title: Trends in socioeconomic inequalities in mortality in small areas of 33 Spanish cities.
abstract: In Spain, several ecological studies have analyzed trends in socioeconomic inequalities in mortality from all causes in urban areas over time. However, the results of these studies are quite heterogeneous finding, in general, that inequalities decreased, or remained stable. Therefore, the objectives of this study are: (1) to identify trends in geographical inequalities in all-cause mortality in the census tracts of 33 Spanish cities between the two periods 1996-1998 and 2005-2007; (2) to analyse trends in the relationship between these geographical inequalities and socioeconomic deprivation; and (3) to obtain an overall measure which summarises the relationship found in each one of the cities and to analyse its variation over time.
  
  
  
  Ecological study of trends with 2 cross-sectional cuts, corresponding to two periods of analysis: 1996-1998 and 2005-2007. Units of analysis were census tracts of the 33 Spanish cities. A deprivation index calculated for each census tracts in all cities was included as a covariate. A Bayesian hierarchical model was used to estimate smoothed Standardized Mortality Ratios (sSMR) by each census tract and period. The geographical distribution of these sSMR was represented using maps of septiles. In addition, two different Bayesian hierarchical models were used to measure the association between all-cause mortality and the deprivation index in each city and period, and by sex: (1) including the association as a fixed effect for each city; (2) including the association as random effects. In both models the data spatial structure can be controlled within each city. The association in each city was measured using relative risks (RR) and their 95 % credible intervals (95 % CI).
  
  
  
  For most cities and in both sexes, mortality rates decline over time. For women, the mortality and deprivation patterns are similar in the first period, while in the second they are different for most cities. For men, RRs remain stable over time in 29 cities, in 3 diminish and in 1 increase. For women, in 30 cities, a non-significant change over time in RR is observed. However, in 4 cities RR diminishes. In overall terms, inequalities decrease (with a probability of 0.9) in both men (RR = 1.13, 95 % CI = 1.12-1.15 in the 1st period; RR = 1.11, 95 % CI = 1.09-1.13 in the 2nd period) and women (RR = 1.07, 95 % CI = 1.05-1.08 in the 1st period; RR = 1.04, 95 % CI = 1.02-1.06 in the 2nd period).
  
  
  
  In the future, it is important to conduct further trend studies, allowing to monitoring trends in socioeconomic inequalities in mortality and to identify (among other things) temporal factors that may influence these inequalities.
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), 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), Barcelona, Spain. mmari@aspb.cat.|Universitat Rovira i Virgili, Tarragona, Spain. mmari@aspb.cat.
authors.forename: Marc
authors.initials: M
authors.lastname: Marí-Dell'Olmo
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Agència de Salut Pública de Barcelona, Plaça Lesseps 1, 08023, Barcelona, Spain.|Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.
authors.forename: Mercè
authors.initials: M
authors.lastname: Gotsens
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Agència de Salut Pública de Barcelona, Plaça Lesseps 1, 08023, Barcelona, Spain.|Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.
authors.forename: Laia
authors.initials: L
authors.lastname: Palència
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Agència de Salut Pública de Barcelona, Plaça Lesseps 1, 08023, Barcelona, Spain.|Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.
authors.forename: Maica
authors.initials: M
authors.lastname: Rodríguez-Sanz
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Fundación para el fomento de la investigación sanitaria y biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain.
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Martinez-Beneito
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain.
authors.forename: Mónica
authors.initials: M
authors.lastname: Ballesta
authors.affiliation: Estudios e investigación Sanitaria, Departamento de Sanidad y Consumo, Gobierno Vasco, Vitoria-Gasteiz, Spain.
authors.forename: Montse
authors.initials: M
authors.lastname: Calvo
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain.
authors.forename: Lluís
authors.initials: L
authors.lastname: Cirera
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Observatorio de Salud y Medio Ambiente de Andalucía (OSMAN), Escuela Andaluza de Salud Pública (EASP), Granada, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Daponte
authors.affiliation: Subdirección de Promoción de la Salud y Prevención, Consejería de Sanidad, Comunidad de Madrid, Spain.
authors.forename: Felicitas
authors.initials: F
authors.lastname: Domínguez-Berjón
authors.affiliation: Subdirección de Promoción de la Salud y Prevención, Consejería de Sanidad, Comunidad de Madrid, Spain.
authors.forename: Ana
authors.initials: A
authors.lastname: Gandarillas
authors.affiliation: Registro de Mortalidad, Consejería de Salud y Servicios Sociales, La Rioja, Spain.
authors.forename: Natividad Izco
authors.initials: NI
authors.lastname: Goñi
authors.affiliation: Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain.
authors.forename: Carmen
authors.initials: C
authors.lastname: Martos
authors.affiliation: Instituto de Salud Pública de Navarra, Departamento de Salud, Gobierno de Navarra, Pamplona, Navarra, Spain.
authors.forename: Conchi
authors.initials: C
authors.lastname: Moreno-Iribas
authors.affiliation: Unidad de Investigación en Análisis de la Mortalidad y Estadísticas Sanitarias, Universidad de Alicante, San Vicente del Raspeig, Spain.
authors.forename: Andreu
authors.initials: A
authors.lastname: Nolasco
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain.
authors.forename: Diego
authors.initials: D
authors.lastname: Salmerón
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Departamento de Medicina Preventiva y Salud Pública, Universidad de Santiago de Compostela, Santiago de Compostela, Spain.
authors.forename: Margarita
authors.initials: M
authors.lastname: Taracido
authors.affiliation: CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.|Agència de Salut Pública de Barcelona, Plaça Lesseps 1, 08023, Barcelona, Spain.|Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.|Universitat Pompeu Fabra, Barcelona, Spain.
authors.forename: Carme
authors.initials: C
authors.lastname: Borrell
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001499:Bayes Theorem; D019352:Censuses; D002648:Child; D002675:Child, Preschool; D002947:Cities; D003430:Cross-Sectional Studies; D003710:Demography; D005260:Female; D054624:Health Status Disparities; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends*; D012307:Risk Factors; D012959:Socioeconomic Factors; D013030:Spain / Q000453:epidemiology; D014504:Urban Health / Q000639:trends; D055815:Young Adult
keywords: Bayesian methods; Disease mapping; Geographical inequalities; Inequalities in mortality; Mortality; Multilevel analysis; Small areas; Socioeconomic inequalities; Trends; Urban areas