Social inequalities in cause-specific premature mortality in rural and urban France

Background

Social inequalities remain a major determinant of mortality across Europe. This study aimed to quantify cause-specific premature mortality across urban and rural areas in mainland France during the pre-pandemic period, accounting for social inequalities, and to assess their contribution using the population attributable fraction (PAF) approach.

Methods

Cause-specific deaths were obtained from the French national mortality database and linked to municipality-level deprivation quintiles using French European Deprivation Index (F-EDI). Residual life expectancy at age of death was defined according to the Global Burden of Disease (GBD) 2019 reference life table. Age-standardized years of life lost rates (ASYRs) were calculated by sex, deprivation quintile, and rural–urban setting. Social inequalities in mortality were assessed using absolute and relative gaps between the least and most deprived quintiles (Q1-Q5) and PAF, with Q1 as the reference.

Results

ASYRs increased consistently with deprivation in both urban and rural areas. Non-communicable diseases accounted for most premature mortality (85-90% of total YLL), followed by injuries and communicable, maternal, neonatal, and nutritional causes. In urban areas, 18–31% of premature mortality was attributed to social inequalities, compared with 8–20% in rural areas, with higher contributions among males. Absolute difference in ASYRs was slightly larger in rural than urban areas for both sexes (females: 2,854 vs 2,463; males: 6,607 vs 5,618), while relative inequalities were similar (females: 1.30; males: 1.39, comparing Q5 with Q1). Breast cancer showed the largest inequality among females (11-12% higher in Q5), and lung cancer among males (75% higher in Q5 in urban areas and 43% in rural areas).

Conclusions

Social inequalities substantially contributed to premature mortality in pre-pandemic mainland France, with ASYRs increasing with deprivation in both settings, were consistently higher among males.

Key messages

• Counterfactual mortality was greater in urban areas, and more pronounced in males.

• These findings underscore the need for policies tailored to both socioeconomic and geographic differences across rural and urban populations.