Introduction
On December 31, 2019, China reported a cluster of 27 cases of pneumonia of unknown etiology. By January 7, 2020, the country's authorities identified the causative agent as a new type of coronavirus, which was named SARS-CoV-2. The virus spread rapidly, and on March 11, 2020, the World Health Organization declared the COVID-19 situation a pandemic (1-3).
Three days later, on March 14, 2020, Spain declared a state of emergency through Royal Decree 463/2020 to manage the health crisis caused by COVID-19, which included the suspension of in-person educational activities nationwide (4). In May 2020, a partial reopening of educational institutions began, accompanied by a package of preventive and hygiene measures against COVID-19 (5). In September 2020, the Ministry of Health published a report with preventive instructions, hygiene protocols, and health promotion guidelines to resume in-person education at all educational levels for the 2020-2021 academic year (6). This report emphasized the need for students to return to in-person education in a safe, healthy, and sustainable manner, after analyzing the impact of school closures on students' health and well-being, as well as the progression of the pandemic. However, it did not address the potential impact that this package of measures might have on students' compliance based on social determinants of health.
There is substantial scientific evidence linking social determinants of health or health inequities to exposure to SARS-CoV-2 in terms of morbidity and mortality (7-13), even in pediatric populations (10,14). However, the concept of epidemiological vulnerability not only refers to the risk of contracting the infection, delays in diagnosing COVID-19, or difficulties in identifying close contacts, but also includes the population's difficulty in following prevention, control, and containment measures for the infection itself (15). The World Health Organization has recognized the challenges in adhering to COVID-19 measures in vulnerable populations, such as individuals experiencing homelessness, those living in overcrowded conditions, poor housing, marginalized neighborhoods, immigrants, refugees, individuals with disabilities, people residing in closed facilities, those in poverty, and the digital divide (16).
The school population is not exempt from belonging to these vulnerable groups, and therefore, it is reasonable to assume that students may face difficulties in complying with COVID-19 measures, even during their educational activities. A prospective cohort study conducted in Belgium by Callies et al. (17) showed that with lower implementation of preventive and control measures in schools, there was a higher prevalence of antibodies against SARS-CoV-2 among students and teaching staff, suggesting greater virus transmission.
Against this backdrop, the primary objective of the study was to analyze the influence of social determinants of health on compliance with SARS-CoV-2 prevention, control, and containment measures in schoolchildren in the city of Bilbao, as perceived by the teaching staff of educational institutions.
Materials and Methods
Design
Observational, descriptive, and cross-sectional study with an analytical approach.
Population and Study Setting
The study population consisted of 4050 teachers from early childhood education, primary, secondary, and high school levels from public, subsidized private, and private educational institutions located in the city of Bilbao (Basque Country, Spain), across 87 schools. The participants and source of information were the teachers, as they are the individuals best acquainted with the dynamics and social situation of students both individually and collectively, as well as being the key observers of compliance with COVID-19 measures throughout the educational day.
Sample, Sampling, and Sample Size
The entire study population was accessed. The sample size was estimated with a 95% confidence level, a population of 4050 teachers, and a 5% margin of error. Based on this, it was estimated that 352 valid responses were necessary.
Inclusion and Exclusion Criteria
The inclusion criteria were: educational institutions providing early childhood education, primary, secondary, and high school education located in the city of Bilbao, whether public, private subsidized, or private.
Exclusion criteria included: nurseries, vocational training centers, universities, official language schools, Basque language teaching centers (euskaltegis), and academies, irrespective of ownership.
Data Collection Instrument
The instrument used for data collection was an online, self-administered survey designed specifically for this study. It was not validated, as no validated questionnaires were available in our region for this purpose. The ad hoc questionnaire collected information on compliance with COVID-19 measures.
Survey Administration, Data Collection, and Time Frame
The questionnaire was administered between November 5, 2021, and January 5, 2022. To select the sample, the questionnaire was sent via email to the management team of each educational institution, who were then responsible for forwarding the questionnaire link to the teaching staff for completion. Data related to secondary variables or axes of inequality were collected from the Basque Institute of Statistics (18).
Data Analysis
Descriptive analysis was performed, with qualitative variables expressed as frequencies and percentages, and quantitative variables expressed as means and standard deviations if normally distributed, or as medians and interquartile ranges if non-normally distributed. Additionally, bivariate analysis was conducted between sociodemographic variables and both primary and secondary variables. The chi-square test (χ²), Fisher's test, Student's t-test, or the Mann-Whitney U test were used. Data were analyzed using SPSS software, version 21.0. The statistical significance level was set at α or Type I error of 5% (p < 0.05).
Ethical Considerations
The study adhered to the basic ethical principles for clinical research, in accordance with the good clinical practice standards outlined in the Declaration of Helsinki (Fortaleza 2013) and the Oviedo Convention (1997). The handling, communication, and transfer of data complied with the provisions of the General Data Protection Regulation (GDPR) EU 2016/679 of the European Parliament and the Council of the European Union, dated April 27, 2016, which came into effect on May 25, 2018, and its incorporation into Spanish law through Organic Law 3/2018, of December 5, on the protection of personal data and the guarantee of digital rights. No personal data that could identify participants was collected, ensuring the confidentiality of the participants at all times (19,20).
Each participating teacher in the study freely and voluntarily signed the informed consent form online, after being provided with the study information sheet in advance. The study was reviewed and received a favorable opinion from the Research Ethics Committee of the Integrated Health Organization (OSI) Bilbao-Basurto (code: 104.21 CEICHUB) and was authorized by the Nursing Directorate of OSI Bilbao-Basurto for its execution and development.
Results
Description of Sociodemographic Variables: Axes of Inequality
The city of Bilbao has a population of 340,455 inhabitants, of which 10.1% are immigrants. Of the total population, 15.7% are under the age of 20. The municipality has a total area of 4059 hectares and is divided into 8 districts and 40 neighborhoods. It has a population density of 8387.7 inhabitants/km², with an unemployment rate of 13.7%. Table 1 describes the demographic characteristics of the city of Bilbao by district.
Table 1.
Sociodemographic Variables Description (Axes of
Inequality) of the City of Bilbao (Spain)
Source: Based on data from the
Basque Institute of Statistics.
The districts with the highest population are those occupying the central areas of the city (Ibaiondo, Abando, Deusto, and Rekalde), while the districts with the lowest population are the more peripheral ones (Otxarkoaga-Txurdinaga and Basurto-Zorroza). Similarly, the districts with the highest density are Abando and Begoña, while the districts with the lowest density are Basurto-Zorroza, Ibaiondo, Otxarkoaga-Txurdinaga, and Rekalde. Data on family income show significant differences between districts: Abando has the highest income, and Rekalde and Otxarkoaga-Txurdinaga have the lowest. On the other hand, Ibaiondo is the district with the highest percentage of immigrants, the highest percentage of emergency social aid, and the highest number of family households (Table 1).
Description of Secondary Sociodemographic Variables: Educational
The response rate was 24.7% among the total number of teachers in Bilbao, yielding 997 valid responses. Of the 87 educational institutions that met the inclusion criteria, representation was obtained from 81 of them (93.1%), with 47 (58.0%) being public, 30 (37.0%) subsidized private, and 4 (4.9%) private. By district, the number of participating schools was as follows: Deusto, 9 (11.1%); Uribarri, 10 (12.4%); Otxarkoaga-Txurdinaga, 14 (17.3%); Begoña, 7 (8.6%); Ibaiondo, 12 (14.8%); Abando, 15 (18.5%); Rekalde, 10 (12.4%); and Basurto-Zorroza, 4 (4.9%).
Regarding the 997 teachers who participated, significant differences were found based on the type of school (p < 0.0001), with 476 (47.7%) belonging to public schools, 510 (51.2%) to subsidized private schools, and 11 (1.1%) to private schools. By district, the number of teachers was as follows: Deusto, 139 (13.9%); Uribarri, 112 (11.2%); Otxarkoaga-Txurdinaga, 127 (12.7%); Begoña, 111 (11.1%); Ibaiondo, 156 (15.6%); Abando, 205 (20.6%); Rekalde, 110 (11.0%); and Basurto-Zorroza, 37 (3.7%).
By educational level, 118 teachers (11.8%) were from early childhood education, 396 (39.7%) from primary education, 330 (33.1%) from secondary education, and 153 (15.3%) from high school. Statistically significant differences were also found between districts and educational levels (p < 0.0001).
Compliance with Anti-COVID-19 Measures
In general, a high percentage of positive responses regarding the compliance with anti-COVID-19 measures was observed, and statistically significant differences were found according to the educational level (p < 0.0001). Primary and high school teachers reported a higher percentage of compliance by almost all or all students (87.9% and 86.3%, respectively). In contrast, the early childhood education stage showed the lowest compliance rate, with only 68.7%.
Additionally, differences were found based on the type of educational institution (p = 0.001): private schools reported the highest degree of compliance by all or almost all students (100%), followed by subsidized private schools (88.1%) and public schools (77.7%). Similarly, differences were found by district (p = 0.006): Basurto-Zorroza and Otxarkoaga-Txurdinaga reported the lowest compliance by all or almost all students (64.8% and 78%, respectively) (Table 2).
Table 2.
General Compliance with COVID-19 Prevention and
Control Measures
La figura 1 muestra los resultados en cuanto al grado de cumplimiento de cada medida (mascarillas, higiene de manos, distancias y ventilación) en función de la etapa educativa, tipo de centro educativo y distrito.
Figure 1.
Greater versus lesser compliance with different
anti-COVID-19 measures according to educational level, type of educational
institution, and district
Use of Masks
The use of masks was reported in 91% of students in educational institutions. The remaining 9%, who did not wear masks, were all in the early childhood education stage, where the use of masks was not standardized as mandatory.
Among the educational stages that used masks, correct usage was identified in a higher percentage of "almost all" students across all stages, with higher rates as the age increased: primary education (66.7%), secondary education (68.2%), and high school (68.6%), with statistically significant differences (p < 0.0001). Additionally, differences were found between correct mask use and the type of educational institution (p = 0.001), with "almost all" cases using them correctly in public schools (57.6%), subsidized private schools (63.5%), and private schools (81.8%). Similarly, differences were found between correct mask use and the district (p = 0.003), although correct mask use was lower in the districts of Otxarkoaga-Txurdinaga and Basurto-Zorroza (Table 3).
Table 3.
Compliance with COVID-19 Prevention and Control
Measures: Use of Masks (n = 997)
Regarding calls for attention by the teaching staff for students to wear masks correctly, significant differences were found by educational level (p < 0.0001): most frequent in secondary education (35.2%) and occasionally in primary education (37.6%) and high school (37.9%). Similarly, there were differences in this variable by type of educational institution (p = 0.002), with calls for attention being frequent in public schools (35.3%), occasionally in subsidized private schools (35.5%), and rarely in private schools (45.5%). Lastly, differences by district were found (p = 0.004), with Otxarkoaga-Txurdinaga being the district where these calls for attention occurred most frequently.
Regarding mask use outdoors during the school day and educational level, differences were found (p < 0.0001): widespread use among "all" students in primary education, with 69.7%; in secondary education, 51.5%, and in high school, 30.1%. The same differences were observed concerning the type of educational institution (p < 0.0001), where private schools had the highest percentage of "almost all" or "all" students wearing masks outdoors (91%), followed by subsidized private schools (77.4%) and public schools (69.7%). Finally, statistically significant differences were also found by district (p = 0.003), with central districts showing mask use by almost all or all students, such as Begoña (81%) compared to Otxarkoaga-Txurdinaga (68.5%).
When exploring whether students bring a spare mask to school, differences were found by educational stage (p < 0.0001): in primary education, "almost all" (43.4%) brought a spare mask, while "some" brought them in secondary education (40.3%) and high school (47.1%). Similarly, there were differences by type of educational institution (p < 0.0001), with 31.5% of "almost all" or "all" students bringing a spare mask in public schools, 49.8% in subsidized private schools, and 54.6% in private schools. Additionally, differences were found between spare mask use and district (p = 0.040), with Abando being the district where the highest percentage of students brought a spare mask.
Hand Hygiene
Regarding the hand hygiene variable, significant differences were found (p < 0.0001) in the correct performance of hand hygiene by educational stage: it was higher in early childhood education (94.9%) and primary education (92.1%) compared to secondary education (65.8%) and high school (66.7%). No significant differences were found regarding the type of educational institution or district.
Additionally, the regular use of alcohol-based hand sanitizers in the classroom was explored, and statistically significant differences were observed by educational stage (p < 0.0001): in early childhood education, the use was frequent or always at 74.6%; in primary education, at 94.4%; in secondary education, at 88.5%; and in high school, at 85.6%. Differences were also found between the use of alcohol-based hand sanitizers in the classroom and the type of educational institution (p < 0.0001), with 83.5% of classrooms in public schools, 93.7% in subsidized private schools, and 91% in private schools using it frequently or always.
When exploring the availability of alcohol-based hand sanitizers in common areas by type of educational institution, no significant differences were found (p = 0.743). The availability of these dispensers was greater than 90% in public, subsidized private, and private schools. Similarly, differences in the availability of these dispensers by district were reported (p = 0.003), with lower availability in the districts of Otxarkoaga-Txurdinaga, Basurto-Zorroza, and Rekalde, where teachers reported fewer alcohol-based hand sanitizers in common areas of their educational institutions (Table 4).
Table 4.
Compliance with
COVID-19 Prevention and Control Measures: Hand Hygiene (n = 997)
Interpersonal Distance
Regarding the distance between students within the classroom, statistically significant differences were found by educational stage (p < 0.0001). In this regard, 83.1% of early childhood education classrooms reported that the distance between students was less than 0.5 meters, while in primary education, secondary education, and high school, the most frequent response was a distance between 0.5 and 1 meter, with 45.5%, 49.7%, and 41.8%, respectively. Similarly, there were differences between student distances in the classroom and the type of educational institution (p < 0.0001). Public schools reported a higher rate of responses indicating distances between students of 0.5 and 1 meter (42.6%), followed by subsidized private schools (41.8%), while private schools reported distances between 1.5 and 2 meters as the most frequent between their students (45.5%). Finally, differences were found between the distance between students in the classroom and districts (p = 0.002), with the Otxarkoaga-Txurdinaga district having the highest proportion of students maintaining the recommended distance of at least 1.5 meters (Table 5).
Classroom Ventilation
Natural ventilation was present across all educational levels, regardless of the type of educational institution, with no significant differences found (p = 0.792 and p = 0.198, respectively). In line with this, there were also no statistically significant differences between natural ventilation and district (p = 0.254) (Table 5).
Artificial ventilation was absent across all educational levels, although differences were found based on the type of educational institution (p < 0.0001). It was more frequently present in private schools (45.5%), followed by subsidized private schools (9.8%) and public schools (1.3%). Additionally, differences were found for the presence of artificial ventilation by district (p < 0.0001), with Otxarkoaga-Txurdinaga (14.2%) having the highest presence and Basurto-Zorroza (0.0%) the lowest (Table 5). However, when analyzing the district of Otxarkoaga-Txurdinaga by its two neighborhoods, the presence of artificial ventilation was concentrated in Txurdinaga (100%) but absent in Otxarkoaga (0.0%).
Table 5.
Compliance with
COVID-19 Prevention and Control Measures: Distances and Ventilation (n = 997)
Discussion
This study highlights a high level of compliance with COVID-19 prevention and control measures by students, which supports the findings of other studies (21-23). This could explain the results of studies in our area indicating that the most frequent exposure/transmission setting was the family/home environment rather than the educational setting (24-26). Moreover, differences in compliance with anti-COVID-19 measures were found to be related to axes of inequality, such as age, district, or type of educational institution. In this way, public schools and lower-income districts reported lower levels of compliance, which aligns with the study by Lee et al. (27), which showed that individuals from lower educational or socioeconomic levels were more likely to fail to comply with COVID-19 prevention, control, and containment measures.
Social inequalities in health influenced the correct use of masks by students. Higher mask usage was found as the educational stage increased, in private schools, and in socioeconomically advantaged districts. The proportion of students in our study who used masks correctly in the classroom is very similar to the figures found in other studies, around two-thirds of students (28).
Regarding hand hygiene, correct hand hygiene was most frequently reported in early childhood and primary education, which may be explained by the greater supervision or monitoring by teachers in these stages. In line with this, the more frequent regular use of alcohol-based hand sanitizers in primary education compared to other educational stages can be explained. Similarly, districts again emerged as axes of inequality regarding the presence of alcohol-based hand sanitizers in common areas of educational institutions, with lower availability in districts with greater social health inequalities. This can be justified by the additional cost involved in implementing this measure in schools with fewer resources, as evidenced in the study by Lorenc et al. (29).
Regarding the distance between students in the classroom, it can be observed that, in general, in all educational stages, the recommendation of maintaining at least 1.5 meters of distance, as mandated by health authorities, was not met. This finding is supported by the results of the study by Lorenc et al. (29), which showed that students, teachers, and parents reported the impossibility of applying this measure due to the number of students and lack of space in the classrooms. On the other hand, within the ownership of the schools, private schools reported achieving this recommendation at a higher percentage, which could be explained by the lower overcrowding in the classrooms of such institutions—a topic that could be further explored in future research.
In terms of artificial ventilation, although the Otxarkoaga-Txurdinaga district has the highest presence of artificial ventilation (14.2%), it is entirely concentrated in the Txurdinaga neighborhood (100%). This can be explained by the lack of homogeneity between the two neighborhoods, where, for example, the income in Txurdinaga is double that in Otxarkoaga, leaving the latter as one of the poorest and most unequal neighborhoods in Bilbao (30,31). Similarly, purchasing power allows for more artificial ventilation in classrooms, which was present in half of the classrooms in private schools and only in one out of every ten classrooms in public schools. The study by Jones et al. (32) was one of the first to consider ventilation as a factor in preventing and controlling COVID-19 infection. However, research conducted in classrooms of two Swiss schools by Banholzaer et al. (33) demonstrated that mask use is more effective than artificial ventilation, as it reduces aerosol and viral particle concentrations by 69% compared to 39%, respectively.
Limitations
Among the limitations of this study are the use of a non-validated questionnaire and the data collection at the beginning of the school year (during the first term), which led us to assume that teachers with temporary employment contracts might be unaware of the sociodemographic factors of their students.
Conclusiones
The limitations of this study include the use of a non-validated questionnaire and data collection at the beginning of the school year (during the first term), which led us to assume that teachers with temporary contracts might be unaware of the sociodemographic factors of their students. Strengths include the representativeness of the educational institutions and the sample size obtained, which lends external validity to the results of this study.
Acknowledgments
We would like to thank Amaia Vallejo-Angulo and Sendoa
Ballesteros-Peña for their guidance in presenting and obtaining favorable
reports. Thanks to the Euskera Technical Service of OSI Bilbao-Basurto for the
translations provided. Special thanks to Héctor Sánchez-Herrero for his invaluable
support throughout this research. We also appreciate the participation of all
the teachers who selflessly contributed to the completion of this study.
References
1. World Health Organization. Coronavirus disease 2019 (COVID-19): Situation report-51 [internet]. Washington; 2020 mar 11. Disponible en: https://www.who.int/publications/m/item/situation-report---51
2. World Health Organization. WHO director-general´s opening remarks at the media briefing on COVID-19 [internet]. Ginebra; 2020 mar 11. Disponible en: https://www.who.int/news-room/speeches/item/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
3. Ministerio de Sanidad de España. Plan de respuesta temprana en un escenario de control de la pandemia por COVID-19 [internet]. Madrid; 2020. Disponible en: https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/COVID19_Plan_de_respuesta_temprana_escenario_control.pdf
4. Boletín Oficial del Estado. Real Decreto 463/2020, de 14 de marzo, por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el COVID-19. BOE núm. 67 de 14 de marzo de 2020 [internet]. Disponible en: https://www.boe.es/eli/es/rd/2020/03/14/463
5. Ministerio de Sanidad y Ministerio de Educación y Formación Profesional. Medidas de prevención e higiene frente a la COVID-19 para la reapertura parcial de centros educativos en el curso 2019-2020 [internet]. Madrid; 2020. Disponible en: https://www.educacionyfp.gob.es/dam/jcr:52e023fd-339f-48af-96f1-ddd6ad77c4fd/20200514-medidas-sanitarias-para-reapertura-centros-fase-2-final.pdf
6. Ministerio de Sanidad y Ministerio de Educación y Formación Profesional. Medidas de prevención, higiene y promoción de la salud frente a COVID-19 para centros educativos en el curso 2020-2021 [internet]. Madrid; 2020. Disponible en: https://www.sanidad.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/Medidas_centros_educativos_Curso_2020_2021_17.09.20.pdf
7. Mazzalai E, Giannini D, Tosti ME, D’Angelo F, Declich S, Jaljaa A, et al. Risk of covid-19 severe outcomes and mortality in migrants and ethnic minorities compared to the general population in the European WHO region: a systematic review. J Int Migr Integr. 2023;24(3):1305-35. https://doi.org/10.1007/s12134-023-01007-x
8. Agyemang C, Richters A, Jolani S, Hendriks S, Zalpuri S, Yu E, et al. Ethnic minority status as social determinant for COVID-19 infection, hospitalisation, severity, ICU admission and deaths in the early phase of the pandemic: a meta-analysis. BMJ Glob Heal. 2021;6(11):e007433. https://doi.org/10.1136/bmjgh-2021-007433
9. Acosta AM, Garg S, Pham H, Whitaker M, Anglin O, O’Halloran A, et al. Racial and ethnic disparities in rates of COVID-19-associated hospitalization, intensive care unit admission, and in-hospital death in the United States from March 2020 to February 2021. JAMA Netw Open. 2021;4(10):e2130479. https://doi.org/10.1001/jamanetworkopen.2021.30479
10. Abrams EM, Greenhawt M, Shaker M, Pinto AD, Sinha I, Singer A. The COVID-19 pandemic: adverse effects on the social determinants of health in children and families. Ann Allergy Asthma Immunol. 2022;128(1):19-25. https://doi.org/10.1016/j.anai.2021.10.022
11. Yancy CW. COVID-19 and African Americans. JAMA. 2020;323(19):1891-2. https://doi.org/10.1001/jama.2020.6548
12. Burström B, Tao W. Social determinants of health and inequalities in COVID-19. Eur J Public Health. 2020;30(4):617-8. https://doi.org/10.1093/eurpub/ckaa095
13. Tsai J, Wilson M. COVID-19: a potential public health problem for homeless populations. Lancet Public Health. 2020;5(4):e186-7. https://doi.org/10.1016/s2468-2667(20)30053-0
14. Davies P, Evans C, Kanthimathinathan HK, Lillie J, Brierley J, Waters G, et al. Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study. Lancet Child Adolesc Health. 2020;4(9):669-77. https://doi.org/10.1016/s2352-4642(20)30215-7
15. Ministerio de Sanidad de España. Equidad en salud y COVID-19: análisis y propuestas para abordar la vulnerabilidad epidemiológica vinculada a las desigualdades sociales [internet]. Madrid; 2020. Disponible en: https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/COVID19_Equidad_en_salud_y_covid19.pdf
16. World Health Organization Western Pacific Region. Actions for consideration in the care and protection of vulnerable population for COVID-19 [internet]. 2021. Disponible en: https://iris.who.int/bitstream/handle/10665/333043/WPR-DSE-2020-021-eng.pdf?sequence=5
17. Callies M, Kabouche I, Desombere I, Merckx J, Roelants M, Vermeulen M, et al. SARS-CoV-2 infection prevention and control measures in Belgian schools between December 2020 and June 2021 and their association with seroprevalence: a cross-sectional analysis of a prospective cohort study. BMC Public Health. 2023;23(1).1-11. https://doi.org/10.1186/s12889-023-15806-5
18. Instituto Vasco de Estadística (Eustat). Datos estadísticos de Bilbao [internet]. Disponible en: https://www.eustat.eus/municipal/datos_estadisticos/bilbao_c.html
19. Reglamento (UE) 2016/679 del Parlamento Europeo y del Consejo, de 27 de abril de 2016, relativo a la protección de las personas físicas en lo que respecta al tratamiento de datos personales y a la libre circulación de estos datos y por el que se deroga la Directiva 95/46/CE (Reglamento general de protección de datos). Diario Oficial de la Unión Europea núm. 119 [internet], de 4 de mayo de 2016. Disponible en: http://data.europa.eu/eli/reg/2016/679/oj
20. Ley Orgánica 3/2018, de 5 de diciembre, de protección de datos personales y garantía de los derechos digitales [internet]. Boletín Oficial del Estado núm. 294, de 6 de diciembre de 2018. Disponible en: https://www.boe.es/eli/es/lo/2018/12/05/3/con
21. Paulsen M, Zychlinsky Scharff A, de Cassan K, Sugianto RI, Blume C, et al. Children and adolescents' behavioral patterns in response to escalating COVID-19 restriction reveal sex and age differences. J Adolesc Health. 2022;70(3):378-86. https://doi.org/10.1016/j.jadohealth.2021.11.021
22. Nivette A, Ribeaud D, Murray A, Steinhoff A, Bechtiger L, Hepp U, et al. Non-compliance with COVID-19-related public health measures among young adults in Switzerland: Insights from a longitudinal cohort study. Soc Sci Med. 2021;268:113370. https://doi.org/10.1016/j.socscimed.2020.113370
23. Von Soest T, Pedersen W, Bakken A, Sletten MA. Compliance with infection control rules among adolescents in Oslo during the COVID-19 pandemic. Tidsskr Nor Laegeforen. 2020;140(10). https://doi.org/10.4045/tidsskr.20.0449
24. Gamboa-Moreno E, Garitano-Gutiérrez I, Portuondo-Jiménez J, Cabrera-Rodríguez A, Aldeguer-Corbi J, Tapia-Alonso N, Arrospide A, Picón-Santamaría A. Baja transmisión del SARS-CoV-2 en el ámbito escolar: estudio poblacional en Euskadi. Rev Esp Salud Publica [internet]. 2021;95:e202112196. Disponible en: https://pubmed.ncbi.nlm.nih.gov/34927605/
25. Cárdenas-Soriano MP, Medrano-Sánchez JC, Gómez-Martínez JA. Transmisión del SARS-CoV-2 en escolares durante el primer trimestre del curso 2021/2022 en la provincia de Albacete: incidencia e impacto de las nuevas variantes. Aten Primaria. 2023;55(1):102516. https://doi.org/10.1016/j.aprim.2022.102516
26. Jordan I, Fernandez de Sevilla M, Fumado V, Bassat Q, Bonet-Carne E, Fortuny C, et al. transmission of severe acute respiratory syndrome coronavirus 2 infection among children in summer schools applying stringent control measures in Barcelona, Spain. Clin Infect Dis. 2022;74(1):66-73. https://doi.org/10.1093/cid/ciab227
27. Lee GB, Jung SJ, Yiyi Y, Yang JW, Thang HM, Kim HC. Socioeconomic inequality in compliance with precautions and health behavior changes during the COVID-19 outbreak: an analysis of the Korean Community Health Survey 2020. Epidemiol Health. 2022;44:e2022013. https://doi.org/10.4178/epih.e2022013
28. Arvelo W, Fahrenbruch M, Hast M, Puddy R. COVID-19 stats: percentage of middle and high school students aged 13-21 years attending in-person classes who reported observing fellow students wearing a mask all the time,* by School Setting and Activity - United States, October 2020. MMWR Morb Mortal Wkly Rep. 2021;70(6):223. https://doi.org/10.15585/mmwr.mm7006a5
29. Lorenc A, Kesten JM, Kidger J, Langford R, Horwood J. Reducing COVID-19 risk in schools: a qualitative examination of secondary school staff and family views and concerns in the South West of England. BMJ Paediatr Open. 2021;5(1):e000987. https://doi.org/10.1136/bmjpo-2020-000987
30. Instituto Vasco de Estadística (Eustat). Renta familiar media de la C.A. de Euskadi por barrio de residencia de las capitales, según tipo de renta (euros) [internet]. 2021. Disponible en: https://www.eustat.eus/elementos/ele0006200/renta-familiar-media-de-la-ca-de-euskadi-por-barrio-de-residencia-de-las-capitales-segun-tipo-de-renta-euros/tbl0006266_c.html
31. Otxarkoaga-Txurdinaga no remonta. El Correo [internet]. 2023 may 17. Disponible en: https://www.elcorreo.com/elecciones/forales-municipales/otxarkoagatxurdinaga-remonta-20230514164835-nt.html
32. Jones NR, Qureshi ZU, Temple RJ, Larwood JPJ, Greenhalgh T, Bourouiba L. Two metres or one: what is the evidence for physical distancing in covid-19? BMJ. 2020;370:m3223. https://doi.org/10.1136/bmj.m3223
33. Banholzer N, Zürcher K, Jent P, Bittel P, Furrer L, Egger M, et al. SARS-CoV-2 transmission with and without mask wearing or air cleaners in schools in Switzerland: a modeling study of epidemiological, environmental, and molecular data. PLoS Med. 2023;20(5). https://doi.org/10.1371/journal.pmed.1004226
Notes
Conflict of Interest
The authors declare that they have no conflicts of
interest.
Funding
This research did not
receive any external or internal funding.
Author notes
a Correspondence author: airamcabrera89@gmail.com
Additional information
How to
cite: Cabrera-Rodríguez A, Bóveda-San
José A, Alarcia-Mercado J, Menéndez-Pérez F, Barrueta-Beraza MS, Recalde-Polo ME, Martín-González JA, Mármol-López MI. Social
Determinants and Compliance with COVID-19 Measures among Schoolchildren in
Bilbao, Spain: A Cross-Sectional Study. Univ
Med. 2026;67. https://doi.org/10.11144/Javeriana.umed67.sdcc
