1. Give an example of a research question for investigating racial/ethnic health disparities where: [1] SES is a confounder [2] SES is an effect modifier [3] SES is a mediator. Briefly discuss the interpretations/implications of each approach as it relates to understanding health disparities by race/ethnicity.
As I considered the many and intricate roles that SES plays in the association between race/ethnicity and health disparities, I struggled to understand how we can neatly define its role as an effect modifier, a mediator, or a confounder with certainty, or at least with confidence. This is why Hunter’s response resonated with me. SES is an abstract construct in the sense that it is not a single entity that can be easily measured and quantified, with clear and consistent implications or effects.
For example, if we take the classic and well evidenced example of the association between race/ethnicity and pain management:
1- SES is clearly is associated with race/ethnicity, and we can reasonably consider that SES is associated with pain management (ie one’s income might influence how a provider views them as a patient, which might affect their willingness to provide pain management) -> SES would be a confounder
2- Race/ethnicity will very strongly influence an individual’s SES, which could then affect pain management as described above -> SES would be a mediator
3- SES will interact with race (ie SES and race/ethnicity will not simply have additive effects) in the way a provider views a patient and thus their judgment of the patient’s pain and willingness to provide pain management -> SES would be an effect modifier
To further complicate matters, SES is a multidimensional and complex construct. Researcher may use different markers, or even combinations of markers, to represent it, such as income, wealth, education, occupation, poverty level, neighborhood SES characteristics, past SES experiences, and subjective social status. The components selected to represent SES will affect the way ‘SES’ will be viewed in the health disparity that is being studied since not only are some of these components extremely difficult to measure, but they may contribute to and play a role in the relevant study to varying extents.
Finally even timing of exposure to race/ethnicity could alter the influence of SES, ie SES will likely play a different role in the association between race/ethnicity and mental health disparities for an adolescent vs someone in the later stages of life.
The key to finding solutions to, or ways to alleviate or combat heath disparities is to understand the mechanisms of SES in health disparities. For all of the reasons stated above, among others, this becomes crucial yet extremely complex task. As much as there are efforts to tease out the role of SES in health disparities by race/ethnicity, it is also just as useful to understand that these may not always be disentangled.
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.
As my research focuses on the association between atopic dermatitis and depression in pediatric populations, we could consider several effect modifiers, including access to pediatric primary care or dermatological services. If a child suffers from atopic dermatitis, symptoms including pruritus, visible lesions, and poor sleep can cause distress and greatly impair quality of life. However the role of access to healthcare should not be undermined. Although it will likely result in greater quality of life and lower risk for depression for all pediatric patients, for patients with atopic dermatitis, treatment of this condition may result in higher improvement in quality of life compared to the general pediatric population. Access to health care can be studied using distance from healthcare center/pediatric medical providers and/or insurance as a marker.
3. Respond to one other person's post on the forum with a comment or suggestion.
See Hunter Holt’s post.