechanisms that mediate the association between social position and abdominal obesity. We highlight the relevance that psychological and behavioral variables has in obesity.

Unequal Access and Use of Health Care Services among Settled Immigrants, Recent Immigrants, and Locals: A Comparative Analysis of a Nationally Representative Survey in Chile.

Globally, and particularly in the Latin American region, international migration continues to grow. Access and use of health care services by migrants vary according to their country of origin and residence time. We aimed to compare the access and use of health care services between international migrants (including settled migrants from Peru, Argentina, Bolivia, Ecuador; Emerging migrants from Venezuela, Dominican Republic, Colombia, Haiti; and migrants from other countries) and the Chilean population. After performing a secondary data analysis of population-based nationally representative surveys (CASEN 2011-2017), access and use patterns (insurance, complementary insurance, non-consultation, and non-treatment coverage) were described and compared among settled immigrants, recent emerging immigrants, others, and locals. Immigrants had a significantly higher uninsured population compared to locals. Specifically, in CASEN 2017, 19.27% of emerging (95% CI: 15.3-24.1%), 11.79% of settled (95% CI: 10.1-13.7%), and 2.25% of locals (95% CI: 2.1-2.4%) were uninsured. After 2013, settled and recent emerging migrants showed higher percentages of non-consultation. Collaborative and interculturally relevant strategies from human rights and equity perspectives are needed. Initiatives with a particular focus on recent immigrants can contribute to reducing the existing disparities in health care access and use with locals due to lack of insurance and treatment coverage.

The impact of hypoglycemia on healthcare costs: a modeling study from Chile.

BACKGROUND: This study aimed to estimate the expected cost of hypoglycemia in Diabetes Mellitus type-2 patients receiving hypoglycemic treatment in Chile and to explore the effect of the potential reduction of hypoglycemia over the total cost incurred by its public health system. RESEARCH DESIGN AND METHODS: A cost analysis was carried out based on a state transition mathematical model. The model used microsimulation with data from the National Health Survey 2016-2017 in Chile. Costs included follow-up, in-hospital and ambulatory care. Separate analysis was conducted for patients treated with insulin, or sulfonylurea. RESULTS: The annual expected total cost of hypoglycemia estimated for the Chilean public system was USD 288,922,523 (USD 273 per patient). The subgroup treated with insulin reached USD 353 per patient whereas the sulfonylurea subgroup was USD 217 per patient. The analysis revealed that for every 1% reduction of the incidence rate of severe hypoglycemia the cost is reduced 0.79% in total, 0.59% for the insulin subgroup, and 0.95% for the sulfonylurea subgroup. CONCLUSIONS: The cost of hypoglycemia represents a high proportion of the public health budget in Chile, being similar to those resources allocated to provide coverage of diabetic treatments through its universal health benefit plan. ABBREVIATIONS: DM2: type 2 diabetes mellitus; RR: relative risk; ENS: national health survey in Chile.

Perception of discrimination against immigrants compared to Chilean-born and its relationship with access to services and health outcomes / Percepción de discriminación en inmigrantes comparados a nacidos en Chile y su relación con acceso a servicios y resultados de salud

ABSTRACT OBJECTIVES Compare self-perceived discrimination between immigrants and locals in Chile and analyze the relationship between immigration and perceived discrimination and immigration, discrimination and health outcomes, adjusting for sociodemographic characteristics and social capital. METHODS Cross-sectional study, using population-based survey (CASEN2017). We selected 2,409 immigrants (representative of N = 291,270) and 67,857 locals (representative of N = 5,438,036) over 18 years of age surveyed. We estimated logistic regression models, considering the complex sample, with discrimination, self-rated health, medical treatment, healthcare system membership, complementary health insurance, medical consultation and problems when consulting as dependent variables, immigration and discrimination as main exposure variables, and social capital and sociodemographic variables as covariates of the models. RESULTS Immigrants were more likely to perceive discrimination in general compared to locals (OR = 2.31; 95%CI: 1.9-2.9). However, this does not occur for all specific reasons for discrimination; skin color and physical appearance were the most frequent causes of discrimination in immigrants. The interaction between immigration and discrimination was significantly related to worse self-rated health outcomes and treatment for pathologies, disfavoring discrimination against immigrants. In both locals and immigrants, discrimination was not associated with health care access outcomes, except for problems during consultation in locals (OR = 1.61; 95%CI 1.4-1.8). CONCLUSIONS In Chile, experiences of discrimination are intertwined with other forms of rejection and social exclusion, so it is urgent to raise awareness among the population to prevent these discriminatory practices, especially in health care and daily use places. It is essential to address discrimination in order to have an impact on intermediate variables and health outcomes. The extension of the results to the entire immigrant population could be very useful to deepen the problem and improve the estimates made.

RESUMEN OBJETIVOS Comparar la autopercepción de discriminación entre inmigrantes y locales en Chile y analizar la relación entre inmigración y discriminación percibida e inmigración, discriminación y resultados de salud, ajustando por características sociodemográficas y capital social. MÉTODOS Estudio transversal, utilizando encuesta poblacional (CASEN2017). Se seleccionaron 2.409 inmigrantes (representativos de N = 291.270) y 67.857 locales (representativos de N = 5.438.036) mayores de 18 años encuestados. Se estimaron modelos de regresión logística, considerando la muestra compleja, con discriminación, salud autoevaluada, tratamiento médico, pertenencia al sistema de salud, seguros complementarios de salud, consulta médica y problemas al consultar como variables dependientes, inmigración y discriminación como variables de exposición principal, y capital social y variables sociodemográficas como covariables de los modelos. RESULTADOS Inmigrantes tuvieron mayor posibilidad de percibir discriminación en general comparado con locales (OR = 2,31; IC95% 1,9-2,9). Sin embargo, esto no ocurre para todos los motivos específicos de discriminación; color de piel y apariencia física fueron las causas de discriminación más frecuentes en inmigrantes. La interacción entre inmigración y discriminación se relacionó significativamente con peores resultados de salud autoevaluada y tratamiento por patologías, en desfavor de los inmigrantes discriminados. Tanto en locales como en inmigrantes la discriminación no se asoció con resultados de acceso a atención en salud, excepto problemas durante la consulta en locales (OR = 1,61; IC95% 1,4-1,8). CONCLUSIONES En Chile, las experiencias de discriminación se entrelazan con otras formas de rechazo y exclusión social, por lo cual es urgente concientizar a la población para prevenir estas prácticas discriminatorias, sobre todo en la atención en salud y lugares de uso cotidiano. Abordar la discriminación es indispensable para lograr impactar en variables intermedias y resultados de salud. La extensión de los resultados a toda la población inmigrante podría ser de amplia utilidad para profundizar la problemática y mejorar las estimaciones realizadas.

Factores sociodemográficos y económicos asociados a no realizar cuarentena por COVID-19 en población venezolana residente en Chile

Resumen Introducción: el colectivo venezolano residente en Chile ha aumentado en cantidad y en la vulnerabilidad social en que migran. Objetivo: analizar qué elementos sociodemográficos y económicos dificultan la realización de cuarentena en la población venezolana residente en Chile, considerando cómo esto varía según características como estar trabajando, tener seguro de salud, sexo y nivel educacional. Metodología: el diseño corresponde a un estudio cuantitativo observacional de corte transversal desde una encuesta online sobre COVID-19 a extranjeros en Chile, realizada en abril (2020), por medio de una estrategia de muestreo en "bola de nieve" (n=1,690 migrantes). Este análisis secundario se focaliza en participantes venezolanos (N=1,006), por medio de análisis descriptivo, bivariado y de regresión multivariada, con ajuste de Raking para disminuir el sesgo de auto-selección. De estos, el 49,6% fueron mujeres, y la mayoría (el 50%) tenía entre 30 y 49 años. Resultados: la probabilidad de no poder realizar cuarentena es mayor en quienes cuentan con trabajo ((OR=5,35, 95%IC (3,16-9,02)), en relación a los que no; en quienes no poseen previsión de salud ((OR=4,02, 95%IC (1,57-10,32)) y en los que tienen previsión pública (Fonasa) ((OR=3,92, 95%IC (1,84-8,35)), en relación a las personas con previsión privada; en hombres ((OR=2,23, 95%IC (1,50-3,32)) que en mujeres; y en los que tienen nivel educacional menor a nivel superior ((OR=1,74, 95%IC (11,50-3,32)). Conclusión: la asociación encontrada entre no cumplir cuarentena con condiciones laborales y tipo de seguro de salud expone la relevancia de la vulnerabilidad socioeconómica en las oportunidades de llevar adelante medidas de cuidado de salud pública en población migrante venezolana en Chile, como es el seguimiento de confinamiento durante una pandemia. Esto es importante para la planificación sanitaria en futuras crisis socio-sanitarias.

ABSTRACT Introduction: The Venezuelan group residing in Chile has increased in number and in the social vulnerability in which they migrate. Objective: To analyze which sociodemographic and economic elements make it difficult to carry out quarantine in the Venezuelan population residing in Chile, considering how this varies according to characteristics such as being working, having health insurance, sex, and educational level. Methodology: Cross-sectional observational quantitative study from an online poll on COVID-19 to foreigners in Chile, carried out in April (2020), through a "snowball" sampling strategy (n=1,690 migrants). This secondary analysis focuses on Venezuelan participants (N=1,006), through descriptive, bivariate and multivariate regression analysis, with Raking adjustment to reduce self-selection bias. Of these, 49.6% were women, and the majority (50%) were between 30 and 49 years old. Results: The probability of not being able to quarantine is higher in those who have a job ((OR=5.35, 95% CI (3.16-9.02)), in relation to those who do not; in those who do not have a health insurance ((OR=4.02, 95% CI (1.57-10.32)) and in those who have public insurance (i.e. Fonasa) ((OR=3.92, 95% CI ( 1.84-8.35)), in relation to people with private pension; in men ((OR=2.23, 95% CI (1.50-3.32)) than in women; and in those with a lower educational level at a higher level ((OR=1.74, 95% CI (11.50-3.32)). Conclusion: The association found between not complying with quarantine due to working conditions and type of health insurance exposes the relevance of socioeconomic vulnerability in the opportunities to carry out public health care measures in the Venezuelan migrant population in Chile, such as monitoring of confinement during a pandemic. This is important for health planning in future socio-health crises.

Development of the set of scales to assess the job satisfaction among physicians in Peru: validity and reliability assessment.

BACKGROUND: To assess the validity and reliability of the set of scales (general professional activity, health services management, and working conditions) on the different areas of job satisfaction in Peruvian physicians based on the data from the National Survey of Satisfaction of Users in Health (ENSUSALUD). METHOD: We carried out a psychometric study based on the secondary data analysis of Questionnaire 2 of ENSUSALUD-2016. Participants were selected from a two-stage stratified national probability representative sampling by political region. Validity was assessed by exploratory and confirmatory factor analyses, and measurement invariance analysis. We assessed the reliability using internal consistency coefficients (alpha and omega). The set of scales were composed of items related to three different areas of job satisfaction: 1) satisfaction with general professional activity, 2) satisfaction with the health services management, and 3) satisfaction with the working conditions of the health center. RESULTS: We included 2137 participants in the analysis. The general professional activity scale with six items (Comparative Fit Index, CFI = 0.946; Root Mean Square Error of Approximation, RMSEA = 0.071; Standardized Root Mean Square Residual, SRMR = 0.035), the health services management scale with eight items (CFI) = 0.972; RMSEA = 0.081; SRMR = 0.028), showed good measurement properties for the one-dimensional model. The working conditions scale with eight items for individual conditions and three items for infrastructural conditions (CFI = 0.914; RMSEA = 0.080; SRMR = 0.055) presented adequate measurement properties with a two-dimensional model. The invariance analysis showed that comparisons between sex, age, civil status, medical speciality, working in other institutions, work-related illness, chronic disease, and time working in the healthcare center. All scales had adequate internal consistency (ω and α between 0.70 and 0.90). CONCLUSIONS: The set of scales has a solid factorial structure and measurement invariance, making it possible for group comparison. The study achieved stability in the scores as they showed adequate internal consistency coefficients. Based on our findings, these instruments are suitable for measuring job satisfaction among outpatient physicians throughout Peru, as our data is representative of the country level.

Inequities in mental health and mental healthcare between international immigrants and locals in Chile: a narrative review.

Mental health in a context of international migration is a particularly pressing issue, as migration is recognised as a social determinant of physical and mental health. As Chile is increasingly becoming a receiving country of South-South migration, immigrants face mental health inequities, with regards to outcomes and access to care.In order to identify and synthetize mental healthcare inequities faced by international migrants with regards to locals in Chile, a narrative review of the literature on national mental healthcare policies in Chile and a narrative review of the literature on migrants' mental healthcare in Chile were conducted, with a focus on describing mental health outcomes, policy environment and persisting gaps and barriers for both topics. The existing literature on mental healthcare in Chile, both for the general population and for international migrants, following the social determinant of health framework and categorised in terms of i) Inequities in mental health outcomes; ii) Description of the mental health policy environment and iii) Identification of the main barriers to access mental healthcare.Despite incremental policy efforts to improve the reach of mental healthcare in Chile, persisting inequities are identified for both locals and international migrants: lack of funding and low prioritisation, exacerbation of social vulnerability in the context of a mixed health insurance system, and inadequacy of mental healthcare services. International migrants may experience specific layers of vulnerability linked to migration as a social determinant of health, nested in a system that exacerbates social vulnerability.Based on the findings, the article discusses how mental health is a privilege for migrant populations as well as locals experiencing layers of social vulnerability in the Chilean context. International migrants' access to comprehensive and culturally relevant mental healthcare in Chile and other countries is an urgent need in order to contribute to reducing social vulnerability and fostering mechanisms of social inclusion.International migration, social determinants of mental health, mental health inequities, social vulnerability, review.