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Preterm birth is a global health concern. Its adverse consequences may persist throughout the life course, exerting a potentially heavy burden on families, health systems, and societies. In high-income countries, the first children who benefited from improved care are now adults entering middle age. However, there is a clear gap in the knowledge regarding the long-term outcomes of individuals born preterm.
This study aimed to assess the feasibility of recruiting and following up an e-cohort of adults born preterm worldwide and provide estimations of participation, characteristics of participants, the acceptability of questions, and the quality of data collected.
We implemented a prospective, open, observational, and international e-cohort pilot study (Health of Adult People Born Preterm—an e-Cohort Pilot Study [HAPP-e]). Inclusion criteria were being an adult (aged ≥18 years), born preterm (<37 weeks of gestation), having internet access and an email address, and understanding at least 1 of the available languages. A large, multifaceted, and multilingual communication strategy was established. Between December 2019 and June 2021, inclusion and repeated data collection were performed using a secured web platform. We provided descriptive statistics regarding participation in the e-cohort, namely, the number of persons who registered on the platform, signed the consent form, initiated and completed the baseline questionnaire, and initiated and completed the follow-up questionnaire. We also described the main characteristics of the HAPP-e participants and provided an assessment of the quality of the data and the acceptability of sensitive questions.
As of December 31, 2020, a total of 1004 persons had registered on the platform, leading to 527 accounts with a confirmed email and 333 signed consent forms. A total of 333 participants initiated the baseline questionnaire. All participants were invited to follow-up, and 35.7% (119/333) consented to participate, of whom 97.5% (116/119) initiated the follow-up questionnaire. Completion rates were very high both at baseline (296/333, 88.9%) and at follow-up (112/116, 96.6%). This sample of adults born preterm in 34 countries covered a wide range of sociodemographic and health characteristics. The gestational age at birth ranged from 23+6 to 36+6 weeks (median 32, IQR 29-35 weeks). Only 2.1% (7/333) of the participants had previously participated in a cohort of individuals born preterm. Women (252/333, 75.7%) and highly educated participants (235/327, 71.9%) were also overrepresented. Good quality data were collected thanks to validation controls implemented on the web platform. The acceptability of potentially sensitive questions was excellent, as very few participants chose the “I prefer not to say” option when available.
Although we identified room for improvement in specific procedures, this pilot study confirmed the great potential for recruiting a large and diverse sample of adults born preterm worldwide, thereby advancing research on adults born preterm.
Preterm birth, defined as a birth occurring before 37 weeks of gestation, is a global health concern. It has shown an upward trend since 1990 and accounted in 2014 for 10.6% (uncertainty interval 9.0%-12.0%) of births worldwide, representing almost 15 million babies born preterm every year [
Preterm birth remains a major cause of mortality during both the neonatal period and childhood [
In high-income countries, the first children who benefited from improved care are now adults entering middle age [
There is still a clear gap in the knowledge regarding the long-term outcomes of individuals born preterm. Most available data come from cohorts of preterm or high-risk infants initiated in high-income countries between the late 1970s and the early 1990s, with data collection continuing until adult age [
The availability of technologies offers new possibilities for research, leading to the development of “e-epidemiology” [
Taking advantage of e-epidemiology tools, we implemented a pilot cohort study aiming to (1) assess the feasibility of recruiting and following up an e-cohort of adults born preterm worldwide and (2) provide estimations of participation, characteristics of participants, the acceptability of questions, and the quality of data collected.
Health of Adult People Born Preterm—an e-Cohort Pilot Study (HAPP-e) is a prospective, open, observational, international, e-cohort pilot study of adults born preterm. Inclusions in the pilot study started on December 16, 2019. A follow-up evaluation was launched on December 4, 2020. This collaborative project was developed by the Institute of Public Health of the University of Porto (ISPUP) on the epidemiological side and the Institute for Systems and Computer Engineering, Technology and Science on the technical side as part of the Research on European Children and Adults Born Preterm project (RECAP Preterm) [
The inclusion criteria were as follows: being an adult (aged ≥18 years), born preterm (<37 weeks of gestation), having internet access and an email address, and being able to read and understand at least 1 of the available languages. Here, we reported the data of the participants who registered from December 16, 2019, to December 31, 2020, and who were invited to participate in the follow-up evaluation until June 30, 2021.
A multifaceted communication strategy was implemented with the aim of disseminating the project’s existence and encouraging the participation of as many and as diverse individuals as possible, with the support of the ISPUP communication office and the European Foundation for the Care of Newborn Infants. A logo and a visual identity were created and used for all communication purposes.
The HAPP-e website [
Overview of multifaceted communication strategy. ASPHER: Association of Schools of Public Health in the European Region; EFCNI: European Foundation for the Care of Newborn Infants; ES: España (Spain); FR: France; HAPP-e: Health of Adult People Born Preterm—an e-Cohort Pilot Study; ISPUP: Institute of Public Health of the University of Porto; IT: Italy; PT: Portugal; UP: University of Porto.
Inclusion and repeated data collection were performed through a privacy-preserving modular web platform on a server secured by a digital certificate, accessible from the HAPP-e website.
Participation implied a 2-step process. First, a registration module displayed a privacy policy statement and asked for an email address, password, preferred language, and the confirmation of the eligibility criteria. An email was sent automatically with a link to confirm the registration. On logging in, the participants had to comply with a 2-factor authentication implemented by the platform by providing the selected credentials and accessing a link on their email that granted them access to the platform. Second, inside the platform, the first module displayed a detailed information form. After reading this form, adults born preterm were invited to confirm eligibility criteria and electronically sign an informed consent form to participate in the e-cohort. Finally, the participants accessed a second module and completed the baseline questionnaire, which was divided into several subsections to improve their experience. Any step uncompleted after 1 day triggered a reminder sent via email once a week for up to 3 weeks. Accounts were deleted if the email address was not confirmed after 15 days.
All participants who had been in the cohort for >6 months were invited to the follow-up evaluation via email. Once connected to their personal area using a 2-factor authentication, they electronically signed a new informed consent form before completing the follow-up questionnaire. In the case of nonresponse, email reminders were sent once a week for up to 3 weeks.
The baseline questionnaire had a total of 6 sections, with 302 questions (median completion time 45, IQR 33-65 minutes); however, most respondents answered fewer questions, as the questionnaire allowed them to skip sections. The following topics were covered: circumstances and conditions of birth and past health conditions, sociodemographic data, education and employment, health data and biometrics, quality of life, mental health, and lifestyle factors.
The follow-up questionnaire had 8 sections, with 138 questions (median completion time 22, IQR 17-32 minutes), which focused on current living conditions and changes since the baseline questionnaire, relationship with parents, stress, current health (including a few questions about the COVID-19 pandemic), health care consumption, mental health, quality of life, and the perceived impact of preterm birth on certain aspects of life. The participants were also invited to express themselves in a few free-text sections.
Some information was collected only once at baseline, namely, regarding domains with no evolution (circumstances of birth and past health condition), whereas other information was also collected at follow-up (for instance, current health or quality of life), to assess evolutions from a longitudinal perspective.
Validated scales and open-access instruments were used as often as possible (
All participants received personalized feedback on how they compared themselves with other participants on several dimensions assessed in the inclusion questionnaire. Participants were invited to contribute to the definition of topics of interest for the follow-up evaluation through a survey on Twitter and exchanges with members of the Adult Preemie Advocacy Network. Following this survey, we included questions on mental health, stress, and relationship with parents as well as open questions on the perceived impact of preterm birth on everyday life.
Main measures and instruments used in the Health of Adult People Born Preterm—an e-Cohort Pilot Study.
Measurement category | Dimensions measured and instruments used | Baseline questionnaire | Follow-up questionnaire | |
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Core social variables | Year and country of birth, gender, mother tongue, nationality, and ethnicity; European Health Interview Survey (wave 3, 2018 edition) | ✓a | |
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Education | United Nations Educational, Scientific and Cultural Organization (UNESCO) International Standard Classification of Education (ISCED), 2011 | ✓ | ✓ (change from baseline) |
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Employment | International Labour Organization International Standard Classification of Occupations 2008 (ISCO-08); European Health Interview Survey (wave 3, 2018 edition) | ✓ | ✓ (change from baseline) |
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Current living conditions | Country of residence, marital status, household structure, socioeconomic class, and subjective personal finance; European Health Interview Survey (wave 3, 2018 edition) | ✓ | ✓ (change from baseline) |
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Parents | Country of birth, education, and employment | ✓ | |
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Relationship with parents | Parental Bounding Instrument | ✓ | |
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Social support | Multidimensional Scale of Perceived Social Support | ✓ | |
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Circumstances of birth | Gestational age, birth weight, type of pregnancy, cause of preterm birth, and mode of delivery | ✓ | |
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Past health condition | Neonatal morbidity, prematurity-related morbidity during childhood, and past mental health problems | ✓ | |
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Biometrics | Height and weight; European Health Interview Survey (wave 3, 2018 edition) | ✓ | |
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Current general health | Self-perceived general health, long-standing health problems, limitations in activities, diseases in the past 12 months, pain, medications, and functional limitations; Minimum European Health Module; European Health Interview Survey (wave 3, 2018 edition) | ✓ | ✓ |
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Use of medications | European Health Interview Survey (wave 3, 2018 edition) | ✓ | ✓ |
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Oral health | European Health Interview Survey (wave 3, 2018 edition) | ✓ | |
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Sexual and reproductive health | Sexual orientation, infertility, and children; for women only: pregnancy history (including giving birth to a preterm baby) | ✓ | |
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Mental health | DSM-5b Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult | ✓ | ✓ |
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Health care consumption | Follow-up program after preterm birth, hospitalizations, medical consultations, and unmet needs for health care; European Health Interview Survey (wave 3, 2018 edition) | ✓ | |
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Vulnerability to illness | Perceived Vulnerability to Illness Scale | ✓ | |
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COVID-19 | Symptoms, diagnostic tests, serological tests, and quarantine | ✓ | |
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Personality | Big Five Inventory-10 | ✓ | |
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Quality of life | Assessment of quality of life - 8D | ✓ | ✓ |
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Stress | Perceived Stress Scale | ✓ | |
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Resilience | Brief Resilience Scale (partial) | ✓ | |
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Well-being | Short Warwick–Edinburgh Mental Well-being Scale | ✓ | ✓ |
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Satisfaction with life | Satisfaction With Life Scale | ✓ | |
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Bullying | Bullying self-report scale by Wolke et al [ |
✓ | |
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Smoking | European Health Interview Survey (wave 3, 2018 edition) | ✓ | |
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Alcohol consumption | WHOc Alcohol Use Disorders Identification Test | ✓ | |
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Drugs use | WHO Alcohol, Smoking and Substance Involvement Screening Test (1 item) | ✓ | |
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Physical activity | International Physical Activity Questionnaire—short-form | ✓ | |
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Sleep | Pittsburgh Sleep Quality Index | ✓ |
aItem evaluated in that questionnaire.
bDSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
cWHO: World Health Organization.
We reported participation in the e-cohort, namely, the number of persons who (1) registered on the platform, (2) signed the baseline consent form, (3) initiated and completed the baseline questionnaire, (4) signed the follow-up consent form, and (5) initiated and completed the follow-up questionnaire. To assess the geographical catchment area associated with the study, participants’ birth countries were mapped. We also described the main characteristics of the HAPP-e participants and provided an assessment of the quality of data (proportion of missing data) and the acceptability of sensitive questions (assessed by the proportion of participants who answered “I prefer not to say”).
Descriptive analyses of the selected questions collected in the pilot study were conducted to inform the study protocol for a subsequent study. Participant characteristics were described as frequencies and percentages, means and SDs, or medians and IQRs. We compared sociodemographic characteristics by mode of recruitment using chi-square or Fisher exact tests, as appropriate. The validated scales were scored and interpreted according to the recommendations of the authors. We restricted our analyses to the available data. Statistical significance was set at a 2-tailed value of
This pilot study was reviewed and approved by the ISPUP Research Ethics Committee on July 25, 2019 (CE19124). All participants were informed about the study and the confidentiality of their data and electronically signed a consent form before participating in the study at baseline and at follow-up.
As of December 31, 2020, a total of 1004 persons had registered on the platform, and 527 accounts were considered valid (ie, with a confirmed email), among which 333 participants signed the consent form (
The number of baseline questionnaires administered per month from December 2019 to December 2020 was as follows: 4, 33, 120, 27, 8, 10, 10, 13, 11, 21, 8, 33, and 35.
Flowchart of participants enrolled in the Health of Adult People Born Preterm—an e-Cohort Pilot Study.
The participants were born in 34 countries from 6 continents (
Country of birth of participants enrolled in the Health of Adult People Born Preterm—an e-Cohort Pilot Study. The colors correspond to the number of participants per country.
Sociodemographic characteristics of participants enrolled in the Health of Adult People Born Preterm—an e-Cohort Pilot Study (n=333).
Characteristic | Values | ||
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Man | 79 (23.7) | |
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Woman | 252 (75.7) | |
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Other | 2 (0.6) | |
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1935-1939 | 1 (0.3) | |
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1940-1949 | 3 (0.9) | |
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1950-1959 | 9 (2.7) | |
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1960-1969 | 29 (8.7) | |
|
1970-1979 | 41 (12.3) | |
|
1980-1989 | 80 (24) | |
|
1990-1999 | 141 (42.4) | |
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2000-2002 | 29 (8.7) | |
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None | 1 (0.3) | |
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Primary education | 0 (0) | |
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Lower secondary education | 5 (1.5) | |
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Upper secondary education | 53 (16.2) | |
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Postsecondary nontertiary education | 8 (2.5) | |
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Short-cycle tertiary education | 24 (7.3) | |
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Bachelor’s degree | 99 (30.3) | |
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Master’s degree | 102 (31.2) | |
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Doctorate | 34 (10.4) | |
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Not classified | 1 (0.3) | |
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Employed | 182 (55.7) | |
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Unemployed | 23 (7) | |
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Retired | 12 (3.7) | |
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Unable to work owing to health problems | 5 (1.5) | |
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Student | 88 (26.9) | |
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Fulfilling domestic tasks | 5 (1.5) | |
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Other | 12 (3.7) | |
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I prefer not to say | 0 (0) | |
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Manager | 5 (2.9) | |
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Professional | 115 (65.7) | |
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Technician and associate professionals | 12 (6.8) | |
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Clerical support worker | 15 (8.6) | |
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Services and sales worker | 9 (5.1) | |
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Skilled agricultural, forestry, and fishery worker | 1 (0.6) | |
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Craft and related trades worker | 2 (1.1) | |
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Plant and machine operator and assembler | 1 (0.6) | |
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Armed-forces occupation | 1 (0.6) | |
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Other | 14 (8) | |
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Significant other subscale | 5.86 (1.31) | |
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Family subscale | 5.40 (1.50) | |
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Friends subscale | 5.50 (1.32) | |
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Total scale | 5.71 (1.05) |
Participants were informed about the study through different channels: social media or websites (111/333, 33.3%), traditional media (52/333, 15.6%), associations (36/333, 10.8%), word of mouth or health care professionals (58/333, 17.4%), or other (76/333, 22.8%). We observed no differences in gender or education by mode of recruitment (
Sociodemographic characteristics by mode of recruitment (n=333).
Characteristic | Social mediaa (n=111), n (%) | Traditional mediab (n=52), n (%) | Associationc (n=36), n (%) | Contactd (n=58), n (%) | Other (n=76), n (%) | |||
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.29 | |||||||
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Man | 21 (26.6) | 11 (13.9) | 10 (12.7) | 17 (21.5) | 20 (25.3) |
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Woman | 90 (35.7) | 41 (16.3) | 25 (9.9) | 40 (15.9) | 56 (22.2) |
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Other | 0 (0) | 0 (0) | 1 (50) | 1 (50) | 0 (0) |
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.005 | |||||||
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1935-1939 | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (100) |
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1940-1949 | 2 (66.7) | 0 (0) | 0 (0) | 0 (0) | 1 (33.3) |
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1950-1959 | 0 (0) | 3 (33.3) | 1 (11.1) | 2 (22.2) | 3 (33.4) |
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1960-1969 | 4 (13.8) | 12 (41.4) | 5 (17.2) | 5 (17.2) | 3 (10.4) |
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1970-1979 | 13 (31.7) | 7 (17) | 4 (9.8) | 4 (9.8) | 13 (31.7) |
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1980-1989 | 38 (47.4) | 13 (16.3) | 4 (5) | 12 (15) | 13 (16.3) |
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1990-1999 | 49 (34.8) | 14 (9.9) | 18 (12.8) | 27 (19.1) | 33 (23.4) |
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2000-2002 | 5 (17.2) | 3 (10.4) | 4 (13.8) | 8 (27.6) | 9 (31) |
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.25 | |||||||
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Low (up to 12th grade) | 13 (22) | 8 (13.6) | 9 (15.3) | 12 (20.3) | 17 (28.8) |
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High (postsecondary or tertiary education) | 95 (35.6) | 42 (15.7) | 27 (10.1) | 45 (16.9) | 58 (21.7) |
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<.001 | |||||||
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Europe | 59 (23.1) | 46 (18) | 34 (13.3) | 45 (17.7) | 71 (27.8) |
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Africa | 2 (66.7) | 1 (33.3) | 0 (0) | 0 (0) | 0 (0) |
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North America | 4 (57.1) | 0 (0) | 0 (0) | 2 (28.6) | 1 (14.3) |
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South America | 34 (66.7) | 3 (5.9) | 2 (3.9) | 9 (17.6) | 3 (5.9) |
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Oceania | 8 (88.9) | 0 (0) | 0 (0) | 1 (11.1) | 0 (0) |
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Asia | 1 (100) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
|
aSocial media: Facebook, Twitter, Instagram, Pinterest, and study website.
bTraditional media: press, radio, and television.
cAssociation: institutional newsletters and web communications and prematurity-related associations of patients.
dContact: word of mouth and health care professionals.
Only 2.1% (7/333) of the participants had previously participated in a cohort of individuals born preterm. Of note, 70.3% (234/333) of the participants precisely knew their gestational age at birth (in weeks and days), which ranged from 23+6 to 36+6 weeks (median 32, IQR 29-35 weeks). Birth weight ranged from 453 to 3750 g (median 1670, IQR 1100-2182 g). Gestational age and birth weight were unknown in 6.3% (21/333) and 9% (30/333) of the participants, respectively.
A total of 35.7% (119/333) of the participants declared that they had received a diagnosis of at least 1 morbidity during the neonatal period (
Past and current health status assessed at baseline (n=333).
Characteristic | Values, n (%) | ||||
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No | 156 (46.9) | ||
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Yes | 119 (35.7) | ||
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I do not know | 57 (17.1) | ||
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I prefer not to say | 1 (0.3) | ||
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Intraventricular hemorrhage | 9 (3.3) | ||
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Other brain lesion | 5 (1.8) | ||
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Respiratory complication | 61 (22.3) | ||
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Infection | 33 (12) | ||
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Digestive complication | 17 (6.2) | ||
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Visual complication | 10 (3.7) | ||
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Other complication | 41 (15) | ||
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|
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No | 224 (67.3) | ||
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Yes | 64 (19.2) | ||
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I do not know | 44 (13.2) | ||
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I prefer not to say | 1 (0.3) | ||
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|
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Cerebral palsy | 9 (3.1) | ||
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Visual impairment | 10 (3.5) | ||
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Hearing impairment | 12 (4.2) | ||
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Other | 41 (14.2) | ||
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|
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Very good | 85 (26.7) | ||
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Good | 173 (54.4) | ||
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Fair | 51 (16.1) | ||
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Bad | 9 (2.8) | ||
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Very bad | 0 (0) | ||
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Long-standing health problem (n=318) | 150 (47.2) | |||
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|
||||
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No limitation at all | 238 (74.8) | ||
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Limitation but not severe | 60 (22.1) | ||
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Severe limitation | 10 (3.1) | ||
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|
||||
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Very good | 93 (29.2) | ||
|
|
Good | 130 (40.9) | ||
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Fair | 68 (21.4) | ||
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Bad | 21 (6.6) | ||
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Very bad | 6 (1.9) |
Past mental health problems and current long-standing mental health problems were acknowledged by 34.8% (116/333) and 28.7% (89/333) of participants, respectively (
Mental health, quality of life, and personality assessed at baseline (n=333).
Characteristic | Values | |||
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No | 199 (59.8) | ||
|
Yes | 116 (34.8) | ||
|
I don’t know | 18 (5.4) | ||
|
||||
|
No | 203 (65.5) | ||
|
Yes | 89 (28.7) | ||
|
I don’t know | 18 (5.8) | ||
|
I prefer not to say | 0 (0) | ||
|
||||
|
Depression—mild or greater | 156 (50.3) | ||
|
Anger—mild or greater | 133 (42.9) | ||
|
Mania—mild or greater | 138 (44.5) | ||
|
Anxiety—mild or greater | 210 (67.7) | ||
|
Somatic symptoms—mild or greater | 140 (45.2) | ||
|
Suicidal ideation—slight or greater | 73 (23.6) | ||
|
Psychosis—slight or greater | 32 (10.3) | ||
|
Sleep problems—mild or greater | 130 (41.9) | ||
|
Memory issues—mild or greater | 53 (17.1) | ||
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Repetitive thoughts and behaviors—mild or greater | 77 (24.8) | ||
|
Dissociation—mild or greater | 57 (18.4) | ||
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Personality functioning issues—mild or greater | 128 (41.3) | ||
|
Substance use—slight or greater | 107 (34.5) | ||
|
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Independent living | 90.6 (11.0) | ||
|
Pain | 82.3 (21.4) | ||
|
Senses | 83.4 (11.5) | ||
|
Physical superdimension score | 86.3 (10.2) | ||
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Mental health | 64.5 (16.8) | ||
|
Happiness | 62.7 (17.3) | ||
|
Coping | 64.2 (18.8) | ||
|
Relationships | 74.3 (17.0) | ||
|
Self-worth | 64.4 (22.6) | ||
|
Psychosocial superdimension score | 66.8 (16.0) | ||
|
Quality of life total score | 72.5 (13.3) | ||
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Extraversion | 2.75 (1.13) | ||
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Agreeableness | 3.43 (0.85) | ||
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Conscientiousness | 3.66 (0.96) | ||
|
Neuroticism | 3.28 (1.03) | ||
|
Openness to experience | 3.71 (0.94) |
aDSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
According to the Assessment of Quality of Life-8D, the standardized additive mean scores were 86.3 (SD 10.2) for the physical superdimension and 66.8 (SD 16.0) for the psychosocial superdimension (
During the follow-up evaluation, the current general health was perceived as very good by 26.1% (30/115), good by 51.3% (59/115), fair by 19.1% (22/115), bad by 1.7% (2/115), and very bad by 1.7% (2/115) of the participants. Long-standing health problems were mentioned by 47% (54/115) of the patients, including functional limitation (31/115, 27%) and severe functional limitation (6/115, 5.2%). Overall, 34.8% (40/115) of the respondents reported having had any symptoms suggestive of COVID-19 since January 2020, whereas 6.1% (7/115) had a positive reverse transcription polymerase chain reaction or antigen test, and 3.5% (4/115) had a positive serological test.
Current long-standing mental health problems were acknowledged by 23% (26/113) of the participants. The DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure was repeated in the follow-up questionnaire, displaying stable results. The most frequent mental health issues were anxiety (77/113, 68.1%) and depression (62/113, 54.9%).
Overall, 14.9% (17/114) of the respondents participated in a follow-up program for preterm babies when they were children, and 5.3% (6/114) of the respondents participated when they were adolescents. At adult age, 23.7% (27/114) of the participants were asked by their family physician if they were born preterm, whereas 48.3% (55/114) of the participants mentioned their history of preterm birth to their general practitioner. Only 5.3% (6/114) of the participants received specific care or medical examination because they were born preterm.
Owing to the controls implemented in the web platform (skip logics, data entry formatting, intermittent saving, option to resume questionnaire filling, and feedback messages), the completed modules had no missing data. Very few participants chose the “I prefer not to say” option when available (usually <0.5% per question), even for potentially sensitive questions such as ethnicity (0/333, 0%), marital status (1/333, 0.3%), receipt of social benefits (2/327, 0.6%), financial hardship (4/327, 1.2%), current mental health (0/310, 0%), or sexual orientation (9/318, 2.8%).
The HAPP-e pilot study was conducted to assess the feasibility of the methods and procedures for recruiting and following up an e-cohort of preterm adults. Over 1 year, >1000 persons were registered on the platform, and 333 consented to participate. Of those who participated in the baseline assessment, 35.7% (119/333) also consented to participate in the follow-up evaluation. The completion rate among those who started to answer the questionnaires was very high in both evaluations, and good-quality data were collected thanks to controls implemented in the web platform. The acceptability of the potentially sensitive questions was high. Establishing such an e-cohort at the international level is therefore feasible, despite some scientific and technical challenges related to the recruitment and retention of participants.
This pilot study demonstrated that a multifaceted communication strategy is crucial for recruiting a sample of adults born preterm, covering a wide range of sociodemographic and health characteristics. The complementarity of the internet and noninternet recruitment methods made it possible to achieve greater diversity in the ages and countries represented among the participants, which is a clear asset when making comparisons over time and geographical areas. This finding is in line with previous studies focusing on other research populations such as pregnant patients or adults during the COVID-19 pandemic [
A major challenge is that preterm adults are a hard-to-reach group. Indeed, many people do not know their gestational age at birth. Moreover, because being born preterm is not considered a chronic condition yet, most adults born preterm are unaware of the potential long-term consequences and the need for research in this area [
Participation in this pilot study was patterned by gender and socioeconomic position, with a large overrepresentation of women and highly educated participants. These factors are commonly associated with the decision to participate in research and to maintain participation over time both in longitudinal cohorts of individuals born preterm [
Flexible digital procedures have the potential to lower costs by reducing the amount of time study staff members devote to contacting the participants. They may also improve usability and participant satisfaction by offering a convenient method for collecting information. However, disseminating such a study at an international level, solving arising technical problems, dealing with queries from participants, managing data collection instruments, and so on, require a lot of skills, time, financial, and human resources [
In the absence of any previous cohort of adults born preterm at an international level and because of the aforementioned self-selection biases, the representativeness of our sample is difficult to assess. Most of the characteristics of our volunteers are not directly comparable with existing data on adults born preterm because these data are almost exclusively issued from Scandinavian registries. Unfortunately, to our knowledge, there is no international census or representative sample that allows us to compare and weigh our data. Although we did not include a control sample of term-born adults, the results of our study are in general accordance with the findings published in the medical literature. For instance, compared with term-born controls, preterm populations are at an increased risk of mental health disorders, particularly depressive and anxiety disorders, and are less likely to be extroverted but report equally good social support [
This pilot study had several strengths. We carefully respected ethics and security rules, for instance, using transparent, understandable, and detailed web-based consent and secured data infrastructure. We were able to recruit a diverse cohort covering a wide range of gestational ages at birth, year, and country of birth, thanks to a multifaceted communication strategy. Over a year, we recruited >300 participants, which is the same order of magnitude as follow-ups at adult age of existing longitudinal cohorts of individuals born preterm in the 1980s, such as the Bavarian Longitudinal Study [
This pilot study also has some limitations to which a further study should pay attention. All study materials were translated into 6 languages; however, this number should be increased to minimize language access issues as much as possible. Technical limitations had a significant impact on registration and dropout rates. For instance, the platform was not designed to be accessed using smartphones, which is the main device used to access the internet in many countries and by young adults. We also noticed a clear drop in inclusion from the beginning of the COVID-19 pandemic, perhaps because attention was mostly on this new disease, new concerns arising from the successive lockdowns, worries about personal and societal situations, and innumerable solicitations for web-based surveys about COVID-19. Although traditional cohorts frequently use a variety of modes of contact and reminders to increase participation in follow-up evaluations [
On the basis of our experience and the literature, we identified key aspects that should be considered when implementing future studies with a similar design. The platform and questionnaires must be accessible from several types of devices (computer, tablet, and smartphone) and browsers. Adequate technical procedures are required to prevent emails from being considered as spam. The research team should be multicultural and multilingual; include local contact points in several countries; and be reachable via email, phone, and chat services such as WhatsApp. This would support participants with any technical procedures and problems they may encounter, answer queries, update contact details, create personal connections, tailor dissemination strategies, and allow a variety of reminders to be sent (emails, text messages, and phone calls) [
This pilot study demonstrated the feasibility of recruiting and following up an e-cohort of adults born preterm and provided relevant insights into the specific challenges that will be addressed in a subsequent main study, provided adequate funding is secured. This approach has inherent advantages and limitations and should be considered complementary to traditional cohorts.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Health of Adult People Born Preterm—an e-Cohort Pilot Study
Institute of Public Health of the University of Porto
Research on European Children and Adults Born Preterm
The authors are grateful to all the participants who participated in this pilot study and in particular to those who agreed to share their stories and testimonies on our social media channels. The authors also warmly thank their partners in the Research on European Children and Adults Born Preterm (RECAP Preterm) project, whose contribution was very valuable, and all institutions and associations that helped them disseminate the project. This project, as part of the RECAP Preterm project, has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement 733280.
None declared.