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      Ecological association between a deprivation index and mortality in France over the period 1997 – 2001: variations with spatial scale, degree of urbanicity, age, gender and cause of death

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      BMC Public Health
      BioMed Central

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          Abstract

          Background

          Spatial health inequalities have often been analysed in terms of deprivation. The aim of this study was to create an ecological deprivation index and evaluate its association with mortality over the entire mainland France territory. More specifically, the variations with the degree of urbanicity, spatial scale, age, gender and cause of death, which influence the association between mortality and deprivation, have been described.

          Methods

          The deprivation index, 'FDep99', was developed at the ' commune'(smallest administrative unit in France) level as the first component of a principal component analysis of four socioeconomic variables.

          Proxies of the Carstairs and Townsend indices were calculated for comparison.

          The spatial association between FDep99 and mortality was studied using five different spatial scales, and by degree of urbanicity (five urban unit categories), age, gender and cause of death, over the period 1997–2001.

          'Avoidable' causes of death were also considered for subjects aged less than 65 years. They were defined as causes related to risk behaviour and primary prevention (alcohol, smoking, accidents).

          Results

          The association between the FDep99 index and mortality was positive and quasi-log-linear, for all geographic scales. The standardized mortality ratio (SMR) was 24% higher for the communes of the most deprived quintile than for those of the least deprived quintile. The between-urban unit category and between- région heterogeneities of the log-linear associations were not statistically significant. The association was positive for all the categories studied and was significantly greater for subjects aged less than 65 years, for men, and for 'avoidable' mortality.

          The amplitude and regularity of the associations between mortality and the Townsend and Carstairs indices were lower.

          Conclusion

          The deprivation index proposed reflects a major part of spatial socioeconomic heterogeneity, in a homogeneous manner over the whole country. The index may be routinely used by healthcare authorities to observe, analyse, and manage spatial health inequalities.

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          Most cited references44

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          Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter?: the Public Health Disparities Geocoding Project.

          N Krieger (2002)
          Despite the promise of geocoding and use of area-based socioeconomic measures to overcome the paucity of socioeconomic data in US public health surveillance systems, no consensus exists as to which measures should be used or at which level of geography. The authors generated diverse single-variable and composite area-based socioeconomic measures at the census tract, block group, and zip code level for Massachusetts (1990 population: 6,016,425) and Rhode Island (1990 population: 1,003,464) to investigate their associations with mortality rates (1989-1991: 156,366 resident deaths in Massachusetts and 27,291 in Rhode Island) and incidence of primary invasive cancer (1988-1992: 140,610 resident cases in Massachusetts; 1989-1992: 19,808 resident cases in Rhode Island). Analyses of all-cause and cause-specific mortality rates and all-cause and site-specific cancer incidence rates indicated that: 1) block group and tract socioeconomic measures performed comparably within and across both states, but zip code measures for several outcomes detected no gradients or gradients contrary to those observed with tract and block group measures; 2) similar gradients were detected with categories generated by quintiles and by a priori categorical cutpoints; and 3) measures including data on economic poverty were most robust and detected gradients that were unobserved using measures of only education and wealth.
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            Socioeconomic inequalities in morbidity and mortality in western Europe. The EU Working Group on Socioeconomic Inequalities in Health.

            Previous studies of variation in the magnitude of socioeconomic inequalities in health between countries have methodological drawbacks. We tried to overcome these difficulties in a large study that compared inequalities in morbidity and mortality between different countries in western Europe. Data on four indicators of self-reported morbidity by level of education, occupational class, and/or level of income were obtained for 11 countries, and years ranging from 1985 to 1992. Data on total mortality by level of education and/or occupational class were obtained for nine countries for about 1980 to about 1990. We calculated odds ratios or rate ratios to compare a broad lower with a broad upper socioeconomic group. We also calculated an absolute measure for inequalities in mortality, a risk difference, which takes into account differences between countries in average rates of illhealth. Inequalities in health were found in all countries. Odds ratios for morbidity ranged between about 1.5 and 2.5, and rate ratios for mortality between about 1.3 and 1.7. For men's perceived general health, for instance, inequalities by level of education in Norway were larger than in Switzerland or Spain (odds ratios [95% CI]: 2.57 [2.07-3.18], 1.60 [1.30-1.96], 1.65 [1.44-1.88], respectively). For mortality by occupational class, in men aged 30-44, the rate ratio was highest in Finland (1.76 [1.69-1.83]), although there was no large difference in the size of the inequality in those countries with data. For men aged 45-59, for whom France did have data, this country had the largest inequality (1.71 [1.66-1.77]). In the age-group 45-64, the absolute risk difference ranked Finland second after France (9.8% [9.1-10.4], 11.5% [10.7-12.4]), with Sweden and Norway coming out more favourably than on the basis of rate ratios. In a scatter-plot of average rank scores for morbidity versus mortality. Sweden and Norway had larger relative inequalities in health than most other countries for both measures; France fared badly for mortality but was average for morbidity. Our results challenge conventional views on the between-country pattern of inequalities in health in western European countries.
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              Educational differences in smoking: international comparison.

              To investigate international variations in smoking associated with educational level. International comparison of national health, or similar, surveys. Men and women aged 20 to 44 years and 45 to 74 years. 12 European countries, around 1990. Relative differences (odds ratios) and absolute differences in the prevalence of ever smoking and current smoking for men and women in each age group by educational level. In the 45 to 74 year age group, higher rates of current and ever smoking among lower educated subjects were found in some countries only. Among women this was found in Great Britain, Norway, and Sweden, whereas an opposite pattern, with higher educated women smoking more, was found in southern Europe. Among men a similar north-south pattern was found but it was less noticeable than among women. In the 20 to 44 year age group, educational differences in smoking were generally greater than in the older age group, and smoking rates were higher among lower educated people in most countries. Among younger women, a similar north-south pattern was found as among older women. Among younger men, large educational differences in smoking were found for northern European as well as for southern European countries, except for Portugal. These international variations in social gradients in smoking, which are likely to be related to differences between countries in their stage of the smoking epidemic, may have contributed to the socioeconomic differences in mortality from ischaemic heart disease being greater in northern European countries. The observed age patterns suggest that socioeconomic differences in diseases related to smoking will increase in the coming decades in many European countries.
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2009
                22 January 2009
                : 9
                : 33
                Affiliations
                [1 ]INSERM, CépiDc, IFR69, Le Vésinet, France
                [2 ]Institute of Public Health Surveillance (InVS), Saint-Maurice, France
                [3 ]INSERM, U754, Université Paris Sud 11, IFR69, Villejuif, France
                Article
                1471-2458-9-33
                10.1186/1471-2458-9-33
                2637240
                19161613
                fb8e6376-6ca4-43ad-acd7-a376f162edea
                Copyright © 2009 Rey et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 21 August 2008
                : 22 January 2009
                Categories
                Research Article

                Public health
                Public health

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