Evaluating selection bias in a population-based cohort study with low baseline participation: the LIFE-Adult-Study

Participation in epidemiologic studies is steadily declining, which may result in selection bias. It is therefore an ongoing challenge to clarify the determinants of participation to judge possible selection effects and to derive measures to minimise that bias. We evaluated the potential for selection bias in a recent population-based cohort study with low baseline participation and investigated reasons for nonparticipation.

LIFE-Adult is a cohort study in the general population of the city of Leipzig (Germany) designed to gain insights into the distribution and development of civilisation diseases. Nine thousand one hundred forty-five participants aged 40-79 years were randomly sampled in 2011-2014. We compared LIFE-Adult participants with both the Leipzig population and nonparticipants using official statistics and short questionnaire data. We applied descriptive statistics and logistic regression analysis to evaluate the determinants of study participation.

Thirty-one percent of the invited persons participated in the LIFE-Adult baseline examination. Study participants were less often elderly women and more often married, highly educated, employed, and current nonsmokers compared to both the Leipzig population and nonparticipants. They further reported better health than nonparticipants. The observed differences were considerable in education and health variables. They were generally stronger in men than in women. For example, in male study participants aged 50-69, the frequency of high education was 1.5 times that of the general population, and the frequency of myocardial infarction was half that of nonparticipants. Lack of time and interest, as well as health problems were the main reasons for nonparticipation.

Our investigation suggests that the low baseline participation in LIFE-Adult is associated with the typical selection of study participants with higher social status and healthier lifestyle, and additionally less disease. Notably, education and health status seem to be crucial selection factors. Consequently, frequencies of major health conditions in the general population will likely be underestimated. A differential selection related to sex might also distort effect estimates. The extent of the assessment, the interest in the research topic, and health problems of potential participants should in future be considered in LIFE-Adult and in similar studies to raise participation and to minimise selection bias.