1. Introduction
llergic rhinitis is an inflammatory disease of the nasal mucosa. Its prevalence in the general population at all age groups in the world is 10%-40% [1], and it is estimated to be 10%-15% in Iran [2]. Allergic rhinitis can have detrimental effects on the physical, psychological and social aspects of patients’ lives and significantly reduce their quality of life [3]. The effect of allergic rhinitis on the patients’ quality of life is partly influenced by the cultural context in the study population. To the best of our knowledge, the Health-Related Quality of Life (HRQOL) of adults with allergic rhinitis has not been assessed in Iran. The purpose of this study was to evaluate and compare the HRQOL in patients with allergic rhinitis compared to healthy people.
2. Materials and Methods
In this cross-sectional study, participants were 100 patients with persistent allergic rhinitis and 100 age- and sex-matched healthy individuals referred to Amir Al-Momenin Hospital in Rasht, Iran. Allergic rhinitis was diagnosed based on the medical history and clinical examination (having symptoms such as runny nose, itchy nose, sneezing and nasal congestion), a Symptom For Allergic Rhinitis (SFAR) score >7 and the presence of eosinophilia or basophilia in nasal smear. Inclusion criteria were: Age ≥18 years, and moderate to severe persistent allergic rhinitis for at least one year, while the exclusion criteria were: Experience of a tragedy that can lead to an impaired quality of life (within 3 months), and inability to complete the questionnaire. The control subjects were selected from among the hospital staff and friends of the patients who had no any symptoms of rhinitis or a specific disease, and had no consumption of any specific drugs that can affect their quality of life. After obtaining an informed consent from all participants, a demographic form and the 36-Item Short-Form Health Survey (SF-36) were completed for them. The t-test was used to compare the obtained data between the two groups. All statistical analyzes were performed in SPSS V. 19 software.
3. Results
Thirty percent of participants in both groups were male. The mean age of patients was 30.1±7.6 years in the allergic rhinitis group and 29.7±6.0 years in the control group. The mean HRQOL score in patients (66.7±13.8) was lower than in controls (72.9±12.4). This difference was statistically significant (P<0.001). The results demonstrated a significant difference in all subscales of SF-36 between the two groups except in vitality and mental health (P<0.05). The lowest and highest SF-36 scores in patients was related to general health and physical functioning, respectively. Post-hoc test results showed a significant relationship of low HRQOL with male gender and higher level of education (P<0.001).
4. Discussion and Conclusion
The results of this study showed that HRQOL in patients with allergic rhinitis was significantly lower. In a recent systematic review of the effect of allergic respiratory disease on the quality of life, patients with allergic rhinitis also had the lowest score in vitality and the highest score in ​​physical functioning [4]. In line with our findings, Amizadeh et al. showed lower scores in physical functioning and bodily pain in adolescents with allergic rhinitis compared to healthy controls [5]. In our study, the HRQOL in men with allergic rhinitis was significantly lower than in the control group, while there was no significant difference between female patients and controls. One of the possible reasons can be the more involvement of men in social activities compared to women. Similar to our finding, Kalpaklĩoğlu revealed a positive and significant relationship between the quality of life and educational level in all dimensions except in social and physical functioning [6]. 
There were some limitations and disadvantages in our study. Firstly, there were financial problems and family issues which can potentially affect the HRQOL of individuals. Secondly, we could not assess the relationship of the severity of allergic rhinitis or job status with HRQOL in patients. Thirdly, the patients had received various drugs which can effect on their HRQOL. In this study, participants were over 18 years of age. The effect of allergic rhinitis on HRQOL in children can be different than in adults. Hence, further studies on the effect of disease in different age groups and the role of pharmaceutical and non-pharmacological treatment methods in improving the HRQOL of these patients are recommended.

Ethical Considerations
Compliance with ethical guidelines
This study was conducted according to the ethical principles of the Declaration of Helsinki. The ethical approval was obtained from the Research Ethics Committee of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1394.783).

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conceptualization, supervision: Robabeh Soleimani; Methodology: Mir Mohammad Jalali; Investigation: Robabeh Soleimani, Mir Mohammad Jalali, Ali Faghih Habibi; Writing – original draft: Robabeh Soleimani; Writing – review & editing: Robabeh Soleimani, Mir Mohammad Jalali, Ali Faghih Habibi.

Conflicts of interest
The authors declare that there is no conflict of interest. 

Acknowledgements
The authors would like to thank the Vice-Chancellor for Research of Guilan University of Medical Sciences and Dr. Malahat Mosavinejhad for assistance in collecting data. 


References

1. Ghaffari J. [Prevalence of aeroallergens in skin test of asthma, allergic rhinitis, eczema and chronic urticaria patients in Iran (Persian)]. Journal of Mazandaran University of Medical Sciences. 2012; 22(87):139-51. http://jmums.mazums.ac.ir/article-1-816-en.html
2. Corren J. Allergic rhinitis: treating the adult. The Journal of Allergy and Clinical Immunology. 2000; 105(6):S610-5. [DOI:10.1067/mai.2000.106151] [PMID]
3. Rogkakou A, Villa E, Garelli V, Canonica GW. Persistent allergic rhinitis and the XPERT study. World Allergy Organization Journal. 2011; 4(3):S32-6. [DOI:10.1097/1939-4551-4-S3-S32] [PMCID]
4. Afshari F, Khadiwi R, Shirzad H. [Effective factors on Atopic Dermatitis in children of Shahrekord primary schools (Persian)]. Journal of Shahrekord University of Medical Sciences. 2006; 8(3):71-5. http://journal.skums.ac.ir/article-1-531-fa.html
5. Brożek JL, Bousquet J, Agache I, Agarwal A, Bachert C, Bosnic-Anticevich S, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. The Journal of Allergy and Clinical Immunology. 2017; 140(4):950-8. [DOI:10.1016/j.jaci.2017.03.050] [PMID]
6. Jalali MM, Gerami H, Soleimani R, Alizadeh P. Quality of Life in Patients with Allergic Rhinitis in the North of Iran. Journal of Clinical and Diagnostic Research. 2018; 12(6):MC01-4. https://www.jcdr.net/article_abstract.asp?issn=0973-709x&year=2018&volume=12&issue=6&page=MC01&issn=0973-709x&id=11694
7. Craig TJ, McCann JL, Gurevich F, Davies MJ. The correlation between allergic rhinitis and sleep disturbance. The Journal of Allergy and Clinical Immunology. 2004; 114(5):S139-45. [DOI:10.1016/j.jaci.2004.08.044] [PMID]
8. Klossek J-M, Gohler C, Vervloet D, Deslandes B, Dufour X, Neukirch F. Epidemiology of seasonal spring-time allergic rhinitis in adults in France. Presse medicale (Paris, France: 1983). 2005; 34(5):348-52. [DOI:10.1016/S0755-4982(05)83924-7]
9. Bousquet J, Khaltaev N, Cruz A, Denburg J, Fokkens W, Togias A, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (In collaboration with the World Health Organization, GA (2) LEN and AllerGen). Allergy. 2008; 63(Suppl 86):8-160. http://197.255.68.203/handle/123456789/931
10. Juniper E. Quality of life in adults and children with asthma and rhinitis. Allergy. 1997; 52(10):971-7. [DOI:10.1111/j.1398-9995.1997.tb02416.x] [PMID]
11. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care. 1992; 30(6):473-83. [DOI:10.1097/00005650-199206000-00002] [PMID]
12. Casale TB, Dykewicz MS. Clinical implications of the allergic rhinitis-asthma link. The American Journal of the Medical Sciences. 2004; 327(3):127-38. [DOI:10.1097/00000441-200403000-00004] [PMID]
13. Leynaert B, Neukirch C, Liard R, Bousquet J, Neukirch F. Quality of life in allergic rhinitis and asthma: a population-based study of young adults. American Journal of Respiratory and Critical Care Medicine. 2000; 162(4):1391-6. [DOI:10.1164/ajrccm.162.4.9912033] [PMID]
14. Bousquet J, Bullinger M, Fayol C, Marquis P, Valentin B, Burtin B. Assessment of quality of life in patients with perennial allergic rhinitis with the French version of the SF-36 Health Status Questionnaire. The Journal of Allergy and Clinical Immunology. 1994; 94(2):182-8. [DOI:10.1053/ai.1994.v94.a54939]
15. Bousquet J, Knani J, Dhivert H, Richard A, Chicoye A, Ware Jr JE, et al. Quality of life in asthma. I. Internal consistency and validity of the SF-36 questionnaire. American Journal of Respiratory and Critical Care Medicine. 1994; 149(2):371-5. [DOI:10.1164/ajrccm.149.2.8306032] [PMID]
16. Meltzer EO, Nathan RA, Seiner JC, Storms W. Quality of life and rhinitic symptoms: results of a nationwide survey with the SF-36 and RQLQ questionnaires. The Journal of Allergy and Clinical Immunology. 1997; 99(6):S815-9. [DOI:10.1016/S0091-6749(97)80041-3]
17. Valovirta E, Myrseth S-E, Palkonen S. The voice of the patients: allergic rhinitis is not a trivial disease. Current Opinion in Allergy and Clinical Immunology. 2008; 8(1):1-9. [DOI:10.1097/ACI.0b013e3282f3f42f] [PMID]
18. Amizadeh M, Safizadeh H, Bazargan N, Farrokhdoost Z. Survey on the prevalence of allergic rhinitis and its effect on the quality of high school students’ life. Iranian Journal of Otorhinolaryngology. 2013; 25(71):79-84. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3846268/
19. Annesi-Maesano I, Didier A, Klossek M, Chanal I, Moreau D, Bousquet J. The Score for Allergic Rhinitis (SFAR): a simple and valid assessment method in population studies. Allergy. 2002; 57(2):107-14. [DOI:10.1034/j.1398-9995.2002.1o3170.x] [PMID]
20. Pawankar R, Bunnag C, Khaltaev N, Bousquet J. Allergic rhinitis and its impact on asthma in Asia Pacific and the ARIA update 2008. World Allergy Organization Journal. 2012; 5(3):S212-7. [DOI:10.1097/1939-4551-5-S3-S212]
21. Baroody F, Naclerio R. Allergy and Immunology of the upper airway. In: Flint P, Haughey B, Lund V, Niparko J, Robbins K, Thomas J, et al, editors. Cummings otolaryngology head and neck surgery. 6^th ed. Philadelphia: Elsevier Saunders; 2015. https://www.elsevier.com/books/cummings-otolaryngology/flint/978-1-4557-4696-5
22. Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. The Journal of Allergy and Clinical Immunology: In Practice. 2001; 108(Supple 5):S147-334. [DOI:10.1067/mai.2001.118891] [PMID]
23. Ware Jr JE. SF-36 health survey update. Spine. 2000; 25(24):3130-9. [DOI:10.1097/00007632-200012150-00008] [PMID]
24. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The short form health survey (SF-36): translation and validation study of the Iranian version. Quality of Life Research. 2005; 14:875-82. [DOI:10.1007/s11136-004-1014-5] [PMID]
25. Elkholy MM, Khedr MH, Halawa A, Elbaramawy A. Impact of allergic rhinitis on quality of life in patients with bronchial asthma. International Journal of Health Sciences. 2012; 6(2):194-202. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3616948/
26. Guyatt GH. Measurement of health-related quality of life in heart failure. Journal of the American College of Cardiology. 1993; 22(4):A185-91. [DOI:10.1016/0735-1097(93)90488-M]
27. Linneberg A, Dam Petersen K, Hahn-Pedersen J, Hammerby E, Serup-Hansen N, Boxall N. Burden of allergic respiratory disease: a systematic review. Clinical and Molecular Allergy. 2016; 14:12. [DOI:10.1186/s12948-016-0049-9] [PMID] [PMCID]
28. Hellgren J, Balder B, Palmqvist M, Löwhagen O, Tunsäter A, Karlsson G, et al. Quality of life in non-infectious rhinitis and asthma. Rhinology. 2004; 42(4):183-8. https://europepmc.org/article/med/15626249
29. Bunnag C, Leurmarnkul W, Jareoncharsri P, Tunsuriyawong P, Assanasen P, Pawankar R. Quality of life assessment in thai Patients with Allergic Rhinoconjunctivitis using the SF-36 Questionnaire (Thai version). Rhinology. 2005; 43(2):99-103. https://europepmc.org/article/med/16008063
30. Kalpaklĩoğlu A, Baççıoğlu A. Evaluation of quality of life: impact of allergic rhinitis on asthma. Journal of Investigational Allergology and Clinical Immunology. 2008; 18(3):168-73. https://europepmc.org/article/med/18564627