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.
1. SES is a confounder in the association between exercise and risk of heart disease. Patients with disadvantaged SES may not be able to exercise even they want to because of for example lack of access to exercise facilities or unsafe neighborhoods. On the other hand, low SES can be an independent contributor to heart disease through other pathways such as poor diet or higher prevalence of smoking. Implication of this approach is that public heath officials need to find ways to provide better exercise facilities and opportunities to people with lower SES to improve disparities in cardiovascular disease.
2. SES is an effect modifier in the effect of patient education on cardiovascular disease awareness. Patients with higher SES may benefit more from educational programs that require high level of health literacy and patients with low SES background may need dedicated educational programs targeted to their level of health literacy.
3. SES is a mediator in the association between race and referral to kidney transplant in end stage kidney disease patients. End-stage kidney disease patients who are Black or Latino are less likely to be referred for transplant due to issues related to SES including lower social support and economic disadvantages. There are some transplant centers that are addressing this issue directly by establishing programs dedicated to black and Latino patients, helping them navigate the transplant candidacy.
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’m studying the association between cardiovascular disease knowledge and implementation of cardiovascular protective behaviors at home such as home blood pressure monitoring and I’m interested to know if this association is different between different races. I would include race as a covariate in the regression model I will use to evaluate this association.