Inequities in the distribution of COVID-19: an adaptation of WHO's conceptual framework / Desigualdades en la distribución de la COVID-19: una adaptación del marco conceptual de la OMS

The COVID-19 pandemic currently affects populations worldwide. Although everyone is susceptible to the virus, there are numerous accounts of the pandemic having a greater impact on lower socioeconomic groups and minorities, which is a ubiquitous phenomenon. It is essential for public health administrations and governments to uncover and understanding these inequities to develop proper intersectoral policies to tackle this crisis. Therefore, developing a conceptual framework on this topic, describing the social mechanisms that explain the unjust distribution of the incidence and mortality of COVID-19, is a key task. The aim of this paper is to adapt the framework on social determinants of health from the World Health Organization to the specifics of COVID-19 pandemic. Thus, it identifies and explains the structural and intermediate determinants involved in this pandemic, and adds some new elements (such as the role of the oppression systems and communication) which may help to understand, and ultimately tackle, social inequities in COVID-19 distribution. (AU)

La pandemia de COVID-19 afecta actualmente a poblaciones de todo el mundo. Aunque todas las personas son susceptibles de contraer la enfermedad, hay numerosos argumentos de que la pandemia tiene un mayor impacto en los grupos socioeconómicos más desfavorecidos y en las minorías, lo que es un fenómeno omnipresente. Es esencial que las Administraciones de salud pública y los gobiernos comprendan las desigualdades para desarrollar políticas intersectoriales adecuadas para hacer frente a esta crisis. Por lo tanto, es clave desarrollar un marco conceptual sobre este tema, que describa los mecanismos sociales que explican la injusta distribución de la incidencia y la mortalidad de la COVID-19. El objetivo de este trabajo es adaptar el marco sobre determinantes sociales de la salud de la Organización Mundial de la Salud a las particularidades de la pandemia de COVID-19, identificar y explicar los determinantes estructurales e intermedios implicados en esta pandemia, así como añadir algunos elementos nuevos (como el papel de los sistemas de opresión y la comunicación) que pueden ayudar a comprender, y en última instancia a abordar, las desigualdades sociales en la distribución de la COVID-19. (AU)

Inequities in the incidence and mortality due to COVID-19 in nursing homes in Barcelona by characteristics of the nursing homes.

BACKGROUND: Residents of Nursing Homes (NHs) have suffered greater impacts from the COVID-19 pandemic. However, the rates of COVID-19 in these institutions are heterogeneously distributed. Describing and understanding the structural, functional, and socioeconomic differences between NHs is extremely important to avoid new outbreaks. OBJECTIVES: Analyze inequalities in the cumulative incidences (CIs) and in the mortality rates (MRs) due to COVID-19 in the NHs of Barcelona based on the characteristics of the NHs. METHODS: Exploratory ecological study of 232 NHs. The dependent variables were the cumulative incidence and mortality rate due to COVID-19 in NHs between March and June 2020. Structural variables of the NHs were evaluated such as neighborhood socioeconomic position (SEP), isolation and sectorization capacity, occupancy, overcrowding and ownership. RESULTS: The cumulative incidence and mortality rate were higher in the low SEP neighborhoods and lower in those of high SEP neighborhoods. Regarding the isolation and sectorization capacity, Type B NHs had a higher risk of becoming infected and dying, while Type C had a lower risk of dying than Type A. Greater overcrowding was associated with greater morbidity and mortality, and higher occupancy was associated with higher incidence. The risk of becoming infected and dying in public NHs was significantly higher than for-profit NH. CONCLUSIONS: The social components together with the functional and infrastructure characteristics of the NHs influence the cumulative incidence and the mortality rate by COVID-19. It is necessary to redefine the care model in the NHs to guarantee the health of the residents.

Neglected housing insecurity and its relationship with renters health: the case of Barcelona, Spain / Inseguridad residencial desatendida y su relación con la salud de personas inquilinas: el caso de Barcelona, España

Objective:To analyze by gender the relationship of forced displacements due to neglected housing insecurity with the physical and mental health of renters in Barcelona in 2019, distinguishing between economic (EHI) and legal (LHI) housing insecurity.Method:We conducted a cross-sectional study based on the Survey of the Living Conditions of Renters in the Barcelona Metropolitan Area 2019 (1021 women; 584 men). Self-reported health and mental well-being were the dependents variables; the main explanatory variable was neglected housing insecurity. We used adjusted robust Poisson regression models to compare health outcomes among people affected by neglected housing insecurity and those who were not affected.Results:We observed that the probability of worse health outcomes are greater in those affected by EHI, followed by those affected by LHI, both compared to those who have not been affected by housing insecurity. This association are mainly observed in mental health of renters affected by EHI, even after adjusting for socioeconomic and other housing variables (in women PR: 1,17, CI95%: 1,03-1,33; in men PR: 1,21, CI95%: 1,01-1,43).Conclusions:Neglected housing insecurity is associated with worse mental health. Enhancing the visibility of neglected housing insecurity and raising awareness of its effects on health is urgently needed to tackle this massive but hidden problem. (AU)

Objetivo:Analizar la relación de la inseguridad residencial desatendida sobre la salud física y mental de personas inquilinas residentes en Barcelona en 2019, distinguiendo entre inseguridad residencial económica (IRE) y legal (IRL).Método:Estudio transversal basado en la Encuesta de Condiciones de Vida de Personas Inquilinas en el Área Metropolitana de Barcelona 2019 (1021 mujeres y 584 hombres). Las variables dependientes fueron salud autopercibida y bienestar mental, y la principal variable explicativa fue inseguridad residencial desatendida. Se utilizaron modelos ajustados de Poisson robusta para comparar los resultados de salud entre personas afectadas y no afectadas.Resultados:La probabilidad de peor salud fue mayor en las personas afectadas por IRE, seguidas por las afectadas por IRL, ambas comparadas con quienes no habían sido afectadas. Esta asociación fue principalmente observada en la salud mental de las personas inquilinas afectadas por IRE, incluso tras ajustar por variables sociodemográficas y otras de vivienda (en mujeres, PR: 1,17, IC95%: 1,03-1,33; en hombres, PR: 1,21, IC95%: 1,01-1,43).Conclusiones:La inseguridad residencial desatendida se asocia con peor salud mental. Se necesita urgentemente visibilizar la inseguridad residencial desatendida y tomar conciencia de sus efectos en la salud para así afrontar este masivo, pero oculto, problema. (AU)

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.

Neglected housing insecurity and its relationship with renters health: the case of Barcelona, Spain.

OBJECTIVE: To analyze by gender the relationship of forced displacements due to neglected housing insecurity with the physical and mental health of renters in Barcelona in 2019, distinguishing between economic (EHI) and legal (LHI) housing insecurity. METHOD: We conducted a cross-sectional study based on the Survey of the Living Conditions of Renters in the Barcelona Metropolitan Area 2019 (1021 women; 584 men). Self-reported health and mental well-being were the dependents variables; the main explanatory variable was neglected housing insecurity. We used adjusted robust Poisson regression models to compare health outcomes among people affected by neglected housing insecurity and those who were not affected. RESULTS: We observed that the probability of worse health outcomes are greater in those affected by EHI, followed by those affected by LHI, both compared to those who have not been affected by housing insecurity. This association are mainly observed in mental health of renters affected by EHI, even after adjusting for socioeconomic and other housing variables (in women PR: 1,17, CI95%: 1,03-1,33; in men PR: 1,21, CI95%: 1,01-1,43). CONCLUSIONS: Neglected housing insecurity is associated with worse mental health. Enhancing the visibility of neglected housing insecurity and raising awareness of its effects on health is urgently needed to tackle this massive but hidden problem.

Inequities in the distribution of COVID-19: an adaptation of WHO's conceptual framework.

The COVID-19 pandemic currently affects populations worldwide. Although everyone is susceptible to the virus, there are numerous accounts of the pandemic having a greater impact on lower socioeconomic groups and minorities, which is a ubiquitous phenomenon. It is essential for public health administrations and governments to uncover and understanding these inequities to develop proper intersectoral policies to tackle this crisis. Therefore, developing a conceptual framework on this topic, describing the social mechanisms that explain the unjust distribution of the incidence and mortality of COVID-19, is a key task. The aim of this paper is to adapt the framework on social determinants of health from the World Health Organization to the specifics of COVID-19 pandemic. Thus, it identifies and explains the structural and intermediate determinants involved in this pandemic, and adds some new elements (such as the role of the oppression systems and communication) which may help to understand, and ultimately tackle, social inequities in COVID-19 distribution.

Health Effects of Housing Insecurity and Unaffordability in the General Population in Barcelona, Spain.

While the negative effects of housing insecurity and unaffordability on health are well known, most of the studies in Spain have focused on very specific social groups so their findings cannot be extrapolated to the general population. The aim of this study is to assess the effects of housing stress and risk of displacement due to economic reasons, and their combined effect, on the mental and physical health of the general population from a middle-income neighborhood of Barcelona. We conducted a cross-sectional study using a household health survey which included respondents from a representative sample of 1202 non-institutionalized residents (> 18 years old) of the Horta neighborhood. We carried out a descriptive analysis, estimated the prevalence of poor mental and self-rated health (stratifying by the independent variables) and fitted robust Poisson regression models to estimate the effects of housing stress (HS) and the risk of forced displacement (RD) on self-rated health and mental health (GHQ-12). All analyses were stratified by sex. We found a higher likelihood of poor general and mental health among people affected by HS and/or RD compared to those not affected by HS and/or RD. A graded effect of HS and RD emerged mainly on mental health, even after adjusting by socioeconomic variables and housing tenure. The serious problem of housing insecurity and unaffordability in Spain is a widespread public health issue. Evidence-based public policies to improve well-being and health of people under this threat are urgently needed.

¿Cómo influye la situación laboral en los efectos de la inseguridad residencial sobre la salud? / How does employment status influence the effects of residential insecurity on health?

OBJETIVO: Analizar los efectos de la inseguridad residencial sobre la salud y si estos son modificados por la situación laboral en personas participantes en el programa Treball als Barris, en Barcelona, entre 2015 y 2016. MÉTODO: Se realizó un estudio longitudinal con 469 personas a las cuales se les realizó una encuesta, basal y al año de seguimiento, que incluyó información sociodemográfica, residencial, laboral y de salud. Se construyó una variable de trayectorias residenciales con las situaciones al inicio y después del seguimiento. Luego se realizó un análisis descriptivo, se ajustaron modelos de regresión para estimar el efecto de la inseguridad residencial y de la situación laboral sobre la salud, y finalmente se analizó la interacción. RESULTADOS: La inseguridad residencial afectó principalmente la salud de las mujeres (la razón de prevalencia [RP] de mala salud percibida de quienes se mantuvieron en inseguridad residencial fue de 2,29, con un intervalo de confianza del 95% [IC95%] de 1,36-3,84, en comparación con quienes se mantuvieron en seguridad residencial), mientras que en los hombres fue la situación laboral la que tuvo efectos significativos sobre la salud (los desempleados sin subsidio ni prestación presentaron RP de mala salud percibida de 3,16, con IC95% de 1,02-6,15, comparados con quienes trabajaban). Además, parece existir una interacción de la inseguridad residencial y la situación laboral en los efectos sobre la salud mental de los hombres. CONCLUSIÓN: La inseguridad residencial es un fenómeno que se ha intensificado en los últimos años, tiene efectos negativos sobre la salud y podría interactuar con otros determinantes sociales, como el empleo, fundamentalmente en la salud mental de los hombres

OBJECTIVE: This study aims to analyse the effects of housing insecurity on health and whether they are modified by employment status of people belonging to the Treball als Barris programme in Barcelona (Spain) between 2015 and 2016. METHOD: We conducted a longitudinal study using a survey which included sociodemographic, employment and housing status information. This was administered to 469 individuals at baseline and after one year of follow-up. We then carried out a descriptive analysis and fitted regression models to estimate the effects of housing insecurity and employment status on health, and the interaction between them. RESULTS: Among women, we found negative effects of housing insecurity on health (the prevalence ratio [PR] of poor self-reported health among women with housing insecurity was 2.29, with a 95% confidence interval [95%CI] of 1.36-3.84, compared to those in secure housing), while, among men, the main effects on health were due to employment status (PR of poor self-reported health among men who were unemployed without subsidy was 3.16 [95%CI: 1.02-6.15] compared to those who were employed after follow-up). In addition, the results suggest an interaction between housing and employment status on mental health among men. CONCLUSION: Housing insecurity rates have increased in recent years. It produces negative effects on health and can interact with other social determinants such as employment, mainly on men's mental health

[How does the employment status influence the effects of residential insecurity on health?] / ¿Cómo influye la situación laboral en los efectos de la inseguridad residencial sobre la salud?

OBJECTIVE: This study aims to analyze the effects of housing insecurity on health and if those are modified by employment status of people belonging to "Treball als Barris" program in Barcelona between 2015 and 2016. METHODS: We conducted a longitudinal study using a survey which included sociodemographic, employment and housing status information. This was administered to 469 individuals attended by "Treball als Barris" at baseline and after one year of follow-up. Then, we carried out a descriptive analysis and fitted regression models to estimate the effects of housing insecurity and employment status on health, and the interaction between them. RESULTS: Among women, we found negative effects of housing insecurity on health (PR of poor self-reported health among women who stayed under housing insecurity was 2.29 [IC95%: 1.36-3.84] compared to those who stayed secured), while, among men, main effects on health were due to employment status (PR of poor self-reported health among men who were unemployed without subsidy was 3.16 [IC95%: 1.02-6.15] compared to those who were employed after follow-up). In addition, results suggest an interaction between housing and employment status on mental health among. DISCUSSION: Housing insecurity rates have increased in last years. It produces negatives effects on health and can interact with other social determinants such as employment, mainly on men's mental health.

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.

Our lives in boxes: perceived community mediators between housing insecurity and health using a PHOTOVOICE approach.

BACKGROUND: While the negative effects of housing insecurity on health are well known, the mechanisms and mediators of these effects have been less well studied. The aim of this study is to identify perceived mediators involved in the relationship between housing insecurity and health. METHODS: We used a participatory action research approach, the Photovoice methodology. It promotes a reflective process where participants critically discuss housing insecurity and human health and make recommendations to find solutions for the issues identified. This study was conducted with 18 members of the Platform for People Affected by Mortgages who were living in a situation of housing insecurity in Barcelona during the first half of 2017. RESULTS: Participants took 990 photographs, of which 147 were printed for analysis in discussion sessions. 109 of these photographs were then selected for categorization by the participants. 11 major categories emerged, representing various factors related to housing insecurity and health. Most categories were acknowledged as possible mediators of the housing/health problem, including: psychological changes; housing-related material aspects; health-related behaviors; eviction; harassment by financial institutions; and family, neighbors and social network. Others were considered as modifiers that could alter the effects of housing insecurity on health. Co-existing determinants may interact with housing insecurity, thereby increasing negative effects on health. CONCLUSIONS: Through this participatory approach, the Photovoice project gives insight into the mechanisms underlying the relationship between housing insecurity and human health, and provides valuable recommendations to combat this serious public health issue.

The threat of home eviction and its effects on health through the equity lens: A systematic review.

The aims of this review are to gather and systematize the currently available evidence on the effect of the threat of eviction on health and its eventual spillover effects, to assess the quality of the selected studies, and to describe how these findings vary with respect to dimensions of social inequity. We conducted a literature search in March 2016, which yielded 2208 unduplicated articles. The title, abstract and full text of these articles were reviewed by three independent pairs of researchers. We performed a quality assessment of each article, and evaluated whether health inequities had been considered. We selected 47 articles for this review, of which 86% were from Anglo-Saxon countries (mainly the US), and 75% were published after 2009. Most studies used either a cross-sectional (32%), cohort (28%), or qualitative (17%) design. The majority (55%) assessed mental health as a key health indicator, and a notable proportion assessed physical health (38%) and health-related behaviours (19%). Many of the studies evaluated more than one of these health indicators. The average quality score was 7.4 (SD = 1.5). Evidence from these selected articles revealed a general consensus that individuals under threat of eviction present negative health outcomes, both mental (e.g. depression, anxiety, psychological distress, and suicides) and physical (poor self-reported health, high blood pressure and child maltreatment). However, the distribution and extent of these outcomes depend on inequity dimensions such as gender, age, ethnicity and territory. Furthermore, qualitative studies highlighted some of the pathways that may connect the threat of eviction with its health outcomes. The threat of eviction will likely continue to be a major issue in the coming years, so it is important to conduct further research to create effective interventions and courageous policies to tackle this problem.

Housing Policies and Health Inequalities.

A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. The aim of this paper is to summarize the research on the impact of local housing policies on health inequalities, focusing on the issues of access to housing and fuel poverty as studied in the SOPHIE project. Our case studies in Spain showed that people facing housing insecurity, experienced intense levels of mental distress. We found that access to secure and adequate housing can improve the health of these populations, therefore, public policies that address housing instability and their consequences are urgently needed. Housing conditions related to fuel poverty are associated with poorer health and are unevenly distributed across Europe. We found possible positive effects of façade insulation interventions on cold-related mortality in women living in social housing; but not in men. Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, target the most vulnerable groups and be adaptable to their needs.

Los desahucios y la salud, se necesita una respuesta desde la salud pública en España / Evictions and health, a response from the public health in Spain is needed

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Foreclosure and Health in Southern Europe: Results from the Platform for People Affected by Mortgages.

Housing instability has been shown to be related to poorer health outcomes in various studies, mainly in the USA and UK. Affected individuals are more prone to psychiatric (e.g., major depression, anxiety) and physical disorders (e.g., hypertension). This situation has deteriorated with the onset of the economic crisis. One of the most affected countries is Spain, which has high rates of foreclosure and eviction that continue to rise. In response, a civil movement, The Platform for People Affected by Mortgages (PAH), works to provide solutions to its members affected by foreclosure and advocates for the right to decent housing. The aims of this study ware to describe and compare the health status of PAH members from Catalonia to a sample of the general population and to analyze the association between health status and mortgage status, foreclosure stage, and other socioeconomic variables, among members of the PAH. We conducted a cross-sectional study using a self-administered online questionnaire (2014) administered to 905 PAH members in Catalonia (>18 years; 559 women and 346 men). Results were compared with health indicators from The Health Survey of Catalonia 2013 (n = 4830). The dependent variables were poor mental health (GHQ 12 ≥ 3), and poor self-reported health (fair or poor). All analyses were stratified by sex. We computed age-standardized prevalence and prevalence ratios of poor mental and self-reported health in both samples. We also analyzed health outcomes among PAH members according to mortgage status (mortgage holders or guarantors), stage of foreclosure, and other socioeconomic variables by computing prevalence ratios from robust Poisson regression models. The prevalence of poor mental health among PAH members was 90.6 % in women and 84.4 % in men, and 15.5 and 10.2 % in the general population, respectively. The prevalence of poor self-reported health was 55.6 % in women and 39.4 % in men from the PAH, and 19.2 and 16.1 % in the general population, respectively. These health inequalities were independent of socioeconomic status. The prevalence of poor mental health was higher among individuals in the non-payment stage of foreclosure than among those who were up to date with their payments (e.g., PRc = 1.16 [95 % CI 1.04-1.28]). In contrast, self-reported poor health was more prominent in later stages of foreclosure, such as in post-eviction without dation in payment stage in men (PRc = 2.24 [95 %CI = 1.35-3.72]). We observed a considerably higher prevalence of poor mental and self-reported health among male and female PAH members than in the general population. Public policies that tackle housing instability and its consequences are urgently needed in Spain.