Risk perception bias, self-reporting of illness, and the validity of reported results in an epidemiologic study of recreational water associated illnesses

Epidemiologic studies of water associated illness often have to rely on self-reported symptoms of the outcome illness(es) under study. Individual participant's perception of risk, in theory, can affect the validity of self-reported symptoms. The magnitude and effect of possible “risk perception bias” was evaluated as part of a series of randomized trials designed to assess infectious disease transmission via exposure to marine recreational waters with modest sewage contamination. All study subjects were blinded to both their individual indices of exposure and the outcome illnesses under study. Of the five outcome illnesses studied, the effect of “risk perception bias” only effected one: skin ailments. Although analysis of crude rates of skin ailments showed the exposed group (bathers) to be 3.5 times more likely to report skin ailments relative to the non-exposed (non-bathers), when the data was stratified by any perceived health risk of bathing in such waters, this association was shown to be spurious in nature. Bathers having pre-conceived notions of any health risk due to the exposure were 10.63 times more likely to report skin ailments relative to the unexposed (non-bathers) (95% CI 2.36-47.8, P = 0.0002), while bathers without any pre-conceived notion of risk were no more likely to report skin ailments relative to non-bathers (OR = 0.60, 95% CI 0.11-3.24, P = 0.71). Further stratification by exposure grouping showed bathers with pre-conceived notions of excess risk to be 4.78 times more likely to report skin ailments relative to bathers without any notion of excess risk (95% CI 1.04-21.86, P = 0.03), while among non-bathers those with pre-conceived notions of risk were 3.70 times less likely to report skin ailments relative to non-bathers without any pre-conceived notion of risk (95% CI 0.70-19.60, P = 0.10). This study shows that “risk perception bias” can be strong enough to lead to spurious associations in the presence of self-reported symptoms, and should be controlled for in future epidemiologic studies of recreational water associated illnesses and other water associated environmental exposures where the use of self-reported symptoms cannot be avoided.