1. It is often mentioned that racial/ethnic differences in health should not be investigated without consideration of socioeconomic position/status. Describe two ways to account for SES in an analytic model and the interpretations/implications of each approach.
Accounting for SES #1: Socioeconomic status can be measured at the individual level using information related to educational attainment, yearly or monthly income, occupation, and various ownership/wealth/assets items. Additional dimensions might include items related to food security or homeownership. The interpretation at this level is based on the reliability/validity of the measurement.
Accounting for SES #2: SES could also be assessed at the aggregate level using indicators like neighborhood, region, school, facility etc. Aggregate measures can be included in multilevel models to help test for/explain individual-level differences (i.e. an aggregate measure of SES at the school level might be helpful in explaining differences in food security at the individual level.
2. Select a research question investigating associations between multilevel social factors (operating at least two levels) and a health outcome. State the exposures and outcomes, the additional study covariates that would be included in the analytic model, and a discussion of the analytic considerations in an multilevel investigations.
How does monthly income and quality or type of hospital/clinic influence the development of ESRD?
Exposure: age, sex, race/ethnicity, language, insurance provider, ses (individual level, based on current monthly income), hospital/clinic, CHNA facility score (aggregate level score for most recent community health needs assessment)
Outcome: End stage renal disease
Analytic considerations: The model would include individual-level variables (sex, age, race/ethnicity, language, insurance provider, and ses) and institutional-level variables to test for hierarchical effects of the hospital/clinic on ESRD.
Ideally, any differences in the individual-level variables would be further explained by institution-level variables. For example, someone with a below-average individual SES might develop ESRD faster than someone with an above-average individual SES despite visiting the same hospital.