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McGorm KJ, Brown JD, Roberts AG, Greenbank S, Brasacchio D, Sawyer ACP, Oakey H, Colman PG, Craig ME, Davis EA, Soldatos G, Thomson RL, Wentworth JM, Couper JJ, Penno MAS. Experiences of Caregivers and At-Risk Children Enrolled in a Prospective Pregnancy-Birth Cohort Study into the Causes of Type 1 Diabetes: The ENDIA Study. Children 2023; 10:children10040637. [PMID: 37189886 DOI: 10.3390/children10040637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
Background: We sought research experiences of caregivers and their children were enrolled in the Environmental Determinants of Islet Autoimmunity (ENDIA) study. Methods: ENDIA is a pregnancy–birth cohort investigating early-life causes of type 1 diabetes (T1D). Surveys were sent to 1090 families between June 2021 and March 2022 with a median participation of >5 years. Caregivers completed a 12-item survey. Children ≥ 3 years completed a four-item survey. Results: The surveys were completed by 550/1090 families (50.5%) and 324/847 children (38.3%). The research experience was rated as either “excellent” or “good” by 95% of caregivers, and 81% of children were either “ok”, “happy” or “very happy”. The caregivers were motivated by contributing to research and monitoring their children for T1D. Relationships with the research staff influenced the experience. The children most liked virtual reality headsets, toys, and “helping”. Blood tests were least liked by the children and were the foremost reason that 23.4% of the caregivers considered withdrawing. The children valued gifts more than their caregivers. Only 5.9% of responses indicated dissatisfaction with some aspects of the protocol. The self-collection of samples in regional areas, or during the COVID-19 pandemic restrictions, were accepted. Conclusions: This evaluation identified modifiable protocol elements and was conducted to further improve satisfaction. What was important to the children was distinct from their caregivers.
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Reetz J, Richter G, Borzikowsky C, Glinicke C, Darabaneanu S, Buyx A. Consent to research participation: understanding and motivation among German pupils. BMC Med Ethics 2021; 22:93. [PMID: 34271886 PMCID: PMC8283995 DOI: 10.1186/s12910-021-00661-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/07/2021] [Indexed: 11/28/2022] Open
Abstract
Background The EU’s 2006 Paediatric Regulation aims to support authorisation of medicine for children, thus effectively increasing paediatric research. It is ethically imperative to simultaneously establish procedures that protect children’s rights. Method This study endeavours (a) to evaluate whether a template consent form designed by the Standing Working Group of the German-Research-Ethics-Committees (AKEK) adequately informs adolescents about research participation, and (b) to investigate associated phenomena like therapeutic misconception and motives for research participation. In March 2016 a questionnaire study was conducted among 279 pupils (mean age 13.1 years) of a secondary school in northern Germany. Results A majority of participants showed a general good understanding of foundational research ethics concepts as understood from the AKEK consent form. Nevertheless, our data also suggests possible susceptibility to therapeutic misconception. Own health concerns and pro-social considerations were found to be significant motivational factors for participating in research, while anticipation of pain lessens likelihood of participation. Advice from trusted others is an important decisional influence, too. Furthermore, data security was found to be a relevant aspect of adolescents’ decision-making process. Conclusion Bearing in mind adolescents’ generally good understanding, we infer the lack of knowledge about medical research in general to be one source of therapeutic misconception. To further improve the quality of consent we propose a multi-staged approach whereby general research education is completed before an individual becomes a patient or potential participant. To the best of our knowledge this is the first German questionnaire-study addressing issues of informed consent in a large under-age sample. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00661-z.
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Affiliation(s)
- Jana Reetz
- Diakonissenkrankenhaus, Department of Paediatrics, Knuthstraße 1, 24939, Flensburg, Germany
| | - Gesine Richter
- Institute of Experimental Medicine, Division of Biomedical Ethics, Kiel University, University Hospital Schleswig-Holstein, UKSH, Campus KielArnold-Heller-Str. 3, Haus U35, 24105, Kiel, Germany.
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Brunswiker Str. 10, 24105, Kiel, Germany
| | - Christine Glinicke
- Ethics Commission, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3; Haus U 27, 24105, Kiel, Germany
| | - Stephanie Darabaneanu
- Institute of Medical Psychology and Medical Sociology, Kiel University, University Hospital Schleswig-Holstein Kiel, Preußerstrasse 1-9, 24105, Kiel, Germany
| | - Alena Buyx
- Institute of History and Ethics in Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
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Kuemmerle-Deschner JB, Hansmann S, Wulffraat NM, Vastert SJ, Hens K, Anton J, Avcin T, Martini A, Koné-Paut I, Uziel Y, Ravelli A, Wouters C, Shaw D, Özen S, Eikelberg A, Prakken BJ, Ruperto N, Horneff G, Constantin T, Beresford MW, Sikken M, Foster HE, Haug I, Schuller S, Jägle C, Benseler SM. Recommendations for collaborative paediatric research including biobanking in Europe: a Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) initiative. Ann Rheum Dis 2017; 77:319-327. [PMID: 29021237 DOI: 10.1136/annrheumdis-2017-211904] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/19/2017] [Accepted: 09/08/2017] [Indexed: 12/21/2022]
Abstract
Innovative research in childhood rheumatic diseases mandates international collaborations. However, researchers struggle with significant regulatory heterogeneity; an enabling European Union (EU)-wide framework is missing. The aims of the study were to systematically review the evidence for best practice and to establish recommendations for collaborative research. The Paediatric Rheumatology European Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) project enabled a scoping review and expert discussion, which then informed the systematic literature review. Published evidence was synthesised; recommendations were drafted. An iterative review process and consultations with Ethics Committees and European experts for ethical and legal aspects of paediatric research refined the recommendations. SHARE experts and patient representatives vetted the proposed recommendations at a consensus meeting using Nominal Group Technique. Agreement of 80% was mandatory for inclusion. The systematic literature review returned 1319 records. A total of 223 full-text publications plus 22 international normative documents were reviewed; 85 publications and 16 normative documents were included. A total of 21 recommendations were established including general principles (1-3), ethics (4-7), paediatric principles (8 and 9), consent to paediatric research (10-14), paediatric databank and biobank (15 and 16), sharing of data and samples (17-19), and commercialisation and third parties (20 and 21). The refined recommendations resulted in an agreement of >80% for all recommendations. The SHARE initiative established the first recommendations for Paediatric Rheumatology collaborative research across borders in Europe. These provide strong support for an urgently needed European framework and evidence-based guidance for its implementation. Such changes will promote research in children with rheumatic diseases.
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Affiliation(s)
| | - Sandra Hansmann
- Division of Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tübingen, Germany
| | - Nico M Wulffraat
- Paediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Sebastiaan J Vastert
- Paediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Kristien Hens
- Department of Philosophy, University of Antwerp, Antwerp, Belgium
| | - Jordi Anton
- Pediatric Rheumatology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Tadej Avcin
- Departments of Allergy, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Alberto Martini
- Department of Paediatrics, University of Genoa, Gaslini Children's Hospital, G. Gaslini Research Institute, Genoa, Italy
| | - Isabelle Koné-Paut
- Department of Paediatric Rheumatology and Haematology, CEREMAI, GHU Paris-Sud - Hôpital de Bicêtre, APHP, Le Kremlin-Bicêtre, France
| | - Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar-Saba, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Angelo Ravelli
- Department of Paediatrics, University of Genoa, Gaslini Children's Hospital, G. Gaslini Research Institute, Genoa, Italy
| | - Carine Wouters
- Department of Microbiology and Immunology, Laboratory Paediatric Immunology, UZ Leuven Hospital, Leuven, Belgium
| | - David Shaw
- Department of Health, Ethics and Society, CAPHRI Research Institute, Maastricht University, Maastricht, The Netherlands.,Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Seza Özen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Andreas Eikelberg
- Division of Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tübingen, Germany
| | - Berent J Prakken
- Paediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Nicolino Ruperto
- Department of Paediatrics, University of Genoa, Gaslini Children's Hospital, G. Gaslini Research Institute, Genoa, Italy
| | - Gerd Horneff
- Department of General Pediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Tamas Constantin
- Reumatológia, Immunológia, Gyermekgyógyászati Klinika, Budapest, Hungary
| | - Michael W Beresford
- Department of Paediatric Rheumatology, Institute for Translational Medicine, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Marijn Sikken
- JIA Patient Council, Department of Paediatric Rheumatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Helen E Foster
- Department of Paediatric Rheumatology, Great North Children's Hospital, Institute of Cellular Medicine Musculoskeletal Research Group, Newcastle University, Newcastle upon Tyne, UK
| | - Iris Haug
- Division of Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tübingen, Germany
| | - Sabrina Schuller
- Division of Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tübingen, Germany
| | - Christine Jägle
- Division of Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tübingen, Germany
| | - Susanne M Benseler
- Division of Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tübingen, Germany.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
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Grootens-Wiegers P, Visser EG, van Rossum AMC, van Waardhuizen CN, de Wildt SN, Sweep B, van den Broek JM, de Vries MC. Perspectives of adolescents on decision making about participation in a biobank study: a pilot study. BMJ Paediatr Open 2017; 1:e000111. [PMID: 29637137 PMCID: PMC5862224 DOI: 10.1136/bmjpo-2017-000111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To be able to truly involve adolescents in decision making about clinical research participation, we need more insight in the perspective of adolescents themselves. To this end, adolescents in an ongoing biobank study were consulted to test a tentative decision assessment tool. METHODS The perspectives of adolescents (n=8) concerning participation in decision making for research participation were explored in interviews with a tentative tool, which covered six topics: information material usage, understanding, disease perceptions, anxiety, decision-making process and role sharing. RESULTS All adolescents unequivocally expressed the desire to be involved in decision making, but also wanted advice from their parents. The extent of the preferred role of adolescent versus parents varied between individuals. In decision making, adolescents relied on parents for information. More than half hardly used the information material. CONCLUSIONS Adolescents in our study preferred a shared decision-making process. The extent of sharing varied between individuals. The decision assessment tool was a fruitful starting point to discuss adolescents' perspectives and may aid in tailoring the situation to the individual to achieve optimal participation practices. IMPLICATIONS Consulting adolescents about their preferences concerning decision making using the tool will facilitate tailoring of the shared decision-making process and optimising the developing autonomy of minors.
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Affiliation(s)
- Petronella Grootens-Wiegers
- Department of Science Communication and Society, Leiden University, Leiden, The Netherlands.,Committee of Medical Ethics, Leiden University Medical Center, Leiden, The Netherlands
| | - Eline G Visser
- Department of Pediatrics, Division of Infectious Diseases and Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Annemarie M C van Rossum
- Department of Pediatrics, Division of Infectious Diseases and Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Claudia N van Waardhuizen
- Theme Sophia, Sector Research Office-Theme Sophia Biobank, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Leiden, The Netherlands.,Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands
| | - Boudewijn Sweep
- Department of Science Communication and Society, Leiden University, Leiden, The Netherlands
| | - Jos M van den Broek
- Department of Science Communication and Society, Leiden University, Leiden, The Netherlands
| | - Martine C de Vries
- Departments of Pediatrics and Ethics and Health Law, Leiden University Medical Center, Nijmegen, The Netherlands
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Giesbertz NAA, Melham K, Kaye J, van Delden JJM, Bredenoord AL. Personalized assent for pediatric biobanks. BMC Med Ethics 2016; 17:59. [PMID: 27733160 PMCID: PMC5062866 DOI: 10.1186/s12910-016-0142-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/29/2016] [Indexed: 12/22/2022] Open
Abstract
Pediatric biobanking is considered important for generating biomedical knowledge and improving (pediatric) health care. However, the inclusion of children’s samples in biobanks involves specific ethical issues. One of the main concerns is how to appropriately engage children in the consent procedure. We suggest that children should be involved through a personalized assent procedure, which means that both the content and the process of assent are adjusted to the individual child. In this paper we provide guidance on how to put personalized assent into pediatric biobanking practice and consider both the content and process of personalized assent. In the discussion we argue that the assent procedure itself is formative. Investing in the procedure should be a requirement for pediatric biobank research. Although personalized assent will require certain efforts, the pediatric (biobank) community must be aware of its importance. The investment and trust earned can result in ongoing engagement, important longitudinal information, and stability in/for the research infrastructure, as well as increased knowledge among its participants about research activity. Implementing personalized assent will both respect the child and support biobank research.
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Affiliation(s)
- Noor A A Giesbertz
- Department of Medical Humanities, Division Julius Center, University Medical Center Utrecht, Office Stratenum 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands. .,Department of Genetics, Division Biomedical Genetics, University Medical Center Utrecht, KC.04.084.2, P.O. Box 85090, 3508 AB, Utrecht, The Netherlands.
| | - Karen Melham
- Clinical Trials & Research Governance (CTRG) University of Oxford Joint Research Office, Block 60, Churchill Hospital, Headington, Oxford, OX3 7LE, United Kingdom
| | - Jane Kaye
- Nuffield Department of Population Health, HeLEX-Centre for Health, Law and Emerging Technologies at Oxford, University of Oxford, Ewert House, Ewert Place, Banbury Road, Summertown, Oxford, OX2 7DD, UK
| | - Johannes J M van Delden
- Department of Medical Humanities, Division Julius Center, University Medical Center Utrecht, Office Stratenum 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Annelien L Bredenoord
- Department of Medical Humanities, Division Julius Center, University Medical Center Utrecht, Office Stratenum 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
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Giesbertz NA, Bredenoord AL, van Delden JJ. Consent procedures in pediatric biobanks. Eur J Hum Genet 2015; 23:1129-34. [PMID: 25537361 DOI: 10.1038/ejhg.2014.267] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/17/2014] [Accepted: 10/30/2014] [Indexed: 12/03/2022] Open
Abstract
The inclusion of children's samples in biobanks brings forward specific ethical issues. Guidelines indicate that children should be involved in the consent procedure. It is, however, unclear how to allocate an appropriate role for children. Knowledge of current practice will be helpful in addressing this issue. Therefore, we conducted an international multiple-case study on the child's role in consent procedures in pediatric biobanks. Four biobanks were included: (1) LifeLines, (2) Prevention and Incidence of Asthma and Mite Allergy (PIAMA), (3) Young-HUNT3 and (4) the Oxford Radcliffe Biobank contribution to the Children's Cancer and Leukaemia Group tissue bank (ORB/CCLG). Four themes linked to the child's role in the consent procedure emerged from the multiple-case study: (1) motives to involve the child, (2) informing the child, (3) the role of dissent, assent and consent and (4) voluntariness of children to participate. We conclude that biobank characteristics influence the biobank's motives to include children in the consent procedure. Moreover, the motives to include children influence how the children are involved in the consent procedure, and the extent to which children are able to make voluntary decisions as part of the consent procedure. This insight is valuable when designing pediatric biobank governance.
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Abstract
BACKGROUND Assent is an important ethical and legal requirement of paediatric research. Unfortunately, there are significant differences between the guidelines on the details of assent. DISCUSSION What often remains unclear is the scope of the assent, the procedure for acquiring it, and the way in which children's capacity to assent is determined. There is a general growing tendency that suggests that the process of assent should be personalised, that is, tailored to a particular child. This article supports the idea of personalisation. However, we also propose placing limits on personalisation by introducing a suggested requirement of assent starting at a school-age threshold. In some situations RECs/IRBs and researchers could reduce the suggested threshold. SUMMARY A recommended age threshold is likely to serve the interests of children better than ambiguous and flexible criteria for personalised age determination.
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Affiliation(s)
- Marcin Waligora
- Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University, Medical College, Michalowskiego 12, Krakow 31-126, Poland
| | - Vilius Dranseika
- Department of Logic and History of Philosophy, Vilnius University, Vilnius, Lithuania
| | - Jan Piasecki
- Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University, Medical College, Michalowskiego 12, Krakow 31-126, Poland
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Hens K, Van El CE, Borry P, Cambon-Thomsen A, Cornel MC, Forzano F, Lucassen A, Patch C, Tranebjaerg L, Vermeulen E, Salvaterra E, Tibben A, Dierickx K. Developing a policy for paediatric biobanks: principles for good practice. Eur J Hum Genet 2012; 21:2-7. [PMID: 22713814 PMCID: PMC3533257 DOI: 10.1038/ejhg.2012.99] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The participation of minors in biobank research can offer great benefits for science and
health care. However, as minors are a vulnerable population they are also in need of
adequate protective measures when they are enrolled in research. Research using biobanked
biological samples from children poses additional ethical issues to those raised by
research using adult biobanks. For example, small children have only limited capacity, if
any, to understand the meaning and implications of the research and to give a documented
agreement to it. Older minors are gradually acquiring this capacity. We describe
principles for good practice related to the inclusion of minors in biobank research,
focusing on issues related to benefits and subsidiarity, consent, proportionality and
return of results. Some of these issues are currently heavily debated, and we conclude by
providing principles for good practice for policy makers of biobanks, researchers and
anyone involved in dealing with stored tissue samples from children. Actual implementation
of the principles will vary according to different jurisdictions.
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Affiliation(s)
- Kristien Hens
- Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands.
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Genuneit J, Büchele G, Waser M, Kovacs K, Debinska A, Boznanski A, Strunz-Lehner C, Horak E, Cullinan P, Heederik D, Braun-Fahrländer C, von Mutius E. The GABRIEL Advanced Surveys: study design, participation and evaluation of bias. Paediatr Perinat Epidemiol 2011; 25:436-47. [PMID: 21819425 DOI: 10.1111/j.1365-3016.2011.01223.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Exposure to farming environments has been shown to protect substantially against asthma and atopic disease across Europe and in other parts of the world. The GABRIEL Advanced Surveys (GABRIELA) were conducted to determine factors in farming environments which are fundamental to protecting against asthma and atopic disease. The GABRIEL Advanced Surveys have a multi-phase stratified design. In a first-screening phase, a comprehensive population-based survey was conducted to assess the prevalence of exposure to farming environments and of asthma and atopic diseases (n = 103,219). The second phase was designed to ascertain detailed exposure to farming environments and to collect biomaterial and environmental samples in a stratified random sample of phase 1 participants (n = 15,255). A third phase was carried out in a further stratified sample only in Bavaria, southern Germany, aiming at in-depth respiratory disease and exposure assessment including extensive environmental sampling (n = 895). Participation rates in phase 1 were around 60% but only about half of the participating study population consented to further study modules in phase 2. We found that consenting behaviour was related to familial allergies, high parental education, wheeze, doctor diagnosed asthma and rhinoconjunctivitis, and to a lesser extent to exposure to farming environments. The association of exposure to farm environments with asthma or rhinoconjunctivitis was not biased by participation or consenting behaviour. The GABRIEL Advanced Surveys are one of the largest studies to shed light on the protective 'farm effect' on asthma and atopic disease. Bias with regard to the main study question was able to be ruled out by representativeness and high participation rates in phases 2 and 3. The GABRIEL Advanced Surveys have created extensive collections of questionnaire data, biomaterial and environmental samples promising new insights into this area of research.
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Affiliation(s)
- Jon Genuneit
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm LMU Munich, University Children's Hospital, Munich, Germany.
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