BACKGROUND: The socioeconomic and ethnic composition of urban neighbourhoods may affect mortality, but evidence on Central European cities is lacking. The aim of this study was to assess the associations between socioeconomic and ethnic neighbourhood indicators and the mortality of individuals aged 20-64 years old in the two biggest cities of the Slovak Republic. METHODS: We obtained data on the characteristics of neighbourhoods and districts (educational level, unemployment, income and share of Roma) and on individual mortality of residents aged 20-64 years old, for the two largest cities in the Slovak Republic (Bratislava and Kosice) in the period 2003-2005. We performed multilevel Poisson regression analyses adjusted for age and gender on the individual (mortality), neighbourhood (education level and share of Roma in population) and district levels (unemployment and income). RESULTS: The proportions of Roma and of low-educated residents were associated with mortality at the neighbourhood level in both cities. Mutually adjusted, only the association with the proportion of Roma remained in the model (risk ratio 1.02; 95 % confidence interval 1.01-1.04). The area indicators - high education, income and unemployment - were not associated with mortality. CONCLUSION: The proportion of Roma is associated with early mortality in the two biggest cities in the Slovak Republic.

Department of Community and Occupational Health University Medical Center Groningen University of Groningen Groningen The Netherlands

Faculty of Humanities and Natural Sciences University of Presov Presov Slovakia

Graduate School Kosice Institute for Society and Health Safarik University Kosice Slovakia

Institute of Public Health Department of Health Psychology Medical Faculty Safarik University Kosice Slovakia

Kosice Self governing Region Department of Regional Development Land use Planning and Environment Nam Maratonu mieru 1 042 66 Kosice Slovakia

Olomouc University Society and Health Institute Palacky University Olomouc Olomouc Czech Republic

Zobrazit více v PubMed

Mackenbach JP, Stirbu I, Roskam AJR, Schaap MM, Menvielle G, Leinsalu M, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008;358:2468–2481. doi: 10.1056/NEJMsa0707519. PubMed DOI

Marmot M. Social determinants of health inequalities. Lancet. 2005;356:1099–1104. doi: 10.1016/S0140-6736(05)74234-3. PubMed DOI

Macintyre S, Maciver S, Sooman A. Area, class and health: should we be focusing on place or people? J Soc Policy. 1993;22:213–234. doi: 10.1017/S0047279400019310. DOI

Adams RJ, Howard N, Tucker G, Appleton S, Taylor AW, Chittleborough C, et al. Effect of area deprivation on health risks and outcomes: a multilevel, cross-sectional, Australian population study. Int J Public Health. 2009;54:183–192. doi: 10.1007/s00038-009-7113-x. PubMed DOI

Backlund E, Rowe G, Lynch J, Wolfson MC, Kaplan GA, Sorlie PD. Income inequality and mortality: a multilevel prospective study of 521 248 individuals in 50 US states. Int J Epidemiol. 2007;36:590–596. doi: 10.1093/ije/dym012. PubMed DOI

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 milion men. Soc Sci Med. 2004;58:2523–2535. doi: 10.1016/j.socscimed.2003.09.027. PubMed DOI

Breckenkamp J, Mielck A, Razum O. Health inequalities in Germany: do regional-level variables explain differentials in cardiovascular risk? BMC Public Health. 2007;7:132. doi: 10.1186/1471-2458-7-132. PubMed DOI PMC

Cavalini LT, Ponce de Leon ACM. Morbidity and mortality in Brazilian municipalities: a multilevel study of the association between socioeconomic and healthcare indicators. Int J Epidemiol. 2008;37:775–785. doi: 10.1093/ije/dyn088. PubMed DOI

Dalmau-Bueno A, Garcia-Altes A, Mari-Dell'olmo M, Perez K, Espelt A, Kunst AE, et al. Trends in socioeconomic inequalities in cirrhosis mortality in an urban area of Southern Europe: a multilevel approach. J Epidemiol Community Health. 2010;64:720–727. doi: 10.1136/jech.2008.086538. PubMed DOI

Elstad JI. Does the socioeconomic context explain both mortality and income inequality? Prospective register-based study of Norwegian regions. Int J Equity Health. 2011;10:7. doi: 10.1186/1475-9276-10-7. PubMed DOI PMC

Henriksson G, Allebeck P, Weitoft GR, Thelle D. Income distribution and mortality: Implications from a comparison of individual-level analysis and multilevel analysis with Swedish data. Scand J Public Health. 2006;34:287–294. doi: 10.1080/14034940500228364. PubMed DOI

Kravdal O. Mortality effects of average education: a multilevel study of small neighbourhoods in rural and urban areas in Norway. Int J Equity Health. 2009;8:41. doi: 10.1186/1475-9276-8-41. PubMed DOI PMC

Macintyre S, Ellaway A, Cummins S. Place effects on health: how can we conceptualise, operationalise and measure them? Soc Sci Med. 2002;55:125–139. doi: 10.1016/S0277-9536(01)00214-3. PubMed DOI

Marmot M, Commission on Social Determinants of Health Achieving health equity: from root causes to fair outcomes. Lancet. 2007;370:1153–1163. doi: 10.1016/S0140-6736(07)61385-3. PubMed DOI

Pinzone F, Casuccio N, Cusimano R, Mancuso A, Pitarresi A. Mortality in relation to individual- and area-level socioeconomic status in Palermo (Italy): a multilevel analysis. Epidemiol Prev. 2009;33:207–214. PubMed

Reijneveld SA, Verheij RA, de Bakker DH. Relative importance of urbanicity, ethnicity and socioeconomic factors regarding area mortality differences. J Epidemiol Community Health. 1999;53:444–445. doi: 10.1136/jech.53.7.444. PubMed DOI PMC

Reijneveld SA, Veenstra R, de Winter AF, Verhulst FC, Ormel J, de Meer G. Area deprivation affects behavioral problems of young adolescents in mixed urban and rural areas: the TRAILS study. J Adolescent Health. 2010;46:189–96. doi: 10.1016/j.jadohealth.2009.06.004. PubMed DOI

Šlachtová H, Tomášková H, Šplíchalová A, Polaufová P, Fejtková P. Czech socio-economic deprivation index and its correlation with mortality data. Int J Public Health. 2009;54:1–7. PubMed

Bentley R, Kavanagh AM, Subramanian SV, Turrell G. Area disadvantage, individual socio-economic position, and premature cancer mortality in Australia 1998 to 2000: a multilevel analysis. Cancer Causes Control. 2008;19:183–193. doi: 10.1007/s10552-007-9084-7. PubMed DOI

Jackson AL, Davies CA, Leyland AH. Do differences in the administrative structure of populations confound comparisons of geographic health inequalities? BMC Med Res Methodol. 2010;10:74. doi: 10.1186/1471-2288-10-74. PubMed DOI PMC

Meijer M, Rohl J, Bloomfield K, Grittner U. Do neighborhoods affect individual mortality? A systematic review and meta-analysis of multilevel studies. Soc Sci Med. 2012;74:1204–1212. doi: 10.1016/j.socscimed.2011.11.034. PubMed DOI

Turrell G, Kavanagh AM, Draper G, Subramanian SV. Do places affect the probability of death in Australia? A multilevel study of area-level disadvantage, individual-level socioeconomic position and all-cause mortality, 1998–2000. J Epidemiol Community Health. 2007;61:13–19. doi: 10.1136/jech.2006.046094. PubMed DOI PMC

Suzuki E, Kashima S, Kawachi I, Subramanian SV. Social and geographic inequalities in premature adult mortality in Japan: a multilevel observational study from 1970 to 2005. BMJ Open. 2012;2 doi: 10.1136/bmjopen-2011-000425. PubMed DOI PMC

Wilkinson RG, Pickett KE. Income inequality and socioeconomic gradients in mortality. Am J Public Health. 2008;98:699–704. doi: 10.2105/AJPH.2007.109637. PubMed DOI PMC

Borrell C, Pasarín MI. Inequalities in health and urban areas. Gac Sanit. 2004;18:1–4. doi: 10.1016/S0213-9111(04)71991-3. PubMed DOI

Mackenbach JP, Bakker MJ, European Network on Interventions and Policies to Reduce Inequalities in Health Tackling socioeconomic inequalities in health: analysis of European experiences. Lancet. 2003;362:1409–1414. doi: 10.1016/S0140-6736(03)14639-9. PubMed DOI

Stafford M, Martikainen P, Lahelma E, Marmot M. Neighbourhoods and self rated health: a comparison of public sector employees in London and Helsinki. J Epidemiol Community Health. 2004;58:772–778. doi: 10.1136/jech.2003.015941. PubMed DOI PMC

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;59:231–237. doi: 10.1136/jech.2004.022574. PubMed DOI PMC

WHO/UN-HABITAT . Hidden cities: unmasking and overcoming health inequities in urban settings. Geneva: World Health Organization; 2010.

Rosicova K, Madarasova Geckova A, van Dijk JP, Rosic M, Zezula I, Groothoff JW. Socioeconomic indicators and ethnicity as determinants of regional mortality rates in Slovakia. Int J Public Health. 2009;54:274–283. doi: 10.1007/s00038-009-7108-7. PubMed DOI

Bopp M, Minder CE. Mortality by education in German speaking Switzerland, 1990–1997: results from the Swiss National Cohort. Int J Epidemiol. 2003;32:346–354. doi: 10.1093/ije/dyg072. PubMed DOI

Lopez R. Income inequality and self-rated health in US metropolitan areas: a multi-level analysis. Soc Sci Med. 2004;59:2409–2419. doi: 10.1016/j.socscimed.2004.03.033. PubMed DOI

Muller A. Education, income, inequality, and mortality: a multiple regression analysis. BMC Public Health. 2002;324:1–4. PubMed PMC

Von dem Knesebeck O, Verde PE, Dragano N. Education and health in 22 European countries. Soc Sci Med. 2006;63:1344–1351. doi: 10.1016/j.socscimed.2006.03.043. PubMed DOI

Behanova M, Nagyova I, Katreniakova Z, van Ameijden EJC, van Dijk JP, Reijneveld SA. The effect of urban-area unemployment on the mental health of citizens differs between Slovak and Dutch cities. Health Place. 2013;24:210–215. doi: 10.1016/j.healthplace.2013.09.013. PubMed DOI

Behanova M, Nagyova I, Katreniakova Z, van Ameijden EJC, van Dijk JP, Reijneveld SA. Health-risk behaviours in deprived urban neighbourhoods: a comparison between Slovak and Dutch cities. Int J Public Health. 2014;59:405–414. doi: 10.1007/s00038-013-0536-4. PubMed DOI

Mackenbach JP. Health inequalities: Europe in profile. Rotterdam: University Medical Centre, Department of Public Health; 2006.

Zatonski W, Manczuk M, Sulkowska U. Closing the health gap in European Union. Warsaw: Cancer Epidemiology and Prevention Division, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology; 2008.

EU-MIDIS, European Union Minorities and Discrimination Survey. Main Results Report. 2009. European Union Agency for Fundamental Rights.

Vasecka M, Dzambazovic R. Socialno-ekonomicka situacia Romov na Slovensku ako potencionalnych migrantov a ziadatelov o azyl v krajinach EU. Socialna a ekonomicka situacia potencionalnych ziadatelov o azyl zo Slovenskej Republiky. International Organization for Migration (IOM); 2000. p. 17–62.

Filadelfiová J, Gerbery D, Škobla D. Správa o životných podmienkach rómskych domácností na Slovensku (Report on the Living Conditions of Roma in Slovakia) Bratislava: UNDP, Regional Bureau for Europe and the CIS; 2006.

Statistical Office of the Slovak Republic . Population by education from Population and Housing Census. Bratislava: Statistical Office of the Slovak Republic; 2002.

Statistical Office of the Slovak Republic . Monthly Statistics of unemployment. Bratislava: Centre of Labour, Social Affairs and Family of the Slovak Republic (UPSVAR); 2009.

The Regional Statistical Yearbook of Slovakia 2006. Bratislava: Statistical Office of the Slovak Republic; 2007.

Statistical Office of the Slovak Republic . Population by nationality from Population and Housing Census. Bratislava: Statistical Office of the Slovak Republic; 2011.

Langford IH, Day RJ. Poisson regression. In: Leyland AH, Goldstein H, editors. Multilevel modelling of health statistics. Chichester: Wiley; 2001. pp. 45–57.

Korec P. Regionálny rozvoj Slovenska v rokoch 1989–2004 (Regional development of the Slovak Republic in years 1989–2004) Geografika: Bratislava; 2005.

Vaňo, B, Haviarová E, 2003. Demografické trendy rómskej populácie (Demographic trends of the Roma population). In: Vašečka, M., ed., Čačipen Pal o Roma. Súhrnná správa o Rómoch na Slovensku (A Global Report on Roma in Slovakia), IVO (Institute for Public Affairs), Bratislava.

Borrell C, Marí-Dell`Olmo M, Serral G, Martínez-Beneito M, Gotsens M. Inequalities in mortality in small areas of eleven Spanish cities (the multicenter MEDEA project) Health Place. 2010;16:703–711. doi: 10.1016/j.healthplace.2010.03.002. PubMed DOI

Diez-Roux AV, Green Franklin T, Alazraqui M, Spinelli H. Intraurban variations in adult mortality in a large Latin American city. J Urban Health. 2007;84:319–333. doi: 10.1007/s11524-007-9159-5. PubMed DOI PMC

Rosicova K, Madarasova Geckova A, van Dijk J, Kollarova J, Rosic M, Groothoff JW. Regional socioeconomic indicators and ethnicity as predictors of regional infant mortality rate in Slovakia. Int J Public Health. 2011;56:523–531. doi: 10.1007/s00038-010-0199-3. PubMed DOI PMC

Rosicova K, Madarasova Geckova A, Rosic M, Speybroeck N, Groothoff JW, van Dijk J. Socioeconomic factors, ethnicity and alcohol-related mortality in regions in Slovakia. What might a tree analysis add to our understanding? Health Place. 2011;17:701–709. doi: 10.1016/j.healthplace.2011.01.004. PubMed DOI

van Hooijdonk C, Droomers M, Deerenberg IM, Mackenbach JP, Kunst AE. Higher mortality in urban neighbourhoods in The Netherlands: who is at risk? J Epidemiol Community Health. 2008;62:499–505. doi: 10.1136/jech.2007.060145. PubMed DOI

Ginter E, Krajcovicova-Kudlackova M, Kacala O, Kovacic V, Valachovicova M. Health status of Romanies (Gypsies) in the Slovak Republic and in the neighbouring countries. Bratisl Lek Listy. 2001;102:479–484. PubMed

Hajioff S, McKee M. The health of the Roma people: a review of the published literature. J Epidemiol Community Health. 2000;54:864–869. doi: 10.1136/jech.54.11.864. PubMed DOI PMC

Koupilova I, Epstein H, Holcik J, Hajioff S, McKee M. Health needs of the Roma population in the Czech and Slovak Republics. Soc Sci Med. 2001;53:1191–1204. doi: 10.1016/S0277-9536(00)00419-6. PubMed DOI

Kosa Z, Szeles G, Kardos L, Kosa K, Nemeth R, Orszagh S, et al. A comparative health survey of the inhabitants of Roma settlements in Hungary. Am J Public Health. 2007;97:853–859. doi: 10.2105/AJPH.2005.072173. PubMed DOI PMC

Kolarcik P, Madarasova Geckova A, Orosova O, van Dijk JP, Reijneveld SA. To what extent does socioeconomic status explain differences in health between Roma and non-Roma adolescents in Slovakia? Soc Sci Med. 2009;68:1279–1284. doi: 10.1016/j.socscimed.2008.12.044. PubMed DOI

Vokó Z, Csépe P, Németh R, Kósa K, Széles G, Ádány R. Does socioeconomic status fully mediate the effect of ethnicity on the health of Roma people in Hungary? J Epidemiol Community Health. 2009;63:455–460. doi: 10.1136/jech.2008.079715. PubMed DOI

Kolarcik P. Self-reported health and health risky behaviour of Roma adolescents in Slovakia: A comparison with non-Roma (PhD thesis). Rijksuniversiteit Groningen; 2012.

European Union Agency for Fundamental Rights, UNDP. The situation of Roma in 11 EU Member States: Survey results at a glance. Luxembourg: Publications Office of the European Union; 2012.

Population and Housing Census 2001. Selected indicators - Methodological notes. Statistical Office of the Slovak Republic; 2008. http://slovak.statistics.sk/wps/portal/ext/themes/demography/census/metadata/!ut/p/b1/jdBLDoIwEAbgs3gBOuVR2mVBKZiKhQJqNwaNMSSCLozG24vGhSa-ZjfJ909mBhk0R6arT822Pjb7rt7dekOWlVQ0CDAHGk8wJJFUlRoVOA-gB4tnIPyiB2mqy4pmTsbs__Kh4LHrSwAqhQcJj8ucZY4D3PkvDx-Kw6_8GJlm1VrndWuB5bFA59g5gG4BHtohszrgDf33UGklc2ZK8JhPo0gKUKbaklsEOQHAPwA315wB19uTON9u0F606FDW5bzi04atR1cAYJFsiQ!/dl4/d5/L2dJQSEvUUt3QS80SmtFL1o2X1ZMUDhCQjFBMEc3VDEwSU5OU.

Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report. Geneva: World Health Organization; 2008. Accessed 6 Aug 2014.