Changes in regional variation in mortality over five decades - The contribution of age and socioeconomic population composition

Abstract

Existing evidence suggests that within-country area variation in mortality has increased in several high-income countries. Little is known about the role of changes in the population composition of areas in these trends. In this study, we look at mortality variation across Finnish municipalities over five decades. We examine trends by sex, age categories and two broad cause of death groups and assess the role of individual-level compositional factors. Analyses rely on individual-level register data on the total Finnish population aged 30 years and over. We estimated two-level Weibull survival-models with individuals nested in areas for 10 periods between 1972 and 2018 to assess municipal-level variation in mortality. Median hazard ratio (MHR) was used as our summary measure and analyses were adjusted for age and socioeconomic characteristics. The results show a clear overall growth in area variation in mortality with MHR increasing from 1.14 (95% CI 1.12-1.15) to 1.28 (CI 1.26-1.30) among men and 1.17 (CI 1.15-1.18) to 1.30 (CI 1.27-1.32) among women. This growth, however, was fully attenuated by adjustment for age. Area differentials were largest and increased most among men at ages 30-49, and particularly for external causes. This increase was largely due to increasing differentiation in the socioeconomic composition of municipalities. In conclusion, our study shows increases in mortality differentials across municipalities that are mostly attributable to increasing differentiation between municipalities in terms of individual compositional factors.

Keywords: Health inequalities; Long-term trends; Mortality; Multilevel modelling; Regional variation.

Fig. 1

Differentials in mortality across Finnish municipalities in 1972–1975 and 2016–2018 among men and women aged 30 and over, represented by municipality-specific HR and 95% confidence intervals with the reference being the average hazard of all municipalities. Notes: HRs are predicted from empty models (model 0) and y-axis is on log scale. Width of confidence intervals is inversely related to municipality size.

Fig. 2

Median hazard ratio (MHR) for 10 periods between 1972-1975 and 2016–2018 from empty (model 0) and age-adjusted (model 1) models, and a model adjusted for age and socioeconomic characteristics (model 2), by sex, population aged 30+.

Fig. 3

Median hazard ratio (MHR) from age-adjusted models (model 1) for ten periods between 1972-1975 and 2016–2018, by age category and sex.

Fig. A1

Percentage change between 1972-1975 and 2016–2018 in the share of population 70 years and over, by municipality and sex.

Fig. A2

Municipality specific hazard-ratios in 1972–1975 and 2016–2018 among men and women aged 30 and over. Maps in the upper panel (a) display hazard ratios predicted from unadjusted models (model 0) and maps in the lower panel (b) are from models adjusted for age and socioeconomic characteristics (model 2).

Fig. A3

Differentials in mortality across Finnish municipalities in 1972–1975 and 2016–2018 among men and women aged 30 and over, represented by municipality-specific HR and 95% confidence intervals predicted from models adjusted for age (model 1) and for age and socioeconomic characteristics (model 2).