No change was described by 41% when summarizing their sex life during the pandemic. The second theme Positive change was experienced by 25%, and the third theme Negative change by 21%. An overarching theme then emerged as: “Still the same trajectories, but the pandemic could be a catalyst for improved or worsened sex- life.” For those intimate partnered individuals who already had problems with intimacy and sexuality before the COVID-19 pandemic it seemed to remain the same or deteriorated throughout the pandemic. For those with positive experiences of intimacy and sexuality before the COVID-19 pandemic it remained the same or improved throughout the pandemic. These findings are relevant for researchers and clinicians in developing preventive and supportive interventions in the context of crisis and social isolation.This qualitative study explores experiences of intimacy and sexuality during the first phase of the COVID-19 pandemic of 3357 participants from Croatia, the Czech Republic, the Netherlands, France, Germany, Portugal, Sweden, and Turkey. Data were collected through open-ended questions within a survey on sexuality during the pandemic. Based on a reflexive thematic analysis three themes occurred. The first theme  Since the World Health Organization declared COVID-19 a pandemic on March 11, 2020 WHO, . But, quThe importance of sexual relations, sexual health, and sexuality as significant determinants of relationships and general well-being are well documented  from eight countries Croatia (n = 492), the Czech Republic (n = 537), France, (n = 358) Germany (n = 529), the Netherlands (n = 926), Portugal (n = 476), Sweden (n = 356), and Turkey (n = 1139), completed an online survey between May and July 2020. Median time to complete the questionnaire was below nine minutes, and there were no compensation offered.Participants were recruited as part of a larger online survey with eight European countries, housed by one institution/country. Inclusion criteria were cohabiting partnered individuals over 18 years. The participants were recruited via national news websites, and online social networks. The study was advertised as focusing on possible impact of the pandemic on intimacy and sexuality in longterm relationships. All participants were asked the same questions in eight different languages. As described more in detail in Štulhofer et al., , 4,813 rn = 323), the Czech Republic (n = 402), the Netherlands (n = 714), France (n = 264), Germany (n = 365), Portugal (n = 281), Sweden (n = 270), and Turkey (n = 738). The majority of respondents self-identified as women . Mean age in the sample was 39.2 years . Nine participants had another gender identity than women or men, and 11 reported being in another type of partnership than same-sex or opposite-sex relationships. A total of 55.4% had children in their household.A total of 3,357 participants completed the following open-ended question at the end of the online questionnaire: “Finally, we would like to ask you to write one (or two) sentences that summarize your sex life during these times of pandemic”. As shown in Table The survey in the target languages was administered online using GDPR -compliant software. Since answers to the open-ended question were completed in eight different languages, the initial dataset included multilingual answers. To enable the analysis, all answers were first translated to English within each countries’ research teams. Each set was then checked by a second bilingual researcher and/or professional for most of the participating countries. Specialty in the field was deemed important to ensure not only semantic but also conceptual equivalence; this process ensured a rigorous translation and transliteration process for a reliable analysis  in the summary of their sex life during the COVID-19 pandemic. Thus, change became the key concept in the coding. Next, we coded and themed the responses (meaning units) into the following themes: No change, Positive change, Negative change, and Ambiguous or unclear statements. The latter theme was omitted from the final analysis, as it did not connect to the research questions and/or was not understandable or not possible to analyze further . The size of this theme was 417 statements (12.4%).In the third phase, the themes were linked together with codes, such as within No change: “As good as before,” and “As bad as before,” within Negative change: “No privacy, too close,” “Stress, sickness, quarrel, divorce,” and “Lack of other sex partners inside or outside the relationship.” Lastly, within Positive change: “More intimacy, closeness,” “More time, less stress,” and “New ways of having sex.” Throughout the analysis, the two researchers looked for patterns, tendencies, and underlying meanings of change and explanations for change. Thus, the themes generated an over-arching theme: “Still the same trajectories, but the pandemic could be a catalyst for improved or worsened sex-life”. Table .Table 2TBraun and Clarke , p. 593 Less than half of all participants  fell under the theme No change when summarizing their sex life during the first phase of the COVID-19 pandemic. The other half consisted of 830 (24.7%) who fell under the theme Positive change and 720 (21.4%) who stated Negative change. Finally, 417 (12.4%) fell under the theme Ambiguous or unclear in relation to change and was deducted from the final analysis. The pattern was similar across the participating countries.change  described their sex life in positive or negative ways. Therefore, the statements of No change were divided into “As good as before” and “As bad as before.”The participants who fell under No No change described their sex life in positive ways in relation to how they also described their relationship before the pandemic, for example “As perfect as always." Some of the participants referred to frequencies in their sex life and assessed whether it had increased or decreased. If not, it was seen as a satisfactory and stable sex life. A participant from the Czech Republic wrote:Nothing has changed. We have sex at least 3 times a week. Both before the pandemic and now.Quite a few of those who stated Satisfactory and no difference from before the pandemic.Others described their sex life in positive terms, without mentioning frequencies. A Swedish participant stated:My husband and I are very active, we have always taken time for our intimacy, the pandemic has not changed anything. He looks for it more but the two of us have a lot of desire for each other. We had to adapt to a lot in the pandemic, but we are used to dealing with a lot when we have 5 children, however we try to make sure that our couple time is not affected.The ability to adapt to changes seemed to increase the options to maintain what is perceived as a good sex-life during crisis. Several participants described the importance of flexibility and adjustment to new situations as a key factor of a positive relationship and satisfactory sex-life. A participant from Portugal wrote:Nothing can endanger my love for my partner, not even a tiny virus.Furthermore, emotionally stable, and loving relationships were described as a well-grounded foundation when the participants within this theme confronted the crisis. The participants who were satisfied with their sex life and their relationships pointed out that the pandemic could not change that. A participant from Croatia stated:No change. “It was bad, and it is still bad” concluded the statements from these participants who summarized their sex life in a consistently negative way. Previous sexual problems, sexual dysfunctions, relational problems, and emotional distance were stated as backgrounds to their reports. Several participants described sexless relationships both before and during the pandemic. A French participant stated:Before, during, after the pandemic, no sex life with my partner.The opposite from those who stated “As good as before” also became clear and obvious among the participants who stated Once a month is more than enough with my partner, if possible. My problem is not the pandemic, it's my partner.Because of problems in their relationship in general, several had a non-existing sex life or rare sexual interactions, not connected to the pandemic. A Turkish participant said:Our sex life is affected by two toddlers at home. That has not changed with the arrival of a pandemic.More than several participants stated that their sex-life had not changed due to the pandemic. Instead, it was influenced by ordinary caring duties and responsibilities connected to relationships and family life, such as having children, struggling with teenagers, having puppies, elderly parents, and so on. “Children” was one of the most frequent words in the participants’ answers and referred to tiredness, a lack of privacy and time for the sexual relationship. In line with this, one woman  from Germany described the current situation as: "significantly less sex-life through existing early pregnancy." A participant from Czech Republic stated:n = 830, 24.7%) who stated Positive change during the pandemic compared to their sex life before the pandemic, described it in different ways: “More intimacy, closeness,” “More time, less stress”, and “New ways of having sex.”Participants  described their sex life as: “Strengthening, building, relieving,”, just as a French woman  stated: “Fulfilling and renewed. Full of novelty.” Furthermore, many participants stated that they valued their partner more and grasped the moment of expressing intimacy and closeness within their relationship during the pandemic. A participant from the Czech Republic stated how their relationship had improved during the pandemic:We are still fundamentally as close to each other as we were before the pandemic, but we are paying even more attention to each other and have become more empathetic/open to each other's concerns.In line with this, many participants stated that they were paying more attention to each other’s health and well-being. A participant from Germany stated:We can be sexually active also outside evening hours, which is good for our sex- life.Several participants described the importance of having more time and being under less job-related stress, which enabled a more gratifying sex life. Furthermore, several couples described how, before the pandemic, they were often exhausted after work and family care. Lockdown and remote work made it possible to have sex at previously unusual times, for example during daytime, when they were more alert and had more energy. A participant from the Czech Republic stated:We have more time, we sleep longer. We are more relaxed, but mentally tense. We have more work-related stress — sex helps among other things to release the stress.Less fatigue and more time for the couple was oft-repeated statement, regardless of the country of residence. That also meant that partnered individuals had more time to sleep and felt less stressed. Another participant from the Czech Republic described using sex as a coping mechanism while under work-related stress:We use more free time for sex and sexual activities.Moreover, several participants described that they used this access to more free time for sexual activities, not only for sleep. One participant from Germany stated:Remember the wild times of passion! Innovate and take advantage of the time we didn't have before the pandemic (try to see the positive).Making the best of a tough period was described by several participants across countries. More time during daytime also helped some couples remember the first phase of their relationship and sex-life. One participant from Portugal wrote:A desire to have children has definitely arisen which was not there before. So now we explicitly pay attention to having sex on the fertile days, which we left to chance before.Even though several participants described a family situation with children and teenagers living together during the pandemic as taxing (see Negative Change), there were also those who appreciated a closer family-life with more time together. This can also be a suitable time to become pregnant, for those who wish to have children without the usual everyday stress. A woman  from the Czech Republic stated that “during the pandemic, I finally got pregnant after 3 years of trying.” In line with this, a participant from Germany described how the COVID-19 pandemic led to a desire to have children, which in turn led to more sex:Sex through FaceTime with my partner has become an opportunity.Some participants mentioned experiences of new ways of having sex as one positive change during the COVID-19 pandemic. Internet or virtual sex was mentioned as, for example, looking at erotic or pornographic films or pictures. One French woman  stated the word "virtual" while describing their sex life. Some describe the option to have cybersex either through web camera or via “sexting” . This was seen as a positive option for couples who could not be together physically during the pandemic, for example when one went away on a work-trip or had to take care of their old parents, or lived in a poly-relationship. A Swedish participant states:Fantastic. Trying out several new things as we spend more time together. All kinds of positions, toys and role-play.Other new ways of having sex that the participants mentioned were role-play and using sex-toys. A participant from the Netherlands described the positive ways that their sex- life improved during the pandemic:It's fun, and we discover new things. there is a lot of trust between the two of us, and this is the basis for new discoveries.Furthermore, new ways of having sex seemed to connect to a relationship that already was stable and included trust and loving aspects. The COVID-19 pandemic was then seen as an option for discovery of sexual variations. A participant from Germany stated:We have been more innovative. Sex at lunch, and so on.New ways of having sex were also associated with opportunities to have sex at other times than usual, for example during the day instead of in the evening. That made some of the couples more open to sexual variations. A Croatian man  said: "We have more time to experiment." In line with this, a Swedish participant stated:Negative change during the COVID-19 pandemic. These changes were described in statements connected to the following themes: “No privacy, too close,” “Stress, sickness, quarrel, divorce,” and “Lack of other sex partners inside or outside the relationship.”Around one fifth of all participants  fell under At first, I thought we would have more time for sex now. But now we both work from home and can hardly separate work and private life . We also spend about 22-23 of 24 hours together. Now we have sex less often than usual.Given the fact that a lot of couples experienced a new situation with different levels of quarantine due to the pandemic, the consequences of home or remote work and home-schooling also influenced the sex-life of several individuals. Some described having a lack of privacy as distressing, especially for those who otherwise appreciated the space when going away from home during the day, as one woman  form the Czech Republic explained: “Disturbing, I miss the privacy and intimacy because we cannot go anywhere.” Furthermore, this was described as if the attraction and the positive tension with their partner had disappeared. Therefore, their sex life deteriorated, as one French woman  states: “Living together 24/7 is a turn off.” One participant from Germany stated:I am overwhelmed. I have telework, classes from home to manage, and the management of the home. I feel embarrassed that I don't have privacy and space for romance; sex is the last thing I think about.Working at home also influenced couples’ possibilities for privacy during the COVID-19 pandemic. For example, tasks such as digital teaching and digital meetings that require a web camera put an extra dimension on losing a sense of privacy, blurring boundaries between professional and private life and spaces. A participant from Portugal described how this influenced the couple’s sex-life:I am a medical student and I'm helping in a hospital. I am too tired for sex and generally I'm more exhausted, so it is unimaginable for me to put energy into sex. I miss motivation, I have an older partner who previously wanted sex less than I did, and now during the pandemic, it is vice versa.A number of participants were professionally overwhelmed by the COVID-19 pandemic, for example those who worked at hospitals, crisis centres or social welfare institutions: "I work on a crisis team. I am more overworked and tired than before the crisis and therefore I have less desire for sex,” one woman  from the Netherlands described. Experiencing an extraordinary weight at their jobs spilled over into their private life. This exceptional work situation occurring concurrently with private worries seemed to increase feelings of stress and fatigue. One participant from the Czech Republic described:My partner doesn't want to have sex now because he finds it scary that I come into contact with other people for my work. I don't mind because I don't have a high libido. That's fine.Furthermore, experiences of wearing a face-mask during the pandemic also influenced couples’ sex life in a negative way. According to a woman  from Germany, it led to tiredness: "Little change, frequency of event lower because of tiredness caused by constantly wearing a mask." A Czech Republican woman  mentioned that the face- mask influenced the individual’s way of showing sexual emotions, with kisses excluded. Not least, several mentioned the risk of being infected by COVID-19 via their partner. A participant from the Netherlands described the consequences of this for their sex-life:Pandemic has affected the relationship between me and my partners from my perspective, not because of the fear of catching the virus but because of some reasons such as not being able to work, mistrust and examining my emotions thoroughly. While my partners´ respect and love increased towards me, I started to lose not my respect but my love and, because of my concern for the future, trust for him/her.Stress and pressure can lead to irritation, quarreling, and sometimes to separations and divorces. Sometimes this was described as consequences of the pandemic, as one Turkish woman  described: "Either take him/her (partner) from home or take me out of home." Nevertheless, it can be difficult to know the origin for quarrel and problems within a relationship. Relational problems might not be related directly to the COVID-19 pandemic, but to other problems such as cramped housing or financial issues. The pandemic could then make this situation even worse. "The intensity of the interaction makes small dramas become big,", as one Portuguese man  put it. Additionally, some participants have lost their jobs during the pandemic, which influenced them emotionally as well as financially. Therefore, it also impacted relationships and sex-lives. A Turkish participant described their situation:The pandemic made me realize my sexual anorexia and the huge gap that there was with my partner. While I was killing myself at work, he was killing himself to satisfy his sexual and emotional needs that I no longer met. Today: I fully live my sexual anorexia and want to separate.In other instances, the COVID-19 pandemic has made individuals within a relationship realize how they want to live their lives, what is important, and also how they want to live in the future. Some participants stated that they had decided to separate during the pandemic. A French participant described their situation:Adio mare!Total zero. My husband has found his recreation in a woman on Facebook. And I can't say that it's the first time he has cheated on me, even virtually. The brain does its own thing when the hands are idle. Others described non-existing sex life, and situations when their partner had  contact with other persons outside their relationships without consent. The COVID-19 pandemic might then illuminate or worsen previous sexual challenges. A participant from Croatia stated:Restricted because sex outside the relationship is currently not possible due to the risk of infection and contact restrictions. Also, the absence of third-party sex is missing. This leads to restrictions of sexual freedom.Some of the participant described a negative change within their sex-lives during the pandemic due to a lack of (sex-) partners inside or outside the relationship. It could be because of physical separation from their regular partner in another city, during for example a work-related trip, or one of the partners within a polyamorous relationship, or other partners while living in open relationships or partners in extramarital relationships or casual sex partners. As one Portuguese man  described sex during the pandemic: "Poorer in the extra-marital part," in line with a man  from the Netherlands: "I have a mistress, but unfortunately I don't see her." A participant from Germany described the situation due to the COVID-19-restrictions:To date different people or try things sexually, as agreed within my open relationship with my steady partner. Because of corona this is not possible now, although I could only fulfil that need to a limited extent even before corona.Limited opportunities for flirting with other persons were also described by another man  from Germany as if "the erotic crackle in the partnership is missing.” One participant from the Netherlands wrote that they had agreed on an open relationship before the pandemic:For the first time, we enjoy having plenty of time for extensive BDSM sessions. However, we miss our partners, with whom we do not live together in the same household.Some participants described more options for sex, but they also described less or no time with partners outside their household. A participant from Germany stated that they cancelled couple’s parties, but “continue[d] to have regular taboo-free and passionate sex.” Another participant from Germany described their current sex life during the pandemic:Little to no sex with my partner. All “massage” salons are closed, so a lot of self-work.Finally, a few of the participants stated the limited options of buying sex as a negative change due to the pandemic. A participant from the Netherlands described that closed “massage salons” led to more masturbation:Finally, an over-arching theme occurred in the results: “Still the same trajectories, but the pandemic could be a catalyst for improved or worsened sex-life”. This overarching theme show that problems with intimacy and sexuality before the COVID-19 pandemic remained the same or deteriorated throughout the pandemic, which mirror a trajectory of stability or worsening. The overarching theme also show that positive experiences of intimacy and sexuality before the COVID-19 pandemic remain or improved throughout the pandemic, which explain the trajectory of stability or improving.n = 1,390) fell under the theme No change when summarizing their sex life before and during the first 2–4 months of the COVID-19 pandemic. Within this theme, about half described their sex-life in positive terms, “As good as before,” and the other half in negative terms, “As bad as before.” In the quantitative part of this project, 53% reported no change in their sexual interest during the pandemic  fell under the theme Positive change during the pandemic, for example: “More intimacy, and closeness,” “More time, less stress,” and “New ways of having sex.” In the quantitative part, 28.5% reported an increase in their sexual interest (ibid.). Finally, one fifth (n = 720) fell under Negative change in our qualitative part compared to the time before the COVID-19 pandemic, citing “No privacy, too close,” “Stress, sickness, quarrel, divorce,”, and “Lack of other sex partners.” Within the quantitative part of the project, 18.5% reported a decrease in their sexual interest  appeared to have a negative effect on the partnership, making sexual life either worse than before or at least as bad as before the pandemic. Overall, it seems that the pandemic, at least in its first phase, served as a catalyst for the important link between the quality of relationship and couple’s sex life.The findings show several aspects of importance for researchers, clinicians, as well as social and medical health care professionals; for example, the importance of noticing that more time with each other makes it better only for those partnered individuals who already have positive sex-life trajectories. Not least, new research questions arise, for example concerning long-term effects of the COVID-19 pandemic on intimacy and sexuality among partnered individuals.


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.  Chile is a high-income country, with a GNI per capita of USD 24,020 in 2020 ; howeverIn terms of the provision of care, the institutions covered by FONASA are public healthcare centers managed by the National System of Healthcare Services (the Spanish acronym is SNSS). The institutions covered by the ISAPREs are privately owned healthcare centers or independent healthcare providers, and the armed forces and police system has dedicated centers . AdditioThe Chilean healthcare system went through a major reform in 2005 during President Ricardo Lagos’ term of office (2000–2006). The reform aimed at guaranteeing equal access to healthcare for high priority health problems to people residing in Chile according to their needs and without discrimination . The heaRegardless of the changes introduced in the 2005 reform, Chile continued to have a socioeconomically segmented healthcare system, which deepened the inequities derived from risk selection and cream-skimming, which are the typical problems of relatively unregulated insurance markets. Thus, the structure of the system ended up with two different subsystems, one for the relatively more socioeconomically advantaged citizens and another for the relatively more disadvantaged, poorer people. This organization contributed to generating a perception of injustice based on the fact that richer people had timely access to many health services, whereas poorer people had to deal with waiting lists, more restricted access to technologies, and a perception of worse health services . MoreoveA sustained period of social, economic, and political unrest took place during October 2019 in Chile, known as the “Social Outburst” or Estallido Social (in Spanish), where, for weeks, mobilization and strikes took place. The outburst was triggered by a rise of CLP 30 for public transport , and people’s demands revolved mainly around the deep inequalities concerning pensions, health, and education in Chile ,18,19. IThereafter, on the 25th of October 2020, an initial national plebiscite was held, where voters decided on: (i) whether they approved or rejected the drafting of a new constitution and (ii) what body should oversee writing it. More than half of eligible voters participated, and the results were: (i) 78% of voters approved the creation of a new constitution and 21% rejected it, and (ii) 79% voted for a democratically elected constitutional convention and 21% voted for a mixed constitutional convention. Previously, on the 11th of April 2020, elections to choose the members of the constitutional convention were held [Registro Único de Participación Popular), which could be performed online or at one of the enabled centers [Once the body was elected and formed, a term of 9 to 12 months was established to work on the draft for a new constitution. During this process, to promote citizen participation, the Popular Initiative for Norms (from Iniciativa Popular de Norma in Spanish) platform was created. This initiative acted as a participation mechanism through which an individual or a group of people could present proposals for constitutional norms to the constitutional convention. A total of 6114 proposals were sent through an online platform and underwent an admissibility revision, after which 2496 were approved and published for the public to vote on; each person could support a total of seven proposals. Physical centers were also enabled so that those with no internet access could inscribe their proposals manually. To be eligible to participate, the people were required to be above 16 years of age, of Chilean nationality, foreign nationality with Chilean residence, or Chileans living abroad. They then had to register in a Single Register of Popular Participation  reached the required 15,000 votes or more to pass on to the next stage of discussion. Of these, 60 were supported by organizations or institutions and 17 by individuals .Citizen participation in public health initiatives has historically been in the form of social movements. These share a common cause and advocate for change in matters such as urban conditions and health, the health of children, and the behavioral and substance-related determinants of health, amongst others . Health As described before, inequality in health was one of the main social demands brought up by citizens during the period of social unrest in Chile. In this context, a survey carried out by the Center for Conflict and Social Cohesion Studies (COES), in December 2019, asked people to assign a score from 1 to 10 regarding the importance of the different social demands, with 10 being very important. A total of 89.5% of people assigned 10 points to health ,27,28. SAdditionally, the last National Health Survey (2021)  showed tOn this basis, we conducted a narrative revision and synthesis of all the available civil proposals put forth as constitutional norms concerning health in order to better understand the most relevant areas of demand and interest for Chileans concerning their health care and their suggestions on how it could be improved. Our general research objective was to describe the main public health themes represented in this process in the country. By describing these themes and identifying the priorities put forth by the civil population, this study can be useful in guiding future reforms, both constitutional reforms and those regarding the health system. The association of these proposals with wider frameworks allows to visualize whether the institutional priorities are aligned with the popular demands and, if so, how. Despite the fact that the new proposal for the constitution was finally rejected during Chile´s referendum in September 2022, this historical societal, democratic, and participatory experience deserves regional and global attention and analysis.Study design: We carried out a qualitative thematic analysis of the health-related civil proposals uploaded to the official website for popular participation in the new constitution in Chile.Data source: The data used were extracted from the “Digital Platform for Popular Participation”, an online, public website created to enable citizen participation during the Chilean constitutional process. The approved proposals were published in the section called “Popular Initiative for Norms”. Each proposal was structured following these headings: Problem at hand; Ideal situation; What the new constitution must contemplate; Article proposal; and Brief background on the person, group, or institution in charge of the initiative.Search strategy: The keywords ‘health’, ‘healthy’, ‘well-being’, ‘quality of life’, and ‘health systems’ were used in the website’s search engine, which displayed the proposals containing these words in any part of the text. The data search and the data retrieval were conducted by SE and BC. The data search and the selection were conducted between January and April 2022.Selection criteria: A total of 145 proposals were founded. A first revision was made based on the title of each proposal, excluding those duplicated and those not relevant to the subject; following this, 126 remained. Previously, a complete reading of these proposals was made, and those whose main content related to health or public health were selected according to their relevance; after which, 106 proposals remained and were fully analyzed for extraction.Data extraction: The extraction of data was conducted by entering the data into a Microsoft Excel table by SE; the data were classified by (i) the general characteristics of the proposal ; (ii) the relevance to public health ; (iii) the mention of Essential Public Health Functions (EPHF), as established by the WHO/PAHO, 2020; and (iv) the mention of additional elements: “interculturality”, “gender”, “right”, or “vulnerability” or, similarly, “global”, “social security”, “health system”, “social”, or “civil participation”. The data extraction was conducted by SE, and the data analysis was conducted by SS and BC.Data analysis: We conducted narrative qualitative analysis , in whicData synthesis and display: Based on these results, sixteen main categories were reached using an inductive approach. These categories were: Mental health; Dental health; Public employees in health; Child and adolescent health; Autonomous health and education; Health, sustainability, and environment; Women, sexual and reproductive health rights; Palliative, chronic pain, and end-of-life care; Medication, specific treatments, and alternative therapies; Occupational medicine; Rare diseases and catastrophic situations; Promotion and prevention in health; Waiting times in health; Citizen participation; Health coverage and financing; and Right to health and the universal health system. In all, they are 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 relevant subgroups; and (iv) social determinants of health, health in all the policies, and community health.Additionally, each proposal is linked to the relevant Health Goals 2030 established by the Ministry of Health of Chile and the relevant Sustainable Development Goals (SDGs) established by the 2030 Agenda, and this detailed information is presented together with the full list of proposals in The sixteen categories reached were grouped into four main areas which organize the results.The thirteen proposals grouped into this category suggest that the new constitution must establish health as a right, with different approaches as to how this will be achieved. “Single, Universal, Plurinational and Integrated Health System for the New Chile that we are building democratically” had 19,852 votes, making it the most popular in this category; it passed on to the next phase of discussion and was supported by the Cabildo “Health, a right”. It puts forth that the new constitution must allow for the transition to a single, universal, plurinational, and integrated health system that replaces the fragmented and inequitable system, where health access is based on subsidiarity, economic capacity, and the profit of the providers.“Health for Chile that includes everyone” had 17,294 votes; it passed on to the next phase of discussion and was supported by the National Confederation of Municipal Health Workers (CONFUSAM). It suggests that health be recognized as a universal human right and that there should be a unique and universal health system, based on solidarity and participation, which incorporates views on gender, interculturality, and decentralization. The proposal states that this system should be financed by progressive and proportional taxes and that it should be based on primary care attention. Similarly, “FENPRUSS and the right to health” obtained 16,460 votes; passed on to the next phase of discussion and was supported by The National Confederation of University Professionals of Health Services (FENPRUSS). In addition to establishing a right to health, this proposal advocates that health systems must focus on the social determinants of health and must be based upon the principles of equity, universality, solidarity, comprehensiveness, interculturality, quality, efficiency, and gender. It puts forth that there should be a universal health system financed by a single, national fund.“Universal Health System” (4598 votes) puts forward that the state must guarantee access to decent and equal health for all people, and for this, there must be a universal health system. Along the same lines as these proposals were “For decent health as a fundamental right for Chile” (842 votes); “Right to health: First world medicine for everyone” (751 votes); “Right to health: autonomy, dignified death, universal health system, binding participation, dignified attention and right to care” (572 votes); “A national health system for Chile: territorial, public, of quality and free” (424 votes); “Universal health system from the moment of birth for the duration of life for all citizens, independently of their socioeconomic situation” (416 votes); “Right to public and private health” (340 votes); “Health is a right” (195 votes); “Universal Health, latest generation hospitals, how and what way to achieve and implement it in Chile” (192 votes); and “’El Bosque’ borough demands a universal health system conceived as a human right for everyone” (191 votes). They all concur that health should be established as a fundamental right and that the state plays an important role in ensuring access to proper healthcare conditions.The proposals are all linked to Health Goal 7. Management, quality, and innovation and the proposal “Health for a Chile that includes everyone”; they also include Health Goal 1. Environmental health and healthy environments. With regard to the SDGs, they are all connected to SDG 3. Good Health and Wellbeing; SDG 10. Reduced Inequalities; and SDG 16. Peace, Justice, and Strong Institutions, except for “Health is a right”, which is not explicitly connected to SDG 16. Additionally, “FENPRUSS and the right to health” is also linked to SDG 5. Gender Equality.Currently, in Chile, there are two main options for health insurance. On one hand, there is the National Health Fund (FONASA), which acts as a public agency that collects and manages the compulsory contributions of employees. Alternatively, people may opt for private insurance through the private healthcare insurers ISAPREs, which is often more expensive. The present constitution states that people have the right to choose between these two. “The right to choose your insurance, health and education in public and private systems” (358 votes) and “Pension system and health insurance” (128 votes) aim at maintaining this principle.Other proposals suggest reforming the current system, and they propose establishing a single, public, and universal plan, where private insurances are a complementary option. This is the case for “Your health, your payment, your right” (3410 votes); “Health without patches: Free, transparent and dignified” (1935 votes); “Right to Health” (1842 votes); and “Public, integrated health system” (382 votes). On the other hand, “Strengthening the health system, so that all Chilean people have access to quality and timely health benefits in an equitable manner” (990 votes) puts forth that the state must ensure universal health coverage, although it does not define how this should be carried out. Similarly, “To eliminate the obligatory health percentage of people in ISAPRES, leaving FONASA as the sole receptor” (220 votes) and “You FONASA, me FONASA, we are all FONASA” (162 votes) specify that there must be a compulsory contribution from every citizen to FONASA, independently of whether they have private insurance.Other financial proposals include “Right to health and the presence of profit” (96 votes), which suggests eliminating all profit from both public and private health systems, and “0.1 of taxes to social security and health” (25 votes), which puts forward that 0.1% of the taxes collected by the state must be directed to a common fund that goes to health  and to another fund that ensures minimum guaranteed pensions.All the proposals are connected to Health Goal 7. Management, quality, and innovation; regarding the SDGs, they are connected to SDG 3. Good Health and Wellbeing; SDG 10. Reduced Inequalities; and SDG 16. Peace, Justice, and Strong Institutions. The proposal “0.1 of taxes to social security and health” is also the only one to be connected to Health Goal 6. Emergencies and disasters.Two proposals were grouped into this category. “Diminish waiting times in access to public health services” (404 votes) says the state must be expedient in helping citizens access health attention and medication, and in cases where there is no availability for a certain service or medication, they must allow access to other professionals or systems. “Guarantees for prolonged waiting times in health” (173 votes) refers to the state’s responsibility in providing aid in cases where waiting for health attention is prolonged. Both proposals are connected to Health Goal 7. Management, quality, and innovation and to SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities.This category held the highest number of proposals, with thirteen proposals alluding exclusively to mental health and two combining mental and dental health. The most popular, “Right to free and quality mental health” , puts forward that “citizens will have the right to free and optimal mental health services”, and ten other proposals support this notion.“Right to mental health with no discrimination, in equal conditions to physical health” (1175 votes) and “Free, quality mental health as a fundamental right, and decentralized priority for Chileans” (323 votes) explicitly mention free mental healthcare. “A right to mental health, promotion of wellbeing, dignified and inclusive mental health services. May no one is left behind” (1755 votes); “Mental health as a right and not a privilege” (1699 votes); “Mental health as a constitutional norm: Guaranteeing the universal right to protection of mental health” (644 votes); “Inalienable right to prevention, detection, diagnosis, attention, treatment and education in mental health” (298 votes); and “The state’s responsibility of encouraging, promoting and guaranteeing quality mental health attention for all Chileans” (293 votes) mention the state’s responsibility in guaranteeing the fulfilment of mental health as a right. “Timely access to free, quality mental health. A patient should never have to say ‘I have been waiting for an appointment for months’” (827 votes) and “Right to quality mental health for everyone” (537 votes) both refer to equal, timely and quality access to mental health.Both “Free physical, mental and dental health” (418 votes) and “Guaranteed access to quality and free mental and dental health at a community level, for everyone, independently of their socioeconomic level” (169 votes) integrate mental and dental health. They state that the new constitution must include free and quality access to these services. On the other hand, “Right to community mental health: closure of psychiatric hospitals” (378 votes) and “Towards the integration of communitarian mental health” (70 votes) specifically touch on community-based mental health, highlighting the importance of cultural relevance to the territory and shifting towards a communitarian, as opposed to individualistic, approach to health. In terms of integrating mental health into other spaces, “Strengthening mental health” (774 votes) argues that public policy must be aimed at the “promotion of mental health in education, health and work areas, as well as equal treatment conditions”.With regard to alignment with wider frameworks, the proposals related to mental health mainly relate to the following Health Goals 2030: 1. Environmental health and healthy environments; 2. Lifestyle; 4. Non-communicable chronic diseases and violence; 5. Development and disability; and 7. Management, quality, and innovation. Additionally, all the proposals feed into SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities. In addition, the proposal titled “Right to mental health with no discrimination, in equal conditions to physical health” also contributes explicitly to SDG 5. Gender Equality.In addition to the two proposals that integrate dental and mental health, six proposals exclusively focus on dental health, with “Right to dental health” (2964 votes) being the most popular initiative. “Oral health as a right” (665 votes); “The right to oral health for all Chileans” (529 votes); and “Oral health as a fundamental right for the elderly population” (809 votes) all allude to the same concept, with the last one, in particular, specifying the importance of including the elderly population. On the other hand “Dental health, urgently” (438 votes), though not alluding to the concept of rights, aims to guarantee dental health to anyone who needs it, in a similar way to “Dental health guaranteed in case of loss of dental pieces” (169 votes).The dental health proposals are aligned with the following Health Goals 2030: 4. Non-communicable chronic diseases and violence and 7. Management, quality, and innovation, insofar as they address oral health, which is included in Goal 4. This is an argument in favor of including the right to dental health as a part of healthcare, signifying changes in the management of the system. The proposal “The right to oral health for all Chileans” also pushes forward a community approach to the topic, which relates to Health Goal 1. Environmental health and healthy environments. Concerning the SDGs, all the proposals are aligned with SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities.The three proposals included in this category refer to the consecration of health and safety in the workplace as a fundamental right and they are all related to Health Goals 1. Environmental health and healthy environments; 2. Lifestyle; and 7. Management, quality, and innovation, as well as SDG 3. Good Health and Wellbeing; SDG 8. Decent Work and Economic Growth; and SDG 10. Reduced Inequalities. These are: “Including health and safety at work (SST) as a fundamental right for workers” (1353 votes); “Safety and health at work is a fundamental right according to OIT . It is necessary to include it in the constitution” (244 votes); and “Right to safety and health at work” (189 votes).The four proposals grouped into this category mainly concern the delivery of end-of-life care, as well as the working and training conditions of healthcare workers. “Care and health protection in the new constitution” (1332 votes), supported by the National Federation of Nurses of Chile, suggests incorporating the right to receive care by making it a state duty to ensure its provision, while the “Right to ‘good death’” (496 votes) and “Mental health and wellbeing of elderly patients and their careers. Professionalizing the care of the elderly” (269 votes) refers particularly to the ensuring of the adequate training of health teams and professionals dedicated to caring. “Right to live without pain”: for compassionate treatment of chronic, non-oncological pain” (226 votes) specifically refers to the right to live without chronic pain and argues that the constitution must ensure the effective right of people to have integral physical and mental health.In terms of alignment with Health Goals, these proposals all relate to at least Health Goals 1. Environmental health and healthy environments and 7. Management, quality, and innovation. However, “Care and health protection in the new constitution” is also linked to 2. Lifestyle and 4. Non-communicable chronic diseases and violence, while the other three have to do with 5. Development and disability. All four proposals are linked to SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities.Fifteen proposals were grouped into this category, which includes the proposals related to access to medication and treatment and different forms of therapies.Medication:This is associated with medication and pharmacies; “Access to quality medication and pharmacies as health centres” (6026 votes) and “Medication as an essential article of public use, and pharmacies as primary health centres” (330 votes) suggest that access to medications must be guaranteed and consider medications to be essential goods. Likewise, they both suggest that pharmacies should acquire a more central role in the healthcare system by providing primary care. “Universal and free access to all remedies and treatments, independently of the disease” (1210 votes), as its name states, looks to establish and guarantee a system of universal and free access to all remedies and medications, independently of the cost of the disease, financed by the state.Specific treatments:Regarding specific treatments, there were six heterogeneous proposals. The most popular proposal was “Obesity and loose skin: our health is your responsibility” with 12,936 votes, and it raised the argument that the state should be responsible for ensuring corrective surgery prior to abdominoplasties, along with promoting healthy lifestyle habits. On a similar note, there was a proposal named “Right to quality esthetic health for everyone”; however, it only obtained 92 votes. With regard to access to physical therapy, “Right to physical therapy and rehabilitation to face disability-School of Physiotherapists” (8225 votes), supported by the Chilean School of Physiotherapists, puts forward that the state must guarantee timely and adequate access to good-quality physical therapy and rehabilitation for all the citizens in the national territory. Two proposals referred to organ donation, “Organ donation and transplants and their promotion as a public policy” (1234 votes) and “Creation of a Nation Organ Transplant Institution” (154 votes). The first makes the state responsible for ensuring organ transplants for those who need them, whereas the second proposes the creation of a separate institution that coordinates organ transplants, guaranteeing transparency and autonomy. Lastly, “Blood as a common good and its equal and opportune availability for all inhabitants of the country” (706 votes) aims to create policies that will ensure timely, efficient, and equal blood transfusion in the country.Alternative therapies:Seven proposals referred specifically to alternative or complementary forms of therapy. “Cannabis to the Constitution now: For the right to freedom in the development of personality, personal sovereignty and wellbeing” counted 44,332 votes. It was the proposal with the highest number of votes concerning health, and it was third in the overall category. It favors the free choice to use cannabis and other psychoactive substances of natural or synthetic origins, in alignment with a balanced and respectful bond with nature. Six other proposals refer to the inclusion of alternative forms of treatment into health systems, supporting the idea that people must be guaranteed a right to choose and to access these forms of medicine should they choose to. These include: “Acupuncture-Chinese Medicine-Integrative therapies” (4140 votes); “Floral therapy as a constitutional right” (1603 votes); “Health and natural medicine: a necessity for Chile” (1493 votes); “Health centred on the human being, with integrative and complementary medicine” (802 votes); “Right to access health care through conventional, traditional or complementary medicine, according to choice” (387 votes); and “Single, a diverse and universal health system with recognition of non-conventional medicine and plurinational” (118 votes).In the medication subcategory, the proposals are all connected to Health Goals 1. Environmental health and healthy environments; 3. Communicable diseases; 4. Non-communicable chronic diseases and violence; and 7. Management, quality, and innovation. In the specific treatments’ subcategory, all the proposals are linked to at least Health Goals 4. Non-communicable chronic diseases and violence and 7. Management, quality, and innovation, and some include 1. Environmental health and healthy environments and/or 5. Development and disability. Finally, the subcategory alternative/complementary therapies are all connected to Health Goals 1. Environmental health and healthy environments; 2. Lifestyle; and 7. Management, quality, and innovation.With regard to the SDGs, while all the proposals are aligned with SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities, the proposal “Cannabis to the Constitution now: For the right to freedom in the development of personality, personal sovereignty and wellbeing” also aligns with SDG 11. Sustainable Cities and Communities, SDG 13. Climate Action, and SDG 15. Life on Land.The three proposals grouped into this category establish that the coverage of costs associated with rare diseases or catastrophic/terminal situations must be guaranteed. “Mandatory and guaranteed coverage of health insurance in cases and diagnosis of rare diseases” (2866 votes) makes the insurance (public or private) responsible for covering these costs in treatments associated with rare diseases. “Right to health by way of treatment of high-cost diseases” (413 votes) and “Elective and free health for the catastrophically ill” (115 votes) refer to the same concept but in the context of catastrophic and terminal conditions. All three proposals are connected to Health Goals 5. Development and disability and 7. Management, quality, and innovation, as well as SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities.Five proposals were grouped into this category. They all specifically refer to children and adolescents as a particular subgroup within the population. “Guaranteed mental health for our children and youth” (513 votes) and “Every child has a right to have a good quality of life and the state must propitiate and guarantee adoption systems and capacitation centres” (137 votes) address vulnerability and suggest reinforcing adoption systems and children’s mental health to provide safe environments and prevent future delinquency. “Equalitarian and independent access to health care for children and adolescents” (53 votes) refers to facilitating the youth’s access to healthcare systems and advocates for removing the requirements of obtaining a parent or tutors’ consent to access health services. Lastly, “Healthcare within educational institutions” (830 votes) and “Strength conditioning and functional training for middle school students, to strengthen physical and mental health and gender equality” (224 votes) bring up the role of schools and educational institutions and suggest health promotion and prevention strategies that could be carried out from within those spaces.All the proposals on child and adolescent health are aligned with at least Health Goal 1. Environmental health and healthy environments and 7. Management, quality, and innovation, as well as SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities. Some proposals also relate to Health Goals 2. Lifestyle; 4. Non-communicable chronic diseases and violence; and/or 5. Development and disability, as well as SDG 4. Quality Education and/or SDG 5. Gender Equality.Eight proposals were grouped into this category. In general, the proposals point towards the importance of sexual and reproductive rights, including access to adequate healthcare and contraceptive methods, as well as the promotion of education in this area. “It will be a law”  together with “Right to sexual and reproductive health with a gender, feminist, intersectional and pluralist focus”  favor abortion, and both were approved for the next phase of discussion. The first proposal defends the idea of abortion being included as a constitutional right; the second proposal suggests a new legal system that guarantees sexual and reproductive health. In contrast, “Always for life”  puts forward that the constitution must protect life from the moment of conception and that the law will protect the life of unborn beings. On a similar note, “Conscientious objection to abortion for healthcare workers”, which aims to give healthcare workers the option to not be part of abortion-related procedures for ethical or personal reasons, received 351 votes.Four other proposals are in line with sexual and reproductive rights: “Guarantee the right to voluntary contraception within the framework of protecting sexual and reproductive rights” (615 votes) promotes the notion of free and quality access to contraceptive methods; “¡Right to sexual health!” (712 votes), which additionally incorporates the importance of training students on sexual health as well as providing sexual education for the general population; “Access to permanent menstrual education and health for girls, women and menstruating people in Chile” (217 votes), which specifically refers to menstrual health and education; and lastly, “Reproductive rights and access to assisted reproduction in the new Chile: a proposal from civilians and scientific societies” (4492 votes), supported by the Chilean Society of Reproductive Rights, puts forward assisted reproduction, suggesting it should be accessible to all people and couples. Finally, “Respected gestation and birth” (375 votes) proposes that doulas should be incorporated into the current health system, as a support for women during different stages of their gestation, birth, and postpartum cycles.The proposals all relate to Health Goals 2. Lifestyle, which explicitly includes reproductive and sexual health, and 7. Management, quality, and innovation, as well as SDG 3. Good Health and Wellbeing, SDG 5. Gender Equality, and SDG 10. Reduced Inequalities.Four proposals were grouped into this category: “Public authorities and staff must use public health, education and transport services” (2911 votes); “State health care for all public workers” (1074 votes); “Government authorities and staff must use public health and education systems” (611 votes); and “Quality public health” (295 votes). They all suggest the compulsory use of public services, including health services, by government authorities and public employees, arguing that this will generate awareness of how they work and will therefore act as an incentive for them to be improved. Not dissimilarly, “Equal health for all” (225 votes) puts forward that all health professionals must provide care to patients covered by the public insurer FONASA, without exclusion.All the proposals are aligned with Health Goals 1. Environmental health and healthy environments and 7. Management, quality, and innovation, as well as SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities.All three proposals in this group refer to the establishment of autonomous entities to manage health and educational matters. “Autonomous health and education” (91 votes); “Autonomy for education and health (85 votes)”; and “Establishment of autonomous organisms for health and education (31 votes)” all concur that having institutions that function independently of the government and the changing political authorities will allow for long-term projects and goals to be reached, and finally, they are all aligned with Health Goals 1. Environmental health and healthy environments and 7. management, quality, and innovation, as well as SDG 3. Good Health and Wellbeing, SDG 4. Quality Education, and SDG 10. Reduced Inequalities.Five proposals were grouped into this category. “Health and quality of life” (6005 votes) and “Right to a good living through the protection against acoustic contamination” (370 votes) focus on acoustic contamination, its impact on physical and psychological health, and the importance of proper regulation to ensure a better quality of life. “The right to health in an environment free of contamination” (712 votes) and “The right to health in an environment with reduced contamination”—both supported by the United for Responsible Technology institution—address the adverse effects of contaminants present in different technologies, and the need for this to be regulated by the state to ensure people’s wellbeing. Finally, “Without a right to food, there is no right to health nor healthy development” (108 votes) refers to the importance of healthy and sustainable food, both in the effort to implement healthier habits and in the effort to be environmentally friendly.All the proposals clearly relate to Health Goal 1. Environmental health and healthy environments, and the proposal “Without a right to food, there is no right to health nor healthy development” can also be linked to 2. Lifestyle and 4. Non-communicable chronic diseases and violence. Regarding the SDGs, all feed into SDG 3. Good health and Wellbeing and SDG 10. Reduced Inequalities; however, additional SDGs become relevant in specific proposals: SDG 2. Zero Hunger, SDG 10. Reduced Inequalities, SDG 11. Sustainable Cities and Communities, SDG 13. Climate Action, and SDG 15. Life on Land.The six proposals grouped into this category aim at incorporating health promotion and prevention as fundamental pillars of health and wellbeing. Regarding health promotion, “Better health, lifestyle and wellness through physical education, exercise and recreation (187 votes)” and “Incentivized Health” (45 votes) both highlight the importance of incentivizing sports and physical activity. The first proposal is more elaborate than the other one and suggests that this could be achieved by increasing the number of hours allocated to physical education in schools, guaranteeing the promotion of physical and recreational activities for families, encouraging the active use of free time and leisure, and enabling adequate environments for physical activity and exercise for the general population.In terms of preventive measures, there are three proposals. The first one, titled “Constitution and Health: Modernization of the State” (289 votes), suggests that prevention should be at the center of public health policies and that the state should establish a “National Preventive Health System”. On a similar note, the proposal “Right to health access (Disease prevention or free checkups)” (270 votes) suggests that the state must guarantee access to health services, both public and private, with a preventive focus, and “Preventive health as a fundamental right” (162 votes) argues that preventive health must be guaranteed as a fundamental right and a constitutional principle, focusing on nutrition and the elimination of sedentarism. Lastly, “Right to knowledge and formation in first aid and basic health concepts” (130 votes), looks to guarantee education on first aid skills and aims at the prevention of high-incidence diseases in Chile.With regards to Health Goals, all proposals are aligned with at least 1. Environmental health and healthy environments and 2. Lifestyle, and some are also related to 3. Communicable diseases, 4. Non-communicable chronic diseases and violence, 5. Development and disability, and/or 7. Management, quality, and innovation.Four proposals specifically refer to the participation of citizens and communities in decision making in health. “Right to an integral and participative health: creating wellbeing from the communities” (541 votes); “For a right to health based on the community” (483 votes); and “Binding citizen participation in health” (184 votes) put forward that communities must be systematically involved in decision making and that there must be sustained participation in areas concerning health. “Towards an open, binding and feminist health” (87 votes), suggests a series of reforms and changes, both ideological and structural, that incorporate a transversal perspective on health and include active, binding citizen participation.The proposals are connected to Health Goal 7. Management, quality, and innovation and SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities. The last proposal, “Towards an open, binding and feminist health” also relates explicitly to SDG 5. Gender Equality.Our study reviewed the proposals linked to health pushed forward by civil society for their inclusion in the new constitution of Chile through the online platform “Iniciativa popular de norma” (Popular Initiative for Norms). After careful consideration, 126 proposals were selected for review and classified into 16 categories. This study analyzed these proposals at a historical time for Chile, in which civil participation in the elaboration of the new constitution was promoted. We conducted this narrative synthesis of all the available civil proposals put forth as constitutional norms concerning health to better understand the most relevant areas of demand and interest for Chileans concerning their health care and their suggestions on how it could be improved.The first important finding, in line with our research assumptions based on the last National Health Survey, has to do with the proposals linked to the right to health and the establishment of a universal health system. Health was indeed one of the main issues at hand during the 2019 “estallido social”, and one of the grievances expressed was the fragmentation of the healthcare system between the public and the private sector, where the private healthcare sector operates for high profit and on a discriminatory basis according to the patient’s capacity to match contribution with estimated needs, while the public healthcare is understaffed and underfunded and struggling to respond to the healthcare needs of the majority of Chile’s population ,32,33. TThe second main finding of this review, in a similar line, is the number of proposals related to mental health, which are as many as that of the one more broadly focused on the right to health. Mental health is a key issue in Chile, considering, on the one hand, that the prevalence of suicide and common mental disorders in Chile is high ,35 and, The third main finding is that beyond only healthcare, many proposals also include the need to address the social determinants of health and to approach health from a community perspective. The Chilean public health system is characterized by a family and communitarian approach to primary care, which strives to be patient-centered and delivers integral and continuous care , somethiNow, as much as the Popular Initiative for Norms appeared to be a far reaching and inclusive participation mechanism, the fact is that how these proposals would then be managed by the constitutional convention raised much criticism. The proposals were to be discussed by members of the convention and then put to the vote amongst them, leaving no relevance to the number of votes from the public or to other aspects and leaving the final call up to the political conformation of the convention, where left and center-left representatives predominated. This raises questions on how effective this democratic mechanism is if it incises the final draft of the new constitution and how representative of the nation’s interest it is.In association with this last point, although we found that the proposals associated with health were multiple, diverse, and with a general trend towards improving quality and access in health nationwide, various themes that are still deficient in our health system were missed. One example of this is migrant health. Not one proposal made specific mention to this group and the challenges they face in our national health system. Administrative and cultural barriers continue to perpetuate their vulnerability in Chile ; yet, thCivil proposals represent an important effort from civil society, either grassroots organizations, institutions, or individuals, towards having a say in the formulation of the new constitution. However local this effort might be, it can also be placed in a greater policy framework at the national level—the Health Goals 2030 established by the Ministry of Health of Chile—and in another framework at the global level, the SDGs. Regarding the Health Goals 2030, it is worth noting that most of the proposals are linked to Goal 7. Management, quality, and innovation, suggesting that changes in the way in which care is guaranteed and delivered are especially needed. Furthermore, virtually all the proposals are connected to SDG 3. Good Health and Wellbeing and SDG 10. Reduced Inequalities. These aspects of discussion that emerged from this unique study of civil proposals in Chile is informative on how society perceives and makes demands for the selected public health strategies in the context of a highly unequal high-income country in the Latin American region. This is the case for many countries worldwide as they share the complex condition of simultaneously dealing with the health issues of sub-populations that experience chronic conditions and cancer as well as those of other sub-groups that continue to suffer the health effects of poverty and exclusion, including historical and re-emerging infectious diseases. The segmented and fragmented health system in Chile is struggling to deal with multiple and competing health needs, and the people of the country are demanding more universal coverage and more equity-based planning and effective delivery at the point of care. The existing design of the health systems in almost all countries in Latin America is being challenged, and in some cases, the idea of a health system reform is currently under discussion, as it is in the case of Chile.These proposals represent a call for a definite departure from the current constitution, in which the constitutional rights to health are only very sparingly defined as the right to choose between public and private coverage. Although it is unlikely that all aspects brought up in the many proposals reviewed will make it into the final constitution, considering the current inequities in both physical and mental health in Chile, the new constitution must be a catalyst for change in how health is approached and guaranteed. Furthermore, this process contributes to tearing down the authoritarian legacy of the Pinochet dictatorship. It is a process that was a long time coming and establishes another crucial precedent after the return to democracy in 1990, where people have the opportunity to update one of the most important frameworks guiding the country. More specifically, with regard to health and healthcare, the proposals show a strong demand from the population to have a say in matters of health, healthcare, and public health.This study has a number of limitations and strengths. In terms of its limitations, it describes only the civil proposals that were effectively uploaded in the national platform. Hence, it represents successfully submitted proposals, not all the attempts to submit proposals in the process, and the effective number of incomplete submissions is impossible to know as there is no recollection of them in the system. Moreover, individuals or organizations could only upload a maximum of seven proposals; so, there might be additional relevant proposals that were not prioritized and, therefore, are not represented in this analysis. Despite these limitations, this study is the first of its kind to analyze the proposals related to health that were uploaded and voted for during the elaboration of the new constitution for Chile. This national process is remarkable in its spirit of promoting wide civil participation. From our thematic analysis, we were able to describe the main areas of interest and the issues of concern of the citizens in the country, most of which were related to the right to health and the establishment of a universal health system, improving mental health, and the need to address the social determinants of health and to approach health from a community perspective. These three main areas of relevance to this analysis are strongly linked to broader global public health concerns, including the Health Goals 2030 and the SDGs.Chile is a high-income country in Latin America that faces great socioeconomic inequality and a segmented–public and private–health system. In response to the serious political crisis, Chile’s political parties came together recently to deliberate on an institutional solution, attending to the social demands of fairness around several issues, such as pensions, health, and education. The result was the elaboration of the “Agreement for Social Peace and the New Constitution’’. In this context, we conducted a narrative revision and synthesis of all the available civil proposals put forth as constitutional norms concerning health to better understand the most relevant areas of demand and interest for Chileans concerning their health care and their suggestions on how it could be improved. We believed that, despite the fact that the proposal for the new constitution was finally rejected during Chile´s referendum last September 2022, this historical societal, democratic, and participatory experience could be relevant in providing information on the societal interests related to public health matters in highly unequal high-income countries in the Latin American region, with Chile as a case study.Our general research objective was to describe the main public health themes represented in this process in the country. We found 16 main categories: Mental health; Dental health; Public employees in health; Child and adolescent health; Autonomous health and education; Health, sustainability, and environment; Women, sexual and reproductive health rights; Palliative, chronic pain, and end-of-life care; Medication, specific treatments and alternative therapies; Occupational medicine; Rare diseases and catastrophic situations; Promotion and prevention in health; Waiting times in health; Citizen participation; Health coverage and financing; Right to health and a universal health system. In conclusion, the main areas of interest and issues of concern of the citizens in the country are related to four relevant dimensions: the right to health and the establishment of a universal health system; effective access to selected healthcare services; improving health outcomes for all and for relevant subgroups; and the social determinants of health, health in all the policies, and community health. These four main areas were also strongly linked to broader global public health concerns including the Health Goals 2030 and the SDGs.


Correction: BMC anesthesiol 23, 42 (2023)10.1186/s12871-023-02004-4Following the publication of the article , it was In the first paragraph of the discussion section of the article, there is the statement ‘To the best of our knowledge, this is the first randomized controlled trial to compare postoperative analgesia to use different local anesthetic volumes for ESPB after thoracotomy’. However, in the third paragraph of the discussion section, there is the statement ‘To our knowledge, there are no studies comparing ESPB block applications using different local anesthetic volumes’. This second statement did not specify that ESPB application covers thoracotomy patients. The correct expression should have been ‘To our knowledge, there are no studies comparing ESPB block applications using different local anesthetic volumes after thoracotomy’. However, Abdella et al  comparedA citation error was made in the same paragraph of the discussion section. The studies of Forero et al. were mixed. Then, the citation was made to another article by Forero et al.Correctly cite ‘To our knowledge, there are no studies comparing ESPB block applications using different local anesthetic volumes after thoracotomy. However, in a case series with different volumes, it was reported that the block level increased up to 9 dermatomes in a case in which 30 ml of local anesthetic was applied . In studWe apologize for any inconvenience caused by this error.


SOS Préma in France. This article brings together recent studies on partnership in the NICU. It is an innovative topic in neonatology with vast issues to explore.Parents with a sick child in a neonatal intensive care unit (NICU) usually experience stress, anxiety, and vulnerability. These precarious feelings can affect early parent–child interactions and have consequences for the child’s neurodevelopment. Parents who have had a sick child in an NICU (veteran parents) can offer helpful interventions for these vulnerable families. This article is a scoping review of parental interventions used with the families of NICU infants, and an overview of French perspectives. Two independent reviewers studied the scientific literature published in English between 2001 to 2021 using Covidence software. The databases used were MEDLINE, ISI Web of Science, the Cochrane Database, and Google Scholar. Themes were identified from the articles’ results using an open coding approach. The data are presented in a narrative format. Ten articles were included, and four major themes addressed: (1) description of activities, (2) recommendations, (3) impact, and (4) barriers . Activities were very diverse, and a step-by-step implementation was recommended by all authors. Peer-support interventions might be a potential resource for those anxious parents and improve their NICU experiences. These challenges are described by  Sick children in a neonatal intensive care unit (NICU) are always a challenging experience for their parents ,2,3. TheMoreover, the mothers’ stress and depression can harm her self-confidence as a caretaker for her child, even with basic routines during and after hospitalization .Psychoanalysts and pediatricians, such as Freud, Winnicot, Bowlby, and Brazelton, showed that early interactions and bonding are essential for the child’s neurodevelopment , and stuTherefore, it is expected that interventions addressing the mother’s stress, depression, and anxiety after a premature birth may help improve early interaction between parents and their children, as well as enhance the children’s outcomes ,16. ManyInterventions offered by veteran parents in NICUs is increasing as a resource. These veteran parents, or resource parents (RPs), have experienced the hospitalization of their own child in an NICU and, from that unique perspective, are able to offer support to NICU families, as well as contribute to clinical, research, and teaching activities ,22.Such interventions are expanding in North America, and the literature discussing how to implement partnership with parents is increasing ,24,25,26This article is based on a scoping review in which we accessed recent data on current knowledge, recommendations, potential impacts, as well as barriers for implementation of partnership with parents in the NICU. As the literature mainly comes from North America, we included the work of SOS Préma in France, a French association mostly composed of volunteer parents who have had an NICU experience, to offset cultural differences between France and North America.The main objective of this study was to describe such interventions and their impacts based on scientific sources.We also describe how SOS Préma in France implements partnerships with parents based on the report of the president of the association.SOS Préma team.Scoping review: A scoping review is an ideal tool for the first step in understanding the literature in an innovative research field ,28. As r(1)How can we implement and develop parents’ interventions in NICUs?(2)Is there a direct impact on the babies’ outcomes from this partnership?(3)What are the barriers for implementation?Our review aimed to answer the following questions:Identification of relevant studiesThis is a scoping review and a reflection on current experiences and themes from the literature by French NICU providers and the Reviewed studies were published from 2011 to 2021, representing a ten-year overview, and corresponded to the growing development of these practices. Inclusion criteria: Included articles were peer-reviewed, written in English, and focused on parents’ partnership with healthcare providers in different types of NICU activities: clinical care, peer support, research, administration, and teaching.Exclusion criteria: Studies of parents’ participation during the hospitalization of their child were excluded, as well as studies about family-integrated care, parents’ perspectives or opinion, bereaved parents, and studies on partnership in pediatric or adult population. Publications before 2010 were also excluded. The electronic databases searched were MEDLINE, ISI Web of Science, the Cochrane Database, and Google Scholar. Bibliographies of all selected articles were checked, and the following Medical Subject Headings (MeSH) terms were used: “resource parents”, “veteran parents”, “peer-to-peer”, “peer support groups”, “peer counselling”, “partnership with parents”, “parents’ engagement”, and “family stakeholders”. These MeSH terms were combined with: “NICU”, “newborn”, “neonate”, and “preterm babies”. Two reviewers independently selected the articles using Covidence software.Themes from the selected articles were identified using an open coding approach . Data presentationThe first and last author  exhaustively read the articles in their entirety, paying special attention to the description of the partnership interventions, recommendations, impacts, and barriers.The data from the selected articles are presented in a narrative format. From t electronic searches, we identified 239 articles, including 7 duplicates that were removed and 100 that were excluded after abstract review. There were 152 full texts assessed for eligibility, 9 of which were included upon agreement between the two independent investigators .A summary of the characteristics of the nine included articles is presented in After analyzing included studies, four general themes were identified : descripThe most common activity described and developed by resource parents is peer-to-peer support ,25. A laCreating committeesPromoting partnerships with parents in an NICU requires time and organization. A step-by-step implementation is recommended by all authors ,22,25,26RecruitmentFor a better understanding of and involvement in NICUs, committees should be created with all healthcare team members , along with one or two resource parents. How to recruit these parents is still under debate; it is not possible to currently give guidelines, because it depends on each unit’s culture and interaction between parents and providers. Some authors recommended institutions create a job position dedicated to a partnership program . Other aRecruitment can be discussed during hospitalization, but the timing between the parents becoming participants and the babies’ hospital discharge is not yet clear. Some activities are more complex and present higher levels of risk . A “pyraRemunerationIt is hard to avoid bias during the recruitment of veteran parents. We can imagine that parents from higher social and economic levels would be more comfortable being involved; healthcare providers might also have easier and more fluid interactions with them. In addition, parents who still are in a healing process would be more likely to participate and return to work with the neonatal team, if they perceive this type of involvement as a recuperative and meaningful experience .RemunerTraining and supportRemuneration for the resource parents is also debated and may help reduce the bias of recruitment associated with lower-income families. Nevertheless, money should not be the motivation for a partnership, because it implies psychological risks. At minimum, compensation for meals and transportation should always be provided ,21.TraiResource parents should receive training from healthcare providers to participate in some activities, especially those involving direct interactions with the birth parents (peer-to-peer), and as well as with simulation projects ,24.NICU partnerships with parents is an innovative way to improve care. However, not all risks and barriers are yet known. Thus, authors recommended a team of support for these parents from all caregivers .It is hard to measure the quantitative impact of a partnership, as it is always associated with other interventions in an NICU and is already known to have a positive effect on babies’ outcomes. These include Kangaroo care or a newborn individualized developmental care and assessment program (NIDCAP) . An impoNevertheless, we already know that there is an indirect impact with partnerships. The literature describes potential impacts on parents, such as increasing parents’ self-confidence, parents’ capacity to solve problems, adaptative coping, self-esteem, and resilience ,24,25,26“the clinical environment of the neonate, provides the optimal settings and best possible long-term outcomes for the infant and family” [The potential impacts on the babies’ environment and development were also described, especially when the resource parents were involved in a quality-improvement interventions . Celenza family” . Finally, we now know that such initiatives are safe and can help resource parents find meaning in their NICU experience, as well as play a role in their own healing process ,22.Barriers and difficulties mainly come from priorities given to technical activities; the neonatal unit’s culture and philosophy; issues in program development, coordination, recruiting, and training time; remuneration; and the unknown outcomes for the babies and their families ,21,25.SOS Préma were included to reflect the French perspective.Recommendations suggested in the articles we reviewed are shared to help providers overcome these barriers; however, recommendations from North America might not be applicable in European cultures. It is important for each project team to develop their own approach by considering their resources, culture, and population profile. It is for this reason that information and recommendations from SOS Préma has sought to provide all premature newborns the following parallel, three-axis approach in order for the infants to have the best opportunity to thrive: 1. support for families, 2. dialogue with medical teams, and 3. raising public authorities’ awareness.Since 2004, the French association SOS Préma has approximately 70 volunteer parents dispersed throughout the country in about sixty local branches. Their main mission is to support parents in hospital neonatal medical units, as well as after the infant’s discharge. Some parents act as moderators for the association on social networks; some answer the association′s toll-free hotline; others participate in updating the informational documents and booklets given to parents during hospitalization. The volunteers are required to sign an agreement with the hospital and the satellite location.Groupe de Réflexion et d’Évaluation de l’Environnement du Nouveau-né) [All participants are parents of a child born prematurely or hospitalized at birth. They may become association volunteers after an initial training of approximately six hours and two interviews, including one with the association′s psychologist. Parents also receive ongoing training during an annual two and a half day seminar. These training sessions not only focus on the association itself, but also on the psychological experiences of the parents, the operations of the hospital, fundraising, and communications. Additionally, sessions include scientific aspects such as developmental care or French recommendations of GREEN (veau-né) .SOS Préma association to be asked at the national level to address users in working groups ), as well as being asked to participate at the local level . Additionally, the association may participate in research in France or in Europe . The objective is not only to bring the voice of families to professionals, but also to successfully achieve “scientific popularization” for families.It is increasingly common for the The association also organizes a yearly two-day training for professionals. These sessions concentrate on themes regarding prematurity and hospitalization of newborns.SOS Préma Prize), along with dissemination of new practices, by offering necessary equipment throughout France. As an example, in 2019, a donation of 60 transport carriers was offered to facilitate a parental/infant skin-to-skin transfer from the delivery room to the neonatal physician services.These are supported by testimonials from volunteer parents and scientifically reinforced by recognized professionals. Finally, the association financially supports projects , the organization of a General Assembly on prematurity (2013), the creation of a parliamentary study group on “prematurity and the vulnerable new-born” (2016), and the creation of paternity leave during the hospitalization of a premature newborn (2019). Here again, the testimonies of volunteer parents are essential to raise public awareness.SOS Préma’s three work areas creates a unique parental bond that enables them to play a key role within the association.Engaging parents in SOS Préma training days assert such a forceful impact on professionals. Even though these results are not published, the SOS Préma professional training website includes the results of a satisfaction survey completed by professionals after training days with RP [Parental testimony is not contestable, and the strength of these testimonies make the  with RP . Ninety- with RP . By convSOS Préma psychologist to assure that the essentials are being said without modifying the reality of the experience, and that a proper professional distance is always maintained. Later, each testimony is refined by the The asset of volunteer parents comes with challenges. First, there is a heterogeneity of volunteer parents throughout the country. The association does not “recruit”, and it cannot seek new volunteers when there is a volunteer shortage in a specific locality. This dilemma leaves many hospitals in need of an on-site representative, but with no candidates available to them.SOS Préma activities rely on the availability of a volunteer. The volunteers’ availability is subject to their personal or professional needs for time off; thus, the association cannot impose specific times or expectations in order to meet commitments. As a result, the association employs a team of eight permanent staff, including several parents who have experienced the birth of a premature infant.Moreover, many This permanent staff is not representative of the population of parents who have had an experience in an NICU. Representation is an issue that is also described in the literature .Another challenge is the cost associated with the volunteer program. The training and equipment of a new volunteer represents a financial investment one hopes will yield benefits for several years. However, over the course of time, volunteers’ interests and availability wane. Therefore, associations need to develop other forms of commitment to “build loyalty”.Offering new activities to stimulate interest and engagement is an interesting solution, especially for volunteers who have been committed for long periods of time.This article brings together recent studies on partnerships in NICUs. It is an innovative field of research in neonatology, and there remains much to explore. To date, no study has described any negative or adverse effects of partnerships with parents. It appears that this intervention is safe for families and for RPs, as long as they are supported by healthcare providers.Though interventions to help parents in the NICU clearly improve early interactions between parents and infants, the impact on long-term development has not yet been demonstrated, and more studies are needed.When developing partnerships, the following may occur: Systemic barriers, such as a lack of financial resources, lack of time, lack of dedicated human resources to organize an appropriate and ethical partnership with parents as recommended .Lack of scientific evidence.Cultural and human barriers. Recruiting parents is not easy and caregivers may not always be ready to work in partnership with and learn from parents. Partnerships with parents is a new paradigm for the relationship between parents and providers.Even if these barriers exist, partnerships with parents in the NICU might be one possible way of improving the quality of care and children’s outcomes.