Socioeconomic inequalities in mortality among Italian and immigrant residents: A longitudinal population-based study

A socioeconomic mortality gradient, favourable to the most advantaged social groups, has been documented in high migratory pressure (HMPCs) and highly developed countries, including Italy. However, little is known about how this association differs between natives and immigrants. This study aimed to evaluate the association between education level, occupational class and mortality among Italian and immigrant residents.

Using a longitudinal design, the 2011 Italian Census population was followed up to 2019. All-cause mortality was retrieved by record linkage with the Causes of Death register. The association between education/occupational class and mortality was evaluated in subjects aged 30-64, separately by sex, citizenship/macro area of origin. Mortality rate ratios (MRR) and 95 % confidence intervals were estimated using negative binomial regression models.

Of the 23,572,516 subjects analysed, 7 % were immigrants from HMPCs; of the 410,746 deaths, 3 % were from HMPCs. Among Italians, a mortality gradient by education was observed (low/high adjMRR: 2.37 [2.16-2.60] males; 1.79 [1.64-1.96] females), whereas a weaker association with no trend was found for HMPC immigrants (adjMRR: 1.12 [1.00-1.25] males; 1.12 [1.00-1.26] females). Regarding occupational class, for immigrants from HMPCs, a higher mortality was observed in male "farmers" and "inactives" compared to "non-manual workers" (adjMRR = 1.31 [1.06-1.61] and adjMRR = 1.67 [1.50-1.85], respectively); and in females for "inactive" subjects (adjMRR = 1.48 [1.35-1.62]).A higher mortality for the less educated was observed for males from Romania, India and China, and for females from Central-Eastern Europe, Sub-Saharan Africa and Central and South America. A lower mortality was found for the least educated from Morocco.

The higher mortality among less educated subjects was confirmed among Italians, while it was less evident among immigrants from HMPCs. However, differences observed between citizenships, macro-areas of origin and sex highlight the need for social policies accounting for specific risk factors and cultural specificities affecting correct lifestyles and health service access.