Gac Sanit. 2021;35(3):282–288 Special article Barcelona Salut als Barris: Twelve years’ experience of tackling social health inequalities through community-based interventions Ferran Daban a,b,c,∗ , M. Isabel Pasarín a,b,c,d , Carme Borrell a,b,c,d , Lucía Artazcoz a,b,c,d , Anna Pérez a,b , Ana Fernández a,b,d , Victoria Porthé a,d , Elia Díez a,b,c,d , and the Barcelona Health in the Neighbourhoods Group1 a Agència de Salut Pública de Barcelona, Barcelona, Spain b Institut d’Investigació Biomèdica Sant Pau, Barcelona, Spain c Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain d CIBER de Epidemiología y Salud Pública (CIBERESP), Spain a r t i c l e i n f o a b s t r a c t Article history: Community health can reduce inequalities in health and improve the health of the most disadvantaged Received 9 December 2019 populations. In 2007, Barcelona Salut als Barris (Barcelona Health in the Neighbourhoods) was launched, Accepted 7 February 2020 a community health programme to reduce social inequalities in health. In 2018, this programme reached Available online 9 June 2020 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 main- Keywords: tained during the economic crisis and were tripled when the programme became a political priority in Health the last municipal government. During the 12-year period, partnerships with stakeholders were gener- Community health Health inequalities ally stable and productive. Maximum community participation was obtained in the detection of health Effective interventions 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 inter- ventions 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. © 2020 SESPAS. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Barcelona Salut als Barris: La experiencia de doce años abordando las desigualdades sociales en salud a través de intervenciones comunitarias r e s u m e n Palabras clave: La salud comunitaria puede reducir las inequidades en salud y mejorar la salud de las poblaciones más Salud desfavorecidas. En 2007 se inició Barcelona Salut als Barris (Barcelona Salud en los Barrios), un programa Salud comunitaria de salud comunitaria para reducir las desigualdades sociales en salud. En 2018, el programa alcanzó Desigualdades en salud los 25 barrios más desfavorecidos de la ciudad. Este artículo comparte las lecciones aprendidas tras Intervenciones efectivas 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 ∗ Corresponding author. E-mail address: fdaban@aspb.cat (F. Daban). 1 Barcelona Health in the Neighbourhoods Group: Carles Ariza, Montse Bartroli, Núria Calzada, Catrina Clotas, Neus Ferrer, Irene Garcia-Subirats, Inmaculada González, Olga Juárez, María José López, Marta Olabarria, Laia Palència, Vanessa Puig and Esther Sánchez-Ledesma. https://doi.org/10.1016/j.gaceta.2020.02.007 0213-9111/© 2020 SESPAS. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/). F. Daban et al. / Gac Sanit. 2021;35(3):282–288 283 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. © 2020 SESPAS. Publicado por Elsevier España, S.L.U. Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction research project, BHiN was carried out in two neighbourhoods of Barcelona, and after 3 years, the feasibility and achievements of In the last few decades, social inequalities in health have the community model were assessed with good results.15 Subse- become a priority in public health at the supranational, national quently, the rest of the neighbourhoods benefitted by the Catalonia and local levels.1 In cities, citizen’s health is influenced by the Neighbourhoods Law were progressively included in the BHiN natural and built environments, as well as by socioeconomic strategy, until encompassing all of them in 2015. Since then, other determinants. These social determinants affect citizens’ health neighbourhoods have been incorporated using the Urban Heart by worsening the health of those living in the most underprivi- instrument in Barcelona, a tool that includes 15 health and social leged neighbourhoods.2 Community health has been defined as a determinants-related indicators that allowed identification of the multi-sector and multidisciplinary approach to engage and work neighbourhoods in the city with the worse indicators.28 In 2018, with communities to improve people’s health and quality of life.3 BHiN reached the 25 most disadvantaged neighbourhoods in the Despite the difficulties of evaluating community health, current city.29 data support the idea that such evaluation can be effective in This article aimed to describe some lessons learned about the addressing social inequalities in health4 and can help to improve history of the BHiN strategy after 12 years of collaborative work. health and social support in disadvantaged populations.5–7 Several The article describes the structural aspects of the programme, its community health programmes in urban areas (such as in Glasgow, implementation process and its most relevant health outcomes Rotterdam, and Amsterdam) have been shown to improve health through documentary analysis30 and consensus among all authors. and socioeconomic factors and reduce social inequalities.8–11 In Spain, programmes with this aim have been steadily implemented Structural aspects of the programme in cities and territories, such as Gente Saludable,12 RIU Project,13 COMSALUT Programme14 and Barcelona Salut als Barris (Barcelona The running costs and other implementation related variables Health in the Neighbourhoods).15 Other strategies also promote from 2007 to 2018 are shown in Table 1. BHiN has been imple- health through community participation, such as the mapping mented in the neighbourhoods with the worst Family Available of health assets, aimed at strengthening social networks and Income Index (Fig. 1). This index includes five indicators and reflects facilitating the creation of intersectoral spaces.16,17 In Barcelona, the distribution of the neighbourhood mean family income com- strategies such as the Social Services Community Plan,18 Commu- pared with the city mean.28 During the 12 years of BHiN, three nity Development Plans19 and Barcelona Neighbourhoods Plan,20 different stages can be distinguished, defined by the municipal have created highly important synergies that have reinforced com- government, the economic context and the resources allocated munity health interventions.4,21 to the programme: stage 1 (from 2007 to 2008), stage 2 (from 2009 to 2015), and stage 3 (from 2016 to 2018). In stage 1, the Barcelona Health in the Neighbourhoods programme: programme was funded by a research grant; in stage 2, limited history and context resources were allocated by the Public Health Agency of Barcelona; and in stage 3, the resources were tripled by the new left-wing Barcelona, with a population of 1,620,343 inhabitants,22 is government (Barcelona en Comú) since social inequalities in health organised into 73 neighbourhoods. In 2004, the Catalonia Neigh- became a priority in their political agenda.19,31 This political will bourhoods Law (Law 2/2004) was designed to improve living transformed the programme, generating the following substantial conditions in the most disadvantaged neighbourhoods of Cat- positive changes: a) an increase in the number of neighbourhoods alonia, mainly through town planning interventions.23 A year served; b) an increase in the number and variety of interventions; later, the Health in the Neighbourhoods programme was developed and c) the hiring of 13 new public health professionals (Table 1). by the Catalonian Department of Health to improve the health of These changes improved the coordination between the programme residents of those neighbourhoods benefitted by the Neighbour- and the stakeholders and the generation of a new annual report hoods Law and to reduce social inequalities in health between of process indicators.29 From 2007 to 2018, the programme grew neighbourhoods through community health interventions.24 In progressively, even though the city faced a major economic crisis. Barcelona, this programme was reinforced and called Barcelona The increase of served neighbourhoods, interventions, direct par- Health in the Neighbourhoods (BHiN). BHiN is a community health ticipants and entities was directly proportional to the economic programme carried out in the most disadvantaged neighbourhoods resources allocated to the programme each year (Table 1). of Barcelona to reduce health inequalities between them and the rest of the city. The programme was launched in 2007 with the Description of implementation process of the five co-leadership of: a) the Public Health Agency of Barcelona; b) the programme phases: methodological lessons and concerns institution responsible for health care in the city (Consorci San- itari de Barcelona); and c) the city Council. Nowadays, BHiN is As already stated, BHiN encompasses five phases. The main one of the oldest community health strategies in Spain.25 The strengths and lessons learned in each phase are summarised in programme, based on public health, health promotion and com- Table I in online Appendix. In the first phase, alliances with munity health models;26,27 encompasses five phases: 1) alliances stakeholders remained fairly stable and productive during the 12 with stakeholders; 2) health needs assessment; 3) an action plan; years. The alliances were established at the political, technical 4) monitoring and evaluation; and 5) sustainability (see Table I and community level in each neighbourhood. These characteristics in online Appendix). From 2007-2008, BHiN was partially funded contributed to the sustainability and maturity of the programme by a research grant from the Spanish Ministry of Health. As a and generated effective community-based interventions that were 284 Table 1 Barcelona Health in the Neighbourhoods running costs and other implementation-related variables per year. From 2007 to 2018. STAGE 1 STAGE 2 STAGE 3 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 F. Daban et al. / Gac Sanit. 2021;35(3):282–288 Intervened neighbourhoods (N◦ ) 1 2 6 7 10 10 10 13 13 21a 23b 25c Interventions (N◦ ) 0 17 17 28 28 38 38 46 46 113a 167b 183c Direct participants (N◦ ) NA NA NA 2.043d,e NA 3.192d,h NA NA 4.560d,i 9.961a 11.734b 13.600c Participating entities (N◦ ) NA NA NA NA NA NA 97j NA NA 310a 350b 460c Human resources (D ) 102.267,78 103.390,23 156.784,55 286.087,69 283.316,36 276.953,25 268.284,61 276.953,25 301.076,76 805.703,55 754.173,23 859.138,79 Professionals by category 2 GHk 1 PHTm 2 PHTm 8 PHTm 8 PHTm 8 PHTm 3 HoDl 2 PHNn 6 PHNn 13 PHNn 12 PHNn 13 PHNn 3 HoDl 3 HoDl 3 HoDl 3 HoDl 3 HoDl Interventions budget (D ) 0 40.000 60.000 60.000 60.000 60.000 60.000 60.000 120.000 311.000o 540.000o 630.000o Unemployment rate (%)p 6,7 6,7 12,7 16,9 14,1 17,1 18,1 17,0 13,8 13,3 10,2 9,3 Municipal government Partit Socialista de Catalunya (Social-Democratic Party) Convergencia i Unió (Christian Democrat Party and Liberal) Barcelona en Comú (Left-wing Coalition Party) Total budget (D ) 102.267,78 143.390,23 216.784,55 346.087,69 343.316,36 336.953,25 328.284,61 336.953,25 421.076,76 1.116.703,55 1.294.173,23 1.489.138,79 Evaluation reports of all BHIN: a Report 2016; bReport 2017; cReport 2018 N◦ direct participants according to neighborhoods: dPoble Sec; eRoquetes: fSant Pere-Sta Caterina-La Ribera; gZona Nord; h Barceloneta; iBon Pastor I Baró de Viver (Neighbourhoods evaluation report) j Ferran Daban, Núria Calzada, Maribel Pasarín, Elia Díez, Lucia Artazcoz, Carme Borrell. Summary of activity of Health in the Neighbourhoods, 2013. Barcelona: Agència de Salut Pública de Barcelona, 2013 Professionals by category and % of time dedicated: kResearch grant holder (100%); lHead of Department (33%); mPublic health technician (100%); nPublic health nurse (50%) o Government Measure19 p Unemployment rate in all of Barcelona (Labour Force Survey, 2◦ trimester) http://www.bcn.cat/estadistica/catala/dades/ttreball/epa/epa/patu/evtated.htm NA: Not available F. Daban et al. / Gac Sanit. 2021;35(3):282–288 285 Figure 1. Family Available Income Index in 2017 and first year of BHiN implementation in the neighbourhoods from 2007 to 2018. Compound index that includes five indicators (people aged 25 years or more with university education (%), registered unemployment among people aged 16 to 64 years (%), number of cars per inhabitant, new cars (less than 2 years) with more than 16 Hp (%) and second-hand housing prices).28 . replicated in other neighbourhoods. All five phases were directed b) lack of time for formal evaluation; c) the difficulty of collecting by multidisciplinary and multisectoral working groups. Profes- data from vulnerable groups about sensitive or upsetting topics; d) sionals working on the community development plans usually cultural alignment with different migrant populations with distinct played an important role, leading community networks and con- languages, values and cultural traditions; and e) lack of awareness tributing to building trust within the working group. The second of the importance of evaluation. Despite these difficulties, most phase, health needs assessment, was successfully carried out in interventions were evaluated or are currently in the process of eval- all neighbourhoods. Quantitative and qualitative methods were uation (see Table II in online Appendix). Finally in the fifth phase, combined for data collection, analysis and interpretation. This was the sustainability, was reached after an average of 3 to 5 years of the phase with the highest neighbourhood participation. Commu- collaborative work in each neighbourhood. The increase in human nity organisations and neighbourhood residents participated in the and economic resources was crucial to sustain the programme and design of the qualitative process for the detection of needs and interventions. In this phase, a health needs assessment was carried assets, and subsequently in 1-day meeting group to determine a out again to identify new needs and generate new interventions, list of priorities.32 Later, in the third phase, action plan, commu- with the process thus being iterative and circular (see Table I in nity programmes were implemented to address the selected health online Appendix). priorities. Action plans from 2007 to 2015 were characterised by the design, implementation and evaluation of new interventions. Effectiveness of interventions and health outcomes Whenever possible, the design of the interventions was based on the available evidence and combined with the proposals of the As mentioned above, most interventions were evaluated and working groups. In the last years (2016-2018), the action plan showed positive results and some are currently under assessment was characterised by scaling up and adapting the interventions (see Table II in online Appendix): a) a parenting skills programme to new neighbourhoods, although in neighbourhoods with active improved child-rearing skills and social support among parents, working groups, new interventions were launched that addressed and reduced children’s negative behaviours and parental stress;33 health priorities. This was the phase in which the working group b) a community counselling intervention increased the consistent was most active and motivated, generating more than six inter- use of contraception in participants and reduced adolescent fertil- ventions in some neighbourhoods.30 In contrast, only one or two ity rates in the neighbourhoods included in the programme;34 c) an interventions were carried out in other neighbourhoods for differ- intervention providing weekly outings for elderly people isolated at ent reasons (see Table I in online Appendix). During 2018, in the home due to architectural barriers improved self-rated health and 25 neighbourhoods involved in BHiN, a total of 183 interventions mental health, and reduced participants’ anxiety;35 and d) an occu- were co-produced with more than 460 different agents and more pational training programme for young people increased young than 13,600 participants.29 Not all interventions were different: women’s self-esteem.36 Other interventions showed favourable most were effective interventions carried out in stages 1 and 2 that preliminary results.37,38 Finally, an as example of the evalua- were scaled up to new neighbourhoods from stage three. In the tion process, we are currently evaluating the effectiveness and fourth phase, monitoring and evaluation processes represented a cost-effectiveness of a programme of health schools for older peo- major challenge. The main reasons were: a) professional overload; ple, which provide 22 weekly planned group sessions.39 286 F. Daban et al. / Gac Sanit. 2021;35(3):282–288 Lessons learned: strengths, limitations and barriers interventions; c) lack of time; and d) interventions perceived as not useful to cover the needs of these individuals. Some strategies BHiN is a community health programme that grew progressively are being implemented to reach people who are most in need: a) over a 12-year period. We identified four main strengths: designing the intervention together with these persons; b) trans- lating the information into different languages; and c) increasing • A consistent methodology maintained over time:26,27 the inter- the resources devoted to dissemination. ventions were designed through multisectoral working groups, Regarding evaluation, an important limitation was the small based on prior assessment of health needs and assets and on the sample size of participants per intervention, making it neces- scientific evidence. sary to analyse different years and neighbourhoods together, with • Community work:29 the interventions were implemented all the limitations that this might entail. On some occasions, it through community work and were evaluated. This circular pro- proved difficult to properly explain the importance of evaluation cess progressively improved over the years due to a continued to the other sectors involved, causing resistance to the evaluation intersectoral and community strategy. process. • Political will that led to the growth of economic and human resources:19,31 political commitment in the last 4 years con- tributed very positively to the sustainability and maturity of Challenges BHiN. This support came when the programme already had 8 years of experience, an important factor that helped to increase One of the main challenges of the programme was the sus- its efficiency. tainability of the interventions (see Table I in online Appendix). Interventions that were most likely to be sustained were those The stability of available funds: as the funds allocated to the pro- that had the full involvement of several sectors and those need- gram increased, the served neighbourhoods, interventions, direct ing fewer resources. Strategies to consolidate the sustainability participants, entities and human resources increased. Community of the interventions with higher economic costs implied trans- health programmes need resources to be successfully implemented fer the intervention to other sectors or the direct involvement of and to become an effective strategy to improve health and social other administrations. It is essential that community programmes support in disadvantaged populations. influence the agendas, objectives and plans of different stake- We also identified some limitations and barriers for the imple- holders in the neighbourhood. Another challenge is to guarantee mentation of the programme, such as limited citizen participation that the interventions designed and implemented have an inter- in the working groups. Citizens have usually participated through sectional perspective, that is, that they are culture and gender entities or neighbourhood associations. The main reasons for the sensitive.41 low participation were the schedule of meetings, limited avail- Some of the evaluated interventions showed positive health ability of time, cultural diversity with highly diverse views, and effects in their participants.33–38 It is also known that community lack of motivation (see Table I in online Appendix). Overcoming processes and intersectorial work can improve people’s health and these barriers is crucial as citizen participation can provide knowl- reduce social inequalities in health.7 These effective interventions edge and ideas that can be useful to improve population health.40 have been scaled up to other neighbourhoods in order to expand More inclusive, flexible and motivating community spaces should their effects, and community processes were increased in most of be promoted to broaden participation. the neighbourhoods intervened.29 However, we have not evalu- In some neighbourhoods, the working group was less active in ated the potential effect on health inequalities at the population some phases of the programme, such as health assessment or eval- level. Since there is evidence of the effectiveness of this type of uation, mainly due to lack of time or experience in methodological intervention and their community processes in reducing health aspects (see Table I in online Appendix). To address these barriers inequalities,4,7 in the near future we will evaluate these effects at and promote community health action, the Public Health Agency of the population level in Barcelona city. Barcelona provided training to community agents. In addition, the A series of relevant factors to reduce social inequalities in health Catalonian Department of Health developed the COMSALUT pro- came together in the last few years in Barcelona;31 even so, sus- gramme, to facilitate methodology tools and coaching to primary tained and better collaborative work between agents and sectors, health care teams and public health technicians to boost local com- enhanced technical capacity, higher citizen participation and the munity health.14 It would be beneficial if other sectors that could continuous support of the political sector must be attained to more play a key role in the development of BHiN were to participate in effectively address social health inequalities through community these resources to achieve the full potential of community-based health action. New and sustained relationships must be forged to programmes. Another limitation identified in working groups was promote this collaboration.40 the difficulty of maintaining motivation over time, especially in groups where interventions were delayed or scarce. In addition, in some neighbourhoods, the action plan failed because of a lack Conclusion of communication, lack of time, and conflicts of interest among the members of the working group. In contrast, groups with good BHiN is a good example of a community health programme communication, a tradition of community action, and focused on aiming to tackle health inequalities. The experience of these 12 the common good, generated several interventions and remained years may serve future programmes in other territories with simi- motivated.30 One of the most satisfactory elements of the work- lar objectives. Key factors in its scope and results are political will, ing group members was seeing the interventions and the results strong technical capacity and methodology, economic resources, of their work. Likewise, scheduled renewal of members after some strong partnerships and continued intersectoral and community years could help to promote new ideas and sustain motivation. work. An important objective was to reach and work together with persons most in need (e.g. socially isolated older people, some migrant populations, and long term unemployed people), but this Editor in charge was not always possible. This failure can be explained by several factors: a) lack of motivation; b) lack of information about the C. Álvarez-Dardet. F. Daban et al. / Gac Sanit. 2021;35(3):282–288 287 Authorship contributions 10. Buck D, Gregory S. Improving the public’s health. A resource for local author- ities. London;: First Publ. The Kings’ Fund; 2013. Available at: https://www. kingsfund.org.uk/sites/default/files/field/field publication file/improving-the- F. Daban, C. Borrell, M.I. Pasarín, L. Artazcoz and E. Díez con- publics-health-kingsfund-dec13.pdf. ceived and designed the study and interpreted the data. F. Daban 11. Droomers M, Jongeneel-Grimen B, Kramer D, et al. The impact of intervening and V. Porthé wrote the first draft and analysed and interpreted the in green space in Dutch deprived neighbourhoods on physical activity and gen- eral health: results from the quasi-experimental URBAN40 study. J Epidemiol data. A. Pérez and A. Fernández critically reviewed previous drafts Community Health. 2015;70:147–54. of the manuscript and made substantial intellectual contributions. 12. Esteban-Peña M, Gerechter-Fernández S, Martínez-Simancas AM, et al. Calidad The BHiN group contributed substantially to the drafting and criti- de vida percibida en el programa municipal comunitario de promoción de la salud «Gente saludable». 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