Long-term impact of the 2008 economic crisis in Spain on road traffic collisions mortality by socioeconomic position.

We aimed to assess the effect of the 2008 crisis on road traffic collision (RTC) mortality in Spain, by socioeconomic position (SEP) and type of road use. This prospective, country-wide study covered all adults living in Spain and aged ≥30 years in November 2001. The long-term effect of the crisis was assessed by measuring the monthly percentage change (MPC) in RTC mortality between the pre-crisis (2002-2007) and crisis period (2008-2011). During the recession, RTC mortality fell more in people with low compared to high SEP, so MPCs difference between periods were of a higher magnitude in the low compared to high SEP groups, especially among men motorcyclists. RTC mortality trends were favorable following the 2008 crisis, particularly among low-SEP groups. In men motorcyclists, the upward trend of the pre-crisis period reversed course.

No effect of the Penalty Point System on road traffic accident mortality among men with a high socioeconomic status in Spain.

The purpose of this study was to assess the effect of the Penalty Point System (PPS) on road traffic accident mortality by gender and socioeconomic status. We conducted a nationwide prospective study covering adult people living in Spain on November 2001. They were followed up until 30 Nov 2007 to determine vital status and cause of death. An interrupted time-series analysis was used to assess whether PPS (explanatory variable) had both immediate and long-term effect on the rates of road traffic accident mortality (RTAMs) separately by gender. Subjects were classified by socioeconomic status (low and high) using two indicators: educational attainment (up to lower secondary education; upper secondary education or more) and occupation (manual and non-manual workers). We performed several segmented Poisson regression models, controlling for trend, seasonality, 2004 road safety measures and fuel consumption as proxy for traffic exposure. Among men, we found a decrease on the RTAMs immediately after PPS in those with low educational level (16.2 %, IC95 %: 6.1 %-25.2 %) and manual workers (16.3 %, IC95 %: 2.8 %-27.8 %), and a non-significant increase among those with high education level and non-manual workers (6.2 % and 1.8 %). Among women, there were no significant differences in the immediate effect of PPS by socioeconomic status. We did not identify significant trend changes between pre-PPS and post-PPS periods in any socioeconomic group. In a context of downward trend of traffic mortality, the PPS implementation led to an immediate reduction on death rates only among men with a low socioeconomic status.

[Frequency of medical consultations in the adult population in Spain, before and after the restriction of access to undocumented immigrants]. / Frecuencia de consultas al médico en población adulta en España, antes y después de la restricción de acceso a los inmigrantes indocumentados.

OBJECTIVE: To study the frequency of medical consultations in autochthonous and immigrant populations in Spain, before and after a government measure of 2012 that restricted the use of public health services to undocumented immigrants. MATERIAL AND METHODS: The data were taken from the European Health Surveys in Spain in 2009 and 2014. An analysis was made of the consultations with the family doctor and the consultations with the medical specialist in autochthonous and immigrant populations from 18 to 64 years. Percentage increases were calculated in the frequency of people who consulted in 2014 with respect to 2009, and, in each year, the percentage ratio (PR) of consultation in immigrants with respect autochthonous, with 95% confidence intervals (95% CI). RESULTS: The frequency of consultations increased in 2014 compared to 2009, with the exception of family doctor's consultation with the autochthonous women. The highest increases occurred in visits to medical specialists in immigrants (39.9%), in autochthonous (21.6%), and in visits by the family doctor to immigrant women. After adjusting for age and socioeconomic variables and indicators of need for assistance, there were no significant differences in both years between immigrants and autochthonous in the 2types of consultations. CONCLUSIONS: The frequency of consultations to the family doctor or medical specialist did not decrease in Spain between 2009 and 2014 in the immigrant population.

miR-10b and miR-223-3p in serum microvesicles signal progression from prediabetes to type 2 diabetes.

PURPOSE: Type 2 diabetes frequently remains undiagnosed for years, whereas early detection of affected individuals would facilitate the implementation of timely and cost-effective therapies, hence decreasing morbidity. With the intention of identifying novel diagnostic biomarkers, we characterized the miRNA profile of microvesicles isolated from retroactive serum samples of normoglycemic individuals and two groups of subjects with prediabetes that in the following 4 years either progressed to overt diabetes or remained stable. METHODS: We profiled miRNAs in serum microvesicles of a selected group of control and prediabetic individuals participating in the PREDAPS cohort study. Half of the subjects with prediabetes were diagnosed with diabetes during the 4 years of follow-up, while the glycemic status of the other half remained unchanged. RESULTS: We identified two miRNAs, miR-10b and miR-223-3p, which target components of the insulin signaling pathway and whose ratio discriminates between these two subgroups of prediabetic individuals at a stage at which other features, including glycemia, are less proficient at separating them. In global, the profile of miRNAs in microvesicles of prediabetic subjects primed to progress to overt diabetes was more similar to that of diabetic patients than the profile of prediabetic subjects who did not progress. CONCLUSION: We have identified a miRNA signature in serum microvesicles that can be used as a new screening biomarker to identify subjects with prediabetes at high risk of developing diabetes, hence allowing the implementation of earlier, and probably more effective, therapeutic interventions.

The turn of the gradient? Educational differences in breast cancer mortality in 18 European populations during the 2000s.

This study aims to investigate the association between educational level and breast cancer mortality in Europe in the 2000s. Unlike most other causes of death, breast cancer mortality tends to be positively related to education, with higher educated women showing higher mortality rates. Research has however shown that the association is changing from being positive over non-existent to negative in some countries. To investigate these patterns, data from national mortality registers and censuses were collected and harmonized for 18 European populations. The study population included all women aged 30-74. Age-standardized mortality rates, mortality rate ratios, and slope and relative indexes of inequality were computed by education. The population was stratified according to age (women aged 30-49 and women aged 50-74). The relation between educational level and breast cancer mortality was predominantly negative in women aged 30-49, mortality rates being lower among highly educated women and higher among low educated women, although few outcomes were statistically significant. Among women aged 50-74, the association was mostly positive and statistically significant in some populations. A comparison with earlier research in the 1990s revealed a changing pattern of breast cancer mortality. Positive educational differences that used to be significant in the 1990s were no longer significant in the 2000s, indicating that inequalities have decreased or disappeared. This evolution is in line with the "fundamental causes" theory which stipulates that whenever medical insights and treatment become available to combat a disease, a negative association with socio-economic position will arise, independently of the underlying risk factors.

[Inequalities in premature mortality by indicators of material welfare in Navarre. Population monitoring study 2001-2008]. / Desigualdades en mortalidad prematura según indicadores de bienestarmaterial en Navarra. Estudio poblacional de seguimiento 2001-2008.

BACKGROUND: To show the inequalities in premature mortality according to indicators of material welfare in Navarre. METHODS: All citizens under 75 years of age living in Navarre in 2001 were monitored for seven years to determine their vital status. House size and number of household vehicles was used as the socioeconomic status indicator. The age-adjusted total mortality rate and mortality rate from cause-specific mortality were estimated by these indicators. RESULTS: The rate ratio for all causes of death in the lower categories depending on house size is 1.14 (IC 95%: 1.05-1.24) and 1.25 (IC 95%: 1.18-1.32) in women and men respectively and 1.46 (IC 95%: 1.36-1.57) and 1.97 (IC 95%: 1.89-2.05) depending on the number of vehicles. AIDS is the leading cause of death having a greater difference in mortality rates among people with lower and higher material welfare. Other causes of death with a high difference in mortality rates are digestive diseases and diabetes mellitus in women and digestive diseases and respiratory diseases in men. CONCLUSIONS: The mortality rate in the Navarre population shows an inverse gradient to material welfare,except for some cancer sites. This gradient is higher among men than among women.

Trends in the prevalence of childhood overweight and obesity according to socioeconomic status: Spain, 1987-2007.

BACKGROUND/OBJECTIVES: To ascertain trends in the prevalence of overweight and obesity among Spanish children and adolescents according to the socioeconomic status of the family household and area of residence across the period 1987-2007. SUBJECTS/METHODS: For study purposes, data were drawn from the 1987, 1995, 1997, 2001 and 2007 Spanish National Health Surveys. Overweight and obesity were estimated on the basis of body mass index. The following indicators of socioeconomic status were used: educational level of primary household earner and per capita income of province of residence. The statistical significance of the trend in the prevalence of overweight and obesity was assessed for each category of socioeconomic status. The χ2 test for trend was used in the case of educational level and a linear regression in the case of per capita income of province of residence. RESULTS: Although the prevalence of overweight and obesity had levelled off among boys and girls aged 5 to 9 years, it nevertheless showed a significant upward trend among those aged 10 to 15 years from families whose primary household earner had a lower educational level. The prevalence of overweight among boys in this last group was 13.1% in 1987 and 31.5% in 2007. From 1997 onwards, the prevalence of overweight and obesity among boys and girls aged 10 to 15 years increased in both the richest and the remaining provinces, although the magnitude of this increase was greater in the latter. Specifically, in these provinces the prevalence increased from 18 to 28.9% over the period of study. CONCLUSIONS: The prevalence of overweight and obesity in the childhood population in Spain has stabilised, except among adolescents, whether from lower-income families or lower-income areas, among whom a rising trend is in evidence.

Explaining educational differences in leisure-time physical activity in Europe: the contribution of work-related factors.

Although educational differences in leisure-time physical activity (LTPA) exist across Europe, the independent effect of educational level on leisure-time physical activity has rarely been explored. This study examines the relative contribution of occupational class, employment status, and educational level to LTPA across 12 European countries. The data were obtained from 12 European health surveys conducted at the turn of the century and identified in the EUROTHINE project. All information was self-reported. Logistic regression was applied and relative inequality index (RII) was calculated. Analyses were limited to those in the prime working-age (age 30-59; total N=137,646) men and women. In all 12 European countries, LTPA was more common in the high-educated than in the low-educated. The association between education and LTPA remained mostly unchanged after adjusting for marital status, urbanization, and self-rated health. After further adjusting for occupational class and employment status, the educational differences in LTPA were only slightly attenuated. An inverse association was found between educational level and LTPA across almost all 12 European countries. Occupational class and employment status had only a modest effect on educational differences in LTPA in most of the examined countries, suggesting that education remains an important predictor of LTPA.

Heterogeneous trend in smoking prevalence by sex and age group following the implementation of a national smoke-free law.

OBJECTIVE: Given the limited evidence available about the effects of clean indoor air laws on smoking behaviour in the general population, the impact of national smoke-free workplace, bar and restaurant legislation, implemented on 1 January 2006, on smoking prevalence in Spain was assessed in this study. METHODS: Population-based trend analysis using estimates for 27 periods from the beginning of 2000 to the end of 2008-three periods per year. To calculate the period per cent change in smoking prevalence, the permutation test for joinpoint regression to detect significant changes was used. RESULTS: In men and women aged 15-24 years, the prevalence of smoking declined between the first period in 2000 and the third period in 2008, whereas in women aged 45-64 years, it increased by 1.7% per period. A declining trend was detected up to the first period in 2006 in men and women aged 25-44 years and in men aged 45-64 years, but between the beginning of 2006 and the end of 2008 the prevalence of smoking increased by 1.2%, 0.7% and 2.0% per period in men aged 25-44 years, in women aged 25-44 years and in men aged 45-64 years, respectively. CONCLUSIONS: 3 years after a national smoke-free law was implemented, the trend in smoking prevalence in some population groups was unchanged; however, in others, the declining trend of previous years was reversed. The similarity of these findings to those observed in other countries suggests that clean indoor air laws, although effective in reducing exposure to second-hand smoke, may not achieve the secondary objective of reducing the prevalence of smoking in the population.

Trends in principal cancer risk factors in Spain.

Using data furnished by successive national health surveys, this article describes trends in the prevalence of smoking, physical inactivity, obesity, consumption of fruit and vegetables, and excessive alcohol consumption in Spain. For most of these factors, trends are shown since the end of the 1980s, and in the case of smoking, since the end of the 1970s. The findings indicate decreases in smoking--except among women aged 45-64 years--physical inactivity and high-risk alcohol consumption, and increases in consumption of fruit and vegetables, and obesity. The inclusion of these risk factors in cancer prevention strategies continues to be a matter of priority, in some cases because they display high prevalences despite their downward trend, as occurs with smoking among men and physical inactivity in the overall population, and in others because they display an upward trend, e.g. smoking among women aged 45-64 years and obesity in the overall population.

Heterogeneity by age in educational inequalities in cause-specific mortality in women in the Region of Madrid.

BACKGROUND: Within Europe, women in the southern regions have the lowest inequalities in mortality. This study evaluates inequalities in mortality from different causes by educational level and their contribution to total mortality inequalities in adult women in one of these regions. METHODS: The 2001 population census in the Region of Madrid was linked with deaths in the following 20 months according to the mortality registry. The population of women was stratified into three age groups, and the mortality rate ratio and mortality rate difference by educational level were estimated in each age group. The contribution of each cause of death to total mortality inequality was estimated based on the absolute index of inequality. RESULTS: In women aged 45-64 years, no significant relation was observed between educational level and mortality from the leading causes of death. In women aged 25-44 years and in those aged 65 and over, the mortality rate ratios and differences from the leading causes of death gradually increased from the highest to the lowest educational level. AIDS, respiratory diseases and digestive diseases, in young adult women, and cardiovascular diseases, in older women, were the causes of death that contributed most to inequality in mortality. CONCLUSIONS: At the beginning of the twenty-first century, mortality inequalities by educational level were not seen in middle-aged adult women in the Region of Madrid. In contrast, mortality inequalities were found in young women and in older women, although the main causes of death that contributed to these inequalities were different in each group.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century.

AIMS/HYPOTHESIS: The aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women. METHODS: We analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated. RESULTS: In the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4-1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9-2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6-4.6), while in men it is 2.0 (95% CI 1.7-2.4). CONCLUSIONS/INTERPRETATION: In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries.

BACKGROUND: Recently a scale was introduced to quantify the implementation of tobacco control policies at country level. Our study used this scale to examine the potential impact of these policies on quit ratios in European countries. Special attention was given to smoking cessation among lower educational groups. METHODS: Cross-sectional data were derived from national health surveys from 18 European countries. In the analyses we distinguished between country, sex, two age groups (25-39 and 40-59 years) and educational level. Age-standardised quit ratios were calculated as total former-smokers divided by total ever-smokers. In regression analyses we explored the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS). RESULTS: Quit ratios were especially high (>45%) in Sweden, England, The Netherlands, Belgium and France and relatively low (<30%) in Lithuania and Latvia. Higher educated smokers were more likely to have quit smoking than lower educated smokers in all age-sex groups in all countries. National score on the tobacco control scale was positively associated with quit ratios in all age-sex groups. The association of quit ratios with score on TCS did not show consistent differences between high and low education. Of all tobacco control policies of which the TCS is constructed, price policies showed the strongest association with quit ratios, followed by an advertising ban. CONCLUSION: Countries with more developed tobacco control policies have higher quit ratios than countries with less developed tobacco control policies. High and low educated smokers benefit about equally from the nationwide tobacco control policies.

Educational differences in cancer mortality among women and men: a gender pattern that differs across Europe.

We used longitudinal mortality data sets for the 1990s to compare socioeconomic inequalities in total cancer mortality between women and men aged 30-74 in 12 different European populations (Madrid, Basque region, Barcelona, Slovenia, Turin, Switzerland, France, Belgium, Denmark, Norway, Sweden, Finland) and to investigate which cancer sites explain the differences found. We measured socioeconomic status using educational level and computed relative indices of inequality (RII). We observed large variations within Europe for educational differences in total cancer mortality among men and women. Three patterns were observed: Denmark, Norway and Sweden (significant RII around 1.3-1.4 among both men and women); France, Switzerland, Belgium and Finland (significant RII around 1.7-1.8 among men and around 1.2 among women); Spanish populations, Slovenia and Turin (significant RII from 1.29 to 1.88 among men; no differences among women except in the Basque region, where RII is significantly lower than 1). Lung, upper aerodigestive tract and breast cancers explained most of the variations between gender and populations in the magnitude of inequalities in total cancer mortality. Given time trends in cancer mortality, the gap in the magnitude of socioeconomic inequalities in cancer mortality between gender and between European populations will probably decrease in the future.

Impact of cumulative area-based adverse socioeconomic environment on body mass index and overweight.

OBJECTIVE: Although the relationship between area socioeconomic environment and obesity is known, previous research has measured area socioeconomic environment at only one point in time. This study evaluates the relationship of cumulative area-based adverse socioeconomic environment with body mass index (BMI) and overweight. DESIGN: Cross-sectional study. SETTING: Spain. PARTICIPANTS: 17 917 subjects in 2001. MAIN OUTCOME MEASURE: Information from 1980, 1990 and 2000 was used for the percentage of the population with low educational achievement, gross domestic product per capita (GDPpc), and Gini coefficient to estimate BMI and prevalence of overweight by the number of times each province had an adverse exposure to each of these measures of socioeconomic environment. RESULTS: After adjusting for individual variables and sports facilities in the area, the difference in BMI in residents of provinces with the highest percentage of population with low educational achievement in 1980, 1990 and 2000, compared with residents of provinces with no history of adverse socioeconomic environment based on this indicator, was 0.61 kg/m(2), whereas the prevalence of overweight was 1.46 times higher. Similar results were obtained for residents of provinces with cumulative low GDPpc versus residents of provinces that had never had low GDPpc. Neither BMI nor overweight were associated with cumulative income inequality based on the Gini coefficient. CONCLUSION: Cumulative adverse socioeconomic environment based on indicators of educational level or wealth, but not of income inequality, is positively associated with BMI and overweight. This association is not explained by individual characteristics or by the availability of sports facilities.

Influence of childhood socioeconomic circumstances, height, and obesity on pulse pressure and systolic and diastolic blood pressure in older people.

This study assesses the association of childhood socioeconomic circumstances, height, and obesity with components of blood pressure. We selected 4009 people representative of the Spanish population aged 60 years and older, and estimated systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) according to childhood social class, height, and obesity. No association was found between childhood social class and blood pressure. SBP showed an inverse gradient and DBP a direct gradient with height, although an independent association between height and DBP was found only in women. Stature was independently associated with increased DBP in women with central obesity, but there was no association between height and DBP in women without central obesity. Short stature was independently associated with increased PP. Body mass index and waist-to-hip ratio were independently associated with increased DBP in women, and waist-to-hip ratio was independently associated with increased PP in men, while waist circumference was independently associated with increased DBP and increased PP in women. These results do not support the assumed effect of socioeconomic circumstances in early life on blood pressure, which may depend on the context and/or study population. The relations observed between height and blood pressure support the hypothesis that PP could be a mediator of the association between short stature and increased cardiovascular risk. The relationship between obesity measures and components of blood pressure reinforces the recommendation to reduce body weight in order to reduce blood pressure.

Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s.

OBJECTIVE: To assess the association between socioeconomic status and ischaemic heart disease (IHD) mortality in 10 western European populations during the 1990s. DESIGN: Longitudinal study. SETTING: 10 European populations (95,009,822 person years). METHODS: Longitudinal data on IHD mortality by educational level were obtained from registries in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Age standardised rates and rate ratios (RRs) of IHD mortality by educational level were calculated by using Poisson regression. RESULTS: IHD mortality was higher in those with a lower socioeconomic status than in those with a higher socioeconomic status among men aged 30-59 (RR 1.55, 95% confidence interval (CI) 1.51 to 1.60) and 60 years and over (RR 1.22, 95% CI 1.21 to 1.24), and among women aged 30-59 (RR 2.13, 95% CI 1.98 to 2.29) and 60 years and over (RR 1.36, 95% CI 1.33 to 1.38). Socioeconomic disparities in IHD mortality were larger in the Scandinavian countries and England/Wales, of moderate size in Belgium, Switzerland, and Austria, and smaller in southern European populations among men and younger women (p < 0.0001). For elderly women the north-south gradient was smaller and there was less variation between populations. No socioeconomic disparities in IHD mortality existed among elderly men in southern Europe. CONCLUSIONS: Socioeconomic disparities in IHD mortality were larger in northern than in southern European populations during the 1990s. This partly reflects the pattern of socioeconomic disparities in cardiovascular risk factors in Europe. Population wide strategies to reduce risk factor prevalence combined with interventions targeted at the lower socioeconomic groups can contribute to reduce IHD mortality in Europe.

Education level inequalities and transportation injury mortality in the middle aged and elderly in European settings.

OBJECTIVE: To study the differential distribution of transportation injury mortality by educational level in nine European settings, among people older than 30 years, during the 1990s. METHODS: Deaths of men and women older than 30 years from transportation injuries were studied. Rate differences and rate ratios (RR) between high and low educational level rates were obtained. RESULTS: Among men, those of low educational level had higher death rates in all settings, a pattern that was maintained in the different settings; no inequalities were found among women. Among men, in all the settings, the RR was higher in the 30-49 age group (RR 1.46, 95% CI 1.32 to 1.61) than in the age groups 50-69 and > or = 70 years, a pattern that was maintained in the different settings. For women for all the settings together, no differences were found among educational levels in the three age groups. In the different settings, only three had a high RR in the youngest age group, Finland (RR 1.33, 95% CI 1.01 to 1.74), Belgium (RR 1.38; 95% CI 1.13 to 1.67), and Austria (RR 1.49, 95% CI 0.75 to 2.96). CONCLUSION: This study provides new evidence on the importance of socioeconomic inequalities in transportation injury mortality across Europe. This applies to men, but not to women. Greater attention should be placed on opportunities to select intervention strategies tailored to tackle socioeconomic inequalities in transportation injuries.

Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries.

BACKGROUND: Few studies have compared socioeconomic inequalities in the prevalence of both fatal and non-fatal diseases. This paper aims to give the first international overview for several common chronic diseases. METHODS: Micro-level data were pooled from non-standardized national health surveys conducted in eight European countries in the 1990s. Surveys ranged in size from 3700 to 41 200 participants. The prevalence of 17 chronic disease groups were analysed in relation to education. Standardized prevalence rates and age-adjusted odds ratios (ORs) were calculated. RESULTS: Most diseases showed higher prevalence among the lower education group. Stroke, diseases of the nervous system, diabetes, and arthritis displayed relatively large inequalities (OR > 1.50). No socioeconomic differences were evident for cancer, kidney diseases, and skin diseases. Allergy was more common in the higher education group. Relative socioeconomic differences were often smaller among the 60-79 age group as compared with the 25-59 age group. Cancer was more prevalent among the lower educated in the 25-59 age group, but among the higher educated in the 60-79 age group. For diabetes, hypertension, and heart disease, socioeconomic differences were larger among women as compared with men. Inequalities in heart disease were larger in northern European countries as compared with southern European countries. CONCLUSION: There are large variations between chronic diseases in the size and pattern of socioeconomic differences in their prevalence. The large inequalities that are found for some specific fatal diseases (e.g. stroke) and non-fatal diseases (e.g. arthritis) require special attention in equity-oriented research and policies.

Neighbourhood unemployment and all cause mortality: a comparison of six countries.

STUDY OBJECTIVE: Studies have shown that living in more deprived neighbourhoods is related to higher mortality rates, independent of individual socioeconomic characteristics. One approach that contributes to understanding the processes underlying this association is to examine whether the relation is modified by the country context. In this study, the size of the association between neighbourhood unemployment rates and all cause mortality was compared across samples from six countries (United States, Netherlands, England, Finland, Italy, and Spain). DESIGN: Data from three prospective cohort studies (ARIC (US), GLOBE (Netherlands), and Whitehall II (England)) and three population based register studies (Helsinki, Turin, Madrid) were analysed. In each study, neighbourhood unemployment rates were derived from census, register based data. Cox proportional hazard models, taking into account the possible correlation of outcomes among people of the same neighbourhood, were used to assess the associations between neighbourhood unemployment and all cause mortality, adjusted for education and occupation at the individual level. RESULTS: In men, after adjustment for age, education, and occupation, living in the quartile of neighbourhoods with the highest compared with the lowest unemployment rates was associated with increased hazards of mortality (14%-46%), although for the Whitehall II study associations were not statistically significant. Similar patterns were found in women, but associations were not statistically significant in two of the five studies that included women. CONCLUSIONS: Living in more deprived neighbourhoods is associated with increased all cause mortality in the US and five European countries, independent of individual socioeconomic characteristics. There is no evidence that country substantially modified this association.