A sustained period of social, economic, and political unrest took place during October of 2019 in Chile. As an institutional solution, the “Agreement for Social Peace and the New Constitution” was signed. In this document, most political parties committed to reestablishing peace and public order in Chile, agreeing on the initiation of a constitutional process. To promote participation of civil society actors, the “Popular Initiative for Norms” was enabled. This was a platform where civilians could submit proposals for constitutional norms to be discussed by the Constitutional Convention. We aimed to analyze proposals related to migrants and migrant health.We conducted a qualitative thematic analysis of the proposals. Sixteen of them were related to migrants, and we analyzed their association to health. We also evaluated their link to the Health Goals 2030 set out by the Chilean Ministry of Health and the Global Action Plan 2019–2023 for Promoting the Health of Refugees and Migrants by the World Health Organization.Four main thematic categories were identified: 1) Humans rights of migrants, refugees, and asylum seekers; 2) Nationality and regularization of migrants and refugees; 3) Political participation and cultural integration of migrants and refugees; and 4) Specific regulations on slavery and human trafficking. These resonated with broader frameworks established in the Health Goals 2030 (Chile) and the Global Action Plan 2019–2023 for Promoting the Health of Refugees and Migrants by the World Health Organization.The ‘Popular Initiative for Norms’ was a non-binding participatory mechanism. Although the proposals sent through were not guaranteed to be included in the constitutional draft—and despite the final draft being rejected last September 2022—the platform allowed to gain insights into civilian opinions. Our findings showed that there is an incipient yet weak recognition of the rights and situation of migrants in Chile. There was no direct mention of health nor an explicit contemplation of social determinants of health. Despite there being an urgent need to define strategies for migrants’ health in Chile, this study demonstrated that civil awareness and interest are still insufficient.The online version contains supplementary material available at 10.1186/s12889-023-16093-w. Worldwide, a total of 214 million people is estimated to be on the move today . In the In Latin America, economic disparities and lack of work opportunities have fueled a rise in migration fluxes within the region during the last two decades, with the main destination being the ‘South Cone’: Argentina, Chile, and Brazil. One of the main countries of origin of migrants in the region is Venezuela, where the economic crisis, shortage of food and medical attention, and political polarization have led to 4.1 million Venezuelan refugees and migrants being forced to live outside their country as of July 2021, with 2.8 million in Colombia, 1.29 million in Perú and 455,000 in Chile [According to data from the International Organization for Migration (IOM), between 2018 and the first half of 2022, Chile has become one of the countries with the largest migratory growth in the world . In 2019Temporary visas can be granted for family reunification, employment, and investment, among others. Most visa applications fall under these categories, however the number of asylum applications has grown since 2015, when 623 applications were submitted. In 2018, 5727 were registered, however numbers fell again in 2019, and 1628 applications were reported for 2020. It is important to note that of the 19339 asylum claims registered between January 2010 and June 2021, only 689 have been accepted. Finally, in the first semester of 2021, the main country of origin for asylum applicants in Chile was Venezuela (73%) and among the 7 people whose claim was accepted in 2020, 4 were Venezuelan nationals . In termAlthough international migrants, refugees and asylum seekers are a diverse group in terms of migratory status, country of origin, and socioeconomic level, foreign-born people in Chile tend to experience more multidimensional poverty than their local counterpart, 24% compared to 20% at national level, despite higher educational levels,and a higher proportion of this population group being included in the labour market than the Chilean population . MultidiConsidering this context, and that migration is a social determinant of health, it becomes necessary to establish public policies that specifically address this group of people, with a focus on social determinants of health and public health promotion, where efforts are tailored towards ensuring equitable access to quality health services, free of discrimination, exclusion, and stigma . In ChilEstallido Social. Mobilization and strikes revolved mainly around deep inequalities concerning pensions, health and education [Acuerdo Por la Paz Social y la Nueva Constitución) [Triggered by a 30 peso (about USD 0.20) rise in the cost of public transport, a sustained period of social, economic and political unrest took place during October of 2019 in Chile, known as the “Social Outburst'' or ducation . Howeveritución) , signed Registro Único de Participación Popular) [Citizen participation has had a central role in Chile’s constitutional process, shaping its evolution: from the demonstrations that questioned constitutional change in 2019; to the referendum that enabled its initiation; and finally, to the election of the body in charge of writing the draft. During the drafting period, different mechanisms were put in place to promote the continuity of citizen participation. One of these was the Popular Initiative for Norms, a virtual, online space where individuals or civil society groups could submit contributions and ideas to be discussed by the Convention, bringing forward issues meaningful to the public. Physical centers were enabled so that those with no internet access could inscribe their proposals manually. To be eligible to participate, people were required to be above 16 years of age, of Chilean nationality, foreign nationality with Chilean residence, or Chileans living abroad. They also had to register in Single Register of Popular Participation (Popular) , which cComisión de Participación Popular), where they excluded proposals that went against statal obligations assumed by the Human Rights International Treaties and proposals that were impertinent to the constitutional debate, as well as those that were incomplete in its form.A total of 6,114 proposals were sent through the platform and underwent an admissibility revision, after which 2,496 were approved and published for the general public to vote. The admissibility revision was presided by the Popular Participation Commission  reached the required 15,000 votes or more to pass on to being discussed. Of these, 60 were supported by organizations or institutions and 17 by individuals .The proposed Constitutional document was finally rejected by the population that voted in the September 2022 referendum, however, we consider that the democratic process of soliciting proposals from civil society, especially given wide participation, provides insights into the population’s interests, needs and vision concerning migrants and their integration into the Chilean society.Given that migration from Latin America and the Caribbean is a relatively new phenomenon in Chile, but of growing and significant magnitude, the findings of this study can be useful to get a sense of how migrants and migratory issues are currently perceived by civilians and organizations in times of political upheaval, and to analyze if health concerns are taken into consideration. We therefore decided to focus our analysis on proposals associated with migrants and refugees with a public health perspective. Additionally, we linked these proposals to both national and international guidelines, to explore the extent of alignment.We conducted a qualitative thematic analysis of migrant-related civil proposals uploaded to the official website for Popular Participation during the constitutional process in Chile.Data was extracted from the “Digital Platform for Popular Participation” a free access website, created to enable civil society participation during the Chilean constitutional process. Individuals and civil society organizations could send a maximum of 7 proposals for constitutional norms. To be eligible to participate, individuals or group representatives had to be over 16 years of age and of Chilean nationality, or foreigners with residency in Chile, or Chileans living abroad. Additionally, they required having a national identification card or to be registered with “clave única”, a digital password that allows access to state procedures . The appThe keywords ‘migration’, ‘migrants’, ‘nationality’ and ‘multicultural’ 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.A total of 31 proposals were obtained. A first filter was applied based on the title of each proposal, excluding those duplicated and those not relevant to the subject, after which 16 remained. Subsequently a complete reading of these proposals was made, and all 16 proposals were fully analyzed for extraction purposes.Data was extracted using Microsoft Excel, and classified by i) general characteristics of the proposal ; ii) association with public health  Mention of Essential Public Health Functions (EPHF) as established by the WHO/PAHO, 2020; and iv) Mention of additional elements: “intercultural”, “gender”, “right”, “vulnerability” or similar, “global”, “social security”, “health system”, “social” or “civil participation”. This table is available in Spanish, in Supplementary File Based on the dominant themes inherent in the data, four thematic categories were reached by SE, using an inductive approach , and revThe main themes identified were: 1) Humans rights of migrants, refugees, and asylum seekers; 2) Nationality and regularization of migrants and refugees; 3) Political participation and cultural integration of migrants and refugees; and 4) Specific regulations on slavery and human trafficking . Of these, the ‘Jesuit Migrant Service’ (Servicio Jesuita Migrante (SJM)), holds the longest trajectory, dating its origins to 1980, when it began as a volunteer-run religious group that lent general assistance and guidance to newcomers. It posteriorly professionalized and now holds a strong presence in the media, carrying out investigative work, advocacy, and judicial consulting. The ‘National Board of Migrants and Refugees’, ‘Chile Migrates’, and ‘Migrates Chile’ are all recent organizations (founded 2020–2021) that advocate for migrant and refugee human rights and help individuals in administrative and legal matters. ‘Liberate’ is a women led NGO born in 2015 that advocates, educates, and investigates on human trade and trafficking, as well as legally and psychologically aiding victims. Lastly, a conglomerate of feminist, gender activist NGOs from the Bio-Bio region (south of Chile) united to support one proposal.Seven proposals were grouped into this category. They all refer to the protection of the human rights of vulnerable groups within society, some from a broad perspective and others referring particularly to migrants, refugees, and asylum seekers, with a shared stance of being supportive of migrants.ensure the right to equality” by “establishing a country with no prejudice and discrimination and including it in the constitution”, which in turn “will allow to formulate laws that penalize racism, building a better society”. This proposal has a particular focus on physical appearance, highlighting the presence of discrimination that exists towards “dark skinned” migrants in Chile, in comparison to “blonde” foreigners. It also touches on the discrimination present towards darker skinned Chileans and indigenous groups. Amongst the proposals associated to migration, this was the only one that alluded to racial issues.From a broad perspective, the proposal “No to racism” (1.1) (55 votes) aims to ““establish a normative and political framework that ensures the respect and guarantee of these peoples’ rights in an order of non-discrimination” and must confront the structures that perpetuate this situation.“Guarantee of the rights of people in a situation of structural vulnerability” (1.2) (135 votes) affirms that the State must recognize the existence of a structural violation of human rights affecting vulnerable minorities, including women, sexual dissidences, migrants, amongst others. It suggests that the Constitution must respect all people according to their own realities (…) with a focus on gender and equity”.The initiative “Principle of intersectionality in the judicial system” (1.3)  follows a similar line and focuses on unequal access to justice. Although it is mainly centered on women and mothers, it includes all minority groups that have historically been discriminated against. It brings forward the idea that, to protect human rights, the judicial system must incorporate the concept of intersectionality, meaning to “Three proposals refer particularly to the rights of migrants and asylum seekers. “Promotion and defense of the rights of migrants, asylum seekers and refugees” (1.4) (127 votes) suggests that integration and inclusion should be reached by the development of appropriate public policies, whereas two others refer particularly to the right to migrate and receive asylum.“the new constitution must recognize the right of every person to migrate from and to Chile, respecting Human Rights”. Additionally, it considers that the Constitution must “guarantee direct participation of these groups in political and administrative processes that may affect them”. This proposal was supported by the Fundación Chile Migra (‘Chile Migrates Foundation’) and was the most popular initiative concerning migrants. The initiative “Asylum against oppression” (1.6) (549 votes) also argues for the inclusion of asylum as a fundamental human right, emphasizing the principle of non-refoulement. It was supported by the Servicio Jesuita a Migrantes (‘Jesuit service to migrants’) and states that Chile should “advance towards an intercultural, fair and dignified society for everyone”.One of these proposals, “Constitutional recognition of migration as a human right and the rights of migrants and refugees in Chile and of Chileans living abroad” (1.5)  states that “the State and society have the duty to advance, strengthen and improve the quality of life of any person in need for shelter, be they foreign or national citizens” and that this should be done by way of building more comprehensive, integrated, and safe refuge centers.From a more concrete point of view, the initiative “The State’s social duty with people in need of shelter” (1.7) (36 votes) raises awareness on the lack of shelters for people in need. It argues that With regards to alignment with wider frameworks, the proposals on human rights mainly align with the following Health Goals 2030: 1. Environmental health and healthy environments, 4. Non-communicable chronic diseases and Violence and 7. Management, quality, and innovation. In relation to the WHO Global Action Plan, these proposals are aligned with Priority 3: ‘Advocate the mainstreaming of refugee and migrant health into global, regional and country agendas and the promotion of: refugee-sensitive and migrant-sensitive health policies and legal and social protection (…)’ and Priority 4: ‘Enhance capacity to tackle the social determinants of health and to accelerate progress towards achieving the Sustainable Development Goals’.This category includes proposals related to naturalization processes in Chile. Opposing initiatives are seen, where one supports that obtaining the Chilean nationality should be facilitated and more expedient, and the other suggests that stricter measures should be put in place. A third proposal raises the idea of creating a new administrative body to help assist in the regularization process of migrants, and a fourth one broadly alludes to the concept of nationality, referring to respecting the nation and identifying with the homeland.“nationality could be granted to those who can demonstrate two years of continuous residence on the national territory”. This proposal emphasizes the importance of “being recognized as an equal by the State and society”.“We should all be Chilean” (2.1) (37 votes), an initiative put forward by a Venezuelan resident in Chile, touches on the fact that recent laws have made it more difficult to obtain the Chilean nationality. It suggests that there should not be discrimination based on residential visas and that, ideally, “recognizing and judging claims filed against the arbitrary acts or provisions of the administrative authorities”, that would ideally lead to a regular migration process.Also, in support of facilitating the regularization process, is the “Creation of an administrative dispute court” (2.2) (446 votes). This proposal advocates for the creation of an independent, administrative body which has the responsibility for (or capability of) , raised by a Chilean citizen, suggests that irregular immigration is partly explained by the fact that any child born in Chile obtains the nationality (ius solis principle), generating a “perverse incentive that facilitates illegal (sic) immigration”. It argues that this principle should be changed in the new Constitution to the ius sanguinis principle, where at least one of the parents must have the Chilean nationality for the children to obtain it.On the other hand, the initiative “Chilean nationality” (2.3) (158 votes)The first two proposals are aligned with Health Goals 2030 4. Non communicable chronic diseases and Violence and 7. Management, quality, and innovation, well as Priority 3 of the WHO Global Action Plan described above. The third proposal does not align with any guiding principles.This category includes opposing initiatives concerning migrants' participation in political decision making. One initiative supports increasing the political participation of migrants, as well as recognizing their contribution to the country’s development, whereas another recommends increasing the minimum amount of time after which a foreign citizen can engage in electoral processes. In terms of cultural integration and identification matters, two proposals favor an inclusive approach towards migrants and minorities.“Immigrant political rights” (3.1) (72 votes) establishes that “political inclusion of migrants is necessary to contribute to the development of a democracy that is able to represent the diversity of people and collectives that build society” and that “increasing their effective electoral participation is important so that political parties and candidates may consider them as active subjects within the voting groups”.“completely informed vote, considering the internal reality of the country and avoiding external political interference (…) with no externalities or unfunded fears”.On the other hand, “Right to vote for foreign citizens starting from 10 years of obtaining permanent residence” (3.2) (107 votes)—as its name states—suggests that the right to vote for foreign citizens should only be conceded after 10 years of obtaining permanent residence. It argues that this would ensure a Whereas the first proposal aligns with Health Goal 7 and Priority 3 mentioned above, the second one does not show associations with either framework.“the rights of diverse communities in our country, including some migrant groups with a determined representation, to use their own flags and/or their own emblems.” Although it primarily focuses of indigenous communities and afro descendant tribes, it states that this would be a way to acknowledge “the contribution of other migrant communities to the development of our country”.A third proposal in this category is “Proposal to incorporate and recognize other flags and emblems belonging to indigenous communities, afro descendant tribes and migrant people'' (3.3) (23 votes). It recognizes , raises the notion that “we are all part and members of a nation that should be recognized and respected by all. One flag and emblem that is respected as such”, irrespectively of our background, and therefore have the same rights and obligations. It suggests that the new Constitution must state that “any person who born in Chile or who has fulfilled the necessary requirements, is Chilean”.In broader terms, “Our nationality” (3.4) (140 votes)Following the trend of the previous proposals, the first in this segment aligns to Health Goal 7 and Priority 3, whereas the second does not align with either.In this category, both proposals refer to human trafficking and slavery as contemporary forms of abuse that are often overlooked and where migrants and undocumented individuals are especially vulnerable. They suggest that a constitutional stand on these matters would allow for an exclusive allocation of human and economic resources necessary to address and overcome this pressing matter.“people without value, not recognized as equal by the State nor their employers”. It suggests that implementing the right not to be submitted to slavery in the Constitution would allow the legal and judicial system to “prosecute these crimes and protect the victims, with a focus on human rights and gender”, and demands “the allocation of resources to implement laws and public policies on modern slavery”.The proposal, “Prohibition of slavery” (4.2) (141 votes) states that ‘modern slavery’ is manifested through human trafficking, forced labor, and sexual exploitation. It mentions that these phenomena have increased due to the migratory crisis and restrictive migratory policies, whereby irregular migrants become “the constitution should mandate the state to facilitate and dedicate exclusive funds to face human trafficking, particularly institution-related trafficking, with a focus on human rights”.From a local point of view, the proposal “Recognition of the existence of human trafficking associated with children and adolescent institutions” (4.1) (69 votes) criticizes the state’s lack of responsibility regarding investigation and legislation on human trafficking, specifically referring to cases reported within Chile’s SENAME . It mentions that current public policies make migrant population more vulnerable to suffer from this practice and establishes that Both these proposals align with Health Goals 1. Environmental health and healthy environments and 4. Non communicable chronic diseases and Violence, along with Global Action Plan priorities 1. “Promote the health of refugees and migrants through a mix of short-term and long-term public health interventions”, 2. “Promote continuity and quality of essential health care, while developing, reinforcing and implementing occupational health and safety measures”, as well as with priority 4 mentioned previously.Overall, only one of the proposals reached the minimum number of votes to pass on to be discussed in the constitutional convention, and none of the proposals explicitly referred to migrant health. There are alignments with national and international frameworks, the more explicit ones regarding Health Goal 4. ‘Non communicable chronic diseases and Violence’ and Global Action Plan priorities 3. “Advocate the mainstreaming of refugee and migrant health into global, regional and country agendas and the promotion of refugee-sensitive and migrant-sensitive health policies and legal and social protection (…)” and 4. “Enhance capacity to tackle the social determinants of health and to accelerate progress towards achieving the Sustainable Development Goals, including universal health coverage”.As recognized by the United Nations (UN), making or reforming a given Constitution is ‘an exceptional opportunity for a state to create a common vision of its future’ . In thatIn our first category of analysis, regarding the promotion and defense of the human rights of migrants and refugees, the majority were supported by pro-migrant institutions and votes were higher than other categories. This could reflect an increased awareness of the significant human rights challenges faced by this group, as well as effective advocacy by supporting movements. Globally, commitments have been made to protect migrants’ human rights as seen in the New York Declaration on Refugees and Migrants  and the Bicentenario Survey (2021), which demonstrate an increased ‘perception of great conflict’ between Chileans and migrants, from the point of view of the local population, as well as a significant increase in the idea that immigration is excessive [Migrant Voices Survey (2021)) showed a high prevalence of discrimination reported by foreigners, and was more pronounced among Afro descendants [Another proposal in this same category referred to establishing equality as a right, by placing a ban on racism and discrimination. It is concerning, nonetheless, that it only reached a total of 55 votes. This could reveal that Chilean society falls behind other countries in terms of its acceptance of racial and ethnic diversity and inclusion. Our findings complement the results presented by the local xcessive . From micendants .Racism and discrimination should be a public health concern, as they can have deep repercussions on both individual and structural levels in terms of determinants of health. Individually, racism and discrimination have long been associated with adverse effects on mental and physical health , and strWith regards to regularization issues, our findings show some support for guaranteeing a regular migration process and opposing opinions on the prerequisites for obtaining nationality. Countries often use nationality or legal status as a condition for who may and may not enjoy access to healthcare facilities . HoweverDespite these efforts, in Chile barriers associated with migratory status persist, and access to healthcare is lower among migrant populations when compared to locals –41. ThisOne way to effectively engage migrants into their host society and functioning systems, as stated by the International Organization for Migration (IOM), is to focus on having a strong integration policy, understanding integration as a two-way process which requires dialogue and mutual adaptation, as well as respect for a core set of values and tolerance . Our finProposals focusing on political participation were opposing. On one hand, a representative of the migrant community demonstrated the importance of promoting migrants’ political participation and, on the other hand, a Chilean citizen expressed their apprehension towards promoting foreigners' participation. In Chile, foreigners who have resided in the country for more than five years may exercise the right to vote, making it one of the five countries that grants voting rights to non-naturalized immigrants . DespiteReferring to cultural integration, proposals were also conflicting. While one of them supported acceptance of diversity, it seems problematic that it received the lowest number of votes among all the proposals included in our study. The contrary proposal held more than five times the number of votes, and picks up on a more nationalist tone, stating ‘we are all members of a nation and respect one flag and emblem’. This last ideology, as described by Goksel, could be explained by a ‘Western interpretation of citizenship based on national identity and commonality as the foundation of democracy’. According to his analysis, cultural pluralism and ethnic diversity have been increasingly perceived as a threat, due to differences sometimes considered ‘irreconcilable’ with standards of Western societies . NonetheLastly, our findings show that there is recognition of modern slavery and human trafficking as a reality that particularly affects the migrant community. This is revealing because, although issues regarding Chile’s SENAME  have been present for years, human trafficking is scarcely documented in Chile, especially when compared to other countries of the region . Modern Regarding broader local and international frameworks, most of the proposals align with the guiding principles of working towards constructing favorable environments for migrants to have healthier, safer, and dignified conditions, which suggests that civilians tend to be in favor with such commitments. There was no direct mention of health nor an explicit contemplation of social determinants of health, however, constructing favorable environments for migrants to have healthier, safer, and dignified conditions acts on the social determinants that shape the health of international migrants.th of September 2022, and its results were striking. In a historical process, where the vote was obligatory, the rejection option won with 61,87% of votes (7.886.434 million people) vs 38,13% of approval (4.860.266 million people) [The final plebiscite in the matter of accepting or rejecting the Constitutional Convention’s proposal for a new Constitution took place on the 4 people) . FollowiThis study has several strengths and limitations. The Popular Initiative for Norms received a large volume of inputs, as it was a widespread, online platform. Although there was a preliminary filter to those proposals that did not follow certain criteria, there was no thematic organization of all the initiatives sent through. This study is the first of its kind to analyze citizen’s constitutional proposals related to social and health protection of migrants in Chile and link their associations to broader institutional frameworks.However, there are various limitations to this study. Firstly, the platform only allowed for national citizens or foreigners in regular migratory status to put forth ideas. This excludes those in opposite, more vulnerable situations and therefore could fail to represent their point of view. Additionally, the platform does not give the option of uploading proposals in other languages, meaning that views from individuals that do not speak or write Spanish are excluded.Our findings show emerging awareness and acceptance of migrants in Chile, as it is a topic taken into consideration for the country’s new Constitution. However, despite the important rise in migratory fluxes during the last few years, it still does not seem to be a priority, nor does it resonate widely among Chile’s citizens. Equally, although we analyzed these proposals through the lens of the social determinants of health, this was not something that was put forward by those who formulated them.With regards to alignment with wider national and international frameworks, the proposals predominantly align with the Chilean Ministry of Health Goals that prioritize providing healthy environments and preventing violence, and the WHO Global Action Plan priorities of generating refugee-sensitive and migrant-sensitive health policies and legal and social protection.While there is an urgent and evident need to define strategies in addressing migrants’ health in Chile, this study demonstrates that we must start by the first step, which is acknowledging migrants as subjects of human rights and as a population group which requires tailored policies and initiatives. Although the new constitutional proposal in Chile was rejected in September 2022, this study suggests that there is some emerging civil awareness on the topic of migration that deserves further recognition and discussion.Additional file 1.


Adolescents are at an increased risk of mental health problems due to the natural processes of development and maturation. Given that their mental health is mainly assessed by adults and not by the adolescents themselves, the purpose of this study is to reveal adolescents’ perceptions of mental health. Semi-structured, in-depth interviews were conducted, and an inductive qualitative approach with thematic analysis was used. The qualitative study consisted of 19 adolescents aged 11–17 years. Five themes were identified: (1) What does mental health mean to you? ; (2) needs ; (3) risk factors ; (4) red flags ; and (5) role of mental health professionals (subthemes: attentiveness to and proper pace for adolescent and acceptance of adolescent’s life in its entirety). This study revealed that adolescents view their mental health not only from their own emotional and behavioral perspectives but also through the prism of relationships with other people. The World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” . It is nFirst, adolescence is associated with many changes, starting with a cascade of developmental changes in the young person’s body, such as rapid physical growth, metabolic development, sleep, and circadian changes, as well as puberty . This trThus, while growing up, adolescents also acquire more self-expression and psychosocial abilities , developAlthough international health policies are increasingly focusing on the relevance of the young person’s voice and empowering the young person to manage their care and treatment, clinicians in child and adolescent mental health often rely on reports from parents, teachers, or other professionals about a young person’s needs and treatment progress ,14. TherGiven that adolescents’ mental health is mainly assessed by adults and not by the adolescents themselves, a more immediate, direct understanding of adolescents’ direct thoughts could provide additional comprehension about the overall understanding of their mental condition and how to improve it. A better understanding would provide more opportunities to empower adolescents by helping them take certain actions as well as seek help. To get a broader understanding of the adolescent perspective, this study used a qualitative design and aimed to reveal adolescents’ perceptions of mental health as a concept.This study was approached using a qualitative research strategy. The target group was 11–17-year-old schoolchildren of both genders. The participants were collected using convenience sampling with an emphasis on diversity in terms of age, gender, and urban/rural residence.age 11–17 years old (grades 5–11);ability to speak, write, and understand the Lithuanian language;written consent of the adolescent to participate in the study;written consent of both parents for an adolescent to participate in the study.The design of the study was constructed by this article’s authors . The perThe participants were encouraged to talk by asking them open-ended questions in one-on-one interviews. All researchers were practicing psychologists and/or worked at universities as researchers in the field of child and adolescent psychology. The total sample consisted of 19 adolescents: 10 girls and 9 boys from various urban and rural locations .Data were collected from April to July 2021 through in-depth interviews. Due to COVID-19 restrictions, the participants could opt for in-person or online interviews . The semi-structured interviews were audio-taped and transcribed verbatim. The median duration of interviews was 22 min. The interview had one main question: “Each person understands mental health differently, individually. I would like to hear from you what you think about mental health. Please, describe what mental health means to you?”. If necessary, additional questions were also asked: “How would you describe your mental health?”, “What people help you maintain good mental health?”, “What do you do yourself to maintain good mental health?”, and “What harms your mental health?”.https://otranscribe.com/, accessed on 3 May 2023).The interviews were audio-taped and transcribed verbatim using the oTranscribe web app . During the conversations, most frequently, the adolescents started sharing their perceptions relating mental health to emotions. They shared both positive and negative emotions that they could experience internally or express externally. The following positive emotions were most frequently mentioned: happiness, joyfulness, a positive attitude, a good mood, empathy, and not feeling angry or miserable. “<…> a person is happy and, umm, well, they are happy, satisfied with everything” . The negative emotions reflected during the interviews were the following: sadness, anger, depression, anxiety, nervousness, bad mood, and pessimism. Additionally, some adolescents defined mental health as the system in charge of emotions, “I understand mental health as a system that is responsible for a person’s emotions, and if it malfunctions, emotions also malfunction” . Moreover, some participants suggested that good mental health implies a proper expression and control of emotions: “<…> one shows adequate emotions, and they are not distorted in any way or they are not wrong emotions in certain situations”  or “They sometimes say you have mental health disorders, or that you are not able to control your emotions” .Customary behavior (16/19). The majority of study participants associated mental health with behavioral expression. They emphasized that an adolescent with good mental health should not stand out from the people around them; they should respond to situations similar to their peers and should conform to a certain norm established in society: “You react to most things with the same emotions as most people. And, umm, that is what is called ‘a norm’ <…> if, say, my mental health is okay, then, similarly, he should, well, he should react in the way that I do” . When speaking about customary behavior, the adolescents provided multiple examples and situations, primarily reflecting on their learning environment, academic performance, and ability to learn at a similar level with their classmates: “<…> if one is learning something, one is learning at the same pace as all the others, as most of the others. And if one is, so to say, not mentally okay, then it may be a bit more difficult for them and a person may somewhat get left behind” . In addition, such standards of behavior include polite behavior in public , conscientiousness, and comprehension based on their age. Finally, some referred to being just not eccentric: “<…> not being weird, maybe even. Just ordinary” .Relationships with others (16/19). From an adolescent perspective, relationships are an integral part of mental health—more than half of adolescents participating in interviews spoke about this aspect. When pondering on relationships as a feature of mental health, they specified relationships with their parents, friends, and teachers. They perceived mental health as communication with others, the proper way of speaking , the ability to accept the opinion of others, to listen to the interlocutor, to help others, or ask for help. Some adolescents also mentioned that having conflicts and enemies is an indicator of poor mental health: “<…> gets involved in multiple conflicts, has conflicts… with other children <…>” .This study has also identified the most important needs of adolescents that are often ignored by the surrounding population but are relevant for adolescent mental health. Here, the participants expressed the need for communication and support, self-expression, and a safe and personal environment—the needs that are crucial during adolescence.Communication and support (18/19). This subtheme came up in nearly all interviews. The study participants highlighted the need to communicate, to be heard, to be appreciated, and to get attention and support: “<…> we are created to communicate with other people” , and “<…> a person cannot be lonely” . A good relationship with one’s parents was among the most frequently mentioned factors: “The main thing, I don’t know, probably, just like for everyone else, is family. Actually, I am really happy that I am in a very good relationship with my parents. If something starts annoying me, I don’t know, or if things seem to be getting out of control, or simply something is not right with my life, I can always approach them, talk to them” . To some extent, the relationship may not indicate direct communication, but rather a perceived sense of support: “Sometimes, I do not even have to say anything to them” . Adolescents also mentioned the relationships with peers and classmates with whom they could talk, and whose ideas and problems were similar. From the perspective of adolescents, belonging to a peer group and frequent meetings with friends helps improve their mental health and constitutes one of their key needs. Other significant people mentioned were teachers, grandparents, cousins, other relatives, and sometimes even strangers, and all people who are together with adolescents, who listen to them, are supportive, provide considerable attention, or just pay a compliment. Another resource for better mental health in adolescents is pets: the significance of this relationship was highlighted through the need to take care of them and to spend time together, which has an overall positive and calming effect.Self-expression and freedom of decision-making (13/19). This need was reflected in over half of the conversations with study participants. The adolescents shared that having dreams and making them come true is highly important for good mental health: “Those goals of mine, they somehow motivate me, and then I feel good” . Being engaged in one’s favorite activities and having new experiences also have a positive effect on mental health. The participants spoke about various activities that were helpful in improving their mental health. Usually, these are creative activities such as sewing, playing a musical instrument, or drawing, through which they are also able to express their emotions. Furthermore, the adolescents mentioned more intellectual activities, e.g., reading, learning, or problem-solving based on books or movies. Other participants emphasized the need to behave and make decisions freely and independently without others telling them how: “When that help is forced onto you, and you have not even asked for it, you do not actually need it, then, well… well, then it is not really needed. <…> When you are offered a detailed plan that will make things alright if you follow it. Thank you… thanks… No! I do not know. I am an independent person. I do not need others to tell me what to do and where to do, and how, and with whom, and why” .Safe and personal environment (11/19). Slightly more than half of the interviewees revealed the need for safety and peace of mind in their current environment. The adolescents mentioned that for good mental health, it is crucial to feel safe with the people one lives with. A safe school environment was also indicated because adolescents tend to spend most of their day at school. One participant said that her mental health was poor because: “I feel good neither at school nor at home” . Fear of being scolded was also indicated: “<…> somehow you think that what you are doing is bad, even though you are doing everything correctly. You think that you will be told off although you have done nothing bad” . The need for peacefulness and personal, private space was also emphasized: “<…> those most important people can simply be too annoying with their wish to know how they could help you, even though you do not need their help and just want to stay alone for a couple of days, left in peace. How can I put it–to retreat for a while, think everything over, and then get back on the track” .The data collected during the study has enabled us to define certain risk factors for adolescent mental health. Based on the ideas expressed by participants, harmful relationships and social media are most damaging to their mental health.Unhealthy relationships (14/19). The study participants mentioned harmful relationships as one of the risk factors for adolescent mental health. According to adolescents, this involves having bad friends and enemies, teasing, calling names, or bullying from peers. They also mentioned that teasing can be both face-to-face and online. Moreover, the study revealed that bullying from teachers, impolite comments, and underestimation also have a damaging effect on adolescents’ mental health. When it comes to the family environment, there must be no bad feelings between parents and siblings because conflicts with the closest people also harm adolescents’ mental health.Social media dangers (6/19). Social media was identified by adolescents as another factor with a negative effect on mental health. Long screen time  and the information presented there are potentially harmful since adolescents cannot assess them critically or select the most reliable sources of information: “Say, if you take YouTube. If you are following some content developers there, and they just do some negative stuff, this may damage your understanding of the world” . Furthermore, the effect of social media on the self-esteem of an adolescent was also highlighted: “<…> adolescents like identifying themselves with others so that… when you are watching photos or things like that on social networks, and… you see that someone is doing well, or that they are just succeeding in something, or that they are okay, while you have not probably achieved such things. This just goes to your head, even though this, ummm, should not really mean much to you” . One girl also stressed that social media is often more dangerous to girls because this might affect how they see their own bodies or perceive what is beautiful: “<…> a lot of girls have this bad attitude towards their bodies, as they say. That she has to be, that she has to look in a certain way, that she has to be pretty. That she has to be suitable for others, for that whole world, the environment” .During the conversations with adolescents, certain aspects were observed that should draw the attention of others and that signal poor mental health. Help and attention from the surrounding people are required when an adolescent is in social exclusion, introverted, or behaves destructively.Self-exclusion from social life (12/19). More than half of the study participants said that separation from others is a highly important factor that has a damaging effect on adolescents’ mental health. When speaking about self-exclusion, the adolescents provided the following examples: sitting on a bench without communicating with anyone, sitting somewhere in a corner all alone, spending time in their room without communicating even with family members, or not going out with friends. According to participants, loneliness, avoidance of any communication, ignoring others, or trying to stay invisible constitute the risk factors for mental health: “<…> sitting there in the corner, not showing oneself to anyone–just trying to stay invisible so that no one would notice him. So… hidden” ; “<…> he just started ignoring and not speaking with others; I guess it could spot that he really needs help and assistance through that difficult period” . The participants believe that such behavior indicates poor mental health and has a negative impact. Moreover, doing nothing and not learning during lessons were also mentioned by adolescents as the type of behavior that has a damaging effect on mental health: “<…> he did not even try to do anything in lessons, and for teachers… they blamed teachers for their wrongdoings and sought recognition among friends” .Self-destructive behavior (12/19). By this, the adolescents had in mind various types of risky behavior. Addictions—such as smoking, drinking alcohol, or drug use—were among the most frequently mentioned examples. In addition, adolescents noted destructive behavior directed towards others, such as fighting with peers, reckless, impulsive behavior, or behavior that can hardly be understood or expected by others. Some adolescents (3 out of 19) mentioned suicidal thoughts, thoughts about self-harm, and attempts to commit suicide (by cutting wrists or using drugs): “If you found him there with his wrists cut open, or with a heroin needle” .The last theme revealed the role of mental health specialists working specifically with adolescents, where personal attention to an adolescent, a proper pace, and a holistic approach when assessing their mental health are worth considering.Attentiveness to and proper pace for adolescents (14/19). The study participants mentioned that a specialist should not hurry, but rather start a conversation with simple, more optimistic questions  or pleasant things . Only then should they move on to more complicated questions regarding emotions or problems. Adolescents argued such a sequence of conversation by their difficulties speaking about themselves openly, problems in the identification of their own emotions, or even concealment of mental state: “I do not really think that when mental health is poor or bad it is possible to notice it every time <…> if a person wants to hide it, they will hide it, and you will never suspect that” ; or “<…> there are people who suffer from poor mental health, but they somehow try to cover this up” . Nonetheless, adolescents trust mental health professionals and think that they can offer them the best possible help. The study participants also said that for having a more casual conversation, specialists should try to identify themselves with an adolescent: “[specialists could] remember their own adolescence troubles, their own adolescent days” . It is very important to ask adolescents how they are feeling instead of following the predominant stereotypes in society—especially when speaking about the mental health of young boys.Acceptance of the adolescent’s life in its entirety (14/19). When asked about the key areas reflecting adolescent mental health, the adolescents indicated a large variety of them. In their opinion, a holistic approach is important, i.e., their childhood experiences have to be analyzed in great detail, as well as their home environment and living conditions, various aspects of their upbringing, and their relationship with parents and pets. The participants also shared much about the relevance of friends—having them, keeping good relationships, social support, and even the mental condition of friends. In addition, the school environment was indicated because adolescents’ behavior at school reveals much about their mental health. Regarding behavioral patterns, it is crucial that adolescents have favorite activities, their own leisure time, and no addictions. According to study participants, all these factors are important when assessing adolescents’ mental health. These aspects should not be considered in isolation; therefore, specialists should pay attention to them during a conversation with adolescents.One of the public health issues is mental health problems suffered by young people, so it is crucial to hear the views of adolescents about the things that affect their lives . Since tHowever, in our study, a slightly different perception of the mental health of the adolescents themselves emerged: in addition to the aforementioned emotional and physical health, the participants of this study emphasized relationships with others and one’s behavior. Specifically, adolescents defined their understanding of mental health in terms of non-differentiating behavior that conforms to societal and peer norms. On the one hand, the expressed approach is confirmed by the creation and adaptation of classifications of mental disorders , which define norm-compliant, adaptive behavior, and deviation from being considered a mental disorder. On the other hand, adolescents at this stage of their lives often want to stand out from other peers through communication, self-expression choices, different, un-usual reactions to social situations, experimentation, or different levels of risk .The importance of relationships was an un-expected aspect of perceptions of mental health among adolescents. In this study, it was one of the main pillars of mental health since it was mentioned and approached from various perspectives in the interviews, even though theoretically, relationships are not a direct constituent of mental health. Our study participants specified relationships with their parents, friends, teachers, or even strangers. The importance of peer communication and social relationships in adolescence is demonstrated in previous studies, which indicate adolescents’ transition towards independence, spending less time with family but more with friends and romantic partners . Social Our study participants talked about independence from parents and their instructions. These results are in line with other researchers’ findings that one of the most challenging tasks in adolescence is learning to find a balance between independence and dependence within social relationships . HoweverEven though adolescents often seek to be independent and to separate from their parents (according to their development and the tasks related to it), when facing difficulties, attention, connection, and the opportunity to talk with parents are important. This is supported by a systematic review by Radez et al. , where iOverall, the role of adults in adolescents’ mental health also extends to teachers. Studies on bullying experiences confirmed that social support from family and teachers reduces the likelihood of depressive and anxiety symptoms, while higher social support from the family increases the probability of better subjective well-being .Slightly less than relationships with adults, those with agemates were also mentioned by adolescents. Here they emphasized that harmful relationships are one of the risk factors for adolescent mental health, especially bullying and having bad friends (or even enemies). Studies show that bullying victimization during childhood affects not only short-term but also long-term well-being ,28. BullAdolescents also expressed their concerns about the impact of social media on mental health. In previous studies of adolescent samples, social media use was commonly associated with decreased face-to-face human interaction, addictive-like behaviors, social pressure experienced by adolescents due to social comparisons, and even suicidal behavior . Our stuAnother facet of poor adolescent mental health reported by our study participants was self-destructive behavior, implying smoking, drinking alcohol, or drug use. Even though it is a direct behavioral component, previous research shows that it relates to mental health. For instance, Ferreira et al.  found thIn our study, some adolescents mentioned suicidal thoughts, thoughts about self-harm, and attempts to commit suicide. Such self-harm behavior shows a danger not only to mental but also to physical health. Studies confirm that having thoughts about suicide or attempting suicide significantly correlates with the number of role models seen as smoking or drinking . It can Young people who do not feel well in their home environment may seek support and strive to belong to a peer group . A recent study revealed that disengagement coping predicted suicidal ideation, past attempts, and depressive symptoms among youth . MoreoveThus, our study findings that adolescents associate risk behaviors, bullying, suicidal intentions, and other negative factors with their mental health indirectly demonstrate the relevance of safety in adolescent life.The associations with bullying indicate the relevance of a safe environment and communication to the mental health of adolescents. In our study, the participants shared their need to have a safe place at school and at home. Their idea was that the environment should be free of bullying and fighting and have private space if one needs it. Researchers show that collaborative, proactive anti-bullying policies could foster a safe environment for youth . For adoA final theme that emerged from our research was the role of mental health professionals. Previous research shows that young people seeking help may have fears of being taken away from their parents , of losiWhen considering why adolescents mentioned that a mental health professional should be the one who listens to them and accepts them, there is an assumption that maybe young people do not get that from their close environment (family or friends). On the other hand, perhaps the experiences that adolescents had were not satisfactory to them, since professionals often tend to look for the causes of problems according to certain protocols or symptom checklists, instead of listening only to the problems or concerns expressed by the adolescent.However, when assessing mental health, the professionals are distinct in that they look from the perspective of the presence or absence of disorders. A systematic review by Radez et al.  found thSeveral strengths and limitations of this study should be mentioned. One of the advantages is that the problem was analyzed using a qualitative study design. This design enabled us to discover not only the relevance of certain mental health symptoms but also the subjective causes of certain phenomena. In this study, we specifically wanted to find out the perception of adolescents themselves about mental health—what is important to them, what are the presumed causes and effects. Additionally, our sample was sufficiently diverse and balanced in terms of age, gender, and residence to reveal a wider range of adolescents’ experiences and perceptions. This provides experiences of living in different contexts.However, the major limitation of this study is the relatively small sample, so its findings should be generalized with caution. Thus, large-scale representative studies would enable checking the applicability of these findings in the general adolescent population. Moreover, only volunteers participated in our study, so the findings may be less representative of shy or less reflective adolescents.The context of the COVID-19 pandemic when this study was conducted may also have affected the results, even though there were no interview questions related to the pandemic or isolation. Nonetheless, ample evidence was published during the pandemic showing that it had affected adolescent mental health. To see if the pandemic had an impact on mental health perception as a construct, post-pandemic research is needed. More so, given the qualitative nature of our study, checking its findings with a quantitative design may provide more robust conclusions.A growing number of adolescents with psychological problems and mental health issues  shows a Most adolescents define mental health as the ability to control their emotions and adjust their behavior according to societal and age norms, which is reflected in the quality of their relationships with other people. Assessment of adolescent mental health is also revealed through essential needs: supportive communication with significant people, a sense of a safe and private space, and the opportunity to engage in pleasant activities that help self-expression. Adolescents single out bullying and un-pleasant and annoying mutual communication from peers or adults as the most harmful factors for mental health. At the same time, time spent on social media and its harmful content can affect adolescents’ perceptions of the environment and themselves. Key risk factors that can help predict poor adolescent mental health include withdrawal, non-social behavior, and risky substance- or self-harm-related behaviors. To strengthen mental health, adolescents play a significant role in mental health care. Teenagers expect from professionals simple, un-hurried communication and a detailed conversation about important, significant aspects of life for a teenager.


The public policy called Explicit health guarantees (GES) could serve as a basis for the future implementation of universal health coverage in Chile. An improvement in the quality of health of the Chilean population has been observed since the launching of the GES, which has a high adherence . This work seeks the social determinants related to a portion of the remaining 16% of people who do not use the GES.n = 164,786) from the National Socioeconomic Characterization Survey (CASEN) 2020. The GES recipients included in the study responded that they had been under medical treatment for 20 of the 85 pathologies included in the GES, and they had not had access to such policy due to “trust in physician/facility,“ “decided not to wait,“ or “lack of information.” The CASEN survey chose the 20 pathologies. The Average Marginal Effects of social determinants of the non-use of the GES health plan were predicted using multivariable and panel multinomial probit regression analyses, where the outcome variable assumed three possible values (the three reasons for not accessing) while taking those variables reported in previous studies as independent variables.This secondary analysis study used a sample of GES recipients (A higher probability of non-access due to distrust in the physician/facility among adults with higher economic income was found. Among those who prefer not to wait are vulnerable groups of people: women, people with a lower-middle income, those who belong to groups with longer waiting times, and ethnic groups. The people who least access the GES due to lack of information correspond to part of the migrant population and those belonging to the lowest income group.The GES policy must necessarily improve the timeliness and quality of the services to make them attractive to groups that currently do not have access to them, managing waiting times rather than referrals and using patient-centered evaluations, especially in those most vulnerable groups that do not access GES because they choose not to wait or lack the necessary information, thereby improving their health literacy. Universal health coverage (UHC) is a public policy promoted by the United Nations that seeks to ensure that all people have equitable access to quality health services, when and where they need them, without financial hardship. The objective is to cover the full range of health services throughout life, from promotion to prevention, treatment, rehabilitation, and necessary palliative care . Each coWith the application of the UHC policy, a key challenge observed in different countries is to incorporate equity criteria among the healthcare demanders; financial and non-financial barriers place some groups in a disadvantaged or vulnerable position –11. AmonIn this context, Chile has implemented a model called Explicit Health Guarantees (GES) Law 19.666/2004). This health policy establishes the set of benefits  that both the public provider  and private providers  must cover for their respective beneficiary populations. The guarantees established by law are related to the access (obligation of public and private entities to provide the service), quality , financial protection (predetermined co-payments), and timeliness of care (deadlines for delivery of services) . The abo.666/2004The data for this quantitative secondary analysis study were obtained from the National Socioeconomic Characterization Survey, CASEN 2020, carried out by the Surveys and Longitudinal Studies Center of the Catholic University of Chile (PUC). The sample units of the Casen 2020 survey are households selected in a probabilistic, stratified, and multistage manner. Within the dwelling, all family units and persons who are members of each one are identified. Interviewers applied a paper-and-pencil survey in a face-to-face procedure. The GES recipients included in the study responded that they had been under medical treatment for 20 of the 85 pathologies included in the GES (the CASEN survey chose these 20 pathologies) and provided information regarding the following issue: “Why this medical treatment was not covered by the AUGE-GES system (S30).“ Thus, the data for this study comprised a sample of 1,446 people who answered the last question due to “trust in physician/facility,“ “decided not to wait,“ or “lack of information,” using the expansion factor (expr) to reach 164,786 individuals. The regional expander (expr) allows us to obtain results of individuals and family units expanded at national, regional, and area levels , being representative of the country’s total population . All intn = 107,643; 65%); 2) “You decided not to wait to access care through AUGE-GES to solve your problem more quickly” ; and 3) “I did not know that AUGE-GES covered my condition” . For simplicity, the following labeling of the variables were used: “trust in physician/facility,“ “decided not to wait,“ and “lack of information,“ respectively. Thus, the dependent variable is the nominal categorical, with three response options .In response to the CASEN 2020’s question: “Why this medical treatment was not covered by the AUGE-GES system?”, respondents had nine response options (excluding those associated with COVID-19), which are indicated by their frequency percentages: (1) “You preferred to choose another physician or facility or to continue with your usual physician” (47%); (2) “You decided not to wait to access care through AUGE-GES, to solve your problem more quickly” (14%); (3) “You thought that AUGE-GES care could be of low quality” (3%); (4) “Your health insurance covered your need better than AUGE-GES” (6%); (5) “The procedure to access AUGE-GES is complicated” (5%): (6) “AUGE-GES did not cover the needs of your medical condition” (9%): (7) “I did not know that AUGE-GES covered my condition” (13%); (8) “I do not belong to the age group covered by AUGE-GES” (2%); and (9) “Your usual physician advised you not to seek care under AUGE-GES” (1%). Based on that information, this research poses the following question: Which social determinants relate to non-access to the GES plan? In defining the outcome variable, the nine response options were grouped, according to Tanahashi’s model , into thThe independent variables were grouped following classifications from previous studies , 20, 22.β1, β2, and β3, representing “trust in physician/facility,” “decided not to wait,” and “lack of information”, were used to analyze data and obtain the Average Marginal Effects (AMEs) [First, a descriptive analysis of the variables was performed. Subsequently, a multinomial probit model was generated to establish the relationship between the three options for non-use of the GES health plan (outcome variable) and the independent variables. For statistical analysis, the Stata14 software was employed. A set of coefficients, namely s (AMEs) . Throughχ2 (68) = 20,613.56, p < .0001. The goodness of fit, Count R2 = 0.66, indicates good explanatory power. The independent variables explained between 11.7% (Cox-Snell) and 14.1% (Nagelkerke) of the variance of the outcome variable. The model, by default, established “trust in physician/facility” as the reference group; therefore, it estimated a model for non-access to the GES plan due to “decided not to wait” and “lack of information.“The model’s estimation was based on 164,786 observations, and the log-likelihood was − 134,953.17, n = 107,643) were primarily men , had a public health mandatory insurance , had no supplementary health insurance , were not indigenous peoples’ descendants , were born within the country , had no informal job , and were mostly aged between 36 and 60 years .People who did not access the GES plan due to “trust in physician/facility”  were mostly women , had public health insurance , had no supplementary health insurance , were not descendants of indigenous peoples , were born in the country , had no informal job , and were mostly aged between 36 and 60 years .Likewise, people who did not access the GES plan because they “decided not to wait”  were mostly women , had public health insurance , had no supplementary health insurance , were not descendants of indigenous peoples , were born in the country , had no informal job , and were mostly aged between 36 and 60 years .Similarly, those individuals who did not access the GES plan due to “lack of information”  of not accessing the GES plan due to “trust in physician/facility” than people aged between 0 and 18 years (reference group defined by the model). At the same time, the former had lower AMEs of non-access, with regards to the same age group, due to “decided not to wait” and “lack of information” . Likewise, people of the 36 to 60-year bracket had higher AMEs of not accessing the GES plan due to “trust in physician/facility” and “decided not to wait”  than people belonging aged between 0 and 18 years; however, those between 36 and 60 years had lower AMEs of not accessing, concerning the same age bracket, due to “lack of information” (-6.8%). In addition, people older than 61 years had higher AMEs (7.8%) of not accessing the GES plan due to “trust in physician/facility” than people aged between 0 and 18 years. Also, at the same time, they had lower AMEs of not accessing the plan due to waiting lists and lack of information   compared to people living in the Austral zone of Chile. Also, people living in the central, small northern, large northern, and southern zones had higher AMEs of not accessing the GES plan due to waiting lists than those living in the Austral zone of Chile . People living in the Austral zone of Chile had higher AMEs of not accessing the GES plan due to “lack of information” compared to all the other zones of the country.Within social variables Table , people People whose occupations were classified as “farmers and skilled agricultural, livestock, forestry, and fishing workers” and “managers and administrative directors” had higher AMEs of not accessing the GES plan due to “trust in physician/facility” . Moreover, people whose occupations were related to “craftsmen and artisans” and “administrative support staff” had lower AMEs of not accessing the plan due to waiting lists . On the other hand, people whose trades were related to “plant, machine, and assembler operators” were the only ones who presented higher AMEs of not accessing the GES plan due to “lack of information” (2.7%).People of quintile II had the lowest AMEs of not accessing the GES plan due to “trust in physician/facility” (-10.5%) having quintile V as the base. However, they also provided the highest AMEs of not accessing the GES due to waiting lists (7.2%). In this line, people belonging to the lowest income quintile (quintile I) showed the highest AMEs (12.7%) of not accessing the GES plan to a “lack of information” concerning the highest income quintile (quintile V).People with private health insurance had higher AMEs (9.8%) of not accessing GES due to “trust in physician/facility” and lower AMEs of not accessing the plan because they “decided not to wait” and “lack of information” , regarding people whit public health insurance. At the same time, people having supplementary health insurance had higher AMEs (3.8%) of not accessing GES because they “decided not to wait.“Regarding health variables Table , people Although there are many reasons why people do not use the GES plan, in this study, we consider the three most frequent reasons given by the CASEN 2020 participants, which represented 74% of the total cases (excluding the COVID-19 reason). The first and most frequent reason is “you preferred to choose another physician or facility or to continue with your usual physician” (47%). This explanation alludes to a trust problem that emerges after a first evaluation and derivation from the treating physician. The second alternative, “you decided not to wait to access care through AUGE-GES to solve your problem more quickly,“ implies that the beneficiary opted for faster care outside the GES system. Both explanations suggest that these beneficiaries may choose and take an option other than that offered by the GES system. However, the third explanation points out a lack of information that resulted in the beneficiary not using the GES plan . Following, we will emphasize those results that present AMEs equal to or higher than 5%, considering the grouping indicated in the introduction of this work.First, regarding demographic variables, women do not access the GES Plan because they are unwilling to wait. Globally, evidence indicates that women are major healthcare users , so thisLikewise, those aged 18 to 35, 36 to 60, and 61years and over are more likely to opt for another physician/facility compared to those under 18, which is not surprising given that these age ranges contain the majority of the population and that they also have decision-making independence and financial autonomy. Likewise, if a person has an indigenous background, it is more likely that they will not have access to GES and will opt for a faster alternative. This piece of information is consistent with the facts that these groups are less favored in public health programs , 22 and In terms of geographic areas, the metropolitan region concentrates close to 50% of the country’s population and is, therefore, the region with the most significant provision of health services; thus, it is not surprising that it is the region where there is the greatest probability of opting for alternative care due to distrust in the physician/facility, as indicated by the GES . Likewise, all geographic zones (excluding the Metropolitan Region) have a higher chance of not accessing the GES due to waiting times compared to the Austral zone as a base, which is consistent with the fact that the health services of the Austral zone  together present only 1.8% of the cases of delay at the national level by 2020. At the same time, the highest number of days of delay is found in the Central Zone , whereas the highest average number of waiting days is observed in the Ñuble Region (Southern Zone) .Regarding social variables, people with the private health insurance system (ISAPREs) have the most significant possibility of not having access due to their trust in the physician or the treating institution. This situation is related to the fact that those with private health insurance have the highest income in the country and, therefore, a more significant financial freedom to choose. People in income quintile II (income of approximately US$ 400 per month) are more likely than those in quintile V  to not have access to the GES program due to the waiting list. This information could be related to the fact that people in Quintile II correspond to those people enrolled in public health insurance at level B , which is where 60% of the waiting list is concentrated (among the four FONASA groups) . On the People with no formal education are those who access GES the least, seeking faster care due to waiting lists. Although these people are highly likely to have low incomes, they also correspond to the profile of public health insurance users (FONASA A and B), who account for 74% of the delays in the GES program. Regarding occupational categories, there is a greater possibility of not accessing GES due to perceived trust in health professionals or teams, in decreasing order, among “farmers and skilled agricultural, forestry, and fishing workers,“ “managing and administrative directors,“ “professionals, scientists, and intellectuals, " craftsmen and artisans,“ “administrative support staff,“ “service workers and trade and market salespeople,“ “technicians and middle professionals” . This information suggests that managers, professionals, and skilled workers may have the financial resources (savings or debt) to opt for health care that gives them more confidence.Finally, regarding health variables, our results indicate that people who have “cervical cancer,“ “bronchial asthma,“ “primary arterial hypertension,“ “diabetes mellitus,“ and “depression” are more likely not to use the GES due to trust in the physician/facility. Moreover, those with “chronic obstructive pulmonary disease” do so because they seek a faster health care service. As of December 2020, the waiting list represented 51,894 people, with an average number of days of delay of 132. In addition, cancer is the health problem with the highest cumulative attention. For example, cervical cancer stands out with 853 persons on the waiting list and an average of 84 days of delay because the oncology units’ operations (both public and private) reduced their capacity due to the conversion of beds for the hospitalization of COVID-19 patients. Persons with chronic obstructive pulmonary disease had a delay of 142 days. Along the same lines, people suffering from depression had a delay of 97 days. In addition, according to official figures, diabetes patients had a delay of 114 days, and those with bronchial asthma of 160 days, those with arterial hypertension of 122 days . All theCoinciding with the implementation of the health policy known as GES, the quality of the Chilean population’s health has improved , 18. FurAmong the profiles of people who opt for health care other than that offered by the GES are those who do so because of the trust in the treating physician or the respective institution . This group generally includes adults with higher incomes (who have greater economic freedom), including part of the migrant population. Coincidently, people who belong to the private health insurance system (with higher incomes), who have a skilled job or occupation that allows them greater financial freedom (availability of savings or debt capacity), people who live in the metropolitan region , and people who suffer from some pathologies with a greater length of time to receive care. To improve the GES system for this type of beneficiary, together with improvements in the health supply , health promotion communication campaigns should address the advantages of the GES plan and the achievements obtained through the implementation of this public health policy.Among the people who do not use the GES program to seek more expeditious care, our findings point out they are mainly people from vulnerable groups: women, people from native ethnic groups, lower-middle income people, those who are in the segment with the most prolonged delay in care (FONASA-Level B), people who do not live in the metropolitan region, and people affected by pathologies with delays in care. Concerning this type of beneficiaries, the GES system must unequivocally improve the timeliness of the health supply , considering that the current major problems are the delay times or waiting lists .People who do not access GES due to lacking information or knowledge also belong to vulnerable groups: part of the migrant population and people with the lowest economic income , 20, 22.In sum, our findings indicate that recipients who do not access GES because of a lack of trust in the physician/facility are predominantly people from the highest income quintiles and have private health insurance (ISAPRES). In turn, those who do not access because they either decided not to wait or lacked information correspond to groups of greater vulnerability. Due to a lack of information, recipients without access reach mainly migrants and people from the lowest income quintile. Likewise, among those who decide not to wait, women, people of native descent, and people without education stand out. Regarding pathologies, the greater probability of not accessing GES in the case of cervical cancer, primary arterial hypertension, and diabetes mellitus is related to trust in the physician/facility, in the case of depression and moderate or severe bronchial asthma due to confidence in the physician/facility and lack of information, while chronic obstructive pulmonary disease due to not waiting. This information reinforces the challenge of refining the model by focusing on managing waiting times rather than referrals and using patient-centered evaluations, especially in those most vulnerable groups that do not access GES because they choose not to wait or lack the necessary information.As a strength, based on secondary data, this study gives feedback regarding implementing a public policy. It generates information that can contribute to building options to overcome barriers to access to health care, especially for the most vulnerable groups. Regarding limitations, the data used in the study, Casen 2020, were collected in the context of a pandemic. About possible future research, the GES plan could be a suitable basement for a Universal Health Plan. Therefore, it is relevant to continue the follow-up, especially looking for evidence of the interaction between social determinants; beyond each one, looking for the multisectoral and transdisciplinary nature of access to health services.


The core sociological subject of ‘social cohesion’ (hereafter SC) has re-emerged as a key concept in the social sciences. On the one hand, SC is thought to be influenced by a society’s degree of inequalities and the quality of its welfare state. On the other hand, SC is thought to be instrumental in its own right to other factors such as economic growth, institutional quality, and individual well-being. In recent years, a few attempts have been made to measure SC empirically. Many current indices have not been sufficiently theoretically substantiated, and do not consider the importance of different ‘social levels’ when explaining and measuring SC as both cause and effect of other correlates. Very often, SC is simply defined as a ‘social quality’ or a quality of a collective. As a result, measures are often aggregate macro-indices leading to a loss of the information base of any social ‘units’ below the macro-societal-level. Contributing to this important methodological debate, this paper provides a conceptual reformulation of SC. Hence, when assessing SC based on a multi-dimensional index, it is insightful and feasible to evaluate both its internal variation as well as its holistic validity. In fact, it is proposed that these two aspects of measurement stand in direct relationship to one-another. The paper starts out with a discussion of SC as a ‘social fact’ in the Durkheimian sense. In addition, three bridging propositions on the measurement of SC are advanced: (a) SC as outcome or consequence at the level of individual attitudes and orientations (‘micro’); (b) SC as degree of dissimilarity and presence of latent conflict within a society at the level of salient social categories (‘meso’), and (c) SC as predictor, social determinant and hence antecedent at the societal-level (‘macro’). Using all rounds of the European Social Survey with a very large sample size, the advantages of this approach are illustrated by singling-out the important link between socio-economic inequalities, social cohesion and individual subjective well-being in a path of action. It would be fair to say that the question of social cohesion (in other words—‘what keeps a society together?’) is as old as the discipline of sociology itself, and has preoccupied, in one way or another, many of the most influential names within the field  and predictor (antecedent) of other events and processes, without further clarification  and “Vergesellschaftung” (society formation). However, contrary to Durkheim, Weber did not see these phenomena as rooted in social facts, but instead in the “affectual or traditional feelings of individuals in the case of community—and rational agreements by mutual consent —in the case of society formation” .In a more recent contribution, Welzel and Inglehart  made a dindividual-level . Secondly, the ‘dissimilarity’ of SC orientations at the ‘group-level’ provides an important indication of the quality of social relations between different groups within a society and hence its cohesiveness. Here, we can ask if major within-country social categorisations (e.g. socio-economic classes) differ significantly in their orientations of cohesion. Finally, when we aggregate these orientations to the level of societies, we do not only obtain an indicator of the overall degree of SC in a society, but also SC as a social fact and hence a social determinant  in its own right. Here we can ask, for instance, whether the societal degree of SC has an impact on individual well-being, human capabilities  SC, although a distinct reality, is essentially a ‘product’ of the aggregation of these individual attitudes, or what I have called here individual ‘orientations’, to denote their directionality. The actions of these individuals are not directly related to each other, as with more interpersonal interactions and networks . In the case of SC, we are dealing with broadly generalised social bonds among fellow members of a society that enable its basic social togetherness. However, they are indirectly related to each other in the sense that members and salient social categorisations need to share to some degree these attitudes conducive to SC.Taking Durkheim’s social facts seriously, SC is a collective phenomenon, but the characteristics of solidarity  are only observable in individuals. Thus, it can be claimed that the A key distinction needs to be drawn here between such orientations indicating more general social bonds on the one hand, and more specific individual human values on the other  social cohesion index (SCI). The confirmatory factor analysis produces factor scores for all three dimensions with a mean of zero but with different standard deviations. To be able to combine the three components into one overall index, the three dimensions need to be normalised to be on the same scale of measurement . After this step, the following aggregation method for the final SCI is used: the three resulting proportions are given equal weights in aggregating them into the index. Thus, each constitutive component is ‘weighted’ as one third (1/3) of the overall SCI. The SCI is thus also a normalised measure ranging from zero to one, with zero corresponding to a theoretically non-cohesive value and one corresponding to a highly cohesive value. However, one and the same SCI score of two individuals can mean that these individuals score quite differently on the three constative dimensions. This combinatory logic prescribes “compositional substitutability” among partial responses . The individual-level predictors of age, gender, education, income, employment status and self-rated discrimination all derive from the ESS survey Table . The pos A.7. TheThe models show that age and gender have a significant, albeit substantively very small effect on SC orientations. The degree of education (years of schooling) has a significantly positive effect particularly on orientations of openness, confirming that education allows for “better cross-cultural understanding and more effective civic participation” . In a lagged multiple regression model, income inequalities in earlier waves still significantly affect later waves of SCI entropy, even when controlling for earlier waves of income and education  within societies. It is here that observing the ‘meso-level’ becomes very insightful. Across these categories within societies, major differences in the orientation of cohesion may arise because of ‘horizontal’ Stewart,  or ‘catep < 0.01; pairs: 115). Generally, as the regional CV increases, the overall degree of SC in society decreases. Overall, the CV values largely affirm known regional divisions and hence latent conflict in these societies, particularly in the case of Kosovo  in cross-regional orientations of cohesion by using this data and thereby assess the regional dissimilarity of SC for each society Fig. . The coe Yannis, : 41, Gre Yannis, : 135, Sp Yannis, : 1, Ukra Yannis, : 1529. T Yannis, ". This ip = 0.87; pairs = 100). Thus, the findings seem to suggest that certain cleavages have stronger potential to produce latent conflict and impair societal cohesion than others. At least in the European context, it can be said that regional cleavages are more salient than those based on socio-economic status.Importantly, the SCI allows us to investigate which societies exhibit higher dissimilarities, and on which categorisations these dissimilarities are based on. The prominent Bertelsmann Cohesion Radar ? If the macro-SCI has a significant effect on self-reported SWB over and above individual traits as well as other important societal factors such as wealth and inequalities, then such a link can indeed be also empirically established. The evidence from the multi-level regression models suggests that aggregate SC as a societal condition has without a doubt a very strong and significant effect on SWB as an individual-level outcome Table .Table 2MAlthough all components of SC have a significant effect on SWB, it is evident that social trust has the strongest substantive effect, confirming previous studies that have established this link  in the case of SC. Adding to the debate of “misconceptions of measurement equivalence”  at the meso-level; and a variety of statistics at the macro-level which convey a more up-to-date assessment of SC in a larger and more diverse sample of contemporary European societies. A more nuanced profile of SC in these societies than currently found is certainly possible. With regard to the link between inequalities, SC and SWB, the study is able to confirm that individual orientations of SC (and their dissimilarity) are significantly affected by inequalities, while SWB is significantly affected by the degree of societal cohesion over and above inequalities and other relevant factors. This highly-cited relationship is distinctly analysed here in a path of action at three different levels. The findings provide more insight as to how cohesion is affected at the individual-level, and how in turn it has a predicative power in its own right when aggregated to the level of collectives. The analysis at the ‘meso-level’ provides additional insights into the internal within-country social dynamics and cleavages—in this case regional—that can influence societal level cohesion.


The USA has the highest incarceration rate in the word, comprising ∼5% of the world’s population, but accounting for ∼25% of the world’s incarcerated population . This meThere is clear and compelling evidence that incarcerated individuals are disproportionately afflicted by chronic physical and mental illness. For example, individuals with a history of incarceration are more likely to have asthma, diabetes, and incident hypertension relative to the general population [pulation –5. Substpulation . Incarcepulation . While spulation –10, thesRaises awareness about the health disparities and inequities faced by groups targeted by the criminal legal system continuum;Increases motivation of clinical and translational science researchers to become engaged in this research;www.kumc.edu/cjtracs).Provides best practice strategies that researchers can employ to conduct this research  program represents a robust research infrastructure “designed to develop innovative solutions that will improve the efficiency, quality and impact of the process for turning observations in the laboratory, clinic, and community into interventions that improve the health of individuals and the public” . More th