Young Adults and Allergic Rhinitis: A Population Often Overlooked but in Need of Targeted Help

Abstract

Allergic Rhinitis (AR) currently affects 27% of young adults (18–24 years old) in Australia. Although the nature of AR and its management are well-researched in adult and paediatric populations, little is known about young adults. Given the biopsychosocial developmental challenges faced by young adults, this study aims to investigate young adults’ AR management and the source of its influence. A total of 185 young adults with AR in Australia completed an online survey. Seventy-eight percent were female and had a mean age of 21.9 years old. The majority (99%) had moderate to severe symptoms and affected at least one aspect of their quality of life (97%). Despite this, only 11% of participants were using appropriate medications. Parents (50%) were the most common influencer in young adults’ medication use, and general practitioners were most commonly sought for information (63%) and advice (70%). Young adults do not manage their AR with appropriate medications despite consulting healthcare providers, and this was reflected in the heavy burden reported on their quality of life. This study bridges our gap in understanding and shows that young adults lack developmentally appropriate support to equip them with the health literacy skills required to transition into adult healthcare.

1. Introduction

Allergic Rhinitis (AR) affects 27% of young adults in Australia, especially those between 18 and 24 years old. AR is the second most common chronic condition in this age group [1]. It is well understood that when AR is undertreated or untreated, it impinges a significant burden on the quality of life of children and adults from both an individual and socioeconomic standpoint. Uncontrolled AR impairs sleep quality, the ability to concentrate during the daytime, and the ability to take part in social, educational, and workplace activities [2,3]. The nature of AR and its management are well-researched in both adult and paediatric populations; however, our understanding of AR in young adults is still currently limited [2].

Uncontrolled AR has also been shown to increase the risk of uncontrolled asthma and, therefore, elevate asthma-related burden. This information increases the significance of asthma being listed in the top five causes of health-related burden for young adults and highlights the importance of developing an understanding of how AR is managed in this age group [1]. While interventions designed to support young people with asthma have been explored and delivered, the same attention has not been given to AR [4]. Given that AR can be a lifelong condition if not resolved by allergen immunotherapy, this gap is important and must be addressed. Young adults have unique health attitudes and management behaviours that are influenced by the developmental and psychosocial challenges they experience [5,6].

Although young adults have an increased independence and responsibility, they also have increased risk-taking behaviour and lower healthy behaviours, including sleep, diet, and exercise. The health of young adults shows a decline from adolescence because they are no longer being cared for and monitored by their parents [7]. The health behaviours of young adults are characterised by their poor treatment adherence, increased prevalence of chronic conditions, mental health challenges, and health-damaging behaviours [6,8,9]. Multiple studies have reported a lack of support as young adults transition from child to adult in the healthcare systems [5,8,10]. Davey et al. (2013) reported that young adults would need advice on how to communicate with their healthcare providers to develop assertiveness and to make informed health management decisions, both of which are required to manage AR [10]. Therefore, it is important to investigate how these unique challenges influence their AR management strategies and the nature of their AR networks [6,11].

Given that AR is a predominantly self-managed condition and the unique biopsychosocial developmental challenges faced by young adults, understanding how young adults perceive and manage their AR is paramount if healthcare providers are to support them effectively [12]. This study aims to explore young adults’ AR status, how they manage their condition, and the sources of influences associated with their AR management practices.

2. Materials and Methods

This study used a cross-sectional observational study to collect data using an anonymous online survey (Appendix A) to elicit young adults’ AR status, how they manage their condition and influences associated with their AR management. This survey was available online for completion September 2020–September 2023. All participants were provided with brief information about the study and then asked to provide informed consent prior to participating in this study.

2.1. Participant Recruitment

This study recruited potential participants via social media (Facebook, Linkedin, Twitter, and Google), recruitment agency (HealthMatch), Woolcock Institute of Medical Research’s volunteer portal, and universities (University of Sydney’s volunteer portal and Student News, the University of Canberra Canvas site for students who were in the following courses: Medical Imaging, Speech Pathology, Psychology, Public Health and all initial teacher education subjects in Early Childhood and Primary and Secondary Teaching).

Potential participants were sent a public survey link generated by Research Electronic Data Capture (REDCap), where the participant information sheet can be found. Once they consent, potential participants were screened for eligibility for this study. Participants who were 18–26 years old, have experienced AR or nasal allergies, and resided in Australia were eligible. Participants who did not have AR, did not complete the survey, or are not within the age range were excluded from the study.

Once they were deemed eligible for the study, they were asked to complete the survey, which took approximately 10 min to complete.

2.2. Survey Development

The survey was developed based on empirical evidence relating to AR [6,11,13,14,15,16,17]. The questions in the survey relate to the severity of their AR symptoms they experience and how they manage their symptoms, i.e., the medication use and who they ask for advice and more information when they need it for their AR management.

2.3. Data Collection

Deidentified data were collected using an online survey on REDCap that collected data on the following domains:

(1)

Demographics:

• Age
• Gender
• Occupation

(2)

AR status:

• Frequency and severity of AR symptoms experienced
• Burden of AR on quality of life
• Diagnosis of AR

(3)

AR management:

• Medications and/or non-pharmacological management strategies used to manage AR
• Medication appropriateness
• Medication-taking behaviour
• Medication access

(4)

Influence associated with AR management

• AR networks that include the individuals consulted and resources used to make decisions on AR management

2.4. Data Management

(1)

AR status: The AR status for this study was classified into four categories: mild-intermittent, mild-persistent, moderate-severe intermittent, and moderate-severe persistent, based on the severity and frequency of symptoms reported.

• Severity of symptom(s): The severity of symptoms was determined by the degree of burden of each symptom experienced, rated on a visual analogue scale (VAS) in response to the question “At its very worst, how bothersome is this symptom?”, it was determined for this study that <20 mm is mild, 20–49 mm is moderate and ≥50 mm is severe [18]. The highest VAS score recorded among all the symptoms reported was then used to determine the overall AR status as mild or moderate-severe.
• Frequency of symptom(s): The AR symptoms that occurred less than 4 days per week or less than 4 weeks per year were classified as intermittent, and AR symptoms that occurred more than 4 days per week and more than 4 weeks per year were classified as persistent [19]. Although AR can be classified into intermittent and persistent, this classification does not influence the treatment recommended, as treatments are recommended based on the severity of symptoms [18].

(2)

Medication appropriateness: The appropriateness of medications used by participants was based on the participant’s AR status and the medications they reported using. The participants’ appropriateness of medication use was determined “optimal” if it was consistent with current guideline recommendations [18]; otherwise, it was deemed “sub-optimal”.

2.5. Data Analysis

IBM SPSS Statistics Version 29 and GraphPad Prism Version 9 were used analyse the data and generate the figures in results, respectively. Descriptive analysis was performed on demographic data, AR status, burden on quality of life, medications use, and patterns of medication use. Categorical variables were analysed using the Pearson Chi-square test, and continuous variables were analysed using the independent sample t-test.

3. Results

3.1. Demographics

Participants were recruited between September 2020 to September 2023. Of the 255 participants who accessed the survey, 98% (n = 252) consented, and 73% (n = 185) were eligible for the study. Seventy-eight percent (156/185) of participants were females, and the mean (s.d) age was 21.9 (2.3) years old. Seventy-nine of the participants were students, with 14% working, 3% unemployed, and 2% in other professions. The majority (96%, 177/185) reported that they are responsible for managing their condition, and the age at which they start to take responsibility for their AR management ranges from 4 to 24 years old with a mean (s.d) age of 15.8 (2.9) years old.

3.2. AR Status

Participants mostly experienced sneezing (92%) at a severe level (mean VAS = 69), runny nose (88%) at a severe level (mean VAS = 75), and itchy eyes (79%) also at a severe level (mean VAS = 78) (Figure 1). The other symptoms (12%) experienced include coughing, difficulty breathing, fatigue, headache, itchy skin, itchy ears, watery eyes, sore throat, swollen eyes, and painful sinuses. More than half of the participants’ AR status were classified as moderate-severe persistent (61%), followed by moderate-severe intermittent (38%), mild intermittent (0.5%), and mild persistent (0.5%). Thirty-four percent of participants reported having coexisting asthma.

The majority of the participants (97%) reported that their symptoms affect at least one aspect of their quality of life in Figure 2, with symptoms most commonly reported as generally troublesome (74%) followed by the impact on their study/work productivity (63%) and daily activities (62%).

3.3. AR Management

The majority manage their AR with medication only (56%), 35% manage with both medication and non-pharmacological strategies and 3% manage with non-pharmacological strategies only.

Of those who reported managing their AR using non-pharmacological strategies (n = 69), trigger avoidance was the most common strategy used (19%), followed by saline wash (13%), staying indoors (10%), and having a hot shower (10%).

Of those who reported managing their AR with medication (91%, 167/185), 89% of the participants purchased their medication for themselves and predominantly from the pharmacy (86%) and supermarket (37%), as shown in Figure 3. More than a third of the participants purchase medication from more than one location (e.g., pharmacy and supermarket).

The medications reportedly used by the participants were compared against guideline recommendation medications in Figure 4. Overall, only 11% (19/167) of participants were using optimal medications for their reported AR status. Oral antihistamines were taken by 92% of the participants to manage AR, but only 1% of the participants should be recommended according to the guidelines. Intranasal corticosteroids were taken by 38% of the participants but recommended for 94% of participants.

The frequency of medication use by participants is portrayed in Figure 5. All medications were most commonly taken daily when participants were experiencing symptoms, especially for antihistamine tablets (44%), antihistamine nasal spray (39%), anti-inflammatory nasal spray (43%), antihistamine eyedrop (38%), and cold and flu tablets (44%). However, saline washes are most commonly taken only when participants are exposed to a trigger (46%).

3.4. Influences Associated with AR Management

Participants report on how they realised they have AR in Figure 6. More than half of the participants (56%) have had AR since childhood, and 51% were told by their parents. Participants were most commonly self-diagnosed (44%) and officially diagnosed by general practitioners (GPs) (42%), followed by specialists (18%) and pharmacists (14%).

As seen in Figure 7, parents were the most commonly reported influencer (50%) in participants’ medication use, followed by GPs (47%) and experiments based on past experience (43%).

Participants most commonly seek a GP for more information about their AR medication (63%) and advice when their AR medication stops working (70%), as shown in Figure 8. This pattern is followed by pharmacists (55% vs. 48%, respectively) and the internet (54% vs. 28%, respectively).

Participants ranked the three most important influencers in their AR management in Figure 9. Overall, GPs were the most important influencer followed by pharmacists. Comparing the three rankings, GPs were the most important influence in the first (33%) and third (21%) rankings, whereas pharmacists were most important in the second rank (31%).

4. Discussion

To our knowledge, this research into young adults’ AR status, management behaviours, and influences associated with AR management is the first of its kind. This study shows that the AR status of young adults was mostly moderate-severe and revealed that AR places a significant burden on their day-to-day lives. This burden is not surprising as it was indicated that the majority of this cohort was managing their AR with inappropriate medications that were not effective in treating the severity of their symptoms. This study also showed that GPs, pharmacists, parents, and personal experience were most commonly used to guide young adults’ AR management, demonstrating that healthcare professionals (HCPs) advice is still valued and important in the digital age among the digital generation. These findings highlight a disconnect between the influences on young adults’ AR management and the outcomes of their management behaviours. This study has enabled the identification of priority areas for improving AR in young adults and lays the foundation for future investigations of AR and more in-depth qualitative research with this cohort. A particular focus should be placed on the quality of care provided to young adults during their transition to adult healthcare.

Almost all participants in this study had moderate-severe AR. This is consistent with the research conducted in the adult population with AR in community pharmacies [20] and is not dissimilar to research conducted with parents of children with AR [21]. Despite this high severity, it was interesting to see that young adults did not report the use of any allergen immunotherapy; there is clearly a need to have this young adult population referred to their doctor to confirm their condition and also for assessment and evaluation of the need for allergen immunotherapy. The high severity of AR experienced by young adults also highlights that they require more support to improve their understanding of AR and its management. This will help them establish good AR management behaviours. Research shows that people with AR can tolerate a very high burden from their AR symptoms and often do not recognise that, with appropriate medication and management, their symptoms can be treated effectively [22].

It was also observed that most young adults reported that AR impacted on at least one aspect of their day-to-day living. In this study, just over half of the cohort experienced an impact associated with their sleep quality and work or study productivity, and also over half of the participants were experiencing nasal congestion. These two findings have been directly linked in previous studies [23]. In adult populations, AR-related sleep impairments have been associated with reduced daytime productivity, high levels of absenteeism, and presenteeism and have also been reported to burden people’s mental health [24]. During young adulthood, biological and developmental changes are known to alter the sleep cycle and reduce sleep duration [25]. When the burden of AR-induced sleep impairment is combined with the sleep challenges already faced by young adults, the burden of sleep impairments on young adults may be exacerbated further. These results highlight the importance of improving medication management and AR control in young adults, particularly as intranasal corticosteroids have been found to reduce nasal congestion and its associated sleep impairments [19,26].

Another result that highlights the importance of addressing AR in young adults is the significant proportion of study participants with an asthma diagnosis. More than one-third of study participants have coexisting asthma, which is slightly higher than what has been reported in other studies but remains in line with reports on the AR-asthma comorbidity [14,19,27]. For people experiencing co-morbid AR and asthma, the importance of appropriate AR management is heightened due to the united nature of both conditions [13,28]. The upper and lower airways are closely linked, and sub-optimal AR management can impair asthma management and may increase the likelihood of asthma exacerbations in these patients [27]. The use of appropriate medications can reduce the asthma burden imposed by AR [29]. Participants with asthma were not managing their AR significantly better than those without, suggesting that HCPs could do more to discuss AR management with patients presenting with asthma.

This study also identified that, as with the general AR population, most young adults use inappropriate medications to manage their AR. Only 11% of the study participants were using medications that are appropriate to treat the severity of their symptoms. This is in line with the results of a recent Australian study, which found 15% of adults with AR selected optimal medications [20]. These results are reflected by the high number of participants experiencing an AR burden on their day-to-to day living. In reviewing the medications used, the majority were using antihistamine tablets. Although this finding is consistent with many other studies investigating AR medication use in adults [20,30,31] and oral medications are known to be patients’ preference, the high level of antihistamine tablets use in this cohort is not appropriate for their predominant moderate-severe AR status. Instead, anti-inflammatory nasal spray should be recommended as their first-line medication [13], however this was only reported to be used in just over a third of participants. The management of AR with inappropriate medication shows that both pharmacists and GPs need to be aware of the current guidelines for AR and also patients’ perceptions in their self-management of AR. Currently, there are still unmet needs in GP practices, as some are not aware of the current AR guidelines to recommend the most appropriate medication and allergen immunotherapy [32].

While it is important that people with AR are aware of the most appropriate medication for their AR, they should also be aware of the optimal way to use the medication. Exploration of the young adults and the resources they accessed for their AR management decision-making revealed that HCPs played an important role. The study participants with a formal diagnosis were most commonly diagnosed by a GP, and they also reported that their AR management was influenced by their HCP. In the young adult age group, although the influence of parents on AR medication use remains high, they do seek GPs or pharmacists for more information on AR, and, most importantly, when their AR medication stopped working.

In addition to HCPs, young adults in this study relied heavily on their parents for guidance on how to treat their AR with medication, which may indicate they are still undergoing transition into becoming autonomous adults [33]. The high burden of AR and severity of symptoms in this young adult cohort indicates that the management of the transition process for young adults needs to be improved. As young adults transition from adolescence to adulthood, they need to be empowered with health literacy skills that enable them to become competent and confident in self-managing their AR [5,33]. Supporting the development of these skills will benefit young adults’ AR management both now and in the future by helping them to communicate with HCPs, reducing the trivialisation of AR, guiding appropriate medication selection, and ultimately reducing the likelihood they will experience feelings of treatment fatigue [15]. HCPs will need to support young adults’ self-management needs in AR and provide appropriate medication recommendations. HCPs must consider the unique biopsychosocial developmental characteristics of young adults and address these by providing developmentally appropriate support [33,34]. Well-equipped and trained HCPs can effectively manage young adults undergoing transition to adult healthcare [33]. HCPs should spend time listening to young adults and work to embed health education in their conversations with young adults [33]. By engaging with young adults in a supportive way, HCPs can develop young adults’ feelings of self-efficacy and autonomy; in turn, young adults will be more inclined to view their interactions with HCPs positively and are more likely to return for advice in the future [5,34,35].

This study also showed that the majority of participants in this study purchased their AR medication in the pharmacy, highlighting the importance of pharmacists as an influence on young adults’ AR management. Pharmacists are well placed to identify people’s AR severity, increase their awareness of the importance of managing AR appropriately, recommend appropriate medications, and refer them to GPs or specialists if necessary [13,36]. Many people with AR believe they should be able to manage the condition without needing to consult a HCP, particularly due to the high availability of over-the-counter medications in Australia [22]. Although some young adults approached a pharmacist in this study, there is still a fair proportion who don’t and may not realise that they should consult HCPs about their AR and may be less confident in approaching pharmacists to ask for advice [10]. When dealing with young adults, pharmacists may need to approach the patient first and must make it clear that they have the time and knowledge to discuss AR with young adults [5,33,35].

Given that young adults in this study deemed the internet as one of their main sources of information on AR, technology and mobile health (mHealth) can provide readily accessible support for people with AR and is recommended in the EAACI transition guidelines for young adults [33,36]. It is, therefore, important that mHealth is promoted as a reliable resource. Mobile Airways Sentinel Network (MASK)-Air^®, a mHealth application initiated and developed by ARIA utilises a clinical decision support system (CDSS) to monitor and evaluate AR status and medication use [36]. Given that the internet is one of the main sources that young adults seek for information on AR, this can help support young adults’ self-management, AR awareness, and their symptom control.

When considering the results of this study, the following limitations must be considered. The study participants’ AR was not reported to be confirmed by HCP or Immunoglobulin E (IgE) test. It is possible that some participants were not experiencing AR and may have had non-allergy-related rhinitis [37]. Another limitation is that given that almost all participants had moderate-severe AR, these results are only appropriate for young adults with moderate-severe AR, and the application of these results in a young adult population with mild AR should be considered carefully. Using a recruitment strategy of advertising the study at the University may have introduced the risk of bias in this study as the participants may have a higher level of education and, therefore have higher health literacy skills than other young adults. However, this research does provide insight into a population with AR that has thus far not been researched, and the future research into young adults with AR should be explored.

5. Conclusions

The results of this study have revealed that despite seeking advice from appropriate sources of information, most young adults with AR manage the condition sub-optimally. As a result of this poor management, they are experiencing a substantial AR-induced burden on their day-to-day living. While participants valued GPs and pharmacists, they also relied heavily on their parents’ influence on their medication use, indicating they were undergoing a period of transition to adult healthcare. The aforementioned gap between the quality of influences and their management behaviours suggests that young adults with AR are not provided with adequate support as they transition to adult healthcare. It is therefore important to establish a developmentally appropriate transition process that encourages feelings of autonomy and self-efficacy in young adults with AR to improve their current management behaviours in AR. To achieve this, further investigation into the interactions between young adults and their HCPs and their perspectives about their AR will help identify gaps in the transitional care provided to young adults with AR.