Regular articleThe public health burden of material deprivation: excess mortality in leading causes of death in Spain☆
Introduction
As in many other western countries, overall death rates have fallen steadily in Spain in the past decade [1]. Mortality due to some leading causes of death such as ischemic heart disease [2] and cerebrovascular diseases [3], [4], for example, has clearly declined. These improvements in the nation’s health have not diminished health inequality across regions of Spain, however. Overall mortality indicators remain the worst in the most deprived areas of the country and they show considerable variations by region parallel to the variations in material deprivation levels [5], [6].
We previously investigated the extent and pattern of associations between material deprivation and top 10 leading causes of deaths in Spain [7]. Given the strong association we observed for many of the leading causes, a pressing public health issue is the societal burden of excess mortality that is imposed on deprived areas by such inequalities. The concept of “excess of death” goes back at least to William Farr [8] and has been used in a number of studies [9], [10], [11]. In previous research [6], we found that a deprivation index 1 predicted mortality for the age group 65 or over but not for the age group 0–64, while, in contrast, an index 2 predicted mortality for both age groups. In this study, we estimate the number and proportion of excess deaths in each of top 10 leading mortality causes for each gender and these two age groups. To our knowledge this is the first nation-wide study which has estimated the public health burden of deprivation-associated excess mortality by leading causes of death.
Section snippets
Methods
We used a large nation-wide mortality dataset in 2218 small areas of Spain covering a 9-year period between 1987 and 1995. Data on top 10 leading causes of death were obtained from death certificates of the National Institute of Statistics of Spain by age and gender in each small area. The numbers of cause-specific deaths are shown in Table 1 by cause and gender. Top 10 leading causes of death accounted for 57% of 1,568,186 total deaths among men and 61% of 1,389,913 total deaths among women.
Results
Table 2 shows descriptive data on population and mortality, socioeconomic indicators, and deprivation indices for each of the 17 regions of Spain. Deprivation indices varied remarkably across Autonomous Communities: the worst deprivation indices were seen in southern regions such as Andalusia and Extremadura, while most northern regions such as Navarre, Catalonia, Rioja, and Aragon showed better scores. Table 3a, Table 3b, Table 4a, Table 4b show the number of annual deathsfor each of the 17
Discussion
Over the past years, studies on health inequalities have emphasized the large public health impact of socioeconomic determinants [14], [15], [16], [17]. A study in the northern region of England found that 930 excess deaths could be annually prevented in the wards with the highest mortality [9]. In Britain, in the 3-year period of 1990–1992, it was calculated that there were 77,000 excess deaths representing about 4% of all mortality [18]. In another study in England and Wales all-cause
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This study was partially funded by a grant from the Fondo de Investigaciones Sanitarias (FIS 99/1225). There was no conflict of interest.