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The Health Status of Nonparticipants in a Population-based Health Study: The Hordaland Health Study
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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“non-participants of health surveys generally have worse health than participants,29”
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“It should be also mentioned that people with mental disorders could be less likely to participate in cross-sectional population surveys and therefore our results may be under-estimates of true population prevalence (Arias-de la Torre et al., 2020; Knudsen et al., 2010).”
From Prevalence and age patterns of depression in the United Kingdom. A population-based study (2021) · cites this paper as Knudsen et al., 2010
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“Previous studies have shown that alcohol use and mental distress are moderately associated with non-response [17], though probably not a major cause, as controlling for other variables weakened the associations [18].”
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“As a result, only a small percentage of self-selected individuals take full advantage of health promotion opportunities (9,10).”
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“Respondents to population surveys are more likely to be older, female, better educated, healthier and less socially disadvantaged than non-respondents (Knudsen et al., 2010; Galea and Tracy, 2007).”
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“(1) and provide more specific insights into the potential biases that can occur from differences in socioeconomic position and the health status of participants and nonparticipants in epidemiologic surveys.”
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Metadata
- Authors
- Knudsen, A. K., Hotopf, M., Skogen, J. C., Overland, S., & Mykletun, A.
- Affiliations
- University of Bergen (NO)
- Corresponding author
- Knudsen, A. K.
- 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
- 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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