Abstract
Health surveys are an important resource for monitoring population health, but selective nonresponse may impede valid inference. This study aimed to assess nonresponse bias in a population-sampled health survey in Scotland, with a focus on alcohol-related outcomes. Nonresponse bias was assessed by examining whether rates of alcohol-related harm (i.e., hospitalization or death) and all-cause mortality among respondents to the Scottish Health Surveys (from 1995 to 2010) were equivalent to those in the general population, and whether the extent of any bias varied according to sociodemographic attributes or over time. Data from consenting respondents (aged 20–64 years) to 6 Scottish Health Surveys were confidentially linked to death and hospitalization records and compared with general population counterparts. Directly age-standardized incidence rates of alcohol-related harm and all-cause mortality were lower among Scottish Health Survey respondents compared with the general population. For all years combined, the survey-to-population rate ratios were 0.69 (95% confidence interval: 0.61, 0.76) for the incidence of alcohol-related harm and 0.89 (95% confidence interval: 0.83, 0.96) for all-cause mortality. Bias was more pronounced among persons residing in more deprived areas; limited evidence was found for regional or temporal variation. This suggests that corresponding underestimation of population rates of alcohol consumption is likely to be socially patterned.
Highlights
Nonresponse bias was assessed by examining whether rates of alcohol-related harm and all-cause mortality among respondents to the Scottish Health Surveys were equivalent to those in the general population, and whether the extent of any bias varied according to sociodemographic attributes or over time
Over all time periods combined, the survey-to-population rate ratios for the incidence of alcohol-related harm were 0.65 (95% confidence interval (CI): 0.56, 0.73) among men and 0.76 among women
When combining data across all survey years, we found that greater nonresponse bias was associated with increased deprivation for both the incidence of alcohol-related harm (RR = 0.92, 95% CI: 0.86, 0.99) and all-cause mortality (RR = 0.96, 95% CI: 0.92, 1.01)
Summary
The validity of survey estimates of alcohol consumption attracts particular scrutiny, because hazardous and harmful drinkers may be difficult to contact and locate They may be more likely to reside outside the typical survey sampling frame, and those who refuse to participate may have different consumption patterns again. Nonresponse generally does not distort comparisons between subgroups of participants, for example, in survey estimates of socioeconomic health disparities [7, 12, 14] This is not always the case [13, 15], and little is known about the potential impact on estimates of social patterning of alcohol-related outcomes in particular. Understanding trends over time can be important if varying response levels are associated with changing nonresponse bias
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