Associations between socioeconomic index and mortality in rural and urban small geographic areas of Catalonia, Spain: Ecological study

Caro-Mendivelso J, Elorza-Ricart JM, Hermosilla E, Méndez-Boo L, García-Gil M, Prieto-Alhambra D, Medina M


Objective: To analyse the association between MEDEA (Mortality in small areas of Spain and socioeconomic and environmental inequalities) index and mortality in urban and rural areas of Catalonia.

Methods: An ecological study based on the analysis of census section.  The data source used for census section and variables to calculate the MEDEA index was the census (2001). Mortality data were obtained from System for the Development of Research in Primary Care (SIDIAP). The census sections were classified as rural or urban. The association between mortality and the socioeconomic index was analysed as categorical variable (quintiles). Poisson models were fitted to study the association between MEDEA index and mortality. Analysis was done with the STATA software, version 12.

Results: In January 2009, a total of 4,526,071 adults (> 14 years old) were assigned to ICS (Institut Català de la Salut ) primary healthcare centres. The identified population lived in 5,214 census sections out of a total of 5,222 existing areas, from which 4096 (78.5%) were urban. The association between MEDEA quintiles and mortality was significant for urban areas excluding Barcelona: excess mortality was 5% (IRR = 1.05 IC 95% 1.01-1.10), being higher in urban areas (IRR = 1.11 95% CI 1.08 to 1.15) and even higher in Barcelona (IRR = 1.24 95% CI 1.18 to 1.31). This association was not significant for rural areas (IRR = 0.95 CI 95% 0.88-1.02).

Conclusions:Socioeconomic deprivation, measured with the MEDEA index, was related with an increase in total mortality in urban areas of Catalonia. In rural areas there was no association with mortality.

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Díez-Roux AV. Investigating neighborhood and area effects on health. Am J Public Health. 2001;91:1783-9.

Díez-Roux AV. The study of group-level factors in epidemiology: Rethinking Variables, Study Designs, and Analytical Approaches. Epidemiol Rev. 2004;26:104-11.

Puigpinós-Riera R, Marí-Dell’Olmo M, Gotsens M, et al. Cancer mortality inequalities in urban areas: a Bayesian small area analysis in Spanish cities. International Journal of Health Geographics. 2011;10:6.

Manrique-Garcia E, Sidorchuk A, Hallqvist J, et al. Socioeconomic position and incidence of acute myocardial infarction: a meta-analysis. J Epidemiol Community Health. 2011;65:301-9.

Fukuda Y, Nakamura K, Takehito T. Higher mortality in areas of lower socioeconomic position measured by a single index of deprivation in Japan. Public Health.2007;121:163-73.

Padilla C, Lalloué B, Pies C, et al. An Ecological study to identify census blocks supporting a higher burden of disease: infant mortality in the lille metropolitan area, France. Matern Child Health J.2014;18:171-9.

Stringhini S, Dugravot A, Shipley M. Health behaviours, socioeconomic status, and mortality: Further Analyses of the British Whitehall II and the French GAZEL prospective Cohorts. PLoS Med.2011;8:e1000419.

Townsend P, Phillimore P, Beattie A. Health and deprivation. Inequality and the North. London: Routledge; 1988.

Domínguez-Berjón MF, Borrell C, Cano-Serral G, et al. Constructing a deprivation index based on census data in large Spanish cities(the MEDEA project). Gac Sanit. 2008;22:179-87.

Benach J, Borrell C, Chamizo H. Desigualdades sociales en mortalidad en áreas pequeñas. La Salud Pública y el futuro del Estado del Bienestar. Informe SESPAS 1998.

Rey G, Jougla E, Fouillet A, et al. 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. BMC Public Health 2009, 9:33.

Pampalon R, Hamel D, Gamache P. Health inequalities in urban and rural Canada: comparing inequalities in survival according to an individual and area-based deprivation index.Health Place.2010;16:416-20.

Meijer M, Engholm G, Grittner U, et al. A socioeconomic deprivation index for small areas in Denmark. Scand J Public Health. 2013;41:560-9.

McLennan D, Barnes H, Noble M, Davies J, Garratt E, Dibben C. The English indices of deprivation 2010 . 2011. London: Department for Communities and Local Government. Available online at:[verified April 2015].

Sánchez-Cantalejo C, Ocaña-Riola R, Fernández-Ajuria A. Deprivation index for small areas in Spain. Social Indicators Research. 2008;89:259–73.

Ocaña-Riola R, Saurina C , Fernández-Ajuria A, et al. Area deprivation and mortality in the provincial capital cities of Andalusia and Catalonia (Spain). J Epidemiol Community Health. 2008;62:147–52.

Benach J, Yasui Y, Borrell C,et al. Material deprivation and leading causes of death by gender: evidence from a nationwide small area study. J Epidemiol Community Health 2001;55:239–245.

Domínguez-Berjón MF, Borrell C. Mortality and socioeconomic deprivation in the census tracts and districts of Barcelona. Gac Sanit. 2005;19:363-9.

Borrell C, Marí-Dell’Olmo M, Serral G,et al. Inequalities in mortality in small areas of eleven Spanish cities (the multicenter MEDEA project). Helath&Place.2010;16: 703-711.

Salcedo N, Saez M, Bragulat B, et al. Does the effect of gender modify the relationship between deprivation and mortality?. BMC Public Health 2012, 12:574.

Martínez-Beneito MA, Zurriaga O, Botella-Rocamora P, et al. Do socioeconomic inequalities in mortality vary between different Spanish cities? a pooled cross-sectional analysis. BMC Public Health 2013, 13:480.

Bertin M, Chevrier C, Pelé F, et al. Can a deprivation index be used legitimately over both urban and rural areas?. Int J Health Geogr 2014, 13:22.

Bolíbar B, Fina F, Morros R, et al. SIDIAP database: electronic clinical records in primary care as a source of information for epidemiologic research. Med Clin (Barc).2012;138: 617-21.

Programa de desarrollo rural de Catalunya. Período de programación 2007-2013. Generalitat de Catalunya. Departament d’Agricultura, Ramaderia, Pesca, Alimentació i Medi Natural. Decisión C (2008) 702. Versión séptima, Mayo de 2011.

Domínguez Amorós M, Monllor Rico N, Simó Solsona M. "Món rural i joves. Realitat juvenil i polítiques de joventut als municipis rurals de Catalunya". 2010. Col•lecció Estudis, 31. Generalitat de Catalunya.

Lambert D. Zero-inflated Poisson Regression, with an Application to Defects in Manufacturing. Technometrics 1992;34.

Barnett S, Roderick P, Martin D, et al. A multilevel analysis of the effects of rurality and social deprivation on premature limiting long term illness. J Epidemiol Community Health 2001;55:44–51.

Gartner A, Farewell D, Roach P, et al. Rural/urban mortality differences in England and Wales and the effect of deprivation adjustment. Soc Sci Med. 2011;72: 1685-1694.

Farmer JC, Baird AG, Iversen L. Rural deprivation: reflecting reality. Br J Gen Pract 2001; 51: 486-91.

Lerxtundi-Manterola A, Saurina C, Saez M, et al. Construcción de un índice de privación material para los municipios de la Región Sanitaria Girona. Estudios de economía aplicada. Asociación Internacional de Economía aplicada. 2005;23:331-353.

Exeter D, Boyle P, Norman P. Deprivation (im)mobility and cause-specific premature mortality in Scotland. Soc Sci Med 2011;72:389-97.

Krieger N. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health. 1992;82:703-10.

Barr B, Bambra C, Whitehead M, et al. The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study. BMJ 2014;348:g3231.



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