Inequality in health: socioeconomic diVerentials in mortality in Rome, 1990–95

Study objective—Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relation between SES and mortality in the metropolitan area of Rome during the six year period 1990–1995, and to examine variations in mortality diVerentials between 1990–92 and 1993–95. Design—Rome has a population of approximately 2 800 000, with 6100 census tracts (CTs). During the study period, 149 002 deaths occurred among residents. The cause-specific mortality rates were compared among four socioeconomic categories defined by a socioeconomic index, derived from characteristics of the CT of residence. Main results—Among men, total mortality and mortality for the major causes of death showed an inverse association with SES. Among 15–44 year old men, the strong positive association between total mortality and low SES was attributable to AIDS and overdose mortality. Among women, a positive association with lower SES was observed for stomach cancer, uterus cancer and cardiovascular disease, whereas mortality for lung and breast cancers was higher in the groups with higher SES. Comparing the periods 1990–92 and 1993–95, diVerences in total mortality between socioeconomic groups widened in both sexes. Increasing diVerences were observed for tuberculosis and lung cancer among men, and for uterus cancer, traYc accidents, and overdose mortality among women. Conclusions—The use of an area-based indicator of SES limits the interpretations of the findings. However, despite the possible limitations, these results suggest that social class diVerences in mortality in Rome are increasing. Time changes in lifestyle and in the prevalence of risk behaviours may produce diVerences in disease incidence. Moreover, inequalities in the access to medical care and in the quality of care may contribute to an increasing diVerentials in mortality. (J Epidemiol Community Health 1999;53:687–693) The inverse association between socioeconomic status (SES) and health is well known, with persons of a lower SES being at greater risk of disease and mortality than more affluent people. Furthermore, the magnitude of socioeconomic diVerentials in mortality seems to have been increasing in the past several decades in various countries. In recent years, the Italian National Health Service has been undergoing changes because of limited resources for health expenditures. These changes, however, have been taking place without a systematic evaluation of socioeconomic diVerentials in health. In fact, evidence of socioeconomic heterogeneity in health is still limited in Italy because of the lack of individual data on SES at the national level. A national study conducted during the early 1980s indicated that total mortality among men aged 45–59 years was 35% higher for those in manual occupations compared with those with non-manual occupations; cancer and gastrointestinal disease accounted for most of the diVerence. A longitudinal study on the risk of cancer and socioeconomic characteristics of the general population in the city of Turin showed a negative correlation between incidence of most types of cancer and various social class indicators in 1985–87. Several studies have indicated that measures of SES at the small area level (that is, postal code or census tract (CT)) are a powerful tool in analysing social class diVerences in health. This study describes social diVerentials in mortality in the metropolitan area of Rome using an indicator of SES based on the characteristics of the CT of residence (that is, the smallest territorial unit for which population data were available). DiVerentials in mortality in the period 1990–95 were evaluated, and changes during this period were assessed.