Faraz Vahid Shahidi, Abtin Parnia, Arjumand Siddiqi

Recent epidemiologic findings suggest that socioeconomic inequalities in health may be widening over time. We examined trends in socioeconomic inequalities in premature and avoidable mortality in Canada. We conducted a population-based repeated cohort study using the 1991, 1996, 2001, 2006 and 2011 Canadian Census Health and Environment Cohorts. We linked individual-level Census records for adults aged 25-74 years to register-based mortality data. We defined premature mortality as death before age 75 years. For each census cohort, we estimated age-standardized rates, risk differences and risk ratios for premature and avoidable mortality by level of household income and education. We identified 16 284 045 Census records. Between 1991 and 2016, premature mortality rates declined in all socioeconomic groups except for women without a high school diploma. Absolute income-related inequalities narrowed among men (from 2478 to 1915 deaths per 100 000) and widened among women (from 1008 to 1085 deaths per 100 000). Absolute education-related inequalities widened among men and women. Relative socioeconomic inequalities in premature mortality widened progressively over the study period. For example, the relative risk of premature mortality associated with the lowest income quintile increased from 2.10 (95% confidence interval [CI] 2.02-2.17) to 2.79 (95% CI 2.66-2.91) among men and from 1.72 (95% CI 1.63- 1.81) to 2.50 (95% CI 2.36-2.64) among women. Similar overall trends were observed for avoidable mortality. Socioeconomically disadvantaged groups have not benefited equally from recent declines in premature and avoidable mortality in Canada. Efforts to reduce socioeconomic inequalities and associated patterns of disadvantage are necessary to prevent this pattern of widening health inequalities from persisting or worsening over time.