European District Study Maps Persistent Avoidable Mortality Gaps

The study, published in the European Journal of Population, examines spatial differences and trends in avoidable mortality at the district level, a scale that provides a more nuanced view of health inequalities than national averages alone. By utilizing official cause-of-death statistics, the team identified persistent clusters of high and low mortality that often transcend national borders, suggesting that local socioeconomic and structural determinants play a central role in shaping health outcomes.

The study focused on avoidable mortality, a metric that captures deaths which could potentially be prevented through effective healthcare delivery or public health interventions. This concept comprises two key components: amenable mortality and preventable mortality. Amenable mortality refers to deaths that should not occur if individuals receive timely and appropriate medical care, such as those from treatable conditions like infectious diseases or early-stage cancers. In contrast, preventable mortality encompasses deaths that could be avoided primarily through public health measures, behavioral changes, or policy interventions, including deaths due to smoking-related illnesses and traffic accidents. The analysis excluded deaths occurring at advanced ages of 75 years or older, as the reliability of death certification and the concept of avoidability become increasingly uncertain in this age group.

The research team analyzed data from Austria, Belgium, Czechia, France, Germany, Italy, Poland, Slovakia, Spain, and Switzerland. The dataset included 581 districts, of which 205 were classified as border districts according to Eurostat’s Methodological Manual on Territorial Typologies. To ensure consistency across countries with varying administrative structures, the researchers relied on data at the NUTS-3 level or equivalent administrative units. For example, they used Bezirke for Austria and Raumordnungsregionen for Germany. The data were stratified by year, country, district, cause of death, sex, and age group, with causes of death categorized using the ninth and tenth revisions of the International Classification of Diseases (ICD). To address the statistical instability that can arise from low death counts in less-populated districts, the researchers pooled the data into three-year periods, ranging from 2002–2004 to 2017–2019. This approach allowed for a more stable assessment of long-term trends while deliberately excluding the pandemic years to avoid conflating exceptional mortality with historical dynamics.

To quantify these trends, the researchers calculated age-standardised death rates (SDR) using the direct method of standardisation, applying age-specific mortality rates to a common European standard population of 2013. They presented the results using deciles, categorizing the SDR values into ten equal groups for both time periods and for amenable and preventable mortality separately for men and women. This method highlighted both spatial and temporal differences in avoidable mortality. Additionally, the team provided boxplots and interquartile ranges to show the distribution of SDRs across districts, stratified by country, offering a detailed view of the variation within and between nations.

The results indicated that avoidable mortality rates declined across most European districts for both sexes during the study period. However, marked disparities persisted between men and women, as well as between amenable and preventable mortality. Men consistently exhibited higher SDRs than women, nearly double in most cases, across both periods and causes. The disparity between the sexes was more pronounced for preventable mortality than for amenable mortality. In 2002–2004, preventable SDRs per 100,000 inhabitants ranged from an interquartile range of 29 among women to 82 among men. By 2017–2019, this range extended from 24 among women to 62 among men. These values underscore that preventable mortality, particularly among men, remains higher on average and shows greater variability across member states.

Geographically, districts in Central and Eastern Europe consistently exhibited higher SDRs than those in Western and Southern Europe. For amenable mortality, Slovak regions bordering Hungary were among the highest in 2002–2004, whereas by 2017–2019, the highest SDRs were observed in Polish districts. Similarly, for preventable mortality, the highest rates were concentrated in Poland and, for females, in Czech districts bordering Germany. In contrast, the lowest amenable mortality was found in Western and Southern Europe. Male SDRs remained lowest in central and western Switzerland, adjacent Austrian regions, and southern France, while female SDRs were lowest in northern Spain, France, Switzerland, and Austria. Germany occupied an intermediate position, with amenable SDRs lower than its Eastern European neighbors but persistently higher than those in Western Europe.

The study also revealed notable within-country variations. In Spain and Italy, southern regions experienced more pronounced declines than their northern counterparts, yet a persistent North–South gradient remained for both countries. In Germany, northeastern regions showed higher amenable SDRs than those in the southwest, and internal disparities for amenable mortality actually increased over the study period. This widening gap contrasted with the general trend in countries like Spain, France, and Austria, which made more progress in narrowing their regional divides. For preventable mortality, disparities also rose for men in Poland and for women in Belgium. Throughout the study period, Switzerland consistently exhibited one of the lowest levels of within-country disparity.

Using emerging hotspot analysis, the researchers identified spatiotemporal clusters of high-mortality hotspots and low-mortality coldspots. This method combines spatial and temporal statistics to classify how mortality clusters evolve over time, using the Getis-Ord Gi* statistic to identify significant spatial clusters and the Mann–Kendall test to classify each district into categories such as new, persistent, intensifying, or diminishing. The analysis was stratified for Eastern European countries (Poland, Slovakia, and Czechia) and Western European countries (Belgium, Italy, France, Spain, Austria, and Germany) to reveal region-specific dynamics that might be obscured by the overarching East–West disparity.

In Western Europe, persistent and intensifying hotspots for amenable mortality were observed across northern and central Germany, while southern Germany was characterized by temporary hotspots. Consecutive coldspots covered western Austria, northern Italy, Switzerland, and most of France and Spain. For preventable mortality, cross-border hotspots were detected along the French-Belgian border, persisting over time and encompassing the entire Wallonia region for women. In Eastern Europe, neither intensifying nor persistent hotspots were found. Instead, consecutive coldspots were widespread, occurring in central Czechia and eastern Poland for women, and across nearly the entire Czechia and southeastern Poland for men. Temporary hotspots were more diffuse, covering much of western and central Poland and the whole of Slovakia for women.

The findings suggest that national boundaries are not always the most meaningful lines for explaining health outcomes. Instead, local socioeconomic and structural determinants of health play a central role, spilling across administrative boundaries. The persistence of hotspots in structurally disadvantaged areas, such as the French-Belgian border region, reflects shared vulnerabilities including deindustrialization, demographic decline, and socioeconomic disadvantage. Conversely, the emergence of a large, stable cross-border coldspot encompassing parts of Switzerland, Austria, Italy, France, and Spain reflects a shared context of long-term economic prosperity and high standards of healthcare access. These patterns indicate that health outcomes are shaped by regional context rather than national averages alone.

The study acknowledges several limitations, including the age restrictions and selection of causes of death inherent in the concept of avoidable mortality. Variations in death certification practices across different countries also complicate cross-national comparisons. To mitigate potential inconsistencies in coding precision, the researchers classified cause-specific death groups based on 3-digit ICD codes rather than the more granular 4-digit codes. Working with district-level data introduces statistical noise due to small population sizes, which was addressed by aggregating data into three-year periods and using emerging hotspot analysis to emphasize persistent over transient trends. The scope of country selection was also constrained by data availability, limiting the inclusion of some EU member states.

Despite these limitations, the study represents the first large-scale, spatiotemporal analysis of avoidable mortality at the district level across diverse European contexts. The findings challenge the notion of a simple East–West divide, highlighting Germany’s intermediate position and the existence of persistent preventable mortality hotspots within Western Europe. The results suggest that addressing health inequalities requires targeted, place-based, and transnational strategies. Persistent hotspots highlight areas where targeted interventions are urgently needed, while coldspots may offer lessons for best practices. By integrating health equity objectives into broader regional development and cohesion strategies, policymakers can better address the complex interplay of national, regional, and socioeconomic factors that shape health outcomes in Europe.

Subject of Research: Spatial Differences in Avoidable Mortality Across 581 European Districts, 2002–2019

Article Title: Spatial Differences in Avoidable Mortality Across 581 European Districts, 2002–2019

Article References: Stroisch, S., Mühlichen, M., Grigoriev, P., & Vogt, T. (2026). Spatial Differences in Avoidable Mortality Across 581 European Districts, 2002–2019. European Journal of Population, 42(1), Article 5. https://doi.org/10.1007/s10680-025-09761-7

Image Credits: AI Generated

DOI: 10.1007/s10680-025-09761-7

Keywords: Spatial, Differences, Avoidable, Mortality, Across, European, Districts, scientific research