Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality


The objective of this study is to ascertain whether income inequality and per capita income of area of residence show a relationship with mortality in Spain. Data are from a nation-wide prospective study with a 7-year mortality follow-up covering all persons living in Spain’s 50 provinces in 2001. In total 28,944,854 subjects aged 25 years or over at baseline were studied. Rate ratio for total mortality and cause-specific mortality, according to provincial income inequality and per capita income in two age groups, 25–64 years (adult population) and 65 years and over (elderly population). Provincial income inequality was not related to total mortality or cause-specific mortality. Total mortality rate ratios among residents of the poorest versus the richest provinces were 0.89 (95 % CI 0.95–0.93) in men and 0.91 (0.87–0.96) in women, among the adult population; and 1.02 (0.97–1.08) in men and 1.08 (1.02–1.16) in women, among the elderly population. With the exception of cardiovascular-disease mortality for which no association with per capita income was observed, adult residents of the poorest provinces registered the lowest mortality rate ratio for other causes of death. Elderly residents of the poorest provinces registered the highest mortality rate ratio for cardiovascular disease and the lowest mortality rate ratio for cancer and external causes. Aside from cardiovascular-disease mortality, the lowest mortality for most causes of death was registered by residents of the poorest provinces. Nevertheless, these findings need to be confirmed by similar studies using smaller areas as the unit of analysis.

This is a preview of subscription content, log in to check access.


  1. 1.

    Pickett KE, Pearl M. Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review. J Epidemiol Community Health. 2001;55:111–22.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  2. 2.

    Riva M, Gauvin L, Barnett TA. Toward the next generation of research into small area effects on health: a synthesis of multilevel investigations published since July 1998. J Epidemiol Community Health. 2007;61:853–61.

    PubMed Central  Article  PubMed  Google Scholar 

  3. 3.

    Meijer M, Röhl J, Bloomfield K, Grittner U. Do neighborhoods affect individual mortality? A systematic review and meta-analysis of multilevel studies. Soc Sci Med. 2012;74:1204–12.

    Article  PubMed  Google Scholar 

  4. 4.

    Regidor E, Navarro P, Dominguez V, Rodriguez C. Inequalities in income and long-term disability in Spain: analysis of recent hypotheses using cross sectional study based on individual data. BMJ. 1997;315:1130–5.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  5. 5.

    Pascual C, Regidor E, Astasio P, Ortega P, Navarro P, Domínguez V. The association of current and sustained area-based adverse socioeconomic environment with physical inactivity. Soc Sci Med. 2007;65:454–66.

    Article  PubMed  Google Scholar 

  6. 6.

    Regidor E, Gutiérrez-Fisac JL, Ronda E, Calle ME, Martínez D, Domínguez V. Impact of cumulative area-based adverse socioeconomic environment on body mass index and overweight. J Epidemiol Community Health. 2008;62:231–8.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Karlsdotter K, Martín Martín JJ, López del Amo González MP. Multilevel analysis of income, income inequalities and health in Spain. Soc Sci Med. 2012;74:1099–106.

    Article  PubMed  Google Scholar 

  8. 8.

    Regidor E, Santos JM, Ortega P, Calle ME, Astasio P, Martínez D. Decreasing income inequality and emergence of the association between income and premature mortality: Spain, 1970–2010. Health Place. 2014;27:30–7.

    Article  PubMed  Google Scholar 

  9. 9.

    Huisman M, Kunst AE, Bopp M, Borgan J-K, Borrell C, Costa G, et al. Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations. Lancet. 2005;365:493–500.

    Article  PubMed  Google Scholar 

  10. 10.

    Mackenbach JP, Stirbu I, Roskam A-JR, Schaap MM, Menvielle G, Leinsalu M, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008;358:2468–81.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Martikainen P, Kauppinen TM, Valkonen T. Effects of the characteristics of neighbourhoods and the characteristics of people on cause specific mortality: a register based follow up study of 252,000 men. J Epidemiol Community Health. 2003;57:210–7.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  12. 12.

    Steenland K, Henley J, Calle E, Thun M. Individual- and area-level socioeconomic status variables as predictors of mortality in a cohort of 179,383 persons. Am J Epidemiol. 2004;159:1047–56.

    Article  PubMed  Google Scholar 

  13. 13.

    Kibele EU. Individual- and area-level effects on mortality risk in Germany, both East and West, among male Germans aged 65+. Int J Public Health. 2014;59:439–48.

    Article  PubMed  Google Scholar 

  14. 14.

    Spanish Statistical Office. Social indicators. http://www.ine.es/en/inebmenu/mnu_sintesis_en.htm Accessed 1 July 2014.

  15. 15.

    Spanish Statistical Office. 2001 Population and housing census. http://www.ine.es/inebmenu/mnu_cifraspob.htm. Accessed 1 July 2014.

  16. 16.

    Macintyre S, Ellaway A. Neighborhoods and health: an overview. In: Kawachi I, Berkman LF, editors. Neighborhoods and health. Oxford: Oxford University Press; 2003. p. 20–49.

    Google Scholar 

  17. 17.

    Osypuk T, Galea S. What level Macro? Choosing appropriate levels to assess how place influences population health. In: Galea S. Macrosocial determinants of population health 2007: 399–436.

  18. 18.

    Lochner K, Pamuk E, Makuc D, Kennedy BP, Kawachi I. State-level income inequality and individual mortality risk: a prospective, multilevel study. Am J Public Health. 2001;91:385–91.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  19. 19.

    Backlund E, Rowe G, Lynch J, Wolfson MC, Kaplan GA, Sorlie PD. Income inequality and mortality: a multilevel prospective study of 521248 individuals in 50 US states. Int J Epidemiol. 2007;36:590–6.

    Article  PubMed  Google Scholar 

  20. 20.

    Auger N, Hamel D, Martinez J, Ross NA. Mitigating effect of immigration on the relation between income inequality and mortality: a prospective study of 2 million Canadians. J Epidemiol Community Health. 2012;66(6):e5.

    Article  PubMed  Google Scholar 

  21. 21.

    Soobader M, LeClere FB. Aggregation and the measurement of income inequality: effects on morbidity. Soc Sci Med. 1999;48:733–44.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Fiscella K, Franks P. Poverty or income inequality as predictor of mortality: longitudinal cohort study. BMJ. 1997;314:1724–7.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  23. 23.

    Fiscella K, Franks P. Individual income, income inequality, health, and mortality: what are the relationships? Health Serv Res. 2000;35:307–18.

    PubMed Central  CAS  PubMed  Google Scholar 

  24. 24.

    Osler M, Prescott E, Gronbaek M, Christensen U, Due P, Engholm G. Income inequality, individual income, and mortality in Danish adults: analysis of pooled data from two cohort studies. BMJ J. 2002;324:13–6.

    Article  Google Scholar 

  25. 25.

    Blakely T, Atkinson J, O’Dea D. No association of income inequality with adult mortality within New Zealand: a multi-level study of 1.4 million 25–64 year olds. J Epidemiol Community Health. 2003;57:279–84.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  26. 26.

    Blomgren J, Martikainen P, Makela P, Valkonen T. The effects of regional characteristics on alcohol-related mortality—a register-based multilevel analysis of 1.1 million men. Soc Sci Med. 2004;58:2523–35.

    Article  PubMed  Google Scholar 

  27. 27.

    Gerdtham UG, Johannesson M. Absolute income, relative income, income inequality, and mortality. J Human Res. 2004;39:228–47.

    Article  Google Scholar 

  28. 28.

    Henriksson G, Allebeck P, Weitoft GR, Thelle D. Are manual workers at higher risk of death than non-manual employees when living in Swedish municipalities with higher income inequality? Eur J Public Health. 2007;17:139–44.

    Article  PubMed  Google Scholar 

  29. 29.

    Regidor E, Calle ME, Navarro P, Dominguez V. Trends in the association between average income, poverty and income inequality and life expectancy in Spain. Soc Sci Med. 2003;56:961–71.

    Article  PubMed  Google Scholar 

  30. 30.

    Wilkinson RG. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996.

    Google Scholar 

  31. 31.

    Kawachi I, Kennedy BP. The health of nations. Why inequality is harmful to your health. New York: The New Press; 2002.

    Google Scholar 

  32. 32.

    Davey Smith G. Income inequality and mortality: why are they related? Income inequality goes hand in hand with underinvestment in human resources. BMJ. 1996;312:987–8.

    Article  Google Scholar 

  33. 33.

    Lynch JW, Davey Smith G, Kaplan GA, House J. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ. 2000;320:1200–4.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  34. 34.

    Connolly S, O´Reilly D, Rosato M. Increasing inequalities in health: is it an artefact caused by the selective movement of people? Soc Sci Med. 2007;64:2008–15.

    Article  PubMed  Google Scholar 

  35. 35.

    Boyle P, Exeter D, Flowerdew R. The role of population change in widening the mortality gap in Scotland. Area. 2004;36(2):164–73.

    Article  Google Scholar 

  36. 36.

    Maruzzi M, Krzyzanowski M, Bertollini R. Health impact assessment of air pollution: providing further evidence for public health action. Eur Respir J. 2003;21(Suppl 40):86s–91s.

    Article  Google Scholar 

  37. 37.

    Ministerio de Agricultura, Alimentación y Medio Ambiente. Evaluación de la calidad del aire en España (Assessment of air quality in Spain). http://www.magrama.gob.es/es/estadistica/temas/estadisticas-ambientales/mem06_3_1_3_evaluacioncalidadaire_tcm7-15536.pdf. Accessed 22 Dec 2014.

  38. 38.

    World Health Organization. Department of Public Health and Environment. Urban outdoor air pollution database September 2011. http://www.who.int/phe. Accessed 22 Dec 2014.

  39. 39.

    Anderson RT, Sorlie P, Kacklund E, Hohnson N, Kaplan GA. Mortality effects of community socioeconomic status. Epidemiology. 1997;8:42–7.

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Karpati AM, Bassett MT, McCord C. Neighborhood mortality inequalities in New York City, 1989–1991 and 1999–2001. J Epidemiol Community Health. 2006;60:1060–4.

    PubMed Central  Article  PubMed  Google Scholar 

  41. 41.

    Lochner KA, Kawachi I, Brennan RT, Buka SL. Social capital and neighborhood mortality rates in Chicago. Soc Sci Med. 2003;56:1797–805.

    Article  PubMed  Google Scholar 

  42. 42.

    van Lenthe FJ, Borrell LN, Costa G, Diez Roux AV, Kauppinen TM, Marinacci C, et al. Neighbourhood unemployment and all cause mortality: a comparison of six countries. J Epidemiol Community Health. 2005;59:231–7.

    PubMed Central  Article  PubMed  Google Scholar 

  43. 43.

    Waitzman NJ, Smith KR. Phantom of the area: poverty-area residence and mortality in the United States. Am J Public Health. 1998;88:973–6.

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  44. 44.

    Wight RG, Cummings JR, Karlamangla AS, Aneshensel CS. Urban neighborhood context and mortality in late life. J Aging Health. 2010;22:197–218.

    PubMed Central  Article  PubMed  Google Scholar 

  45. 45.

    Yao L, Robert S. The contributions of race, individual socioeconomic status, and neighborhood socioeconomic context on the self-rated health trajectories and mortality of older adults. Res Aging. 2008;30:251–73.

    Article  Google Scholar 

  46. 46.

    Regidor E, Martínez D, Astasio P, Ortega P, Calle ME, Domínguez V. Association of income with use of and access to health services in Spain at the beginning of the XXI century. Gac Sanit. 2006;20:352–9.

    Article  PubMed  Google Scholar 

  47. 47.

    Grau M, Elosua R, Cabrera de León A, Guembe MJ, Baena-Díez JM, Vega Alonso T, Javier Félix F, Zorrilla B, Rigo F, Lapetra J, Gavrila D, Segura A, Sanz H, Fernández-Bergés D, Fitó M, Marrugat J. Cardiovascular risk factors in Spain in the first decade of the 21st Century, a pooled analysis with individual data from 11 population-based studies: the DARIOS study. Rev Esp Cardiol. 2011;64:295–304.

    Article  PubMed  Google Scholar 

  48. 48.

    Fundación BBV. Renta nacional de España y su distribución provincial. Serie homogénea. Años a 1993 y avances 1994 a 1997 Fundación BBV Documenta: Bilbao 1955; 1999.

  49. 49.

    Galobardes B, Lynch JW, Davey Smith G. Childhood socioeconomic circumstances and cause-specific mortality in adulthood: systematic review and interpretation. Epidemiol Rev. 2004;26:7–21.

    Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Enrique Regidor.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Regidor, E., Vallejo, F., Giráldez-García, C. et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol 30, 637–648 (2015). https://doi.org/10.1007/s10654-015-0013-x

Download citation


  • National prospective study
  • Multilevel study
  • Income inequality
  • Per capita income
  • Mortality
  • Leading causes of death
  • Spain