ABSTRACT

OBJECTIVE

Summarize the literature on the relationship between composite socioeconomic indicators and mortality in different geographical areas of Brazil.

METHODS

This scoping review included articles published between January 1, 2000, and August 31, 2020, retrieved by means of a bibliographic search carried out in the Medline, Scopus, Web of Science, and Lilacs databases. Studies reporting on the association between composite socioeconomic indicators and all-cause, or specific cause of death in any age group in different geographical areas were selected. The review summarized the measures constructed, their associations with the outcomes, and potential study limitations.

RESULTS

Of the 77 full texts that met the inclusion criteria, the study reviewed 24. The area level of composite socioeconomic indicators analyzed comprised municipalities (n = 6), districts (n = 5), census tracts (n = 4), state (n = 2), country (n = 2), and other areas (n = 5). Six studies used composite socioeconomic indicators such as the Human Development Index, Gross Domestic Product, and the Gini Index; the remaining 18 papers created their own socioeconomic measures based on sociodemographic and health indicators. Socioeconomic status was inversely associated with higher rates of all-cause mortality, external cause mortality, suicide, homicide, fetal and infant mortality, respiratory and circulatory diseases, stroke, infectious and parasitic diseases, malnutrition, gastroenteritis, and oropharyngeal cancer. Higher mortality rates due to colorectal cancer, leukemia, a general group of neoplasms, traffic accident, and suicide, in turn, were observed in less deprived areas and/or those with more significant socioeconomic development. Underreporting of death and differences in mortality coverage in Brazilian areas were cited as the main limitation.

CONCLUSIONS

Studies analyzed mortality inequalities in different geographical areas by means of composite socioeconomic indicators, showing that the association directions vary according to the mortality outcome. But studies on all-cause mortality and at the census tract level remain scarce. The results may guide the development of new composite socioeconomic indicators for use in mortality inequality analysis.

Mortality, trends; Geographic Locations, epidemiology; Socioeconomic Factors; Health Status Disparities; Review

INTRODUCTION

Observed within different sociodemographic groups¹1. Rocha SMR. Pobreza no Brasil: afinal, de que se trata? 3. ed. Rio de Janeiro: Editora FGV; 2007., the inverse relationship between low socioeconomic status and mortality is a well-established fact in the literature and has mostly been analyzed by single-variable socioeconomic indicators such as income, education, wealth, race/ethnicity, marital status, social class, and occupation⁴4. Bosworth B. Increasing disparities in mortality by socioeconomic status. Annu Rev Public Health. 2018;39:237-51. https://doi.org/10.1146/annurev-publhealth-040617-014615
https://doi.org/10.1146/annurev-publheal... ,⁵5. Williams J, Allen L, Wickramasinghe K, Mikkelsen B, Roberts N, Townsend N. A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries. J Gob Health. 2018;8(2):020409. https://doi.org/10.7189/jogh.08.020409
https://doi.org/10.7189/jogh.08.020409... . Composite socioeconomic indicators such as the Human Development Index, deprivation scores, and social-vulnerability indexes⁶6. Ruiz JI, Nuhu K, McDaniel JT, Popoff F, Izcovich A, Criniti JM. Inequality as a powerful predictor of infant and maternal mortality around the world. PloS One. 2015;10(10):e0140796. https://doi.org/10.1371/journal.pone.0140796
https://doi.org/10.1371/journal.pone.014... have also been used to study mortality inequalities in populations. These more complex measures broaden the knowledge on socioeconomic disparities, especially in analyses that consider different geographical levels, such as municipalities, or other small areas.

In Brazil, several studies provide evidence of higher mortality rates in more impoverished areas⁹9. Anele CR, Hirakata VN, Goldani MZ, Silva CH. The influence of the municipal human development index and maternal education on infant mortality: an investigation in a retrospective cohort study in the extreme south of Brazil. BMC Public Health 2021;21:194. https://doi.org/10.1186/s12889-021-10226-9
https://doi.org/10.1186/s12889-021-10226... . Many are the composite socioeconomic measures available at the municipal level, such as the Social Vulnerability Index (Índice de Vulnerabilidade Social – IVS)¹²12. Instituto de Pesquisa Econômica Aplicada. Atlas da vulnerabilidade social. 2021. https://dados.gov.br/dataset/ivs (last access on 05/21/2021).
https://dados.gov.br/dataset/ivs... , and the Municipal Human Development Index (MHDI)¹³13. United Nations Development Programme. Atlas of human development in Brazil. New York; UNDP; 2021 [cited 2021 May 5]. Available from: http://www.atlasbrasil.org.br/
http://www.atlasbrasil.org.br/... – still, mortality rates can be highly heterogeneous¹⁴14. Schmertmann CP, Gonzaga MR. Bayesian estimation of age-specific mortality and life expectancy for small areas with defective vital records. Demography. 2018;55(4):1363-88. https://doi.org/10.1007/s13524-018-0695-2
https://doi.org/10.1007/s13524-018-0695-... , making more disaggregated analyses desirable. Smaller spatial units like districts or census tracts (which include districts), however, often lack socioeconomic information¹⁵15. Ichihara MYT, Ramos D, Rebouças P, Oliveira FJ, Ferreira AJF, Teixeira C, et al. Area deprivation measures used in Brazil: a scoping review. Rev Saude Publica. 2018;52:83. https://doi.org/10.11606/S1518-8787.2018052000933
https://doi.org/10.11606/S1518-8787.2018... , resulting in few studies on mortality inequality at this level of analysis.

Using indicators to analyze mortality inequalities at different geographical levels has been most beneficial for researchers and health policy makers to identify the risks of death in population groups and to define public policies and interventions¹⁶16. Exeter DJ, Zhao J, Crengle S, Lee A, Browne M. The New Zealand Indices of Multiple Deprivation (IMD): a new suite of indicators for social and health research in Aotearoa, New Zealand. PloS One. 2017;12(8):e0181260. https://doi.org/10.1371/journal.pone.0181260
https://doi.org/10.1371/journal.pone.018... ,¹⁷17. Leyland AH, Dundas R, McLoone P, Boddy FA. Cause-specific inequalities in mortality in Scotland: two decades of change. A population-based study. BMC Public Health 2007;7:172. https://doi.org/10.1186/1471-2458-7-172
https://doi.org/10.1186/1471-2458-7-172... . Mapping the construction of composite socioeconomic indicators, and their association with mortality outcomes at different geographical levels in Brazil, is of paramount importance to guide the development of new composite indicators and their use in studies analyzing mortality inequalities. As such, this study summarizes the literature on the relationship between composite socioeconomic indicators and mortality in different geographical areas of Brazil.

Specific Research Questions

To do so, we formulated the following research questions:

Research question 1: Which composite socioeconomic indicators are most used to understand mortality inequalities across different Brazilian geographical areas?

Research question 2: What are the characteristics of these composite measures of area-level socioeconomic indicators, and are there any limitations to understanding geographical mortality inequalities in Brazil?

METHODS

This scoping review follows the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement extension for Scoping Reviews (PRISMA-ScR)¹⁸18. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquho H, Levac D, Moher D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
https://doi.org/10.7326/M18-0850... . Its protocol was submitted and published on the Open Science Framework (OSF) (https://osf.io/vmt9f/).

We used the population, concept, and context framework to define our research question¹⁹19. Aromataris E, Munn Z, editors. JBI manual for evidence synthesis. Adelaide (AU): Joanna Briggs Institute; 2020.. Population was defined as individuals who had died in Brazil, considering all-cause, or specific causes of death in any age range; concept was understood as the aggregate measures of socioeconomic position; and the context was the geographical level in Brazil (i.e., state, municipality, census tract level, districts, and others)¹⁸18. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquho H, Levac D, Moher D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
https://doi.org/10.7326/M18-0850... .

Eligibility Criteria

This scoping review included papers that: i) were published in peer-reviewed journals between January 1, 2000 and August 31, 2020; ii) had cross-sectional, cohort, case-control, and ecological study designs; iii) analyzed the relationship (i.e., association or descriptive relationship) between socioeconomic status and all-cause, cause-specific, or prevalence mortality rates; iv) outcomes for the general population could be provided by administrative or primary data, without age group or geographical area level restriction. Articles that exclusively accounted for single measures of the socioeconomic condition, reviews, trials, intervention studies, editorials, comments, and case reports were excluded.

Outcomes

Primary outcomes consisted of all-cause mortality, while secondary outcomes comprised cause-specific mortality – both defined according to the International Classification of Diseases (ICD). Data were processed from baseline to follow-up. If a study reported multiple follow-ups, only the most recent data was included.

Information Sources and Search Strategy

We performed a bibliographic search on August 31, 2020, in the Medline, Scopus, Web of Science, and Latin American and Caribbean Health Science Literature (Lilacs) databases. The authors, aided by an experienced librarian, drafted the search strategy bellow, used for PubMed/Medline:

An adapted version of this search strategy was drafted and used for the Web of Science, Scopus, and Lilacs databases. Final search results were exported into EndNote, and two blinded authors removed any duplicates. All references were managed in EndNote X7. We did not search for gray literature.

Selection of Evidence Sources and Data Charting

Three pairs of reviewers independently evaluated the titles, abstracts, and full texts of the selected articles. Prior to standardized data extraction, the reviewers were trained on key study descriptors to harmonize the extraction: i) article identification (language, authors, year, and journal of publication); ii) composite socioeconomic measure (name, data source, variables used, level of analysis, and geographical coverage); iii) mortality outcomes (cause of death, age group, data sources, and type of measure); iv) statistical analysis; and v) main findings. Disagreements between reviewers were resolved by means of discussion, and in collaboration with a third reviewer as necessary. We did not estimate the agreement rate for the reviews. Finally, two pairs of reviewers verified all the previously extracted information. Information was summarized in tables and boxes.

Summary of Results

Data analysis was carried out following the narrative summary approach²⁰20. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme. Version 1. Lancaster (UK): Lancaster University; 2006 [cited 2021 May 5]. Available from: https://www.lancaster.ac.uk/media/lancaster-university/content-assets/documents/fhm/dhr/chir/NSsynthesisguidanceVersion1-April2006.pdf
https://www.lancaster.ac.uk/media/lancas... . Results were tabulated considering the publication year, geographical coverage, and mortality outcomes of the study. The summary included: the different socioeconomic indicators available, the all-cause and specific cause of death, and the main findings and limitations –as well as critical points the authors failed to address – of the selected studies. Information was summarized according to the population coverage of the socioeconomic measure, area level, composition and scale of the socioeconomic inequality measures incorporated, data and information sources used, and analytic methods used to describe the relationship between socioeconomic inequalities and mortality outcomes.

RESULTS

We retrieved a total of 806 papers – of which we removed 208 duplicates and excluded other 521 following title screening, leaving a total of 77 full-text articles for assessment. Figure describes the exclusion process during the full-text review. Most studies were excluded for not including a composite socioeconomic measure (n = 33), or not being peer-reviewed articles (n = 12). After screening, 24 articles remained for the scoping review.

Evenly distributed across two study periods, most studies covered the municipal level (n = 16) (Table). The articles reviewed measure socioeconomic indicators at the country (n = 2), state (n = 2), municipal (n = 6), district (n = 5), and census tract (n = 4) level, as well as other geographic areas (n = 5). Mortality outcomes mainly comprised cause-specific rates (n = 19), and age-specific mortality outcomes (n = 11) (Table).

Box 1 presents the selected articles organized according to composite socioeconomic measures and mortality outcomes. Some studies assessed mortality outcomes at the small area level (census tract)²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... , making it difficult to generalize their results for the whole of Brazil, since the combined composite socioeconomic measure was only constructed for a given geographical area (Box 1).

Most articles (n = 16) elaborated composite socioeconomic indicators using Brazilian Demographic Census data: two, ten, and four articles, respectively, were written using data from the 1991²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,²⁶26. Macedo AC, Paim JS, Silva LMV, Costa MCN. Violência e desigualdade social: mortalidade por homicídios e condições de vida em Salvador, Brasil. Rev Saude Publica. 2001;35(6):515-22. https://doi.org/10.1590/S0034-89102001000600004
https://doi.org/10.1590/S0034-8910200100... , 2000²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... , and 2010²⁴24. Silveira IH, Junger WL. Green spaces and mortality due to cardiovascular diseases in the city of Rio de Janeiro. Rev Saude Publica. 2018;52:49. https://doi.org/10.11606/S1518-8787.2018052000290
https://doi.org/10.11606/S1518-8787.2018... ,³⁴34. Drachler ML, Lobato MAO, Lermen JI, Fagundes S, Ferla AA, Drachler CW, et al. Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS. Cienc Saude Colet. 2014;19(9):3849-58. https://doi.org/10.1590/1413-81232014199.12012013
https://doi.org/10.1590/1413-81232014199... censuses. Other data sources included the Municipal Planning Secretariat, the State System of Statistical Data Analysis Foundation (Fundação Sistema Estadual de Análise de Dados Estatísticos – SEADE), the Mortality Information Improvement Program of São Paulo (Programa de Aprimoramento das Informações de Mortalidade – PRO-AIM), the Institute for Economic Research Foundation (Fundação Instituto de Pesquisas Econômicas – Fipe), the Brazilian Agency for Heritage Studies, and the Metropolitan Company of São Paulo (Companhia Metropolitana de São Paulo – Metrô).

Four studies used global indicators as measures, such as the Human Development Index (HDI), which considers variables related to income, education, and longevity²³23. Antunes JLF, Borrell C, Pérez G, Boing AF, Wünsch-Filho V. Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and São Paulo, Brazil, 1995-2003. Int J Equity Health. 2008;7:14. https://doi.org/10.1186/1475-9276-7-14
https://doi.org/10.1186/1475-9276-7-14... ,³⁷37. Machado DB, Pescarini JM, Araújo LFSC, Barreto ML. Austerity policies in Brazil may affect violence related outcomes. Cienc Saude Colet. 2019;24(12):4385-94. https://doi.org/10.1590/1413-812320182412.07422019
https://doi.org/10.1590/1413-81232018241... ; and the Gross Domestic Product (GDP), i.e., the sum of all final goods and services produced in a given period of time²⁸28. Medeiros CRG, Meneghel SN, Gerhardt TE. Desigualdades na mortalidade por doenças cardiovasculares em pequenos municípios. Cienc Saude Colet. 2012;17(11):2953-62. https://doi.org/10.1590/S1413-81232012001100012
https://doi.org/10.1590/S1413-8123201200... . One study⁴⁰40. Guimarães RM, Rocha PGM, Muzi CD, Ramos RS. Increase income and mortality of colorrectal cancer in Brazil, 2001-2009. Arq Gastroenterol. 2013;50(1):64-9. https://doi.org/10.1590/s0004-28032013000100012
https://doi.org/10.1590/s0004-2803201300... used the Gini Index, a single global index that evaluates income inequality, in conjunction with other variables to compose socioeconomic inequality measures (Box 1).

The papers reviewed used a wide variety of variables to create composite socioeconomic measures, most commonly per capita or household income (n = 17)²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... , schooling (n = 17)²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... , household status (n = 12)²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... ,²⁴24. Silveira IH, Junger WL. Green spaces and mortality due to cardiovascular diseases in the city of Rio de Janeiro. Rev Saude Publica. 2018;52:49. https://doi.org/10.11606/S1518-8787.2018052000290
https://doi.org/10.11606/S1518-8787.2018... ,²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,²⁸28. Medeiros CRG, Meneghel SN, Gerhardt TE. Desigualdades na mortalidade por doenças cardiovasculares em pequenos municípios. Cienc Saude Colet. 2012;17(11):2953-62. https://doi.org/10.1590/S1413-81232012001100012
https://doi.org/10.1590/S1413-8123201200... ,²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... ,³²32. Bastos MJRP, Pereira JdA, Smarzaro DC, et al. Ecological analysis of accidents and lethal violence in Vitória, Southeastern Brazil. Rev Saude Publica. 2009;43(1):123-32. https://doi.org/10.1590/S0034-89102009000100016
https://doi.org/10.1590/S0034-8910200900... ,³⁴34. Drachler ML, Lobato MAO, Lermen JI, Fagundes S, Ferla AA, Drachler CW, et al. Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS. Cienc Saude Colet. 2014;19(9):3849-58. https://doi.org/10.1590/1413-81232014199.12012013
https://doi.org/10.1590/1413-81232014199... , and employment (n = 5)²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... ,²³23. Antunes JLF, Borrell C, Pérez G, Boing AF, Wünsch-Filho V. Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and São Paulo, Brazil, 1995-2003. Int J Equity Health. 2008;7:14. https://doi.org/10.1186/1475-9276-7-14
https://doi.org/10.1186/1475-9276-7-14... ,²⁷27. Ribeiro KB, Lopes LF, Camargo B. Trends in childhood leukemia mortality in Brazil and correlation with social inequalities. Cancer. 2007;10(8):1823-31. https://doi.org/10.1002/cncr.22982
https://doi.org/10.1002/cncr.22982... ,³⁵35. Faria R, Santana P. Variações espaciais e desigualdades regionais no indicador de mortalidade infantil do estado de Minas Gerais, Brasil. Saude Soc. 2016;25(3):736-49. https://doi.org/10.1590/S0104-12902016147609
https://doi.org/10.1590/S0104-1290201614... ,⁴⁴44. Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of delayed epidemiological cardiovascular transition. Int J Stroke 2009;4(1):40-1. https://doi.org/10.1111/j.1747-4949.2009.00240.x
https://doi.org/10.1111/j.1747-4949.2009... (Box 1). Social classes⁴²42. Campos TP, Carvalho MS, Barcellos CC. Mortalidade infantil no Rio de Janeiro, Brasil: áreas de risco e trajetória dos pacientes até os serviços de saúde. Rev Panam Salud Publica. 2000 [cited 2021 May 5];8(3):164-71. Available from: https://www.scielosp.org/pdf/rpsp/2000.v8n3/164-171/pt
https://www.scielosp.org/pdf/rpsp/2000.v... , inequality⁴⁴44. Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of delayed epidemiological cardiovascular transition. Int J Stroke 2009;4(1):40-1. https://doi.org/10.1111/j.1747-4949.2009.00240.x
https://doi.org/10.1111/j.1747-4949.2009... , proportion of extreme poverty⁴¹41. Alves JD, Arroyo LH, Arcoverde MAM, Cartagena-Ramos D, Berra TZ, Alves LS, et al. Magnitud de los determinantes sociales en el riesgo de mortalidad por tuberculosis en el Centro-Oeste de Brasil. Gac Sanit. 2020;34(2):171-8. https://doi.org/10.1016/j.gaceta.2019.01.004
https://doi.org/10.1016/j.gaceta.2019.01... , and quality of life²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... were less frequently used (Box 2). We also described the grouping of variables in their respective dimensions for construction of the combined measures in each article, as well as the source and year of the data used to measure socioeconomic inequalities (Box 1).

Most articles (n = 17) used the Mortality Information System (Sistema de Informação em Mortalidade – SIM), from the Unified Health System IT Department (Departamento de Informática do Sistema Único de Saúde – Datasus) as the source of mortality data²³23. Antunes JLF, Borrell C, Pérez G, Boing AF, Wünsch-Filho V. Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and São Paulo, Brazil, 1995-2003. Int J Equity Health. 2008;7:14. https://doi.org/10.1186/1475-9276-7-14
https://doi.org/10.1186/1475-9276-7-14... ,²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,²⁷27. Ribeiro KB, Lopes LF, Camargo B. Trends in childhood leukemia mortality in Brazil and correlation with social inequalities. Cancer. 2007;10(8):1823-31. https://doi.org/10.1002/cncr.22982
https://doi.org/10.1002/cncr.22982... . Other studies used mortality systems from the Municipal Health Department²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... ,²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... ,²⁶26. Macedo AC, Paim JS, Silva LMV, Costa MCN. Violência e desigualdade social: mortalidade por homicídios e condições de vida em Salvador, Brasil. Rev Saude Publica. 2001;35(6):515-22. https://doi.org/10.1590/S0034-89102001000600004
https://doi.org/10.1590/S0034-8910200100... ,³²32. Bastos MJRP, Pereira JdA, Smarzaro DC, et al. Ecological analysis of accidents and lethal violence in Vitória, Southeastern Brazil. Rev Saude Publica. 2009;43(1):123-32. https://doi.org/10.1590/S0034-89102009000100016
https://doi.org/10.1590/S0034-8910200900... ,³³33. Belon AP, Barros MBA. Reduction of social inequalities in life expectancy in a city of Southeastern Brazil. Int J Equity Health 2011;10:36. https://doi.org/10.1186/1475-9276-10-36
https://doi.org/10.1186/1475-9276-10-36... ,⁴²42. Campos TP, Carvalho MS, Barcellos CC. Mortalidade infantil no Rio de Janeiro, Brasil: áreas de risco e trajetória dos pacientes até os serviços de saúde. Rev Panam Salud Publica. 2000 [cited 2021 May 5];8(3):164-71. Available from: https://www.scielosp.org/pdf/rpsp/2000.v8n3/164-171/pt
https://www.scielosp.org/pdf/rpsp/2000.v... ,⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... , and records from the Forensic Medicine Institute (Instituto Médico Legal – IML)⁴⁵45. Araújo EM, Araújo TM, Santana F. Distribuição desigual da mortalidade por causas externas: avaliação de aspectos socioeconômicos. Rev Baiana Saude Publica. 2005;29(2):262-72. https://doi.org/10.22278/2318-2660.2005.v29.n2.a1007
https://doi.org/10.22278/2318-2660.2005.... . Only one study did not specify the source of mortality data used³⁰30. Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):370-9. https://doi.org/10.1590/s0066-782x2008000600004
https://doi.org/10.1590/s0066-782x200800... . The source of population count data used as the denominator for the mortality rates was either the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE) censuses or the Live Birth Information System (Sistema de Informação sobre Nascidos Vivos – SINASC) (Box 1).

Mortality rates were mostly presented in non-standardized form²⁴24. Silveira IH, Junger WL. Green spaces and mortality due to cardiovascular diseases in the city of Rio de Janeiro. Rev Saude Publica. 2018;52:49. https://doi.org/10.11606/S1518-8787.2018052000290
https://doi.org/10.11606/S1518-8787.2018... ,³⁰30. Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):370-9. https://doi.org/10.1590/s0066-782x2008000600004
https://doi.org/10.1590/s0066-782x200800... ,³²32. Bastos MJRP, Pereira JdA, Smarzaro DC, et al. Ecological analysis of accidents and lethal violence in Vitória, Southeastern Brazil. Rev Saude Publica. 2009;43(1):123-32. https://doi.org/10.1590/S0034-89102009000100016
https://doi.org/10.1590/S0034-8910200900... ,³⁷37. Machado DB, Pescarini JM, Araújo LFSC, Barreto ML. Austerity policies in Brazil may affect violence related outcomes. Cienc Saude Colet. 2019;24(12):4385-94. https://doi.org/10.1590/1413-812320182412.07422019
https://doi.org/10.1590/1413-81232018241... ,⁴⁵45. Araújo EM, Araújo TM, Santana F. Distribuição desigual da mortalidade por causas externas: avaliação de aspectos socioeconômicos. Rev Baiana Saude Publica. 2005;29(2):262-72. https://doi.org/10.22278/2318-2660.2005.v29.n2.a1007
https://doi.org/10.22278/2318-2660.2005.... , and commonly calculated for a specific age group, such as infant mortality³⁴34. Drachler ML, Lobato MAO, Lermen JI, Fagundes S, Ferla AA, Drachler CW, et al. Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS. Cienc Saude Colet. 2014;19(9):3849-58. https://doi.org/10.1590/1413-81232014199.12012013
https://doi.org/10.1590/1413-81232014199... and mortality of older adults²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... (Box 1). One study evaluated life expectancy³³33. Belon AP, Barros MBA. Reduction of social inequalities in life expectancy in a city of Southeastern Brazil. Int J Equity Health 2011;10:36. https://doi.org/10.1186/1475-9276-10-36
https://doi.org/10.1186/1475-9276-10-36... . To tackle the different frequency distributions in diverse populations, some authors chose age-standardized rates²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,²⁷27. Ribeiro KB, Lopes LF, Camargo B. Trends in childhood leukemia mortality in Brazil and correlation with social inequalities. Cancer. 2007;10(8):1823-31. https://doi.org/10.1002/cncr.22982
https://doi.org/10.1002/cncr.22982... ,⁴⁰40. Guimarães RM, Rocha PGM, Muzi CD, Ramos RS. Increase income and mortality of colorrectal cancer in Brazil, 2001-2009. Arq Gastroenterol. 2013;50(1):64-9. https://doi.org/10.1590/s0004-28032013000100012
https://doi.org/10.1590/s0004-2803201300... ,⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... ,⁴⁶46. Guimarães EA. O processo de implementação do Programa Minha Casa Minha Vida para a população de baixa renda: o caso de Viçosa, MG [dissertação]. Viçosa, MG: Universidade Federal de Viçosa; 2013., or stratification of rates by different age groups and other population characteristics, such as sex and race/ethnicity²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... ,²³23. Antunes JLF, Borrell C, Pérez G, Boing AF, Wünsch-Filho V. Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and São Paulo, Brazil, 1995-2003. Int J Equity Health. 2008;7:14. https://doi.org/10.1186/1475-9276-7-14
https://doi.org/10.1186/1475-9276-7-14... ,³⁰30. Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):370-9. https://doi.org/10.1590/s0066-782x2008000600004
https://doi.org/10.1590/s0066-782x200800... ,³⁸38. Schuck-Paim C, Taylor RJ, Alonso WJ, Weinberger DM, Simonsen L. Effect of pneumococcal conjugate vaccine introduction on childhood pneumonia mortality in Brazil: a retrospective observational study. Lancet Glob Health. 2019;7(2):e249-56. https://doi.org/10.1016/S2214-109X(18)30455-8
https://doi.org/10.1016/S2214-109X(18)30... ,³⁹39. Alarcão ACJ, Dell’ Agnolo CM, Vissoci JR, Carvalho ECA, Staton CA, Andrade L, et al. Suicide mortality among youth in southern Brazil: a spatiotemporal evaluation of socioeconomic vulnerability. Braz J Psychiatry. 2020;42(1):46-53. https://doi.org/10.1590/1516-4446-2018-0352
https://doi.org/10.1590/1516-4446-2018-0... ,⁴⁴44. Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of delayed epidemiological cardiovascular transition. Int J Stroke 2009;4(1):40-1. https://doi.org/10.1111/j.1747-4949.2009.00240.x
https://doi.org/10.1111/j.1747-4949.2009... . The studies either estimated the rates for each year or measured the average mortality rate between periods. They also used proportional mortality linked to causes or age groups²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,⁴²42. Campos TP, Carvalho MS, Barcellos CC. Mortalidade infantil no Rio de Janeiro, Brasil: áreas de risco e trajetória dos pacientes até os serviços de saúde. Rev Panam Salud Publica. 2000 [cited 2021 May 5];8(3):164-71. Available from: https://www.scielosp.org/pdf/rpsp/2000.v8n3/164-171/pt
https://www.scielosp.org/pdf/rpsp/2000.v... . Cause-specific mortality rates comprised external causes²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... ,²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,³⁸38. Schuck-Paim C, Taylor RJ, Alonso WJ, Weinberger DM, Simonsen L. Effect of pneumococcal conjugate vaccine introduction on childhood pneumonia mortality in Brazil: a retrospective observational study. Lancet Glob Health. 2019;7(2):e249-56. https://doi.org/10.1016/S2214-109X(18)30455-8
https://doi.org/10.1016/S2214-109X(18)30... ,⁴¹41. Alves JD, Arroyo LH, Arcoverde MAM, Cartagena-Ramos D, Berra TZ, Alves LS, et al. Magnitud de los determinantes sociales en el riesgo de mortalidad por tuberculosis en el Centro-Oeste de Brasil. Gac Sanit. 2020;34(2):171-8. https://doi.org/10.1016/j.gaceta.2019.01.004
https://doi.org/10.1016/j.gaceta.2019.01... , infectious and parasitic diseases²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... ,²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,³⁸38. Schuck-Paim C, Taylor RJ, Alonso WJ, Weinberger DM, Simonsen L. Effect of pneumococcal conjugate vaccine introduction on childhood pneumonia mortality in Brazil: a retrospective observational study. Lancet Glob Health. 2019;7(2):e249-56. https://doi.org/10.1016/S2214-109X(18)30455-8
https://doi.org/10.1016/S2214-109X(18)30... ,⁴¹41. Alves JD, Arroyo LH, Arcoverde MAM, Cartagena-Ramos D, Berra TZ, Alves LS, et al. Magnitud de los determinantes sociales en el riesgo de mortalidad por tuberculosis en el Centro-Oeste de Brasil. Gac Sanit. 2020;34(2):171-8. https://doi.org/10.1016/j.gaceta.2019.01.004
https://doi.org/10.1016/j.gaceta.2019.01... , and chronic and degenerative diseases²³23. Antunes JLF, Borrell C, Pérez G, Boing AF, Wünsch-Filho V. Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and São Paulo, Brazil, 1995-2003. Int J Equity Health. 2008;7:14. https://doi.org/10.1186/1475-9276-7-14
https://doi.org/10.1186/1475-9276-7-14... (Box 1). Age-specific mortality rates consisted mainly of children³⁴34. Drachler ML, Lobato MAO, Lermen JI, Fagundes S, Ferla AA, Drachler CW, et al. Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS. Cienc Saude Colet. 2014;19(9):3849-58. https://doi.org/10.1590/1413-81232014199.12012013
https://doi.org/10.1590/1413-81232014199... . Only two studies estimated all-cause mortality rates²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... ,³³33. Belon AP, Barros MBA. Reduction of social inequalities in life expectancy in a city of Southeastern Brazil. Int J Equity Health 2011;10:36. https://doi.org/10.1186/1475-9276-10-36
https://doi.org/10.1186/1475-9276-10-36... (Box 1).

Most studies (n = 14) presented descriptive statistics and/or spatial distribution analysis, correlating mortality outcomes with the classification of socioeconomic inequalities by area. Areas with the worst socioeconomic characteristics had higher mortality indicators for the following causes: all-cause mortality⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... ,⁴⁵45. Araújo EM, Araújo TM, Santana F. Distribuição desigual da mortalidade por causas externas: avaliação de aspectos socioeconômicos. Rev Baiana Saude Publica. 2005;29(2):262-72. https://doi.org/10.22278/2318-2660.2005.v29.n2.a1007
https://doi.org/10.22278/2318-2660.2005.... , external causes⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... , suicide³⁷37. Machado DB, Pescarini JM, Araújo LFSC, Barreto ML. Austerity policies in Brazil may affect violence related outcomes. Cienc Saude Colet. 2019;24(12):4385-94. https://doi.org/10.1590/1413-812320182412.07422019
https://doi.org/10.1590/1413-81232018241... ,³⁹39. Alarcão ACJ, Dell’ Agnolo CM, Vissoci JR, Carvalho ECA, Staton CA, Andrade L, et al. Suicide mortality among youth in southern Brazil: a spatiotemporal evaluation of socioeconomic vulnerability. Braz J Psychiatry. 2020;42(1):46-53. https://doi.org/10.1590/1516-4446-2018-0352
https://doi.org/10.1590/1516-4446-2018-0... , homicide²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... ,²⁶26. Macedo AC, Paim JS, Silva LMV, Costa MCN. Violência e desigualdade social: mortalidade por homicídios e condições de vida em Salvador, Brasil. Rev Saude Publica. 2001;35(6):515-22. https://doi.org/10.1590/S0034-89102001000600004
https://doi.org/10.1590/S0034-8910200100... ,³⁷37. Machado DB, Pescarini JM, Araújo LFSC, Barreto ML. Austerity policies in Brazil may affect violence related outcomes. Cienc Saude Colet. 2019;24(12):4385-94. https://doi.org/10.1590/1413-812320182412.07422019
https://doi.org/10.1590/1413-81232018241... ,⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... ,⁴⁵45. Araújo EM, Araújo TM, Santana F. Distribuição desigual da mortalidade por causas externas: avaliação de aspectos socioeconômicos. Rev Baiana Saude Publica. 2005;29(2):262-72. https://doi.org/10.22278/2318-2660.2005.v29.n2.a1007
https://doi.org/10.22278/2318-2660.2005.... , fetal mortality³⁶36. Bonfim CV, Silva APSC, Oliveira CM, Vilela MBR, Freire NCF. Spatial analysis of inequalities in fetal and infant mortality due to avoidable causes. Rev Bras Enferm. 2020;73 Suppl 4:e20190088. https://doi.org/10.1590/0034-7167-2019-0088
https://doi.org/10.1590/0034-7167-2019-0... , infant mortality³⁴34. Drachler ML, Lobato MAO, Lermen JI, Fagundes S, Ferla AA, Drachler CW, et al. Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS. Cienc Saude Colet. 2014;19(9):3849-58. https://doi.org/10.1590/1413-81232014199.12012013
https://doi.org/10.1590/1413-81232014199... , respiratory system diseases²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , circulatory system diseases⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... , stroke⁴⁴44. Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of delayed epidemiological cardiovascular transition. Int J Stroke 2009;4(1):40-1. https://doi.org/10.1111/j.1747-4949.2009.00240.x
https://doi.org/10.1111/j.1747-4949.2009... , infectious and parasitic diseases²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... ,²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , diarrhea²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , malnutrition²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , gastroenteritis²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , and oropharyngeal cancer²³23. Antunes JLF, Borrell C, Pérez G, Boing AF, Wünsch-Filho V. Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and São Paulo, Brazil, 1995-2003. Int J Equity Health. 2008;7:14. https://doi.org/10.1186/1475-9276-7-14
https://doi.org/10.1186/1475-9276-7-14... .

Higher mortality rates due to colorectal cancer⁴⁰40. Guimarães RM, Rocha PGM, Muzi CD, Ramos RS. Increase income and mortality of colorrectal cancer in Brazil, 2001-2009. Arq Gastroenterol. 2013;50(1):64-9. https://doi.org/10.1590/s0004-28032013000100012
https://doi.org/10.1590/s0004-2803201300... , leukemia²⁷27. Ribeiro KB, Lopes LF, Camargo B. Trends in childhood leukemia mortality in Brazil and correlation with social inequalities. Cancer. 2007;10(8):1823-31. https://doi.org/10.1002/cncr.22982
https://doi.org/10.1002/cncr.22982... , a general group of neoplasms²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , traffic accidents³²32. Bastos MJRP, Pereira JdA, Smarzaro DC, et al. Ecological analysis of accidents and lethal violence in Vitória, Southeastern Brazil. Rev Saude Publica. 2009;43(1):123-32. https://doi.org/10.1590/S0034-89102009000100016
https://doi.org/10.1590/S0034-8910200900... ,⁴⁵45. Araújo EM, Araújo TM, Santana F. Distribuição desigual da mortalidade por causas externas: avaliação de aspectos socioeconômicos. Rev Baiana Saude Publica. 2005;29(2):262-72. https://doi.org/10.22278/2318-2660.2005.v29.n2.a1007
https://doi.org/10.22278/2318-2660.2005.... , and suicide³²32. Bastos MJRP, Pereira JdA, Smarzaro DC, et al. Ecological analysis of accidents and lethal violence in Vitória, Southeastern Brazil. Rev Saude Publica. 2009;43(1):123-32. https://doi.org/10.1590/S0034-89102009000100016
https://doi.org/10.1590/S0034-8910200900... , in turn, were observed in less deprived areas and/or those with more significant socioeconomic development. Medeiros et al.²⁸28. Medeiros CRG, Meneghel SN, Gerhardt TE. Desigualdades na mortalidade por doenças cardiovasculares em pequenos municípios. Cienc Saude Colet. 2012;17(11):2953-62. https://doi.org/10.1590/S1413-81232012001100012
https://doi.org/10.1590/S1413-8123201200... (2012) showed that the variables in the socioeconomic development measure only partially explained the differences in mortality rates due to cardiovascular diseases in a group of socioeconomically similar municipalities, being more strongly associated with other determinants.

Studies found higher mortality risks for tuberculosis (RR = 2.9)⁴¹41. Alves JD, Arroyo LH, Arcoverde MAM, Cartagena-Ramos D, Berra TZ, Alves LS, et al. Magnitud de los determinantes sociales en el riesgo de mortalidad por tuberculosis en el Centro-Oeste de Brasil. Gac Sanit. 2020;34(2):171-8. https://doi.org/10.1016/j.gaceta.2019.01.004
https://doi.org/10.1016/j.gaceta.2019.01... , pneumonia (RR = 3.9)²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , cardiovascular diseases (RR = 3.3)³⁰30. Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):370-9. https://doi.org/10.1590/s0066-782x2008000600004
https://doi.org/10.1590/s0066-782x200800... , cerebrovascular diseases (RR = 3.9)³⁰30. Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):370-9. https://doi.org/10.1590/s0066-782x2008000600004
https://doi.org/10.1590/s0066-782x200800... , stroke (OR = 2.0)⁴⁵45. Araújo EM, Araújo TM, Santana F. Distribuição desigual da mortalidade por causas externas: avaliação de aspectos socioeconômicos. Rev Baiana Saude Publica. 2005;29(2):262-72. https://doi.org/10.22278/2318-2660.2005.v29.n2.a1007
https://doi.org/10.22278/2318-2660.2005.... , homicide (RR = 5.1)²⁶26. Macedo AC, Paim JS, Silva LMV, Costa MCN. Violência e desigualdade social: mortalidade por homicídios e condições de vida em Salvador, Brasil. Rev Saude Publica. 2001;35(6):515-22. https://doi.org/10.1590/S0034-89102001000600004
https://doi.org/10.1590/S0034-8910200100... , traffic accidents (RR = 2.9)²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , and infectious and parasitic diseases among children (RR = 1.48)²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... in more deprived areas compared with less deprived areas. But no statistically significant association was found between mortality rates and indicator measures, such as the Composite Social Deprivation Indicator (Indicador Composto de Carência Social – ICS)²⁹29. Silva VL, Leal MCC, Marino JG, Marques APO. Associação entre carência social e causas de morte entre idosos residentes no Município de Recife, Pernambuco, Brasil. Cad Saude Publica 2008;24(5):1013-23. https://doi.org/10.1590/S0102-311X2008000500008
https://doi.org/10.1590/S0102-311X200800... , the socioeconomic composition of districts⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... and the Composite Deprivation Index⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... (Box 2). Moreover, a study evaluating life expectancy at birth showed that this variable was 6.9 and 5.5 years less, respectively, for men and women living in impoverished areas, compared with those living in less deprived areas³³33. Belon AP, Barros MBA. Reduction of social inequalities in life expectancy in a city of Southeastern Brazil. Int J Equity Health 2011;10:36. https://doi.org/10.1186/1475-9276-10-36
https://doi.org/10.1186/1475-9276-10-36... .

Limitations Discussed by the Studies

Studies based on the ecological approach²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... reported some disadvantages regarding the assessment of mortality inequalities using composite socioeconomic measures (Box 2). As these studies were not designed to find an association between socioeconomic factors and mortality at the individual level³²32. Bastos MJRP, Pereira JdA, Smarzaro DC, et al. Ecological analysis of accidents and lethal violence in Vitória, Southeastern Brazil. Rev Saude Publica. 2009;43(1):123-32. https://doi.org/10.1590/S0034-89102009000100016
https://doi.org/10.1590/S0034-8910200900... ,⁴⁷47. Silva RM, Sousa GS, Vieira LJES, Caldas JMP, Minayo MCS. Suicidal ideation and attempts of older women in Northeastern Brazil. Rev Bras Enferm. 2018;71 Suppl 2:755-62. https://doi.org/10.1590/0034-7167-2017-0413
https://doi.org/10.1590/0034-7167-2017-0... ,⁴⁸48. Ribeiro F, Leist A. Who is going to pay the price of Covid-19? Reflections about an unequal Brazil. Int J Equity Health. 2020;19:91. https://doi.org/10.1186/s12939-020-01207-2
https://doi.org/10.1186/s12939-020-01207... , and the potential explanation pointed to a decrease in heterogeneous spatial contexts, particularly in large areas and populations²²22. Vilela MBR, Bonfim C, Medeiros Z. Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil. Rev Bras Saude Mater Infant. 2008;8(4):445-61. https://doi.org/10.1590/S1519-38292008000400011
https://doi.org/10.1590/S1519-3829200800... ,²⁶26. Macedo AC, Paim JS, Silva LMV, Costa MCN. Violência e desigualdade social: mortalidade por homicídios e condições de vida em Salvador, Brasil. Rev Saude Publica. 2001;35(6):515-22. https://doi.org/10.1590/S0034-89102001000600004
https://doi.org/10.1590/S0034-8910200100... ,³²32. Bastos MJRP, Pereira JdA, Smarzaro DC, et al. Ecological analysis of accidents and lethal violence in Vitória, Southeastern Brazil. Rev Saude Publica. 2009;43(1):123-32. https://doi.org/10.1590/S0034-89102009000100016
https://doi.org/10.1590/S0034-8910200900... ,³³33. Belon AP, Barros MBA. Reduction of social inequalities in life expectancy in a city of Southeastern Brazil. Int J Equity Health 2011;10:36. https://doi.org/10.1186/1475-9276-10-36
https://doi.org/10.1186/1475-9276-10-36... ,⁴³43. Oliveira DC, Barreira ÁS, Trunk MT, Guzmán AF. Efecto de las desigualdades socioeconómicas en la mortalidad de la ciudad de Fortaleza, Ceará, Brasil durante el año 2007. Rev Esp Salud Publica. 2010 [cited 2021 May 5];84(4):441-500. Available from: https://scielo.isciii.es/pdf/resp/v84n4/breve4.pdf
https://scielo.isciii.es/pdf/resp/v84n4/... , their results may not necessarily reflect the situation of individuals belonging to each socioeconomic strata (Box 2). Other limitations concerned the use of secondary data, even if from official governmental sources, which could mask underreporting of death, and the difference in SIM coverage between the different areas studied²⁸28. Medeiros CRG, Meneghel SN, Gerhardt TE. Desigualdades na mortalidade por doenças cardiovasculares em pequenos municípios. Cienc Saude Colet. 2012;17(11):2953-62. https://doi.org/10.1590/S1413-81232012001100012
https://doi.org/10.1590/S1413-8123201200... ,³⁵35. Faria R, Santana P. Variações espaciais e desigualdades regionais no indicador de mortalidade infantil do estado de Minas Gerais, Brasil. Saude Soc. 2016;25(3):736-49. https://doi.org/10.1590/S0104-12902016147609
https://doi.org/10.1590/S0104-1290201614... . As for analytical and measurement strategies, the studies discussed limitations in the availability of mortality data in censuses³⁶36. Bonfim CV, Silva APSC, Oliveira CM, Vilela MBR, Freire NCF. Spatial analysis of inequalities in fetal and infant mortality due to avoidable causes. Rev Bras Enferm. 2020;73 Suppl 4:e20190088. https://doi.org/10.1590/0034-7167-2019-0088
https://doi.org/10.1590/0034-7167-2019-0... ,³⁷37. Machado DB, Pescarini JM, Araújo LFSC, Barreto ML. Austerity policies in Brazil may affect violence related outcomes. Cienc Saude Colet. 2019;24(12):4385-94. https://doi.org/10.1590/1413-812320182412.07422019
https://doi.org/10.1590/1413-81232018241... ,⁴¹41. Alves JD, Arroyo LH, Arcoverde MAM, Cartagena-Ramos D, Berra TZ, Alves LS, et al. Magnitud de los determinantes sociales en el riesgo de mortalidad por tuberculosis en el Centro-Oeste de Brasil. Gac Sanit. 2020;34(2):171-8. https://doi.org/10.1016/j.gaceta.2019.01.004
https://doi.org/10.1016/j.gaceta.2019.01... , the difficulty of using rate smoothing methods in smaller areas⁴⁴44. Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of delayed epidemiological cardiovascular transition. Int J Stroke 2009;4(1):40-1. https://doi.org/10.1111/j.1747-4949.2009.00240.x
https://doi.org/10.1111/j.1747-4949.2009... and more robust methods to assess the association between mortality and the composite socioeconomic measures used²³23. Antunes JLF, Borrell C, Pérez G, Boing AF, Wünsch-Filho V. Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and São Paulo, Brazil, 1995-2003. Int J Equity Health. 2008;7:14. https://doi.org/10.1186/1475-9276-7-14
https://doi.org/10.1186/1475-9276-7-14... ,³⁹39. Alarcão ACJ, Dell’ Agnolo CM, Vissoci JR, Carvalho ECA, Staton CA, Andrade L, et al. Suicide mortality among youth in southern Brazil: a spatiotemporal evaluation of socioeconomic vulnerability. Braz J Psychiatry. 2020;42(1):46-53. https://doi.org/10.1590/1516-4446-2018-0352
https://doi.org/10.1590/1516-4446-2018-0... (Box 2).

Study Limitations Noted by this Review

Some of the studies reviewed did not discuss possible study limitations, as described above²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... ,²⁵25. Teixeira MG, Meyer MA, Costa MCN, Paim JS, Silva LMV. Mortalidade por doenças infecciosas e parasitárias em Salvador - Bahia: evolução e diferenciais intra-urbanos segundo condições de vida. Rev Soc Bras Med Trop. 2002;35(5):491-7. https://doi.org/10.1590/S0037-86822002000500012
https://doi.org/10.1590/S0037-8682200200... ,³⁰30. Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):370-9. https://doi.org/10.1590/s0066-782x2008000600004
https://doi.org/10.1590/s0066-782x200800... ,³⁴34. Drachler ML, Lobato MAO, Lermen JI, Fagundes S, Ferla AA, Drachler CW, et al. Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS. Cienc Saude Colet. 2014;19(9):3849-58. https://doi.org/10.1590/1413-81232014199.12012013
https://doi.org/10.1590/1413-81232014199... ,⁴²42. Campos TP, Carvalho MS, Barcellos CC. Mortalidade infantil no Rio de Janeiro, Brasil: áreas de risco e trajetória dos pacientes até os serviços de saúde. Rev Panam Salud Publica. 2000 [cited 2021 May 5];8(3):164-71. Available from: https://www.scielosp.org/pdf/rpsp/2000.v8n3/164-171/pt
https://www.scielosp.org/pdf/rpsp/2000.v... ,⁴⁴44. Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of delayed epidemiological cardiovascular transition. Int J Stroke 2009;4(1):40-1. https://doi.org/10.1111/j.1747-4949.2009.00240.x
https://doi.org/10.1111/j.1747-4949.2009... . Other important limitations also went unaddressed, such as the presence of a garbage code – i.e., causes of deaths that should not be considered underlying causes of deaths⁴⁹49. Ministério da Saude (BR), Secretaria de Vigilância em Saúde, Departamento de Análise da Situação de Saúde. Manual para investigação do óbito com causa mal definida. Brasília, DF; 2009 [cited 2021 May 5]. (Série A. Normas e Manuais Técnicos). Available from: https://bvsms.saude.gov.br/bvs/publicacoes/manual_investigacao_obito.pdf
https://bvsms.saude.gov.br/bvs/publicaco... –, and ill-defined causes of death (IDCD), which could influence the results when correction and distribution, respectively, are not performed⁴⁹49. Ministério da Saude (BR), Secretaria de Vigilância em Saúde, Departamento de Análise da Situação de Saúde. Manual para investigação do óbito com causa mal definida. Brasília, DF; 2009 [cited 2021 May 5]. (Série A. Normas e Manuais Técnicos). Available from: https://bvsms.saude.gov.br/bvs/publicacoes/manual_investigacao_obito.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . We must also point out the lack of discussion regarding the uncertainty of mortality data in some Brazilian regions (north and northeast) and at small area levels, such as the census tract. The quality of the mortality information system also varies across these regions and could be a source of bias and therefore should be discussed. Since the composite socioeconomic measures used in mortality iniquity studies also vary, these should be addressed as the differences in definitions and concepts (i.e., deprivation, vulnerability, socioeconomic status, and poverty) could influence the interpretation of their findings.

DISCUSSION

To our knowledge, this is the first study to provide a comprehensive overview of the available literature on composite socioeconomic measures and mortality in different geographical areas of Brazil, and to identify the methodological challenges in analyzing these associations. Our main findings reveal that while some of the composite socioeconomic measures used in mortality studies covered the entire country, they were limited by the area of analysis – the municipality. Only four studies used the census tract as the small area level to assess mortality data, but their results were restricted to specific municipalities²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... . Cause-specific mortality outcomes (i.e., external causes, chronic and degenerative diseases, infectious and parasitic diseases) were the most frequent.

Most studies used descriptive and spatial analysis to estimate the relationship between socioeconomic measures and mortality outcomes, with a few articles employing regression analysis to estimate this association. None of the studies reviewed used a gradient analysis to estimate the aforementioned relationship. Some articles presented a gradient analysis according to socioeconomic status, where the lowest socioeconomic status had the highest mortality rates and the greatest increase in some mortality outcomes, or specific causes of death, as observed in other countries⁶6. Ruiz JI, Nuhu K, McDaniel JT, Popoff F, Izcovich A, Criniti JM. Inequality as a powerful predictor of infant and maternal mortality around the world. PloS One. 2015;10(10):e0140796. https://doi.org/10.1371/journal.pone.0140796
https://doi.org/10.1371/journal.pone.014... ,⁸8. McCartney G, Popham F, Katikireddi SV, Walsh D, Schofield L. How do trends in mortality inequalities by deprivation and education in Scotland and England & Wales compare? A repeat cross-sectional study. BMJ Open 2017;7(7):e017590. https://doi.org/10.1136/bmjopen-2017-017590
https://doi.org/10.1136/bmjopen-2017-017... . But we also found studies citing lower mortality rates in the lower socioeconomic strata, particularly for cancers²¹21. Peres MFT, Vicentin D, Nery MB, Lima RS, Souza ER, Cerda M, et al. Queda dos homicídios em São Paulo, Brasil: uma análise descritiva. Rev Panam Salud Publica. 2011;29(1):17-26. https://doi.org/10.1590/s1020-49892011000100003
https://doi.org/10.1590/s1020-4989201100... ,²⁷27. Ribeiro KB, Lopes LF, Camargo B. Trends in childhood leukemia mortality in Brazil and correlation with social inequalities. Cancer. 2007;10(8):1823-31. https://doi.org/10.1002/cncr.22982
https://doi.org/10.1002/cncr.22982... ,³⁷37. Machado DB, Pescarini JM, Araújo LFSC, Barreto ML. Austerity policies in Brazil may affect violence related outcomes. Cienc Saude Colet. 2019;24(12):4385-94. https://doi.org/10.1590/1413-812320182412.07422019
https://doi.org/10.1590/1413-81232018241... ,³⁸38. Schuck-Paim C, Taylor RJ, Alonso WJ, Weinberger DM, Simonsen L. Effect of pneumococcal conjugate vaccine introduction on childhood pneumonia mortality in Brazil: a retrospective observational study. Lancet Glob Health. 2019;7(2):e249-56. https://doi.org/10.1016/S2214-109X(18)30455-8
https://doi.org/10.1016/S2214-109X(18)30... .

Currently in Brazil, we have a variety of socioeconomic indices that are construed based on different socioeconomic and geographical variables, and with different concepts. Thus, none of the development or vulnerability indicators, or similar concepts are available nationally for the entire country at different geographic levels¹⁵15. Ichihara MYT, Ramos D, Rebouças P, Oliveira FJ, Ferreira AJF, Teixeira C, et al. Area deprivation measures used in Brazil: a scoping review. Rev Saude Publica. 2018;52:83. https://doi.org/10.11606/S1518-8787.2018052000933
https://doi.org/10.11606/S1518-8787.2018... . Besides, current measures address concepts other than socioeconomic conditions. Although deprivation, poverty, and vulnerability broadly refer to a person’s impoverished state compared to society as a whole, they are theoretically distinct. Vulnerability refers to the risk of experiencing a decline in well-being, or in the quality of living conditions. Similarly, material deprivation can be defined as lack of income, and other resources⁵⁰50. Dutta I, Foster J, Mishra A. On measuring vulnerability to poverty. Soc Choice Welf. 2011;37(4):743-61. https://doi.org;10.1007/s00355-011-0570-1
https://doi.org;10.1007/s00355-011-0570-... . Poverty, in turn, is measured by alternative concepts based on subsistence, basic needs, and relative deprivation⁵¹51. Townsend P. Deprivation. J Soc Policy 1987;16(2):125-46. https://doi.org/10.1017/S0047279400020341
https://doi.org/10.1017/S004727940002034... .

Socioeconomic measures are popular and widely used in studies focused on assessing health outcomes and economic and social development results¹1. Rocha SMR. Pobreza no Brasil: afinal, de que se trata? 3. ed. Rio de Janeiro: Editora FGV; 2007.. In Brazil, however, we have a lack of studies using standardized measures covering the entire country, as well as those related to all-cause mortality – since most of the studies reviewed here used cause-specific mortality. Since the distribution of all-cause and cause-specific mortality rates is a key metric for assessing population health, a better understanding of the impact of lower socioeconomic conditions on different levels and mortality trends can help policymakers plan and develop priorities for allocating health resources⁵²52. Benedetti MSG, Saraty SB, Martins AG, Miranda MJ, Abreu DMX. Evaluation study of the garbage codes research project in the northern region of Brazil. Rev Bras Epidemiol. 2019;22 Suppl 3:e19006.supl. 3. https://doi.org/10.1590/1980-549720190006.supl.3
https://doi.org/10.1590/1980-54972019000... .

In Brazil, the register of deaths is compulsory and such records are reported in national information systems, such as the Ministry of Health’s Mortality Information System (SIM) and the Civil Registry Statistics System (RC). Moreover, the last IBGE Demographic Census, carried out in 2010, gathered information on deaths for the entire population of Brazil included in it⁵³53. Lima EEC, Gonzaga MR, Freire FHMA, Queiroz BL. Alternative information sources on deaths in Brazil in the context of the COVID-19 pandemic. Ottawa (CA): Centre of Excellence for CRVS Systems; 2021 [cited 2021 May 5]. Available from: https://idl-bnc-idrc.dspacedirect.org/bitstream/handle/10625/60088/IDL%20-%2060088.pdf?sequence=2
https://idl-bnc-idrc.dspacedirect.org/bi... . Deaths in Brazil require certification by a physician, and are defined according to ICD codes⁵⁴54. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Ill-defined causes of death in Brazil: a redistribution method based on the investigation of such causes. Rev Saude Publica. 2014;48(4):671-81. https://doi.org/10.1590/S0034-8910.2014048005146
https://doi.org/10.1590/S0034-8910.20140... .

Despite great advances in recent decades in the quality of mortality information systems in Brazil, we still have significant underreporting of deaths, especially in less-developed regions of the north and northeast, added to the differences by sex, age, and area of residence⁵⁵55. Queiroz BL, Lima EEC, Freire FHMA, Gonzaga MR. Temporal and spatial trends of adult mortality in small areas of Brazil, 1980-2010. Genus. 2020;76:36. https://doi.org/10.1186/s41118-020-00105-3
https://doi.org/10.1186/s41118-020-00105... ,⁵⁶56. Queiroz BL, Gonzaga MR, Vasconcelos AMN, Lopes BT, Abreu DMX. Comparative analysis of completeness of death registration, adult mortality and life expectancy at birth in Brazil at the subnational level. Popul Health Metrics. 2020;18:11. https://doi.org/10.1186/s12963-020-00213-4
https://doi.org/10.1186/s12963-020-00213... . In small areas, the issue of significant data uncertainty regarding the number of deaths makes mortality estimates even more innacurate¹⁴14. Schmertmann CP, Gonzaga MR. Bayesian estimation of age-specific mortality and life expectancy for small areas with defective vital records. Demography. 2018;55(4):1363-88. https://doi.org/10.1007/s13524-018-0695-2
https://doi.org/10.1007/s13524-018-0695-... . Consequently, studies that use mortality indicators without correcting for underreporting may not effectively measure mortality rates in the region and instead report false and misleading associations. Similarly, the last decade saw a reduction in the percentage of garbage codes in the mortality information system, which demonstrates its improved quality⁵⁷57. Teixeira RA, Naghavi M, Guimarães MDC, Ishitani LH, França EB. Quality of cause-of-death data in Brazil: Garbage codes among registered deaths in 2000 and 2015. Rev Bras Epidemiol. 2019;22 Suppl 3:e19002.supl.3. https://doi.org/10.1590/1980-549720190002.supl.3
https://doi.org/10.1590/1980-54972019000... . Also, after inclusion of the IDCD reclassification results in the country’s official statistics published in 2010, the percentage of IDCD decreased from 8.6% to 7.0% among reported deaths. Such percentage, however, is still relatively high, presenting significant disparities between states and regions. This variation also occurs intra-regionally, with IDCD percentages close to 30.0% in some states’ macro-regions⁵⁴54. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Ill-defined causes of death in Brazil: a redistribution method based on the investigation of such causes. Rev Saude Publica. 2014;48(4):671-81. https://doi.org/10.1590/S0034-8910.2014048005146
https://doi.org/10.1590/S0034-8910.20140... . In 2015, for example, studies observed an estimated 97.2% of deaths recorded in the mortality system³¹31. Oliveira ATR, organizador. Sistemas de estatísticas vitais no Brasil: avanços, perspectivas e desafios. Rio de Janeiro: IBGE; 2018 [cited 2021 May 5]. (Estudos e análises. Informação demográfica e socioeconômica; nº 7). Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101575.pdf
https://biblioteca.ibge.gov.br/visualiza... . Despite improvements in the quality and integrity of the SIM database over time, we still find heterogeneity in the frequency and completeness of reports⁵⁷57. Teixeira RA, Naghavi M, Guimarães MDC, Ishitani LH, França EB. Quality of cause-of-death data in Brazil: Garbage codes among registered deaths in 2000 and 2015. Rev Bras Epidemiol. 2019;22 Suppl 3:e19002.supl.3. https://doi.org/10.1590/1980-549720190002.supl.3
https://doi.org/10.1590/1980-54972019000... ,⁵⁸58. Lima EEC, Queiroz BL. Evolution of the death registry system in Brazil: associations with changes in the mortality profile, under-registration of death counts, and ill-defined causes of death. Cad Saude Publica. 2014;30(8):1721-30. https://doi.org/10.1590/0102-311X00131113
https://doi.org/10.1590/0102-311X0013111... . Moreover, underestimation and mis-coding of deaths is more problematic in older adults and young children groups³¹31. Oliveira ATR, organizador. Sistemas de estatísticas vitais no Brasil: avanços, perspectivas e desafios. Rio de Janeiro: IBGE; 2018 [cited 2021 May 5]. (Estudos e análises. Informação demográfica e socioeconômica; nº 7). Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101575.pdf
https://biblioteca.ibge.gov.br/visualiza... ,⁵⁹59. Szwarcwald CL, Leal MC, Esteves-Pereira AP, Almeida WS, Frias PG, Damacena GN, et al. Avaliação das informações do Sistema de Informações sobre Nascidos Vivos (SINASC), Brasil. Cad Saude Publica. 2019;35(10):e00214918. https://doi.org/10.1590/0102-311X00214918
https://doi.org/10.1590/0102-311X0021491... .

All-cause and cause-specific mortality analyses should therefore be carried out using methods that consider correction for deaths by the remaining IDCD. Since the magnitude of these causes can be affected, this can introduce biases in comparisons between locations with different IDCD percentages, and between different socioeconomic groups. Due to issues with information quality, analyses of trends and leading causes of mortality in many low- and middle-income countries, such as Brazil, are usually restricted to areas with a higher socioeconomic status or larger cities; while places with the poorest quality of information on deaths have the heaviest disease burden. Such an issue requires further exploration in new studies to better understand the relationship between inequalities and mortality rates across the country⁵⁴54. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Ill-defined causes of death in Brazil: a redistribution method based on the investigation of such causes. Rev Saude Publica. 2014;48(4):671-81. https://doi.org/10.1590/S0034-8910.2014048005146
https://doi.org/10.1590/S0034-8910.20140... .

Death distribution reflects the countries’ socioeconomic development contexts⁶⁰60. Ezzati M, Pearson-Stuttard J, Bennett JE, Mathers CD. Acting on non-communicable diseases in low-and middle-income tropical countries. Nature. 2018;559(7715):507-16. https://doi.org/10.1038/s41586-018-0306-9
https://doi.org/10.1038/s41586-018-0306-... ,⁶¹61. Wang X, Auchincloss AH, Barber S, Mayne SL, Griswold ME, Sims M, et al. Neighborhood social environment as risk factors to health behavior among African Americans: The Jackson Heart Study. Health Place. 2017;45:199-207. https://doi.org/10.1016/j.healthplace.2017.04.002
https://doi.org/10.1016/j.healthplace.20... . Historical data from developed countries show that as their socioeconomic and health conditions improved, mortality rates tended to consistently decrease⁶⁰60. Ezzati M, Pearson-Stuttard J, Bennett JE, Mathers CD. Acting on non-communicable diseases in low-and middle-income tropical countries. Nature. 2018;559(7715):507-16. https://doi.org/10.1038/s41586-018-0306-9
https://doi.org/10.1038/s41586-018-0306-... ,⁶¹61. Wang X, Auchincloss AH, Barber S, Mayne SL, Griswold ME, Sims M, et al. Neighborhood social environment as risk factors to health behavior among African Americans: The Jackson Heart Study. Health Place. 2017;45:199-207. https://doi.org/10.1016/j.healthplace.2017.04.002
https://doi.org/10.1016/j.healthplace.20... – trend that has yet to become homogeneous for middle- and low-income countries, which possess substantial regional differences⁶⁰60. Ezzati M, Pearson-Stuttard J, Bennett JE, Mathers CD. Acting on non-communicable diseases in low-and middle-income tropical countries. Nature. 2018;559(7715):507-16. https://doi.org/10.1038/s41586-018-0306-9
https://doi.org/10.1038/s41586-018-0306-... ,⁶¹61. Wang X, Auchincloss AH, Barber S, Mayne SL, Griswold ME, Sims M, et al. Neighborhood social environment as risk factors to health behavior among African Americans: The Jackson Heart Study. Health Place. 2017;45:199-207. https://doi.org/10.1016/j.healthplace.2017.04.002
https://doi.org/10.1016/j.healthplace.20... . People of low socioeconomic status, defined by their per capita and/or household income, schooling, employment status, type of household, and internal and associated conditions, etc., are more likely to die younger than those of high socioeconomic status⁶²62. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2:19-31. https://www.jstor.org/stable/23646782
https://www.jstor.org/stable/23646782... .

Low socioeconomic status is consistently associated with an increased risk of premature and all-cause mortality. The reviewed studies show that the worst all-cause and cause-specific mortality outcomes were associated with the worst socioeconomic measures. The mechanisms by which this social status can negatively affect health are diverse and include difficulty purchasing food, inadequate housing/neighborhoods, and barriers to accessing health and social services. Other social determinants may also explain these findings, such as: alcohol and tobacco consumption; different cultural standards related to healthy and unhealthy behavior; stress and low self-esteem associated with low socioeconomic status, which can lead to harmful physiological changes; less social capital in impoverished communities; and environmental factors (i.e., high crime/violence rates, lack of public transportation, polluted roads, fast food outlets, and waste disposal sites⁴4. Bosworth B. Increasing disparities in mortality by socioeconomic status. Annu Rev Public Health. 2018;39:237-51. https://doi.org/10.1146/annurev-publhealth-040617-014615
https://doi.org/10.1146/annurev-publheal... ,⁶³63. Silva VL, Cesse EAP, Albuquerque MFPM. Social determinants of death among the elderly: a systematic literature review. Rev Bras Epidemiol. 2014;17 Supp 2:178-93. https://doi.org/10.1590/1809-4503201400060015
https://doi.org/10.1590/1809-45032014000... ,⁶⁴64. Skalická V, Ringdal K, Witvliet MI. Socioeconomic inequalities in mortality and repeated measurement of explanatory risk factors in a 25 year follow-up. PloS One. 2015;10(4):e0124690. https://doi.org/10.1371/journal.pone.0124690
https://doi.org/10.1371/journal.pone.012... ). Regarding difficulties in accessing health services, studies report issues with prenatal care and early childhood care services, control of infectious diseases, and lack of access to dental services. They also point to the existence of social selection, a form of reverse causality in which disease causes, or deepens, social inequalities⁶⁵65. Acheson D. Independent inquiry into inequalities in health report. Richmond (UK): The Stationery Office; 1998 [cited 2021 May 5]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/265503/ih.pdf
https://assets.publishing.service.gov.uk... .

Despite consistent reference to low socioeconomic status as a predictor for mortality, the aggregate scale of socioeconomic inequity on mortality in small areas in Brazil is still unclear. Existing socioeconomic measures only estimate social and economic inequalities down to the municipal level for the entire country¹²12. Instituto de Pesquisa Econômica Aplicada. Atlas da vulnerabilidade social. 2021. https://dados.gov.br/dataset/ivs (last access on 05/21/2021).
https://dados.gov.br/dataset/ivs... ,¹³13. United Nations Development Programme. Atlas of human development in Brazil. New York; UNDP; 2021 [cited 2021 May 5]. Available from: http://www.atlasbrasil.org.br/
http://www.atlasbrasil.org.br/... . And those few measures available for disaggregated levels (i.e., census sector) are usually restricted to a single municipality or state. When evaluating a municipality, a better general socioeconomic condition may thus mask smaller pockets of extreme poverty. At the census tract level, the socioeconomic deprivation measure can identify areas with higher and lower mortality risks within the same municipality. Ultimately, identifying small areas with the worst mortality outcomes can guide the reallocation of resources and implementation of public policies.

Strengths and Limitations

To our knowledge, the present study is the first to review the literature on the relationship between composite socioeconomic indicators and mortality outcomes at different geographic levels in Brazil, and to identify the methodological challenges in analyzing these associations. Since we used a standard data extraction form for each paper included in the scoping review, our data should be as robust and standardized as possible. As the evidence reviewed may have been limited by the variety of terms/concepts related to composite socioeconomic measures such as deprivation, vulnerability, poverty, and socioeconomic status, our study also has limitations. Nevertheless, we consider that our search strategy, and the databases searched, included the main scientific literature on this topic. Our scoping review did not require a full risk of bias as it was not designed to produce an estimate of the effect of inequality on mortality. Instead, we summarized the limitations discussed by each study, highlighting any possible limitation that could influence the findings and was not reported.

CONCLUSIONS

This scoping review showed that studies have found higher rates, or higher percentages of increased mortality rates, in areas considered to be more impoverished, vulnerable, or have less socioeconomic development – despite remaining methodological omissions in measuring mortality disparities at lower geographic levels. Area-based deprivation indicators can facilitate linking information for socioeconomic and health conditions in the same area. The possibility of using a concise deprivation measure available for the lowest geographic level (census tract) across the country is essential for assessing health outcomes and for implementing public policies to reduce mortality inequalities in Brazil. Area-based deprivation indicators can also contribute to monitoring progress against the Sustainable Development Goal targets for different health outcomes.

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