Evaluation of a smoke-free beaches intervention in Barcelona: a quasi-experimental study.

BACKGROUND: We aim to assess the effect of a smoke-free beaches (SFB) intervention in Barcelona on smoking during the 2021 bathing season. METHODS: Quasi-experimental pre-post design (pre-intervention period: 15-28 May; post-intervention period: 29 May-12 September). Based on users' profiles and location, four beaches were assigned to the intervention group (IG) and five to the comparison group (CG). The intervention involved: a mayoral decree (29 May), a communication campaign and beach on-site information. We established two 3 m × 3 m transects per beach from the coastline to the promenade. Trained teams collected smoking-related information in the transects through observations and surveys to beach users. Outcomes are as follows: percentage of people reporting witnessing smoking behaviours the last fortnight and percentage of people observed smoking. We calculated and compared prevalence ratios (PRs) with adjusted Poisson regressions. RESULTS: 3751 interviews (1721 IG; 2030 CG) and 1108 observations (498 IG, 610 CG) were carried out. SFB were associated with a significant reduction in the percentage of people reporting witnessing smoking (IG (pre: 87.2%; post: 49.7%); CG (pre: 86.2%; post: 74.1%); PR (95% CI): 0.7 (0.6 to 0.8)); and in the users observed smoking in the beach (IG (pre: 3.8%; post: 3.0%); CG (pre: 2.3%; post: 9.9%); PR (95% CI): 0.3 (0.3 to 0.4)). Satisfaction scores were 8.3 (IG) and 8.1 (CG) out of 10. CONCLUSION: An SFB intervention is an effective and well-accepted measure to reduce smoking and smokers' visibility. Smoke-free measures should be extended to beaches and other non-regulated outdoor areas.

Neighbourhood income inequalities in mental health in Barcelona 2001-2016: a Bayesian smoothed estimate / Desigualdades de renta por barrios en salud mental en Barcelona 2001-2016: una estimación de alisado bayesiano

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. (AU)

Objetivo: Obtener estimadores de salud en áreas pequeñas (como los barrios) utilizando datos de encuestas supone hacer frente al problema de insuficiente tamaño muestral. Para superar esta limitación exploramos técnicas de alisado con el fin de estimar la prevalencia de mala salud mental a nivel de barrio y analizar su patrón por renta en la ciudad de Barcelona (España). Método: Se aplicó un modelo de alisado bayesiano con transformación logística-normal a cuatro muestras transversales repetidas de la Encuesta de Salud de Barcelona para los años 2001, 2006, 2011 y 2016. La salud mental fue identificada con el Cuestionario General de Salud de 12-items. Las desigualdades de ingreso se analizaron por cuantiles de la renta por barrio para cada año y las tendencias en el análisis conjunto. Resultados: La prevalencia de mala salud mental oscila entre el 14,6% en 2001 y el 18,9% en 2016. La diferencia entre barrios fue del 12,4% en 2001, del 16,7% en 2006, del 14,2% en 2011 y del 20,0% en 2016. La odds ratio y el intervalo creíble al 95% (IC95%) de experimentar mala salud mental fue 1,4 veces superior (IC95%: 1,02-1,91) en los barrios menos aventajados respecto de los más aventajados en 2001, de 1,61 (IC95%: 1,01-2,59) en 2006 y de 2,31 (IC95%: 1,57-3,40) en 2016. Conclusiones: Este estudio muestra que las técnicas de alisado bayesiano permiten la detección de desigualdades en salud a nivel de barrios para su monitorización e intervención con el fin de reducirlas. En Barcelona, los problemas de salud mental son más prevalentes en los barrios de menor renta y se incrementaron en 2016. (AU)

Evaluation of a Community Intervention to Reduce Harmful Alcohol Consumption among Adult Population: A Study Protocol.

Harmful alcohol consumption is shaped by a complex range of structural, social, and individual determinants that interact with inequality axes, which can be addressed at the community level. Under the framework of Barcelona Health in the Neighborhoods, which is a community strategy to reduce health inequalities in Barcelona's most deprived neighborhoods, a community steering group will co-design a multicomponent community intervention. Aims: to assess its effects on: (1) alcohol accessibility, availability, and consumption at the environmental level, and (2) psychosocial and cognitive determinants of harmful alcohol consumption at the individual level. Methods: Quasi-experimental design with a comparison group, and pre- and post-intervention measures. Three Barcelona neighborhoods will be assigned to the intervention or comparison group based on three criteria: healthcare data on alcohol use, socioeconomic characteristics, and population size. The intervention includes activities promoting community mobilization, law enforcement, and communication campaigns in the intervened neighborhoods. Non-participant observations in standardized census sections will be performed in public spaces to collect information on three outcomes: alcohol accessibility, availability, and signs of alcohol consumption. Data collection includes a survey to a sample of 622 subjects to detect differences on these outcomes: risk awareness, knowledge, and self-efficacy about harmful alcohol consumption and drinking patterns. Discussion: This protocol to assess the effects of a multicomponent community intervention on harmful alcohol consumption at the environmental and population level will provide evidence on effective community health interventions and enable informed decisions for policy makers. This protocol could also be used as an implementation guide for studies aimed at reducing harmful drinking in cities with similar characteristics.

Health Inequalities by Sexual Orientation: Results from the 2016-2017 Barcelona Health Survey.

Purpose: The aim of this study was to assess health inequalities by sexual attraction in the 2016-2017 Barcelona population, stratifying by sex. Methods: Data came from the 2016-2017 Barcelona Health Survey, where 3362 adults answered among other instruments the EuroQol-5 dimensions-5 levels (EQ-5D-5L), which measures five dimensions and summarizes health-related quality of life into a single utility index score. To assess health differences by sexual attraction, we constructed Tobit models for the EQ-5D index score and Poisson regression models for the EQ-5D dimensions. Nested models were constructed to examine the mediating role of discrimination and health-related variables. Results: After adjusting for sociodemographic variables, women feeling attraction to more than one sex showed a lower EQ-5D index score (worse health) than those with only other sex attraction (-0.042, p = 0.012), and higher prevalence of problems with mobility, usual activities, and anxiety/depression with the following adjusted prevalence ratios (aPR) and confidence intervals (CIs): 1.79 (95% CI 1.05-3.05), 1.84 (95% CI 1.05-3.21), and 1.76 (95% CI 1.27-2.43). Women feeling attraction only to their same sex also presented higher prevalence of anxiety/depression (aPR = 1.46, CI 95% 1.10-1.92). In contrast, differences were not observed for men. Conclusion: Women, but not men, feeling attraction to more than one sex and only same-sex attraction in Barcelona in 2016-2017 presented worse health than those feeling only other sex attraction, with discrimination playing a mediating role in explaining such inequalities. These results among women indicate the need to develop public health strategies in Barcelona addressed to lesbian and bisexual women, considering the intersection of gender and sexual orientation.

Confidence in a Vaccine against COVID-19 among Registered Nurses in Barcelona, Spain across Two Time Periods.

OBJECTIVE: To report the vaccine hesitancy (VH) for a vaccine against COVID-19 in registered nurses in Barcelona, with measurements taken at two stages, prior to the vaccination campaign and once 75% vaccination coverage had been reached. METHODS: A self-completed online survey was administered in December 2020 and again in July 2021 through the College of Nurses of Barcelona. It measured the prevalence of VH against a government-approved vaccine recommended by their employer, their intention to be vaccinated, perceptions of disease risk and vaccine protection, attitudes and beliefs to vaccination and social norm. Bivariate analysis according to VH and application time are presented. RESULTS: 2430 valid responses were obtained in the first measurement and 2027 in the second. At both times, 86% were women and 69% worked mainly in the public sector. Prior to the vaccine availability, VH was 34.2%, decreasing to 17.9%. Risk perceptions were significantly lower in those with VH compared to non-VH, in all groups studied and at both times, while safety and efficacy perceptions increased in all groups, significantly less in VH. The greatest benefit of the COVID-19 vaccine is perceived by pharmaceutical companies. VH nurses perceived a more hesitant social environment. CONCLUSION: As the vaccination was rolled out, VH in nurses declined, with time improving the confidence in the safety and efficacy of the vaccines. Risk perceptions also decreased over time, except for the perception of severity in HCW where it increased. Trust in institutions impacts trust in vaccines.

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.

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.

Barcelona Salut als Barris: twelve years' experience of tackling social health inequalities through community-based interventions / Barcelona Salut als Barris: la experiencia de doce años abordando las desigualdades sociales en salud a través de intervenciones comunitarias

Community health can reduce inequalities in health and improve the health of the most disadvantaged populations. In 2007, Barcelona Salut als Barris (Barcelona Health in the Neighbourhoods) was launched, a community health programme to reduce social inequalities in health. In 2018, this programme reached the 25 most disadvantaged neighbourhoods of the city. This article shares the lessons learned after 12 years of work. The programme was initially funded by a research grant and the funds were maintained during the economic crisis and were tripled when the programme became a political priority in the last municipal government. During the 12-year period, partnerships with stakeholders were generally stable and productive. Maximum community participation was obtained in the detection of health assets and needs and in action plans. During 2018, Barcelona Salut als Barris worked with more than 460 agents that co-produced 183 interventions involving more than 13,600 people. Most of the interventions assessed showed improvements in the health of participants, which could help to reduce health inequalities. The greatest difficulties were: a) citizen participation, b) the sustainability of working groups over the years, c) conflicts of interest, d) the sustainability of interventions, e) reaching certain minority groups and f) evaluation. The increase in resources in the last period contributed to the maturity and expansion of the programme. Key factors in its scope and results were political will, strong technical capacity and methodology, strong intersectoral partnerships and continued community work. (AU)

La salud comunitaria puede reducir las inequidades en salud y mejorar la salud de las poblaciones más desfavorecidas. En 2007 se inició Barcelona Salut als Barris (Barcelona Salud en los Barrios), un programa de salud comunitaria para reducir las desigualdades sociales en salud. En 2018, el programa alcanzó los 25 barrios más desfavorecidos de la ciudad. Este artículo comparte las lecciones aprendidas tras 12 años de trabajo. Los primeros fondos del programa procedieron de una beca de investigación, se mantuvieron durante la crisis económica y se triplicaron cuando pasó a ser una prioridad política en el último gobierno municipal. Durante estos 12 años, las alianzas con las partes interesadas se mantuvieron, en general, estables y productivas. La máxima participación comunitaria se obtuvo en la detección de activos y necesidades en salud y en los planes de acción. Durante 2018, Barcelona Salut als Barris trabajó con más de 460 agentes que coprodujeron 183 intervenciones en las que participaron más de 13.600 personas. Gran parte de las intervenciones evaluadas mostraron mejoras en la salud de las personas participantes, pudiendo contribuir a la reducción de desigualdades. Las mayores dificultades fueron: a) la participación ciudadana, b) la sostenibilidad de los grupos de trabajo a lo largo de los años, c) los conflictos de intereses, d) la sostenibilidad de las intervenciones, e) acceder a algunos grupos minoritarios y e) la evaluación. El aumento de los recursos del último periodo contribuyó a la madurez y la extensión del programa. La voluntad política, una sólida capacidad técnica y metodológica, consolidadas alianzas intersectoriales y el trabajo comunitario continuado han sido factores clave de su alcance y resultados. (AU)

Vaccine hesitancy among paediatric nurses: Prevalence and associated factors.

OBJECTIVE: This study describes the prevalence of vaccine hesitancy associated with the Catalan systematic childhood vaccination calendar and some related psychosocial determinants among paediatric primary care nurses in Barcelona (Spain). METHODS: Cross-sectional descriptive study. In 2017 we invited the paediatric nurses (N = 165) working in Barcelona public primary health centres with paediatric departments (N = 41) to participate. They answered a questionnaire with sociodemographic and behavioural variables: severity and perceived probability of contracting the diseases of the vaccines in the vaccination schedule; safety and protection offered by each vaccine; and beliefs, social norms, and knowledge about vaccines. Outcome variable was vaccine hesitancy, dichotomized into not hesitant (nurses who would vaccinate their own offspring), and hesitant (including those who would not vaccinate them, those who had doubts and those who would delay the administration of one or more vaccines). We performed bivariate analysis and adjusted logistic regression models. RESULTS: 83% of paediatric nurses (N = 137) agreed to participate. 67.9% had the intention to vaccinate their children of all the vaccines in the systematic schedule. 32.1% of nurses experienced vaccine hesitancy, especially about the HPV (21.9%) and varicella (17.5%) vaccines. The multivariate analysis suggests associations between hesitancy and low perception of the severity of whooping cough (aOR: 3.88; 95%CI:1.32-11.4), low perception of safety of the HPV vaccine (aOR:8.5;95%CI:1.24-57.8), the belief that vaccines are administered too early (aOR:6.09;95%CI:1.98-18.8), and not having children (aOR:4.05;95%CI:1.22-13.3). CONCLUSIONS: Although most paediatric nurses had the intention to vaccinate their own children, almost one-third reported some kind of vaccine hesitancy, mainly related to doubts about HPV and varicella vaccines, as well as some misconceptions. These factors should be addressed to enhance nurses' fundamental role in promoting vaccination to families.

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention / Mejorando la salud mental y el bienestar de las personas mayores aisladas en casa debido a las barreras arquitectónicas: una intervención de salud comunitaria

Objetivos: Explorar los efectos sobre la salud de una intervención de salud comunitaria en personas mayores aisladas en casa debido a problemas de movilidad o a barreras arquitectónicas, identificar las características asociadas y evaluar la satisfacción de las personas participantes. Diseño: Estudio cuasi-experimental antes-después. Emplazamiento: Cinco barrios de baja renta de Barcelona durante 2010-15. Participantes: Se entrevistó a 147 participantes, ≥59 años, antes y 6 meses después de la intervención. Intervención: Equipos de atención primaria, trabajadores sociales, de salud pública y otros agentes comunitarios desarrollaron una intervención que consistía en salidas semanales, facilitadas por voluntarios. Mediciones: Se evalúo la salud autopercibida, la salud mental utilizando la escala GHQ-12 y la calidad de vida mediante la escala EuroQol. La satisfacción se evaluó mediante un conjunto de preguntas. Analizamos los datos previos y posteriores con pruebas de McNemar y modelos de regresión lineal y de Poisson ajustados. Resultados: A los 6 meses, los participantes mostraron mejoras en la salud percibida, en la salud mental y en la reducción de la ansiedad. Las mejoras fueron mayores entre las mujeres, las personas que no habían salido de casa durante ≥4 meses, las de bajo nivel educativo y las que habían realizado ≥9 salidas. La salud percibida (aRR: 1,29 [1,04-1,62]) y las mejoras en salud mental [(β: 2,92 [1,64-4,2]) permanecieron significativas en los modelos multivariados. La satisfacción media fue de 9,3 sobre 10. Conclusión: Esta intervención de salud comunitaria parece mejorar varios resultados de salud en las personas mayores aisladas, especialmente en los grupos más vulnerables. Replicar este tipo de intervención podría funcionar en contextos similares.(AU)

Objectives: To explore the health effects of a community health intervention on older people who are isolated at home due to mobility problems or architectural barriers, to identify associated characteristics and to assess participants’ satisfaction.Design: Quasi-experimental before–after study. Setting: Five low-income neighbourhoods of Barcelona during 2010–15. Participants: 147 participants, aged ≥59, living in isolation due to mobility problems or architectural barriers were interviewed before the intervention and after 6 months. Intervention: Primary Health Care teams, public health and social workers, and other community agents carried out a community health intervention, consisting of weekly outings, facilitated by volunteers. Measurements: We assessed self-rated health, mental health using the General Health Questionnaire (GHQ-12), and quality of life through the EuroQol scale. Satisfaction with the programme was evaluated using a set of questions. We analysed pre and post data with McNemar tests and fitted lineal and Poisson regression models. Results: At 6 months, participants showed improvements in self-rated health and mental health and a reduction of anxiety. Improvements were greater among women, those who had not left home for ≥4 months, those with lower educational level, and those who had made ≥9 outings. Self-rated health [aRR: 1.29(1.04–1.62)] and mental health improvements [β: 2.92(1.64–4.2)] remained significant in the multivariate models. Mean satisfaction was 9.3 out of 10. Conclusion: This community health intervention appears to improve several health outcomes in isolated elderly people, especially among the most vulnerable groups. Replications of this type of intervention could work in similar contexts.(AU)

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention.

OBJECTIVES: To explore the health effects of a community health intervention on older people who are isolated at home due to mobility problems or architectural barriers, to identify associated characteristics and to assess participants' satisfaction. DESIGN: Quasi-experimental before-after study. SETTING: Five low-income neighbourhoods of Barcelona during 2010-15. PARTICIPANTS: 147 participants, aged ≥59, living in isolation due to mobility problems or architectural barriers were interviewed before the intervention and after 6 months. INTERVENTION: Primary Health Care teams, public health and social workers, and other community agents carried out a community health intervention, consisting of weekly outings, facilitated by volunteers. MEASUREMENTS: We assessed self-rated health, mental health using the General Health Questionnaire (GHQ-12), and quality of life through the EuroQol scale. Satisfaction with the programme was evaluated using a set of questions. We analysed pre and post data with McNemar tests and fitted lineal and Poisson regression models. RESULTS: At 6 months, participants showed improvements in self-rated health and mental health and a reduction of anxiety. Improvements were greater among women, those who had not left home for ≥4 months, those with lower educational level, and those who had made ≥9 outings. Self-rated health [aRR: 1.29(1.04-1.62)] and mental health improvements [ß: 2.92(1.64-4.2)] remained significant in the multivariate models. Mean satisfaction was 9.3 out of 10. CONCLUSION: This community health intervention appears to improve several health outcomes in isolated elderly people, especially among the most vulnerable groups. Replications of this type of intervention could work in similar contexts.

Barcelona Salut als Barris: Twelve years' experience of tackling social health inequalities through community-based interventions.

Community health can reduce inequalities in health and improve the health of the most disadvantaged populations. In 2007, Barcelona Salut als Barris (Barcelona Health in the Neighbourhoods) was launched, a community health programme to reduce social inequalities in health. In 2018, this programme reached the 25 most disadvantaged neighbourhoods of the city. This article shares the lessons learned after 12 years of work. The programme was initially funded by a research grant and the funds were maintained during the economic crisis and were tripled when the programme became a political priority in the last municipal government. During the 12-year period, partnerships with stakeholders were generally stable and productive. Maximum community participation was obtained in the detection of health assets and needs and in action plans. During 2018, Barcelona Salut als Barris worked with more than 460 agents that co-produced 183 interventions involving more than 13,600 people. Most of the interventions assessed showed improvements in the health of participants, which could help to reduce health inequalities. The greatest difficulties were: a) citizen participation, b) the sustainability of working groups over the years, c) conflicts of interest, d) the sustainability of interventions, e) reaching certain minority groups and f) evaluation. The increase in resources in the last period contributed to the maturity and expansion of the programme. Key factors in its scope and results were political will, strong technical capacity and methodology, strong intersectoral partnerships and continued community work.

Community-Based Interventions to Reduce Alcohol Consumption and Alcohol-Related Harm in Adults.

Alcohol consumption was associated with 3 million deaths worldwide in 2016. Although community action has proven to be effective and has become a priority area of the global strategy to reduce alcohol consumption, there is a gap in the knowledge of community interventions to reduce alcohol use among adults. This study aims to analyze the evidence on effective community-based interventions to reduce alcohol consumption and harm among adults and to identify their components and underlying theories. Search strategy involved five databases (January 2000-March 2020). We included multicomponent, evaluated, and community interventions addressing to adults in urban settings of high-income countries. Furthermore, two conceptual frameworks were adapted to identify the social determinants of alcohol related harms and modifiable factors through community interventions. The initial search yielded 164 articles. The final sample included eight primary studies. Six of them were effective and shared three components (community mobilization; law enforcement and media campaigns), they combined approaches at individual and environmental levels addressing structural determinants of health and some cultural aspects related to consumption. Health outcomes focused mainly on reducing consumption, modifying patterns and acute effects on health. Few studies addressed social problems arising from harmful consumption. This review has identified several effective community-based interventions to reduce harmful use of alcohol among adults as well as some mechanisms and theories supporting them. It also provides a framework to guide new designs, with potential evidence of factors, as well as possible combinations of methods to improve health at community level across different settings and contexts.

Perceived pathways between tourism gentrification and health: A participatory Photovoice study in the Gòtic neighborhood in Barcelona.

Tourism gentrification is as process of urban change and neighborhoods transformation, according to the needs of affluent visitors, increasing in some global cities. However, the link between tourism gentrification and resident's health is still an understudied topic. Using Photovoice, a participatory action research method, the aim of this study was to identify the perceived pathways that underlie the relationship between tourism gentrification and health among residents of Gòtic neighborhood, in Barcelona. The study was conducted between January 2018 and January 2019. Thirteen residents, recruited from two neighborhood organizations, took photographs of how tourism gentrification of the neighborhood was affecting their health. Participants analyzed and critically discussed their photographs in small group sessions. Through a consensus-building process, participants categorized 35 photographs and identified 7 emerging categories acknowledged as possible pathways between tourism gentrification and health, in Gòtic neighborhood: 1) decline of social networks; 2) loss of identity; 3) environmental changes; 4) pollution; 5) changes in services and stores; 6) property speculation/eviction and; 7) activism by residents. This Photovoice study recognizes important pathways underlying the relationship between tourism gentrification in the Gòtic neighborhood and the health of its residents, by altering the built environment, the social environment or psychological factors. Among them, six pathways were related to negative health outcomes, both physical and mental (respiratory diseases; worse nutrition habits; sleep deprivation; stress, anxiety and depression). 'Activism by residents' was perceived to buffer the negative health effects of living in a touristic area. The study also provides recommendations to tackle this serious urban health issue.

Study Protocol for the Evaluation of the Health Effects of Superblocks in Barcelona: The "Salut Als Carrers" (Health in the Streets) Project.

Superblocks are currently being introduced in Barcelona to respond to the city's scarcity of green spaces and high levels of air pollution, traffic injuries, and sedentariness. The aim is to calm the streets by reducing the number of square meters dedicated to private vehicles and to reclaim part of this public space for people. Salut als Carrers (Health in the Streets) is a project to evaluate the potential environmental and health effects of the superblock model with an equity perspective in Barcelona. This study aims to explain the various interventions implemented in different neighborhoods in Barcelona and the methods that will be used to evaluate them in a quasi-experimental and health impact assessment (HIA) approaches. Given the complexity of the intervention evaluated, the project employs mixed methodologies. Quantitative methods include: (a) a pre-post health survey of 1200 people randomly selected from the municipal register asked about self-perceived health and quality of life, social support, mental health, mobility, physical activity, neighborhood characteristics, and housing; (b) pre-post environmental measurements, mainly of nitrogen dioxide (NO2), particulate matter of less than 10 µm (PM10), and particulate matter of less than 2.5 µm (PM2.5) and black carbon; (c) pre-post environmental walkability measures using the Microscale Audit of Pedestrian Streetscapes (MAPS) tool; (d) use of public space and physical activity levels using the System for Observing Play and Recreation in Communities (SOPARC), a validated observation tool; (e) pre-post traffic injury measures with a comparison group; and (f) the comparison and integration of pre-post assessment with previous HIAs and the improvement of future HIAs. Qualitative studies will be performed to analyze residents' perception of these effects by using: (a) various focus groups according to different participant characteristics who are more or less likely to use the superblocks; and (b) a guerrilla ethnography, which is a method that combines ethnographic observation and semi-structured interviews. This study, which evaluates the impact of an ambitious urban-renewal program on health, will help to assess the effectiveness of public policy in terms of health and health inequalities.

How does a targeted active labour market program impact on the well-being of the unemployed? A concept mapping study on Barcelona "Employment in the Neighbourhoods".

BACKGROUND: The "Employment in the neighbourhoods" program is an innovative, tailor-made Active Labour Market Program that has been implemented in 12 neighbourhoods in Barcelona (Spain). Its goal is to get people from deprived, high-unemployment neighbourhoods back to work. The aim of this study was to describe the effects of the program on participants' quality of life, and identify the mechanisms underlying these effects, according to their own perception and the perception of technical staff who assisted them. METHODS: We used Concept Mapping, a mixed methods approach combining qualitative and quantitative analysis, to develop a conceptual map of the participants' and technical staffs' perceptions about changes in the participants' quality of life. Data collection occurred within the generation and structuring steps where participants brainstormed answers to a focus question, and then rated and sorted the responses. To create maps, we used Concept Systems Incorporated software, which conducted two main forms of analysis, a multidimensional scaling analysis, and a hierarchical cluster analysis. RESULTS: Study participants reported several positive effects on mental health and emotional wellbeing, including self-esteem and empowerment, and considered that this was achieved through strengthened social networks, skills acquisition, emotional coaching, and personalized technical assistance. They also described some negative impacts, mainly related to the labour market situation. We observed marked gender differences in the discourses of program participants. CONCLUSIONS: The results obtained have allowed us to identify different perceived effects and mechanisms by which the "Employment in the Neighbourhoods" Active Labour Market Programme can influence quality of life of participants from the most deprived areas of Barcelona.

Las desigualdades en salud como prioridad política en Barcelona / Health inequalities as a political priority in Barcelona

Existe abundante información e investigaciones sobre las desigualdades en salud en Barcelona, pero este tema no estuvo claramente priorizado en la agenda política. Con la llegada al gobierno de un partido de la nueva izquierda (Barcelona en Comú) en 2015 hubo un impulso importante de la agenda política para reducir las desigualdades, también las de salud. El objetivo de esta revisión es describir el avance realizado respecto a las desigualdades en salud en estos 4 años, sobre todo en los ámbitos donde ha participado la salud pública. Respecto a la evidencia y la comunicación sobre las desigualdades en salud, se presentan los avances en el Informe Anual de Salud de Barcelona y la creación del Observatorio de Salud, Desigualdades e Impactos de las Políticas Municipales. Las políticas que se presentan se refieren a diferentes estrategias municipales, el Plan de Salud, el impulso del programa Barcelona Salud en los Barrios y el Plan para el Abordaje de las Desigualdades en la Agència de Salut Pública de Barcelona. La conjunción de la voluntad política, la capacidad técnica y el impulso de la ciudadanía han facilitado un avance en la ciudad de Barcelona en las políticas para reducir las desigualdades sociales en salud

There is a wealth of information and research on health inequalities in Barcelona, but this issue has not been clearly prioritised on the political agenda. The arrival in government of a new left-wing party (Barcelona en Comú) in 2015, gave an important boost to the political agenda to reduce inequalities and health inequalities. The aim of this review is to describe the progress made in relation to health inequalities in these four years and especially in the areas involving public health. With respect to evidence and communication on health inequalities, the progress made is presented in the Barcelona annual health report and the creation of the Observatory on Health, Inequalities and Impacts of Municipal Policies. The policies presented refer to different municipal strategies, the Health Plan, the promotion of the Barcelona Health in the Neighbourhoods programme and the Plan for Tackling Inequalities in the Barcelona Public Health Agency. The combination of political will, technical capacity and the drive of citizens have facilitated progress in the city of Barcelona in policies to reduce social inequalities in health

Impact of a community contraceptive counselling intervention on adolescent fertility rates: a quasi-experimental study.

BACKGROUND: From 2000 to 2008, in urban areas in Spain, adolescent fertility and abortion rates underwent unprecedented increases, consecutive to intensive immigration from developing countries. To address unmet needs for contraception information and services, a community-based, gender-sensitive and culturally adapted brief counselling intervention (SIRIAN program) was launched in some deprived neighbourhoods with a high proportion of immigrants in Barcelona. Once a randomized controlled trial demonstrated its effectiveness in increasing the use of contraceptives, we aim to examine its population impact on adolescent fertility rates. METHODS: Quasi-experimental study with comparison group, using population data from 2005 to 2016. Five neighbourhoods in the lowest tercile of Disposable Household Income were intervened in 2011-13. The comparison group included the three neighbourhoods which were in the same municipal district and in the lowest Disposable Household Income tercile, and displayed the highest adolescent fertility rates. Generalized linear models were fitted to assess absolute adolescent fertility rates and adjusted by immigrant population between pre-intervention (2005-10) and post-intervention periods (2011-16); Difference in Differences and relative pre-post changes analysis were performed. RESULTS: In 2005-10 the intervention group adolescent fertility rate was 27.90 (per 1000 women 15-19) and 21.84 in the comparison group. In 2011-16 intervention areas experienced great declines (adolescent fertility rate change: - 12.30 (- 12.45 to - 12.21); p < 0.001), while comparison neighbourhoods remained unchanged (adolescent fertility rate change: 1.91 (- 2.25 to 6.07); p = 0.368). A reduction of - 10.97 points (- 13.91 to - 8.03); p < 0.001) is associated to the intervention. CONCLUSION: Adolescent fertility rate significantly declined in the intervention group but remained stable in the comparison group. This quasi-experimental study provide evidence that, in a country with universal health coverage, a community counselling intervention that increases access to contraception, knowledge and sexual health care in hard-to-reach segments of the population can contribute to substantially reduce adolescent fertility rates. Reducing adolescent fertility rates could become a feasible goal in cities with similar conditions.

[Health inequalities as a political priority in Barcelona]. / Las desigualdades en salud como prioridad política en Barcelona.

There is a wealth of information and research on health inequalities in Barcelona, but this issue has not been clearly prioritised on the political agenda. The arrival in government of a new left-wing party (Barcelona en Comú) in 2015, gave an important boost to the political agenda to reduce inequalities and health inequalities. The aim of this review is to describe the progress made in relation to health inequalities in these four years and especially in the areas involving public health. With respect to evidence and communication on health inequalities, the progress made is presented in the Barcelona annual health report and the creation of the Observatory on Health, Inequalities and Impacts of Municipal Policies. The policies presented refer to different municipal strategies, the Health Plan, the promotion of the Barcelona Health in the Neighbourhoods programme and the Plan for Tackling Inequalities in the Barcelona Public Health Agency. The combination of political will, technical capacity and the drive of citizens have facilitated progress in the city of Barcelona in policies to reduce social inequalities in health.

Salud comunitaria confinada: reflexiones y experiencias desde la salud pública local / Confined community health: reflections and experiences from the local public health

Este artículo pretende compartir las reflexiones sobre la acción comunitaria en que la Agència de Salut Pública de Barcelona ha estado involucrada en la emergencia de COVID-19. El trabajo realizado puede ordenarse en tres etapas, frecuentemente solapadas: detectar necesidades o problemas, e informar; contactar con las personas participantes y agentes territoriales para valorar qué hacer y cómo hacerlo; y adaptar las intervenciones a la "nueva normalidad" y generar respuestas con los activos comunitarios a las necesidades detectadas. Los problemas emergentes incluyeron: no poder realizar el confinamiento (por falta de casa, condiciones materiales, vivir en situación de violencia); brecha digital (falta de conocimientos, dispositivos, acceso a Wifi); mayor exposición al COVID-19 en los trabajos esenciales pero precarizados, feminizados y racializados (cuidados, limpieza, alimentación), frecuentes en los barrios en que trabajamos; barreras idiomáticas y culturales para seguir las recomendaciones; pérdida de empleo; ingresos insuficientes para cubrir necesidades básicas; dificultades de conciliación; aislamiento social; y deterioro de la salud emocional provocado por la situación. Durante el proceso, algunas intervenciones se adaptaron para continuar de forma telemática, y se intentaron cubrir las necesidades primarias sobre conocimientos y dispositivos de algunas personas participantes a través de las redes solidarias y recursos existentes. La acción comunitaria en salud, desde una mirada crítica, interseccional y local, mediante trabajo intersectorial y la participación de la comunidad, puede contribuir a: facilitar una respuesta adaptada al contexto en caso de crisis sanitaria y mitigar los efectos derivados de esta crisis económica y social

This paper aims to share the reflections related to the community actions in which the Agència de Salut Pública de Barcelona has been involved during the emergency of COVID-19. The tasks carried out can be arranged in three stages, frequently overlapping: detection of needs and problems; contact with key stakeholders to assess what to do and how to do it; adaptation of the interventions to the "new normal" and generation of new responses. The emerging problems included: not being able to do the confinement (due to homelessness, material conditions, living in a situation of violence); digital gap (lack of knowledge, devices, access to Wifi); greater exposure to COVID-19 in the essential but precarious, feminized and racialized jobs (care, cleaning, food shops) that are the most frequent in the neighborhoods in where we work; language and cultural barriers that preclude to follow recommendations; to lose employment; insufficient income to cover basic needs; social isolation; and the deterioration of emotional health caused by the situation. During the process, some interventions were adapted to be delivered on-line. Solidarity networks and local resources were key to meet basic needs, but also other needs related to lack of digital knowledge or device. Community action in health, from a critical, intersectional and local perspective, and with intersectoral work and community participation, can contribute to: facilitate a contextualized response in the event of a health crisis; mitigate the effects derived from its economic and social crisis