Methodologic and Logistic Issues in Conducting Longitudinal Birth Cohort Studies: Lessons Learned from the Centers for Children's Environmental Health and Disease Prevention Research

Eskenazi, Brenda, Gladstone, Eleanor A., Berkowitz, Gertrud S., Drew, Christina H., Faustman, Elaine M., Holland, Nina T., Lanphear, Bruce, Meisel, Stefanie J., Perera, Frederica P., Rauh, Virginia A., Sweeney, Anne, Whyatt, Robin M., Yolton, Kimberly, Environmental Health Perspectives

In anticipation of the National Children's Study, lessons can be learned from the smaller birth cohort studies conducted by five Centers for Children's Environmental Health and Disease Prevention Research funded by the National Institute of Environmental Health Sciences and the U.S. Environmental Protection Agency. The populations studied are diverse in ethnicity and social class and reside in urban and rural environments. Although almost all of the centers chose to enroll participants through medical care facilities, they had to develop independent staffs and structures because of the overburdened medical care system. Some of the lessons learned by the centers include the importance of continuous funding, building community partnerships to conduct culturally appropriate research, hiring bilingual and bicultural staff from the community, prioritizing research goals, developing biorepositories to ensure future utility of samples, instituting quality control procedures for all aspects of specimen and data collection, maintaining frequent contact with study participants, ensuring ethical conduct of the research in a changing medical-legal climate, and communicating results in a timely and appropriate manner to participants and the wider community. All centers underestimated the necessary start-up time, staff, and costs in conducting these birth cohort studies. Despite the logistical complexity and added expenses, all centers emphasize the importance of studying the impact of environmental exposures on those children most at risk, those living in minority and low-income communities. These centers present barriers encountered, solutions found, and considerations for future research, with the hope that the lessons learned can help inform the planning and conduct of the National Children's Study. Key words: biologic samples, biorepository, birth cohort, children, environmental health, ethics, growth, National Children's Study, neurodevelopment, pregnancy. Environ Health Perspect 113:1419-1429 (2005). doi: 10.1289/ehp.7670 available via http://dx.doi.org/[Online 24 June 2005]

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Longitudinal birth cohort studies provide a rich source of information about antecedents of disease that originate in pregnancy or childhood. There have been two previous major longitudinal birth cohort studies in the United States: the Child Health and Development Studies (van den Berg et al. 1988) and the National Collaborative Perinatal Project (Niswander and Gordon 1972). Since these studies were conducted, > 40 years ago, science and research infrastructures have changed dramatically in the United States. These changes include but are not limited to advances in biomarkers and molecular and cellular biology, the use of computers in tracking and statistics, the increased difficulty of integrating research into routine clinical practice, the diversity and health disparity of the population, and growing complexities of medical-legal-ethical issues. The standards for quality research have risen considerably and with them the logistical complexities in conducting such research.

The purpose of this article is to outline the methods used by the five Centers for Children's Environmental Health and Disease Prevention Research (Children's Centers) that are conducting birth cohort studies. Three centers (University of California, Berkeley, Columbia University, and Mount Sinai School of Medicine) began their studies in 1998, and two centers (University of Cincinnati and University of Illinois) in 2000. All but two centers (Columbia and Mount Sinai), which had prior funding, started enrollment approximately 1 year after funding. Table 1 provides an overview of the five centers (also see Kimmel et al. 2005), each of which recruited racially/ethnically diverse and often low-income populations (Appalachian, Dominican, Hmong, Laotian, Mexican, African American, and Puerto Rican). Our centers worked closely with our respective communities to develop partnerships, strengthen community infrastructure, build trust, and conduct culturally appropriate research (Israel et al. 2005). We present here some of the barriers we faced and our solutions, with the hope that the lessons learned from our experience will assist in the planning and conduct of the National Children's Study (2005).

Recruitment and Enrollment

Table 2 shows the eligibility criteria and recruitment strategies for each of the studies. Four centers recruited pregnant women. Three centers enrolled women before their third trimester of pregnancy; one center (Columbia) enrolled women throughout pregnancy, and another (Illinois) recruited couples before and during pregnancy.

The center at Illinois attempted to screen all Hmong and Laotian families in the study catchment area for eligibility, using telephone directories as suggested by community leaders. Study workers contacted all people with Hmong or Laotian surnames listed in the directory to describe the study and determine eligibility. Home visits were scheduled with eligible, willing families and were repeated every 2 months. Pregnancy tests were performed at each visit, and couples were enrolled in the cohort study when the women became pregnant.

The other four centers recruited through multiple hospital or clinic sites. They attempted to recruit as many consecutive, eligible patients as possible. The center at Berkeley used clinic staff to screen women for eligibility; eligible women were shown a video about the study and, if interested, were referred to a study worker. Berkeley also enrolled fathers, with only half participating. The center at Cincinnati, with a Health Insurance Portability and Accountability Act (HIPAA 1996) waiver, received weekly information about new patients directly from the clinics. Eligible patients were sent a letter describing the study and a mail-in postcard to decline further contact; those who did not return the postcard were contacted by phone to set up an appointment. The study staff at Columbia recruited participants by approaching women in clinic waiting areas, and the Mount Sinai staff recruited women from a prenatal clinic and two private practices.

Eligibility and exclusion criteria varied. The study populations differed considerably with respect to race/ethnicity, socioeconomic status, and geographic setting (urban vs. rural). Only one center specifically recruited primiparas; the same center was unique in its enrollment of mothers < 18 years of age. Although enrolling minors was not a problem for this center, other centers chose not to include minors because of additional institutional review board (IRB) requirements. Three centers excluded infants from continued follow-up if prenatal specimens or data were not collected. One of these centers also excluded infants if they were high risk (< 32 weeks gestation, < 1,500 g, or having congenital malformations). Some centers determined eligibility by race (e.g., African American) or country of birth (e.g., Dominican), whereas others determined eligibility by language (e.g., Spanish or English speaking). A number of the centers required some stability in residence or in medical care (e.g., planning to deliver at the hospital where the study was based) to be eligible. One center required that the women had lived in the study area for at least a year before pregnancy and planned to remain for at least a year afterward.

Overcoming barriers to recruitment and enrollment. Participation rates for the studies ranged from 25 to 64%. All centers gathered demographic information on all eligible women, permitting later comparison of participants with eligible nonparticipants.

The most important barriers to participation, especially for working women, were the time required for each visit and the length of the follow-up period. Centers that recruited patients from clinic waiting areas found that even short waiting periods, especially in private practice offices, were a barrier. The one center using clinic staff for recruitment found that they were already overburdened and had little time for recruitment. Some centers also found that women were reluctant to enroll without their husband's approval.

Many of the populations of interest in children's environmental health studies are economically disadvantaged, undereducated, non-English-speaking, and distrustful of Western medicine and research. Many centers found that hiring study staff familiar with or from the target population was necessary for successful recruitment. Recruitment by or at clinics known by the community to respect patient confidentiality was particularly successful. In addition, response rates were improved by allowing potential participants time to discuss the study with their families before enrollment.

Assessment Methods

The centers have used a variety of tools to gather information about their cohort study participants (Table 3). At multiple time points during and after pregnancy, mothers completed questionnaires that focused on demographics, medical history, and exposure information (Appendix 1). Illinois included prepregnancy baseline questionnaires and menstrual cycle tracking. Several centers also completed multiple home visits over the course of the study. Questionnaires and home visits were completed in intervals ranging from every 3 months to annually; home visits were usually conducted at the same time points as questionnaires. In addition, all centers conducted neurodevelopmental and growth assessments, and most collected information on medical conditions such as asthma.

Growth, Development, and Other Health Outcomes

Most centers conducted neurodevelopmental assessments and growth assessment at numerous age points after birth (Dietrich et al. 2005). Various standardized neurodevelopmental assessment tools were used to assess the neonate, infant, and child. Two centers plan to collect school-based evaluations such as report cards and teacher ratings of classroom behavior. All centers used standardized anthropometric measurement protocols to measure height, weight, and head circumference at each contact point, some taking multiple measurements to reduce measurement error. Most centers used questionnaires and medical record review to obtain prenatal and child health information for respiratory disease (Eggleston et al. 2005) and other outcomes. Medical records were either abstracted for complete information or to confirm reported conditions. One center received all prenatal and delivery information on computer-ready forms from the participating hospital.

Social Environment

As prescribed by the centers' Request for Application, many of the participants in these studies were from marginalized, low-income communities. Hence, most centers assessed aspects of the children's social environment (Appendix 1) expected to affect their health and development. These measurements were obtained from observation, face-to-face interviews, and/or direct child assessment. All centers gathered information about the home environment and household composition, including presence of the father. Almost all centers used the Home Observation for the Measurement of the Environment scale (Caldwell and Bradley 1984). Others included measures of maternal depression, social support, parenting and marital stress, and use of childcare services. Centers that included immigrant populations obtained information on immigration history, and acculturation. Socioeconomic status was ascertained by all centers; besides measuring total income and income per person supported, a few centers determined overall material hardship, food security, and use of social services.

Physical Environment

All centers assessed housing quality via questionnaire. In addition, three centers conducted home visits (see Table 3). Two centers used Global Positioning System (GPS) devices to determine the proximity of the home to services, pesticide applications, and high-crime or traffic areas (Gilliland et al. 2005). To assess the condition of the housing stock, centers either modified a measure developed by the U.S. Department of Housing and Urban Development (Jacobs et al. 2002) or developed their own instruments, which included visual assessments for molds/mildew, deteriorated paint, safety hazards, leaks, roach/rodent infestations, and other factors (Appendix 2). Because there are few validated tools to assess exposure to indoor pollutants, creating these materials was challenging. Home inspections themselves were time-consuming and required extensive training, in some cases provided by county housing inspectors. Several centers opted to visit homes multiple times to reassess household exposures, which may vary by season (Yiin et 'al. 2000) or change when Families relocate.

During the home inspections, centers collected ambient measurements and samples, including wall moisture levels, mattress and floor dust samples, and air samples (Table 4).

Collecting environmental measurements often required the purchase of expensive, specialized collection equipment (e.g., air monitors) and a …

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Publication information: Article title: Methodologic and Logistic Issues in Conducting Longitudinal Birth Cohort Studies: Lessons Learned from the Centers for Children's Environmental Health and Disease Prevention Research. Contributors: Eskenazi, Brenda - Author, Gladstone, Eleanor A. - Author, Berkowitz, Gertrud S. - Author, Drew, Christina H. - Author, Faustman, Elaine M. - Author, Holland, Nina T. - Author, Lanphear, Bruce - Author, Meisel, Stefanie J. - Author, Perera, Frederica P. - Author, Rauh, Virginia A. - Author, Sweeney, Anne - Author, Whyatt, Robin M. - Author, Yolton, Kimberly - Author. Journal title: Environmental Health Perspectives. Volume: 113. Issue: 10 Publication date: October 2005. Page number: 1419+. © 2006 National Institute of Environmental Health Sciences. COPYRIGHT 2005 Gale Group.

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