Mapping the cause-specific premature mortality reveals large between-districts disparity in Belgium, 2003-2009

Trends in socioeconomic inequalities in cause-specific premature mortality in Belgium, 1998-2019

BACKGROUND

Higher levels of socioeconomic deprivation have been consistently associated with increased risk of premature mortality, but a detailed analysis by causes of death is lacking in Belgium. We aim to investigate the association between area deprivation and all-cause and cause-specific premature mortality in Belgium over the period 1998-2019.

METHODS

We used the 2001 and 2011 Belgian Indices of Multiple Deprivation to assign statistical sectors, the smallest geographical units in the country, into deprivation deciles. All-cause and cause-specific premature mortality rates, population attributable fraction, and potential years of life lost due to inequality were estimated by period, sex, and deprivation deciles.

RESULTS

Men and women living in the most deprived areas were 1.96 and 1.78 times more likely to die prematurely compared to those living in the least deprived areas over the period under study (1998-2019). About 28% of all premature deaths could be attributed to socioeconomic inequality and about 30% of potential years of life lost would be averted if the whole population of Belgium faced the premature mortality rates of the least deprived areas.

CONCLUSION

Premature mortality rates have declined over time, but inequality has increased due to a faster pace of decrease in the least deprived areas compared to the most deprived areas. As the causes of death related to poor lifestyle choices contribute the most to the inequality gap, more effective, country-level interventions should be put in place to target segments of the population living in the most deprived areas as they are facing disproportionately high risks of dying.

Heterogeneity in subnational mortality in the context of the COVID-19 pandemic: the case of Belgian districts in 2020

BACKGROUND

The COVID-19 pandemic has led to major shocks in mortality trends in many countries. Yet few studies have evaluated the heterogeneity of the mortality shocks at the sub-national level, rigorously accounting for the different sources of uncertainty.

METHODS

Using death registration data from Belgium, we first assess change in the heterogeneity of districts' standardized mortality ratios in 2020, when compared to previous years. We then measure the shock effect of the pandemic using district-level values of life expectancy, comparing districts' observed and projected life expectancy, accounting for all sources of uncertainty (stemming from life-table construction at district level and from projection methods at country and district levels). Bayesian modelling makes it easy to combine the different sources of uncertainty in the assessment of the shock. This is of particular interest at a finer geographical scale characterized by high stochastic variation in annual death counts.

RESULTS

The heterogeneity in the impact of the pandemic on all-cause mortality across districts is substantial: while some districts barely show any impact, the Bruxelles-Capitale and Mons districts experienced a decrease in life expectancy at birth of 2.24 (95% CI:1.33-3.05) and 2.10 (95% CI:0.86-3.30) years, respectively. The year 2020 was associated with an increase in the heterogeneity of mortality levels at a subnational scale in comparison to past years, measured in terms of both standardized mortality ratios and life expectancies at birth. Decisions on uncertainty thresholds have a large bearing on the interpretation of the results.

CONCLUSION

Developing sub-national mortality estimates taking careful account of uncertainty is key to identifying which areas have been disproportionately affected.

Spatial analysis of alcohol-related mortality in Slovakia

OBJECTIVE

The aim of our study was to investigate the relationship between alcohol-related mortality in Slovak regions, as represented by Nomenclature of Territorial Units for Statistics (NUTS) III level.

METHODS

We used data from mortality reports spanning 1996-2017 in the Slovak Republic. Data was provided by the National Health Information Centre in Slovakia. We applied two-dimensional correspondence analysis where the dimensions are regions and selected alcohol-related deaths diagnoses are classified by the International Classification of Diseases.

RESULTS

Analysis revealed a relationship between the Prešov region and diagnoses I42 - Cardiomyopathy and K29 - Alcoholic gastritis. Furthermore, the Banská Bystrica and Žilina regions correspond to G31 - Degeneration of nervous system due to alcohol and K86 - Alcohol-induced chronic pancreatitis. In the case of K70 - Alcoholic liver disease - the Banská Bystrica, Trenčín and Nitra regions are identified as regions which have an intermediate relationship with this diagnosis. The Trnava region corresponds to F10 - Acute alcohol intoxication. The Trenčín and Nitra regions correspond closely to G62 - Alcoholic polyneuropathy. Perfect correspondence can be seen between the Košice region and K73 - Chronic hepatitis, not elsewhere classified. K74 - Fibrosis and cirrhosis of liver diagnosis also corresponds with the Košice region.

CONCLUSIONS

The results of this analysis provide valuable insights for national and regional health policymakers in the process of preparing high-quality health regional plans, as well as retrospectively assessing the success of existing health policies and interventions in this area. Facts presented in the study justify the need for specialised health care, which is part of the process of building an Integrated Health Care Centre in Slovakia.

Educational inequalities in premature mortality by region in the Belgian population in the 2000s

BACKGROUND

In Belgium, socio-economic inequalities in mortality have long been described at country-level. As Belgium is a federal state with many responsibilities in health policies being transferred to the regional levels, regional breakdown of health indicators is becoming increasingly relevant for policy-makers, as a tool for planning and evaluation. We analyzed the educational disparities by region for all-cause and cause-specific premature mortality in the Belgian population.

METHODS

Residents with Belgian nationality at birth registered in the census 2001 aged 25-64 were included, and followed up for 10 years though a linkage with the cause-of-death database. The role of 3 socio-economic variables (education, employment and housing) in explaining the regional mortality difference was explored through a Poisson regression. Age-standardised mortality rates (ASMRs) by educational level (EL), rate differences (RD), rate ratios (RR), and population attributable fractions (PAF) were computed in the 3 regions of Belgium and compared with pairwise regional ratios. The global PAFs were also decomposed into the main causes of death.

RESULTS

Regional health gaps are observed within each EL, with ASMRs in Brussels and Wallonia exceeding those of Flanders by about 50% in males and 40% in females among Belgian. Individual SE variables only explained up to half of the regional differences. Educational inequalities were also larger in Brussels and Wallonia than in Flanders, with RDs ratios reaching 1.8 and 1.6 for Brussels versus Flanders, and Wallonia versus Flanders respectively; regional ratios in relative inequalities (RRs and PAFs) were smaller. This pattern was observed for all-cause and most specific causes of premature mortality. Ranking the cause-specific PAFs revealed a higher health impact of inequalities in causes combining high mortality rate and relative inequality, with lung cancer and ischemic heart disease on top for all regions and both sexes. The ranking showed few regional differences.

CONCLUSIONS

For the first time in Belgium, educational inequalities were studied by region. Among the Belgian, educational inequalities were higher in Brussels, followed by Wallonia and Flanders. The region-specific PAF decomposition, leading to a ranking of causes according to their population-level impact on overall inequality, is useful for regional policy-making processes.

General practice patients treated for substance use problems: a cross-national observational study in Belgium

Background

General Practitioners (GPs) are well placed to care for patients with (chronic) substance use problems. This pilot was carried out to study the feasibility and usefulness of a continuous surveillance of substance use problems among general practice patients. The objectives were (i) to describe variables with missing values exceeding 1% and whether patients were reported without substance-related problems; (ii) the profile and the magnitude of the patient population that is treated for substance use problems.

Methods

Observational study by the Belgian Network of Sentinel General Practices (SGP) in 2013. Baseline (at the first encounter) and 7-month follow-up data were reported of all patients treated for substance use problems. Two main measurements were type of substance use and patient status at follow-up. Multiple logistic regression analysis was used to examine patient status at follow-up.

Results

Of 479 patients, 47.2% had problems with alcohol alone, 20.3% with prescription drugs, 16.7% with illicit drugs other than heroin or methadone and 15.9% with heroin or methadone. Problems with alcohol alone were more prevalent in Flanders (53.0%; 95% confidence interval (CI) 46.8–59.1%) than in Wallonia-Brussels (39.8%; 95% CI 33.1–46.8%), while problems with heroin or methadone were more prevalent in Wallonia-Brussels (27.0%; 95% CI 21.1–33.5%) than in Flanders (7.1%; 95% CI 4.3–10.9%). At follow-up, 32.8% of the patients had dropped out, 29.0% had discontinued GP treatment and 38.2% had continued GP treatment. Overall, 32.4% of 479 patients had continued GP treatment for substance use problems during the study period. In Wallonia-Brussels, this proportion was higher (42.7%; 95% CI 35.9–49.6%) than in Flanders (24.3%; 95% CI 19.2–29.8%).

Conclusions

A continuous surveillance of the general practice population treated for substance use problems seems to be feasible and useful. The latter is suggested by the specific profile and the relative magnitude of the population. Inter-regional health system differences should be taken into account to estimate the epidemiology of substance use problems among general practice patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3885-0) contains supplementary material, which is available to authorized users.

The geographic pattern of Belgian mortality: can socio-economic characteristics explain area differences?

Background

Country averages for health outcomes hide important within-country variations. This paper probes into the geographic Belgian pattern of all-cause mortality and wishes to investigate the contribution of individual and area socio-economic characteristics to geographic mortality differences in men aged 45–64 during the period 2001–2011.

Methods

Data originate from a linkage between the Belgian census of 2001 and register data on mortality and emigration during the period 2001–2011. Mortality rate ratios (MRRs) are estimated for districts and sub-districts compared to the Belgian average mortality level using Poisson regression modelling. Individual socio-economic position (SEP) indicators are added to examine the impact of these characteristics on the observed geographic pattern. In order to scrutinize the contribution of area-level socio-economic characteristics, random intercepts Poisson modelling is performed with predictors at the individual and the sub-district level. Random intercepts and slopes models are fitted to explore variability of individual-level SEP effects.

Results

All-cause MRRs for middle-aged Belgian men are higher in the geographic areas of the Walloon region and the Brussels-Capital Region (BCR) compared to those in the Flemish region. The highest MRRs are observed in the inner city of the BCR and in several Walloon cities. Their disadvantage can partially be explained by the lower individual SEP of men living in these areas. Similarly, the relatively low MRRs observed in the districts of Halle-Vilvoorde, Arlon and Virton can be related to the higher individual SEP. Among the area-level characteristics, both the percentage of men employed and the percentage of labourers in a sub-district have a protective effect on the individual MRR, regardless of individual SEP. Variability in individual-level SEP effects is limited.

Conclusions

Individual SEP partly explains the observed mortality gap in Belgium for some areas. The percentage of men employed and the percentage of labourers in a sub-district have an additional effect on the individual MRR aside from that of individual SEP. However, these socio-economic factors cannot explain all of the observed differences. Other mechanisms such as public health policy, cultural habits and environmental influences contribute to the observed geographic pattern in all-cause mortality among middle-aged men.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-016-0135-y) contains supplementary material, which is available to authorized users.