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Social differences in avoidable mortality between small areas of 15 European cities: an ecological study

Rasmus Hoffmann1*, Gerard Borsboom1, Marc Saez23, Marc Mari Dell’Olmo3, Bo Burström4, Diana Corman4, Claudia Costa5, Patrick Deboosere6, M Felicitas Domínguez-Berjón7, Dagmar Dzúrová8, Ana Gandarillas7, Mercè Gotsens3, Katalin Kovács9, Johan Mackenbach1, Pekka Martikainen10, Laia Maynou1123, Joana Morrison12, Laia Palència3, Gloria Pérez12, Hynek Pikhart12, Maica Rodríguez-Sanz13, Paula Santana5, Carme Saurina23, Lasse Tarkiainen10 and Carme Borrell13

Author Affiliations

1 Department of Public Health, Erasmus Medical Center, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands

2 Research Group on Statistics, Econometrics and Health (GRECS), University of Girona, Campus de Montilivi, Girona 17071, Spain

3 CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain

4 Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm 17177, Sweden

5 Centro de Estudos de Geografia e de Ordenamento do Territorio (CEGOT), Departamento de Geografia, Colégio de S. Jerónimo, Universidade de Coimbra, Coimbra 3000-043, Portugal

6 Department of Social research, Vrije Universiteit Brussel, Pleinlaan 2, Elsene, Brussels 1050, Belgium

7 Subdirección de Promoción de la Salud y Prevención. Consejería de Sanidad, San Martín de Porres, 6, 28035, Madrid 28037, Spain

8 Department of Social Geography and Regional Development, Faculty of Science, Charles University in Prague, Albertov 6, Prague 2 12843, Czech Republic

9 Demographic Research Institute, HCSO, 1024, 1/3 Buday L. u., Budapest, Hungary

10 Department of Social Research, University of Helsinki, P.O. Box 18, Helsinki 00014, Finland

11 London School of Hygiene and Tropical Medicine, London, UK

12 Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, United Kingdom

13 Agència de Salut Pública de Barcelona, Plaça Lesseps, 1, Barcelona 08023, Spain

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International Journal of Health Geographics 2014, 13:8  doi:10.1186/1476-072X-13-8

Published: 12 March 2014



Health and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation.


We determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollié. Ecological regression analysis was used to assess the association between social deprivation and mortality.


Mortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe.


There are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.

Avoidable mortality; Health inequality; Small area; Urban health; Spatial analysis; Bayesian methods