title: Why does Spain have smaller inequalities in mortality? An exploration of potential explanations.
abstract: BACKGROUND
  While educational inequalities in mortality are substantial in most European countries, they are relatively small in Spain. A better understanding of the causes of these smaller inequalities in Spain may help to develop policies to reduce inequalities in mortality elsewhere. The aim of the present study was therefore to identify the specific causes of death and determinants contributing to these smaller inequalities.
  
  
  METHODS
  Data on mortality by education were obtained from longitudinal mortality studies in three Spanish populations (Barcelona, Madrid, the Basque Country), and six other Western European populations. Data on determinants by education were obtained from health interview surveys.
  
  
  RESULTS
  The Spanish populations have considerably smaller absolute inequalities in mortality than other Western European populations. This is due mainly to smaller inequalities in mortality from cardiovascular disease (men) and cancer (women). Inequalities in mortality from most other causes are not smaller in Spain than elsewhere. Spain also has smaller inequalities in smoking and sedentary lifestyle and this is due to more smoking and physical inactivity in higher educated groups.
  
  
  CONCLUSIONS
  Overall, the situation with regard to health inequalities does not appear to be more favourable in Spain than in other Western European populations. Smaller inequalities in mortality from cardiovascular disease and cancer in Spain are likely to be related to its later socio-economic modernization. Although these smaller inequalities in mortality seem to be a historical coincidence rather than the outcome of deliberate policies, the Spanish example does suggest that large inequalities in total mortality are not inevitable.
authors.affiliation: 1 Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Ivana
authors.initials: I
authors.lastname: Kulhánová
authors.affiliation: 2 Health Studies and Research Unit, Department of Health and Consumer Affairs, Basque Government, Vitoria-Gasteiz, Spain3 Department of Sociology 2, University of the Basque Country (UPV/EHU), Leioa, Spain.
authors.forename: Amaia
authors.initials: A
authors.lastname: Bacigalupe
authors.affiliation: 1 Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Terje A
authors.initials: TA
authors.lastname: Eikemo
authors.affiliation: 4 Agència de Salut Pública de Barcelona, Barcelona, Spain.
authors.forename: Carme
authors.initials: C
authors.lastname: Borrell
authors.affiliation: 5 Department of Preventive Medicine and Public Health, Universidad Complutense de Madrid, Madrid, Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Regidor
authors.affiliation: 2 Health Studies and Research Unit, Department of Health and Consumer Affairs, Basque Government, Vitoria-Gasteiz, Spain.
authors.forename: Santiago
authors.initials: S
authors.lastname: Esnaola
authors.affiliation: 1 Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands j.mackenbach@erasmusmc.nl.
authors.forename: Johan P
authors.initials: JP
authors.lastname: Mackenbach
mesh_terms: D000328:Adult; D000368:Aged; D002423:Cause of Death; D004522:Educational Status; D005060:Europe / Q000453:epidemiology; D005260:Female; D006306:Health Surveys; D006801:Humans; D008019:Life Style; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009026:Mortality; D012923:Social Class; D013030:Spain / Q000453:epidemiology