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BMC Public Health
Published in: BMC Public Health 1/2018

Open Access 01-12-2018 | Research article

Associations of cause-specific mortality with area level deprivation and travel time to health care in France from 1990 to 2007, a multilevel analysis

Authors: Walid Ghosn, Gwenn Menvielle, Stéphane Rican, Grégoire Rey

Published in: BMC Public Health | Issue 1/2018

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Abstract

Background

It is now widely accepted that social and physical environment participate in shaping health. While mortality is used to guide public health policies and is considered as a synthetic measure of population health, few studies deals with the contextual features potentially associated with mortality in a representative sample of an entire country. This paper investigates the possible role of area deprivation (FDep99) and travel time to health care on French cause-specific mortality in a proper multilevel setting.

Methods

The study population was a 1% sample representative of the French population aged from 30 to 79 years in 1990 and followed up until 2007. A frailty Cox model was used to measure individual, contextual effects and spatial variances for several causes of death. The chosen contextual scale was the Zone d’Emploi of 1994 (348 units) which delimits the daily commute of people. The geographical accessibility to health care score was constructed with principal component analysis, using 40 variables of hospital specialties and health practitioners’ travel time.

Results

The outcomes highlight a positive and significant association between area deprivation and mortality for all causes (HR = 1.24), cancers, cerebrovascular diseases, ischemic heart diseases, and preventable and amenable diseases (HR from 1.14 to 1.29). These contextual associations exhibit no substantial differences by sex except for premature ischemic heart diseases mortality which was much greater in women. Unexpectedly, mortality decreased as the time to reach health care resources increased. Only geographical disparities in cerebrovascular and ischemic heart diseases mortality were explained by compositional and contextual effects.

Discussion

The findings suggest the presence of confounding factors in the association between mortality and travel time to health care, possibly owing to population density and health-selected migration. Although the spatial scale considered to define the context of residence was relatively large, the associations with area deprivation were strong in comparison to the existing literature and significant for almost all the causes of deaths investigated.

Conclusion

The broad spectrum of diseases associated with area deprivation and individual education support the idea of a need for a global health policy targeting both individual and territories to reduce social and socio-spatial inequalities.
Appendix
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Metadata
Title
Associations of cause-specific mortality with area level deprivation and travel time to health care in France from 1990 to 2007, a multilevel analysis
Authors
Walid Ghosn
Gwenn Menvielle
Stéphane Rican
Grégoire Rey
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2018
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-017-4562-7

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