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 [1, 2]. Local strategies dealing with health inequalities are usually based on instructions from the local authority to the technical workforce to achieve sectorial objectives. However, a number of recent documents have reinforced the idea that people working in the public health sector play an important role in reducing health inequalities [3]. Furthermore, a disconnect between the local authority and employees can lead to a failure to achieve political objectives and proposed activities [4]. In addition, to have an impact on health equity, health professionals need to develop appropriate skills and attitudes to allow them to become advocates for change [5].

In the city of Barcelona, the arrival of a new left wing party in local government in 2015 was a substantial boost the role of reducing health inequalities in the political agenda. Two of these are “The strategy for inclusion and the reduction of inequalities” [6] and “The Neighbourhoods Plan” [7], which included the participation of the ASPB. In this context, the Barcelona Public Health Agency (Agència de Salut Pública de Barcelona, henceforth ASPB) had the opportunity to participate and lead most of the political spaces that opened up at that time.

The ASPB has demonstrated leadership in tackling health inequalities [8] describing them [9,10,11,12] and intervening to reduce them [13]. The ASPB is responsible for public health in the city (not health services) and, although it has attempted to decrease social inequalities, the intensity of activities depends not only on the political will of each government, but also to the intrinsic activity of each department and on the skills of the workforce. Taking advantage of the favorable political context after 2015, we decided to generate a plan to identify the potential contribution of public health workers to reducing inequalities in health in the city, as well as the worker’s shortfalls or needs in taking such action. The objectives of this study were to describe how social and health inequalities were addressed in the ASPB from 2017 to 19 and the actions proposed after a participatory process to design a plan to systematically incorporate health inequalities in ASPB actions.

Methods

The ASPB has 304 workers in different areas of public health (including 1 managing director, 8 directors and 20 head of services or departments). In the first stage of the project, we selected all areas except for health protection and laboratory services because these are the departments that are least likely to work with health inequalities in their daily work. The workers included in the initial stage were 172 employees (56%).

The stages were:

  1. 1)

    The leading group was constituted by the managing director, 2 directors, 2 heads of service/department and 3 public health technical staff, all of whom are experts in health inequalities.

  2. 2)

    Diagnostic phase consisted first of semi-structured interviews with heads of departments or directorates (Table 1). Second, a world cafe workshop [14, 15] with all participating workers was held to answer 2 questions: i) how do you address the determinant of inequalities (e.g. housing, occupation etc.) in the service where you work? ii) What could be done to improve the performance of the service where you work in relation to this determinant? At the end of the session, a summary list was obtained of the points discussed at each table and session of the world cafe. Following the conceptual framework of social determinants of health in urban areas used in the ASPB [16] in this phase, 2 participatory sessions were proposed. In each of the sessions, there was a conversation table for each of the determinants of the conceptual model itself with a total of 10 tables: urban planning and mobility; housing, environment, food safety, occupation, education, social transfers, health and social services, participation and citizenship, and family settings. Each table consisted of 4 to 5 participants and one of the participants was the reporter, who had previously attended a training session to encourage discussion and to collect and present the conclusions of each table.

    Table 1 Checklist for the semi-structured interview in the plan for addressing health inequalities in the Barcelona Public Health Agency
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  3. 3)

    Prioritisation of organisation-wide actions was carried out following 2 methods: First, a “Quick and Colourful” voting session. This approach consisted of an open method. All ASPB staff included in the group was provided with 10 coloured stickers with which to vote. Participants gave an overview of each of the actions proposed by the world cafe workshop and were instructed to consider all the actions and to 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 were assessed using a Hanlon matrix criteria [17]: 1) Magnitude, 2) Utility, 3) Feasibility, divided in the following concepts: (a) is this action opportune? (b) Human and material resources: (c) Legal regulations (d) Acceptability (e) Sustainability. The actions with the highest scores were those prioritised in their service.

  1. 4)

    Definition of plan objectives: To define the objectives of the plan, the services or departments had to include them in their annual objectives; in this way, the objectives of the plan had to be part of the objectives at their 3 levels of command (departmental, managerial and organisational).

  2. 5)

    Evaluation: The objectives will be evaluated at the end of 2021: 1) Performance of the prioritised actions by the departments, and 2) Satisfaction and the effect of training among participants.

Ethics approval was not required in this study.

Results

Semi-structured interviews with 12 (60%) department heads revealed that 3 (25%) of them did not include axes of inequality or social determinants of health in their daily activities or products. The remaining 9 departments included some axes of inequality, especially those at the regional and socioeconomic level, or all axes of inequalities (age, ethnicity, socioeconomic position, gender and region).

World cafe workshops with 63 participants (37% of included workers) led to the emergence of 40 actions (Table 2) that could be grouped in 7 lines of action (Table 3).

Table 2 Results of the world cafe participatory workshop. Barcelona 2017–2018
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Table 3 Methods and results obtained in the plan for tackling inequalities at the Barcelona Public Health Agency
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Priorization by “Quick and Colourful” voting allowed 108 workers (63%) in the selected areas of the ASPB to participate in the session resulting in 31 actions being ordered by votes (highlight actions with more than 30 votes can be seen in Table 4). The 31 voted actions were 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 the following 7 actions were prioritised (Table 3):

  1. 1.

    To make progress in collaborative networking with the districts and the neighbourhood key agents in order to integrate the interventions aiming to reduce health inequalities.

  2. 2.

    To promote evaluation of the policies of the City Council to prevent gentrification and increased inequalities.

  3. 3.

    To enhance the ability of the ASPB to participate in the design, implementation and evaluation of City Council policies to reduce health inequalities.

  4. 4.

    To incorporate the axes of inequalities in all the products and interventions of the ASPB.

  5. 5.

    To improve information on vulnerable groups by defining new categories of social class or socioeconomic position.

  6. 6.

    To incorporate the gender perspective in all ASPB actions.

  7. 7.

    To participate in an internal training plan to address social inequalities.

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
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These actions were included in the annual objectives of the 12 departments and services to be achieved in 2021. The methods and results are summarised in Table 3.

Actions already implemented

  1. 1)

    Internal training plan to address social inequalities

During the third quarter of 2018, 2019 and until March 2020 (before the covid-19 pandemic), a basic training module on social determinants of health and health inequalities was designed, consisting of a theoretical part and another part adapted to the needs of staff attending the training module. At the time of this publication, 5 training workshops have been held, attended by 100 people (30% of staff). At the end of 2021, 160 workers (48% of staff) had been trained. Because we have been recording satisfaction and pre- and post-training data, we will be able to evaluate the effect of training on participants’ knowledge of social inequalities.

As a consequence of the training plan, for 2020, the Departments of Environmental Quality and Intervention and Health Information Systems decided to review the existing scientific evidence on environmental health inequalities, to review the availability and current use of indicators at the ASPB, and finally to define a road map to improve information on inequalities in environmental health.

  1. 2)

    Addressing gender-based violence from a public health perspective

At the beginning of 2019, a working group on gender violence was organized at the ASPB aiming to: review the existing evidence to develop a conceptual framework [18] and to analyze gender-based violence in the context of couples in the city of Barcelona.

  1. 3)

    Annual planning

Targets related to the Plan were included in the annual planning of all services and directorates in 2019, 2020 and 2021.

Discussion

The results show how a local public health organisation can successfully introduce health inequalities in the actions of diverse areas of the organisation through participatory methods. The diagnosis showed that health inequalities were unequally addressed and not always with the same intensity. Therefore, tasks were prioritized to level up the activities implemented in all departments and mainly in those not yet implementing them. This study confirms that the approach to inequalities in health must be carried out at both the organizational level and at the level of specific public health departments.

In Barcelona, policies for the reduction of health inequalities have been undertaken in the last years, as in other cities [19], although bureaucratic restraints and resistance from various levels of the administration have been described as important barriers [9]. In addition, verticality in decision making has negative consequences for compliance with reducing inequalities [13]. Our plan is a good example of how an organisation can not only address health inequalities in different public health areas, but also of how improvement actions can be achieved from the participatory process. In this regard, in our review of the scientific literature, we found no similar cases to that described herein.

In our experience in the city of Barcelona, it is very difficult to align all the stakeholders in tackling health inequalities [2] e.g. in the ASPB some departments are more ahead of others in describing inequalities in health [20].

In our participatory plan, the public health workforce assessed health inequalities as substantial and expressed the need to incorporate health determinants and health inequalities into the activities and products of the ASPB. Public health information systems collect little information about social class and other axes of inequality [21]. In addition, it is important to have data from information sources which are not common, e.g. data from environmental contexts [22].

Another improvement action was to increase citizen participation in ASPB action. An emerging body of research suggests that actively engaging affected stakeholders has the potential to make a positive difference in achieving outcomes [23]. One of the keys to enhancing citizen participation is providing citizens with access to better information that is easily understood [24].

Intersectoriality is expressed by workers as the need to make progress in collaborative networking with the districts and the neighbourhoods and also to increase the ability of the ASPB to participate in the design, implementation and evaluation of City Council policies. Some of the problems identified with intersectoral working are the persistence of the traditional perspective and the lack of multi-intersectoral knowledge, co-operation and function between sectors and stakeholders. However, members of the ASPB believe that intersectorality would have a positive effect on health inequalities [17]. To be effective, the processes of collaborative governance underlying area-based programmers require the attention of the local authority, including the creation and governing of networks, a competent public health workforce and supportive infrastructures [13].

Training in health inequalities

The participatory process revealed that not all the workforce in the ASPB had the same background and knowledge for dealing with health inequalities. The participatory methods also revealed the need to develop an internal training plan in health inequalities. Currently, due to the plan, some relevant training is already taking place, for example in basic concepts of social determinants of health, axes of inequality, and health inequalities, etc. Much of this education tends to focus on a specific department [12]. There is evidence that training health professionals about social determinants of health generates awareness of the potential root causes of health inequalities and the importance of addressing them both in and with communities [25]. There is also evidence that public health professionals must develop appropriate skills and attitudes to be advocates for change [26].

To implement this plan, the ASPB will need to devote both human and economic resources in both the medium and long term to achieve its objectives. In addition, ASPB workers, as well as the various departments, will be in different phases of the execution of the plan: While some workers have already received training and can contribute to the improvement actions of their department, others have yet to receive training.

The gender perspective

The public health workforce in the city of Barcelona and in other high-income countries is predominantly female. One of the most voted actions was related to avoiding or minimizing inequalities in the workplace, showing the need for women with children in their care to balance work and personal life [27]. Another policy for gender equity that ASPB has taken into account is gender responsive budgeting to best respond to the actions prioritised by its workforce. Europe provides many examples [22, 28] to be followed by the ASPB. In addition, the Barcelona City Council has approved the gender equality plan for the city [29].

ASPB workers assign high priority to the prevention of gender-based violence from the public health perspective. Policies to reduce health inequalities are rarely included to reduce gender violence in strategic actions [30]. In addition, the inclusion of the gender perspective in actions of the ASPB was highly prioritised by its workers. Last year’s gender perspective has therefore been introduced by City Council and into the policies currently being implemented in the city.

Learned lesson of the COVID-19 pandemic

The participatory process of the plan’s implementation has been finished before COVID-19 pandemic. However, there are some lessons learned in the last 2 years of the pandemic due to the links of it with inequality in health. The COVID-19 pandemic, described as a syndemic, allows us to rethink the relationship between human health and planetary health. The pandemic affects populations worldwide but, although everyone is susceptible to the virus, there are numerous evidences of having a greater impact on lower socioeconomic groups and minorities. As we state in this plan, it is essential for public health administrations understanding inequalities to develop policies to tackle them. A conceptual framework helped us to identify and explain the interactions between biological, social, and environmental factors as part of the structural and intermediate determinants involved in this pandemic [31].

Another lesson learned that derived from the pandemics is that the classic model of epidemiological surveillance has been overwhelmed by the pandemic. A new approach requires not only the guidance of the experts in virology or epidemiologists but also that of other professionals in public health and other disciplines with a broader vision of the connection between political, social and economic factors and infectious diseases [32]. In addition, during the pandemic, the indicators produced by the health administration of Barcelona clearly showed the unequal distribution of incidence of COVID-19 and the policy responses to them [33].

Limitations

One of the limitations of this plan, and specifically of participatory methods, is that the participants’ own social status or limited or insufficient information may result in a lack of variability. However, participatory methods see people as active agents and include dimensions previously not applied in other approaches. In addition, participatory methods were conducted with the participation of a wide range of the workforce.

Another limitation is that the results could reflect the existing power relations in the community. In our case, department heads and people with decision-making responsibility were excluded from the participatory sessions with the workers, leaving the session exclusively for them.

Some areas of the ASPB, such as health protection and laboratory analysis services, did not participate in the process. However, there have been multiple reflections and interpretations on food safety from the point of view of equity that need to be included in the health protection departments of the ASPB in the near future as part of this plan.

Conclusions

We conclude that to reduce social inequalities in health, the evidence indicates that political commitment is essential. In addition, the participation of ASPB public health professionals produced a plan of improvement actions to address inequalities in a participatory manner and almost certainly with a greater capacity to involve ASPB workers than if these measures had been proposed by the ASPB management. In the future, the progress of this plan will need to be assessed, both in terms of process and results. The experience shown in this article could be useful for other municipalities that have included tackling inequalities in health in their political agenda.