Spatial variation in cause-specific premature mortality and its association with socioeconomic deprivation in Belgium from 2000 to 2019

Otavova et al. Archives of Public Health (2025) 83:256 https://doi.org/10.1186/s13690-025-01694-1 Archives of Public Health Open Access RESEARCH Spatial variation in cause-specific premature mortality and its association with socioeconomic deprivation in Belgium from 2000 to 2019 Martina Otavova1,2,3*, Benjamin-Samuel Schlüter4, Christel Faes2, Catherine Bouland5, Eva M. Declercq6, Bram Vandeninden2,4, Brecht Devleesschauwer7,8 and Bruno Masquelier1 Abstract Background Premature mortality risks vary in space and time among subpopulations and are influenced by numerous factors, including levels of socioeconomic deprivation. In Belgium, socioeconomic deprivation has recently been quantified using the Belgian Indices of Multiple Deprivation; however, its contribution to the spatial patterns of premature mortality has not yet been assessed. This study aims to investigate the variation in premature mortality risks and their association with socioeconomic deprivation. Methods The Belgian Index of Multiple Deprivation 2011 and its deprivation domains, including employment, income, education, housing, and crime, are used to measure overall and domain-specific deprivation in all 589 municipalities in Belgium between 2000 and 2019. We estimate the all-cause and cause-specific relative risks of dying prematurely using Bayesian hierarchical models. Results The spatial patterns of relative risks varied by cause of death. The most common pattern observed was a North-South gradient, with higher risks in Wallonia and lower risks in Flanders. Subnational variation increased over time for all causes of death, differing by cause. Higher deprivation levels were linked to greater premature mortality risks, particularly associated with employment and housing deprivation. In both sexes, the strongest associations with deprivation were observed for deaths due to alcohol consumption, COPD, and diabetes mellitus. Conclusion This study highlights the significant associations between socioeconomic deprivation and the risk of premature death in Belgium, revealing notable spatial disparities. The North-South gradient underscores the persistent regional inequalities, with Wallonia bearing the highest burden of premature mortality risks. These results emphasize the importance of addressing the complex interplay of socioeconomic factors in shaping health outcomes and the need for targeted public health interventions to reduce premature mortality and promote health equity across Belgium. *Correspondence: Martina Otavova Full list of author information is available at the end of the article © The Author(s) 2025. 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To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Otavova et al. Archives of Public Health (2025) 83:256 Page 2 of 19 Keywords Relative risk of premature death, Health inequality, Deprivation, Belgian index of multiple deprivation, Belgium Text box 1. Contributions to the literature • This study examines the subnational variation in cause-specific relative risks of premature death across municipalities in Belgium from 2000 to 2019. • Over time, subnational variation in the relative risk of premature death has increased; however, the extent of this increase varies depending on the specific cause of death. • The strength of the relationship between premature death risks and overall or domain-specific deprivation varied by cause of death. In most cases, the association was positive, except for deaths resulting from road accidents, which showed a negative relationship. Introduction Population-level risks of premature mortality vary in space and time between subpopulations and are influenced by many factors, including levels of socioeconomic deprivation. It is a well-known fact that mortality risks are often driven by poverty, with the poor experiencing greater risks than more affluent populations [1–3]. However, poverty is just one aspect of deprivation, which is a far more complex construct. Deprivation is also defined by factors such as unemployment, low education, inadequate housing, adverse environmental conditions, and poor health. Thus, addressing the spatio-temporal variation in premature mortality risks associated with socioeconomic deprivation, rather than focusing solely on poverty, is an important task for researchers and policymakers. It enables them to assess the direction of inequalities in premature mortality trends over time and identify the high-risk areas that require intervention. In Belgium, socioeconomic inequalities in mortality have mostly been studied at the country level [4, 5]. In 2017, Renard et al. used education attainment as a proxy for socioeconomic status and confirmed a reduction in premature mortality in men and women in the period of 1991–2001, as well as an increase in relative inequalities in both sexes [6]. In 2018, Eggerickx et al. studied the evolution of social disparities in Belgian mortality between 1991 and 2016 and found a significant increase in mortality inequalities since the 1990s [7]. The increase in socioeconomic health inequalities is even more evident at the sub-national level, with higher premature mortality risks in Wallonia compared to Flanders, as concluded by Renard et al. (2014), who investigated the burden of premature mortality for men and women between 1993 and 2009 [8]. According to Van Oyen et al. (2002), compared to the Flemish region, people living in the Walloon region also live shorter and tend to have poorer health while doing so: they live more years in poor perceived health, more years with functional limitations, and more years in poor mental well-being [9]. Renard et al. (2015) also reported large between-district disparities in cardiovascular, cerebrovascular, diabetes, alcohol-related, mental- and neurological diseases, and non-transport accidents premature mortality [10]. A more recent study by Otavova et al. (2024) confirmed large disparities in premature mortality, suggesting that men and women living in the most deprived areas of Belgium were 1.96 and (...truncated)