Pérez et al. International Journal for Equity in Health (2022) 21:129 https://doi.org/10.1186/s12939-022-01724-2 RESEARCH Open Access Tackling health inequalities in a public health organization: the case of the Barcelona Public Health Agency Gloria Pérez1,2,3,4, M. Isabel Pasarín1,2,3,4, Vanessa Puig‑Barrachina1,2, Katherine Pérez1,3,4, Maica Rodríguez‑Sanz1,2,3,4, Lucia Artazcoz1,2,3,4 and Carme Borrell1,2,3,4* Abstract Background: Municipalities are important actors in the implementation of policies to tackle health inequalities, which requires political will, the availability of financial support, and technical and human resources. With the aim of aligning with local government political priorities, in 2017 the Barcelona Public Health Agency (Agència de Salut Pública de Barcelona, henceforth ASPB), which is responsible for the public health functions of the city, launched a strategy to improve the approach to tackling health inequalities in all its services. The objectives of this study were to show how social health inequalities were addressed in the ASPB from 2017 to 19 and to describe which actions were proposed after a participatory process aiming to create a plan to systematically incorporate health inequalities in ASPB actions. Methods: The ASPB has 304 workers, 8 directors and 20 services or departments. Participatory methodologies were carried out: 1) semi-structured interviews with department heads (N = 12, 60%); 2) world cafe workshops open to a group of workers (N = 63, 37%); 3) a Quick and Colorful voting session open to a group of workers (N = 108, 63%); and 4) Hanlon matrix with 19 actions to be prioritized (N = 12 services, 60%). Results: Semi-structured interviews and world cafe workshops provided 40 potential actions. After a step by step process of participatory prioritization, seven lines of action emerged: 1) to make progress in collaborative networking; 2) to promote policy evaluation; 3) to increase the ability of the ASPB to evaluate policies to reduce health inequalities; 4) to incorporate the axes of inequalities in all ASPB products; 5) to improve information on vulnerable groups; 6) to incorporate the gender perspective; and 7) to participate in an internal training plan to address health inequalities. Conclusions: The participation of ASPB public health professionals and staff allowed the organization to design a shared plan of actions to address health inequalities. This experience could be useful for other municipalities whose political agendas include tackling inequalities in health. Keywords: Inequalities, Public health, Participatory research, Policies Introduction Tackling health inequalities at the local level requires specific actions on the political agenda, the availability of financial support, and technical and human resources *Correspondence: cborrell@aspb.cat [1, 2]. Local strategies dealing with health inequalities are 1 Agència de Salut Pública de Barcelona (ASPB), Plaça Lesseps 1, usually based on instructions from the local authority to 08023 Barcelona, Spain the technical workforce to achieve sectorial objectives. Full list of author information is available at the end of the article © The Author(s) 2022. 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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. Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 2 of 10 However, a number of recent documents have reinforced and 3 public health technical staff, all of whom are the idea that people working in the public health sector experts in health inequalities. play an important role in reducing health inequalities 2) Diagnostic phase consisted first of semi-structured [3]. Furthermore, a disconnect between the local author- interviews with heads of departments or directo- ity and employees can lead to a failure to achieve politi- rates (Table 1). Second, a world cafe workshop [14, cal objectives and proposed activities [4]. In addition, 15] with all participating workers was held to answer to have an impact on health equity, health professionals 2 questions: i) how do you address the determinant need to develop appropriate skills and attitudes to allow of inequalities (e.g. housing, occupation etc.) in the them to become advocates for change [5]. service where you work? ii) What could be done to In the city of Barcelona, the arrival of a new left wing improve the performance of the service where you party in local government in 2015 was a substantial boost work in relation to this determinant? At the end the role of reducing health inequalities in the politi- of the session, a summary list was obtained of the cal agenda. Two of these are “The strategy for inclusion points discussed at each table and session of the and the reduction of inequalities” [6] and “The Neigh- world cafe. Following the conceptual framework of bourhoods Plan” [7], which included the participation of social determinants of health in urban areas used in the ASPB. In this context, the Barcelona Public Health the ASPB [16] in this phase, 2 participatory sessions Agency (Agència de Salut Pública de Barcelona, hence- were proposed. In each of the sessions, there was a forth ASPB) had the opportunity to participate and lead conversation table for each of the determinants of most of the political spaces that opened up at that time. the conceptual model itself with a total of 10 tables: The ASPB has demonstrated leadership in tackling urban planning and mobility; housing, environment, health inequalities [8] describing them [9–12] and inter- food safety, occupation, education, social transfers, vening to reduce them [13]. The ASPB is responsible for health and social services, participation and citizen- public health in the city (not health services) and, although ship, and family settings. Each table consisted of 4 it has attempted to decrease social inequalities, the inten- to 5 participants and one of the participants was the sity of activities depends not only on the political will of reporter, who had previously attended a training ses- each government, but also to the intrinsic activity of each sion to encourage discussion and to collect and pre- department and on the skills of the workforce. Taking sent the conclusions of each table. advantage of the favorable political context after 2015, we 3) Prioritisation of organisation-wide actions was car- decided to generate a plan to identify the potential contri- ried out following 2 methods: First, a “Quick and bution of public health workers to reducing inequalities in Colourful” voting session. This approach consisted health in the city, as well as the worker’s shortfalls or needs of an open method. All ASPB staff included in the in taking such action. The objectives of this study were to group was provided with 10 coloured stickers with describe how social and health inequalities were addressed which to vote. Participants gave an overview of each in the ASPB from 2017 to 19 and the actions proposed of the actions proposed by the world cafe workshop after a participatory process to design a plan to systemati- and were instructed to consider all the actions and to cally incorporate health inequalities in ASPB actions. prioritise them by voting. Votes were tallied for each action and the overall scores were then rank ordered. Second, prioritised actions at the organisational level Methods were assessed using a Hanlon matrix criteria [17]: 1) The ASPB has 304 workers in different areas of public Magnitude, 2) Utility, 3) Feasibility, divided in the fol- health (including 1 managing director, 8 directors and 20 lowing concepts: (a) is this action opportune? (b) head of services or departments). In the first stage of the Human and material resources: (c) Legal regulations project, we selected all areas except for health protection (d) Acceptability (e) Sustainability. The actions with the and laboratory services because these are the depart- highest scores were those prioritised in their service. ments that are least likely to work with health inequalities in their daily work. The workers included in the initial 4) Definition of plan objectives: To define the objec- stage were 172 employees (56%). tives of the plan, the services or departments had to The stages were: include them in their annual objectives; in this way, the objectives of the plan had to be part of the objec- 1) The leading group was constituted by the managing tives at their 3 levels of command (departmental, director, 2 directors, 2 heads of service/department managerial and organisational). Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 3 of 10 Table 1 Checklist for the semi-structured interview in the plan for addressing health inequalities in the Barcelona Public Health Agency The purpose of this checklist is to promote internal reflection on the degree to which health inequalities are addressed during the formulation and implementation of the lines of work of the ASPB’s services portfolio and to identify the actions in which the ASPB has to incorporate health inequalities in order to improve its performance. The following checklist will apply to each of the lines of work described in the ASPB’s services portfolio. As the person in charge of the line of work, you have to answer the following questions, always with reference only to the line of work. Name of the service or directorate: Name and surname of the person or persons who filled out this checklist: 1. Objectives Describe the main objectives of your service or directorate: 2. Population Yes No Are there any goals in your service or directorate aimed at a specific population group? (mark the answer) If the answer to the previous question is YES, describe what population group or work groups you are referring to 3. Axes of inequality How are the axes of inequality addressed in each of the following objectives of the work in your service or directorate? (mark all the answers that apply) Objectives Inequality axes Gender Age Country of Social Socioeconomic position (other Territory of Other origin or race class than social class as education level) residence (indicate) Health surveillance Intervention design, prioritisation and implementation Evaluation of interventions Surveillance and health control Final products (reports, sheet facts, letters) Other (indicate) 4. Intrasectoriality and intersectoriality Yes No In this service or directorate is there a need to work regularly with other areas / services of the ASPB (mark the answer) If YES, indicates which areas or services In this service or directorate, is there a need to work regularly with other areas / services EXTERNAL TO the ASPB (mark the answer) If YES, indicates which areas or services 5. Observations Indicate everything you want to highlight 5) Evaluation: The objectives will be evaluated at the Priorization by “Quick and Colourful” voting allowed end of 2021: 1) Performance of the prioritised actions 108 workers (63%) in the selected areas of the ASPB to by the departments, and 2) Satisfaction and the effect participate in the session resulting in 31 actions being of training among participants. ordered by votes (highlight actions with more than 30 votes can be seen in Table 4). The 31 voted actions were Ethics approval was not required in this study. grouped in 19 actions by 2 professionals of the leading group. These 19 actions were prioritised by the services and directorates using the modified Hanlon matrix and Results the following 7 actions were prioritised (Table 3): Semi-structured interviews with 12 (60%) department heads revealed that 3 (25%) of them did not include axes 1. To make progress in collaborative networking with of inequality or social determinants of health in their the districts and the neighbourhood key agents in daily activities or products. The remaining 9 departments order to integrate the interventions aiming to reduce included some axes of inequality, especially those at the health inequalities. regional and socioeconomic level, or all axes of inequali- 2. To promote evaluation of the policies of the City Coun- ties (age, ethnicity, socioeconomic position, gender and cil to prevent gentrification and increased inequalities. region). 3. To enhance the ability of the ASPB to participate in World cafe workshops with 63 participants (37% of the design, implementation and evaluation of City included workers) led to the emergence of 40 actions Council policies to reduce health inequalities. (Table 2) that could be grouped in 7 lines of action 4. To incorporate the axes of inequalities in all the (Table 3). products and interventions of the ASPB. Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 4 of 10 Table 2 Results of the world cafe participatory workshop. Barcelona 2017–2018 Actions 1. Improve the training of ASPB staff and clinical resources linked to social determinants, inequalities and axes of inequalities. Also include training in the perspective of gender. 2. Provide arguments to the technical workforce to communicate the results of the process of prioritisation in the interventions when they have to interact with the general population. 3. Improve internal training on participation techniques to adapt interventions to the needs of the population e.g. families, neighbourhoods, etc. 4. Improve the visibility and external communication of the ASPB by providing all the necessary mechanisms such as social networks, sessions, inter‑ ventions and products, and free delivery days that allow the ASPB to respond to the population’s health concerns. 5. Systematically use easy reading and computer graphics for ASPB products and presentations in order to adapt technical discourse to the general population. 6. Improve internal communication in the ASPB between services, programmes, circuits and ASPB resources using participatory techniques to achieve this goal. 7. Change the ASPB services portfolio so that it better reflects what are made by the ASPB, e.g. the heath in the neighbourhoods programme, which would facilitate this program. 8. Provide the ASPB with a checklist tool that would help to identify the inclusion of axes of inequality in ASPB interventions, programs and products. 9. Have a person or group of people who liaise with different departments of the ASPB to support the process of incorporating the axes of inequality into the various activities of the ASPB and resolve doubts. 10. Because of the complexity of inequalities, it was thought that a single person could not serve as a point of reference and be an expert on all the issues. This was a point to be discussed in a group of experts in the ASPB. 11. Incorporate the gender perspective into all the activities carried out by the ASPB. 12. Incorporate gender-based violence into the lines of work of the ASPB. 13. Increase ASPB co-production capacity in the design and implementation of City Council policies. 14. Participate in the decision-making process of all issues affecting the health of the city’s population by, for example, detecting cases of lead detec‑ tion, infestations, participate in the decision-making tables of all those who struggle to serve environments to promote healthy leisure. 15. Improve communication and information on the resources of the sectors of the City Council with which the ASPB regularly works, such as social services, education, housing and mobility to increase the effectiveness of joint work. 16. Make progress in collaborative networking with districts and the key agents of the neighbourhood to allow integration of the interventions. 17. Work to ensure that the Department of Health of the regional Government incorporates health into the school curriculum in a clear and opera‑ tional manner. 18. Promote the evaluation of the policies of the City Council to prevent gentrification and increased inequalities and generate recommendations by the sectors involved. 19. Evaluate the impact on health as well as, for example, the impact of traffic noise on health. 20. Prioritise ASPB interventions and/or recommendations aimed preferably at modifying the causes of health risks, rather than adapting to risk situa‑ tions as is the case for example, when giving priority to actions to reduce the sources of noise instead of recommending double glazing. 21. In assessing ASPB interventions, systematically incorporate assessment of the impact on health inequalities and that of gentrification, for example, in the case of superblocks and differences between intervening zones and adjacent zones. 22. To work in cases of lead detection and how they generate inequalities. 23. To think about reducing residues in our activities, interventions and programs, and not only recycling them. 24. Include social clauses for external companies that work for ASPB. 25. Review whether the working conditions of ASPB employees make it difficult to address social inequalities in health, and assess the measures needed to avoid or reduce them (e.g. working hours). 26. To identify the ASPB’s working conditions to be able to carry out an organisation-wide action to improve them. 27. Improve citizen participation in the different stages of ASPB studies or interventions by using more innovative participatory techniques that make participation easier and more attractive. 28. Implement participatory techniques with differential approaches to ensure the co-production of certain collectives such as families, the most vulnerable groups, etc. For example, using cultural mediators to generate greater participation of vulnerable collectives. 29. Report the results of our participatory processes to the population. 30. Provide opportunities for internal coordination and knowledge sharing between ASPB services through innovative participatory techniques, allowing the sharing of information on actions. 31. Adapt interventions to changing realities and make the actions more flexible so that they respond to the population’s diversity. This flexibility in interventions could improve co-production with the community as a whole. Include in the participatory diagnostics and in the design of interven‑ tions neighbourhood residents that are not organized in the work tables where technicians, organizations and neighbourhood associations normally participate. Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 5 of 10 Table 2 (continued) Actions 32. Incorporate the various axes of inequality in the interventions designed for the ASPB and those in which there is some type of participation. 33. Propose interventions in vulnerable populations and those with which the ASPB has worked less, for example, interventions for female sex work‑ ers, since all interventions are aimed primarily at men, probably originating with the beginning of the AIDS epidemic. 34. Increase coordination between programmes so that some interventions are shared, for example, food safety interventions could think of actions related to energy poverty. 35. Improve collaborative relationships with other sectors or entities to share information/indicators for inclusion in the different products produced by the ASPB, e.g. indicators to make visible the problems of habitat, gentrification, etc. 36. Improve the various information systems of the ASPB to ensure the collection of relevant data for the analysis of health inequalities. 37. Propose collection of inequalities in the information systems of other entities, such as primary care. 38. To define a way of systematically collecting inequitable gaps in all ASPB-dependent information sources across the organisation. 39. Identify and improve information on vulnerable groups not only according to the region but also by defining new categories of social class or socioeconomic position. For example, people with disabilities are a precarious collective hidden within the collective of workers and very precarious workers with long working hours, low pay, and poor working conditions. 40. Increase knowledge on the physical environment, for example, on walking, shopping, healthy eating, mobility and urbanization that allows ASPB staff to diagnose needs and design interventions. 5. To improve information on vulnerable groups by to improve information on inequalities in environmental defining new categories of social class or socioeco- health. nomic position. 6. To incorporate the gender perspective in all ASPB 2) Addressing gender-based violence from a public actions. health perspective 7. To participate in an internal training plan to address social inequalities. At the beginning of 2019, a working group on gender violence was organized at the ASPB aiming to: review the These actions were included in the annual objectives of existing evidence to develop a conceptual framework [18] the 12 departments and services to be achieved in 2021. and to analyze gender-based violence in the context of The methods and results are summarised in Table 3. couples in the city of Barcelona. Actions already implemented 3) Annual planning 1) Internal training plan to address social inequalities Targets related to the Plan were included in the annual planning of all services and directorates in 2019, 2020 During the third quarter of 2018, 2019 and until March and 2021. 2020 (before the covid-19 pandemic), a basic train- ing module on social determinants of health and health inequalities was designed, consisting of a theoretical part Discussion and another part adapted to the needs of staff attending The results show how a local public health organisa- the training module. At the time of this publication, 5 tion can successfully introduce health inequalities in the training workshops have been held, attended by 100 peo- actions of diverse areas of the organisation through par- ple (30% of staff ). At the end of 2021, 160 workers (48% ticipatory methods. The diagnosis showed that health of staff ) had been trained. Because we have been record- inequalities were unequally addressed and not always ing satisfaction and pre- and post-training data, we will with the same intensity. Therefore, tasks were prioritized be able to evaluate the effect of training on participants’ to level up the activities implemented in all departments knowledge of social inequalities. and mainly in those not yet implementing them. This As a consequence of the training plan, for 2020, the study confirms that the approach to inequalities in health Departments of Environmental Quality and Interven- must be carried out at both the organizational level and tion and Health Information Systems decided to review at the level of specific public health departments. the existing scientific evidence on environmental health In Barcelona, policies for the reduction of health inequalities, to review the availability and current use of inequalities have been undertaken in the last years, as indicators at the ASPB, and finally to define a road map in other cities [19], although bureaucratic restraints and resistance from various levels of the administration have Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 6 of 10 Table 3 Methods and results obtained in the plan for tackling inequalities at the Barcelona Public Health Agency Methods/participation Questions Results: improvement lines Semi-structured interviews (N = 12 partici‑ For more details about the checklist see Table 1 1. Inter- and intrasectorality at the ASPB pants department heads) - Are the general objectives of the service 2. Health surveillance in services basically focused described? on monotoring and controlling diseases - Which specific population does the activity 3. Information systems target? 4. Knowledge transfer - Are the axes of inequality tackling? 5. Participatory methodologies in ASPB pro‑ - Are intra-and intersectorality described? grammes and interventions - What would you improve? 6. Inclusion of axes of inequality in ASPB products 7. Availability of “checklist”-type management tools to verify the incorporation of axes of inequal‑ ity into ASPB products World cafe conversation (N = 63 participants and - What are the determinants of inequalities in 40 actions grouped in 7 lines (for more details see 10 reporters) the service where you work? Table 2): - What could bedone to improve our perfor‑ 1. Define actions to improve the efforts of the mance in relation to these determinants? ASPB to reduce health inequalities 2. Review current ASPB lines of work to detect if they include health inequalities 3. When necessary, incorporate axes of inequality into ASPB work and products 4. Increase citizen participation in ASPB action 5. Develop an internal training plan to address health inequalities 6. Develop a communication plan about health inequalities 7. Develop a cross-cutting gender plan "Quick and colourful" voting session (N = 108 Multiple voting of 40 actions 31 actions with a number of votes (for more participants) details see Table 4) 2 cross-cutting actions selected: a. Address gender-based violence from a public health perspective. b. Design and provide an internal training plan to address social inequalities Prioritisation by services and directorates (N = 12 Hanlon matrix: prioritization of 19 actions by Actions from 2019 to 2020: the 7 prioritised services and manegement) services actions per service/managemet direction to be included in the service objectives were: 1. To make progress in collaborative networking with the districts and the neighbourhood key agents in order to integrate interventions aiming to reduce health inequalities 2. To promote assessment of the policies of the City Council to prevent gentrification and increased inequalities 3. To increase the ability of the ASPB to participate in the design, implementation and evaluation of City Council policies to reduce health inequalities 4. To incorporate axes of inequality in all the prod‑ ucts and interventions of the ASPB 5. To improve information on vulnerable groups by defining new categories of social class or socioeconomic position 6. To include the gender perspective in all ASPB actions 7. To participate in an internal training plan to address social inequalities ASPB Agència de Salut Publica de Barcelona been described as important barriers [9]. In addi- different public health areas, but also of how improve- tion, verticality in decision making has negative con- ment actions can be achieved from the participatory sequences for compliance with reducing inequalities process. In this regard, in our review of the scientific [13]. Our plan is a good example of how an organi- literature, we found no similar cases to that described sation can not only address health inequalities in herein. Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 7 of 10 Table 4 Results of the “Quick and Colorful” voting prioritization session of actions to improve tackling health inequalities in the Barcelona Public Health Agency, Barcelona 2017–2018 Lines Actions Number Carried out by of votes Incorporate axes of inequality into the ASPB Design a checklist that allows you to review 22 Services work and products. ASPB products and actions. Incorporate axes of inequality in all the 33 Services products and interventions of the ASPB. Improve the various information systems of 20 Services the ASPB to ensure analysis of health inequali‑ ties. Improve the information on vulnerable groups 26 Services by defining new categories of social class or socioeconomic position. Improve the information and collection sys‑ 20 External tems that do not depend on the ASPB. Increase coordination between program- 62 Services mers so that some interventions are shared as follows. Increase citizen participation in ASPB action Improve citizen participation by using more 30 Services innovative participatory techniques. Guarantee participation of the most 59 Services vulnerable collectives with participatory techniques with differential approaches. Report the results of our participatory 32 Services processes to the population. Define actions to improve the work of the ASPB Define an intersectional management strategy. 5 Services Improve information on the resources of the 11 Services sectors of the City Council with which the ASPB works regularly. Make progress in collaborative networking 40 Services with the districts and the neighbourhood key agents in order to integrate interven- tions. Increase the ability of the ASPB to partici- 46 Services pate in the design, implementation and evaluation of City Council policies. Promote the evaluation of the policies of 37 Services the City Council to prevent gentrification and increased inequalities. Work to promote the incorporation of 90 External health in the school curriculum in a clear and operative way by the Department of Health. Perform an internal training plan Design an internal training plan to address 33 Organisation-wide social inequalities. Define an internal training plan from the 19 Organisation-wide gender perspective. Define an internal training plan in participatory 13 Organisation-wide techniques Define an internal training plan for intersec‑ 11 Organisation-wide tional action. Organize a cross-cutting group with consulta‑ 4 Services tive functions. Develop a cross-cutting gender plan Gender equality plan. 6 Services Gender perspective on all ASPB actions. 44 Services Address gender-based violence from a 65 Organisation-wide public health perspective. Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 8 of 10 Table 4 (continued) Lines Actions Number Carried out by of votes Develop a communication plan Define an ASPB communication plan. 6 Communication area Improve the visibility and external com- 37 Communication area munication of the ASPB. Systematically use tools such as easy 52 Communication area reading to adapt technical discourse to the general population. Improve organization-wide communica- 62 Communication area tion within the ASPB using participatory techniques. Review current ASPB lines of work Identify areas of work in which action could be 23 Services taken to improve the approach to inequalities in ASPB services. Review the portfolio of services of the ASPB to 30 Services better respond to the reality of social inequali‑ ties in health. Identify working conditions in the ASPB. 36 Human resources manager directorate Assess the measures needed to avoid or 101 Human resources manager directorate minimize inequalities in the workplace (e.g., working hours). Note: Actions with more than 30 votes are highlighted in bold In our experience in the city of Barcelona, it is very dif- members of the ASPB believe that intersectorality would ficult to align all the stakeholders in tackling health ine- have a positive effect on health inequalities [17]. To qualities [2] e.g. in the ASPB some departments are more be effective, the processes of collaborative governance ahead of others in describing inequalities in health [20]. underlying area-based programmers require the atten- In our participatory plan, the public health workforce tion of the local authority, including the creation and assessed health inequalities as substantial and expressed governing of networks, a competent public health work- the need to incorporate health determinants and health force and supportive infrastructures [13]. inequalities into the activities and products of the ASPB. Public health information systems collect little informa- Training in health inequalities tion about social class and other axes of inequality [21]. The participatory process revealed that not all the In addition, it is important to have data from information workforce in the ASPB had the same background and sources which are not common, e.g. data from environ- knowledge for dealing with health inequalities. The par- mental contexts [22]. ticipatory methods also revealed the need to develop an Another improvement action was to increase citi- internal training plan in health inequalities. Currently, zen participation in ASPB action. An emerging body of due to the plan, some relevant training is already taking research suggests that actively engaging affected stake- place, for example in basic concepts of social determi- holders has the potential to make a positive difference in nants of health, axes of inequality, and health inequali- achieving outcomes [23]. One of the keys to enhancing ties, etc. Much of this education tends to focus on a citizen participation is providing citizens with access to specific department [12]. There is evidence that training better information that is easily understood [24]. health professionals about social determinants of health Intersectoriality is expressed by workers as the need to generates awareness of the potential root causes of health make progress in collaborative networking with the dis- inequalities and the importance of addressing them both tricts and the neighbourhoods and also to increase the in and with communities [25]. There is also evidence that ability of the ASPB to participate in the design, imple- public health professionals must develop appropriate mentation and evaluation of City Council policies. Some skills and attitudes to be advocates for change [26]. of the problems identified with intersectoral working To implement this plan, the ASPB will need to devote are the persistence of the traditional perspective and the both human and economic resources in both the medium lack of multi-intersectoral knowledge, co-operation and and long term to achieve its objectives. In addition, ASPB function between sectors and stakeholders. However, workers, as well as the various departments, will be in Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 9 of 10 different phases of the execution of the plan: While some broader vision of the connection between political, social workers have already received training and can contrib- and economic factors and infectious diseases [32]. In ute to the improvement actions of their department, oth- addition, during the pandemic, the indicators produced ers have yet to receive training. by the health administration of Barcelona clearly showed the unequal distribution of incidence of COVID-19 and The gender perspective the policy responses to them [33]. The public health workforce in the city of Barcelona and in other high-income countries is predominantly Limitations female. One of the most voted actions was related to One of the limitations of this plan, and specifically of par- avoiding or minimizing inequalities in the workplace, ticipatory methods, is that the participants’ own social showing the need for women with children in their care status or limited or insufficient information may result to balance work and personal life [27]. Another policy in a lack of variability. However, participatory meth- for gender equity that ASPB has taken into account is ods see people as active agents and include dimensions gender responsive budgeting to best respond to the previously not applied in other approaches. In addition, actions prioritised by its workforce. Europe provides participatory methods were conducted with the partici- many examples [22, 28] to be followed by the ASPB. In pation of a wide range of the workforce. addition, the Barcelona City Council has approved the Another limitation is that the results could reflect the gender equality plan for the city [29]. existing power relations in the community. In our case, ASPB workers assign high priority to the preven- department heads and people with decision-making tion of gender-based violence from the public health responsibility were excluded from the participatory sessions perspective. Policies to reduce health inequalities are with the workers, leaving the session exclusively for them. rarely included to reduce gender violence in strategic Some areas of the ASPB, such as health protection and lab- actions [30]. In addition, the inclusion of the gender oratory analysis services, did not participate in the process. perspective in actions of the ASPB was highly priori- However, there have been multiple reflections and interpre- tised by its workers. Last year’s gender perspective has tations on food safety from the point of view of equity that therefore been introduced by City Council and into the need to be included in the health protection departments of policies currently being implemented in the city. the ASPB in the near future as part of this plan. Learned lesson of the COVID‑19 pandemic Conclusions The participatory process of the plan’s implementa- We conclude that to reduce social inequalities in health, tion has been finished before COVID-19 pandemic. the evidence indicates that political commitment is essen- However, there are some lessons learned in the last 2 tial. In addition, the participation of ASPB public health years of the pandemic due to the links of it with ine- professionals produced a plan of improvement actions to quality in health. The COVID-19 pandemic, described address inequalities in a participatory manner and almost as a syndemic, allows us to rethink the relationship certainly with a greater capacity to involve ASPB workers between human health and planetary health. The pan- than if these measures had been proposed by the ASPB demic affects populations worldwide but, although management. In the future, the progress of this plan will everyone is susceptible to the virus, there are numer- need to be assessed, both in terms of process and results. ous evidences of having a greater impact on lower The experience shown in this article could be useful for socioeconomic groups and minorities. As we state in other municipalities that have included tackling inequali- this plan, it is essential for public health administra- ties in health in their political agenda. tions understanding inequalities to develop policies Acknowledgements to tackle them. A conceptual framework helped us to Our thanks to all the employees of the Barcelona Public Health Agency who identify and explain the interactions between biologi- contributed to the success of the participatory process on which this plan is cal, social, and environmental factors as part of the based. We also thank Gail Craigie for editorial assistance. structural and intermediate determinants involved in Authors’ contributions this pandemic [31]. CB, MIP and GP conceived the original idea of this study and drafted the first Another lesson learned that derived from the pandem- version of the manuscript. GP, KP, LA, MR, VPB contributed significantly to the design, analysis and the discussion of the results. All authors contributed to ics is that the classic model of epidemiological surveil- the final version with a critically revision of the manuscript. All authors have lance has been overwhelmed by the pandemic. A new read and approved the manuscript. approach requires not only the guidance of the experts Funding in virology or epidemiologists but also that of other pro- No funding. fessionals in public health and other disciplines with a Pérez et al. International Journal for Equity in Health (2022) 21:129 Page 10 of 10 Availability of data and materials 13. Vázquez N, Molina MC, Ramos P, Artazcoz L. Effectiveness of a parent-train‑ The datasets used and/or analysed during the current study are available from ing program in Spain: reducing the southern European evaluation gap. Gac the corresponding author on reasonable request. Sanit. 2019;33(1):10–6. 14. Sheridan K, Adams-Eaton F, Trimble A, Renton A, Bertotti M. Community engagement using world Café: the well London experience. Groupwork. Declarations 2010;20(3):32–50. 15. Fouché C, Light G. An invitation to dialogue: “the world café” in social work. Ethics approval and consent to participate Qual Soc Work. 2011;10(1):28–48. Not applicable. 16. Borrell C, Pons-Vigués M, Morrison J, Díez È. Factors and processes influenc‑ ing health inequalities in urban areas. J Epidemiol Community Health. Consent for publication 2013;67(5):389–91. Not applicable. 17. Borroto Chao R, Liz Alvarez M. Diagnóstico comunitario de la situación de salud. Rev Cuba Med Gen Integr. 1996;12(3):289–94 Available from: http://​ Competing interests scielo.​sld.​cu/​scielo.​php?​script=​sci_​artte​xt&​pid=​S0864-​21251​99600​03000​ The authors of the paper work in the Organization analyzed in the paper. 14&​lng=​es&​nrm=​iso&​tlng=​es. 18. Artazcoz L, Garrido A, Juarez O, Otero I, Pasarin M, Perez K, Salvador M. Author details Intimate partner violence from a public health perspective: conceptual 1 Agència de Salut Pública de Barcelona (ASPB), Plaça Lesseps 1, 08023 Bar‑ framework. Barcelona Societat. 2019;1–16. Avalaible at: https://​ajunt​ament.​ celona, Spain. 2 Experimental and Health Sciences Department, Universitat barce​lona.​cat/​drets​socia​ls/​sites/​defau​lt/​files/​revis​ta-​ingles/​10-​actua​litat-​ Pompeu Fabra, Carrer Dr Aiguader 80, 08003 Barcelona, Spain. 3 Centro de viole​ncia-​mascl​ista-​en.​pdf [accesed May 19 2021]. Investigación Biomédica en Red de Epidemiología y Salut Pública (CIBERESP), 19. The mayor of London. The London health inequalities strategy. London: C/ Monforte de Lemos 3‑5. Pabellón 11. Planta 0, Madrid 28029 Madrid, Spain. London government UK; 2010. Avalaible at: London_health_inequali‑ 4 Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Carrer Sant Quintí, ties_strategy_-_final_-published_april_2010.pdf [accesed May 19 2021] 77‑79, 08041 Barcelona, Spain. 20. Franco M, Diez J, Gullon P, Margolles M, Cofiño R, Pasarin MI, et al. Towards a policy relevant neighborhoods and health agenda: engaging citizens, Received: 6 April 2022 Accepted: 29 July 2022 researchers, policy makers and public health professionals. SESPAS Report 2018. Gac Sanit. 2018;32(Suppl 1):69–73. 21. Krieger N, Chen JT, Ebel G. Can we monitor socioeconomic inequalities in health? A survey of U.S. health departments’ data collection and reporting practices. Public Health Rep. 1997;112(6):481–91. References 22. Puig-Barrachina V, Ruiz ME, García-Calvente MD, Malmusi D, Sánchez E, 1. Schmidt M, Joosen I, Kunst AE, Klazinga NS, Stronks K. Generating political Camprubí L, et al. How to resist austerity: the case of the gender budgeting priority to tackle health disparities: a case study in the Dutch city of the strategy in Andalusia. Gend Work Organ. 2017;24(1):34–55. Hague. Am Jof Public Health. 2010;100(S1):S210–5. 23. McWilliam CL. Using a participatory research process to make a difference in 2. Morrison J, Pons-Vigués M, Díez E, Pasarin MI, Salas-Nicás S, Borrell C. Percep‑ policy on aging. Can Public Policy. 1997;1(Supplement(51)):70–89. tions and beliefs of public policymakers in a southern European city. Int J 24. Church J, Saunders D, Wanke M, Pong R, Spooner C, Dorgan M. Citizen par‑ Equity Health. 2015;14(1):18. ticipation in health decision-making: past experience and future prospects. 3. Scottish government. Equally well: report of the ministerial task force on J Public Health Policy. 2002;23(1):12–32. health inequalities. Galsgow; 2008. Avalaible at http://​www.​gov.​scot/​resou​ 25. National Academies of Sciences. A Framework for Educating Health rce/​doc/​229649/​00622​06.​pdf. [accesed May 19 2021] Professionals to Address theSocial Determinants of Health. Washington DC: 4. Plochg T, Schmidt M, Klazinga NS, Stronks K. Health governance by collabo‑ National Academie Press; 2016. ration: a case study on an area-based programme to tackle health inequali‑ 26. UK Department of Health. Tackling Health Inequalities: 2007 Status Report ties in the Dutch city of the Hague. Eur J Pub Health. 2013;23(6):939–46. on the Programme for Action. Avalaible at: https://​dera.​ioe.​ac.​uk/​7313/7/​ 5. Institute of medicine. A Framework for Educating Health Professionals to dh_​083472_​Redac​ted.​pdf [accesed May 19 2021]. Address the Social Determinants of Health. Washington (DC); 2016. Avali‑ 27. International Labour Organization. Guidelines on gender in employment able at: https://​www.​nap.​edu/​catal​og/​21923/a-​frame​work-​for-​educa​ting-​ policies. 2009. Avalaible at: https://​www.​ilo.​org/​wcmsp5/​groups/​publi​c/%​ health-​profe​ssion​als-​to-​addre​ss-​the-​social-​deter​minan​ts-​of-​health. [accesed 2D%​2D-​ed_​emp/​docum​ents/​instr​uctio​nalma​terial/​wcms_​103611.​pdf May 19 2021] [accesed May 19 2021]. 6. Barcelona city council. Strategy for inclusion and reducing social inequality 28. National Commission for the Promotion of Equality in Malta. Gender responsive in Barcelona. Barcelona; 2017. Available at:https://​ajunt​ament.​barce​lona.​cat/​ budgeting. A study on GRB initiatives in Sweden, Switzerland, Italy, United King‑ drets​socia​ls/​sites/​defau​lt/​files/​arxius-​docum​ents/​strat​egy_​inclu​sion_​2017-​ dom and France, 2009. Avalaible at: https://​ncpe.​gov.​mt/​en/​Docum​ents/​Proje​ 2027_​en.​pdf. [accesed May 19 2021] cts_​and_​Speci​fic_​Initi​atives/​Living_​Equal​ity/​grb.​pdf [accesed May 19 2021]. 7. Ajuntament de Barcelona. El pla dels barris de Barcelona. Barcelona; 2017. 29. Ajuntament de Barcelona. Plan for equality between women and men Acalaible at: https://​plade​barris.​barce​lona/​ca/9s9[accesed May 19 2021] 2020–2023. Barcelona; 2019. Avalaible at: https://​ajunt​ament.​barce​lona.​ 8. Borrell C, Pasarín MI, Díez E, Pérez K, Malmusi D, Pérez G, et al. Las cat/​premsa/​wp-​conte​nt/​uploa​ds/​2019/​12/​PLA-​IGUAL​TAT-​2020-​2023.​pdf. desigualdades en salud como prioridad política en Barcelona. Gac Sanit. [accesed May 19 2021] 2020;34(1):69–76. 30. Consorci Sanitari de Barcelona. Health plan 2016–2020. Barcelona; 2015. 9. Brugal MT, Borrell C, Díaz-Quijano E, Pasarín MI, García-Olalla P, Villalbí JR. Avalaible at: http://​www.​csb.​cat/​wp-​conte​nt/​uploa​ds/​2015/​04/​23-​setem​ Deprivation and AIDS in a southern European city: different patterns across bre-​CSB-​Pla-​de-​salut-​de-​Barce​lona-​2016.​pdf [accesed May 19 2021] transmission group. Eur J Pub Health. 2003;13(3):259–61. 31. Vásquez-Vera H, León-Gómez BB, Borrell C, Jacques-Aviñó C, López MJ, 10. Garcia-Subirats I, Pérez G, Rodríguez-Sanz M, Ruiz-Muñoz D, Salvador J. Medina-Perucha L, et al. Inequities in the distribution of COVID-19: an adap‑ Neighborhood inequalities in adverse pregnancy outcomes in an urban set‑ tation of WHO’s conceptual framework. Gac Sanit. 2022; (in press). ting in Spain: a multilevel approach. J Urban Health. 2012;89(3):447–63. 32. Horton R. Offline: COVID-19 is not a pandemic. Lancet. 2022;10255:874. 11. Rodríguez-Sanz M, Gotsens M, Marí-Dell’Olmo M, Mehdipanah R, Borrell 33. Malmusi D, Pasarin MI, Mari-Dell’Olmo M, Artazcoz L, Diez E, Tolosa S, et al. C. Twenty years of socioeconomic inequalities in premature mortality in Multi-level policy responses to tackle socioeconomic inequalities in the inci‑ Barcelona: the influence of population and neighbourhood changes. Health dence of COVID-19 in a European urban area. Int J Equity Health. 2022;21:28. Place. 2016;39:142–52. 12. Novoa AM, Pérez G, Espelt A, Echave C, de Olalla P, Calvo MJ, et al. The expe‑ rience of implementing urban HEART Barcelona: a tool for action. J Urban Publisher’s Note Health. 2018;95(5):647–61. Springer Nature remains neutral with regard to jurisdictional claims in pub‑ lished maps and institutional affiliations.