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

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.

Figure 1

SMR as a function of the various deprivation index quintiles, on the commune scale, by degree of urbanicity (UUC). SMR: standardized mortality ratio for the period 1997–2001. FDep99: First component of a PCA on the commune scale of the variables: median income, % blue-collar workers, % high school graduates, and unemployment rate. Townsend and Carstairs: sum of standardized variables.

Figure 2

Geographic distribution of the FDep99 index and all-cause mortality on the region and canton scales. FDep99: First component of a PCA on the commune scale of the variables: median income, % blue-collar workers, % high school graduates, and unemployment rate. SMR: standardized mortality ratio for the period 1997–2001.

Figure 3

SMR as a function of FDep99 index, by scale. FDep99: First component of a PCA on the commune scale of the variables: median income, % blue-collar workers, % high school graduates, and unemployment rate. SMR: standardized mortality ratio for the period 1997–2001.

Figure 4

All-cause mortality differentials with FDep99 index (SMRQ5/SMRQ1), by age and gender. FDep99: First component of a PCA on the commune scale of the variables: median income, % blue-collar workers, % high school graduates, and unemployment rate. SMR: standardized mortality ratio for the period 1997–2001. SMRQ5/SMRQ1: ratio of the SMR of communes whose FDep99 index was higher than the fourth quintile and SMR of the communes whose FDep99 index was lower than the first quintile.