title: Comparative observational study of mortality amenable by health policy and care between rural and urban Finland: no excess segregation of mortality in the capital despite its increasing residential differentiation.
abstract: BACKGROUND
  Large cities are often claimed to display more distinct geographical and socioeconomic health inequalities than other areas due to increasing residential differentiation. Our aim was to assess whether geographical inequalities in mortality within the capital (City of Helsinki) both exceeded that in other types of geographical areas in Finland, and whether those differences were dependent on socioeconomic inequalities.
  
  
  METHODS
  We analysed the inequality of distribution separately for overall, ischemic heart disease and alcohol-related mortality, and mortality amenable (AM) to health care interventions in 1992-2008 in three types of geographical areas in Finland: City of Helsinki, other large cities, and small towns and rural areas. Mortality data were acquired as secondary data from the Causes of Death statistics from Statistics Finland. The assessment of changing geographical differences over time, that is geographical inequalities, was performed using Gini coefficients. As some of these differences might arise from socioeconomic factors, we assessed socioeconomic differences with concentration indices in parallel to an analysis of geographical differences. To conclude the analysis, we compared the changes over time of these inequalities between the three geographical areas.
  
  
  RESULTS
  While mortality rates mainly decreased, alcohol-related mortality in the lowest income quintile increased. Statistically significant differences over time were found in all mortality groups, varying between geographical areas. Socioeconomic differences existed in all mortality groups and geographical areas. In the study period, geographical differences in mortality remained relatively stable but income differences increased substantially. For instance, the values of concentration indices for AM changed by 54 % in men (p < 0.027) and by 62 % in women (p < 0.016). Only slight differences existed in the time trends of Gini or in the concentration indices between the geographical areas.
  
  
  CONCLUSIONS
  No geographical or income-related differences in the distribution of mortality existed between Helsinki and other urban or rural areas of Finland. This suggests that the effect of increasing residential differentiation in the capital may have been mitigated by the policies of positive discrimination and social mixing. One of the main reasons for the increase in health inequalities was growth of alcohol-related mortality, especially among those with the lowest incomes.
authors.affiliation: Department of Social Services and Health Care, City of Helsinki, P.O. Box 6100, 00099, Helsinki, Finland. markku.lehikoinen@helsinki.fi.|Network of Academic Health Centres and Department of General Practice and Primary Health Care, University of Helsinki, P.O. Box 20 , Tukholmankatu 8 B, 00014, Helsinki, Finland. markku.lehikoinen@helsinki.fi.
authors.forename: Markku
authors.initials: M
authors.lastname: Lehikoinen
authors.affiliation: Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland.
authors.forename: Martti
authors.initials: M
authors.lastname: Arffman
authors.affiliation: Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland.
authors.forename: Kristiina
authors.initials: K
authors.lastname: Manderbacka
authors.affiliation: Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland.|Institute of Behavioural Sciences, University of Helsinki, P.O. Box 9, 00014, Helsinki, Finland.
authors.forename: Marko
authors.initials: M
authors.lastname: Elovainio
authors.affiliation: Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland.|School of Health Sciences, University of Tampere, 33014, Tampere, Finland.
authors.forename: Ilmo
authors.initials: I
authors.lastname: Keskimäki
mesh_terms: D000328:Adult; D000368:Aged; D019973:Alcohol-Related Disorders / Q000453:epidemiology / Q000401:mortality; D005260:Female; D005387:Finland / Q000453:epidemiology; D006291:Health Policy; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D017202:Myocardial Ischemia / Q000453:epidemiology / Q000401:mortality; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D014505:Urban Population / Q000706:statistics & numerical data
keywords: Health inequalities; Positive discrimination; Register data; Residential differentiation; Social mixing