Evaluation of selection bias in a cross-sectional survey

Selection bias is inherent in all occupational cohorts. Selection bias at entry has long been known and is commonly referred to as a "healthy worker effect." Less well appreciated is selection during the life of a cohort resulting from life-style factors (e.g., cigarette smoking); aging with accompanying chronic diseases, economic and demographic circumstances; and diseases that might result from exposures suffered by the cohort being studied, that influence whether individuals remain in a trade. These factors weigh differently at different times. Thus, at any point in time, "surviving" members of a cohort reflect an amalgam of selection factors. When such groups are studied in cross-sectional surveys there can be uncertainty whether clinical, radiological and physiological findings are necessarily representative for the trade or occupation as a whole. We analyzed the results of a large clinical field survey of long-term asbestos insulation workers to investigate whether the non-participants differed substantially from those who were examined. Five thousand three hundred and fifty-five (5,355) men, of an initial cohort of 17,800 established January 1, 1967, had reached 30 or more years from onset of their work by July 1, 1981. All were invited to come for examination. Two thousand and seventy-seven (2,077) came, and 3,278 did not. We questioned a sample of 1,393 non-responders to see why they failed to appear. The answers did not give evidence of significant health-related selection influence. Sickness only infrequently kept them away. We then followed both groups--those examined and those not examined--to the end of 1987 for their mortality experience. There was no great difference. The non-responders had somewhat fewer deaths overall and proportionately fewer of asbestos-associated cancers, such as mesothelioma and lung cancer. The results indicated that, in this cohort, there did not seem to be health-related selection bias that determined whether or not cohort members responded to invitations for examinations.