Malmusi et al. International Journal for Equity in Health (2022) 21:28 https://doi.org/10.1186/s12939-022-01628-1 RESEARCH Open Access Multi-level policy responses to tackle socioeconomic inequalities in the incidence of COVID-19 in a European urban area Davide Malmusi1,2, M. Isabel Pasarín2,3,4, Marc Marí‑Dell’Olmo2,3,4, Lucía Artazcoz2,3,4,5, Elia Diez2,3,4,5, Sara Tolosa3, Maica Rodríguez‑Sanz2,3,4, Glòria Pérez2,3,4,5, Conchita Peña‑Gallardo6 and Carme Borrell2,3,4,5* Abstract 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 espe‑ cially 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 emer‑ gency 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 availabil‑ ity 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. Keywords: COVID-19, Inequalities, Public policies, Urban areas Background Spain has been hit hard by the SARS-CoV-2 pandemic, experiencing the largest drop in life expectancy in 2020 *Correspondence: cborrell@aspb.cat in the whole of Europe: 1.6 years [1]. In the first wave, 3 Agència de Salut Pública de Barcelona, Pl. Lesseps 1, 08023 Barcelona, metropolitan areas like Madrid and Barcelona regis- Spain tered very high rates of healthcare system contacts and Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 2 of 11 hospital admissions. The second wave started to emerge 1510). Area socioeconomic status was based on the 2016 early in the summer, driven by a new variant of the virus personal income index at the census tract level [4]. The that later became predominant in Europe. number of residents was obtained from the 2019 Munici- COVID-19 has spread worldwide and across all levels pal census. of society and, as such, has required a population-based We calculated the cumulative incidence of COVID-19 and universal approach, involving various levels of gov- (new cases per 100,000 inhabitants) by neighborhood ernance, such as supranational bodies, country, regional and five income groups (quintiles of census tracts) by sex governments and local governments, and community in the first four waves (see Figs. 2 and 3 for the range of movements. It is at this local level, where specific needs dates). For each sex and wave, we adjusted hierarchical have been identified in all phases of the pandemic. Many Bayesian spatial models proposed by Besag, York, and of them required rapid responses, equalizing access con- Mollié [5–7] including the average income categorized ditions for socially disadvantaged groups to prevent an in quintiles to obtain the relative risk (RR) of cumulative increase in social inequalities in health. COVID-19 has incidences in each quintile compared with the richest shown social inequalities in its incidence, which has been areas as the reference group. reported to be higher in people with lower socioeco- nomic position and in ethnic minorities [2]. Equity‑oriented policy responses to COVID‑19 The city of Barcelona has a long tradition in both the Among a very wide range of local responses to tackle the study of socioeconomic inequalities in health and in the pandemic and its social and economic consequences, we development of policy responses to tackle them at the describe in the Results section nine local interventions local level. It is also a city with large social contrasts, selected by the authors considering the following crite- high levels of poverty in some neighborhoods, and with ria: a) a leading or important collaborative role of public a highly diverse population, with more than a quarter of health services; b) including policies that were either: 1) residents being born abroad and coming from very differ- addressed to specific settings or the general population ent origins [3]. This article aimed to describe the trend in but with an orientation to equity; or (2) directly address- socioeconomic inequalities in the incidence of COVID- ing socioeconomic inequalities or socially deprived pop- 19 in Barcelona across its different waves, and to explain ulations; and/or (3) specifically designed as a response to different multisectoral, equity-oriented policy responses socioeconomic inequalities related to COVID-19. delivered by public health and municipal services. Results Methods Area‑based socioeconomic inequalities in the incidence Area‑based socioeconomic inequalities in the incidence of COVID‑19: the data of COVID‑19 During the four first waves, 104,447 cases of COVID-19 First, we present the surveillance system set up to moni- were diagnosed. The value of the cumulative incidence tor area-based socioeconomic inequalities in the inci- could not be compared in the four waves because the dence of COVID-19. At the start of the pandemic, as periods analyzed did not contain the same days, and in part of COVID-19 surveillance, the Agència de Salut the first wave, PCR tests were insufficient and the cases Pública de Barcelona (ASPB; a consortium between the shown were mainly those of hospitalized persons or municipal and regional governments, in charge of pub- healthcare workers. lic health surveillance, protection and promotion in the Figure 1 shows the average income per person by cen- city) prepared a website showing daily data by age, sex, sus tract, as well as the disposable family income per cap- neighborhood, basic health area, census tract and cen- ita by neighborhood [8]. Figure 2 shows the distribution sus tract income levels (https://​webs.​aspb.​cat/​covid​ of the cumulative incidence of COVID-19 by neighbor- 19ald​iabcn). Here, we present data on Barcelona resi- hood for men and women in the four waves. A general dents (1,674,903 on 6/30/2019), excluding people living pattern of a higher incidence in low-income neighbor- or working in nursing homes because the nursing home hoods can be observed. address does not necessarily reflect the residents’ socio- Figure 3 shows the cumulative incidence by income economic position. However, the system enables identi- quintiles (of census tracts), sex and wave, and the RRs fication of the impact of the pandemic in nursing homes. of this incidence. Inequalities were more pronounced in We collected daily data on confirmed COVID-19 cases the second wave, showing an increasing gradient in the from the Catalan Department of Health. The address of incidence as income decreased. The RR for the poorest residence (> 98% valid addresses) was geocoded to assign income quintile census tracts compared to the richest each case to one of the 73 neighborhoods (median popu- was 1.43 (95% credible interval-CI-: 1.22–1.67) for men lation 21,351) and 1068 census tracts (median population and 1.58 (95% CI: 1.35–1.83) for women. In the third and Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 3 of 11 Fig. 1 Average income per person by census tract (2016) and disposable family income by neighborhood per capita (2017). Source of average income: https://​www.​ine.​es/​prensa/​exper​iment​al_​atlas.​pdf. https://​inesp​ain.​maps.​arcgis.​com/​apps/​Minim​alGal​lery/​index.​html?​appid=​c8b41​b2c47​ 1845a​fbc8f​8eb20​c5438​2e#. Source of disposable income per capita: https://​ajunt​ament.​barce​lona.​cat/​barce​lonae​conom​ia/​ca/​renda-​famil​iar/​ renda-​famil​iar/​distr​ibucio-​terri​torial-​de-​la-​renda-​famil​iar-​dispo​nible-​capita fourth waves, these inequalities tended to decrease. RRs sectorization, isolation and quarantines, training of pro- also showed this pattern and tended to be higher among fessionals or closing some nursing homes. The ASPB led women than men. the development of contingency plans. In June 2020, the board turned into a technical office devoted to COVID Equity‑oriented policy responses to COVID‑19 prevention and surveillance in nursing homes with about In the following subsections and in Table 1, the selected 10 professionals working full- or part-time. Since March nine examples of interventions are described. 2021, the ASPB has been adapting contingency plans to the vaccination phase. The success of this good practice 1. Policies addressed to a specific setting or the general was largely possible due to the strong commitment of the population but with an orientation to equity institutions and the members of the group in a context of extreme complexity. Currently, rethinking the model of nursing homes is on the political agenda. Interventions in nursing homes In Barcelona, as in other European cities, the COVID- Interventions in schools 19 pandemic had a disproportionate effect on nursing In March 13, 2020, schools were closed in Catalonia and homes. As of June 2021, there were 229 nursing homes did not reopen in the 2019–20 school year. Mandatory in Barcelona with 9664 residents and 7400 workers. schooling from 6 to 16 years is one of the main equity- Since March 2020, there have been 5735 confirmed cases promoting public policies, with clear repercussions on (72.4% women). Differences across Spanish regions in the health inequalities [10], and opening schools on a face- incidence of COVID-19 and fatalities in nursing homes to-face basis was considered a high priority objective for have been related to underinvestment and traditionally the 2020–21 academic year, even if the pandemic was not very poor working conditions [9]. under control. In Barcelona, a joint office was created In March 2020 a city-level executive board was created with the main education, health services, public health with the representation of social services, public health and municipal managers and technicians, in order to plan and healthcare services. This group had very frequent in- and coordinate actions to support schools in implement- person and online meetings, which allowed rapid deci- ing measures to control COVID-19 and in maintaining as sions to be taken about difficult issues such as replacing much in-person activity as possible. During the 2020–21 some boards in nursing homes with critical management school year, 15% of classes have been isolated at home or problems concerning COVID-related mortality, relo- quarantined at some point, but school days have been cating residents, public health interventions for correct mostly in-person. Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 4 of 11 Fig. 2 Distribution of cumulative incidence of COVID per 100,000 inhabitants in the neigborhoods for men and women in the four waves. Wave 1: 02/25/2020–07/04/2020 (40 days); wave 2: 10/01/2020–12/06/2020 (67 days); wave 3: 12/07/2020–03/14/2021 (98 days); wave 4: 03/14/2021– 05/31/2021 (78 days) Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 5 of 11 Fig. 3 Cumulative incidence and RR by five groups of average income per person at census tract level by sex in the four waves. Wave 1: 02/25/2020–07/04/2020 (40 days); wave 2: 10/01/2020–12/06/2020 (67 days); wave 3: 12/07/2020–03/14/2021 (98 days); wave 4: 03/14/2021– 05/31/2021 (78 days) Table 1 Selected equity-oriented interventions to tackle the incidence of COVID-19 and inequalities in Barcelona Intervention Description Target population(s) Activity indicators Expected or measured Calendar impact Addressed to a specific setting or the general population but with an orientation to equity Interventions in Nursing Activities for the prevention Residents, workers and admin‑ Contingency plans in 229 nurs‑ Control of COVID-19 outbreaks The office started at the end of homes and control of COVID-19 in istrators in nursing homes ing homes in nursing homes March 2020 - present nursing homes. A joint office was created for management and organization Interventions in schools Activities for the surveillance, Students, workers and admin‑ Only 15% of classes and 7% of That the majority of students 9/14/2020–6/22/2021 prevention and control of istrators in school centers students confined to home or could attend school in person. COVID-19 in schools. Strong quarantined Control of COVID-19 outbreaks support of school directors. in schools Joint office was created for management and organization Malmusi et al. International Journal for Equity in Health Communicating risks and Risk communication and com‑ General population, profes‑ 13 press releases, 166 media 958,690 visits vs. 412,225 visits March 2020 - present containment measures munity engagement strategies sionals, decision-makers. requests answered and 783 in a comparative period. 76% to increase the reach of valid media appearances new visitors. information. A website with COVID-19 indicators and with all the public health informa‑ (2022) 21:28 tion and recommendations related to COVID-19. Directly targeted at addressing socioeconomic inequalities or socially deprived populations Health hotels Nine hotels converted into People infected with COVID 2881 people hosted Accelerating hospital dis‑ March 2020 - present accommodation for mild and with inadequate housing charges, cutting transmission COVID-19 cases, supervised by conditions to follow isolation chains with cohabitants and healthcare personnel rules community, providing social support to vulnerable popula‑ tions Quarantine support program Home delivery of food baskets People infected with COVID 8272 people received food Cutting transmission chains 4/22/2020–7/16/2021 or cooked meals, personal and their contacts without baskets, 948 families received with cohabitants and commu‑ protective equipment, clean‑ resources or social networks cooked meals nity, providing social support ing and personal hygiene to vulnerable populations products, home cleaning and disinfection service, waste disposal, dog walking Special facility for homeless Residential center with harm Homeless people with drug 70 beds; 182 different people Improvement in quality of 4/4/2020 - present people with drug dependency reduction programs for drug dependency, including alcohol have lived in the center to date life of homeless and addicted problems use (supervised consumption people. A place for isolation spaces and controlled alcohol if infected with the disease or consumption program) becoming a close contact Page 6 of 11 Table 1 (continued) Intervention Description Target population(s) Activity indicators Expected or measured Calendar impact Adapting community Use the previous structure of Neighborhoods with the great‑ 13 community programs Address determinants of 2 stages: first: April 2020–Sep‑ health interventions to tackle the community health net‑ est socioeconomic depriva‑ adapted to pandemic situation health, such as social isolation, tember 2020Second: October COVID-19 work, as well as a communica‑ tion, in which the Barcelona which are worsened by the 2020 - to date tion network, to detect needs Health in the Neighborhoods pandemic or problems during periods of program is implemented (25 Malmusi et al. International Journal for Equity in Health confinement; contact with par‑ of the 73 neighborhoods of ticipants and territorial agents Barcelona) to assess what to do and how; generate responses with com‑ munity assets to the needs detected; adapt interventions (2022) 21:28 to the “new normal” Specifically designed as a response to the appearance of socioeconomic inequalities related to COVID-19 Mass screening campaigns Opening of free, voluntary PCR Four neighborhoods with the 5394 tests, 151 were positive Cutting transmission chains. 8/15/2020–9/20/2020 in high incidence areas testing points in community highest incidence in the last Sensitizing residents about the centers for residents in the 15 days high incidence in the com‑ whole neighborhood or in munity selected census tracts, for 2–3 days per point Vaccination scheduling Universal strategy (online Neighborhoods with lower 25 support points/1689 users Increase in vaccination cover‑ 5/26/2021–11/22/2021 support points and street self-scheduling) combined vaccination coverage in the 19 street points/2081 vac‑ age.Reduction of the gap points for vaccination without with strategy targeting groups first weeks of vaccination cinated between extreme coverages appointment with vulnerabilities (personal (32 to 15%) support points for online scheduling, and vaccination street points). A joint office was created for management and organization Page 7 of 11 Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 8 of 11 Communicating risks and containment measures housing conditions to follow isolation rules without put- As part of the response plans to the pandemic, public ting their cohabitants at risk. In the latter case, persons health authorities developed risk communication [11] were detected and referred by social workers in primary and community engagement strategies to increase the healthcare centers. From March 2020 to June 2021, 9 reach of valid information to professionals, decision- facilities were set up and hosted 2881 persons. makers and the general population, efficiently spread rec- However, there was still room to support a wider set ommended measures, and reduce misinformation [12]. of situations with a less intense use of resources: for The ASPB created a website with frequently asked example, preventing people infected with COVID and questions (FAQs) about COVID-19, available in three their contacts with insufficient economic resources or languages (Catalan, Spanish and English) and continu- social networks from going out to buy food or from shar- ously updated. From 18th February 2020 to 27th June ing a kitchen with other families. This was the rationale 2021, the FAQs have had 283,067 visits, 33% of them in to allow social workers from the health system to acti- March 2020. Communication actions were continuously vate the “Cooked Meals at Home” program of munici- coordinated with the Catalan Department of Health, pal social services and, since April, to set up a municipal responsible for official public health messages, as well as “Quarantine Support Program”, based on prescription by with the City Council, to disseminate messages as much health system social workerswhich offered home deliv- as possible to the population. The website with COVID- ery of a food basket (or cooked meals when necessary), 19 indicators (covid19aldiabcn explained above) had personal protective equipment, cleaning and personal 136,437 visits from 08/01/2020 to 06/27/2021. Later, a hygiene products, a home cleaning and disinfection ser- specific website was created with all the public health vice, waste disposal, and dog walking. By July 2021, 9902 information related to COVID-19, which also added persons in 2796 apartments had received some kind of information and recommendations about environmen- service or home delivery from the program. tal and occupational health, food safety, health promo- tion, etc. The ASPB website received 958,690 visits from 02/18/2020 to 06/27/2021 vs. 412,225 visits in a compar- Special facilities and actions for homeless people ative period before those dates, and a 76% of new visitors. In the first 3 weeks of the lockdown, which limited the In this period, 13 press releases were issued, 166 media free use of public space, the City Council prepared a con- requests were answered and 783 media appearances were tingency plan to ensure residential and accommodation registered. facilities for homeless people. Social intervention teams An important strategy was the reinforcement of com- matched people sleeping rough to the available facilities municating COVID-19 risk and preventive measures in and with new centers to receive meals and clothing and high-incidence neighborhoods through street-informers, to enable showers. In collaboration with social entities, cultural mediators-translators and collaboration with several accommodation facilities were set up: one for community leaders, using simple messages and for- 58 chronic homeless people, another with 59 places for mats, informative sessions and popular channels such as women, one with 30 places in single rooms for homeless WhatsApp. people with mild Covid-19 symptoms, and two spaces with 225 places in pavilions at the Barcelona Fair. A 2. Policies directly addressing socioeconomic inequali- center with 70 places was also set up for homeless peo- ties or socialy deprived populations ple with addictions to drugs or alcohol and another for 42 young and adolescent male homeless persons [13]. The center for homeless people with drug depend- ency, both on illegal drugs and alcohol, had, in fact, Interventions to support isolation: “health hotels” been included in the city’s “drug action plans” since and “Quarantine support program” 2009: the pandemic allowed the opening of such a resi- At the beginning of the pandemic, it became evident dential center for the first time in the city, and indeed that there was a need for interventions to help those in the country, with harm reduction services; therefore, groups with the greatest difficulty in carrying out isola- the center did not require residents to be abstinent. This tion and quarantine for COVID-19. Within 2 weeks of allowed initiation of intervention and recovery plans the declaration of pandemic, some hotels were converted tailored to each hosted individual’s life situation. Of the into “health hotels”, supervised by healthcare person- 70 places provided, a minimum of 25 of them would be nel and aimed at both accelerating hospital discharges reserved for women, and 14 months after opening, 32 for people recovering from COVID-19 symptoms, and places were occupied by women, 33 by men and 1 by a relocating those with mild infections and inadequate non-binary person. Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 9 of 11 Fig. 4 Vaccine coverage of the first dose of vaccine against COVID-19, in the group aged 60–69 years, on May 4, 2021 and November 30, 2021, by Basic Health Areas of the city of Barcelona Adapting community health interventions and using incidence. More than 5000 tests were undertaken finding community health networks to tackle COVID‑19 151 positive cases. Another example of addressing inequalities has been the existence of a direct communication link between public health services and local communities to detect Inequalities in vaccination coverage and strategies for their and respond to needs, through the community groups reduction created in previous years (for example, the local com- Vaccinations have been the key to change the course of missions of the Barcelona Health in Neighborhoods pro- the pandemic and lower the incidence of the disease. gram). Above all, we have tried to reactivate community For people aged 70 years and older, primary health- health programs early, and to prevent the social isolation care (PHC) teams made an active personal appeal by that COVID-19 has entailed from making certain groups telephone and vaccinated these persons in the same (e.g., the elderly) even more vulnerable: to this end, vari- PHC centers: on June 15, this group had a coverage ous programs were adapted to the situation implied by of over 90%, with a maximum range of 10 percentage COVID-19, most of them with the aim of reducing social points between the minimum and maximum of the isolation in neighborhoods with the lowest socioeco- 66 Basic Health Areas (BHA) of the city (a BHA is the nomic level [14]. geographic area assigned to a PHC team). However, to increase the system’s capacity and comply with distance 3. Policies specifically designed as a response to area- and capacity restrictions, more vaccination points were level socioeconomic inequalities related to COVID- opened, aimed at groups younger than 70 years. These 19 groups are required to use an online self-appointment system. A few weeks after starting the first group, aged from 60 to 69 years, a gap in coverage of first dose was detected, from 40 to 72% across BHA (see Fig. 4), with Mass screening campaigns in high incidence areas lower coverage in the most deprived BHA. The same In summer 2020, COVID-19 cases began to rise again, happened when starting younger age groups. Through and their geographical distribution was clearly unequal. a rapid consultation with community groups, we iden- Taking advantage from the increased capacity to perform tified digital, language and cultural barriers as factors PCR tests, mass screening campaigns were undertaken that could be influencing this delay in coverage. To this in order to detect incident cases of COVID-19 in pub- end, public health and healthcare services joined forces lic spaces of several deprived neighborhoods with high with municipal services of the districts with low cov- erage areas, to set up a network of 25 support points, Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 10 of 11 aimed at helping people to schedule appointments, and sensitivity of many of these sectors to equity issues, and later also 19 specific vaccination street points without their willingness to respond to the needs of the most scheduling the visit. In November, the range in cover- vulnerable groups detected through their contact with age was 82 to 95% across BHA (Fig. 4). the health systems, together with the rapid availabil- ity of area-based data on the ASPB website, generated a political momentum in which policymakers asked public Discussion health officials to maximize efforts to develop policies Socioeconomic inequalities in COVID‑19 in Barcelona to tackle these inequalities, coordinating actions in spe- in the different waves cific settings and enabling practical supports to equalize In a city that has been significantly affected by the opportunities for self-isolation [24, 25]. Moreover, pub- COVID-19 pandemic, we have shown socioeconomic lic health services made an effort to produce accessible inequalities in the incidence of COVID-19, namely and easy-to-read information about COVID-19 for pro- area-based income-related inequalities. This social gra- fessionals, decision-makers and citizens [26], although dient was more or less present in all four waves, being changing or delayed official information and uncertain- moderate in the first wave, based on hospitalized cases, ties reflected in the media sometimes generated mistrust largest in the second wave, especially for areas in the and/or misunderstandings [27]. lowest income quintile, and almost absent in the two All these policies required intense organizational and latter waves, with a significantly higher risk only for personal efforts, and rapid and creative action to address women in the lowest quintile neighborhoods. The population needs as soon as they became evident. Natu- daily online availability of these indicators has been an rally, the urgency to act resulted in many trial and error important surveillance tool to stimulate public policies experiences, inefficiencies in resource use, and a limited to tackle inequalities. possibility to systematically evaluate impacts. Patterns of geographic and income-related inequali- ties in COVID-19 in the first and second waves in Bar- celona have been described elsewhere [15–18], and a Conclusions wider discussion on potential explanations has previ- In this paper we have shown how COVID-19 hit Barce- ously been reported [6]. The smaller inequalities in the lona neighborhoods unequally, with variations between first wave could be related to the insufficiency of diag- waves, and we have described a selection of targeted nostic tests, reserved to healthcare workers and severe policies and collaborative interventions that helped to cases; thus the epidemic was underestimated more in address the needs of the most disadvantaged popula- some areas of the city with high levels of young immi- tions. Policies did not eliminate socioeconomic inequali- grant population. When massive testing was under- ties in the incidence of COVID-19, but we suggest that taken, these areas appeared as those with the highest they might have buffered the extent of inequalities and incidence, and inequalities linked to living and work- prevented them from being larger. Lastly, a community- ing conditions, such as job types (frontline jobs, fewer based approach might have helped to tackle emerging opportunities to work from home) [18, 19] and hous- inequalities in vaccination coverage by identifying and ing conditions (small dwellings, sometimes shared with addressing digital and cultural barriers to online booking. other families) became evident [20–23]. The third and Further studies would be needed to evaluate their actual fourth waves started when several restrictions were impact on inequalities [28]. In Barcelona, several tradi- lifted, e.g. on interprovince mobility and restaurant tional limitations in information systems were overcome opening: it is likely that affluent classes experienced and surveillance methods will be reproducible in future the most changes in social contacts from the lift- epidemics or vaccination campaigns. The challenge now ing of restrictions, thus counterbalancing the factors is to work to maintain those policies, working methods described above and potentially resulting in smaller and priorities, as well as to tackle all social and economic inequalities. inequalities due to the impacts of the pandemic. Multisectoral equity‑oriented policies to tackle Abbreviations the COVID‑19 pandemic: lessons learned RR: Relative risk; ASPB: Agència de Salut Pública de Barcelona; PHC: Primary The challenge of a pandemic that threatened to over- healthcare; BHA: Basic Health Areas. whelm the capacity of the health system mobilized the Acknowledgments efforts of civil society and all sectors of local and regional Not applicable. government, which broke traditional boundaries to coordinate their forces in an exceptional moment. The Malmusi et al. International Journal for Equity in Health (2022) 21:28 Page 11 of 11 Authors’ contributions 8. Ajuntament de Barcelona. Distribució territorial de la renda familiar DM defined the structure of the manuscript, wrote the first draft of the Discus‑ disponible per càpita a Barcelona 2017, vol. 2017: Repos Obert Coneix sion as well as other parts of the manuscript and wrote the joint draft. MIP l’Ajuntament Barcelona. p. 1–19. and CB were also major contributors in writing parts of the manuscript. MMD 9. Marbán-Gallego V, Codorniu-Ulia M, Rodríguez CG. The impact of performed statistical analysis and created figures, except Fig. 4 (ST). LA, ED, ST, COVID-19 on the elderly dependent population in Spain with special MRS, GP and CPG wrote sections with the explanation of policies. All authors reference to the residential care sector. Cienc e Saude Coletiva. discussed subsequent drafts and read and approved the final manuscript. 2021;26:159–68. 10. Borrell C, Pons-Vigués M, Morrison J, Díez È. Factors and processes Authors’ information influencing health inequalities in urban areas. J Epidemiol Community DM is Director of Health Services of the Barcelona City Council. CB is the Health. 2013;67:389-91. General Manager and MIP and LA are in charge of Directions at ASPB. CPG is 11. World Health Organization. Risk communication and community Director of Citizen Service at Consorci Sanitari de Barcelona. engagement readiness and response to coronavirus disease (COVID- 19): interim guidance, 19 March 2020. Copenhagen: World Health Funding Organization; 2020. No specific funding was obtained for this work. 12. De Vries D, Kinsman J, Cremers L, Rios M, Takács J, Ciotti M, et al. Com‑ munity engagement for public health events caused by communi‑ Availability of data and materials cable disease threats in the EU/EEA. Stockholm: European Centre for The datasets used and/or analyzed during the current study are available Disease Prevention and Control; 2020. from the corresponding author on reasonable request. Some of the data are 13. Sales A. Sensellarisme i pobresa en temps de confinament. Mesures publicly available and visualized at the “#COVID19aldiaBCN” website: https://​ d’emergència i perspectives de futur. Barcelona Soc Rev Coneix Anàlisi webs.​aspb.​cat/​covid​19ald​iabcn/ Soc. 2020;26:23–7. 14. Calzada N, Daban F, Diez E, Ferrer N, Gallardo R, Moreno D, et al. Salud comunitaria confinada: reflexiones y experiencias desde la Salud Declarations Pública local. Rev Esp Salud Publica. 2020;94:1–10. 15. Whittle RS, Diaz-Artiles A. An ecological study of socioeconomic pre‑ Ethics approval and consent to participate dictors in detection of COVID-19 cases across neighborhoods in new Not applicable. The analysis reported are based on secondary, anonymous York City. BMC Med. 2020;18:271. data. 16. Mollalo A, Vahedi B, Rivera KM. GIS-based spatial modeling of COVID- 19 incidence rate in the continental United States. Sci Total Environ. Consent for publication 2020;728:138884. Not applicable. 17. Mesa Vieira C, Franco OH, Gómez Restrepo C, Abel T. COVID-19: the forgotten priorities of the pandemic. Maturitas. 2020;136:38-41. Competing interests 18. Marmot M, Allen J, Goldblatt P, Herd E, Morrison J. Build Back fairer: the The authors work in the public administrations involved in the policies COVID-19 Marmot review. The Pandemic, Socioeconomic and Health explained in this article (see Authors’ information below for more details). Inequalities in England. London: Institute of Health Equity; 2020. 19. van Dorn A, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities Author details in the US. Lancet. 2020;395:1243. 1 Ajuntament de Barcelona, Barcelona, Spain. 2 CIBER de Epidemiología y Salud 20. Abrams EM, Szefler SJ. COVID-19 and the impact of social determinants Pública (CIBERESP), Madrid, Spain. 3 Agència de Salut Pública de Barcelona, Pl. of health. Lancet Respir Med. 2020;8:659-61. Lesseps 1, 08023 Barcelona, Spain. 4 Institut d’Investigació Biomèdica Sant Pau 21. Harlem G. Descriptive analysis of social determinant factors in urban (IIB Sant Pau), Barcelona, Spain. 5 Present Address: Universitat Pompeu Fabra, communities affected by COVID-19. J Public Heal (Oxf ). 2020;42:466-9. Barcelona, Spain. 6 Consorci Sanitari de Barcelona, Barcelona, Spain. 22. Nassif-Pires L, De Lima XL, Masterson T, Nikiforos M, Rios-Avila F. Pan‑ demic of Inequality. Econ Public Policy Brief Arch. 2020;ppb_149. Received: 15 September 2021 Accepted: 31 January 2022 23. Vásquez-Vera H, Biaani León-Gómez B, Borrell C, Jacques-Aviñó C, López MJ, Medina-Perucha L, et al. Inequities in the distribution of COVID-19: an adaptation of WHO’s conceptual framework. Gac Sanit. 2021. https://​doi.​org/​10.​1016/j.​gaceta.​2021.​10.​004. 24. Kerkhoff AD, Sachdev D, Mizany S, Rojas S, Gandhi M, Peng J, et al. References Evaluation of a novel community-based COVID-19 “test-to-care” model 1. Life expectancy by age and sex [Internet]. 2021 [cited 2021 Jun 26]. for low-income populations. PLoS One. 2020;15:e0239400. Available from: https://​ec.​europa.​eu/​euros​tat/​datab​rowser/​view/​ 25. Patel J, Fernandes G, Sridhar D. How can we improve self-isolation and DEMO_​MLEXP​EC/​bookm​ark/​table?​lang=​en&​bookm​arkId=​eb24a​8d3-​ quarantine for covid-19. BMJ. 2021;372:1–6. 8cc6-​483a-​b320-​b7b0f​55064​f9. 26. Hyland-Wood B, Gardner J, Leask J, Ecker UKH. Toward effective gov‑ 2. Bambra C, Riordan R, Ford J, Matthews F. The COVID-19 pandemic and ernment communication strategies in the era of COVID-19. Humanit health inequalities. J Epidemiol Community Health. 2020;74:964-8. Soc Sci Commun. 2021;8:30. 3. Anuari Estadístic de la Ciutat de Barcelona 2020. Barcelona: Oficina 27. Babalola, S, Krenn, S., Rimal, R, Serlemitsos, E., Shaivitz, M, Shat‑ Municipal de Dades Departament d’Estadística i Difusió de Dades; tuck, D, Storey D. KAP COVID Dashboard. Johns Hopkins Center for 2020. communication programs, Massachusetts Institute of Technology, 4. Instituto Nacional de Estadística. Estadística experimental – Atlas de global outbreak alert and response network, Facebook Data for Good Distribución de Renta de los Hogares [Internet]. 2019 [cited 2021 Jun [Internet] 2020 [cited 2021 Jun 29]. Available from: https://​ccp.​jhu.​edu/​ 28]. Available from: https://​www.​ine.​es/​prensa/​exper​iment​al_​atlas.​pdf. kap-​covid/ 5. Besag J, York J, Mollié A. Bayesian image restoration, with two applica‑ 28. Cash-Gibson L, Pericàs JM, Martinez-Herrera E, Benach J. Health inequali‑ tions in spatial statistics. Ann Inst Stat Math. 1991;43:1–20. ties in the time of COVID-19: the globally reinforcing need to strengthen 6. Marí-Dell’olmo M, Gotsens M, Pasarín MI, Rodríguez-Sanz M, Artazcoz health inequalities research capacities. Int J Health Serv. 2021;51:300–4. L, de Olalla PG, et al. Socioeconomic inequalities in COVID-19 in a European urban area: two waves, two patterns. Int J Environ Res Public Health. 2021;18:1–12. Publisher’s Note 7. Rue H, Martino S, Lindgren F. Functions which allow to perform full Springer Nature remains neutral with regard to jurisdictional claims in pub‑ Bayesian analysis of latent Gaussian models using Integrated Nested lished maps and institutional affiliations. Laplace Approximaxion; 2014.