Findings from Nurses’ Health Study benefit women’s health: Researchers recruiting for third round
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* Kim Krisberg

For more than 30 years, Ingrid Fetkoeter has been committed to what has become the world’s largest, longest-running study of women’s health. In fact, Fetkoeter is so committed to the Nurses’ Health Study that she has authorized her doctors to send all of her medical records to study researchers after she dies.

“I even started clipping out and saving articles about (the study),” said Fetkoeter, NP, RN, who retired from nursing in 2011 after 50 years in the field. “Over the years, it got to be that you couldn’t open a health magazine without finding a result from the Nurses’ Health Study. I’m just so proud to be a part of it.”

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/43/9/1.1/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/43/9/1.1/F1)

Students in the School of Nursing at the University of Southern Mississippi practice procedures on mannequins during classroom instruction in 2010. The Nurses’ Health Study, which is recruiting participants, is involving nursing students for the first time.

Photo courtesy Southern Mississippi Office of University Communications

Fetkoeter, now 72 years old, enrolled in the Nurses’ Health Study in 1976 after hearing about it via a local nursing licensing agency. The study, which ended up recruiting 122,000 female nurses to participate, was launched to examine the long-term risk factors for cardiovascular disease and cancer in women. Today, 90 percent of those nurses — including Fetkoeter — are still participating via surveys they receive by mail. The study does not focus on nursing practices, instead using female nurses as subjects for study of women’s health.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/43/9/1.1/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/43/9/1.1/F2)

The latest round of the Nurses’ Health Study began in 2010 with a goal of recruiting 100,000 new female nurses and nursing students. Volunteers can sign up now online to take part.

Photo courtesy iStockphoto

The study that Fetkoeter enrolled in is now known as Nurses’ Health Study 1 and was just the first iteration of the decades-long endeavor. Nurses’ Health Study 2 began in 1989 to examine diet and lifestyle risk factors and successfully recruited more than 116,680 nurses, of which 90 percent are still participating, and the Nurses’ Health Study 3 began in 2010 with a goal of recruiting 100,000 new female nurses and nursing students. Oftentimes, previous study participants are integral to recruiting new nurses to enroll and Fetkoeter is no exception. The retired nurse is using her Facebook page to encourage the next generation of nurses to contribute their knowledge and experiences to keeping the massive women’s health study going strong.

“The study really does speak for itself,” she told *The Nation’s Health*.

Indeed, findings from the studies have led to real changes in how health professionals care for women. For example, according to APHA member Walter Willett, MD, MPH, who helped launch the second and third rounds of the study and serves as principal investigator, findings on oral contraceptives and their relationship to cardiovascular disease led to changes in prescribing practices and a reformulation of contraceptive pills. Findings on vitamin A consumption and the risk of hip fractures led to the reformulation of vitamin supplements and contributed to practices such as fortifying breakfast cereals. And findings on the timing of postmenopausal hormone use and the risk of heart disease and breast cancer offered new guidance to doctors caring for women.

“The Nurses’ Health Study has been a milestone because it is providing the most detailed information anywhere in the world on diet and many other factors, operating across the lifespan, in relation to almost all major diseases in women,” said Willett, a professor of epidemiology and nutrition at the Harvard School of Public Health.

Focusing on nurses, who were initially recruited for their ability to accurately report on health issues, has been key to the studies’ success. Willett said nurses offer a “fairly good cross-section of American women, excluding the most poor and rich,” and are able to provide high-quality data about their health and medication use. Participants are also overwhelmingly committed to the research.

For the most recent study, Nurses’ Health Study 3, researchers are examining health issues related to lifestyle, pregnancy and fertility, and environment. The study is also collecting data on the occupational health risks specific to nursing, partnering with the National Institute for Occupational Safety and Health to develop a thorough assessment of workplace exposures to which nurses are particularly susceptible.

Researchers are now working to recruit female registered nurses, licensed practical nurses, licensed vocational nurses and nursing students ages 20 to 46 who live in the U.S. or Canada. The third study is the first for which students are eligible — a decision motivated, in part, by the fact that many risk factors for serious disease begin in childhood and early adult life, Willett said. As of late August, about 35,000 nurses and nursing students had enrolled in Nurses’ Health Study 3, and enrollment will remain open until researchers hit the 100,000 mark, said Jorge Chavarro, MD, ScM, ScD, who serves as project director for Nurses’ Health Study 3 and is an assistant professor of epidemiology and nutrition at the Harvard School of Public Health. Also for the first time, the Nurses’ Health Study 3 will be entirely Web-based.

“I think it’s a necessity of doing research today,” said Chavarro. “More and more, people today are very comfortable with answering questionnaires online, so as an investigator, we have to adapt to the modes of communication people are using in their daily lives.”

Upon enrollment, each participant enters into a personalized study timeline — “that study timeline is yours and yours only and depends exclusively on when you answer questions,” Chavarro said. Questionnaires are sent out every six months and take about 20 minutes to 40 minutes to complete. For example, participants who enrolled in 2010 are now answering their sixth questionnaire. Researchers are also piloting different methods for collecting biological samples from study participants, currently conducting such collection on a small scale to find the most efficient approach.

In addition, Chavarro said researchers are working on ways to provide feedback and respond to questions from study participants much more quickly. He noted that researchers are now receiving many more communications per patient than in previous studies, and younger enrollees expect a quicker turnaround to their inquiries.

Another goal for the Nurses’ Health Study 3 is to increase the diversity of participants. Willett noted that minority women were under-represented in previous study rounds, mainly due to their lower representation within the nursing profession. However, for the third study, researchers are working closely with minority nurses associations to attract a more diverse cohort.

“The racial and ethnic background of the U.S. is changing and we want the study to reflect that,” Chavarro told *The Nation’s Health*.

At the moment, Chavarro said the main focus for study staff is working to optimize recruitment and retention of participants. However, data from the third cohort is now under internal review and some initial results could come as soon as next year, he said.

Chavarro noted that findings from the Nurses’ Health Study not only have clear medical applications, but implications for public health as well. For example, he said, study findings on the relationship between trans fatty acids and heart disease helped lay the foundation for labeling laws and in some communities and countries, trans fat bans.

“We’re using data every day in public health that came from the nurses’ health studies,” Chavarro said. “We hope that the data that we’re collecting at this moment will lead to unexpected and unanticipated major breakthroughs.”

For Samantha Franz, RN, FNP-C, a nurse at Rappahannock Family Physicians in Fredericksburg, Va., enrolling in the Nurses’ Health Study 3 was an “opportunity to carry forth the legacy that nurses before us have started.” Franz first heard about the Nurses’ Health Study 20 years ago during an epidemiology class. Her professor’s enthusiastic endorsement of the study and of nurses as the ideal study participants made a lasting impression on Franz. So when she saw an ad on Facebook recruiting for the Nurses’ Health Study 3, she promptly enrolled. Franz said she is committed to sticking with the study for the long run.

“It almost feels like an obligation — like I owe it to nursing to help sustain the study and I’m proud to be a part of it,” Franz said. “As nurses, we understand where the data is going and how the data can contribute to wellness and disease prevention. We can incorporate the research into our work so it’s easy to see the benefits of participation.”

To learn more about the Nurses’ Health Study 3 and how to enroll, visit [www.nhs3.org](http://www.nhs3.org).

*   Copyright The Nation’s Health, American Public Health Association