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Mediation of the effect of childhood socioeconomic position by educational attainment on adult chronic disease in Chile



We estimated the roles of childhood socioeconomic position (ChSEP) and education attainment on chronic diseases in Chilean adults, mediated through structural determinants and health behaviors, to identify potential pro-equity interventions.


We analyzed Chile’s longitudinal Social Protection Surveys, a national sample of 14,788 adults with follow-up to 2009. Controlled direct effects (CDE) and natural effects (NDE and NIE) of ChSEP and education on number of chronic diseases were estimated with negative binomial models.


CDE of low ChSEP with education fixed at 12 years showed a 12% increase with 4% indirect effects. CDEs at favorable levels of BMI, smoking, alcohol use, and physical activity were similar. CDE estimates for education adjusted for ChSEP were larger with negligible mediation. CDEs for women were generally larger.


Low ChSEP exerts a primarily direct effect on later chronic disease, modestly mediated by education. Education attainment showed larger direct effects with minimal mediation by behaviors. Strengthening current–early child development and education policies, particularly gender aspects, may reduce social inequalities and key pathways for reducing chronic disease inequalities in Chile.

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The authors thank Chile’s National Fund for Health Research and Development (Fondo Nacional de Investigación y Desarrollo en Salud, FONIS. Grant no. SA13|20138) for funding this study. They also thank the Subsecretaría de Previsión Social of the Ministerio de Trabajo y Previsión Social of Chile for access to the data bases of the Social Protection Survey (Encuesta de Protección Social). The results and conclusions are the sole responsibility of the authors and in no way commit the Government of Chile. The first author gratefully acknowledges the support and setting provided by a writing residency at the Rockefeller Foundation’s Bellagio Center (2014), where the paper was first developed.

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Correspondence to Patricia Frenz.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study, using anonymized data from the Chilean Social Protection Survey (Encuesta de Protection Social), which is publically available from Chile’s Ministry of Labor and Social Prevision (Ministerio de Trabajo y Previsión Social), was approved by the Ethics Committee for Research on Human Subjects of the Faculty of Medicine of the University of Chile.

Informed consent

Informed consent was obtained from all individual participants included in the Social Protection Survey (Encuesta de Protección Social).

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Frenz, P., Kaufman, J.S., Nazzal, C. et al. Mediation of the effect of childhood socioeconomic position by educational attainment on adult chronic disease in Chile. Int J Public Health 62, 1007–1017 (2017).

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  • Chile
  • Childhood socioeconomic condition
  • Non-communicable disease
  • Behavioral risk factors
  • Mediation
  • Health disparities