Does the socioeconomic context explain both mortality and income inequality? Prospective register-based study of Norwegian regions

BACKGROUND Studies from various countries have observed worse population health in geographical areas with more income inequality. The psychosocial interpretation of this association is that large income disparities are harmful to health because they generate relative deprivation and undermine social cohesion. An alternative explanation contends that the association between income inequality and ill health arises because the underlying social and economic structures will influence both the level of illness and disease and the size of income differences. This paper examines whether the observed association between mortality and income inequality in Norwegian regions can be accounted for by the socioeconomic characteristics of the regions. METHODS Norwegian register data covering the entire population were utilised. An extensive set of contextual and individual predictors were included in multilevel Poisson regression analyses of mortality 1994-2003 among 1.6 millions individuals born 1929-63, distributed across 35 residential regions. RESULTS Mean income, composition of economic branches, and percentage highly educated in the regions were clearly connected to the level of income inequality. These social and economic characteristics of the regions were also markedly related to regional mortality levels, after adjustment for population composition, i.e., the individual-level variables. Moreover, regional mortality was significantly higher in regions with larger income disparities. The regions' social and economic structure did not, however, account for the association between regional income inequality and mortality. A distinct independent effect of income inequality on mortality remained after adjustment for regional-level social and economic characteristics. CONCLUSIONS The results indicate that the broader socioeconomic context in Norwegian regions has a substantial impact both on mortality and on the level of income disparities. However, the results also suggest, in a way compatible with the psychosocial interpretation, that on top of the general socioeconomic influences, a higher level of income inequality adds independently to higher mortality levels. PREVIOUS PUBLICATION: This article is a reworked version of the study 'Er inntektsforskjeller dødelige?' [Are income inequalities lethal?] which was published in Norwegian in Tidsskrift for velferdsforskning [Journal for welfare research], Vol. 13 (4), 2010.