Twenty years of socioeconomic inequalities in premature mortality in Barcelona: The influence of population and neighbourhood changes

Highlights

• In Barcelona since 2000’s the populations of poor neighbourhoods have increased and renewed with young people and foreigners.

• Neighbourhood’s mortality inequalities decreased, after marked decrease in deprived neighbourhoods with large immigration.

• However, with the current economic crisis, socioeconomic mortality inequalities in Barcelona tend to increase again.

Abstract

The objective of this study was to analyse trends in socioeconomic inequalities in premature mortality in Barcelona from 1992 to 2011, accounting for population changes. We conducted a repeated cross-sectional study of the Barcelona population (25–64 years) using generalized linear mixed models for trend analysis, and found that socioeconomic inequalities in premature mortality persisted between neighbourhoods, but tended to diminish. However, the reduction in inequality was related to an increase in the number of foreign-born individuals mainly in socioeconomic disadvantaged neighbourhoods, in which the decrease in premature mortality was more marked. To study trends in geographical inequalities in mortality, it is essential to understand demographic changes occurred in different places related to local levels of deprivation.

Introduction

In urban contexts, it is well known that neighbourhood characteristics, especially the socioeconomic context, have an independent effect on a variety of health outcomes, including mortality (Pickett and Pearl, 2001, Meijer, 2012). A common finding is that living in more deprived neighbourhoods is associated with increased mortality, independently of individual socioeconomic characteristics (Van Lenthe et al., 2005), and this effect is stronger among men and in younger age groups (Meijer et al., 2012). In the European context, the INEQ-CITIES project, which used small area analysis, has shown strong evidence of socioeconomic inequalities in mortality in 16 European cities, with mortality increasing in parallel with socioeconomic deprivation. Inequality is greater in eastern and northern European cities and lesser in some western and southern European cities (Borrell et al., 2014).

However, only a few studies have analysed trends in socioeconomic inequalities in mortality among neighbourhoods and small areas at the urban level, and the findings have been inconsistent. Previous studies in the United Kingdom (Norman et al., 2011), Scotland (Leyland, 2007, Exeter et al., 2011) and Sydney (Hayes et al., 2002) observed a decreasing trend in mortality, but an increase in socio-spatial inequality in mortality. Stable socio-spatial patterns in mortality have been reported in other cities, such as New York (Karpati et al., 2006), Montreal (Pampalon et al., 2008), Turin (Marinacci, 2004) and Rome (Cesaroni et al., 2006). In Spain, the findings from various cities have been inconsistent in terms of trends in socioeconomic inequalities in mortality observed using small-area analysis: some studies report an increase (Ruiz-Ramos et al., 2014), others a stable trend (Nolasco et al., 2009) and others a decrease (Rodríguez et al., 2014, Rodríguez-Fonseca, 2013, Dalmau-Bueno et al., 2010).

From a broad perspective, both places and populations should be regarded as dynamic. Over the last few decades, cities have undergone continuous reurbanisation processes (Haase et al., 2009), leading to substantial changes in population structure as a result of migration, aging, and declining fertility, which affect population health and health inequalities (Lawrence, 2013). At a national level, several studies have found that mortality was inversely related to population growth; mortality rates were higher in areas with decreasing population and lower in those with increasing population as a result of immigration. These differences are probably the result of health selection bias (Smith et al., 1998, Molarius and Janson, 2000, Regidor et al., 2002, Boyle et al., 2004). Despite this, recent studies suggest that the negative relationship between population change and mortality in Scotland is an artefact of the relationship between deprivation and mortality, since declining areas tend to be more deprived (Exeter, 2005, Exeter, 2009, Popham et al., 2011). However, longitudinal studies in England and Wales have shown that both deprivation and health-selective migration are responsible for the increased inequality in mortality between the least and most deprived areas (Norman et al., 2005, Connolly et al., 2007). Similarly, a study in France reported a large increase in the population in deprived areas, and found that this was associated with a decrease in relative socioeconomic inequalities in mortality (Ghosn et al., 2013). In this regard, when studying trends in geographical inequalities in mortality, it is important to understand demographic changes in relation to deprivation. However, at urban context few studies have accounted for changes in the composition of the population and its contribution in explaining changes in socioeconomic and mortality inequalities between areas.

Barcelona has undergone continuous changes in both the city and its population. The urban transformation that began in the mid-1980s has combined cultural strategies with urban regeneration (namely, the 1992 Olympic Games and the 2004 Universal Forum of Cultures) (Degen and García, 2012), as well as a series of urban renewal programmes introduced to deal with deprived neighbourhoods and inner-city areas (Arbaci and Tapada-Berteli, 2012). Moreover, while the city's population began to decrease in the 1990s, it rose rapidly again after 2000, mainly due to a large influx of foreigners who migrated to Spain for economic reasons. Since most of this recently arrived immigrant population is young, this influx has had an impact on the age structure of the general population (Domínguez Mújica and Guerra Talavera, 2009). The foreign population in Barcelona represented 3.9% of residents in 2000, growing to 18.9% in 2009, most of which has settled in specific areas of the city centre and the periphery (Bayona and Gay, 2011).

In this context, the objectives of this study were two-fold: first, to describe the population changes that occurred in neighbourhoods of Barcelona over the past two decades; and second, to analyse trends, between 1992 and 2011, in socioeconomic inequalities in premature mortality between neighbourhoods while taking population changes into account.