Allergic conditions and allergic rhinitis (AR)
Allergic conditions are common, and their prevalence is increasing worldwide.1,2 The concomitant relationship of allergic conditions with asthma, rhinitis, sinusitis and urticaria is widely accepted.3 The severity of these and their subsequent impact on the individual’s quality of life, as well as health and economic systems, have been under investigation as a matter of urgency.4
As an allergic condition of the upper airways, AR has been described as the most ‘modern’ of allergic conditions, escalating over the past 50 years.4 After exposure to an allergen, allergic rhinitis develops in susceptible individuals as a result of an IgE-mediated inflammation5 generally presenting as nasal discomfort with sneezing, discharge and/or congestion. However, other physical symptoms involving itching of the eyes, ears and throat may be experienced along with headaches, fatigue and sleeping difficulties.
AR is not specific to age, gender, race, ethnicity or culture, although genetic pre-disposition, environmental and lifestyle interactions may contribute to an individual’s risk of developing the condition.4 The prevalence of AR in Australia closely parallels the statistics observed for Europe. Approximately 16% of Australians suffer from AR including 25% of younger adults aged 25–44 years.6
To more fully understand the impact of this condition and deliver appropriate treatment, AR is categorized according to the duration and frequency of symptoms.7 If a patient experiences symptoms for <4 days a week and for <4 weeks continuously in a year, then the episode is categorized as ‘intermittent’ AR (IAR). If a patient experiences symptoms occurring for more than 4 days a week and for more than 4 weeks continuously in a year, then the episode is categorized as ‘persistent’ AR.7,8
Treatment and management
Conservative treatment plans, with the emphasis on pharmacotherapy for immediate relief of symptoms have not reduced the allergy ‘epidemic’.2 As an alternative to this dependency on medication, a model based on preventative management plans has been implemented via a nationally coordinated approach in the Finnish Allergy Program.2 Others suggest that optimal treatment regimes should comprise multifaceted programmes with patient education, allergen avoidance, pharmacotherapy, allergen-specific immunology and possibly surgery.3–9
Treatment plans based primarily on pharmacology may be further constrained by patient adherence rates. An Australian AR study reported that 46% of patients who categorized themselves as having ‘moderate’ symptoms, ‘sometimes’ took their medication.10 Similarly, poor adherence to asthma medications has been explained in terms of patient concerns about possible side effects of medications taken long term.11 Within the general population in developed countries, non-adherence to long-term therapies for patients with chronic diseases has been described as a ‘world wide problem of striking magnitude’.12 The issue of non-adherence continues in spite of the safety profile of medications such as antihistamines being studied and positive outcomes reported.13 This situation has given rise to the claim that ‘minimal medical intervention is universally desirable’.3 Patients’ poor adherence supports the need for a multifaceted approach for AR treatment plans.
One such approach is the process of goal setting in assisting patients to self-manage chronic disease. Studies incorporating goal setting into a disease state management service have been reported in case of asthma,11,14,15 diabetes16 and hypertension in older men17 and with conditions such as pain18 and weight loss.19,20 An innovative approach using goal setting to help people self-manage their IAR was piloted in community pharmacies in Sydney, Australia, in 2005.21 The findings from this study demonstrated the value of a goal-setting intervention in achieving improvements in IAR-related clinical and humanistic outcomes20 and supports the notion that a multifaceted individualized collaboration between patients and health-care professionals (HCP) has the potential to ease the allergy burden to the patient. This approach was refined and implemented on a larger scale – the Pharmacy Allergic Rhinitis Intervention Service (PARIS). The outcomes of this study demonstrated the value of training non-clinicians in the goal-setting intervention for people with IAR.21
The goal-setting process involves identifying the particular symptoms and triggers that affect the individual patient and devising strategies that will enable them to meet the goal of minimizing or eliminating the said symptom(s) and trigger(s). What is not known at this stage, however, is neither an understanding of the types and range of strategies that are devised as part of a self-management intervention conducted between HCP and patients with IAR nor their value in minimizing or controlling the symptoms and triggers of this chronic condition. This paper reports the findings of an exploration of these factors by analysing data gathered for the intervention arm of the PARIS project. That is, data were retrieved from the records of the intervention group participants and as such provides a secondary analysis of a section of the randomized control trial. Data regarding symptoms, triggers and their related strategies were not part of the control group study design.
The aims addressed in this paper are to (i) examine the range and proportion of symptoms and triggers experienced by a sample of patients suffering from IAR; (ii) conduct a qualitative analysis of strategies that were undertaken by these patients to control their symptoms and triggers; and (iii) measure medication adherence.