To verify the prevalence and factors associated with active transportation to school (ATS) among Brazilian adolescents attending public schools.Crossectional study with a representative sample of 1,984 adolescents (55.9% girls). Sociodemographic variables included were: gender, age, parental schooling, and socioeconomic status. Psychosocial factors included were: social support from parents and friends for physical activity. Walking, cycling, or skateboarding to school were considered models of active transportation. Binary logistic regression models verified sociodemographic and psychosocial factors association with ATS, adopting p < 0.05.The prevalence of active transportation to school was 37.7% (16.2% boys and 21.5% girls). For boys, ATS was associated with: social support from parents in practicing physical activity together as a family , giving them rides , and remarking their good performance on it ; as well as the social support from friends in practicing physical activity together . For girls, the likelihood of using ATS increased with age  and having friends who practice physical activity together with them .Age and social support for physical activity were associated with ATS. Parents who practice together, give rides, and remark on physical activities increase the likelihood of adolescent boys using ATS. Social support from friends to physical activity increased the likelihood of both genders using ATS. This study followed the recommendations of the National Health Council (Resolution No. 466/2012) for research involving human beings, and it was approved by the Research Ethics Committee of the Universidade Federal do Paraná (CAAE: 98133218.8.0000.0102) and authorized by adolescents’ parents or legal guardians upon signing the informed consent form.According to the 2017 school census, conducted by the National Institute for Educational Studies and Research Anísio Teixeira (INEP), the public schools of the city had 53,760 adolescents, of both genders and aged from 15 to 17 years, enrolled in high school. G*Power was used to estimate the sample. We adopted a 1.49 prevalence ratio (PR) between social support and physical activitySampling procedure was initiated by conglomerates, in three stages. First, all public schools within each of the nine administrative regions of Curitiba were stratified; second, two schools of each region were drawn; third, one class of each high school year was randomly selected, considering the number of students required by gender for a given administrative region of the municipality. The random selection contemplated both morning and afternoon classes. All students from the selected classes were invited to participate in the study.The total of 2,506 adolescents were invited to participate in the study. Those who failed in presenting the informed consent form signed by a parent or legal guardian (n = 100), those who refused to participate in the study, and those who were absent on the collection day (n = 56) were not included. We excluded those who reported physical or cognitive limitations associated with PA practice (n = 12) and those aged 18 years (n = 125). Adolescents who answered the questionnaires incorrectly (n = 229) were considered sample loss. 1,984 adolescents composed the study analytical sample. A posteriori power analyses showed that this sample could identify statistically significant prevalence ratios above OR = 1.28 as an increase in the use of active transportation to school, and below OR = 0.77 as lower likelihood in using active transportation to school, considering a 34% prevalence of adolescents with poor social support and without the habit of using active transportation.Gender was self-reported  and age was estimated from the date of birth informed by the adolescent and classified into 15, 16, or 17 years. Parental schooling, as well as socioeconomic status, were classified according to the Brazilian Association of Research Companies (BARC)Social support from parents and friends for PA practice was measured using a 10-item scale – the ASAFA Scale, – which presents satisfactory internal consistency ,For analysis, and aiming to ensure comparability to related studies,We assessed the used mode of transportation to and from school during a typical week . Students who reported walking, cycling, or skateboarding to and from school were considered “active”; the others were considered “passive.” This question presented adequate test-retest reliability  and has been applied by related studiesTo avoid bias related to the complex sampling process (stratified cluster), association analyses were corrected by the complex delineation, using the complex sample command in the SPSS Statics 23.0. Such procedure was adopted to ensure that estimates would reflect population data from the elementary sampling units.Prevalence was described by relative and absolute frequency distribution. Pearson's chi-square test was used to compare proportions between genders; then a post hoc test was used to demonstrate which categories showed the greatest difference. The crude and adjusted binary logistic regression was applied to verify the association of demographic factors and social support from parents and friends for ATS. Following the stepwise criterion, p-value ≤ 0.20 was adopted for input variables in the fitting model. All analyses were performed separately for each gender; 5% significance level was adopted.The sample was composed of 1,984 adolescents, 55.9% of which were female. Among these, 748 (37.7%) only reported using active transportation to school in a typical week: 16.2% boys and 21.5% girls. Regarding social support from friends, boys who reported having friends that always practice PA were more likely to use ATS . Boys who have friends that watch them performing PA were less likely to use ATS .,,–Adolescence is a critical moment for establishing physical activity (PA) habits; yet, the literature has depicted this life period with a gradual engagement decline across the various domains of PARegarding the prevalence of ATS in this research, 37% of the adolescents reported practicing this behavior. A recent systematic review on ATS among Brazilian adolescents identified a great variability in prevalence, ranging from 34.3% to 75.7%, depending on the evaluated study–Regarding gender, we found that 21.5% of ATS is used by girls. Other studies,,Studies have considered sociodemographic factors as possible influencers of ATS among adolescents,,–Conversely, this study found no association between ATS and sociodemographic factors such as parental schooling and socioeconomic status, deemed as important predictors of the different PA contexts (transportation and leisure)Social support is associated with adolescents’ increased engagement in the different domains of PAAs for girls, having friends who practice PA with them was associated with ATS. Some studies state that the lack of company is the main barrier for girls to practice PA in leisure timeInterestingly, the use of ATS was less likely among boys with encouraging parents and friends who watch their PA practice, and girls with friends who invite them to practice PA. This study does not explain what motivates such associations, but it reinforces the need for a more detailed research on how each social support characteristic can impact different types of PA practice among adolescents, possibly integrating quantitative and qualitative methods of research. Both genders presented associations related to social support from friends, differently from social support from parents, which was associated only in boys. This may be explained by a greater influence of parents for male children when it comes to practicing PA, enabling this finding to be a discussion topic for future studies investigating actions for gender equity.When interpreting this study results, we should consider some limitations. First, due to the cross-sectional design, no causal relationship can be drawn from the results. Second, a self-reported questionnaire may lead participants to overestimate or underestimate the use of the transport modes at issue. The lack of knowledge regarding distance is a fundamental limitation. Further studies should consider including objective measures  and subjective measures of transport behavior. Our study sample is formed only by students from public schools, which precludes the extrapolation of results to higher classes. However, the representative sample and statistical analyses ensure data interpretation for large populations of public schools – a key point in the field of interventions related to public health and prevention. This study also corroborates the investigation of sociodemographic and psychosocial factors for ATS among a representative sample of adolescents. We did not investigate the significant association between ATS and body mass index (BMI) and recommended levels of physical activity; however, we suggest that further studies evaluate this relationship for a greater clarification on ATS.The results show a 37.7% prevalence of active transportation to school (ATS): 16.2% among boys and 21.5% among girls. We found no association between sociodemographic factors and ATS, except age for girls. Social support for physical activity (PA) practice, from both parents and friends, was associated with ATS. For boys, ATS was associated with having parents who: practice PA together with them, provide transportation for PA, and remark their good performance on it; as well as having friends who practice PA together with them. For girls, ATS was solely associated with age and having friends who practice PA together with them. –––O transporte ativo para a escola (TAE) é uma maneira eficaz de aumentar os níveis gerais de atividade física (AF) em adolescentes,,,,,Modelos ecológicos afirmam que os comportamentos de saúde, como o transporte ativo, são influenciados por vários fatores em múltiplos níveis, incluindo fatores psicossociais e ambientaisNo Brasil, nos últimos anos, ocorreram tentativas de melhorar as características do ambiente urbano, podendo favorecer o uso de transporte ativo pela população, como a criação de ciclovias e ciclofaixasTrata-se de um estudo com delineamento transversal, realizado no ano de 2018, com amostra representativa de adolescentes de 15 a 17 anos de idade matriculados no ensino médio da rede estadual da cidade de Curitiba, Paraná, Brasil. O estudo seguiu as normas de pesquisa envolvendo seres humanos do Conselho Nacional de Saúde (resolução nº 466/2012), sendo aprovado pelo Comitê de Ética em Pesquisa da Universidade Federal do Paraná (CAAE: 98133218.8.0000.0102) e autorizado pelos pais ou responsáveis dos adolescentes pela assinatura do termo de consentimento livre e esclarecido (TCLE).De acordo com o Censo Escolar de 2017, realizado pelo Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira (Inep), havia naquele ano 53.760 adolescentes no ensino médio, de ambos os sexos, com idades entre 15 e 17 anos, nas escolas estaduais da rede de ensino público da cidade. Para o cálculo amostral, foi utilizado o software G*Power. Foi considerada uma razão de prevalências (RP) de 1,49 entre o apoio social (AS) e a prática de atividades físicasA amostragem partiu do processo de conglomerados, em três estágios. No primeiro, todas as escolas estaduais foram estratificadas de acordo com cada uma das nove regiões administrativas do município de Curitiba; no segundo, foi realizado um sorteio de duas escolas em cada uma das nove regiões administrativas; no terceiro, foi realizada uma seleção aleatória simples de uma turma de cada ano do ensino médio, de acordo com a quantidade de escolares necessária por sexo para determinada região administrativa do município. A seleção aleatória contemplou turmas do turno matutino e vespertino. Por fim, todos os alunos de cada turma foram convidados a participar do estudo.a posteriori mostraram que essa amostra poderia identificar razões de prevalências estatisticamente significantes acima de RP = 1,28 como aumento do uso do transporte ativo para escola e abaixo de RP = 0,77 como menos propensos a utilizar transporte ativo para escola, considerando uma prevalência de 34% de adolescentes com baixo apoio social e que não realizam transporte ativo.No total foram convidados a participar do estudo 2.506 adolescentes. Os que não apresentaram o TCLE assinado pelos pais ou responsáveis (n = 100), que se negaram a participar do estudo ou que faltaram no dia da coleta (n = 56) não foram incluídos. Aqueles que informaram limitações físicas ou cognitivas que limitassem a prática de AF (n = 12) e que tinham 18 anos (n = 125) foram excluídos. Os que responderam aos questionários incorretamente (n = 229) foram considerados como perda amostral. Assim, a amostra analítica do estudo foi de 1.984 adolescentes. Análises de poder amostral realizadas O sexo foi autorreportado (masculino ou feminino) e a idade calculada a partir da data de nascimento informada pelo adolescente e classificada em 15, 16 ou 17 anos. A escolaridade dos pais e responsáveis, bem como o nível socioeconômico, foram avaliados conforme a classificação da Associação Brasileira de Empresas de Pesquisa (ABEP)O apoio social de pais e amigos para a prática de AF foi mensurado por uma escala de 10 itens, a escala Asafa, que apresenta consistência interna satisfatória ,Para efeitos de análise, e com o objetivo de garantir comparabilidade com estudos semelhantes,Foi avaliado o modo de transporte usado para ir e voltar da escola durante uma semana típica . Todos os estudantes que relataram caminhar ou andar de bicicleta ou skate para ir e voltar da escola foram classificados como “ativos” e os demais como “passivos”. Essa questão mostrou confiabilidade teste-reteste adequada  e tem sido utilizada em estudos semelhantescomplex sample do software SPSS versão 23.0. Tal procedimento foi utilizado para assegurar que as estimativas reflitam os dados populacionais das unidades elementares da amostra.Para evitar viés relacionado ao processo de seleção amostral com característica complexa (estratificação por conglomerado), as análises de associação foram corrigidas pelo delineamento complexo, utilizando o comando post hoc para demonstrar quais categorias apresentaram maior diferença. Foi utilizada a regressão logística binária de forma bruta e ajustada para verificar a associação dos fatores demográficos e apoio social de pais e amigos com o TAE. Pelo critério stepwise, foi adotado o valor de p ≤ 0,20 para entrada da variável no modelo ajustado. Todas as análises foram realizadas separadamente para cada sexo e foi adotado um nível de significância de 5%.As prevalências foram descritas pela distribuição de frequência relativa e absoluta. O teste qui-quadrado de Pearson foi utilizado para comparar proporções entre os sexos, e em seguida foi utilizado um A amostra foi composta por 1.984 adolescentes, sendo 55,9% do sexo feminino. Desses, somente 748  relataram utilizar transporte ativo para a escola em uma semana habitual, sendo 16,2% meninos e 21,5% meninas. Nas As associações dos fatores sociodemográficos e do apoio social com o TAE para meninos podem ser verificadas na Com relação ao apoio social dos amigos, meninos que indicaram ter amigos que sempre praticam AF apresentaram maiores chances de realizar o TAE . Além disso, meninos que têm amigos que os assistem realizando AF foram menos propensos a realizar o TAE .A ,,–A adolescência apresenta-se como um importante momento para a consolidação dos hábitos de AF; de fato, a literatura vem demonstrando essa fase da vida como um período de declínio gradual do engajamento nos diversos domínios da AFCom relação à prevalência do TAE nesta investigação, 37% dos adolescentes indicaram ter esse tipo de comportamento. Em recente revisão sistemática sobre o TAE em adolescentes brasileiros, os autores identificaram uma grande variabilidade nas prevalências, mais especificamente de 34,3% a 75,7%, dependendo do estudo avaliado–Em relação ao sexo, o presente estudo mostrou que 21,5% do TAE é realizado por meninas. Outros estudos,,Fatores sociodemográficos têm sido considerados como possíveis influenciadores do TAE em adolescentes,,–Por outro lado, fatores sociodemográficos como a escolaridade dos pais e o nível socioeconômico, que são apresentados como importantes preditores dos diferentes contextos da AF (transporte e lazer)O apoio social apresenta-se associado com o maior engajamento de adolescentes com a AF em seus diferentes domíniosJá para as meninas, ter amigos que praticam AF com elas associou-se ao TAE. Alguns estudos mencionam que para meninas a principal barreira para a prática de AF no lazer é a falta de companhiaCuriosamente, meninos com pais que incentivam e amigos que assistem à prática de AF e meninas com amigos que as convidam para a prática de AF foram menos propensos à realização do TAE. Este estudo não apresenta explicações plausíveis para essas associações, mas reforça a necessidade de uma investigação mais detalhada sobre como cada característica de apoio social pode impactar diferentes tipos de prática de AF nesses adolescentes, possivelmente incluindo uma interação entre metodologias de investigações quantitativas e qualitativas. Em síntese, as associações referentes ao apoio social de amigos ocorreram em ambos os sexos, diferentemente do apoio social dos pais, que esteve associado somente no sexo masculino. É possível que esses dados sejam resultados de uma maior influência dos pais para filhos do sexo masculino quando o assunto é praticar AF, o que torna esse resultado tema de discussão para futuros estudos que busquem investigar ações para a equidade entre os sexos.Alguns pontos devem ser considerados na interpretação dos resultados deste estudo. A primeira limitação é que nenhuma relação causal pode ser desenhada devido ao delineamento transversal. Em segundo lugar, um questionário autorrelatado pode levar os participantes a superestimar ou subestimar o uso de modos de transportes questionados. O não conhecimento da distância torna-se uma limitação fundamental. Futuros estudos devem considerar a inclusão de medidas objetivas  somadas a medidas subjetivas do comportamento de transporte. O fato de a amostra ser formada apenas por estudantes da rede pública impossibilita a extrapolação dos resultados para classes mais elevadas. Entretanto, a amostra representativa e as análises estatísticas asseguram uma interpretação dos dados para grandes populações de escolas da rede pública, um ponto importante no domínio de intervenções relacionadas à saúde pública e preventiva. Ademais, o estudo colabora na investigação dos fatores sociodemográficos e psicossociais para o TAE em uma amostra representativa de adolescentes. Apesar de não ter investigado a relação significativa do TAE com o índice de massa corporal (IMC) e níveis recomendados de atividade física, os autores sugerem que futuros estudos avaliem essa relação, com o objetivo de agregar maiores esclarecimentos sobre o TAE.Os resultados indicam uma prevalência de TAE de 37,7%, sendo 16,2% entre meninos e 21,5% entre meninas. Os fatores sociodemográficos não foram associados com o TAE, exceto a idade para as meninas. O apoio social para a prática de AF, tanto de pais quanto de amigos, associou-se ao TAE. Para os meninos, ter pais que praticam AF junto, fornecem transporte para a AF e comentam que o adolescente faz bem a AF apresentou associação com o TAE, assim como ter amigos que praticam AF junto. Para as meninas, apenas a idade e ter amigos que praticam AF junto se associaram ao TAE.


Bringing faculty to a realization of the importance of direct observation is a major task during the transition to competency-based medical education. Musicians generally already endorse a strong coaching culture. We included a live cello masterclass in an oncology faculty and trainee workshop in order to demonstrate coaching and feedback. Based on participant post-event interviews, the musical masterclass was a highly effective catalyst for self-reflection in regards to teaching practices and led to new and revised perspectives on observation and coaching in medicine. With just a musician-trainee, music coach, and faculty moderator, this effective demonstration can be easily replicated.Amener le corps professoral à réaliser l’importance de l’observation directe est une tâche majeure à accomplir au cours de la transition vers la formation médicale axée sur les compétences. Habituellement, les musiciens font preuve d’une solide culture de coaching. Nous avons intégré un cours de maître de violoncelle donné en direct à un atelier destiné au corps professoral et résidents d’oncologie afin de démontrer le « coaching » et la rétroaction. En se basant sur les entrevues effectuées après l’événement, le cours de maître de musique a été un catalyseur efficace pour l’auto-réflexion sur les pratiques d'enseignement et a donné lieu à des perspectives nouvelles et ajustées sur l’observation et le « coaching » en médecine. Cette démonstration convaincante, qui ne nécessite qu’un musicien en formation, un « coach » en musique et un modérateur du corps professoral, peut facilement être reproduite.1 Music and sports have very strong cultures of cyclical observation, feedback, and performance within a faculty-trainee relationship (“coaching”).2Direct observation is a prerequisite for assessment in competency-based medical education, and sustained observation of performance has been identified as crucial to the faculty-trainee relationship 3 we incorporated a classical cello masterclass into a CBME introduction workshop. The study was approved through the Western University Health Sciences Research Ethics Board.Hoping to address our  faculty’s reluctance towards giving constructive feedback and underestimation of observation importance, as well as trainees’ often limited receptivity towards feedback,https://www.youtube.com/watch?v=Bi3PEoDdF_g&t=1297s.The 40 attendees witnessed a professional cellist work with one of the authors (MS), an amateur cellist. The moderator (KP) then elicited audience observations and facilitated a 45-minute discussion. The audience articulated their observations and how the coaching observed might be transferred to clinical teaching. A video is available at 4 of the post-event interview transcripts by MS and KP indicated that the demonstrationThirteen attendees were interviewed by the authors . Thematitriggered reflection by the audience on their own teaching/learning habits,highlighted indicators of high-quality teaching in general, andwas an educational tool with a beneficial effect on the audience including changed perspectives on giving and receiving of feedback .Faculty realized how current teaching practices were limited:I think the main issues with our training here is that we aren’t doing enough direct observation and enough coaching. Most of the interactions I have observed would be residents seeing a patient, coming out of the room and just describing what they did or saw with very little feedback. (Faculty #11)Both trainees and faculty reported noticing other elements of effective teaching:Timelinessof feedbackIn the moment really struck me. Immediate in time. …. (Faculty #12)Feedback receptivityIn…medicine it is all emotional. We all take any criticism as a personal affront …[but] you didn’t take any of it personally you were just making those corrections and it was just a technique change and there was no personal “oh I’m so hurt that she didn’t like the way I played that.” (Trainee #5)Specificity…the advice she gave was very specific and it was very limited. … It was that small little bites with the positive reinforcement but still what needed to be said was said. (Trainee #5)Residents in particular felt having a faculty member as the “musician-trainee” in the workshop was helpful:I do think this is a nice way to transition the residents …Once you see your attendings getting feedback, then you don’t feel so bad because everyone gets feedback which is critical and important. (Trainee #1)5 in such workshops (our next step!) in order to introduce a coaching culture as early as possible in their professional development.We have since repeated this workshop in a Program Directors’ retreat and in a faculty course on coaching. We would encourage other centres to try this, and to consider including medical students


As projeções para o dia 19 de março de 2021 estimam 242.738 [232.202 – 255.044] mortes, que poderiam ser reduzidas para 241.668 [231.337 – 253.770], caso a vacina fosse rapidamente administrada, e para 223.910 [215.565 – 233.360], caso a máscara fosse utilizada em 95% das situações em todos os locais. Preocupa a magnitude do número de casos e óbitos por única doença em tão pouco tempo. No momento, quando há crescimento de novos casos e internações, começar a vacinar terá impacto na redução de mortes e internações em intervalo curto. Apesar do esforço da comunidade científica, não há um tratamento específico para bloquear a replicação viral. Nesse sentido, programas de vacinação são poderosos aliados e, em virtude do notável progresso da ciência, já dispomos desse recurso.A Organização Mundial da Saúde reconheceu a COVID-19 como pandemia em 11 de março de 2020 e, desde então, essa emergência de saúde pública converteu-se na principal causa de óbitos no mundo, o que tornou seu enfrentamento uma prioridade inquestionável. Ao escrevermos este editorial contabilizávamos 86.969.386 casos confirmados e 1.915.657 mortes por COVID-19 no mundo, dos quais 8.013.708 casos ocorreram no Brasil e resultaram em 201.460 mortes.O Brasil, por intermédio do Sistema Único de Saúde (SUS), tem se notabilizado pelo êxito da execução de programas de vacinação da sua população. É premente a instituição de política pública para vacinar dentro dos princípios do SUS: universalidade, integralidade e equidade. Entretanto, diante dos movimentos antivacina que têm surgido em nível mundial, é necessário um forte esforço para que se obtenha a adesão da população. No passado, já enfrentamos com muito êxito essa incredulidade, como na Revolta da Vacina vivida por Oswaldo Cruz. Miremo-nos nesse exemplo para superar essa grave crise sanitária.3No Brasil, entre 17 de março e 22 de maio de 2020, houve número maior de óbitos nas capitais das regiões Norte, Nordeste e Sudeste, especialmente em São Paulo, Rio de Janeiro, Fortaleza, Recife, Belém e Manaus, com menor ocorrência de notificação de óbitos nas capitais do Sul e do Centro-Oeste e nos municípios do interior. Observamos aumento de notificação de óbitos por causas cardiovasculares inespecíficas em todas as regiões, nas capitais e no interior, principalmente nas regiões Norte, Nordeste e Sudeste. Por outro lado, houve redução percentual das notificações de óbitos por síndrome coronariana aguda (SCA) e acidente vascular cerebral (AVC), com maior magnitude no Nordeste, seguindo-se as regiões Centro-Oeste e Sudeste .3A pandemia pelo coronavírus em 2020 no Brasil aumentou o número de óbitos gerais, por doenças cardiovasculares (DCV) e por causas inespecíficas, assim como o número de mortes súbitas em domicílio. As diferenças regionais exprimem as desigualdades socioeconômicas e étnicas de um país continental, sendo ainda consequência de um sistema de saúde com recursos heterogêneos e mal distribuídos.COVID-19 é a novidade pandêmica. A DCV é nossa realidade endêmica, consolidada e irresoluta. Ambas comprometem a saúde em todos os aspectos, individuais e coletivos, físicos, psíquicos, sociais e econômicos. Em comum, ceifam vidas produtivas e promissoras.Ainda carecemos de estudos duplo-cegos, randomizados, placebo-controlados que mostrem a relação de causalidade entre vacinação contra COVID-19 e benefício nos cardiopatas. Utilizemos então a melhor evidência disponível.4Apesar de terem surgido antes mesmo dos imunologistas, as vacinas provocaram impacto no controle ou até erradicação de doenças outrora devastadoras. A varíola matava 29% das crianças na Londres dos séculos XVII e XVIII e foi declarada extinta em 1980. Quem entre nós fez diagnóstico de miocardite diftérica nos últimos 10 anos? Quantos casos de tétano neonatal foram internados em seu hospital em 2020? Vacinações mudaram a história natural das epidemias de difteria em 1940, de poliomielite em 1956, de coqueluche em 1950, de sarampo em 1968, de doença meningocócica em 1999, entre muitas outras. Entretanto, o vacilo nas campanhas resultou, invariavelmente, em reincidência.5 A vacinação depende, em muito, da recomendação do cardiologista, que é, sobretudo, “o clínico” do cardiopata, ouvido em diversas situações. O conhecimento e consequente convencimento sobre a necessidade da vacina é determinante para sua difusão. A vacina da influenza é o exemplo inequívoco: acha-se disponível, é de fácil acesso em campanhas, mas sua cobertura não ultrapassa 25% dos pacientes com insuficiência cardíaca (IC).6A vacinação contra influenza é a experiência exitosa baseada em evidências mais próxima da atual situação pandêmica pela COVID-19. Apesar de a vacinação contra influenza ser recomendada pelas principais diretrizes em cardiologia, a cobertura vacinal é baixa e aumentou pouco na última década.5 O15 Hoje, sabe-se que a vacinação é medida eficaz na prevenção secundária, pois reduz internações hospitalares por IC, AVC e SCA, além de reduzir mortalidade geral de modo mais expressivo que muitos medicamentos ou intervenções.6A necessidade da vacinação contra influenza em cardiopatas foi determinada primeiramente pelos relatos históricos de aumento de mortalidade nas epidemias e, posteriormente, por estudos epidemiológicos.16A influenza predispõe a pneumonia bacteriana secundária e, dessa forma, descompensa o paciente com IC. Sim, é fato. Entretanto, deve-se ressaltar que a síndrome inflamatória sistêmica secundária à influenza leva a alteração dos fatores de coagulação, hiperagregabilidade plaquetária, além de aumento das proteínas de fase inflamatória, das citocinas e do fator de necrose tumoral. Consequentemente, tem-se incremento dos fenômenos trombóticos e depósito de fibrina, hipocontratilidade do cardiomiócito, inflamação e aceleração da aterogênese e do remodelamento . Assim,A COVID-19 trouxe à tona a discussão dos mesmos mecanismos e manifestações já muito bem estudados na influenza. É inegável que a resposta inflamatória apresentada na COVID-19 seja mais exuberante e grave, associada ao risco de trombose. Portanto, conhecemos as peculiaridades da imunização nesse subgrupo de indivíduos e somos capazes de recomendar providências eficientes para ampliar as chances de sucesso do programa de imunização contra a COVID-19.17 Descontadas as confusões suscitadas por interpretações inadequadas de estudos ecológicos, o conceito de grupo de risco manteve-se nas publicações subsequentes. Na verdade, fato já conhecido desde os estudos da influenza. O paciente com IC é um indubitável exemplo de grupo prioritário e a Sociedade Brasileira de Cardiologia (SBC) já se manifestou a respeito.18Desde as primeiras séries publicadas a partir da China e da Itália, a gravidade da COVID-19 sobressaiu nos portadores das doenças crônicas não transmissíveis, muito provavelmente tomados em comum pela inflamação sistêmica crônica.Recentemente, a SBC foi convidada pelo Ministério da Saúde para integrar a Câmara Técnica e revisar o Programa Nacional de Imunização contra a COVID-19 e apontou sugestões relativas à vacinação em enfermos acometidos por todas as DCV, definindo e especificando grupos prioritários para a vacinação .19 Moderna20 e AstraZeneca21 incluíram idosos, cardiopatas, diabéticos, obesos graves, afrodescendentes e latinos. E, apesar do número relativamente reduzido, essa inclusão permite-nos inferir a segurança e a eficácia em pacientes cardiopatas. Os efeitos adversos observados foram locais, porém menos comuns nos mais idosos. Os efeitos cardiovasculares observados, como hipertensão, bradicardia, taquicardia, fibrilação atrial, SCA ou tromboembolia pulmonar, tiveram frequência menor que 0,1% e foram semelhantes entre os vacinados e os que receberam placebo ,2Brazil will have 248 476 deaths from COVID-19 on April 4, 2021. By March 19, 2021, 242 738 [232 202 – 255 044] deaths are estimated, and those numbers could be reduced to 241 668 [231 337 – 253 770], with the quick administration of vaccines, and to 223 910 [215 565 – 233 360], with a 95% level of face mask use in public. The magnitude of the number of cases and deaths from a single disease in such a short time is worrisome. Now, when there is a growth in the number of new cases and hospitalizations, starting to vaccinate will have an impact on reducing deaths and hospitalizations in a short interval. Despite the efforts of the scientific community, there is no specific treatment to block viral replication. In this sense, vaccination programs are powerful allies. In addition, due to the remarkable progress of science, we already have this resource.The World Health Organization recognized COVID-19 as a pandemic on March 11, 2020. Since then, this public health emergency has become the leading cause of death in the world and has made addressing it an unquestionable priority. At the time of writing this editorial, we counted 86 969 386 confirmed cases and 1 915 657 deaths from COVID-19 worldwide, of which, 8 013 708 cases in Brazil resulted in 201 460 deaths.Brazil, through its Unified Health System (SUS), has been known for the successful implementation of vaccination programs for its population. The institution of a public policy to vaccinate within the SUS principles, which are universality, integrality, and equity, is urgent. However, because of the antivaccine movements that have emerged worldwide, a strong effort to obtain the population’s adhesion is required. In the past, in the Vaccine Revolt experienced by Oswaldo Cruz, we have successfully faced that disbelief. Let us be inspired by that episode to overcome this serious health crisis.3In Brazil, between March 17 and May 22, 2020, there was a greater number of deaths in the capitals of the Northern, Northeastern and Southeastern regions, especially São Paulo, Rio de Janeiro, Fortaleza, Recife, Belém, and Manaus, and a lower number of reports of death in the capitals of the Southern and West-Central regions, and in the inner country cities. We observed an increase in the number of deaths due to non-specific cardiovascular causes in all regions, in the capitals and in the inner country, mainly in the Northern, Northeastern, and Southeastern regions. On the other hand, there was a percentage reduction in the reports of deaths from acute coronary syndrome (ACS) and stroke, with greater magnitude in the Northeastern region, followed by the West-Central and Southeastern regions .3In 2020, the COVID-19 pandemic in Brazil increased the number of general deaths and of deaths due to cardiovascular diseases (CVD) and non-specific causes, as well as that of sudden deaths at home. Regional differences express the socioeconomic and ethnic inequalities of a continental country, as well as the consequence of a health system with heterogeneous and poorly distributed resources.COVID-19 is the pandemic novelty and CVD are our endemic, consolidated, and irresolute reality. Both compromise health in all aspects, individually and collectively, physically, psychologically, socially, and economically. In common, they reap productive and promising lives.We still lack double-blind, randomized, placebo-controlled studies that show the causal relationship between vaccination against COVID-19 and benefit for cardiac patients. Let us, then, use the best available evidence.thand 18thcenturies, being declared extinct in 1980. Who among us diagnosed diphtheria myocarditis in a patient in the past ten years? How many cases of neonatal tetanus were admitted to your hospital in 2020? Vaccinations changed the natural history of some epidemics, such as that of diphtheria in 1940, of polio in 1956, of pertussis in 1950, of measles in 1968, of meningococcal disease in 1999. However, vacillation in campaigns has invariably resulted in recurrence.4Despite having arisen even before immunologists, vaccines have had an impact on the control and even eradication of once devastating diseases. Smallpox killed 29% of children in London in the 175Vaccination depends to a great extent on the cardiologist’s recommendation. The cardiologist is “the clinician” of the patient with CVD, heard in several situations. The knowledge and consequent conviction about the need for a vaccine is crucial for its dissemination. The influenza vaccine is an unequivocal example: it is available, is easily accessed in campaigns, but its coverage does not exceed 25% of the patients with heart failure (HF).6Influenza vaccination is the successful evidence-based experience closest to the current COVID-19 pandemic situation. Although influenza vaccination is recommended by the main guidelines in cardiology, that vaccination coverage is low and has increased little in the last decade.515Today, influenza vaccination is known to be an effective measure for secondary prevention because it reduces hospital admissions from HF, stroke, and ACS, in addition to reducing overall mortality more significantly than many medications or interventions.6The need for influenza vaccination in cardiac patients has been first determined by historical reports of increased mortality in epidemics, and, later, by epidemiological studies.16Influenza predisposes to secondary bacterial pneumonia and, thus, decompensates patients with HF, and that is a fact. However, it should be noted that the systemic inflammatory syndrome secondary to influenza leads to changes in the coagulation factors and platelet hyperaggregability, and to an increase in inflammatory phase proteins, cytokines, and tumor necrosis factor. Consequently, there is an increase in thrombotic phenomena and fibrin deposition, cardiomyocyte hypocontractility, inflammation, acceleration of atherogenesis, and remodeling . Thus, COVID-19 brought up the discussion of the same mechanisms and manifestations already well studied for influenza. It is undeniable that the COVID-19 inflammatory response is more exuberant and severe, and associated with the risk of thrombosis. Therefore, we are aware of the peculiarities of immunization in that subgroup of individuals and recommend efficient measures to increase the chances of success of the immunization program against COVID-19.17Discounting the confusions caused by inadequate interpretations of ecological studies, the concept of risk group has remained in subsequent publications, which has been an already known fact since the studies about influenza. The patient with HF is an undoubted example of a priority group, and the Brazilian Society of Cardiology (SBC) has already expressed its opinion.18Since the first series published from China and Italy, the severity of COVID-19 has stood out in patients with chronic noncommunicable diseases, most likely because of the chronic systemic inflammation they have in common.Recently, the SBC has been invited by the Ministry of Health to join the Technical Chamber and review the National Immunization Program against COVID-19. The SBC has pointed out suggestions regarding vaccination in patients affected by all CVD, defining and specifying priority groups for vaccination .19Moderna,20and AstraZeneca21have included the elderly, cardiac patients, diabetics, severely obese individuals, Afro-descendants, and Latinos. And, despite their relatively small number, that inclusion allows us to infer safety and efficacy for cardiac patients. The adverse effects observed were local, but less common in the elderly. The cardiovascular effects observed, such as hypertension, bradycardia, tachycardia, atrial fibrillation, ACS, and pulmonary thromboembolism, had a frequency lower than 0.1% and were similar in those who received the vaccines and those who received placebo (There are still few vaccines tested in phase 2 or 3 studies. However, the results are positive and impactful, both in terms of safety and effectiveness. It is worth mentioning that the vaccines supported by Pfizer,placebo .in a clinical study with 12 400 volunteers, the immunizing agent showed 78% effectiveness for mild cases and 100% for moderate and severe cases”.22Thus, the perspective of having vaccines is good.It is worth mentioning that Brazil has entered into partnerships since May 2020 for the research and development of vaccines that include technology transfer through the Oswaldo Cruz Foundation and the Butantan Institute. The vaccine developed by AstraZeneca and the Oxford University has already had its preliminary results published, being in use in England. This vaccine will be produced on a large scale in Brazil. Concomitantly, the vaccine called CoronaVac, developed by the Sinovac laboratory, will be produced at the Butantan Institute, which has reported in the media that “Health is a right for all and a duty of the State, guaranteed through social and economic policies...”. Thus, public health policies that are safe, effective, and cost-effective are part of the existential minimum of each Brazilian, and should be offered in a universal, comprehensive, and free manner. That includes the vaccination campaigns, a true consolidated patrimony of Brazilians and national pride. In view of this, creating all the conditions to offer vaccines in a comprehensive immunization program against COVID-19 is “a right for all and a duty of the State”, under penalty of constitutional duty becoming an inconsequential promise, frustrating the fair expectations deposited in the Brazilian State.It is necessary to emphasize that Brazil has one of the most advanced health legislations in the world. The Brazilian Federal Constitution enshrines access to health as a fundamental right: “to expand, disseminate and encourage, at all levels, the knowledge, diagnosis, prevention and treatment of CVD, developing educational campaigns jointly with the government and other entities and associations, and disseminating the epidemiological aspects of CVD to the civil society, which should be educated about the prevention and treatment possibilities”.23The SBC will not escape the historical legacy, built on the example of Carlos Chagas, Dante Pazzanese, and our pioneers and transmitted for more than seven decades to more than 14 000 members, confirmed in its social purpose. The SBC’s objective is “Despite the high cost of lost lives, the search for an efficient solution to the pandemic has brought us rapid advances in research, based on good quality science, leaving a remarkable legacy and achievements. In one year, the clinical picture, the epidemiological profile and the etiological agent at the molecular level were described, care was improved, empirical and futile treatments were refuted, and vaccines tested in clinical trials were produced. This is science in its fascinating evolution for effectiveness in favor of quality and quantity of life. However, the great lesson has been the need to strengthen the health system, our SUS.The uncompromising defense of SUS, in short, is the defense of the dignity of the human person, a fundamental commitment of the Brazilian State. The SBC and the other scientific societies must ally themselves in the fight for the progress and diffusion of science and for the achievement of public policies capable of improving the lives of each of the more than 220 million Brazilians. The principles that guided the creation of the SBC in 1943, in the middle of the Second World War, are still the same that motivate us in this unprecedented health crisis.


To compare the access to and effective use of health services available among international migrants and Chileans.Caracterización Socioeconómica Nacional ), version 2017. Indicators of access to the health system  and effective use of health services  were described in immigrants and local population, self-reported. Gaps by immigrant status were estimated using logistic regressions, with complex samples. Secondary analysis of the National Socioeconomic Characterization Survey , coverage (OR: 2.7 95%CI: 2.0–3.7) and unsatisfied need. The difference between immigrants and locals was not statistically significant in barriers to health care access (α = 0.005). Disadvantages persist regarding the access to and use of health services by immigrants as opposed to Chileans compared with information from previous years. It is necessary to reduce the gaps between immigrants and people born in Chile, especially in terms of health system access. This is the first barrier to effective use of services. The generation of concrete strategies and health policies that consider an approach of social participation of the immigrant community is suggested to bring the health system closer to this population. It was recognized globally by most countries in the treaty adopted by the United Nations General Assembly in 1966 and came into force in 1976. In 2002, Latin American countries and the Caribbean agreed to initiate efforts to extend social health protection. It also appears as one of the eight Areas of Action defined in the Health Agenda for the Americas 2008–2017. In this agenda, all the Ministers of Health from Ibero-America committed themselves to combating health exclusion and building integrated social protection systems with the signing of the Iquique Declaration in July 20072 . Each dimension is essential for a State to provide and guarantee the right to health in its fundamental aspects. Vertical coverage includes the indicator of effective use of health services or benefits5 , of special relevance for the identification of gaps in health access by the general population and vulnerable groups7 . Differences in the effective use of health benefits between social groups, in the face of the same perceived need, correspond to unjust and preventable differences  that require constant attention and reparation. The indicator of effective use of health services or benefits can be disaggregated into the chain of health need and demand: (i) perceived health need, (ii) expressed and unexpressed demand, (iii) satisfied and unsatisfied demand8 .Social health protection is a concrete safeguard measure of the human right to health. It is developed through three main and complementary dimensions: (i) horizontal coverage ; (ii) vertical coverage (access to benefits); and (iii) financial protection9 . This country has a mixed health system, with a public component (close to 70.0% of the population) that protects the sickest and the poorest, a private component (close to 25.0% of the population) that protects the youngest and wealthiest, and a minor component of the armed forces and public order (5.0%). The Constitution of Chile indicates that free and equal access to health should be provided, but this premise has failed by demonstrating profound health inequalities among social groups, to the detriment of the least advantaged in their socioeconomic position. International migrant population has the right to use the public or private health system if they have a valid residence visa, selecting the type of provision according to co-payment capacity. For migrants going through a visa application process, an opportunity for health access on an equal footing with other migrants and Chileans was created if they document a situation of lack of resources to a witness of faith, usually a social worker, in the same health system .In Chile, there is still a debate about repositioning social health protection as a human right for the entire population residing in our territory, regardless of their sex, ethnicity, socioeconomic level or migratory status10 . Human displacement in all its forms is one of humanity’s greatest challenges. Migration is also recognized as a social determinant of health in the world. The process of migration itself, as well as factors associated with it when some degree of vulnerability or lack of protection of universal rights is experienced, have the potential to affect the physical, mental and emotional health of migrants and their families12 .Health protection for international migrants is a global concern. In ancient times and in modern life, moving from one place to another has always offered the opportunity to improve well-being. International migration represents an issue of global attention, reflecting international processes of social inequality and development, conflict and international stratification of labor, and processes of population ageing, to name only some of its dimensions. Added to this, in the globalization era, and given the ease access to information, the advance in communications and the reduced time and cost of moving from one place to another is faster and less costly today than in the past10 . On the other hand, risks associated with displacement, such as psychosocial disorders, reproductive health problems, increased neonatal mortality, drug abuse, nutritional disorders, alcoholism and exposure to violence have also been described12 . One of the aspects of growing interest on a global scale concerns the continuity of care in the transnational setting. This is due to the risks of health care interruption, mainly due to lack of health access in the receiving country12 .The health of migrants is affected when they are not adequately protected. Accidents, hypothermia, burns, cardiovascular accidents, complications in pregnancy and childbirth, diabetes and hypertension are the conditions most frequently mentioned by the World Health Organization12 . The migratory experience can have a negative impact on all social strata. However, health problems tend to concentrate on those migrants who experience poverty, exclusion and discrimination14 .The most recent estimate from the Department of Foreigners and Migration of the Ministry of Interior and Public Security in Chile, from April 2018, indicated there would be a 6.6% international migrant population, corresponding to a marked increase from 2012 census statistics that estimated 2.5-3.0%. The majority of international migrants come from countries of the Southern Cone , especially Argentina, Colombia, Venezuela, Ecuador, Bolivia and Haiti (2017 Short Census). It is important to recognize the great socioeconomic variability that the international migrant population presents in Chile and in the world. Just as there are migrants of high social hierarchy, there are also those of medium and low socioeconomic levels15 reported that the immigrant population would underutilize healthy child control compared with the local population, would use Pap smears screening similarly to the national one, and would use more prenatal and gynecological care services than locals. In addition, a clear socioeconomic gradient is observed in most of these services.In both Chile and the region as a whole, the evidence for the use of health services by international migrants is limited. Studies conducted by Cabieses et al.The aim of this study was to compare the effective use of the health services available among international and Chilean migrants. This comparison enables us to identify inequality gaps in the use of services, which are potentially modifiable, can have a negative impact on the health of migrants and run counter to the universal goal of social health protection.16 . This survey allows us to observe general patterns of the population that self-reports as an immigrant (born abroad) and to compare it with the Chilean population (born in Chile).Cross-sectional observational study. Secondary analysis of the National Socioeconomic Characterization Survey , version 201716 .The CASEN survey is developed periodically by the Ministry of Social Development. It is an instrument for diagnosis, evaluation and targeting, with the objective of knowing the socioeconomic conditions of the country’s households, especially those groups defined as priorities by social policies. This anonymous and free survey uses a complex probabilistic sample, allowing the representation of individuals in private residences of 324 towns of the 16 regions of the country, excluding towns with difficult access and institutionalized peopleCASEN had 70,948 households in 2017, considering a non-response rate of 26.6%. This survey contains information of 216,439 people residing in private households, of which 207,603  were Chilean and 6,811  immigrants. Thus, 94.6% of the population represented was Chilean and 4.4%, immigrant; 0.94% of the individuals did not report their migratory status, and therefore were excluded from the analysis. Data collection was carried out by a structured direct interview with habitual residents or an adult of the family, able to answer for the other members of the household.The study variables were:1.Access to the health systemAffiliation of a health insurance system [yes/no].Type of health insurance [public/private/other].Both were created by recoding the question “Which health insurance system do you use? .”2.Indicators of effective use of health services17: Self-reports constructed from the variables available in the CASEN 201716 survey   .Perceived need for health: Short-term  and long-term .Demand expressed and not expressed: have consulted the Chilean health system, or not, for those who reported having had some short-term health need [yes/no]; and to be covered or not by the AUGE-GES system in the case of long-term needs.Satisfied and unsatisfied demand: (yes) Appointment or coverage of the perceived health need in short or long term, respectively, or no appointment or coverage for voluntary reasons. (No) no appointment or coverage for involuntary reasons.Reasons for not having an appointment  or coverage .Barriers to health care: Presence of problems during the appointment due to short-term need [yes/no]. Indicator constructed from the questions: When you had an appointment, did you have any of the following problems? a) arriving for the appointment, hospital, clinic, etc. b) to get an appointment/health care (slot). c) to be attended at the establishment  d) paying for care due to cost e) delivery of medications at the healthcare establishment or access to them because of the costs.In cases of short and long-term perceived health need, a higher indicator value reflected a worse health condition. On the other hand, a higher value in the indicators: no access to a health insurance system, demand not expressed, no appointment, no coverage, no appointment or no coverage for involuntary reasons, unsatisfied need and presence of barriers to access, indicated a worse access to health services.3.Sociodemographic control variables: age, sex, area of residence [urban/rural], educational level [no education/basic/high/technical or professional], activity status [employed/unemployed/active], autonomous quintile of total household income.2 with second-order Rao-Scott correction (statistic F).The indicators of access to the health system and effective use of health services were analyzed descriptively for immigrants and people born in Chile, in totality and stratified according to sociodemographic variables. The independence between migratory status and indicators of effective use of health services and access to the health system was analyzed through Pearson’s test χLogistic regression models were performed, adjusted for sociodemographic variables, considering the use of a health insurance system, Demand satisfied in the short and long-term and Barriers to care, as dependent variables, and immigrant status as an independent variable. This is for the total population and for people over 14 years old (adults), additionally considering the activity condition variable.Database management and data analysis was performed using STATA 14 (StataCorp) software, considering the complex design of the survey (conglomerate stratum and expansion factor) and an estimate of variance by linearization by Taylor series. A significance of 0.05 and 95% confidence was considered for all analyses.The total of 16.3% of the country’s immigrants affirmed that they did not use a health insurance system, a value seven times higher compared with the Chileans (2.3%).Immigrants showed significantly less perceived health need than those born in Chile in both short and long-term. In the short-term, in immigrants, 15.1% of the total population reported illness or accident in the three months prior to the survey (vs. 20.2% in Chileans); of these, 9.3% did not have an appointment and 1.7 of every 100 people did not meet their health need by not having an appointment for reasons beyond their control. For Chileans, these values will correspond to 6.1% and 0.7 out of 100, respectively, significantly lower than in immigrants. On the contrary, immigrants and Chileans reported a similar proportion of problems during the appointment (access barriers): approximately 25.0% of consultants for short-term needs . In the long term, 9.6% of the immigrants were in medical treatment for some illness during the year prior to the survey (vs. 26.2% in Chileans), of which 44.4% were for another health condition different from the 20 main AUGE-GES pathologies treated. This percentage corresponded to 27.2% in Chileans. Immigrants significantly reported a higher proportion of no coverage  and unsatisfied needs , being specifically 2.9 and 4.7 times higher in immigrants than in Chileans, respectively   . In terAfter adjusting for socio-demographic variables, immigrants have 7.5 times more chances of not having health insurance than Chileans. The odds were 6.2 times greater in immigrants than in Chileans over 15 years old and considering the activity condition .Sex, having secondary or higher education compared with no schooling, and belonging to the richest income quintile were significant factors in the lack of health provision, disadvantageous to women, people with no schooling and lower income for the total population. In people over 15 years old, in addition, age and unemployment in reference to occupation will turn out to be significant. On the other hand, having a high school education in relation to no schooling ceased to be significant   .Among the 632,770 immigrants with health insurance, 80.0% used the public system, 18.0% from the private system and 2.0% from the armed forces (FF.AA.) or other, while in Chileans these percentages were 82.1%, 15.0% and 2.9%, respectively. The proportion of men and women using the private health system was higher in both immigrants and Chileans. 15.2% (95%CI:12.26–18.79%) of women with pensions used the public system, while in men, 21.0% (95%CI:16.78–26.03%) were immigrants. [Results not presented in the table]The immigrant population presented 21.0% (OR = 0.79) less odds of having short-term health needs (illnesses or accidents) than Chileans. However, their odds of not getting an appointment were 1.7 times higher because of this need and the odds of not satisfying this need or not getting an appointment for involuntary reasons were 3.1 higher. All this after adjusting for sociodemographic variables. This situation was maintained for people older than 15 years. Sex, age, schooling and belonging to the richest quintile were significant variables in non-expression of demand. Education ceased to be significant in individuals over 15 years old, and the rest of the income quintiles (with the exception of the III) and the activity condition became significant   .Immigrants had 2.0% (OR = 0.98) times less chance of presenting access barriers than Chileans. After adjusting for socio-demographic variables, this situation was reversed. Immigrants had a greater chance of presenting access barriers both for the entire population and for those aged 15 years or older. It was not significant for none of the cases   .For long-term needs (treatment of some diseases), immigrants had greater odds of not having their treatment covered despite having a lesser chance of receiving treatment. Specifically, adjusting for sociodemographic variables, immigrants had 53.0% (OR = 0.47) times less odds of being in treatment for some disease than Chileans and 37.0% (OR = 0.63) times less odds that this disease was an AUGE-GES pathology. Among those with AUGE-GES pathologies, the immigrant population had 2.7 times more odds of not being covered and 3.3 times more odds of not satisfying this necessity for coverage than Chileans. Immigrants older than 15 years had a greater chance of not being covered by AUGE-GES and not satisfying their long-term need compared with Chileans. With the exception of sex and basic education in contrast to no schooling, all variables considered were significant in no coverage and no satisfaction. In people over 15 years old, it was also not significant to have a secondary education in contrast to having no schooling   .When analyzing the models of indicators of effective use of health services stratified with and without health provision, the presence of long-term needs and coverage of this immigrant status variable was significant   .The results of this study indicate that immigrants are still at a disadvantage in terms of access and use of health services compared with Chileans. Immigrants presented 7.5 times more chances of not having health insurance than Chileans and a lower perceived need but less appointment, coverage or need satisfaction in the short and long-term. Immigrants were 1.7 times more likely to get an appointment in case of an illness or accident and 3.1 times more likely to not satisfy their need by not attending the appointment for reasons out of their control than people born in Chile. On the other hand, the immigrant population were 2.7 times more likely to not have their treatment covered by AUGE-GES and 3.3 times more likely to not satisfy this need for coverage than Chileans.17 .Many countries have been challenged by the global increase in international migrants recently. This brings a series of challenges for diverse sectors, education, health and social protection, just to name a few, which become more complex to face when this population is in conditions of social vulnerability. Health protection in international migrants is a global concern, and access to health services is a fundamental aspect of this work18 . On the other hand, it has been reported that a significant proportion of them live in conditions of social vulnerability. Because they are in an irregular situation, poverty, inadequate housing conditions, unemployment or informal employment and processes of discrimination and abuse or because of the difficulty in obtaining official residence identity document in the country, which, in matters of health access, is essential in order to use the health pension system19 . The number of 15.7% immigrants were not affiliated to any health system in 2015, a value 5.8 times greater than that compared with people born in Chile. The immigrant population was at a disadvantage as to the local population in other indicators of health access, such as the medical care rate for health problems and the issue with health care access18 .The percentage of first-generation immigrants present in the country increased 0.7% in Chile between 2013 and 2015, and it represents 110,738 immigrants17 . Even more worrying is that some of these indicators have increased between 2013 and 2017. 15.6% of immigrants had no health insurance in 2013, while it was 16.3% in 2017; 8.9% of those with short-term needs did not had an appointment because of this need in 2013, while it was 9.4% in 2017. 27.9% of those in treatment for an AUGE-GES disease were not covered by it in 2013, while this value was 44.6% in 2017.The same problems are observed in previous years by Cabieses et al. regarding the effective use of health services for short and long-term needs and access to the health system17 . Even more so in Chile, where according to the CASEN survey (2015), 18.5% of 12 years old or older immigrants participated or participate in some organization or group18 . The CASEN survey in all its versions is nationally representative and allows a diagnosis of the situation of the immigrant population in the country with respect to various socioeconomic conditions. In this specific case of health, it provides information about health conditions , access to the system, health services, health insurance, use of these and associated payments, which in turn may be associated with each other and with a wide range of demographic, cultural and socioeconomic factors17 . Despite this, the sample selection process of the survey does not seek to represent the international migrant population in particular and the country of birth  has non-response percentages (responds “does not know”) of 0.9% in 2017. On the other hand, the CASEN survey only allows the analysis of residents in homes, leaving out of the scenario the number of immigrants in street situations, which, according to local media, are increasing20 . The analyses carried out from this survey are limited to the variables present in it. Some of the cultural challenges such as differences in perceptions, traditions and lifestyles, among others, represented as barriers to integration and therefore into obstacles and challenges in access to health systems and services19 cannot be analyzed directly. It is therefore widely useful in the future to complement the analyses presented in this manuscript.It is necessary to reduce inequality gaps in health access and use of health services by the migrant population. To this end, concrete health strategies and policies are necessary, allowing, by social determinants of health, to protect the health and well-being of migrants, from the appearance of short and long-term health problems, and factors that may favor them, to their effective resolution. Interventions that consider a social participation approach of the international migrant community and that bring the Chilean health system closer to this population are widely recommendedThis study indicates that disadvantages persist in access to health services and their use among immigrants compared with those born in Chile. It is necessary to reduce the gaps between immigrants and Chileans, especially in terms of affiliation to a health system. This is the first barrier to the effective use of services. We suggest the generation of concrete strategies and health policies that consider a social participation approach of the immigrant community and, additionally, bring the health system closer to this population.Demand model (short-term): N=3,415,253Df=1,289 F=10.64. Model Satisfaction requirement (short-term): N=3,393,049 Df=1,289 F=6.91. Model Barriers: N=3,146. Df=1,288 F=17.78. Adult demand model (short-term): N=2,797,755 Df=1,288 F=6.54. F=6,08. Model Satisfaction of needs in adults (short-term): N=2,778,419 Df=1,288 F=3.72. Model Obstacles in adults: N=2,563,952 Df=1,287 F=13.76. Model Coverage: N=2,974,923 Df=1,295 F=118.55. Model Coverage in adults: N=2,840,844Df=1,295 F=25.94. Model Satisfaction (long-term): N=2,853,809 Df=1,295 F=100.76. Model Adult satisfaction (long-term): N=2,727,317 Df=1,295 F=21.8 1 .El derecho a la salud es un derecho humano universal e inalienable. Fue reconocido de forma global por la mayoría de los países del mundo en el tratado adoptado por la Asamblea General de las Naciones Unidas en 1966 y puesto en vigor en 1976. En 2002, países de América Latina y el Caribe acordaron iniciar esfuerzos para extender la protección social en salud. Esta aparece también como una de las ocho Áreas de Acción definidas en la Agenda de Salud de las Américas 2008–2017. En dicha agenda, todos los Ministros de Salud de Iberoamérica se comprometieron a combatir la exclusión en salud y construir sistemas integrados de protección social con la firma de la declaración de Iquique en Julio 20072 Cada dimensión es esencial para que un Estado otorgue y garantice el derecho a la salud en sus aspectos fundamentales. Dentro de la cobertura vertical está el indicador de uso/utilización efectiva de servicios o prestaciones de salud5 , de especial relevancia para la identificación de brechas de acceso a salud por parte de población general y grupos vulnerables7 . Diferencias de uso efectivo de prestaciones de salud entre grupos sociales, ante igual necesidad sentida, corresponde a diferencias injustas y prevenibles  que requieren de constante atención y reparación. El indicador de uso/utilización efectiva de servicios o prestaciones de salud puede desagregarse en la cadena de necesidad y demanda en salud: (i) necesidad sentida de salud, (ii) demanda expresada y no expresada, (iii) demanda satisfecha y no satisfecha8 .La protección social en salud es una medida concreta de garantía del derecho humano en salud. Se desarrolla a través de tres dimensiones principales y complementarias entre sí: (i) cobertura horizontal ; (ii) cobertura vertical (acceso a prestaciones); y (iii) protección financiera9 . Este país cuenta con un sistema de salud mixto, con componente público  que protege a los más enfermos y a los más pobres, componente privado  que protege a los más jóvenes y adinerados, y componente menor de fuerzas armadas y del orden público . La Constitución de Chile indica que se debe brindar acceso libre e igualitario a la salud, pero esta premisa ha fallado al demostrarse profundas desigualdades en salud entre grupos sociales, en desmedro de los menos aventajados en su posición socioeconómica. La población migrante internacional cuenta con derecho a uso del sistema de salud público o privado si tiene su visa de residencia vigente, seleccionando el tipo de previsión según capacidad de copago. Para migrantes con visa en trámite, se creó la oportunidad de acceso a salud en igualdad de condición que los demás migrantes y chilenos si es que documentan situación de carencia de recursos a un testigo de fe, habitualmente trabajador social, en el mismo sistema de salud .En Chile, aún está presente el debate de reposicionar la protección social en salud como un derecho humano para toda la población residente en nuestro territorio, independientemente de su condición de género, etnia, nivel socioeconómico o estatus migratorio10 . El desplazamiento humano en todas sus formas es uno de los mayores desafíos de la humanidad. La migración es además un reconocido determinante social de la salud en el mundo. El proceso de migrar en sí mismo, así como factores asociados a este cuando se experimenta algún grado de vulnerabilidad o falta de protección a derechos universales, tienen el potencial de afectar la salud física, mental y emocional de las personas migrantes y sus familias12 .La protección de la salud por parte de migrantes internacionales es de preocupación global. En tiempos antiguos y en la vida moderna, el desplazamiento de un lugar a otro siempre ha ofrecido la oportunidad de mejor bienestar. La migración internacional representa un tema de atención mundial, al ser reflejo de procesos internacionales de desigualdad social y de desarrollo, de conflicto y de estratificación internacional del trabajo, y de procesos de envejecimiento poblacional, por mencionar algunas de sus dimensiones. Sumado a esto, en la era de la globalización, y dadas las facilidades de acceso a información, el avance en las comunicaciones y el menor tiempo y costo de los traslados, el llegar de un lugar a otro resulta hoy en día más rápido y menos costoso que en el pasado10 . Por otra parte, riesgos derivados de los desplazamientos, tales como trastornos psicosociales, problemas de salud reproductiva, mayor mortalidad neonatal, uso indebido de drogas, trastornos nutricionales, alcoholismo y exposición a la violencia, también han sido descritos12 . Uno de los aspectos de creciente interés a escala global tiene relación con la continuidad del cuidado en el escenario transnacional. Esto por los riesgos en salud de la interrupción de la atención, fundamentalmente por falta de acceso a ella en el país receptor12 .La salud de personas migrantes puede verse afectada cuando no cuentan con adecuada protección. Accidentes, hipotermia, quemaduras, accidentes cardiovasculares, complicaciones del embarazo y el parto, diabetes e hipertensión, son las afecciones más mencionadas por la Organización Mundial de la Salud12 . La experiencia migratoria puede impactar negativamente en todos los estratos sociales; sin embargo, los problemas de salud tienden a concentrarse en aquellos migrantes que experimentan pobreza, exclusión y discriminación14 .La más reciente estimación del Departamento de Extranjería y Migración del Ministerio del Interior y Seguridad Pública en Chile en abril del 2018 indicaba que existiría un 6,6% de población migrante internacional, correspondiendo a un marcado aumento desde estadísticas censales del 2012 que estimaban un 2,5-3,0%. La mayoría de los migrantes internacionales provienen de países del cono sur (el llamado patrón migratorio “sur-sur” propio de la región de Latinoamérica), en especial Argentina, Colombia, Venezuela, Ecuador, Bolivia y Haití (Censo abreviado del 2017). Es relevante reconocer la gran variabilidad socioeconómica que la población migrante internacional presenta en Chile y el mundo. Así como existen migrantes de alta jerarquía social, también los hay de nivel socioeconómico medio y bajo15 han reportado que la población inmigrante sub-utilizaría el control de niño sano comparado con la población local, utilizaría en forma similar el screening de Papanicolaou a la nacional, y utilizaría más servicios de atención prenatal y ginecológica que la local. Además, se ha observado un claro gradiente socioeconómico en la mayoría de estas prestaciones.Tanto en Chile como en la región en su conjunto, existe evidencia limitada del uso de servicios de salud por parte de población migrante internacional. Estudios realizados por Cabieses y colaboradoresEl objetivo de este estudio fue comparar el uso efectivo de servicios de salud disponibles entre migrantes internacionales y chilenos. Dicha comparación permite identificar brechas de desigualdad en uso de servicios, que son potencialmente modificables, que pueden impactar negativamente en la salud de los migrantes y que van en contra de la meta universal de protección social en salud.16 . Esta encuesta permite observar patrones generales de población que se autorreporta como inmigrante (nacida en el extranjero) y compararla con la chilena (nacida en Chile).Estudio observacional de corte transversal. Análisis secundario de encuesta de Caracterización Socioeconómica Nacional (CASEN), versión 201716 .La encuesta CASEN es desarrollada periódicamente por el Ministerio de Desarrollo Social. Es un instrumento de diagnóstico, evaluación y focalización, con el objetivo de conocer condiciones socioeconómicas de los hogares del país, especialmente aquellos grupos definidos como prioritarios por las políticas sociales. Esta encuesta, anónima y de libre disposición, utiliza un muestreo probabilístico de naturaleza compleja, permitiendo la representatividad de residentes en viviendas particulares de 324 comunas de las 16 regiones del país, excluyendo comunas de difícil acceso y personas institucionalizadasCASEN contó con 70.948 hogares en 2017, considerando una tasa de no respuesta del 26,6%. Esta encuesta contiene información de 216.439 personas residentes en hogares particulares, de las cuales 207.603 (representativos de 16.843.471) eran chilenas y 6.811 (representativas de 777.407) inmigrantes. Así, el 94,6% de la población representada era chilena y 4,4% inmigrante; 0,94% de los individuos no reportaron su estatus migratorio, y por ende fueron excluidos del análisis. La recolección de datos se realizó mediante entrevista estructurada directa a residentes habituales o un adulto de la familia, teniendo la facultad de responder por otros miembros del hogar.Las variables del estudio fueron:1.Acceso al sistema de saludPertenencia a un sistema de previsional de salud [sí/no].Tipo de previsión de salud [pública/privada/otra].Ambos creados a partir de la recodificación de la pregunta “¿A qué sistema previsional de salud pertenece usted? ”17 : Autorreportes construidos a partir de las variables disponibles en encuesta CASEN 201716  y a largo plazo (Durante los últimos 12 meses ¿ha estado en tratamiento médico? [sí/no]).Demanda expresada y no expresada: Haber consultado o no al sistema de salud chileno, para aquellos que reportaron haber tenido alguna necesidad de salud de corto plazo [sí/no]. Y encontrarse cubierto o no el tratamiento por el sistema AUGE-GES en el caso de las necesidades a largo plazo.Demanda satisfecha y no satisfecha: (sí) Consulta o cobertura de la necesidad sentida en salud a corto o largo plazo, respectivamente, o no consulta o cobertura por motivos voluntarios. (no) no consulta o cobertura por motivos involuntarios.Razones de no consulta (¿Por qué no tuvo consulta ni atención?) o cobertura (¿Por qué este tratamiento médico no fue cubierto por el sistema AUGE-GES?).Barreras de atención: Presencia de problemas durante la consulta por necesidad a corto plazo [sí/no]. Indicador construido a partir de las preguntas: Cuando consultó, ¿se le presentó alguno de los siguientes problemas? a) llegar a la consulta, hospital, consultorio, etc. b) conseguir una cita/atención (hora). c) ser atendido en el establecimiento  d) pagar por la atención debido al costo e) entrega de medicamentos en el establecimiento de salud o acceso a ellos por su costo.En los casos de necesidad sentida de salud a corto y largo plazo, un mayor valor del indicador reflejaba una peor condición de salud. Por otro lado, un mayor valor en los indicadores de: no pertenencia a un sistema previsional de salud, demanda no expresada, no consulta, no cobertura, no consulta o no cobertura por motivos involuntarios, necesidad no satisfecha y presencia de barreras de acceso, indicaba un peor acceso a servicios de salud.3.Variables sociodemográficas de control: edad, sexo, zona de residencia [urbano/rural], nivel educacional [sin educación/primaria/secundaria/técnica o profesional], condición de actividad [ocupados/desocupados/inactivos], quintil autónomo del ingreso total del hogar.Los indicadores de acceso al sistema de salud y uso efectivo de servicios de salud fueron analizados descriptivamente para inmigrantes y nacidos en Chile, en su totalidad y estratificados según variables sociodemográficas. Se analizó la independencia entre la condición migratoria e indicadores de uso efectivo de servicios de salud y acceso al sistema de salud mediante el test de Pearson con corrección de segundo orden Rao y Scott (estadístico F).Se realizaron modelos de regresión logística, ajustados por variables sociodemográficas, considerando Pertenencia a un sistema de previsional de salud, Demanda satisfecha a corto y largo plazo y Barreras de atención, como variables dependientes, y condición de inmigrante como variable independiente. Esto para el total de la población y para mayores de 14 años (adultos) considerando adicionalmente la variable condición de actividad.El manejo de base de datos y análisis de estos se realizó mediante el software STATA 14 (StataCorp), considerando el diseño complejo de la encuesta (estrato conglomerado y factor de expansión) y una estimación de varianza por linealización por series de Taylor. Se consideró una significancia de 0,05 y confianza del 95% para todos los análisis.Un 16,3% de los inmigrantes del país afirmaban no pertenecer a un sistema previsional de salud, valor siete veces mayor en comparación con los nacidos en Chile .Los inmigrantes presentaron significativamente una menor necesidad sentida en salud que los nacidos en Chile tanto a largo como a corto plazo. A corto plazo, en inmigrantes, un 15,1% del total de la población reportó enfermedad o accidente en los tres meses previos a la encuesta ; de estos, el 9,3% no consultaron y 1,7 de cada 100 no logró satisfacer su necesidad en salud al no consultar por motivos ajenos a su voluntad. En chilenos, estos valores corresponderán a 6,1% y 0,7 de cada 100, respectivamente, significativamente menores que en inmigrantes. Por el contrario, inmigrantes y chilenos reportaron una proporción similar de presencia de problemas durante la consulta (barreras de acceso): aproximadamente un 25,0% del total de consultantes por necesidades a corto plazo . A largo plazo, un 9,6% de los inmigrantes se encontraba en tratamiento médico por alguna enfermedad durante el año previo a la encuesta , de los cuales el 44,4% eran por otra condición de salud distinta a las 20 principales patologías AUGE-GES consultadas; este porcentaje correspondió al 27,2% en chilenos. Los inmigrantes reportaron significativamente una mayor proporción de no cobertura  y necesidades no satisfechas , siendo específicamente 2,9 y 4,7 veces mayor en inmigrantes que en chilenos, respectivamente   . En térTras ajustar por variables sociodemográficas, los inmigrantes presentan 7,5 veces más chances de no tener previsión de salud que los chilenos. Este chance fue 6,2 veces mayor en inmigrantes que en chilenos en mayores de 15 años y considerando la condición de actividad .El sexo, el tener educación media o superior en comparación con no tener educación, y el pertenecer el quintil de ingreso más rico en comparación con el más pobre, resultaron ser factores significativos en la falta de previsión de salud, en desventaja de las mujeres, personas sin educación y de menores ingresos para el total de la población. En mayores de 15 años, adicionalmente, la edad y desocupación en referencia a la ocupación resultaran ser significativas. Por otro lado, el tener educación media en referencia a no tener educación dejó de ser significativa   .Dentro de los 632.770 inmigrantes con previsión de salud, el 80,0% pertenecía al sistema público, el 18,0% al privado y el 2,0% fuerzas armadas (FF.AA.) u otro, mientras que en chilenos estos porcentajes fueron 82,1%, 15,0% y 2,9% respectivamente. La proporción de pertenecientes al sistema privado de salud en hombres que en mujeres fue mayor tanto en inmigrantes como en nacidos en Chile. El 15,2%  de las mujeres con previsión pertenecían al sistema público, mientras que en hombres un 21,0%  en inmigrantes. [Resultados no presentados en tabla]La población inmigrante presentó significativamente 21,0%  menos chance de tener necesidades a corto plazo en salud (enfermedades o accidentes) que los chilenos. Sin embargo, tuvieron 1,7 veces más chance de no consultar ante esta necesidad y 3,1 veces más chance de no satisfacer esta, es decir, no haber consultado por motivos involuntarios. Todo esto tras ajustar por variables sociodemográficas. Esta situación se mantuvo en mayores de 15 años. Sexo, edad, educación y pertenecer al quintil más rico en contraste con el más pobre fueron variables significativas en la no expresión de la demanda. La educación dejó de ser significativa en mayores de 15 años, y el resto de los quintiles de ingreso (a excepción del III) y la condición de actividad pasaron a serlo   .De manera cruda, los inmigrantes tenían 2,0%  veces menos chance de presentar barreras de acceso que los chilenos. Tras ajustar por variables sociodemográficas, esta situación se invirtió. Los inmigrantes presentaran una mayor chance de presentar barreras de acceso tanto para el total de la población como para los de 15 años o más. Para ninguno de los casos esto fue significativo   .Para las necesidades a largo plazo  de manera significativa, los inmigrantes tuvieron un mayor chance de no tener su tratamiento cubierto pese a presentar un menor chance de estar en tratamiento. Específicamente, ajustando por variables sociodemográficas, los inmigrantes tenían 53,0%  veces menos chance de estar en tratamiento por alguna enfermedad que los chilenos y 37,0%  veces menos chance de que esta enfermedad fuera una patología AUGE-GES. Entre aquellos con patologías AUGE-GES, la población inmigrante tenía 2,7 veces más chance de no estar cubierta y 3,3 veces más chance de no satisfacer esta necesidad de cobertura que los chilenos. En mayores de 15 años, los inmigrantes tuvieron mayor chance de no estar cubiertos por el AUGE-GES y no satisfacer su necesidad a largo plazo que los chilenos. A excepción del sexo y el tener educación básica en contraste con el no tener educación, todas las variables consideradas fueron significativas en la no cobertura y no satisfacción. En mayores de 15 años tampoco fue significativo el tener educación media en contraste con no tener educación   .Al analizar los modelos de indicadores de uso efectivo de servicios de salud estratificados por con y sin previsión de salud, la presencia de necesidades a largo plazo y cobertura de esta la variable condición de inmigrante fue significativa   .Los resultados de este estudio indican que los inmigrantes aún se encuentran en desventaja en términos de acceso y uso a servicios de salud en comparación con los nacidos en Chile. Los inmigrantes presentaron 7,5 veces más chances de no tener previsión de salud que los chilenos y una menor necesidad sentida pero una menor consulta, cobertura o satisfacción de estas necesidades a corto y a largo plazo. Los inmigrantes tenían 1,7 veces más chance de no consultar ante una enfermedad o accidente y 3,1 veces más chance de no satisfacer su necesidad, al no consultar por motivos ajenos a su voluntad, que los nacidos en Chile. Por otro lado, la población inmigrante tenía 2,7 veces más chance de no tener cubierto su tratamiento por el AUGE-GES y 3,3 veces más chance de no satisfacer esta necesidad de cobertura que los chilenos.17 .Muchos países se han visto desafiados por el aumento global de población migrante internacional en los últimos años. Esto trae consigo una seria de desafíos para diversos sectores, educación, salud y protección social, solo por nombrar algunos, los cuales se vuelven más complejos de enfrentar cuando esta población se encuentra en condiciones de vulnerabilidad social. La protección de la salud en migrantes internacionales es de preocupación global, y el acceso a servicios de salud una arista fundamental para esta labor18 . Por otro lado, se ha reportado que una proporción significativa de estos viven en condiciones de vulnerabilidad social, ya sea por encontrarse en situación irregular, pobreza, malas condiciones de vivienda, desempleo o empleo informal y procesos de discriminación y abuso o la dificultada para obtener documentación oficial de identidad de residencia en el país, lo cual en temas de acceso a salud es esencial para poder pertenecer al sistema previsional de salud19 . Para el año 2015, un 15,7% de los inmigrantes no se encontraba afiliado a ningún sistema de salud, valor 5,8 veces mayor que en nacidos en Chile. La población inmigrante se encontraba en situación de desventaja respecto a la población local también en otros indicadores de acceso a salud, como tasa de atención médica ante problema de salud y problema de acceso a atención18 .El porcentaje de inmigrantes de primera generación presentes en el país aumentó en 0,7% en Chile, entre el 2013 y 2015, lo cual se traduce en 110.738 inmigrantes17 . Más preocupante aun es que algunos de estos indicadores han aumentado entre 2013 y 2017. Un 15,6% de los inmigrantes no tenían previsión de salud en 2013, mientras que fueron un 16,3% en 2017; un 8,9% de los que tenían necesidades a corto plazo no consultaron por esta necesidad en 2013, mientras que fue un 9,4% en 2017. Un 27,9% de los que se encontraban en tratamiento por una enfermedad AUGE-GES no se encontraban cubiertos por el mismo en 2013, mientras que este valor fue de 44,6% en 2017.Se observan las mismas falencias que en años anteriores por Cabieses y cols. en cuanto al uso efectivo de servicios de salud por necesidades a corto y largo plazo y acceso al sistema de salud17 ; más aún en Chile, en donde según la encuesta CASEN (2015), un 18,5% de los inmigrantes de 12 años o más han participado o participan en alguna organización o grupo organizado18 . La encuesta CASEN en todas sus versiones es de representación nacional y permite obtener un diagnóstico de la situación de la población inmigrante en el país respecto a diversas condiciones socioeconómicas. En este caso específico de la salud, esta permite conocer: condiciones de salud , acceso al sistema, servicios de salud, seguros de salud, uso de estos y pagos asociados, las cuales a su vez pueden asociarse entre ellas y entre una amplia diversidad de factores demográficos, culturales y socioeconómicos17 . Pese a esto, el proceso de selección muestral de la encuesta no busca representar a la población migrante internacional en particular y la variable de país de nacimiento (que permite la estratificación entre inmigrante y chileno) cuenta con porcentajes no respuesta (responde “no sabe”) en 2017 del 0,9%. Por otro lado, la encuesta CASEN solo permite el análisis de residentes en viviendas, dejando fuera del panorama a aquellos inmigrantes en situación de calle, los cuales según medios locales se encuentran en incremento20 . Los análisis realizados a partir de esta encuesta se encuentran limitados a las variables presentes en ella. Algunos de los desafíos culturales como diferencias en visiones, tradiciones y estilos de vida, entre otros, que se traducen en barreras de integración y por ende en barreras y desafíos en el acceso a sistemas y servicios de salud19 no pueden ser analizados directamente. Es, por tanto, de amplia utilidad a futuro complementar los análisis presentados en este manuscrito.Es necesario reducir brechas de desigualdad en acceso y uso de servicios de salud por parte de población migrante. Para eso, son necesarias estrategias concretas en salud y políticas que permitan, a través los determinantes sociales de la salud, proteger la salud y bienestar de migrantes, desde la aparición de problemas de salud de corto y largo plazo, y factores que puedan favorecer estos, hasta su efectiva resolución. Intervenciones que consideren un enfoque de participación social de la comunidad migrante internacional y que acerquen el sistema de salud chileno a esta población son ampliamente recomendadasEl presente estudio indica que persisten las desventajas en acceso y uso a servicios de salud en inmigrantes en comparación con los nacidos en Chile. Es necesario reducir las brechas entre inmigrantes y nacidos en Chile, sobre todo en cuanto a pertenencia a un sistema de salud. Esta es la primera barrera para un uso efectivo de servicios. Se sugiere generar estrategias concretas y políticas en salud que consideren un enfoque de participación social de la comunidad inmigrante y, adicionalmente, acerquen al sistema de salud a esta población.Modelo Demanda (corto plazo): N=3.415.253Df=1.289 F=10,64. Modelo Satisfacción necesidad (corto plazo): N=3.393.049 Df=1.289 F=6,91. Modelo Barreras: N=3.146. Df=1.288 F=17,78. Modelo Demanda en adultos (corto plazo): N=2.797.755 Df=1.288 F=6,54. F=6,08. Modelo Satisfacción necesidad en adultos (corto plazo): N=2.778.419 Df=1.288 F=3,72. Modelo barreras en adultos: N=2.563.952 Df=1.287 F=13,76. Modelo Cobertura: N=2.974.923 Df=1.295 F=118,55. Modelo Cobertura en adultos: N=2.840.844Df=1.295 F=25,94. Modelo Satisfacción necesidad (largo plazo): N=2.853.809 Df=1.295 F=100,76. Modelo Satisfacción necesidad en adultos (largo plazo): N=2.727.317 Df=1.295 F=21,8