|Year : 2022 | Volume
| Issue : 3 | Page : 251-256
Impact of disability on quality of life and coping in patients with allergic rhinosinusitis: A cross-sectional tertiary hospital-based study
Himanshu Sharma1, Yojana Sharma2, Nisheet M Patel3, Ankur Mahida1, Hansal G Mistry1, Tanya M Rangwala4
1 Department of Psychiatry, Pramukh, Swami Medical College, Bhaikaka University, Anand, India
2 Department of ENT, Pramukh, Swami Medical College, Bhaikaka University, Anand, India
3 Department of Psychiatry, Smt B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Piparia, Vadodara, India
4 Department of Microbiology, B.J. Medical College, Ahmedabad, Gujarat, India
|Date of Submission||06-May-2020|
|Date of Decision||27-Jul-2020|
|Date of Acceptance||13-Sep-2020|
|Date of Web Publication||20-Jul-2021|
Dr. Himanshu Sharma
28, Sardar Nagar Society, Opposite Tirupati Petrol Pump, Mission Road, Karamsad, Anand - 388 325, Gujarat
Source of Support: None, Conflict of Interest: None
Context: Allergic rhinosinusitis (AR) is common disabling disorder which is prevalent more in western India. Most of these patients have chronic rhinosinusitis and nasal polyposes. The present study assessed disability and its impact on quality of life (QoL) in AR that would help to include psychosocial measures along with the drugs treatment. Aims: To study to the impact of Disability, QoL and mechanism of Coping in AR. Settings and Design: The study was conducted in the ENT out-patient department of a tertiary care hospital over a 3 month period. Materials and Methods: Patients with age more than 18 years and without any comorbidity were included in the study. Gujarati versions of Rhinosinusitis Disability Index (for disability), SF-36 survey (QoL) and Coping Strategies Inventory-Short-Form were used. Statistical Analysis: SPSS (IBM Corp. Released 2013.IBM SPSS Statistics for Windows, Version 1.0. Armonk, NY: IBM Corp.) was used for all analysis. Descriptive statistics (mean, standard deviation) and correlation were calculated. Results: A significant impact of disability on QoL (general health and health change) was noted among these patients (P = 0.505, P = 0.370), more in urban than rural patients with greater distress and significant relationship between engagement and disengagement based coping style (r = 0.701). Conversely, social functioning and engagement based coping style had a negative co-relationship (−0.210). Sample was predominantly male using emotional coping than practical one. Conclusions: Faulty coping can lead to increased morbidity which may be altered with disease specific psychoeducation and counseling.
Keywords: Allergic rhinosinusitis, coping strategies, disability, psychoeducation, quality of life
|How to cite this article:|
Sharma H, Sharma Y, Patel NM, Mahida A, Mistry HG, Rangwala TM. Impact of disability on quality of life and coping in patients with allergic rhinosinusitis: A cross-sectional tertiary hospital-based study. Indian J Soc Psychiatry 2022;38:251-6
|How to cite this URL:|
Sharma H, Sharma Y, Patel NM, Mahida A, Mistry HG, Rangwala TM. Impact of disability on quality of life and coping in patients with allergic rhinosinusitis: A cross-sectional tertiary hospital-based study. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Oct 3];38:251-6. Available from: https://www.indjsp.org/text.asp?2022/38/3/251/321883
| Introduction|| |
Allergic rhinitis (AR) is nasal mucosa's inflammation induced by exposure to an allergen which triggers an IgE-mediated inflammation. It is characterized clinically by two or more of the four major symptoms–rhinorrhea, sneezing, nasal itching, and nasal congestion.
According to a review the Indian prevalence of AR is between 20% and 30% with comorbid asthma is present in nearly half the sample. In addition, it is one of the top ten reasons to visit the primary care physicians. But the reported incidence of allergic rhinitis in west is 1.4%–39.7%.
According to the landmark International Study of Asthma and Allergies in Childhood study, allergic rhinitis affects between 10% and 30% of all adults., Also the prevalence has increased over the years. On the other hand, the Asia-Pacific Survey, whose aim was to assess effect of nasal allergy symptoms on the quality of life (QoL) in respondents, found prevalence of AR between 2.5% and 13.2%. Another cross-sectional study using a survey on AR in different countries among 4 world geographical regions-Asia, Europe, the Americas, and Africa, prevalence of AR was reported to be 15%–25%.
The total expenses on AR in USA is almost 11 billion dollars, the direct cost being around 5.5 billion dollars which is almost 30 times the spending in India on drugs of AR and asthma. The CARAS survey shows a higher prevalence of comorbid AR with asthma in Indian subjects, which shows need for early diagnosis and guideline based management of these subjects. It has a negative effect on health, quality of sleep, work productivity, and school performance. Yet, it is often overlooked and underdiagnosed by physicians as well as patients.,
Allergic Rhinitis and its effect on Asthma (ARIA) classified the patients according to nasal and ocular symptoms, QoL, work/school performance and adverse effects of treatment into “mild” and “moderate to severe” allergic rhinitis and the guidelines are specifically for the latter group. This indicates the adverse psychological effects of allergic rhinitis on the sufferers.
Health-related QoL (HRQoL) outcomes such as sleep, work/school performance, social functioning (SF), fatigue and general health (GH) perception are negatively affected in AR. Also, it depends on the level of the tolerance of the individual and; impairment of HRQoL generally increases with increasing degree of symptoms and severity of disease. It was however noted that appropriate treatment along with education provided to patient caused significant improvement in QoL at 4 weeks, which was sustained at 8 weeks. It was seen that Indian adults were bothered by problems at work and by the fact that it affected their feeling of general well being. They were, however, less troubled by the lack of a good night's sleep.,
So, Psycho-education and counseling which is issue based may be useful to increase life quality in allergic rhinosinusitis (AR) patients along with the drug treatment (the latter is out of purview of this study). Looking of dearth of extant literature, especially in Indian subcontinent, on this subject the present study was planned with Aims and Objectives, to study to the impact of disability, QoL and mechanism of coping in AR.
| Materials and Methods|| |
Sample size calculation
Calculation of sample size was done using the standard Open Epi tool (Version 3.01) free online tool. Thus, for a estimated population of 10 lakhs, anticipated frequency (5%); confidence limits 5% (absolute precision); design effect − 1.0 (for a cross sectional study); sample size at 95% confidence interval is 73 (in our study sample size is 80).
A serial convenience sample of consecutive 80 AR patients, meeting all inclusion and exclusion criteria and presenting over a three month period (from March to May 2017) to the ENT out-patient department (OPD) of a tertiary rural based hospital were selected for the study. This is a hospital based sample in a rural setting.
The approval of the Institutional Ethics Committee was taken before starting the project. Informed written consent was obtained from all the subjects. The forms were filled followed by a clinical interview in a single sitting. Approximately 40 min were taken for the whole process and this was included in the patient information sheet. A separate measure like GH Questionnaire to exclude the psychiatric comorbidity was not used as it would have increased the time taken for the study protocol and decreased adherence.
All subjects with age of 18 years or more were selected. All cases, both old and new, diagnosed as AR by an ENT specialist in OPD of our hospital, with or without any complication like nasal polyp, undergoing treatment or underwent any kind of medical and surgical treatment, were included in this study.
The patients of AR with co-morbidities including Asthma, patients with psychiatric illness (on treatment or history), cognitive decline and any clinical condition which made it difficult to fill scales were excluded. Also, those nonconsenting were excluded.
In the present study, the patients were given a questionnaire which included Socio-Demographic Data, Rhinosinusitis Disability Index (RSDI) for assessing disability, SF-36 survey for assessing QoL and Coping Strategies Inventory Short-Form (CSI-SF) for assessing coping mechanisms. Gujarati versions of RSDI, SF-36, and CSI-SF were developed using the standard methodology. English versions were translated into Gujarati. Then an independent translator back translated them and a panel of experts compared and judged them. Minor modifications with full approval of a panel of experts, were made following field trials.
Description of methods
RSDI is a 30-item, Likert-scale survey which consists of three individual sub scales and they are Physical, Functional, and Emotional domains. The total score range between 0 and 120.Higher RSDI total and domain scores imply a higher impact of disease.
SF-36 QoL scale is a 36-Item Short Form Health Survey questionnaire (SF-36) and it is a very useful instrument for evaluating health-related QoL. The 36 items are scored out of 8 scales - physical functioning (PF), bodily pain (BP), GH, SF, vitality (VT), role limitations due to physical health problems (RP), role limitations due to emotional problems (RE) and mental health (MH).
CSI-SF – a brief 16 item scale derived from 78-item CSI was used. The items were rated on a 5-item Likert scale from 1 to 5 as-never, seldom, sometimes, often, and almost always. Through this scale, when faced with difficult situation, self-reported coping responses of different forms in those situations are evaluated. Coping responses are classified into emotion-focused and problem-focused types. Emotion-focused type means more emphasis on affective response to stress and problem focused type means more emphasis on adaptive behavioral response to stress. Emotion-focused and problem-focused types are sub-classified as either engagement type or disengagement type of strategy. Engagement coping means actively dealing with the stressors or stress-related emotions. Disengagement coping means avoiding confrontation of the threat or the related distress which includes responses such as avoidance, denial, and wishful thinking.
SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). Statistics trial version was used for all analysis and Descriptive statistics (mean, standard deviation [SD]) and correlation were calculated wherever indicated for the data.
| Results|| |
The final sample, size was 80 (n = 80). Since RSDI which has only been developed for adult population, those (<18) were excluded. In addition, we excluded asthma (a highly comorbid condition with AR) to get a pure sample for study.
The Social and demographic characteristics of these patients is summarized in [Table 1]. Sufferers were distributed according to their demographic profile. Males were double than the females, the rural population among the patients selected were more than the urban population. Majority of the patients were in the middle age group (43.8%); also majority of the patients were living in a joint family (76.3% vs. 23.8%).
Rhinosinusitis Disability Index domain
Rhinosinusitis Disability scale consists of 30 questions. Amongst them 6,14 and 10 respectively lie physical, emotional and functional domains. On the Likert scale patient's responses could range from never to always [Table 2] shows that the mean score for the Emotional domain is higher (mean = 15.55) than physical (mean = 14.84) and functional (mean = 13.41) ones.
|Table 2: Mean and standard deviation scores of sub domains of rhinosinusitis disability index|
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Rhinosinusitis Disability Index and quality of life
Impact of Rhinosinusitis Disability on QoL is measured by SF-36 questionnaire. The different domains which have an effect on QoL are shown in [Table 3]. It shows that Emotional well-being (EW) (mean = 62.34, SD = 19.81) and SF (mean = 61.10, SD = 20.63) of the patient are highly affected. The sub-domains which have a lesser effect on the QoL are role limitations due to physical health (RLP) (mean = 43.75, SD = 40.67) and role limitation due to emotional problems (RLE) (mean = 44.58, SD = 41.38).
Mean survey on Coping Strategies Inventory-Short-Form
[Table 4] shows the mean score of Disengagement-based coping (D) strategies was marginally higher among AR patients (mean = 21.56, SD = 7.43) than engagement based coping strategies (E) (mean = 20.85, SD = 6.13). Among the other coping mechanisms, the mean score of problem focused coping mechanisms (PFE) (mean = 12.37, SD = 4.13) were higher than Emotion focused coping mechanisms (mean = 8.37, SD = 3.99). On the contrary, in the disengagement strategy, the mean score of Emotion based Disengagement mechanisms (EFD) (mean = 11.1) was higher.
Correlation between Rhinosinusitis Disability Index and quality of life
There is significant correlation between RSDI and QOL at 0.01 and 0.05 levels. Increase in functional complaints indicates that disability negatively affects the PF part of QoL (r = 0.357) at 0.01 level [Table 5].
|Table 5: Correlation between rhinosinusitis disability and quality of life|
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| Discussion|| |
In this study, majority of the sufferers (about 85%) were from lower and middle age group [Table 1]. This may be secondary to alteration of immune function.,,
Majority of this group comprises students and working population. Males (70%) were affected more than females. But according to another study, more females had rhinitis than males and it also suggested that female preponderance was related to increasing age. So, the preponderance of lower age patients in our study might be the reason for the opposite findings. Interestingly more subjects in this study were from joint family, which may be due to “overcrowding” in large families living in small dwellings, though this has not been specifically studied.
It was found that allergic rhinitis affected the emotional domain slightly more than functional and physical domains on RSDI scale [Table 2]. Diametrically opposite findings were reported in a study on 109 patients with allergic rhinitis.
Another study which was conducted in 219 patients, who either had both allergic rhinitis and asthma or had only one of them. It was found that there was significant effect on PF (mean = 83) and SF (mean = 75) in subjects who were diagnosed as allergic rhinitis only. This finding may be due to cultural impact and higher percentage of middle income population (44%) in our study.
In our study (using SF 36 survey) it was found that EW (mean = 62.34, SD = 19.81) and SF (mean = 61.10, SD = 20.63) of the patients was highly affected [Table 3]. Similarly, in a study done in Chinese population it was found that the allergic rhinitis can affect emotional and social well-being in the form of depression, anxiety, somatic pain complaints and withdrawal from social activities and which in turn can have an antagonistic effect on the status of allergic rhinitis patients.
In another study in China which calculated the effect of AR on QoL, using six outcomes: disturbances in sleep (53.8%), limitations in daily life (51.3%), limitations in sports (9.5%), work alteration (31.7%), impairments in learning (5.3%), and nuisance symptoms (8. 3%).The study found that only patients with moderate-to-severe AR and having at least one troublesome symptom listed on the ARIA guidelines consulted with ENT experts.
The 2 general coping strategies are: (1) problem-focused strategies which represent actively doing something to decrease stressful circumstances, and (2) emotion-focused coping strategies that require increased efforts to modulate the emotional consequences of stressful events. Further subdivision of coping strategies is done into an engagement or disengagement type. An engagement coping strategy involves efforts face stressors that in long run decrease long-term psychological and physiological discomforts. A disengagement (avoidance) coping strategy on other hand helps to control exposure to the unpleasant experience (for a short term).But, often in long run leads to physical and psychological distress. Therefore, people who show emotional (disengagement coping) can develop depression, anxiety, and somatic and social dysfunctions symptoms. On other hand, problem-focused coping is linked to less psychosocial dysfunction.
In our study, [Table 4] the mean score of disengagement-based coping (D) (mean = 21.56, SD = 7.43) strategies was higher than engagement-based coping strategies (E) (mean = 20.85, SD = 6.13). Among the other coping mechanisms, the mean score of problem-focused coping mechanisms (PFE) (mean = 12.37, SD = 4.13) were higher than emotion-focused coping mechanisms (mean = 8.37, SD = 3.99).
Braido et al. in a study which is similar to the present one in methodology except that they used Profile of Mood States (POMS) to rate subjective perception of mood of the patients, reported in their sample of 232 subjects that the coping strategies used by their study patients and their mood disturbance (as measured by POMS) had no relation either to the category (intermittent vs. persistent) or category (mild vs. moderate-severe) of AR. Therefore they concluded that even those with severe disease would ignore the problem and not get treated as they ascribed their suffering to the surrounding environmental factors rather than the disease process itself. Therefore, they remained undetected and undertreated. Present study also has similar findings as most subjects study tried to avoid or maladapt to the illness rather than using healthy emotional coping [Table 4]. Also the predominantly male sample in our study used problem focused coping as against emotion based coping in females subject (probably compared to males, females are more emotional). No such difference was quoted by the authors in the former one.
Besides our study had more subjects from the lower and middle income group who face more financial restraints and lack of development opportunities, So evidently avoiding or ignoring their symptoms seem to be a better coping mechanisms among them.,
Table 5 reveals a significant correlation between RSDI and QoL at 0.01 and 0.05 level. It was observed that increasing in the functional complaints negatively affects the PF part of QoL (r = 0.357) at 0.01 level. A similar study using SNOT 22, found that sleep and ear symptoms had a negative impact on QoL in adults with persistent allergic rhinitis which should be routinely checked in their clinical evaluation.
Benninger and Benninger conducted a study for determining the effect of AR on sexual function, sleep, and fatigue and productivity (which decreased even if subjects reported to work). They found that patients with AR were more affected on the sexual and sleep RSDI scores than the patients without AR. In AR subjects fatigue scores were higher, still difference between the AR and non-AR patients in this aspect was not significant.
In another study on AR many subjects reported not being satisfied with the care provided by doctors who finally led to decrease in compliance and an increased reliance on multiple drugs and nonspecific products. The authors reported that good doctor patient relationships also increased treatment compliance.
| Conclusions|| |
AR is a chronic and disabling condition and the present study shows that the sample which was predominantly male used more emotional type of coping than rational. Moreover, due to less “awareness” about the disease the subjects tend to bear unwanted distress and present late for treatment for a very common and imminently treatable condition. This can further precipitate or aggravate the psychological symptoms. Even recent treatment (ARIA) guidelines have been developed for moderate-to-severe category AR keeping the psychosocial dysfunction in mind. So, we suggest that psycho-education and symptom specific counseling should be made part of therapeutic management essentially to improve the fate of AR subjects.
The study has a small sample size and limited demographic selection being a onetime hospital based cross-sectional study; as only more severe cases may present to the hospital. Therefore a cause and effect relationship cannot be established. Lack of a control group can be a relative limitation but it is not required as RSDI is disease specific instrument and hence cannot be applied to healthy subjects. Furthermore, other larger community-based studies have used surveys that may less power than the present study which used standardized scales.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Varshney J, Varshney H. Allergic rhinitis: An overview. Indian J Otolaryngol Head Neck Surg 2015;67:143-9.
Chandrika D, Allergic rhinitis in India: An overview. Int J Otorhinolaryngol Head Neck Surg 2017;3:1-6.
Deb A, Mukherjee S, Saha BK, Sarkar BS, Pal J, Pandey N, et al
. Profile of patients with allergic rhinitis (AR): A clinic based cross-sectional study from Kolkata, India. J Clin Diagn Res 2014;8:67-70.
Strachan D, Sibbald B, Weiland S, Aït-Khaled N, Anabwani G, Anderson HR, et al
. Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: The International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Allergy Immunol 1997;8:161-76.
Pawankar R, Canonica GW, Holgate ST, Lockey RF. World Allergy Association (WAO) white Book on Allergy. Milwaukee (WI): World Allergy Association; 2011.
Katelaris CH, Lai CK, Rhee CS, Lee SH, Yun WD, Lim-Varona L, et al
. Nasal allergies in the Asian-Pacific population: Results from the Allergies in Asia-Pacific Survey. Am J Rhinol Allergy 2011;25 Suppl 1:S3-15.
Passali D, Cingi C, Staffa P, Passali F, Muluk NB, Bellussi ML. The international study of the allergic rhinitis survey: Outcomes from 4 geographical regions. Asia Pac Allergy 2018;8:e7.
Ahmed MA. Comparative data on prevalence, economic burden and epidemiology of allergic rhinitis between USA and India. J Evolut Med Dent Sci 2016;5:2840-2.
Jaggi V, Dalal A, Ramesh BR, Tikkiwal S, Chaudhry A, Kothari N, et al
. Coexistence of allergic rhinitis and asthma in Indian patients: The CARAS survey. Lung India 2019;36:411-6.
] [Full text]
Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol 2010;125:S103-15.
Giavina-Bianchi P, Aun MV, Takejima P, Kalil J, Agondi RC. United airway disease: Current perspectives. J Asthma Allergy 2016;9:93-100.
Brozek JL, Bousquet J, Agache I, Agrawal A, Bachert C. Allergic rhinitis and its impact on Asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol 2017;140:950-8.
Meltzer EO. Quality of life in adults and children with allergic rhinitis. J Allergy Clin Immunol 2001;108:S45-53.
Shah A, Pawankar R. Allergic rhinitis and co-morbid asthma: Perspective from India-ARIA Asia-pacific workshop report. Asian Pac J Allergy Immunol 2009;27:71-7.
Open Epi-Open Source Epidemeologic Statistics for Public Health, Version 3.01. Available from: https://www.openepi.com
. [Last updated on 2013 Apr 06].
Benninger MS, Senior BA. The development of the rhinosinusitis disability index. Arch Otolaryngol Head Neck Surg 1997;123:1175-9.
Lins L, Carvalho FM. SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE Open Med 2016;4:1-12.
Addison CA, Campbell-Jenkins BW, Sarpong DF, Kibler J, Singh M, Dubbert P. Psychometric evaluation of a coping strategies inventory short-form (CSI-SF) in the Jackson heart study cohort. Int J Environ Res Public Health 2007;4:289-95.
Carver CS. Active coping. In: Michalos AC, editors. Encyclopedia of Quality of Life and Well-Being Research. Dordrecht: Springer, Dordrecht; 2014.
Zacharisen M. Rhinitis in children, adolescents, the elderly, and pregnant women. Immunol Allergy Clin North Am 2000;20:424-55.
Mathur SK, Schwantes EA, Jarjour NN, Busse WW. Age-related changes in eosinophil function in human subjects. Chest 2008;133:412-9.
Jarvis D, Luczynska C, Chinn S, Potts J, Sunyer J, Janson C, et al
. Change in prevalence of IgE sensitization and mean total IgE with age and cohort. J Allergy Clin Immunol 2005;116:675-82.
Sinha B, Vibha RS, Chowdhury R. Allergic Rhinitis: A neglected disease A community based assessment among adults in Delhi. J Postgrad Med 2015;61:169-75.
] [Full text]
Chen H, Katz PP, Eisner MD, Yelin EH, Blanc PD. Health-related quality of life in adult rhinitis: The role of perceived control of disease J Allergy Clin Immunol 2004;114:845-50.
Elkholy MM, Khedr MH, Halawa A, Elbaramawy A. Impact of allergic rhinitis on quality of life in patients with bronchial asthma. Int J Health Sci (Qassim) 2012;6:194-202.
Hoehle LP, Marlene M, Speth MM, Phillips KM, Robert A, Gaudin RA, et al
. Association between symptoms of allergic rhinitis with decreased general health-related quality of life. Am J Rhinol Allergy 2017;31:235-39.
Ye L, Miao J, Di R, Zhao Y. The interactive correlation of pain, negative emotion, insomnia and quality of life in Allergic Rhinitis patients. Int J Clin Exp Med 2016;9:16263-272.
Zhang F, Nie C, Wang L, Rosenberg M, Xu J, Krafft T, et al
. The disease burden of patients with allergic rhinitis from a hospital surveillance in Beijing. Sustainability 2017;9:427.
Addison C, Jenkins BC, Letetia Addison L, Wilson G, White M, Bland V, et al
. Coping strategies and self-reported cardiovascular disease in the Jackson heart study cohort. Public Health Preventive Med 2018;4:95-101.
Braido F, Baiardini I, Scichilone N, Musarra A, Menoni S, Ridolo E. Illness perception, mood and coping strategies in allergic rhinitis: Are there differences among Allergic Rhinitis and its Impact on Asthma (ARIA) classes of severity. Rhinology 2014;52:66-7.
Pourmohamadreza-Tajrishi M, Azadfallah P, Hemmati Garakani S, Bakhshi E. The effect of problem-focused coping strategy training on psychological symptoms of mothers of children with down syndrome. Iran J Public Health 2015;44:254-62.
Glasscock DJ, Andersen JH, Labriola M, Rasmussen K, Hansen CD. Can negative life events and coping style help explain socioeconomic differences in perceived stress among adolescents? A cross-sectional study based on the West Jutland cohort study. BMC Public Health 2013;13:532.
Benninger MS, Benninger RM. The impact of allergic rhinitis on sexual activity, sleep, and fatigue. Allergy Asthma Proc 2009;30:358-65.
Marple BF, Fornadley JA, Alpen A, Patel AA, Fineman SM, Fromer L, et al
. Keys to successful management of patients with allergic rhinitis: Focus on patient confidence, compliance, and satisfaction. Am Academy Otolaryngic Allergy Working Group Allergic Rhinitis Otolaryngol Head Neck Surg 2007;136:S107-24.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]