BACKGROUND: Wide social and geographical disparities are reported in France for morbidity and mortalityindicators. Less is known regarding the spatial distribution in general population of self-rated health (SRH) andhealth-related quality of life (HRQoL). Improving the knowledge of the contextual determinants of HRQoLwould help towards a better understanding of their meaning and interest in general population when it comes tocompare with classical objective indicators.OBJECTIVES: The objectives were [1] to assess existing spatial disparities of HRQoL in French generalpopulation and to investigate their evolution in time, [2] to determine individual and contextual determinants ofHRQoL and [3] to explore the ecological associations between HRQoL and subsequent mortality five years later.METHODS: Data were drawn from two large representative cross sectional surveys: the Insee Decennial HealthSurvey led in 2003 (N=22 743 [study 1 and 3] ; N= 16 732 [2]) and the Sofres health survey led in 1995(N=3243 [1]).The MOS SF-36 questionnaire was used in both surveys. [1] Fixed effects linear models combinedwith interaction tests were used for assessing time trends. [2] Mixed effects linear models were used for themultilevel analysis, exploring a causal pathway including individual and macrolevel factors (household, urbanunit and region) assessing demographics, socioeconomics, and features related to the notion of areaattractiveness (deindustrialization, net migration rates). [3] Mortality data were drawn from the French nationalstatistics of mortality (CepiDc-Inserm). Negative binomial regression models were performed to identifyecological associations at the region level between HRQoL recorded in 2003 and subsequent mortality (shortterm [2003-2005]; 5-years later [2007-2009]), stratifying on age, gender and specific causes of death.MAIN RESULTS: [1] A significant decrease in HRQoL was observed between 1995 and 2003, affecting allsociodemographic categories and suggesting likely widening disparities in the most fragile categories. [2]Regional HRQoL disparities were found, persisting after adjusting on socioeconomic individual characteristics.Multilevel analysis showed some evidence for mediation involving contextual factors like deindustrialization,net migration rates, voter abstention rate and health-related behaviors. Cross-level interactions were found aswell. [3] Significant ecological associations were identified at the region level between HRQoL and mortalityfive years later, persisting after adjusting on deprivation. Specific relationships were observed after stratifying onage, gender, specific causes of death; the predictive ability of HRQoL for mortality was varying depending onthe mortality period considered for analysis.CONCLUSIONS: Our results highlight the interest in assessing HRQoL at the population level and in exploringthe contextual determinants at play. Systematic inclusion of validated and multidimensional HRQoLquestionnaires should be supported in national surveys, so as to improve our knowledge of long term temporaltrends in HRQoL, to promote an increased use of contextual multilevel analyses using such data, and eventuallyto help better identifying sub-groups at risk and optimizing public health interventions.
