Associations between gender and health‐related quality of life in people with IgE‐mediated food allergy and their caregivers: A systematic review

Understanding factors that impact health‐related quality of life (HRQL) is essential to inform personalised food allergy management. However, there are inconsistencies about the impact of gender on HRQL in food allergy. This review aimed to collate all investigations of the association between gender and total or subdomain HRQL scores of individuals with food allergy and their caregivers.


| INTRODUC TI ON
2][3] However, these reviews were restricted by limited considerations of patient demographics, especially gender, in the existing literature at the time they were completed.Understanding factors that impact HRQL is essential to inform personalised allergy management and identification of those most in need of intervention.No recent collation of gender-related evidence has been conducted and the modifying role of gender on the association between food allergy and HRQL is not well understood.
Sex and gender differences in HRQL have been observed in other allergic conditions, though are conflated and limited to investigations of the gender binary.An investigation of venom allergy found women had poorer anxiety-related HRQL, especially after experiencing anaphylactic reactions, than men. 6Similarly, poorer asthma-related HRQL was observed in women, despite having similar disease statuses and management practices as men. 7][10] A previous food allergy review did suggest girls reported lower scores in most areas of HRQL than boys, though was restricted by limited existing literature and HRQL was not considered in the presence of intervention. 29][20][21][22][23] Poorer HRQL has been shown in caregivers, mostly mothers, where the experience of food allergy-related anxiety was suggested to be the largest contributing factor. 24An overrepresentation of mothers in the food allergy literature has been noted and can likely be attributed to gender roles in parenting. 1,2,25Mothers are still most often responsible for managing elements of family life that can be affected by food allergy, such as meal Systematic Review Registration: PROSPERO (CRD42022329901).

K E Y W O R D S
food allergy, gender, immunotherapy, quality of life

G R A P H I C A L A B S T R A C T
We systematically reviewed the impact of gender on health-related quality of life (HRQL) in populations with immunoglobulin-E-mediated food allergy.Females with food allergy self-report poorer baseline HRQL than males, regardless of age.Gender may impact total HRQL and subdomain HRQL in food allergy studies.However, selective reporting and narrow considerations of gender in included studies limited the strength of the findings.

Key messages
• Females with food allergy self-report poorer baseline quality of life than males, regardless of age.
• Caregiver gender did not affect proxy-reported child quality of life.
• Broader considerations of gender are needed to understand the lived experience of food allergy.preparation, social outings and healthcare. 2,25Little is yet known about the food allergy-related experience of mothers in relation to other caregivers.Exploration of HRQL across caregiver genders is needed to fully understand the scope of the food allergy burden.
A holistic understanding of the complex interactions between gender and HRQL in food allergy is needed to improve personalised allergy management and understanding of treatment impact.Here, we present a systematic exploration of the existing literature regarding gender influences on food allergy-related HRQL in the setting of standard care (allergen avoidance) and following food allergen intervention, considering both patient and caregiver perspectives.

| ME THODS
This review was conducted and reported consistent with PRISMA guidelines. 26

| Search strategy and selection
A systematic search of Medline and Embase databases was performed, inclusive of all scientific records published between database inception and 4th April 2022.
Search terms were developed in consultation with a biomedical librarian and included terms for 'food allergy' and 'quality of life' (see Figure S1 for the full set of included terms).Search terms for 'sex' and 'gender' were omitted from the search strategy, such that studies investigating the associations between these and HRQL in secondary or subgroup analyses that were not referenced in the publication's title or abstract would not be missed.

Covidence reference management software (Veritas Health
Innovation, Melbourne, Australia) was used to remove duplicate records identified by our search.To reduce selection biases, title and abstract screening was independently performed by two authors to exclude studies clearly outside the scope of the review before full-text review was conducted for the remaining studies to confirm eligibility.
We limited our review to English language studies reporting original HRQL data (as measured with a validated questionnaire) between any sexes and/or genders in populations with IgE-mediated food allergy.Studies investigating HRQL in populations with allergic conditions other than IgE-mediated food allergy were excluded.
Additionally, studies investigating multiple allergic conditions were excluded unless isolated data for participants with food allergy was provided.Interventional and observational studies were both eligible, including any form of intervention (e.g.medicinal, educational, psychological or otherwise) or exposure of interest.As terms for gender and sex may be used interchangeably in the literature, investigations of both concepts were eligible for inclusion.Grey literature, narrative reviews, opinion pieces, conference abstracts, case studies and other systematic reviews were excluded, as these do not contain original research with original datasets, suffer from limited reporting of results (abstracts), or do not recruit a sufficient sample to explore a gender association.

| Data extraction
A bespoke excel spreadsheet was designed and piloted for extraction of study design and HRQL outcome data, including a description of the HRQL instrument used.Data extraction was independently performed by one author and reviewed by a second in May 2022.In the case where HRQL scores for the sex or gender subgroups were not reported, p-values for tests of group differences (i.e.comparing HRQL in males compared to females) were extracted.Special attention was paid to the definition of gender (social construction) or sex (biologically determined) used in studies to allow the association of these paradigms with food-allergy-related HRQL to be explored and to facilitate appropriate comparison of study results.

| Critical appraisal
Quality assessment was performed using the ROBINS-I tool for interventional studies (inclusive of all domains). 27The ROBINS-I tool generates an overall and domain-specific risk of bias ratings (ranging from low to critical) and encompasses assessment of confounding risk, study methodology quality and reporting quality specific to studies involving intervention allocation. 27As there were few restrictions on study types eligible for inclusion, sensitivity analysis of observational studies of exposures identified in our search was performed using the Launch version (1 June 2022) ROBINS-E tool for non-randomised studies of exposures. 28The ROBINS-E assesses confounding, methodological decisions and selective reporting specific to studies of non-randomised exposures, which may not be adequately achieved by the ROBINS-I. 28The risk of bias results were collated and visualised as a traffic light plot.It is important to note our quality assessments relate to the outcomes investigated in this review only; the risk of bias assessments may not reflect the quality of the included studies in measuring their intended outcomes.

| Data synthesis and analysis
A narrative synthesis of data and heterogeneity assessment was performed through descriptive comparison of study results, due to the diversity of included studies.Results were split by study type (interventional/non-interventional) for each of our project aims, as is recommended by Cochrane for narrative synthesis when a variety of study types are included. 29Care was taken to identify situations where multiple reports have been compiled from a single study to avoid repeated reporting, with the results of these multiple reports being interpreted together.As the included studies investigated a range of sex-HRQL or gender-HRQL associations using a variety of HRQL instruments that produce scores on differing scales (see Table S1 for a description of all HRQL instruments included), findings were synthesised and compared in terms of the direction of the association, clinical significance and statistical significance separately for each association.

| Ethical considerations
Oversight from an ethics review panel was not required for this study.

| Review updates
To ensure our review included the most up-to-date information, a second database search was conducted on the 5th of December 2023.The original search and selection strategy was used to screen all records collected from Medline (from the date of the first search), Embase (from the date of the first search) and APA PsycINFO (from inception).APA PsycINFO was included in this second search to ensure all relevant literature specific to psychosocial health had been captured.Two eligible studies were identified through this process, though were unlikely to impact conclusions and were not added to the existing analysis (Figure S2; Table S2).

| Included studies
The search strategy identified a total of 4799 records between Medline and Embase.After removal of duplicates, 3927 publications were screened through titles and abstracts, 426 were reviewed in full and 34 were included in this systematic review (Figure 1).
Of the included studies, one investigated HRQL across all age groups, 30 five considered only cross-sectional HRQL of adults with food allergy, [31][32][33][34][35] and 28 focused on paediatric populations with food allergy 10, (Table 1). Caregver HRQL was investigated in seven of the studies of children with food allergy.10,36,40,44,49,53,62 Ten interventional studies of children with food allergy were identified by our search, nine of which investigated the effects of immunotherapy on HRQL, [53][54][55][56][57][58][59][60]62 and one of which considered the impact of exclusion diets.61 No studies of intervention in adult populations were identified.A variety of HRQL instruments were used in studies, though age-specific versions of the FAQLQ were the most common.
While studies varied in whether they claimed to investigate the relationship between gender or sex and HRQL, all studies considered these concepts in the same way: according to a biologically determined binary categorisation.We hereby refer to all investigations of these concepts using the broader term 'gender' to reflect the intersectionality between sex and gender in included literature, and as they pertain to relationships with a psychosocial construct: HRQL.
Investigations of gender on HRQL were performed as secondary, subgroup or exploratory analyses in all studies and many did not investigate or report on relevant HRQL subscores or total scores.Consequently, selective reporting of partial results limited the data available for extraction.

| Risk of bias assessment
All studies, except that by Dantzer et al., 54 received serious or critical risk of bias ratings according to the ROBINS-I (Figure 2).The most common sources of bias between studies were in the measurement of the HRQL outcome due to participants and study investigators being aware of intervention or exposure statuses (D6), and via inadequate or inconsistent consideration of confounding factors (D1).
5][36][37] All four studies received a slightly poorer quality assessment with the ROBINS-E for inadequate consideration of major sources of bias.However, ROBINS-E results for all other non-interventional studies were consistent with those obtained using the ROBINS-I.

| Gender-HRQL relationships identified
Collation of included studies revealed five key gender-HRQL relationships: the association between the participant's gender and (1) their self-reported HRQL, (2) their caregiver proxy-reported HRQL, and (3) their caregivers' self-reported HRQL, and also the association between caregiver gender and (4) caregiver HRQL and (5) the proxy-reported HRQL of the participant with food allergy (Figure 3).

| Gender in non-interventional studies
Strong evidence for poorer baseline self-reported HRQL in female than male participants with food allergy was present, regardless of age (Figure 4A; Table S3).Female adults self-reported poorer baseline total or subscore HRQL than males across five of the six cross-sectional studies that investigated adult HRQL.Poorer baseline HRQL scores were also observed in female than male children with food allergy when HRQL was self-reported in five of the eight studies to investigate child gender on child self-reported HRQL.
However, there were differing findings about affected HRQL subscores and between HRQL instruments across studies of child selfreported HRQL.Both Cummings et al. 39 and King et al. 10 observed poorer physical subdomain HRQL as measured with the PedsQL 4.0, while Morou et al. 47 observed no gender difference in any PedsQL 4.0 subdomains.Amongst other studies employing the use of FAQLQ instruments, gender differences were commonly observed in subdomains related to dietary risk and emotional impact.One study observed clinically significantly poorer HRQL in females than males across all subscores of the FAQLQ. 52here was limited cumulative evidence for the associations between child gender or caregiver gender and caregiver proxyreported HRQL (Figure 4; Tables S4 and S5).Only two of the nine studies to report data for proxy-reported child HRQL by child gender observed potentially poorer total HRQL in female than male children, with the rest observing no difference.

| Gender in interventional studies
The change in child HRQL between baseline and follow-up in interventional studies appeared to differ between genders, though the direction and presence of association is unclear (Figure 5).Data provided by three immunotherapy studies suggested a potential gender difference in the change in HRQL between baseline and follow-up.Dantzer et al. 54 observed a strong association between gender and HRQL across all scores and measures, reporting male children experienced greater HRQL improvement during follow-up than their female counterparts.Dunn-Galvin et al. 55 and Reier-Nilsen et al. 62 also produced results that suggest slightly poorer HRQL in one gender after follow-up.However, neither of these studies defined a reference gender, such that the direction of association could not be ascertained for these results.In contrast, the results of Epstein-Rigbi et al. [56][57][58][59][60] differed from other included studies, with no gender differences in total HRQL scores being observed at any point during treatment, regardless of whether HRQL was proxy-or self-reported.
However, poorer self-reported emotional impact subdomain HRQL, and poorer proxy-reported food anxiety subdomain HRQL were observed during oral immunotherapy induction. 60The one study to investigate exclusion diets as a form of intervention observed no gender differences in child HRQL 61 (Table S6).

| Caregiver HRQL
No studies reported differences in caregiver self-reported total HRQL between child genders (Figures 4A and 5) or caregiver genders (Figure 4B).However, potential associations were present in caregiver subdomain HRQL.One non-interventional study investigated the impact of child gender on caregiver HRQL subdomains and found a potential gender difference in emotional issues subdomain HRQL. 40However, the reference child gender was not defined for this result and the direction of association remains unclear (Table S7).Two of the four non-interventional studies of

TA B L E 1 (Continued)
caregiver self-reported HRQL by caregiver gender reported poorer subdomain HRQL in mothers than fathers, related to dietary, social, well-being and physical factors (Figure 4B; Table S8).Caregiver subdomain HRQL was not reported in either of the interventional studies to observe caregiver HRQL.Data presented in studies that investigated caregiver HRQL were limited, and an association between gender and caregiver HRQL cannot be confirmed.

| DISCUSS ION
This review suggests there may be gender differences in self- was most often observed in females, whether adult, child or caregiver, as compared to their male counterparts.The only study without a critical or serious risk of bias observed a strong association between gender and HRQL, where male children experienced a greater HRQL improvement over the course of treatment than females. 54Additionally, differences in HRQL between mothers and fathers arose in subscores and components of HRQL, but not in overall HRQL.The heterogeneity in results obtained from included studies emphasises the relationship between gender and HRQL in populations with a food allergy is complex and likely limited by variation in HRQL instruments applied and narrow considerations of gender.

(A) (B)
Credibility is provided to our finding that females with food allergy self-reported poorer baseline HRQL total scores than males by reports of a similar direction of association occurring in studies of sex and gender in other allergic conditions. 6,7,63We identified similar gender differences across HRQL subdomains, with females with food allergy, especially children, reporting poorer outcomes across a range of physical, psychological and social HRQL subscores.5][66] These conditions often occur in those with food allergy, 67,68 and their influences may subsequently have been captured by generic HRQL measures used in the included studies.Multiple authors have argued generic HRQL instruments lack the sensitivity needed to assess food allergy-specific life experiences. 5,69As such, the use of both food allergy-specific and general HRQL measures contributes to the heterogeneity in identified gender-affected subdomains.3][74] Taking this limitation into account, our findings therefore primarily act to convey that gender could interact with multiple aspects of wellbeing in food allergy populations.Purposeful future measurement of the impact of gender on subdomain HRQL, not only total HRQL scores, is recommended.
Collation of interventional studies revealed the direction and presence of association between gender and HRQL was somewhat unclear.Multiple authors have speculated the HRQL of individuals with food allergy is dependent on the allergen involved. 73,75,76This may explain the differences observed in our data, as all interventional studies to observe a difference between genders that was of, or approached, significance were peanut immunotherapy studies. 54,55,62[58][59][60] As such, our findings extend the observations of previous authors, suggesting a potential interaction between gender and allergen type could affect HRQL outcomes during treatment.Despite this potential finding, we are unable to speculate whether the male or female gender is likely to have a greater influence on treatment outcomes due to the poor definition of a reference gender in two of the three identified interventional studies that observed a potential difference between genders. 55,62Future investigations that specifically focus on the role of gender in HRQL are needed to reduce reliance on subgroup and sensitivity analyses that are often limited by selective reporting, as was experienced in this review. 77e observation that caregiver HRQL was not likely affected by child gender across studies is consistent with previous findings of general parental well-being not being associated with child gender. 78wever, observations of a difference in subdomain HRQL between mothers and fathers of participants with food allergy suggested an association between caregiver HRQL and caregiver gender may have been present. 10,40Authors have observed parents who were more involved in their child's allergy management consequently reported more greatly impaired HRQL. 23,25The influence of gender roles in parenting should be acknowledged here, with primary caregiving roles that pose the most risk of food allergy burden, such as food preparation, school and social activities, most often being undertaken by mothers. 25As mothers tend to be more involved in allergy-related care, 23,25,76 it is reasonable that psychosocial-domain associations would be observed more so in mothers than fathers, providing support to our review's findings.However, due to the limited number of studies to observe this, future investigation of the lived experience of gender and gender roles in parenting may be beneficial to fully understand the relationship between caregiver gender and caregiver HRQL.This association is also an important consideration for study designers, as the gender of caregivers completing questionnaires throughout a study has the potential to influence results.Fathers reported poorer SDL and EI subdomain HRQL for their adult (18+ year old) offspring.
studies for inclusion. 79The initial observation that all eligible interventional studies investigated populations of children with food allergy was unexpected.A possible reason for this is that allergy in adults is often understudied compared to allergy in paediatric populations.non-randomised studies are likely to be reliable. 82While this indicates our results are impacted by the biases present in the included studies, the severity of bias across these studies is fairly consistent and their findings are still comparable. 83To prevent any studies that presented extreme quantitative results from severely influencing our findings, we extracted and synthesised data in terms of the general direction of association and the presence of both clinical and statistical significance (see the Supplementary Material).It is also possible that included randomised control studies may have received suboptimal quality assessment results given the ROBINS tools are best-suited to non-randomised studies. 82As such, additional quality assessment with tools specifically suited to assessment of RCTs should be considered in future studies of a diversity of study types. 82,84Subgroup analysis by risk of bias strata could also be considered to observe whether bias risk influences the direction of results, though this would require a greater number of included studies with variation in their risk of bias assessments than was achieved in this review. 83key limitation to the generalisability of our findings is that they only address a narrow definition of gender, with all studies defining sex or gender constructs according to the same biologically determined binary.Little has yet been done to investigate genders outside of binary classification, and as such it is unclear whether biological determinants or psychosocial experience are the main of HRQL outcomes in allergy. 2,10To completely understand the role of gender in food allergy-specific HRQL, clear definitions of sex and gender and analysis across a diversity of genders (beyond the malefemale dichotomy) are required. 85Furthermore, the extensive reliance on p-values below a .05significance threshold to determine a gender difference amongst the studies included in this review does indicate pressure to communicate only results that would be considered statistically significant. 86,87This again emphasises the need for more studies to consider the role of gender in HRQL to determine if our results are consistent and not a consequence of publication bias.

| CON CLUS ION
reported baseline HRQL of adults and children with food allergy, in child HRQL change over the course of immunotherapy treatment, and potentially in caregiver subdomain HRQL.Poorer HRQL F I G U R E 3 Gender-HRQL relationships investigated amongst included studies.Presence of associations derived from collated evidence (in Figures4 and 5).HRQL, health-related quality of life.F I G U R E 2 Risk of bias ratings of all included studies according to the ROBINS-I tool and sensitivity analysis of non-interventional studies using the ROBINS-E tool.D1, Bias due to confounding; D2, Bias due to selection of participants; D3, Bias in classification of interventions; D4, Bias due to deviations from intended interventions; D5, Bias due to missing data; D6, Bias in measurement of outcomes; D7, Bias in selection of the reported result; ROBINS-E, Risk of bias in non-randomised studies of exposures; ROBINS-I, Risk of bias in non-randomised studies of interventions.
This review indicates gender is a likely modifier of HRQL in IgEmediated food allergy.Observation of poorer baseline total HRQL in female adults and children with food allergy, poorer subdomain HRQL in mothers, and potential gender differences in HRQL postintervention, highlight that a tailoring of allergy management approaches to account for gender is needed.Our results are of particular relevance to study design and indicate the influences of both participant and caregiver genders need to be considered to advance understanding of allergy-specific HRQL.Stratification of HRQL results by gender may be especially important in emerging allergen immunotherapy trials, where it remains unclear as to whether one gender experiences a greater magnitude of the effect of treatment than others.This study highlights the need for purposeful consideration of a diversity of gender identities, ages and allergens in future investigations of HRQL to establish whether psychosocial experience or biological factors drive differences in food allergy outcomes.AUTH O R CO NTR I B UTI O N S SA Rosser, M Lloyd and MLK Tang conceived this systematic review and designed the methodology.SA Rosser, M Lloyd and A Hu contributed to dual-reviewer screening of titles, abstracts and full texts.SA Rosser conducted the data extraction and analysis and drafted the preliminary version of the manuscript.Critical appraisal of included studies using the ROBINS-I was performed by SA Rosser and A Hu before sensitivity analysis with the ROBINS-E was performed by SA Rosser and M Lloyd.All authors assisted with interpretation of the results and reviewed and critically appraised the manuscript before submission.ACK N O WLE D G E M ENTS SA Rosser was supported by the Australian Commonwealth Government through an Australian Government Research Training Program (RTP) scholarship, and a PhD scholarship from the Australian Government funded National Allergy Centre of Excellence (NACE), hosted by the Murdoch Children's Research Institute (MCRI), and their work was supported by the Victorian Government's Operational Infrastructure Program.Thanks are given to Dr Ankur Singh and Dr Diego Lopez Peralta from the University of Melbourne for the opportunity to undertake this research.We also acknowledge the help of the Brownless Biomedical Library team at the University of Melbourne in the development of our search strategy.Open access publishing facilitated by The University of Melbourne, as part of the Wiley -The University of Melbourne agreement via the Council of Australian University Librarians.CO N FLI C T O F I NTE R E S T S TATE M E NT MLK Tang declares consultant fees from Pfizer; was a past employee (ended July 2022) of and share interest/options in Prota Therapeutics; is a member of the Medical Advisory Board of Anaphylaxis & Anaphylaxis Australia; is a member of the Board of Directors of Asia Pacific Association of Allergy Asthma and Clinical Immunology and was a past member of the Board of Directors of the WAO (ended 2019); is a member of expert committees of the American Academy of Allergy, Asthma & Immunology, Asia Pacific Association of Allergy Asthma and Clinical Immunology, Australasian Society of Clinical Immunology and Allergy, WAO; and was a past member of the International Union of Immunological Societies (ended 2019).All other authors have no competing interests to declare.

, year Study design Age, range or mean (SD), years
flow diagram for study selection.HRQL, health-related quality of life.Study characteristics by the age category of participants and interventional versus non-interventional study types.
TA B L E 1Abbreviations: EPIT, epicutaneous immunotherapy; EQ-5D-5L, EuroQol five-dimension scale questionnaire-five level version; EQ-5D-Y, EuroQol five-dimension scale questionnaire-Youth version; FAIM-AF, Food Allergy Independent Measure-Adult Form; FAIM-CF, Food Allergy Independent Measure-Child Form; FAIM-PF, Food Allergy Independent Measure-Parent Form; FAIM-TF, Food Allergy Independent Measure-Teen Form; FAQL-PB, Food Allergy Quality of Life-Parental Burden; FAQLQ-AF, Food Allergy Quality of Life Questionnaire-Adult Form; FAQLQ-CF, Food Allergy Quality of Life Questionnaire-Child Form; FAQLQ-PF, Food Allergy Quality of Life Questionnaire-Parent Form; FAQLQ-PF10, short version of the Food Allergy Quality of Life Questionnaire-Parent Form; FAQLQ-TF, Food Allergy Quality of Life Questionnaire-Teen Form; HRQL, health-related quality of life; IT, immunotherapy; NR, not reported; OFC, oral food challenge; OIT, oral immunotherapy; PedsQL 4.0, Paediatric Quality of Life inventory version 4.0 generic core scale; PFA-QL, Paediatric Food Allergy Quality of Life Questionnaire; PFA-QL-PF, Paediatric Food Allergy Quality of Life Questionnaire-Parent Form; RCT, randomised control trial; SLIT, sublingual immunotherapy; UK, United Kingdom; US, United States; WHOQOL-BREF, abbreviated World Health Organisation quality of life questionnaire.a Range of mean ages of participants across included countries.b Multiple reports with the same primary author compiled from the same study.c Modified version of the FAQL-PB with no constraints on recall time.
Collation of direction of effect in non-interventional studies across total and subscore HRQL scores between (A) male and female participants with food allergy and (B) male and female caregivers of participants with food allergy.Studies are grouped by the person whose gender was measured (participant or caregiver) and by the person whose HRQL was measured (participant or caregiver).If betweengender effects are only present in specific subscores, subscores are named.Multiple reports with the same Primary Author are compiled from the same study.AADR, allergen avoidance and dietary restrictions; DR, dietary restrictions; EI, emotional impact; EQ-5D-5L, EuroQol five-dimension scale questionnaire-five level version; EQ-5D-Y, EuroQol five-dimension scale questionnaire-Youth version; FAIM-AF, Food Allergy Independent Measure-Adult Form; FAIM-CF, Food Allergy Independent Measure-Child Form; FAIM-PF, Food Allergy Independent Measure-Parent Form; FAIM-TF, Food Allergy Independent Measure-Teen Form; FAQL-PB, Food Allergy Quality of Life-Parental Burden; FAQLQ-AF, Food Allergy Quality of Life Questionnaire-Adult Form; FAQLQ-CF, Food Allergy Quality of Life Questionnaire-Child Form; FAQLQ-PF, Food Allergy Quality of Life Questionnaire-Parent Form; FAQLQ-PF10, short version of the Food Allergy Quality of Life Questionnaire-Parent Form; FAQLQ-TF, Food Allergy Quality of Life Questionnaire-Teen Form; HRQL, health-related quality of life; IM, independent measure; PedsQL 4.0, Paediatric Quality of Life inventory version 4.0 generic core scale; PFA-QL, Paediatric Food Allergy Quality of Life Questionnaire; PFA-QL-PF, Paediatric Food Allergy Quality of Life Questionnaire-Parent Form; RAE, risk of accidental exposure; SDL, social and dietary restrictions; WHOQOL-BREF, abbreviated World Health Organisation quality of life questionnaire.†Results of this study's analysis were split by child age.Mothers reported poorer SDL subdomain HRQL for their 13-17 year old offspring.
80,81Therefore, adults would be underrepresented in studies of the role of gender in food allergy-specific HRQL interventions.
The high risk of bias amongst included studies should also be addressed.As the ROBINS tools are the preferred tools for assessing non-randomised studies, the poor quality ratings of included