Mortality gradient by education: differences between natives and immigrants in Italian Census cohort

BACKGROUND: A socioeconomic mortality gradient, favourable to the most advantaged social groups, has been documented in both high migratory pressure (HMPCs) and highly developed Countries, including Italy. However, little is known on how this association differs between natives and immigrants. This study aimed at comparing the mortality gradient by education among these population groups, evaluating differences for macro-area of origin or citizenship. METHODS: Using a longitudinal design, the 2011 Census population was followed up to 2019. All-cause mortality was retrieved by record linkage with the Causes of Death register. The association of education (as the main exposure) and social class (based on the Erikson and Goldthorpe classification) with mortality was evaluated in subject aged 30-64, separately by sex, citizenship/macro-area of origin. Mortality rate ratios (MRR) and 95% confidence intervals were estimated using negative binomial regression models, adjusted for age and area of residence. RESULTS: 23,572,516 subjects (7% immigrants from HMPCs) and 410,746 deaths (3% from HMPCs) were analysed. Among natives, a mortality gradient by education was observed (low/high MRR: 2.37[2.16-2.60] males; 1.79[1.64-1.96] females), whereas a weaker association without trend was found for HMPCs immigrants (MRR: 1.12 [1.00-1.25] males; 1.12[1.00-1.26] females). A higher mortality for less educated was observed for males from Romania, India, China, and for females from Central-Eastern Europe, Sub-Saharan Africa and Central and South America. A lower mortality was found for the least educated from Morocco. CONCLUSIONS: The higher mortality among less educated subjects is confirmed among natives, while it is less evident in immigrants from HMPCs. However, differences observed between citizenships, macro-areas of origin, and sex, highlight the need for social policies accounting for specific risk factors and cultural specificities affecting correct lifestyles and health services access. KEY MESSAGES: • A mortality gradient by education was found among natives in Italy, whereas a weaker association without trend was observed for immigrants from high migratory pressure Countries. • The differences observed between citizenships or macro-areas of origin, and sex, highlight the need for social and health policies culturally oriented to specific target population.