1. What are 3 different ways to account for SES in analytic models when investigating racial/ethnic health disparities? Briefly discuss the interpretations/implications of each approach as it relates to understanding health disparities by race/ethnicity.
- SES as a mediator: SES as a variable controlling the relationship between the independent and dependent variables (indirect pathway); this implies that the effect of race/ethnicity on health outcomes is partially (or totally) explained by SES. Race/ethnicity determines SES, which in turn determines health outcomes.
- SES as an effect modifier: SES determines the magnitude of the relationship between race/ethnicity and health outcomes; race/ethnicity effects on health are either magnified or diminished by differences in SES (which are in part determined by race/ethnicity). In this situation, it would be important to include SES in any model as a covariate.
- SES as a contextual variable: collective or group SES may have an effect on the individual-level association between race/ethnicity and health disparities. Contexts like neighborhood and community behavior may impact health behaviors and outcomes.
2. Describe a potential effect modifier, mediator, or contextual variable (for definition of contextual variable, see Diez-Roux reading) for an association of interest to you and relevant to health disparities. For example, for investigating the association between education and hypertension, I might be interested in evaluating whether the association between years of education and hypertension is different for Black men than for White men. Describe how you would study whether this relationship exists.
I am interested in the relationship between diabetes and cognitive aging; I think it would be interesting to look at household income (as a surrogate for SES) as an effect modifier, as this often correlates with health literacy and access to quality preventative care. Using large cohort data (such as Study of Osteoporotic Fractures), I could include categories of household income as a fixed effect in a mixed effects model and display the coefficients for each category of household income.