Cited by 324Survey Methodology and NonresponseStatistical Methods in EpidemiologyHealth disparities and outcomes

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The Health Status of Nonparticipants in a Population-based Health Study: The Hordaland Health Study

Knudsen, A. K., Hotopf, M., Skogen, J. C., Overland, S., Mykletun, A.·2010·American Journal of Epidemiology

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Abstract

The authors aimed to examine whether nonparticipation in a population-based health study was associated with poorer health status; to determine whether specific health problems were overrepresented among nonparticipants; and to explore potential consequences of participation bias on associations between exposures and outcomes. They used data from the Hordaland Health Study (HUSK), conducted in western Norway in 1997-1999. Of 29,400 persons invited, 63.1% participated in the study. Information from HUSK was linked with the Norwegian national registry of disability pensions (DPs), including information about DP diagnosis. The risk of DP receipt was almost twice as high among nonparticipants as participants (relative risk = 1.88, 95% confidence interval: 1.81, 1.95). The association was strongest for DPs received for mental disorders, with a 3-fold increased risk for nonparticipation. Substance abuse, psychotic disorders, and personality disorders were especially overrepresented among nonparticipants. The authors simulated the impact of nonparticipation on associations between exposures and outcomes by excluding HUSK participants with higher symptoms of common mental disorders (exposure) and examining the impact on DP (outcome). This selective exclusion modestly reduced associations between common mental disorders and DP. The authors conclude that nonparticipants have poorer health, but this is disorder-dependent. Participation bias is probably a greater threat to the validity of prevalence studies than to studies of associations between exposures and outcomes.

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“[14] knudsen Ak, Hotopf M, Skogen JC, et al.”
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Clarsen, B. M., Skogen, J. C., Nilsen, T. S., & Aarø, L. E. (2021) · BMC Public Health · doi:10.1186/s12889-021-10764-2 · Cited by 21
“lyses of associations between variables will likely be incorrect [9].”
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“36 This evidence and previous work on health surveys with selection bias because of nonresponse 37,38 suggest that the current conclusion is less likely to be biased by a low response rate.”
Physical health-related quality of life predicts disability pension due to musculoskeletal disorders: seven years follow-up of the Hordaland Health Study Cohort
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“However, bias due to non-participation is probably of less concern in prospective studies [38,39],”
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“10 Existing evidence further suggests health selection whereby participants have better general 6 8 11 12 and mental health, 13 are less likely to be on 6 – 8 or at risk for disability pension award, 11 and also have a higher life expectancy 14 than non-participants.”
Background
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“Individuals with mental health problems likewise tend to be underrepresented in health surveys (Knudsen et al., 2010; Mykletun et al., 2007), and individuals exposed to severe violence might be underrepresented due to exclusion of institutionalized and hospitalized individuals in the Health and…”
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“On the one hand, nonparticipants of health surveys usually have poorer general health than participants (Knudsen et al. 2010).”
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“We acknowledge it is possible that people with greater stress may have chosen not to respond to the surveys [56, 57].”
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“Indeed, the response rate for Australian medical students in the National Mental Health Survey of Doctors and Medical Students(6) was very low at 27%; this is unlikely to be fully representative of the medical student population, thus compromising valid estimates of disorder prevalence.(16) The extent to which mental…”
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“In general, non- responders are often found to be of poorer health, but whether or not non- response leads to biased results varies by type of health outcome studied (Knudsen et al., 2010; Langhammer et al., 2012; Vercambre & Gilbert, 2012).”
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“It was also demonstrated that non-participants of health surveys generally have worse health than participants [44].”
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“In general, individuals that participate in studies are healthier than nonparticipants (Knudsen et al. 2010), and we therefore expect our study population to contain healthier individuals than the student population as such.”
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“Further, our results might give an underestimation of symptoms, since non participants of health surveys tend to have worse health than participants [25].”
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“In general, even highly selective non-participation are not usually expected to influence associations between variables dramatically [44], giving reason to believe that our estimates have not been severely affected by nonparticipation.”
Background
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“This was also the case in HUSK, a comparable study, but with a more limited age-range [39].”
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Self-citation

Authors: Knudsen, A. K., Hotopf, M., Skogen, J. C., Overland, S., & Mykletun, A.
Affiliations: University of Bergen (NO)
Corresponding author: Knudsen, A. K.
ORCID: Knudsen, A. K.
Hotopf, M.
Skogen, J. C.
Mykletun, A.
Venue: American Journal of Epidemiology
Publisher: Oxford University Press (OUP)
Published: 2010-09-15
Volume: 172
Issue: 11
Pages: 1306-1314
ISSN: 0002-9262 (ISSN-L)
1476-6256
DOI: 10.1093/aje/kwq257
OpenAlex: W2163894459
Cited by: 322
References: 40
Citations by year: 2026: 6 · 2025: 19 · 2024: 13 · 2023: 19 · 2022: 26 · 2021: 23 · 2020: 21 · 2019: 24 · 2018: 11 · 2017: 15 · 2016: 20 · 2015: 26 · 2014: 28 · 2013: 29 · 2012: 27
FWCI: 73.33
Type: journal article
Language: en
Open access: closed
Locations: American Journal of Epidemiology (publishedVersion)
PubMed (publishedVersion)
Research Portal (King's College London) (submittedVersion)
HighWire Press Open Archive (submittedVersion)
Funders: National Institute for Health and Care Research (NF-SI-0507-10088)
Topics: Social Sciences › Sociology and Political Science › Survey Methodology and Nonresponse
Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
Social Sciences › Health › Health disparities and outcomes
Keywords: non-participation, participation bias, Hordaland Health Study, disability pension, common mental disorders, substance abuse, psychosis, personality disorders, health status, prevalence studies, exposure-outcome association, research validity
MeSH terms: Adult, Mental Disorders, Community Participation, Diagnosis-Related Groups, Female, Health Status, Health Status Indicators, Humans, Male, Middle Aged, Musculoskeletal Diseases, Norway, Population Surveillance, Surveys and Questionnaires, Selection Bias, Prevalence, Sex Distribution, Insurance, Disability

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The Health Status of Nonparticipants in a Population-based Health Study: The Hordaland Health Study

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