title: Mortality, material deprivation and urbanization: exploring the social patterns of a metropolitan area.
abstract: BACKGROUND
  Socioeconomic inequalities affecting health are of major importance in Europe. The literature enhances the role of social determinants of health, such as socioeconomic characteristics and urbanization, to achieve health equity. Yet, there is still much to know, mainly concerning the association between cause-specific mortality and several social determinants, especially in metropolitan areas. This study aims to describe the geographical pattern of cause-specific mortality in the Lisbon Metropolitan Area (LMA), at small area level (parishes), and analyses the statistical association between mortality risk and health determinants (material deprivation and urbanization level). Fourteen causes have been selected, representing almost 60% of total mortality between 1995 and 2008, particularly those associated with urbanization and material deprivation.
  
  
  METHODS
  A cross-sectional ecological study was carried out. Using a hierarchical Bayesian spatial model, we estimated sex-specific smoothed Standardized Mortality Ratios (sSMR) and measured the relative risks (RR), and 95% credible intervals, for cause-specific mortality relative to 1. urbanization level, 2. material deprivation and 3. material deprivation adjusted by urbanization.
  
  
  RESULTS
  The statistical association between mortality and material deprivation and between mortality and urbanization changes by cause of death and sex. Dementia and MN larynx, trachea, bronchus and lung are the causes of death showing higher relative risk associated with urbanization. Infectious and parasitic diseases, Chronic liver disease and Diabetes are the causes of death presenting higher relative risk associated with material deprivation. Ischemic heart disease was the only cause with a statistical association with both determinants, and MN female breast was the only without any statistical association. Urbanization level reduces the impact of material deprivation for most of the causes of death. Men face a higher impact of material deprivation and urbanization level, than women, in most cause-specific mortality, even when considering the adjusted model.
  
  
  CONCLUSIONS
  Our findings explore the specific pattern of fourteen causes of death in LMA and reveals small areas with an excess risk of mortality associated with material deprivation, thereby identifying problematic areas that could potentially benefit from public policies effecting social inequalities.
authors.affiliation: Departamento de Geografia, Centro de Estudos de Geografia e Ordenamento do Território, Universidade de Coimbra, Colégio S. Jerónimo, Largo D. Dinis, 3000-043, Coimbra, Portugal. paulasantana.coimbra@gmail.com.
authors.forename: Paula
authors.initials: P
authors.lastname: Santana
authors.affiliation: Departamento de Geografia, Centro de Estudos de Geografia e Ordenamento do Território, Universidade de Coimbra, Colégio S. Jerónimo, Largo D. Dinis, 3000-043, Coimbra, Portugal. claudiampcosta@gmail.com.
authors.forename: Claudia
authors.initials: C
authors.lastname: Costa
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), 3-5, Pabellón 11. Planta 0, Monforte de Lemos, 28029, Madrid, Spain. mmari@aspb.cat.|Agència de Salut Pública de Barcelona, Plaça Lesseps, 1, 08023, Barcelona, Spain. mmari@aspb.cat.|Institut d'Investigació Biomèdica (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain. mmari@aspb.cat.
authors.forename: Marc
authors.initials: M
authors.lastname: Marí-Dell'Olmo
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), 3-5, Pabellón 11. Planta 0, Monforte de Lemos, 28029, Madrid, Spain. mgotsens@aspb.cat.|Agència de Salut Pública de Barcelona, Plaça Lesseps, 1, 08023, Barcelona, Spain. mgotsens@aspb.cat.|Institut d'Investigació Biomèdica (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain. mgotsens@aspb.cat.
authors.forename: Mercè
authors.initials: M
authors.lastname: Gotsens
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), 3-5, Pabellón 11. Planta 0, Monforte de Lemos, 28029, Madrid, Spain. cborrell@aspb.cat.|Agència de Salut Pública de Barcelona, Plaça Lesseps, 1, 08023, Barcelona, Spain. cborrell@aspb.cat.|Institut d'Investigació Biomèdica (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain. cborrell@aspb.cat.|Universitat Pompeu Fabra, Doctor Aiguader, 80, 08003, Barcelona, Spain. cborrell@aspb.cat.
authors.forename: Carme
authors.initials: C
authors.lastname: Borrell
mesh_terms: D001499:Bayes Theorem; D003430:Cross-Sectional Studies; D005060:Europe; D005260:Female; D054624:Health Status Disparities; D006801:Humans; D008297:Male; D009026:Mortality; D012307:Risk Factors; D012931:Social Environment; D014505:Urban Population