From citizen voice to urban policy in Bilbao: socioeconomic inequalities in food environment

Background

Urban food environments are key social determinants of health, yet their impacts vary by neighbourhood socioeconomic status (SES), shaping unequal capacity to benefit from public action. Participatory approaches such as Photovoice identify community priorities, but evidence on their translation into policy is limited. This study assessed whether citizen-generated recommendations from three Bilbao neighbourhoods were incorporated into municipal policies four years later.

Methods

A community-based participatory research approach was used. In 2017, 23 residents participated in a Photovoice project and co-created recommendations to improve their food environment. A document analysis assessed alignment between these recommendations and actions included in the Bilbao Municipal Health Plan (2019–2023) and its 2021 follow-up report. Implementation was classified as fulfilled, partially fulfilled, or unmet.

Results

A total of 18 recommendations and 58 actions were identified, revealing socioeconomic gradients in priorities and implementation. While 50% of recommendations were fulfilled, implementation varied by domain. Lifestyle (67%) and sociocultural (60%) recommendations showed higher uptake, whereas physical (43%) and economic (33%) ones were less frequently implemented. Economic actions were entirely unmet in the low-SES neighbourhood. Overall, policy responses favoured behavioural and community-level interventions over structural changes affecting affordability, infrastructure and local food environments.

Conclusions

Citizen-generated recommendations revealed neighbourhood-specific priorities, but policy implementation was uneven. Lifestyle and sociocultural actions were more readily adopted, while economic and physical determinants remained largely unaddressed, particularly in disadvantaged contexts. These findings highlight the need for equity-oriented urban policies prioritising structural interventions.

Key messages

• Citizen priorities for food environments differ by socioeconomic context, reflecting unequal needs across neighbourhoods.

• Policy responses favoured behavioural actions over structural change, limiting their full potential to reduce health inequalities.