Elsevier

Social Science & Medicine

Volume 67, Issue 8, October 2008, Pages 1269-1281
Social Science & Medicine

Recent changes in the geography of social disparities in premature mortality in Québec

https://doi.org/10.1016/j.socscimed.2008.06.010Get rights and content

Abstract

Most recent research reveals that social inequalities in premature mortality are widening. Such findings mainly apply to countries as a whole. In this study, we model recent changes in the association between premature mortality and a deprivation index (a small area-based index) in four geographic settings in Québec, namely the Montréal metropolitan area, other Québec metropolitan areas, mid-size cities, and small towns and rural areas. Deaths from all-cause and specific causes of mortality among people under age 75 are considered for the periods 1989–1993 and 1999–2003. Mortality rates are modeled using negative binomial regressions. Models are fitted for the overall population and for men and women, separately, in every geographic setting. Three measures of inequalities are used: mortality rates for different population groups, rate ratios and rate differences. Results show that social inequalities in premature mortality increase everywhere in Québec except in the Montréal metropolitan area. Presently, the highest mortality rates among deprived groups are found in mid-size cities, small towns and rural areas; the highest rate ratios in the Montréal metropolitan area and other metropolitan areas of Québec; and the highest rate differences in the Montréal metropolitan area, other metropolitan areas of Québec and mid-size cities. These results are discussed with reference to possible explanatory factors, namely relative deprivation, smoking, immigration and internal migration. Indications on future research and policy implications are provided.

Section snippets

Geographic settings

The selected geographic settings are part of the new statistical area classification (SAC) developed by Statistics Canada in 2001 for data dissemination purposes (Statistics Canada, 2003). The SAC groups census subdivisions (municipalities) according to whether they are a component of a census metropolitan area (CMA), a census agglomeration (CA), or a CMA and CA influenced zone (MIZ). A CMA or CA is an area consisting of one or more adjacent municipalities situated around a major urban core. To

Results

In Québec between 1989–1993 and 1999–2003, the premature mortality rate dropped by 15%, from 384 to 325 per 100,000 persons. Premature mortality decreased in every geographic setting but mainly in the CMA of Montréal and in ‘other CMAs’ (Fig. 1). Mid-size cities, small towns and rural areas, which already had higher mortality rates in 1989–1993, increased their relative disadvantage.

A look at changes in premature mortality among the most and least deprived groups reveals that rates declined

Discussion

In recent years, the geography of social disparities in premature mortality has changed substantially in Québec. Social disparities have increased everywhere except in the CMA of Montréal. This CMA still exhibits high inequalities, but it now shares the highest rate ratio with ‘other CMAs’ and the highest rate difference with ‘other CMAs’ and mid-size cities. Furthermore, the most deprived groups living in the CMA of Montréal still have a high premature mortality rate, but this rate is now

Conclusion

This study remains exploratory. Its aim is to describe the recent evolution of social inequalities in mortality in four geographic settings and to suggest hypotheses on the factors underlying this evolution. Clearly, recent changes in social gaps in mortality vary by geographic setting, and results show that, contrary to what was expected, social inequalities are increasing everywhere in Québec except in its major urban center, the CMA of Montréal. With the data available, we went as far as

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