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Associations of cause-specific mortality with area level deprivation and travel time to health care in France from 1990 to 2007, a multilevel analysis.

ABSTRACT: It is now widely accepted that social and physical environment participate in shaping health. While mortality is used to guide public health policies and is considered as a synthetic measure of population health, few studies deals with the contextual features potentially associated with mortality in a representative sample of an entire country. This paper investigates the possible role of area deprivation (FDep99) and travel time to health care on French cause-specific mortality in a proper multilevel setting.The study population was a 1% sample representative of the French population aged from 30 to 79 years in 1990 and followed up until 2007. A frailty Cox model was used to measure individual, contextual effects and spatial variances for several causes of death. The chosen contextual scale was the Zone d'Emploi of 1994 (348 units) which delimits the daily commute of people. The geographical accessibility to health care score was constructed with principal component analysis, using 40 variables of hospital specialties and health practitioners' travel time.The outcomes highlight a positive and significant association between area deprivation and mortality for all causes (HR = 1.24), cancers, cerebrovascular diseases, ischemic heart diseases, and preventable and amenable diseases (HR from 1.14 to 1.29). These contextual associations exhibit no substantial differences by sex except for premature ischemic heart diseases mortality which was much greater in women. Unexpectedly, mortality decreased as the time to reach health care resources increased. Only geographical disparities in cerebrovascular and ischemic heart diseases mortality were explained by compositional and contextual effects.The findings suggest the presence of confounding factors in the association between mortality and travel time to health care, possibly owing to population density and health-selected migration. Although the spatial scale considered to define the context of residence was relatively large, the associations with area deprivation were strong in comparison to the existing literature and significant for almost all the causes of deaths investigated.The broad spectrum of diseases associated with area deprivation and individual education support the idea of a need for a global health policy targeting both individual and territories to reduce social and socio-spatial inequalities.

SUBMITTER: Ghosn W

PROVIDER: S-EPMC5540569 | biostudies-other | 2017 Aug

REPOSITORIES: biostudies-other

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Project description:BACKGROUND: Despite evidence that neighbourhood conditions affect residents' health, no prospective studies of the association between neighbourhood socio-demographic factors and all-cause mortality have been conducted in non-Western societies. Thus, we examined the effects of areal deprivation and population density on all-cause mortality in Japan. METHODS: We employed census and survival data from the Japan Public Health Center-based Prospective Study, Cohort I (n?=?37,455), consisting of middle-aged residents (40 to 59 years at the baseline in 1990) living in four public health centre districts. Data spanned between 1990 and 2010. A multilevel parametric proportional-hazard regression model was applied to estimate the hazard ratios (HRs) of all-cause mortality by two census-based areal variables--areal deprivation index and population density--as well as individualistic variables such as socioeconomic status and various risk factors. RESULTS: We found that areal deprivation and population density had moderate associations with all-cause mortality at the neighbourhood level based on the survival data with 21 years of follow-ups. Even when controlling for individualistic socio-economic status and behavioural factors, the HRs of the two areal factors (using quartile categorical variables) significantly predicted mortality. Further, this analysis indicated an interaction effect of the two factors: areal deprivation prominently affects the health of residents in neighbourhoods with high population density. CONCLUSIONS: We confirmed that neighbourhood socio-demographic factors are significant predictors of all-cause death in Japanese non-metropolitan settings. Although further study is needed to clarify the cause-effect relationship of this association, the present findings suggest that health promotion policies should consider health disparities between neighbourhoods and possibly direct interventions towards reducing mortality in densely populated and highly deprived neighbourhoods.

Project description:BACKGROUND: Relative deprivation has previously been discussed as a possible mechanism underlying the income-health relation. The idea is that income matters to the individual's health, over and above the increased command over resources, as the basis of social comparisons between a person and his or her reference group. The following study aimed to analyze the role of individual-level relative deprivation for all-cause mortality in the Swedish population. The Swedish context, characterized by relatively small income inequalities and promoting values as egalitarianism and equality, together with a large data material provide unique possibilities for analyzing the hypothesized mechanism. METHODS: The data used are prospective longitudinal data from the Swedish population and based on a linkage of registers. Restricting selection to individuals 25-64?years, alive January 1st 1990, gave 4.7 million individuals, for whom a mortality follow-up was done over a 16-year period. The individual level relative deprivation was measured using the Yitzhaki index, calculating the accumulated shortfall between the individual's income and the income of all other's in the person's reference group. All-cause mortality was used as the outcome measure. RESULTS: Relative deprivation, generated through social comparisons, is one possible mechanism within the income and health relation. The present study analyzed different types of objectively defined reference groups, all based on the idea that people compare themselves to similar others. Results show relative deprivation, when measured by the Yitzhaki index, to be significantly associated with mortality. Also, we found a stronger effect among men than among women. Analyzing the association within different income strata, the effect was shown to be weak among the poorest. Revealing the importance of relative deprivation for premature mortality, over and above the effect of absolute income, these results resemble previous findings. CONCLUSION: Relative deprivation, based on social comparisons of income, is significantly associated with premature mortality in Sweden, over and above the effect of absolute income. Also, it was found to be more important among men, but weak among the poorest.

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Associations of cause-specific mortality with area level deprivation and travel time to health care in France from 1990 to 2007, a multilevel analysis.

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