Socioeconomic inequalities in COVID-19 incidence during the first six waves in Barcelona.

BACKGROUND: The emergence of SARS-CoV-2 affected urban areas. In Barcelona, six waves of COVID-19 hit the city between March 2020 and March 2022. Inequalities in the incidence of COVID-19 have been described. However, no studies have examined the daily trends of socioeconomic inequalities and how they changed during the different phases of the pandemic. The aim of this study is to analyse the dynamic socioeconomic inequalities in the incidence of COVID-19 during the six waves in Barcelona. METHODS: We examined the proportion of daily cases observed in the census tracts in the lower income tercile compared with the proportion of daily cases observed in the sum of the lower and higher income terciles. Daily differences in these proportions were assessed as a function of the epidemic waves, sex, age group, daily incidence and daily change in the incidence. A logistic regression model with an autoregressive term was used for statistical analysis. RESULTS: A time-dynamic effect was found for socioeconomic inequalities in the incidence of COVID-19. In fact, belonging to a lower-income area changed from being a risk factor (Waves 1, 2, 4 and 5) to being a protective factor in the sixth wave of the pandemic. Age also had a significant effect on incidence, which also changed over the different waves of the pandemic. Finally, the lower-income areas showed a comparatively lower incidence during the ascending phase of the epidemic waves. CONCLUSION: Socioeconomic inequalities in COVID-19 changed by wave, age group and wave phase.

Trends and determinants of social inequities in cardiovascular risk factors in Spain: a mixed-methods study.

This sequential mixed-methods study aims to: 1) assess spatial and temporal trends in cardiovascular risk factors by socioeconomic position from 2001 to 2020 in Spain; 2) explore public health professionals' perspectives regarding interventions that might have impacted these inequities; and 3) analyze determinants on social inequities in cardiovascular risk factors. First, we will measure the change in absolute and relative social inequities in eight cardiovascular risk factors through time trend analysis using repeated cross-sectional data from both National and European Health Surveys for Spain from 2001 to 2020. Second, we will interview key informants -both at the regional and national level-, to contextualize data obtained in phase 1 and capture the content and variation of policies across regions. Third, we will use econometric methods to analyze how these identified interventions have impacted these social inequities within and across regions.

A City Surveillance System for Social Health Inequalities: The Case of Barcelona.

INTRODUCTION: In the past, health inequalities were not prioritised in the political agenda of Barcelona. The change of city government (2015) was an opportunity to develop a Surveillance System for Social Health Inequalities in the city, which is described in this article. METHODS: The design of the Surveillance System formed part of the Joint Action for Health Equity in Europe (JAHEE), funded by the European Union. Various steps were considered by the experts to set up the System: define its objectives, target population, domains and indicators, and sources of information; perform data analysis; implement and disseminate the system; define the evaluation; and perform regular data updates. RESULTS: The System considers the following domains: social determinants of health, health-related with behaviours, use of healthcare, and health outcomes, and includes eight indicators. As axes of inequality, the experts chose sex, age, social class, country of origin, and geographical area. The Surveillance System for Social Health Inequalities is presented on a website including different types of figures. CONCLUSION: The methodology used to implement the Surveillance System can be used to implement similar systems in other urban areas around the world.

Social inequalities in utilization of a feminist telehealth abortion service in Brazil: A multilevel analysis.

The disruption caused by the COVID-19 pandemic on health services around the world boosted interest over telehealth models of care. In Brazil, where abortion is heavily restricted, abortion seekers have long relied on international telehealth services to access abortion pills. We conducted a cross-sectional multilevel study to assess the effect of individual and contextual social factors on utilization of one such service. For the individual-level, we analyzed data from the records of abortion seekers contacting this feminist international telehealth organization during 2019 (n = 25,920). Individual-level variables were age, race, education level and pregnancy length. Contextual-level units were states, for which we used data from the national Demographic Census and Household Surveys. Contextual-level variables were household income per capita, adjusted net school attendance rate, percentage of racialized women and income Gini Index. We fitted five multilevel Poisson Mixed-effects models with robust variance to estimate prevalence ratios (PR) of service utilization, which was defined as receiving abortion pills through the service. We found that only 8.2% of requesters got abortion pills through the service. Utilization was higher among women who were older, white, more educated and 5-8-weeks pregnant. Independently of this, service utilization was higher in states with higher income and education access, with lower proportions of racialized women, and located in the South, Southeast and Central-West regions. We concluded that while feminist telehealth abortion initiatives provide a life-saving service for some abortion seekers, they are not fully equipped to overcome entrenched social inequalities in their utilization, both at individual and contextual levels.

Climate Change and Health in Urban Areas with a Mediterranean Climate: A Conceptual Framework with a Social and Climate Justice Approach.

The consequences of climate change are becoming increasingly evident and highlight the important interdependence between the well-being of people and ecosystems. Although climate change is a global phenomenon, its causes and consequences vary dramatically across territories and population groups. Among settings particularly susceptible to health impacts from climate change are cities with a Mediterranean climate. Here, impacts will put additional pressure on already-stressed ecosystems and vulnerable economies and societies, increasing health inequalities. Therefore, this article presents and discusses a conceptual framework for understanding the complex relationship between climate change and health in the context of cities with Mediterranean climate from a social and climate justice approach. The different elements that integrate the conceptual framework are: (1) the determinants of climate change; (2) its environmental and social consequences; (3) its direct and indirect impacts on health; and (4) the role of mitigation and adaptation policies. The model places special emphasis on the associated social and health inequalities through (1) the recognition of the role of systems of privilege and oppression; (2) the distinction between structural and intermediate determinants of climate change at the root of health inequalities; (3) the role of individual and collective vulnerability in mediating the effects of climate change on health; and (4) the need to act from a climate justice perspective to reverse health inequities.

Tackling health inequalities in a public health organization: the case of the Barcelona Public Health Agency.

BACKGROUND: Municipalities are important actors in the implementation of policies to tackle health inequalities, which requires political will, the availability of financial support, and technical and human resources. With the aim of aligning with local government political priorities, in 2017 the Barcelona Public Health Agency (Agència de Salut Pública de Barcelona, henceforth ASPB), which is responsible for the public health functions of the city, launched a strategy to improve the approach to tackling health inequalities in all its services. The objectives of this study were to show how social health inequalities were addressed in the ASPB from 2017 to 19 and to describe which actions were proposed after a participatory process aiming to create a plan to systematically incorporate health inequalities in ASPB actions. METHODS: The ASPB has 304 workers, 8 directors and 20 services or departments. Participatory methodologies were carried out: 1) semi-structured interviews with department heads (N = 12, 60%); 2) world cafe workshops open to a group of workers (N = 63, 37%); 3) a Quick and Colorful voting session open to a group of workers (N = 108, 63%); and 4) Hanlon matrix with 19 actions to be prioritized (N = 12 services, 60%). RESULTS: Semi-structured interviews and world cafe workshops provided 40 potential actions. After a step by step process of participatory prioritization, seven lines of action emerged: 1) to make progress in collaborative networking; 2) to promote policy evaluation; 3) to increase the ability of the ASPB to evaluate policies to reduce health inequalities; 4) to incorporate the axes of inequalities in all ASPB products; 5) to improve information on vulnerable groups; 6) to incorporate the gender perspective; and 7) to participate in an internal training plan to address health inequalities. CONCLUSIONS: The participation of ASPB public health professionals and staff allowed the organization to design a shared plan of actions to address health inequalities. This experience could be useful for other municipalities whose political agendas include tackling inequalities in health.

[Socioeconomic inequalities and COVID-19 in Spain. SESPAS Report 2022]. / Desigualdades socioeconómicas y COVID-19 en España. Informe SESPAS 2022.

The COVID-19 pandemic has shown its syndemic nature where the contagion by coronavirus joins the high prevalence of chronic diseases in a context of great social inequality and a clear gradient of those pathologies. The objectives of this article are: 1) to show a conceptual framework of the determinants of social inequality in the COVID-19; 2) to review the available literature on socioeconomic inequalities in various aspects related to COVID-19 in Spain; and 3) propose recommendations to monitor, intervene with policies and communication guides to reduce social inequalities in COVID-19, showing examples developed in Spain. The conceptual framework includes structural and intermediate determinants reflecting the different axes of inequality that characterize the syndemic nature of COVID-19. The literature review published up to July 2021 in Spain describes a socioeconomic gradient of COVID-19, not always consistent among studies, as well as an uneven impact of many measures to control the pandemic. Finally, the proposals for reducing social inequalities in COVID-19 include: 1) to guarantee information systems and research with an equity perspective; 2) to reduce inequalities in COVID-19 through its intermediate, and economic and political determinants; and 3) to design communication models and understanding frameworks that break with hegemonies that hide the relevance of social inequality in the pandemic. Given the syndemic nature of COVID-19 and accumulated knowledge, surveillance systems, interventions and communication must include a clear perspective of health equity.

Monitoring Health Inequalities in 12 European Countries: Lessons Learned from the Joint Action Health Equity Europe.

To raise awareness about health inequalities, a well-functioning health inequality monitoring system (HIMS) is crucial. Drawing on work conducted under the Joint Action Health Equity Europe, the aim of this paper is to illustrate the strengths and weaknesses in current health inequality monitoring based on lessons learned from 12 European countries and to discuss what can be done to strengthen their capacities. Fifty-five statements were used to collect information about the status of the capacities at different steps of the monitoring process. The results indicate that the preconditions for monitoring vary greatly between countries. The availability and quality of data are generally regarded as strong, as is the ability to disaggregate data by age and gender. Regarded as poorer is the ability to disaggregate data by socioeconomic factors, such as education and income, or by other measures of social position, such as ethnicity. Few countries have a proper health inequality monitoring strategy in place and, where in place, it is often regarded as poorly up to date with policymakers' needs. These findings suggest that non-data-related issues might be overlooked aspects of health inequality monitoring. Structures for stakeholder involvement and communication that attracts attention from policymakers are examples of aspects that deserve more effort.

Neighbourhood income inequalities in mental health in Barcelona 2001-2016: a Bayesian smoothed estimate.

OBJECTIVE: Obtaining reliable health estimates at the small area level (such as neighbourhoods) using survey data usually poses the problem of small sample sizes. To overcome this limitation, we explored smoothing techniques in order to estimate poor mental health prevalence at the neighbourhood level and analyse its profile by income in Barcelona city (Spain). METHOD: A Bayesian smoothing model with a logit-normal transformation was applied to four repeated cross-sectional waves of the Barcelona health survey for 2001, 2006, 2011 and 2016. Mental health status was identified from the 12-item General Health Questionnaire. Income inequalities were analysed with neighbourhood income in quantiles for each year and trends in the pooled analysis. RESULTS: The prevalence of poor mental health ranged from 14.6% in 2001 to 18.9% in 2016. The yearly difference between neighbourhoods was 12.4% in 2001, 16.7% in 2006, 14.2% in 2011, and 20.0% in 2016. The odds ratio and 95% credible interval (95%CI) of experiencing poor mental health was 1.40 times higher (95%CI: 1.02-1.91) in less advantaged neighbourhoods than in more advantaged neighbourhoods in 2001, 1.61 times higher (95%CI: 1.01-2.59) in 2006 and 2.31 times higher (95%CI: 1.57-3.40) in 2016. CONCLUSIONS: This study shows that the Bayesian smoothed techniques allows detection of inequalities in health in neighbourhoods and monitoring of interventions against them. In Barcelona, mental health problems are more prevalent in low-income neighbourhoods and raised in 2016.

Gender-based inequalities in the effects of housing on health: A critical review.

Gender and its power relations are produced and reproduced in the housing sphere, leading to inequalities in living conditions and, therefore, in gender inequalities in health outcomes. The aim of the study is to review the published literature on gender, housing and health, to critically evaluate the incorporation of the gender perspective, and to incorporate this perspective into the conceptual framework of housing and health. Using the critical review method, we conducted a literature review in MEDLINE, Scopus, WOS and Redalyc, without restriction of publication date, including studies published up to October 2020. We analyzed the gender perspective in health research using the Gender Perspective in Health Research Questionnaire and described the results according to main housing dimensions. Of the 20,988 articles identified, we selected 90 for full-text analysis, of which 18 were included in the feminist research category, 27 in gender-sensitive, 31 in sex difference and 14 did not include any gender perspective. Regarding the association between housing and health, most studies analyzed affordability (36%) and physical conditions (32%), and trends in health outcomes by gender varied according to each exposure analyzed, although overall the effects were worse for women and non-binary or trans people. To date, very few studies consider the gender perspective. It is urgent to address gender relations in housing and health studies, and to open an interdisciplinary and intersectoral agenda to address this complex relationship.

Housing Insecurity and Mental Health: the Effect of Housing Tenure and the Coexistence of Life Insecurities.

While the adverse effects of housing insecurity on mental health are known, much less is known about the modifiers underlying these effects. The aim of this study was to analyze the mental health of people with housing insecurity by housing tenure and considering the coexistence of other life insecurities (energy poverty and food insecurity). We conducted a cross-sectional study through a survey performed in all people attending the Platform for People Affected by Mortgages or the Alliance against Energy Poverty of Barcelona for the first time between June 2017 and December 2019 and who reported housing insecurity. The dependent variables were the risk of poor mental health, self-reported anxiety and/or depression, and the use of psychotropic drugs. We fitted age-adjusted robust Poisson regression models for each dependent variable and estimated adjusted prevalence ratios (aPR). The study included 256 women and 104 men. The prevalence of poor mental health was 89% in women and 85.3% in men, which was much higher than that in the general population of Barcelona (19.5% and 14.5%, respectively). Among women, mental health was worse in those living in a squat (aPR 1.16; 95% CI: 1.02-1.31) and in those with food insecurity (aPR 1.11; 95% CI: 1.01-1.21). The number of coexisting insecurities showed a gradient effect (3 insecurities: aPR 1.21; 95% CI: 1.01-1.45). Among men, the results showed no clear pattern. Poor mental health was highly prevalent in people with housing insecurity and was exacerbated by the coexistence of life insecurities. Public policymakers should consider the complexity of persons with housing insecurity.

Inequalities in life expectancy by educational level and its decomposition in Barcelona, 2004-2018.

OBJECTIVE: To analyse the gap in life expectancy by educational level in the city of Barcelona from 2004 to 2018 and to decompose this gap by age and causes of death. METHOD: We computed abridged life tables at the age of 25 years by sex from 2004 to 2018 using standard methods. Educational level was categorised in two groups (lower secondary or less vs. upper secondary or higher education). The life expectancy gap was further decomposed by age and by causes of death based in Arriaga's method in 5-year age blocks up to the age of ≥ 90 years and broad causes of death using ICD-10 codes. RESULTS: The life expectancy gap at 25 years by educational level oscillated without trend at around 3.08 years for men and 1.93 years for women. Decomposition by age showed a favourable significant shift in the contribution to this gap from young to older ages for men, with few changes for women. Decomposition by causes of death showed that the diseases concentrating the largest share of the contribution were neoplasms and respiratory and circulatory disease. There was a significant downward trend in external causes for men and in infectious diseases for both men and women but a significant upward trend for respiratory disease for both sexes. CONCLUSIONS: The stability of the life expectancy gap by educational level during the period analysed resulted from a combination of divergent trends by age and causes of death among high and low educational levels.

Multi-level policy responses to tackle socioeconomic inequalities in the incidence of COVID-19 in a European urban area.

BACKGROUND: Spain has been hit hard by COVID-19 since March 2020, especially in its metropolitan areas. We share experiences from Barcelona in measuring socioeconomic inequalities in the incidence of COVID-19 in the different waves, and in implementing coordinated and equity-oriented public health policy responses. METHODS: We collected daily data on confirmed COVID-19 cases, geocoded the address of residence to assign each case to one of the 73 neighborhoods and 1068 census tracts, and calculated the cumulative incidence of COVID-19 by neighborhood and five income groups (quintiles of census tracts) by sex across four waves of the pandemic. We adjusted hierarchical Bayesian spatial models to obtain the relative risk (RR) of cumulative incidences in each quintile compared with the richest areas. A variety of public health policies implemented to tackle the pandemic and especially these inequalities in COVID-19 incidence and vaccination are selected and described. RESULTS: Area-level income inequalities in the incidence of COVID-19 were present at different degree in all four waves. In the second wave (10/1/2020 to 12/6/2020), RR for the poorest income quintile census tracts compared with the richest was 1.43 (95% credible interval-CI-: 1.22-1.67) for men and 1.58 (95% CI: 1.35-1.83) for women. Later, inequalities in vaccination coverage also arose. Equity-oriented policy responses included: "health hotels" or home delivery of basic products for individuals with COVID-19 and without adequate conditions for isolation; new emergency facilities for homeless people, including those with active drug use; mass screening in high incidence areas; contingency plans for nursing homes and schools; adapting community health programs for their early reactivation; digital self-appointment support points and community vaccination days. CONCLUSION: COVID-19 hit Barcelona neighborhoods unequally, with variations between waves. The rapid availability of geolocalized data and by socioeconomic level helped public authorities to implement targeted policies and collaborative interventions for the most vulnerable populations. Further studies would be needed to evaluate their impact.

Socioeconomic inequalities in self-assessed health and mental health in Barcelona, 2001-2016.

OBJECTIVE: Previous research has found persistent socioeconomic inequalities in health outcomes at the national level, with different patterns after the economic crisis. However, inequalities in urban areas are also important. This study analyses socioeconomic inequalities in self-assessed health and mental health in the city of Barcelona. METHOD: Repeated cross-sectional design using quinquennial data from the Barcelona Health Surveys carried out in 2001, 2006, 2011 and 2016 for the population older than 22 years. Robust Poisson regressions models were used to compute socioeconomic gradients and relative (RII) and slope indexes of inequality (SII) by occupational social class, with stratification by sex. RII and SII were also obtained with further adjustment by employment situation. RESULTS: A consistent socioeconomic gradient was found for all years except for 2011. Relative and absolute inequalities followed a V-shape, showing a drop during the economic crisis but widening thereafter to recover pre-crisis figures for self-assessed health and widening for mental health, in both relative and absolute terms in 2016. Adjustment for employment situation reduces inequalities but a large part of these inequalities remains, with variability across years. CONCLUSIONS: The lasting effects of the 2008 economic crisis and the austerity programmes imposed since then may have contributed to the persistence of socioeconomic inequalities in self-assessed health and the widening of those for mental health.

Sociodemographic determinants of intraurban variations in COVID-19 incidence: the case of Barcelona.

BACKGROUND: Intraurban sociodemographic risk factors for COVID-19 have yet to be fully understood. We investigated the relationship between COVID-19 incidence and sociodemographic factors in Barcelona at a fine-grained geography. METHODS: This cross-sectional ecological study is based on 10 550 confirmed cases of COVID-19 registered during the first wave in the municipality of Barcelona (population 1.64 million). We considered 16 variables on the demographic structure, urban density, household conditions, socioeconomic status, mobility and health characteristics for 76 geographical units of analysis (neighbourhoods), using a lasso analysis to identify the most relevant variables. We then fitted a multivariate Quasi-Poisson model that explained the COVID-19 incidence by neighbourhood in relation to these variables. RESULTS: Neighbourhoods with: (1) greater population density, (2) an aged population structure, (3) a high presence of nursing homes, (4) high proportions of individuals who left their residential area during lockdown and/or (5) working in health-related occupations were more likely to register a higher number of cases of COVID-19. Conversely, COVID-19 incidence was negatively associated with (6) percentage of residents with post-secondary education and (7) population born in countries with a high Human Development Index. CONCLUSION: Like other historical pandemics, the incidence of COVID-19 is associated with neighbourhood sociodemographic factors with a greater burden faced by already deprived areas. Because urban social and health injustices already existed in those geographical units with higher COVID-19 incidence in Barcelona, the current pandemic is likely to reinforce both health and social inequalities, and urban environmental injustice all together.

Socioeconomic Inequalities in Chronic Liver Diseases and Cirrhosis Mortality in European Urban Areas before and after the Onset of the 2008 Economic Recession.

OBJECTIVE: To analyse the trends in chronic liver diseases and cirrhosis mortality, and the associated socioeconomic inequalities, in nine European cities and urban areas before and after the onset of the 2008 financial crisis. METHODS: This is an ecological study of trends in three periods of time: two before (2000-2003 and 2004-2008), and one after (2009-2014) the onset of the economic crisis. The units of analysis were the geographical areas of nine cities or urban areas in Europe. We analysed chronic liver diseases and cirrhosis standardised mortality ratios, smoothing them with a hierarchical Bayesian model by each city, area, and sex. An ecological regression model was fitted to analyse the trends in socioeconomic inequalities, and included the socioeconomic deprivation index, the period, and their interaction. RESULTS: In general, chronic liver diseases and cirrhosis mortality rates were higher in men than in women. These rates decreased in all cities during the financial crisis, except among men in Athens (rates increased from 8.50 per 100,000 inhabitants during the second period to 9.42 during the third). Socioeconomic inequalities in chronic liver diseases and cirrhosis mortality were found in six cities/metropolitan areas among men, and in four among women. Finally, in the periods studied, such inequalities did not significantly change. However, among men they increased in Turin and Barcelona and among women, several cities had lower inequalities in the third period. CONCLUSIONS: There are geographical socioeconomic inequalities in chronic liver diseases and cirrhosis mortality, mainly among men, that did not change during the 2008 financial crisis. These results should be monitored in the long term.

The Association of Energy Poverty with Health and Wellbeing in Children in a Mediterranean City.

Children have been identified as being particularly vulnerable to energy poverty (EP), but little empirical research has addressed the effect of EP on children's health and wellbeing, especially in southern Europe. In this work we aimed to provide an in-depth description of the distribution of EP by sociodemographic, socioeconomic and housing characteristics, as well as to analyse the association between EP and health and wellbeing in children in Barcelona. We performed a cross-sectional study using data from the Barcelona Health Survey for 2016 (n = 481 children under 15 years). We analysed the association between EP and health outcomes through prevalence differences and prevalence ratios (PR) and their 95% confidence interval (CI), using Poisson regression models with robust variance. In Barcelona, 10.6% of children were living in EP and large inequalities were found by sociodemographic, socioeconomic and housing characteristics. EP was strongly associated with poor health in children (PR (95% CI): 7.70 (2.86, 20.72)). Living in EP was also associated with poor mental health (PR (95% CI): 2.46 (1.21, 4.99)) and with more cases of asthma (PR (95% CI): 4.19 (1.47, 11.90)) and overweight (PR (95% CI): 1.50 (1.05, 2.15)) in children. It is urgent to develop specific measures to avoid such serious and unfair health effects on children.

"No one should be alone in living this process": trajectories, experiences and user's perceptions about quality of abortion care in a telehealth service in Chile.

Self-managed abortion is a common self-care practice that enables pregnant people to exercise their rights to health, bodily autonomy and to benefit from the advances of science even when living in contexts that do not guarantee these rights. In this interpretative qualitative study, we aimed to understand women's abortion trajectories, experiences with self-managed abortion and assessments of the quality of care provided by Women Help Women (WHW, an international activist non-profit organisation working on abortion access). Grounded in feminist epistemology and health inequalities approaches, we conducted eleven semi-structured interviews in Santiago, Chile. We found that illegality, stigma and expectations surrounding motherhood and abortion determined women's experiences. Participants perceived the WHW service as good, trustworthy, fast and affordable, and valued confidentiality and privacy; the quantity and quality of information; having direct, personalised and timely communication with service staff; being treated with respect; and feeling safe, cared for and supported in their decisions. Most participants considered self-managed abortion appropriate and acceptable given their circumstances. Fear was the dominant feeling in women's narratives. Some participants mentioned missing instant communication, in-person support and professional care. We conclude that support, information and company are key to improving abortion seekers' experiences and enabling their decisions, particularly in legally restrictive settings. Centring care in pregnant people's needs and autonomy is fundamental to ensure safe, appropriate and accessible self-care interventions in reproductive health. Social and legal changes, such as public funding for abortion, destigmatisation and decriminalisation, are needed to realise people's right to higher standards of healthcare.