All-cause and cause-specific mortality attributable to educational inequalities in Spain.

Background: Socioeconomic inequalities in mortality give key information for public health preventive policies. We aim to assess the magnitude of educational inequalities in cause-specific mortality in Spain (2016-21).

Methods: We use mortality register and population exposure data for Spain for individuals aged 35-99 years for 2016-21. These data included information on age, sex, educational attainment, and causes of death. We estimated all-cause and age- and cause-specific mortality attributable to educational inequality (death counts, attributable fractions (AF), and years of life lost (YLL)) by treating the high education group as a counterfactual benchmark.

Results: There were 426,449 average annual deaths in Spain in 2016-21, and we estimated 82,815 average annual deaths (42,867 males and 39,948 females) attributable to education inequality (AF of 19.5%). Deaths attributable to inequality were highly concentrated at ages 75 and over, yet the proportion of deaths attributable to educational inequality was higher at young ages (50% and 31% at ages 35-39 for males and females, respectively). Circulatory system causes of death were the leading cause in terms of deaths attributable to inequality in females (16,051 deaths, AF = 25.9%, YLL = 174,195) and the second cause in males (10,542 deaths, AF = 19.2%, YLL = 179,744). Neoplasms were the leading cause of death in males (10,868 deaths, AF = 16.1%, YLL = 230,958) but not in females (1,520 deaths, AF = 3.4%, YLL = 45,011).

Conclusions: Educational inequality remains a major public health challenge; its population-level impact on mortality is higher compared to the impact of smoking. Public health interventions addressing gender-specific social determinants of inequalities in health have a great potential for reducing mortality.