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. 2013 Sep 24;8(9):e72656.
doi: 10.1371/journal.pone.0072656. eCollection 2013.

Area-level deprivation and overall and cause-specific mortality: 12 years' observation on British women and systematic review of prospective studies

Maria T Sánchez-Santos  1 , Marco Mesa-Frias, Minkyoung Choi, Eveline Nüesch, Angel Asunsolo-Del Barco, Antoinette Amuzu, George Davey Smith, Shah Ebrahim, David Prieto-Merino, Juan P Casas
Affiliations

Area-level deprivation and overall and cause-specific mortality: 12 years' observation on British women and systematic review of prospective studies

Maria T Sánchez-Santos et al. PLoS One. .

Abstract

Background: Prospective studies have suggested a negative impact of area deprivation on overall mortality, but its effect on cause-specific mortality and the mechanisms that account for this association remain unclear. We investigate the association of area deprivation, using Index of Multiple deprivation (IMD), with overall and cause-specific mortality, contextualising findings within a systematic review.

Methods and findings: We used data from 4,286 women from the British Women's Heart Health Study (BWHHS) recruited at 1999-2001 to examine the association of IMD with overall and cause-specific mortality using Cox regression models. One standard deviation (SD) increase in the IMD score had a hazard ratio (HR) of 1.21 (95% CI: 1.13-1.30) for overall mortality after adjustment for age and lifecourse individual deprivation, which was attenuated to 1.15 (95% CI: 1.04-1.26) after further inclusion of mediators (health behaviours, biological factors and use of statins and blood pressure-lowering medications). A more pronounced association was observed for respiratory disease and vascular deaths. The meta-analysis, based on 20 published studies plus the BWHHS (n=21), yielded a summary relative risk (RR) of 1.15 (95% CI: 1.11-1.19) for area deprivation (top [least deprived; reference] vs. bottom tertile) with overall mortality in an age and sex adjusted model, which reduced to 1.06 (95% CI: 1.04-1.08) in a fully adjusted model.

Conclusions: Health behaviours mediate the association between area deprivation and cause-specific mortality. Efforts to modify health behaviours may be more successful if they are combined with measures that tackle area deprivation.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Age-adjusted hazard ratio (95%CI) for overall mortality across categories of index of multiple deprivation.
The vertical axis is plotted in the log-scale. The distances between categories in the horizontal axis correspond to the mean values for index of multiple deprivation (IMD) in England. IMD categories were based on the standard deviation (SD) from the overall score from each country (SD by country: England= 15.7, Wales= 14.3 and Scotland= 16.6). Numbers above each box indicate the corresponding hazard ratios and 95% confidence intervals. The mean and the range were calculated from the overall score from each country by IMD categories.
Figure 2
Figure 2. Survival curves for the lowest and highest index of multiple deprivation categories, adjusted for age, for overall and cause-specific mortality in the BWHHS, 1999-2001 to 2012.
(a) All-cause, (b) all vascular, (c) all cancer, (d) all respiratory disease and (e) others. The Y-axes were truncated to 0.6 for a better visualization. The dashed lines divide the graphs into periods of four years.
Figure 3
Figure 3. Prospective studies of area-level deprivation and all-cause mortality grouped by study characteristics.
For degree of adjustment from individual studies please see Table S7, S8 and Figures S3 and S4 .
See this image and copyright information in PMC

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