Is the link between socioeconomic status and resilience mediated by reserve-building activities: mediation analysis of web-based cross-sectional data from chronic medical illness patient panels

Abstract

Objectives: The purpose of this study is to test the hypothesis that the link between socioeconomic status (SES) and resilience is mediated by reserve-building activities.

Design: Cross-sectional observational study. Structural equation modelling (SEM) was used to test the mediation hypothesis.

Setting: Web-based survey.

Participants: Participants with a chronic medical condition were recruited from Rare Patient Voice.

Primary and secondary outcome measures: DeltaQuest Reserve-Building Measure; demographic variables to capture SES; Centers for Disease Control Healthy Days Core Module; Self-Administered Comorbidity Questionnaire. Resilience was operationalised using residual modelling.

Results: The study sample included 442 patients (mean age 49, 85% female). SES was modelled as a bifactor model composed of general SES and specific factors for personal finance and parent's education. A series of simple mediation models predicting resilience led to the selection of three reserve-building activities for subsequent SEM-based mediation models: Active in the World, Outdoor and Exercise. The full SEM model supported the hypothesis that the relationships from both general SES and personal finance to resilience were mediated by engaging in the three reserve-building activities. In addition, the number of comorbidities partially mediated the relationship between personal finance and reserve-building. Those with more comorbidities generally had lower levels of resilience.

Conclusions: This study provides suggestive evidence that reserve-building activities may be one pathway by which SES is associated with resilience: people of higher SES are more likely to engage in reserve-building activities that are intellectually stimulating, involve Outdoor pursuits and include physical Exercise. These reserve-building activities are not costly to pursue. These findings may empower patients to introduce more such reserve-building activities into their lives.

Keywords: chronic illness; cognitive reserve; resilience; social determinants of health; socioeconomic status.

Figure 1

Theoretical model being tested. It was hypothesised that reserve-building activities would mediate the relationship between SES and resilience. Thus, the direct effect from SES to resilience would be partially or fully attenuated through both variables’ relationship with reserve-building (the mediator). SES, socioeconomic status.

Figure 2

The full mediation model. Reserve-building activities mediate the relationships between resilience and both socioeconomic status (SES) and personal finance. The relevant reserve-building activities are Active in the World, Outdoor, and Exercise. The personal finance to resilience path is also mediated by the participant’s number of comorbid conditions. As indicated in table 4, there are significant total indirect effects from both general SES (b=0.06, p<0.01) and personal finance (b=0.13, p<0.01) to resilience. This model supports the hypothesis that the relationship between general SES and resilience is mediated by engaging in the three reserve-building activities. Bold values indicate significant paths (p<0.05).

Figure 3

A–C The relationship between reserve-building and resilience. Correlation coefficients between the reserve-building activity and resilience are displayed as bar charts, with the left axis showing units. The mean values by socioeconomic status (SES) tertile are displayed as line graphs, with the right axis showing units. The relationship between Active in the World and resilience is similar across SES groups, but the mean level of these activities varied by SES group (figure 3A). For Outdoor activities, the associations with resilience and the group means were not different from each other (figure 3B). For Exercise, however, the medium and high-SES groups showed a statistically significant difference in associations with resilience, and the group means were not different from each other (figure 3C).