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h ps://doi.o g/10.1177/22799036221110020
Jou nal o Public Heal h Resea ch
2022, Vol. 11(3), 1 –14
© The Au ho (s) 2022
DOI: 10.1177/22799036221110020
jou nals.sagepub.com/home/phj
Jou nal o
Public Heal h Resea ch
O iginal A icle
Backg ound
The wide- anging heal h and non-heal h measu es adop ed
o con ol he COVID-19 pandemic a e likely o a ec indi-
iduals’ and popula ions’ heal h-bo h physical and men al-
and well-being as conside able di ec and indi ec impac s
on he social de e minan s o heal h (SDH).1–5 Mo eo e ,
he lack o an equi y pe spec i e in he design and imple-
men a ion o hese measu es has con ibu ed o inc easing
exis ing heal h inequali ies.6 The complexi y and he ex en
o measu es adop ed in he con ex o a majo eme gency
e en such as he COVID-19 ha e made i di icul o ana-
lyze hei impac s ac oss a wide ange o SDH and popula-
ion g oups, especially in he i s mon hs o he pandemic.
I is he e o e essen ial o conduc new s udies in eg a ing
his wide app oach o comp ehensi ely assess hese
impac s on popula ions’ heal h and wellbeing and o in o m
decision-making in cu en o u u e pandemics.
Heal h Impac Assessmen (HIA) is a sys ema ic p o-
cess ha uses an a ay o analy ic me hods and da a sou ces
and conside s inpu om s akeholde s o de e mine he
po en ial e ec s o a p oposed policy, plan, p og am, o
p ojec on he heal h o a popula ion and he dis ibu ion o
hose e ec s wi hin he popula ion.7 Based on he SDH
model8 i is p esen ed as a decision-in o ming ool p o id-
ing a speci ic ehicle o he conside a ion o heal h and
1110020PMJXXX10.1177/22799036221110020Jou nal o Public Heal h Resea chU a an-La esgoi i e al.
esea ch-a icle2022
1Depa men o Sociology and Social Wo k, Uni e si y o Basque
Coun y (UPV/EHU), Leioa, Spain
2Resea ch G oup Social De e minan s o Heal h and Demog aphic
Change-OPIK, Leioa, Spain
3ISPED, Uni e si y o Bo deaux, Bo deaux Popula ion Heal h Resea ch
Cen e U1219-, Bo deaux, F ance
4Depa men o Nu sing I, Uni e si y o he Basque Coun y (UPV/
EHU), Leioa, Spain
Co esponding au ho :
Y González-Rábago, Depa men o Sociology and Social Wo k,
Uni e si y o Basque Coun y (UPV/EHU), Ba io Sa iena s/n, Leioa
48940, Spain.
Email: [email p o ec ed]
Heal h and heal h inequali ies impac
assessmen o non-clinical measu es o
con ol COVID-19 in he Basque Coun y
and Na a e (Spain)
M U a an-La esgoi i1,2, Y González-Rábago1,2 , U Ma ín1,2,
A Ri adeney a-Sicilia3 and M Mo e uel2,4
Abs ac
This a icle desc ibes he esul s o a heal h and heal h inequali ies impac assessmen o he COVID-19 pandemic con ol
measu es in he egions o he Basque Coun y and Na a e in Spain. A li e a u e e iew was conduc ed on Pubmed and
Web o Science (WoS) da abases, in addi ion o indi idual semi-s uc u ed in e iews and ocus g oups wi h expe s,
key in o man s and di e en p o iles o ci izens. A wide a ie y o social de e minan s o heal h ha e been a ec ed by
he measu es, which included indi idual heal h- ela ed beha io s, se ice dis up ion in o mal ca e, educa ional se ings,
and heal h ca e p o ision. These changes ha e pa icula ly a ec ed ce ain popula ion g oups including child en and
adolescen s, olde people, hose wi h heal h condi ions and disabili ies oge he wi h ca egi e s, women, as well as
people wi h low le els o educa ion, income, and esou ces. In u u e scena ios i will be necessa y o pay a en ion o
he po en ial impac s o policy esponses on heal h inequali ies o a oid an inc ease in exis ing heal h gaps.
Keywo ds
Heal h impac assessmen , heal h inequali ies, social de e minan s o heal h, policies, COVID-19
Da e ecei ed: 10 May 2022; accep ed: 11 June 2022
2 Jou nal o Public Heal h Resea ch
well-being in a sys ema ic way.9 While HIA is mainly p o-
mo ed as a p ospec i e ool, used e ospec i ely, i helps
o be e unde s and he consequences o a policy decision
once i has been- o is being-implemen ed and i p o ides
new e idence in o ming u u e policy and decision-
making p ocesses.7,10
This app oach ha e p o ed pa icula ly ele an in
eme gency e en s such as he COVID-19 pandemic, as
e lec ed by he se ies o HIAs conduc ed by he Wales
Heal h Impac Assessmen Suppo Uni (WHIASU) and
wi h a ocus on heal h and heal h equi y impac s o home
con inemen , housing and spa ial planning policies on he
Welsh popula ion.10–13 These HIAs we e aimed o lea n
om he expe ience and assis decision-make s so ha
po en ial inequali ies and ad e se impac s o hei deci-
sions could be educed and oppo uni ies o heal h and
heal h equi y maximized in u u e decisions du ing and
pos he pandemic.
This pape uses his same app oach and ocuses on he
esul s o a HIA e ospec i ely applied o a se o policy
measu es implemen ed in he i s wa es o he COVID-19
pandemic, in he egions o he Basque Coun y and
Na a e, wo o he Spanish egions mos a ec ed by he
pandemic as e ealed by epo ed cases o in ec ions, hos-
pi al admissions and dea hs a ibu ed o he disease, all o
hem abo e he na ional a e age.14
As elsewhe e in Spain, since he i s COVID-19 cases
we e epo ed in Ma ch 2020, a se ies o non-clinical mea-
su es we e in oduced in hese wo egions o con ain he
ansmission o he i us. These included home con ine-
men , es ic ions on mobili y, suspension o economic
ac i i y o sec o s classed as non-essen ial, closu e o
schools and educa ional cen e s, and es ic ions in o mal
ca e se ices and heal h ca e. Weeks la e , a he beginning
o May 2020, he so-called “de-escala ion” p ocess began
wi h he g adual e u n o no mal daily li e and economic
ac i i y, e en hough con ainmen measu es con inued o
some ex end h oughou he subsequen wa es acco dingly
o he e olu ion o he pandemic.
The pu pose o his pape is o add new e idence on he
consequences o non-clinical measu es in esponse o he
COVID-19 pandemic on popula ion heal h as well as hei
di e en ial impac s on di e se social g oups acco dingly
o he SDH pa icula ly a ec ed in hese wo egions in
Spain. Mo e p ecisely, he ange o measu es selec ed o
analysis we e selec ed in he sc eening phase o he HIA
and included (1) Home con inemen and educed mobili y;
(2) Res ic ions on o mal ca e se ices; (3) Res ic ions
on leisu e and social pa icipa ion oppo uni ies; (4)
Res ic ions on o mal educa ion; (5) Regula ion o wo k
en i onmen and employmen ac i i ies; (6) Reo ganiza ion
o heal h ca e se ices.
This pape p esen s and discusses he main esul s
ob ained in he app aisal s age o he HIA when heal h
impac s a e iden i ied and cha ac e ized elying on
published e idence, p o essional expe ise, and local
knowledge. I s ul ima e goal is o p o ide speci ic e i-
dence on heal h and heal h inequali y impac s o con ain-
men measu es in he wo egions and o in o m and
suppo policy making in he eco e y phases and in u u e
pandemic c ises o a oid unexpec ed ha ms o p omo e
heal h equi y.
Design and me hods
The collec ion o e idence o in o m he app aisal s age o
he HIA included a li e a u e e iew and a quali a i e
s udy.
Fi s , a quali a i e s udy was conduc ed aimed o iden-
i y and cha ac e ize he wide heal h and wellbeing
impac s o he analyzed measu es om a local pe spec i e
and wi h a pa icula emphasis in explo ing complex con-
ex ual ac o s eme ging om he da a.
Da a collec ion combined indi idual in e iews wi h
key in o man s (expe s, p o essionals, and decision mak-
e s) and ocus g oups wi h di e en p o iles o ci izens and
membe s o communi y associa ions in he egions o he
Basque Coun y and Na a e (Table 1). The pu pose o he
in e iews was o collec pa icipan s’ iews based on hei
expe knowledge and wo k expe ience ela ed o he ana-
lyzed policy measu es and conce ned SDH. The ocus
g oups we e aimed a explo ing ci izens and associa ions’
expe iences and iew as membe s o di e en social
g oups, specially a ec ed by he pandemic measu es.
In e iewees we e con ac ed by elephone and e-mail ia
he esea ch eam p o essional ne wo ks. Focus g oups
pa icipan s we e iden i ied by asking key in o man s o
assis esea che s in iden i ying hem and hen using he
snowball echnique. Ten indi idual in e iews and 10
ocus g oups in ol ing 63 pa icipan s we e conduc ed.
In e iews and ocus g oups we e conduc ed in Spanish
guided by one (in e iews) o wo ( ocus g oups) esea ch-
e s ained in quali a i e echniques, ollowing a semi-
s uc u ed sc ip adap ed o he pa icipan s’ p o iles and
ollowing he s udy objec i es (Supplemen al ma e ial 1).
The ieldwo k was ca ied ou be ween he mon hs o July
2020 and Ap il 2021. All he pa icipan s ecei ed an
in o ma ion documen ou lining he aims o he s udy,
which hey signed in o de o gi e w i en consen o hei
pa icipa ion, as well as he eco ding and p ocessing o
he da a collec ed. The s udy was app o ed by he E hics
Commi ee o he Uni e si y o he Basque Coun y (no.
M10_2020_264). A hema ic analysis15 was ca ied ou on
collec ed da a, con as ing he main e ol ing opics wi h
he concep ual amewo k o e e ence.
Second, a scoping e iew was conduc ed o ga he and
summa ize cumula ed in e na ional e idence on he heal h
impac s o non-clinical measu es implemen ed a he
beginning o he COVID-19 pandemic. Sea ch was ca ied
ou in Pubmed and WoS da abases and esul s we e
U a an-La esgoi i e al. 3
comple ed wi h g ay li e a u es including epo s om
academic sou ces and public ins i u ions published in he
Spanish con ex .
The li e a u e e iew was ca ied ou based on he main
pandemic con ol measu es iden i ied in he sc eening
phase o he HIA, and anged acco ding o he SDH model
p oposed by he Commission o educe Social Inequali ies
in Heal h in Spain.8 The sea ch s a egy included a combi-
na ion o e ms o cap u ing e idence on: (1) he di e en
measu es in oduced in esponse o he COVID-19 pan-
demic; and (2) he popula ion g oups a ec ed acco dingly
o he di e en ial impac s on he SDH (Supplemen al
ma e ial 2).
The inclusion c i e ia o selec ing a icles we e as ol-
lows: (1) o iginal s udies, e iews and me a-analyses; (2)
s udies conduc ed in he con ex o he COVID-19 pan-
demic add essing he impac o COVID-19 managemen
and con ol measu es; (3) published be ween Janua y 2020
un il 18 May 2021; and (4) w i en in English, Spanish o
F ench. Handsea ching o e e ence lis s and o he ele-
an a icles was also conduc ed. S udies on heal h impac s
in coun ies wi h epidemiological o poli ical con ex s a
emo ed om he Spanish eali y, as well as, con e ence
abs ac s, non-o iginal s udies, and clinical and epidemio-
logical s udies we e excluded om he e iew.
The s udy selec ion p ocess was ca ied ou in wo
phases. Fi s ly, he i le and abs ac we e sc eened and
secondly, he ull ex was ead. Two e iewe s pa ici-
pa ed in he p ocess and selec ed he e e ences in acco -
dance wi h he inclusion and exclusion c i e ia. I hey
we e unable o ag ee, a hi d e iewe was consul ed. Da a
ex ac ion was conduc ed based on he ollowing elemen s:
ype o measu e analyzed, heal h indica o o SDH con-
ce ned, impac on speci ic social g oups, and geog aphical
con ex . The main indings we e summa ized in na a i e
o m.
Resul s
Resul s a e p esen ed acco dingly o he six blocks o mea-
su es s uc u ing he analysis o he collec ed in o ma ion.
The li e a u e sea ch iden i ied 3,381 po en ially ele an
ci a ions. A e emo ing duplica es, 256 a icles we e
included o e iew (Figu e 1).
The analysis p esen ed below syn he izes bo h, he
main indings ex ac ed om he new quali a i e in o ma-
ion and he li e a u e e iew. Addi ional quo a ions om
in e iews and ocus g oups a e included in Supplemen al
Ma e ial 3. Resul s a e p esen ed acco ding o he six
blocks o measu es s uc u ing he impac analysis.
Home con inemen and educed mobili y
The ype and le el o impac on men al, emo ional, and
physical heal h a ied acco ding o di e en social g oups.
Men al heal h impac . Acco ding o he g oup o mo he s
and a he s, child en’s heal h was a ec ed mainly in e ms
o men al, emo ional and, ela ional and physical heal h.
Du ing he lockdowns mo e no iceable eelings o sadness,
ange and us a ion, and o missing o he people we e
epo ed.
Table 1. Pa icipan s in semi-s uc u ed in e iews and ocus g oups.
Da a collec ion echnique Numbe o g oups (pa icipan s) Code used
Focus g oups 10 (63)
Neighbo hood associa ions 2 (8 and 5) FG NAso
People o e 60 yea s o age/People o e 65 yea s o age in a si ua ion o
agili y o ulne abili y 2 (6 and 6) FG olde
Pa en s o gua dians wi h dependen mino s 2 (7 and 6) FG pa en s
Young people aged 19–25 2 (6 and 9) FG young
Women wo ke s inessen ial se ices wi h ca e wo k in he household 2 (6 and 4) FG women
Indi idual semi-s uc u ed in e iews (10)
Field Code used
Social se ices and social policy INT SS&SP
Gende INT gende
Educa ion INT educa ion
Social economy and solida i y INT social economy
Ru al a ea INT u al
Disabled people’s associa ions INT disabled
Social se ices in public adminis a ion INT social wo ke s
Men al heal h and addic ions in ulne able g oups INT MH and addic ions
Immig a ion INT immig a ion
Po e y and social exclusion INT po e y
4 Jou nal o Public Heal h Resea ch
“Two mon hs wi hou going ou in he s ee , ha has been a
shock o hem, hey go used o i (. . .) no being able o
socialize wi h o he child en and no being able o lea n,
disco e , ad ance, ha ’s wha may ha e been missing in hei
quali y o li e” (FG pa en s).
“A he beginning i was ine bu hen, a e wo o h ee
weeks, he would a i e a nigh and s a o say ha he was
sad because he missed his iends (. . .) (FG pa en s).
As o adolescen s and young people, con inemen has
also a ec ed hem in a pa icula way. In a i al s age, in
which he impo ance o con ac wi h iends o pee s
inc eases, he con inemen in he amily con ex may ha e
supposed an un a o able scena io o adolescen s.
Pa icipan s in he FG exp essed he e ec s o con inemen
on hei physical and men al heal h, in ensi ied by he
echnological connec ion.
“(. . .) no being able o lea e he house, ha eeling o lack
o eedom, o no being able o lead a no mal li e, well, in a
ce ain way i did gene a e a ce ain dep ession in me,
some imes anxie y o saying when is his going o end, because
I can’ ” (FG young).
“Abo e all, wha I ha e no iced he mos has been he men al
exhaus ion, because i is 12 hou s in on o he compu e ,
s udying o alking, (. . .) ha ing ha eeling o no
disconnec ing a any ime (. . .)” (FG young).
The e ec s on he physical heal h and psychological dis-
com o o adul s abo e 60 yea s old, consis ed in he
es ic ion o many o he ac i i ies hey ca ied ou on a
day- o-day basis. Al hough o some o hem i was an
oppo uni y o eco e pe sonal ime o egain ce ain
social con ac s, many epo ed ha i had mean a majo
change in he o ganiza ion o hei ime.
“I am 85 yea s old and I li e alone. Imagine how I was a
home, o all long days, alking o he walls alone. And I li ed
h ough i wi h an imp essi e amoun o cou age.” (FG elde ly)
“(. . .) he one who had a bicycle, would go o sca y ides.
The one who was physically well, wen o he moun ain (. . .).
Bu hose o us who needed a chai o ge om he e o he e,
i u ned ou ha we didn’ do any ac i i y a all” (FG elde ly).
“On a pe sonal le el, i has been e y good o me o be a
home, o do hings a home ha I ne e had ime o do. I is
ine o do physical exe cise om ha poin o iew (. . .)” (FG
elde ly).
Resul s om he li e a u e e iew also show ha di icul-
ies in main aining in e pe sonal ela ionships and suppo -
i e heal h beha io s ha e led o inc eased symp oms o
s ess, dep ession, anxie y, i i abili y, ea and insomnia,
among o he s.16–32 Loneliness, a pe cei ed lack o social
suppo and secu i y, along wi h inancial wo ies and con-
s an media exposu e o news abou he pandemic ha e
exace ba ed hese symp oms.33–35
“(. . .) no being able o lea e he house, ha eeling o lack
o eedom, o no being able o lead a no mal li e, well, in a
ce ain way i did gene a e a ce ain dep ession in me,
some imes anxie y o saying when is his going o end, because
I can’ ” (FG young).
“I am 85 yea s old and I li e alone. Imagine how I was a
home, o all long days, alking o he walls alone. And I li ed
h ough i wi h an imp essi e amoun o cou age.” (FG
elde ly)
“I hen had insomnia, nigh ma es, I did no sleep well. In ac ,
I s ill ind i ha d o sleep a nigh and I am a aid o going
h ough ano he con inemen ” (FG pa en s).
Child en and adolescen s, olde people and hose wi h
heal h condi ions and disabili ies, oge he wi h ca egi e s,
as well as women and people wi h low le els o educa ion,
income and esou ces ha e been he mos a ec ed popula-
ion g oups in o he se ings also.16,36–41
Figu e 1. Flow diag am o he li e a u e e iew and included
a icles.
Sou ce: Elabo a ed by au ho s, based on he PRISMA 2020 low
diag am.
U a an-La esgoi i e al. 5
Ca egi e s ha e exp essed hei discom o due o he
o e load o ca e ha ca ing in he pandemic si ua ion and
in he con ex o he imposed es ic ions has en ailed.
“(. . .) e e y hing came oge he , especially he Co id, he
s ess, ha ing o ake ca e o . . ., all hose li le hings. And all
ha plus no being able o go ou , i was e ible” (FG
women).
“Who akes ca e o my child en? Whe e is he amily
econcilia ion? Well, I had o gi e up my sala y o wo
mon hs in o de o ake ca e o my child en while hey we e a
home because hey had no school” (FG women).
People in ec ed wi h COVID-19 and hose close o hem
ha e also epo ed symp oms o emo ional s ess and anxi-
e y,42 in addi ion o di icul ies o g ie ing he loss o a
lo ed one due o es ic ions o mee ing and
accompanying.
“My a he inally passed away on Ma ch 31 and well. . . he
had been hospi alized o a mon h when hey le me isi him,
bu i go o a poin whe e we we e no longe allowed isi s
and i was e y pain ul (. . .)” (FG NAso).
Impac s on heal h- ela ed beha io s. Mos s udies e idenced
how being emale, young and ha ing a highe body mass
index is associa ed wi h a wo sening o ea ing beha io s,
physical ac i i y, and alcohol consump ion.43,44 Besides,
he isk o exposu e o obacco smoke, noise and sc een
ime has inc eased among child en om amilies wi h
lowe le els o educa ion and acing di icul ies o make
ends mee .45–48
In e iewe s ha e epo ed an inc ease in obacco con-
sump ion, in addi ion o o he subs ances such as cannabis
o cocaine. Di icul ies in selling hem in he usual ma ke s
oge he wi h hei sca ci y, ha e inc eased adul e a ion
p ac ices, ha , in he case o cannabis, ha e led o mo e
psychia ic decompensa ions. In addi ion, he e ha e also
been epo s o inc eased consump ion and sale o d ugs
and anxioly ics on he black ma ke , acco ding o key
in o man s wo king wi h ulne able people wi h addic ion
p oblems and psychia ic como bidi ies.
In he quali a i e pa o he s udy, no impo an
changes and impac s on physical ac i i y ha e been
epo ed. Howe e , in he li e a u e e iew, physical
ac i i y has been shown o be one o he mos s ongly
a ec ed heal h- ela ed habi s, wi h a gene alized educ-
ion in physical ac i i y le els and an inc ease in seden-
a y beha io 24,45,46,49–61 The impac o inac i i y would
ha e been mo e impo an in lowe socio-economic
g oups.62,63 Regula exe cise du ing pe iods o con ine-
men has been shown o ha e a bu e ing e ec on he
ad e se impac o educed mobili y on bo h physical and
men al heal h.64,65
Household isola ion has also ad e sely impac ed peo-
ple’s sleep ou ines.51 Young people and essen ial wo ke s
ha e p ima ily epo ed changes in hei sleep, e en need-
ing medica ion o be able o sleep.
“Abo e all, wha I no iced he mos was he men al exhaus ion,
because he e a e 12 hou s in on o he compu e , s udying
(. . .) as a esul o ha , I coun ed on sleeping and some days
I was able o sleep 5 hou s a day” (FG young).
“I s a ed sleeping medica ion in Ap il, I was he las one a
my job o s a aking sleeping medica ion, a my job we we e
all on medica ion o ge o sleep” (FG women).
“I hen had insomnia, nigh ma es, I did no sleep well. In ac ,
I s ill ind i ha d o sleep a nigh and I am a aid o going
h ough ano he con inemen ” (FG pa en s).
In he li e a u e hough con adic o y esul s, ega ding
sleep ou ines, ha e been ound.23,24,58 Simila ly, p olonged
sc een ime in di e en age g oups is epo ed o ha e had
a de imen al e ec on eye ision and emo ional
well-being.
“I has a ec ed me nega i ely. (. . .) I was wi h sc eens all
day and my eyesigh wo sened, I had o ge new glasses.”
(FG elde ly)
Impac s on amily ela ionships and gende iolence. In e -
iewed key in o man s ha e epo ed on an inc eased isk
o exposu e o domes ic and gende iolence in he con-
inemen , which has ac ually make hese si ua ions less
isible less de ec ed and he e o e, less likely o ecei e
help om he ou side. Published li e a u e in o he coun-
ies show he same esul s.66–68
“We ha e de ec ed ha he e was a e y impo an hal in he
numbe o epo ed cases o iolence du ing he i s 15 days o
COVID-19, associa ed wi h he ea o hinking ‘whe e am I going
o be be e , I am no going o go o a shel e ’, I mean, wi h he
possibili y o ge ing in ec ed, while a s ong inc ease was egis e ed
la e on, once de-escala ion was launched” (INT gende ).
Ne e heless, some in e iews show di e ging esul s.
Some in e iewees poin ed o he ac ha ce ain aspec s
o amily coexis ence imp o ed du ing con inemen s, no a-
bly among young couples. On he con a y, o he in e iew-
ees epo ed ha amily discussions had inc eased, mainly
due o he ension caused by he pandemic.
“(. . .) con inemen has been e y good o all o us o suppo
each o he much mo e a he amily le el” (FG young).
“(. . .) e y di icul psychologically o e e yone, back o
schedule, and now he ela ionships al eady damaged by he
ac o ha ing been locked up (. . .)” (FG pa en s).
In he li e a u e, i appea s ha an inc ease in he ime
spen a home would ha e wo sen amily ela ionships
wi hou necessa ily in ol ing domes ic iolence.57,69,70
6 Jou nal o Public Heal h Resea ch
Res ic ions on o mal ca e se ices
Res ic ions imposed on o mal ca e se ices and acili ies
(nu sing homes, occupa ional cen e s, home ca e se ices,
day ca e cen e s, schools) ha e had a de imen al impac
on he wellbeing o use s, in o mal ca e s and esiden ial
ca e wo ke s. Anxie y, dis ess and ea o con agion ha e
been epo ed among he la e .
Besides, acco ding o in e iewees measu es o con ain
he en y and ansmission o he i us in esidences could
ha e igge ed nega i e e ec s on eelings o loneliness
and isola ion. In his line, some key in o man s ha e
poin ed o u u e conside a ions o a oid his ha m.
“(. . .) hings ha e o be e iewed, wi hin he esidences: how
o o ganise he isola ion in o de o be e icien , o make i
compa ible o a oid in ec ion and no o be killed by
loneliness” (INT social wo ke ).
These esul s a e consis en wi h published s udies show-
ing inc eased social isola ion o olde people, which may
ha e led o men al de e io a ion, including p oblems o
diso ien a ion, agi a ion, and dep ession.71,72
The la ges impac s among people wi h men al heal h
p oblems and disabili ies, and disad an aged g oups a isk
o social exclusion, has been ela ed o dep i ed access o
ca egi e s, es ic ions o social ela ionships, and dis up-
ion o hei daily ou ines.73 This has also led o econcili-
a ion issues amongs ca e s.
“(. . .) he e is a g oup, wi hin hese p o iles ha li e a home
and i be o e hey had some suppo and ac i i ies, (. . .) hey
wen o a day cen e, o an occupa ional wo kshop. Now his
supposes econcilia ion p oblems, because hose who ca e o
hem ha e o ake ca e o hem much mo e in ensely” (INT
social wo ke ).
The in ensi ica ion o he ca e bu den, oge he wi h he
p e-exis ing gende gap wi hin his domain has added new
wo kload o amily and in o mal ca egi e s and led o
symp oms o s ess, bu nou and exhaus ion.74–79
“Being wi h my baby gi l, I had o s udy un il 10 a nigh , o
wake up a 5:45 o do he laund y and o ha e ime o do I
don’ know wha else, o cook len ils a 11 p.m. o end up a
how knows when. I was a chaos. (. . .) Suddenly a mee ing o
wha e e who knows a 14.00 while I say o mysel “I ha e o
p epa e ood o my child en”. Wi h my ongue hanging ou . I
was a be o e and a e o me on an emo ional le el, i was
e ible” (FG women).
Mig an women ca egi e s and li e-in wo ke s ha e expe-
ienced inc eased anxie y due o imposed obliga ion o
s ay in he employe s’ homes du ing con inemen .80
People wi h highe socio-economic s a us ha e enjoyed
g ea e oppo uni ies because hey could bea he inancial
cos o p i a e ca e se ices and he suspended he apies
o people wi h a ious disabili ies.
“(. . .) o he s ha e been locked up wi h he people hey ca ed
o and wi hou being able o mo e om he e and, on op o
ha , wi h imposed limi a ions(. . .)” (INT immig a ion).
“To me e e y hing I ha e o do doesn’ seem bad because we
ha e no o he choice, bu many amily uni s, in my house we
need wo sala ies and wha do you do wi h hem (child en)”
(FG pa en s).
The eme gence o communi y and neighbo hood solida i y
ne wo ks, oge he wi h an in ensi ica ion o amily ne -
wo ks, had a bu e e ec , especially among olde people
li ing alone and ulne able g oups wi h lowe socio-
economic s a us and g ea e needs, by p o iding emo ional
suppo and ma e ial esou ces.81,82
“In o he neighbou hoods he e has been o al coo dina ion
be ween he associa ions, he young people, he neighbou hood
uni , he municipal police, he Red C oss, e e y hing.
Coo dina ion has been cons an and so has he elephonic
suppo , he amilies called hem e e y o en, he e was
always a e e al, so he e ha e always been p oblems, so I
was he one who cen alised he p oblems and edi ec ed
hem o he suppo ne wo k o he neighbou hood ne wo k”
(FG NAso).
Res ic ions on o mal educa ion
The closu e o schools and educa ional cen e s has had
di ec and indi ec ad e se consequences on he physical,
men al, and social heal h o child en and hei amilies,83
a ec ing disp opo ionally hose a he lowe socio-
economic le els.84,85
In he quali a i e in e iews o he s udy wi h he expe
in he ield o educa ion, i was poin ed ou ha he ac
ha educa ional cen e s we e no conside ed as essen ial
se ices, ei he in hei educa ional o in hei ca e dimen-
sion, was an a on o he igh o educa ion.
In his sense, li e a u e e iew has also shown simila
dis up ions in schools and school- ela ed social and child
he apy se ices, which has led o highe isks o ood inse-
cu i y, domes ic iolence, and lea ning p ocess de ici , as
well as a dec ease in physical ac i i y, and pee ela ion-
ships.86 Men al heal h p oblems and agg essi e beha io
ha e also been obse ed, pa icula ly among adolescen s.87
Uni e si y s uden s ha e epo ed highe le els o s ess
due o a hea ie s udy load, longe hou s o homewo k,
di icul ies in swi ching o , and p oblems in main aining a
balance be ween educa ional esponsibili ies and o he
household obliga ions.88
Online lea ning may ha e inc eased social and heal h
inequali ies, due o he unequal a ailabili y o echnological
U a an-La esgoi i e al. 7
esou ces, adequa e s udy spaces, and he suppo acili a ed
by schools and eache s.69
“(. . .) single women o amilies wi h child en unde hei
ca e, all o a sudden a home, wi hou connec i i y, wi h
p eca ious housing condi ions, wi h ew skills o a he s and
mo he s, especially single mo he s, o accompany he
child en, in wha was he madness” (INT po e y).
Fu he mo e, school closu es ha e also had a majo impac
on he wellbeing o amilies, being conside ed a s esso
due o he need o econcile i wi h o he asks, such as
elewo king.
“(. . .) a school i ’s OK, bu a home wi h he pa en s (. . .)
my daugh e , she doesn’ do he homewo k alone o 4 hou s.
O cou se, we ha e gone h ough a housand emo ions” (FG
pa en s).
“The eeling o no doing any hing igh , no my job, no being
able o wo k, no being able o ake good ca e o my daugh e
(. . .)” (FG women).
Regula ion o wo k en i onmen and
employmen ac i i ies
The possibili y o elewo king has no been equally dis ib-
u ed be ween sec o s o people wi h di e en socioeco-
nomic s a us, being elewo king mainly he op ion o
people wi h a uni e si y deg ee a he han o less edu-
ca ed people.85,89,90 Ne e heless, his new way o wo king
has made i di icul o swi ch o om wo k and o com-
bine wo king hou s wi h domes ic asks, wi h a bu den ha
disp opo ionally alls on women.91–93
Sel -employed women ha e been pa icula ly a ec ed
due o he lack o economic p o ec ion, ins abili y and
unce ain y su ounding hei ac i i y.
“Fo me he main p oblem is ha I ha e been o ced o ake a
lea e o absence ha in no mal condi ions would no ha e
happened and i has been because o econcilian ion issues
(. . .)” (FG pa en s).
“O cou se, i ’s no he same o me, o example, as a sel -
employed pe son, in he end, wha I do is no wo k, and ha
goes o educe my income, my con ibu ion, my e e y hing. . .”
(FG NAso)
S udies ha e also shown an inc ease in seden a y hou s
ela ed o elewo k.94
Wo ke s in essen ial se ices, mainly women, ha e
been exposed o g ea e wo k p essu e, highe isk o con-
agion and highe mo ali y a es. Heal h wo ke s ha e
epo ed mo e si ua ions o s ess, anxie y, dep ession and
ea o con agion, and hose in social se ices highe le els
o bu nou and emo ional dis ess.
“(. . .) I los 5 kilos, in 3 mon hs, I wen back o smoking.
(. . .)I hadn’ smoked o almos a yea and a hal . (. . .)I
could no change he chip a nigh , I slep wi h wo k in my
head. Ti ed, mo e han physically, an emo ional i edness ha
made me physically i ed” (FG women).
Economic es ic ions ha e led o inc eased a es o unem-
ploymen and job insecu i y. The g oups mos a ec ed
include women, mainly acialized, young people and peo-
ple o e 55, people o low socio-economic s a us, and he
sel -employed. Job insecu i y has been associa ed wi h
highe le els o s ess, dep ession, and anxie y. Loss o
income, because o unemploymen o educed hou s
wo ked, has in u n a ec ed ma e ial li ing
condi ions.95,96
“(. . .) on a physical le el I ha en’ no iced much di e ence,
bu on a psychological le el yes. I has been a s ess o go o
wo k e e y day, o wo k in a supe ma ke whe e people don’
espec any hing, whe e we had no measu es when we s a ed.
(. . .) I ha e e en gone o wo k wi h achyca dia” (FG
women).
Young people ha e also epo ed conce n abou job losses
and incogni a si ua ions.
“In my case, when all his news abou unemploymen
s a ed. . . well, apa om he pandemic, hey we e saying
ha a new economic c isis was coming. (. . .) he u h is ha
I ha e a lo o ques ions abou employmen ” (FG young).
Res ic ions on leisu e and social pa icipa ion
oppo uni ies
Closu e o leisu e and cul u al cen e s as well as dayca e
cen e s has mainly a ec ed he elde ly, people li ing alone
and he adolescen popula ion.97 The o me ha e epo ed
on he nega i e e ec s on hei emo ional well-being due
o he impossibili y o gi ing hugs, mee ing people close
o hem and socializing in gene al.
“(. . .) no being able o gi e kisses, no being able o gi e
hugs, no being able o see my amily, my iends, my nephew,
(. . .) ha has mean a lo o me” (FG elde ly).
In addi ion o social isola ion, he COVID-19 es ic-
ions ha e also inc eased eeling o ea and anxie y,
mainly among he elde ly. The quali a i e s udy has
e ealed hei h ea o being in ec ed by amily membe s,
knowing ha hey we e a ulne able g oup in he ace o
COVID-19, a eeling ha has been ampli ied as a esul o
exchanges wi hin hei social ci cles and in o ma ion di -
used by he media.
“ he issue o ulne abili y (. . .) o hink ha un il he e is no
accine you a e a isk ac o , (. . .) a eeling o agili y and
some e y nega i e eeling” (FG elde ly).
8 Jou nal o Public Heal h Resea ch
A he same ime, elde ly people ha e ound ma e ial and
emo ional suppo in neighbo hood ne wo ks. Technologies
ha e also made possible o bo h, olde and younge peo-
ple, o main ain con ac and social ne wo ks. Ne e heless,
a digi al di ide ac oss age and socioeconomic g oups has
also been e ealed.
“I was asked by olde people when will we open o alk. Jus
o alk. I doesn’ ma e i one was one me e away om he
o he , bu jus o alk” (FG NAso).
“The neighbo hood ne wo k has been he main suppo
ne wo k, we check on each o he ’s pu chases and i necessa y.
Then he e is also he ac ha we all know each o he (. . .)”
(FG young)
“Con inemen has shown us ha we senio s ha e a digi al
di ide (. . .)” (FG elde ly).
Reo ganiza ion o heal h ca e se ices
Res ic ions in he heal hca e p o ision ha e led o
escheduling and cancela ion o appoin men s, making i
mo e di icul o access ce ain hospi al consul a ions
and inc easing wai ing lis s wi h consequen delays in
diagnosis, ea men and ollow-up o diseases and con-
di ions.98–100 Ba ie s o accessing heal h se ices ha e
also dec eased access o p e en i e p og ams and
se ices.101–103
“I hink ha i is also no e e ed, om wha I ha e
expe ienced wi h wo specialis s, i is no e e ed o he
specialis s as i would ha e been e e ed be o e. I seems ha
he only hing mo e impo an , I ha e he eeling, is ela ed o
he COVID o some hing like ha , and i no , hey kind o
elega e you” (FG pa en s).
Di icul ies in accessing heal h ca e ha e had a g ea e
impac in e ms o equi y and quali y o ca e o ce ain
g oups. People wi h physical disabili ies ha e been pa -
icula ly a ec ed by he lack o physio he apy se ices and
hospi al anspo se ices.104,105 People wi h ch onic dis-
eases ha e epo ed inc eased di icul y in accessing ca e
due o he lack o elephone con ac and epo ed isi s o
he heal h cen e s o ea o con agion. Pe ina al and pedi-
a ic ca e use s ha e expe ienced a educ ion in he num-
be o ou ine consul a ions, es ic ions on accompanimen ,
and on epidu al anes hesia access, among o he s.106,107 In
addi ion, he e has been a dec ease in he numbe o con-
sul a ions among undocumen ed mig an s due o di icul-
ies o enew hei esidence pe mi s.
“We ha e encoun e ed p oblems om some hing as silly as
ge ing a egis a ion o m o doing he egis a ion p ocedu e
ha has become impossible. (. . .) in u n has hinde ed he
comple ion o o he p ocedu es. This has mean ha some
people ha e no been able o ge heal h ca e” (INT
inmig a ion).
Telemedicine has shown posi i e esul s in e ms o con e-
nience, p i acy and imesa ing in ce ain cases and o ce -
ain popula ion g oups.108–110 Howe e , a loss o quali y
ca e has been also epo ed, p obably associa ed o he
digi al di ide111–114 and he impossibili y o in-pe son ela-
ionship and physical examina ion.
“I unde s and ha hey ha e done i (. . .). Because we we e
wai ing o see i all his would be o e , as i i would be o e
quickly. (. . .) Bu he con ac , which I hink is so impo an a
he heal h le el, he phone calls, 30 calls du ing he day, and
no o see, he eyes, o look, o see. Because some imes i is no
wo ds ha a e needed only. . .” (FG elde ly).
“Because o example, wha happens wi h people who don’
speak he language? In he case o my mo he , I’m he one
who is ge ing i now ha i ’s all online, e e y hing goes wi h
appoin men s. Nobody is calling me (. . .)” (FG women).
Discussion
The li e a u e e iew and he new quali a i e e idence col-
lec ed in he wo egions a ge ed by ou s udy ha e shown
he impac on heal h and heal h inequali ies o he policy
esponses o con ol and manage he COVID-19 pandemic,
wi h a special emphasis on ulne able popula ion g oups.
In acco dance wi h esul s epo ed elsewhe e, ou
quali a i e esul s show immedia e ad e se e ec s con-
ce ned men al heal h and wellbeing, pa icula ly among
women and essen ial wo ke s,115 elde ly, and young
adul s.116 Consis en wi h o he s udies ou esul s also
indica e ha unde ep esen ed mino i ies wi h lowe
household incomes and in o mal ca egi e s we e also
pa icula ly a isk o expe iencing nega i e heal h
ou comes.117
This s udy has also e idenced he nega i e impac o
COVID-19 lockdown and social isola ion on he elde ly,
especially in e ms o cogni i e de e io a ion, as men-
ioned by o he s.118 Howe e , some au ho s ha e also
shown ha some olde adul s a e no expe iencing
inc eased nega i e men al heal h consequences simila o
o g ea e han hose aced du ing he i s ew mon hs o
he COVID-19 pandemic.119 A he same ime, spending
mo e ime a home ha e led o a g ea e isk o some
women, child en and young people, due o a domes ic io-
lence exace ba ion du ing he pandemic and he limi ed
access o suppo ne wo ks and acili ies. These esul s a e
consis en wi h o he impac assessmen epo s.12
Wi h espec o school closu es, ou esul s a e also in
line wi h s udies concluding ha his measu e could no
only ad e sely impac educa ional ou comes bu also dis-
p opo ionally a ec child en bene i ing om school
b eak as s and lunches and whose access o some heal h
se ices could be also limi ed.120
This s udy has also highligh ed he ad e se e ec s o
policy measu es ela ed o employmen condi ions and
wo k en i onmen , no ably among women, mainly
U a an-La esgoi i e al. 9
acialized, young people and hose o e 55, people o low
socio-economic s a us, and he sel -employed la gely su -
e ing om job insecu i y and unemploymen . Some s ud-
ies ha e s a ed ha p e ious si ua ions o po e y,
p eca ious employmen and housing coupled wi h di icul-
ies in accessing heal h se ices and o he basic bene i s
ha e pa icula ly exposed ce ain ca ego ies o he popula-
ion,12,116,121 as well as hose li ing in economically
dep i ed a eas122,123 o he isk o con agion and o o he
ad e se e ec s o he pandemic. O he unequal impac s
ha e been epo ed among people wi h physical disabili-
ies, ch onic illnesses, women and immig an popula ion
g oups. Finally, in con as wi h hese ad e se e ec s,
some posi i e de elopmen s ha e been documen ed in
e ms o householde s, neighbo s, and communi ies com-
ing oge he o suppo one ano he and pa icula ly ul-
ne able g oups, olde people, and homeless shel e s in line
wi h in e na ional o ganiza ion’s wa ning messages.124
We ecognize ha his s udy has some limi a ions. Fi s ,
in he scoping e iew only wo da abases we e used o he
sea ch, while he inclusion o o he da ase would p o ide
mo e li e a u e. Howe e , we conside ed ha he wo
selec ed da abases, Pubmed and Wos, co e a wide ange
o knowledge ields especially o he in e es o he opic
s udied, and o do a sys ema ic e iew was ou o ou in e -
es . Second, he sea ch pe iod co e s only he ini ial s ages
o he pandemic. Al hough a ew mon hs ha e passed since
he end o he sea ch, he esul s o he scoping e iew
espond o i s objec i es o complemen ing he e idence
ob ained om he quali a i e s udy du ing hese phases o
he pandemic. Ne e heless, we admi ha some s udies
ocusing on he i s mon hs o he pandemic migh ha e
been published in he las yea Thi d, he quali a i e s udy
was ca ied ou in wo speci ic egions inside a coun y,
and i s esul s can be in e p e ed mainly in ha con ex .
Howe e , quali a i e s udies a e in insically local and
need a na ow geog aphic con ex o ca y hem ou .
Simila measu es ha e been adop ed in a wide a ie y o
geog aphic con ex s, hus he impac s iden i ied in he
Basque Coun y and Na a e could se e as a s a ing and
compa ison poin o o he simila egions.
The HIA app oach used in his s udy has allowed a sys-
ema ic p ocess o iden i y, analyze and app aise he wide-
anging consequences o he majo policy measu es in
esponse o he COVID-19 on popula ion heal h, wellbe-
ing and heal h inequali ies. O he s udies ha e also high-
ligh ed he bene i ha HIA can b ing in emphasizing
impac s, which can in o m policy and sha ed lea ning wi h
o he s.10 Howe e , publica ions o da e ha e mainly
ocused on he epidemiological impac s o he pandemic in
ela ion o ansmission a es, mo bidi y, and mo ali y,125
as well as on he economic impac 126 and he e ec i eness
o di e en non-pha maceu ical in e en ions127–129 o
mi iga e he sp ead o he i us. An adap a ion o WHO’s
SDH amewo k o he speci ics o he COVID-19 con ex
has con ibu ed o be e unde s and he complex heal h
and heal h inequali ies impac s o he pandemic.130
Howe e , he e is a need o conduc u he esea ch inco -
po a ing a b oade SDH app oach o be e cap u e he
la ge and unequal consequences o he pandemic ac oss
popula ions.
Mo eo e , i should be no ed in ha non-clinical mea-
su es a e highly dependen on con ex ual ac o s, and hey
ha e been implemen ed o a ying deg ees ac oss coun-
ies in he con ex o he COVID-19 pandemic. Fu u e
esea ch could be ca ied ou in o he con ex s o comple-
men he esul s o his s udy and o iden i y speci ic
aspec s and impac s in o he e i o ies wi h cul u ally,
demog aphically and socio-economically di e en eali-
ies. I also dese es o be men ioned ha his HIA has only
co e ed con ainmen measu es in oduced in he i s
mon hs o he pandemic. This e eals he in e es o u he
explo ing he impac o measu es in oduced in la e s ages
o he pandemic and hei cumula i e e ec on popula ion
heal h, wellbeing and heal h inequali ies. This new knowl-
edge would o be e adap new decisions acco dingly o
he e olu ion o he pandemic and he mos up- o-da e
e idence.
Signi icance o public heal h
This pape has con ibu ed o his gap by in eg a ing a
SDH lens o he analysis o such consequences and by p o-
iding new quali a i e e idence on he expe iences and
eelings o di e en popula ion g oups in wo Spanish
egions. In addi ion and, as poin ed by o he au ho s,10 his
s udy esul s can con ibu e o aising awa eness and be e
unde s anding o he wide heal h impac s o measu es
implemen ed a speed in a global pandemic such as he
COVID-19, as well as o p ospec i ely guide decision
make s in hei ole o p o ec popula ion heal h in simila
c isis in he u u e. And his, wi h a pa icula emphasis on
he di e en ial na u e o impac s on speci ic g oups and
he need o add ess any inequali ies c ea ed o exace ba ed
in such eme gency e en s.
Conclusions
The policies adop ed o cu b he sp ead o he COVID-19
i us ha e had di ec and indi ec impac s on a wide ange
o SDH ha ha e nega i ely a ec ed a wide ange o
heal h indica o s and wellbeing. Mo eo e , hese impac s
ha e been unequally dis ibu ed ac oss social g oups as a
esul o a lack o an equi y pe spec i e when designing
and implemen ing he policy measu es. These unequal and
nega i e heal h consequences need o be sys ema ically
