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OBJECTIVES: This study aims to assess the health effects on mining workers of exposure to chronic intermittent hypoxia (CIH) at high- and very high-altitude mining compared with similar work at lower altitudes in Chile, and it also aims to constitute the baseline of a 5-year follow-up study. METHODS: We designed a cross-sectional study to assess health conditions in 483 miners working at 2 levels of altitude exposure: 336 working at a very high or high altitude (HA; 247 above 3900-4400 m, and 89 at 3000-3900 m), and 147 below 2400 m. Subjects were randomly selected in two stages. First, a selection of mines from a census of mines in each altitude stratum was made. Secondly, workers with less than 2 years of employment at each of the selected mines were recruited. The main outcomes measured at the baseline were mountain sickness, sleep alterations, hypertension, body mass index, and neurocognitive functions. RESULTS: Prevalence of acute mountain sickness (AMS) was 28.4% in the very high-altitude stratum (P = 0.0001 compared with the low stratum), and 71.7% experienced sleep disturbance (P = 0.02). The adjusted odds ratio for AMS was 9.2 (95% confidence interval: 5.2-16.3) when compared with the very high- and low-altitude groups. Motor processing speed and spatial working memory score were lower for the high-altitude group. Hypertension was lower in the highest-altitude subjects, which may be attributed to preoccupational screening even though this was not statistically significant. CONCLUSIONS: Despite longer periods of acclimatization to CIH, subjects continue to present AMS and sleep disturbance. Compromise of executive functions was detected, including working memory at HA. Further rigorous research is warranted to understand long-term health impacts of high-altitude mining, and to provide evidence-based policy recommendations.

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BACKGROUND: Gallbladder cancer is a relevant public health problem in Chile. AIM: To analyze the mortality trend due to gallbladder cancer and hospital discharges due to biliary disease between 2002 and 2014. To analyze the effect on these parameters of the new health system called explicit guaranties in health whose acronym in Spanish is GES. MATERIAL AND METHODS: Mortality and hospital discharge databases available at the website of the Ministry of Health were analyzed. Changes in crude and adjusted rates were evaluated, analyzing data by geographical regions, sex and age. The standardization was carried out using the direct method and using as reference the Chilean population in 2002. The trends were evaluated through the Poisson regression method. RESULTS: There is a 4.5% trend towards a decreasing mortality at a national level, as compared with the figures before GES came into force. Mortality among people aged 35 to 49 decreased by 4% before GES, and by 8% after GES. The trend of hospital discharges varied from -1% before GES, to a 2% increase after GES. Discharges among people aged 35-49 years increased from 0.1% to 2.9%. CONCLUSIONS: The discharge rate increase after GES, does not yet show a break in the reduction of mortality at the national level, although it does benefit the group of 35 to 49 years.

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Background: Gallbladder cancer is a relevant public health problem in Chile. Aim: To analyze the mortality trend due to gallbladder cancer and hospital discharges due to biliary disease between 2002 and 2014. To analyze the effect on these parameters of the new health system called explicit guaranties in health whose acronym in Spanish is GES. Material and Methods: Mortality and hospital discharge databases available at the website of the Ministry of Health were analyzed. Changes in crude and adjusted rates were evaluated, analyzing data by geographical regions, sex and age. The standardization was carried out using the direct method and using as reference the Chilean population in 2002. The trends were evaluated through the Poisson regression method. Results: There is a 4.5% trend towards a decreasing mortality at a national level, as compared with the figures before GES came into force. Mortality among people aged 35 to 49 decreased by 4% before GES, and by 8% after GES. The trend of hospital discharges varied from −1% before GES, to a 2% increase after GES. Discharges among people aged 35-49 years increased from 0.1% to 2.9%. Conclusions: The discharge rate increase after GES, does not yet show a break in the reduction of mortality at the national level, although it does benefit the group of 35 to 49 years.

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Studies examining urban health and the environment must ensure comparability of measures across cities and countries. We describe a data platform and process that integrates health outcomes together with physical and social environment data to examine multilevel aspects of health across cities in 11 Latin American countries. We used two complementary sources to identify cities with ≥ 100,000 inhabitants as of 2010 in Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Nicaragua, Panama, and Peru. We defined cities in three ways: administratively, quantitatively from satellite imagery, and based on country-defined metropolitan areas. In addition to "cities," we identified sub-city units and smaller neighborhoods within them using census hierarchies. Selected physical environment (e.g., urban form, air pollution and transport) and social environment (e.g., income, education, safety) data were compiled for cities, sub-city units, and neighborhoods whenever possible using a range of sources. Harmonized mortality and health survey data were linked to city and sub-city units. Finer georeferencing is underway. We identified 371 cities and 1436 sub-city units in the 11 countries. The median city population was 234,553 inhabitants (IQR 141,942; 500,398). The systematic organization of cities, the initial task of this platform, was accomplished and further ongoing developments include the harmonization of mortality and survey measures using available sources for between country comparisons. A range of physical and social environment indicators can be created using available data. The flexible multilevel data structure accommodates heterogeneity in the data available and allows for varied multilevel research questions related to the associations of physical and social environment variables with variability in health outcomes within and across cities. The creation of such data platforms holds great promise to support researching with greater granularity the field of urban health in Latin America as well as serving as a resource for the evaluation of policies oriented to improve the health and environmental sustainability of cities.

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BACKGROUND: Social determinants differ between countries, which is not always considered when adapting health policies and interventions to face inequalities in noncommunicable diseases and their risk factors. OBJECTIVES: The study sought to analyze educational inequalities in controlled blood pressure (CBP), obesity, and smoking in study populations from Chile and the United States in 2 periods, both countries with large social inequalities. METHODS: The study used data from the first and fifth waves of the MESA (Multiethnic Study of Atherosclerosis) cohort, and the 2003 and 2009 to 2010 Chilean National Health Survey (CNHS) survey outcome measures. The study compared cardiovascular risk factors prevalence as well as relative index of inequality (RII) and slope index of inequality (SII) between the 2 samples. RESULTS: In the CNHS 67.9% and 52.6% of participants had below primary education in 2003 and 2009 to 2010, respectively, compared with 12.3% and 8.1% in the first and fifth waves of the MESA study, respectively. Smoking prevalence was higher and increased in the CNHS compared with the MESA study, concentrated in better-educated women in both years (RII: 0.34; 95% confidence interval [CI]: 0.17 to 0.68; and RII: 0.55; 95% CI: 0.34 to 0.89, respectively). In contrast, smoking decreased over time in the MESA study in all socioeconomic strata, although relative inequalities increased in both sexes (for women, RII: 2.32; 95% CI 1.36 to 3.97; for men, RII: 3.34; 95% CI 2.04 to 5.47). CBP prevalence in both periods was higher in the first and fifth waves of the MESA study (69.7% and 80.2%) compared with the 2003 and 2009 to 2010 CNHS samples (34.2% and 52.3%), but only for the MESA study RII, favoring the better educated, was it significant in both periods and sexes. Obesity inequalities for Chilean women decreased slightly between 2003 and 2009 as prevalence grew in the most educated (RII: 2.21 to 1.68; SII: 0.29 to 0.22, respectively); conversely, they increased for both sexes in the MESA study. CONCLUSIONS: The study findings confirm that patterns and trends in prevalence, and absolute and relative inequalities vary by country, suggesting that context and cultural issues matters.

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OBJECTIVES: We estimated the roles of childhood socioeconomic position (ChSEP) and education attainment on chronic diseases in Chilean adults, mediated through structural determinants and health behaviors, to identify potential pro-equity interventions. METHODS: We analyzed Chile's longitudinal Social Protection Surveys, a national sample of 14,788 adults with follow-up to 2009. Controlled direct effects (CDE) and natural effects (NDE and NIE) of ChSEP and education on number of chronic diseases were estimated with negative binomial models. RESULTS: CDE of low ChSEP with education fixed at 12 years showed a 12% increase with 4% indirect effects. CDEs at favorable levels of BMI, smoking, alcohol use, and physical activity were similar. CDE estimates for education adjusted for ChSEP were larger with negligible mediation. CDEs for women were generally larger. CONCLUSIONS: Low ChSEP exerts a primarily direct effect on later chronic disease, modestly mediated by education. Education attainment showed larger direct effects with minimal mediation by behaviors. Strengthening current-early child development and education policies, particularly gender aspects, may reduce social inequalities and key pathways for reducing chronic disease inequalities in Chile.

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Comparability of population surveys across countries is key to appraising trends in population health. Achieving this requires deep understanding of the methods used in these surveys to examine the extent to which the measurements are comparable. In this study, we obtained detailed protocols of 8 nationally representative surveys from 2007-2013 from Brazil, Chile, Colombia, Mexico, the United Kingdom (England and Scotland), and the United States-countries that that differ in economic and inequity indicators. Data were collected on sampling frame, sample selection procedures, recruitment, data collection methods, content of interview and examination modules, and measurement protocols. We also assessed their adherence to the World Health Organization's "STEPwise Approach to Surveillance" framework for population health surveys. The surveys, which included half a million participants, were highly comparable on sampling methodology, survey questions, and anthropometric measurements. Heterogeneity was found for physical activity questionnaires and biological samples collection. The common age range included by the surveys was adults aged 18-64 years. The methods used in these surveys were similar enough to enable comparative analyses of the data across the 7 countries. This comparability is crucial in assessing and comparing national and subgroup population health, and to assisting the transfer of research and policy knowledge across countries.

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UNLABELLED: In 2005, Chile implemented a universal system of health guarantees (AUGE) aimed at improving equitable access to quality medical care for priority health conditions, including acute myocardial infarction (MI). OBJECTIVE: To evaluate 1-year survival in MI patients before and after AUGE. METHODS: Retrospective cohorts of patients with MI (with and without ST segment elevation) discharged alive from six public hospitals between January 2001-June 2005 (pre-AUGE) and July 2008-March 2009 (post-AUGE). Chilean national mortality and MI Registry (hospital-based) databases were linked using a unique identification number (ICD-10 codes I00-I99 were used to identify cardiovascular deaths). One-year survival was assessed using Weibull multivariate regression. RESULTS: About 1867 patients were discharged alive pre-AUGE and 534 post-AUGE; 25% were women in both periods. When comparing pre-AUGE and post-AUGE, there was an increase in the use of primary and elective angioplasty (1.7 vs 23.6% and 7.3 vs 20.0%), beta-blockers (62 vs 71%) and statins (40 vs 90%); P < 0.001 all. One-year survival was 92% pre-AUGE (95% CI: 91-93%) and 96% post-AUGE (95% CI: 94-97%) (HR = 0.50, 95% CI: 0.31-0.82; P = 0.003). The post-AUGE improvement persisted after adjusting for variables associated with long-term case-fatality (HR = 0.44, 95% CI: 0.26-0.75). Percutaneous coronary intervention (HR = 0.31, 95% CI: 0.09-0.99) and statins use at discharge (HR = 0.45, 95% CI: 0.31-0.66) had the highest effects associated with lower case-fatality and both treatments increased in the post-AUGE period. CONCLUSIONS: The implementation of AUGE in Chile appears to have contributed to improved treatment of MI in public hospitals and increased 1-year survival, which is consistent with its aim to improve access to quality medical care and to reduce health inequities.

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Chile's 'health guarantees' approach to providing universal and equitable coverage for quality healthcare in a dual public-private health system has generated global interest. The programme, called AUGE, defines legally enforceable rights to explicit healthcare benefits for priority health conditions, which incrementally covered 56 problems representing 75% of the disease burden between 2005 and 2009. It was accompanied by other health reform measures to increase public financing and public sector planning to secure the guarantees nationwide, as well as the state's stewardship role. We analysed data from household surveys conducted before and after the AUGE reform to estimate changes in levels of unmet health need, defined as the lack of a healthcare visit for a health problem occurring in the last 30 days, by age, sex, income, education, health insurance, residence and ethnicity; fitting logistic regression models and using predictive margins. The overall prevalence of unmet health need was much lower in 2009 (17.6%, 95% CI: 16.5%, 18.6%) than in 2000 (30.0%, 95% CI: 28.3%, 31.7%). Differences by income and education extremes and rural-urban residence disappeared. In 2009, people who had been in treatment for a condition covered by AUGE in the past year had a lower adjusted prevalence of unmet need for their recent problem (11.7%, 95% CI: 10.5%, 13.2%) than who had not (21.0%, 95% CI: 19.6%, 22.4%). Despite limitations including cross-sectional and self-reported data, our findings suggest that the Chilean health system has become more equitable and responsive to need. While these changes cannot be directly attributed to AUGE, they were coincident with the AUGE reforms. However, healthcare equity concerns are still present, relating to quality of care, health system barriers and differential access for health conditions that are not covered by AUGE.

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