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Neighbourhood-level marginalization and avoidable mortality in Ontario, Canada: a population-based study

  • Quantitative Research
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Abstract

Objective

To examine the impact of neighbourhood marginalization on avoidable mortality (AM) from preventable and treatable causes of death.

Methods

All premature deaths between 1993 and 2014 (N = 691,453) in Ontario, Canada, were assigned to quintiles of neighbourhood marginalization using the four dimensions of the Ontario Marginalization Index: dependency, ethnic concentration, material deprivation, and residential instability. We conducted two multivariate logistic regressions to examine the association between neighbourhood marginalization, first with AM compared with non-AM as the outcome, and second with AM from preventable causes compared with treatable causes as the outcome. All models were adjusted for decedent age, sex, urban/rural location, and level of comorbidity.

Results

A total of 463,015 deaths were classified as AM and 228,438 deaths were classified as non-AM. Persons living in the most materially deprived (OR, 1.24; 95% CI, 1.22 to 1.27) and residentially unstable neighbourhoods (OR, 1.13; 95% CI, 1.11 to 1.15) had greater odds of AM, particularly from preventable causes. Those living in the most dependent (OR, 0.91; 95% CI, 0.89 to 0.93) and ethnically concentrated neighbourhoods (OR, 0.93; 95% CI, 0.91 to 0.93) had lower odds of AM, although when AM occurred, it was more likely to arise from treatable causes.

Conclusion

Different marginalization dimensions have unique associations with AM. By identifying how different aspects of neighbourhood marginalization influence AM, these results may have important implications for future public health efforts to reduce inequities in avoidable deaths.

Résumé

Objectif

Examiner les incidences de la marginalisation du quartier sur la mortalité évitable due aux causes de décès évitables et traitables.

Méthode

Tous les décès prématurés survenus entre 1993 et 2014 (n = 691 453) en Ontario, au Canada, ont été associés à un quintile de marginalisation du quartier à l’aide des quatre dimensions de l’indice de marginalisation ontarien : la dépendance, la concentration ethnique, la défavorisation matérielle et l’instabilité résidentielle. Nous avons effectué deux régressions logistiques multivariées pour examiner l’association entre la marginalisation du quartier, la première axée sur la mortalité évitable (MÉ) comparée à la mortalité inévitable, et la seconde axée sur la MÉ de causes évitables comparée à la MÉ de causes traitables. Tous les modèles ont été ajustés en fonction de l’âge, du sexe, du milieu de vie (urbain ou rural) et des niveaux de comorbidité de la personne décédée.

Résultats

En tout, 463 015 décès ont été catégorisés comme étant évitables, et 228 438 décès comme étant inévitables. Les résidents des quartiers les plus défavorisés sur le plan matériel (RC : 1,24, IC de 95 % : 1,22 à 1,27) et les plus instables sur le plan résidentiel (RC : 1,13, IC de 95 % : 1,11 à 1,15) présentaient une probabilité accrue de MÉ, particulièrement de causes évitables. Chez les résidents des quartiers présentant la plus grande dépendance (RC : 0,91, IC de 95 % : 0,89 à 0,93) et la plus grande concentration ethnique (RC : 0,93, IC de 95 % : 0,91 à 0,93), la probabilité de MÉ était plus faible, mais quand elle survenait, elle était plus susceptible de découler de causes traitables.

Conclusion

Différentes dimensions de la marginalisation présentent des associations uniques avec la MÉ. En indiquant comment différents aspects de la marginalisation du quartier influencent la MÉ, ces résultats peuvent avoir des conséquences importantes pour les futures démarches de santé publique visant à réduire les inégalités devant la mortalité évitable.

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Funding

This study is financially supported by the Bruyère Research Institute through the Big Data Research Program. This study was also supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Author information

Authors and Affiliations

  1. School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada

    Austin Zygmunt

  2. Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada

    Peter Tanuseputro, Isac Lima, Meltem Tuna & Claire E. Kendall

  3. ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada

    Peter Tanuseputro, Paul James, Isac Lima, Meltem Tuna & Claire E. Kendall

  4. CT Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Canada

    Peter Tanuseputro & Claire E. Kendall

  5. Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Canada

    Peter Tanuseputro

  6. Department of Medicine, University Health Network, University of Toronto, Toronto, Canada

    Paul James

  7. Department of Family Medicine, University of Ottawa, Ottawa, Canada

    Claire E. Kendall

  8. Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada

    Claire E. Kendall

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  1. Austin Zygmunt
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Correspondence to Austin Zygmunt.

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Competing interest

The authors declare that they have no conflict of interest.

Ethics approval

ICES is a prescribed entity under section 45 of Ontario’s Personal Health Information Protection Act. Section 45 authorizes ICES to collect personal health information, without consent, for the purpose of analysis or compiling statistical information with respect to the management of, evaluation or monitoring of, the allocation of resources to or planning for all or part of the health system. Projects conducted under section 45, by definition, do not require review by a Research Ethics Board. This project was conducted under section 45, and approved by ICES’ Privacy and Compliance Office.

Data

Parts of this material are based on data and/or information compiled and provided by Canadian Institute for Health Information (CIHI). Parts of this report are based on Ontario Registrar General (ORG) information on deaths, the original source of which is Service Ontario. We attest that we have obtained appropriate permissions and paid any required fees for use of copyright protected materials.

Data sharing

The data set from this study is held securely in coded form at ICES. While data sharing agreements prohibit ICES from making the data set publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS. The full data set creation plan and underlying analytic code are available from the authors upon request, understanding that the programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

Disclaimer

The funder of the study had no role in the study design; data collection, analysis, or interpretation; or writing of the report. The opinions, results, and conclusions reported in this paper are those of the authors and are independent and do not necessarily reflect those of the funding sources, CIHI, and ORG or Ministry of Government Services. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.

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Zygmunt, A., Tanuseputro, P., James, P. et al. Neighbourhood-level marginalization and avoidable mortality in Ontario, Canada: a population-based study. Can J Public Health 111, 169–181 (2020). https://doi.org/10.17269/s41997-019-00270-9

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