ORIGINAL ARTICLE
The Clinical Respiratory Journal
Gender differences revealed by the Brief Illness Perception Questionnaire in allergic rhinitis Dragica Pesut1,2, Sanvila Raskovic1,3, Vesna Tomic-Spiric1,3, Milica Bulajic4, Mirjana Bogic1,3, Bogdana Bursuc5 and Aleksandra Peric-Popadic1,3 1 Internal Medicine Department, School of Medicine University of Belgrade, Belgrade, Serbia 2 Clinical Centre of Serbia, Teaching Hospital of Lung Diseases, Belgrade, Serbia 3 Clinical Centre of Serbia, Teaching Hospital of Immunology and Allergology, Belgrade, Serbia 4 Laboratory of Statistics, Faculty of Organizational Sciences, Belgrade, Serbia 5 Department of Psychotherapy, Mind Institute, Bucharest, Romania
Abstract Background: The increasing prevalence of allergic rhinitis (AR) is reported worldwide. Illness perception (IP) assessment is warranted in current routine clinical practice to assist communication between patients and medical staff, and improve adherence to treatment and disease outcome. Objective: To investigate a group of patients with AR in terms of their IP by the Brief Illness Perception Questionnaire (BIPQ) and to correlate the findings with demographic and clinical features. Methods: In this observational questionnaire-based study, a successive series of patients treated for AR at the Allergology and Immunology Teaching Hospital, Clinical Centre of Serbia in Belgrade, were enrolled from September 2010 to January 2011, and 93 valid questionnaires were analyzed. Each item of the BIPQ assessed one dimension of IP like the consequences, timeline, personal control, treatment control, identity, coherence, emotional representation and concern. Results: The patients’ average age: 35.25 ± 12.42; male/female ratio: 0.79; the overall BIPQ score = 34.69 ± 11.89. The highest item-related scores were found for treatment control (8.17 ± 2.28), illness understanding (7.34 ± 2.96) and emotional representation (6.30 ± 3.45), and the lowest for identity (4.8 ± 2.78) and affection (4.83 ± 2.65). Women compared with men perceive AR as a significantly more threatening disease (P = 0.04). No significant correlation between the BIPQ total or item-related scores was found for any other demographic or clinical feature. Conclusion: The BIPQ, which allows rapid assessment of IP and reveals gender differences in AR, is a convenient tool for use in routine clinical practice. Further investigation is needed to demonstrate how IP may influence patients’ behavior in AR, treatment adherence and disease outcome. Please cite this paper as: Pesut D, Raskovic S, Tomic-Spiric V, Bulajic M, Bogic M, Bursuc B and Peric-Popadic A. Gender differences revealed by the Brief Illness Perception Questionnaire in allergic rhinitis. Clin Respir J 2014; 8: 364–368.
Ethics The Ethical board of the Clinical Centre of Serbia, Belgrade, approved the study (12/4-B).
364
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Key words allergic rhinitis – Brief Illness Perception Questionnaire – gender – illness perception – questionnaire Correspondence Dragica Pesut, MD, PhD, University of Belgrade School of Medicine, Internal Medicine Department; Clinical Centre of Serbia, Teaching Hospital of Respiratory Medicine, Koste Todorovica 26, 11000 Belgrade, Serbia. Tel: +381 11 366 39 56 Fax: +381 11 2681 591 email: [email protected] Received: 15 June 2013 Revision requested: 24 October 2013 Accepted: 20 November 2013 DOI:10.1111/crj.12082 Authorship and contributorship All the authors have met the authorship criteria as follows: D. P. concepted the idea and together with B. B. developed study design. D. P. obtained approval for use of the Brief Illness Perception Questionnaire. A. P. P., S. R., V. T. S. and M. B. collected patients’ data. M. B. performed statistical analysis. All the authors analyzed and discussed the results, and B. B. contributed for important intellectual content. D. P. together with B. B. and M. B. drafted the manuscript. All the authors have read and approved the final version of the manuscript to be submitted. D. P. has taken responsibility for the paper as a whole from its conception to the final version to be submitted to the journal. The results of the study were presented at the 30th Congress of the European Academy of Allergy and Clinical Immunology (EAACI) 11–15 June 2011, Istanbul, Turkey.
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Pesut et al.
Introduction Allergic rhinitis (AR), the most frequent manifestation of atopic reaction on inhalatory allergens, affects about 10–30% of the world’s population (1, 2). It is considered a major chronic respiratory disease because of its dramatically increased prevalence during the last decade (3, 4), important influence on patients’ every day activities, productivity, learning, sleep and quality of life in general (5–7). AR is characterized by the clinical symptoms of sneezing, itching, rhinorrhea, and nasal congestion. Frequently, these are accompanied by eye, ear and throat symptoms, or postnasal drip. The symptoms arise as a result of inflammation induced by immunoglobulin E-mediated immune response to a specific allergen. About 30% of the patients with AR develop allergic asthma and aggressive whereas proper treatment of rhinitis may prevent asthma development (8–10). Assessment of IP is warranted in current routine clinical practice. How patients relate to the overall experience of their disease has a direct impact over their behavior, treatment adherence and disease outcome (11). While several studies focused on quality of life in chronic rhinitis (12–15), IP in AR has been studied only rarely, and semistructured questionnaires were the basic tools (16). IP assessment matters. Sometimes discrepancies between objective findings and subjective symptoms reporting or discrepancies between objective indicators of disease control and control perception may be present like in recently reported results in asthma patients (17). Identifying patients prone to such discrepancies may help to understand disease control problems. The aim of our study was to investigate a group of patients with AR in terms of their IP by means of the Brief Illness Perception Questionnaire (BIPQ) and to correlate the findings with demographic and clinical features.
Materials and methods In this observational questionnaire-based study, successive series of patients treated for AR at the Allergology and Immunology Teaching Hospital of the Clinical Centre of Serbia in Belgrade were enrolled from September 2010 to January 2011. Inclusion criteria were diagnosis of AR, the age of 18 years and above, and absence of comorbidity with similar/ overlapping symptoms with AR (asthma, chronic rhinosinusitis, otitis media and recurrent nasal polyposis) or/and mental disorder. The Ethical Board
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Illness perception in allergic rhinitis
Table 1. The AR patients’ demographic and social data and the correlation with BIPQ score Characteristic Age* (years) Mean Median Range Sex Male Female Residence Rural Urban Tobacco smoking status Current smokers Former smokers Nonsmokers Profession Worker Clerk Other Unknown Exposure to air pollution Yes No Unknown Number of previous medical None Up to three More than three
n = 93
P value
35.25 ± 12.42 34 18–68
N.S.
52 (56%) 41 (44%)
P = 0.04
8 (8.6%) 84 (90.3%)
N.S.
12 (12.9) 15 (16.1) 66 (71%)
N.S.
16 (17.2%) 16 (17.2%) 53 (57%) 8 (8.8%)
N.S
83 (89.2%) 9 (9.7%) 1 (1.1%) visits for AR 28 (30.1%) 25 (26.9%) 38 (40.9%)
N.S.
N.S.
The results are presented as absolute numbers and percentage of available data unless otherwise specified. *Mean ± standard deviation (SD). AR, allergic rhinitis; BIPQ, Brief Illness Perception Questionnaire; N.S., nonsignificant.
of the Clinical Centre of Serbia, Belgrade, approved the study (12/4-B). The questionnaire contained a self-created part to obtain demographic (sex and age) and social (marital status, profession and education) factors, tobacco smoking status, number of patient’s visits, etc. (the items are listed in Table 1). The other part was the original BIPQ. Having informed consent, all the patients voluntarily completed the BIPQ and the questionnaires for demographic and social data. The BIPQ is a nine-item questionnaire used to measure IPs along the following dimensions: identity (patient’s ability to refer particular symptom to the disease itself), consequences, timeline, personal control, treatment control, concern, understanding and emotional representations (11). Each dimension is measured by a single item scored on an 11-point Likert scale, with higher scores indicating stronger 365
Illness perception in allergic rhinitis
Pesut et al.
Figure 1. The Brief Illness Perception Questionnaire (BIPQ) – item-related scores. Each dimension of the BIPQ is measured by a single item scored on an 11-point Likert scale, with higher scores indicating stronger endorsement of that item. The highest score is found for treatment control and the lowest for identity.
endorsement of that item. According to the original instructions, summary score was also calculated by adding all of the BIPQ individual items to reflect the overall positivity or negativity of an individual’s IPs. Finally, the BIPQ included an open question aimed to assess patients’ opinion toward the three main causes of the disease in a rank order. The BIPQ forward and backward translation process caused no difficulties. After linguistic validation, BIPQ versions conceptually and linguistically equivalent to original instrument were offered to the patients in their native language. Implementation of the BIPQ in research on renal disease, type 2 diabetes mellitus, myocardial infarction, asthma and minor disturbances showed good test–retest validity (11), and the other study led to its intercultural validation (18). The calculated minimum number of the study group participants is 85 (11). The data were entered in Microsoft Excel worksheets (Microsoft, Redmond, WA, USA), and IBM SPSS Statistics for Windows, Version 19 (IBM Corp., Armonk, NY, USA) was used for the analysis. We used original instructions to score the BIPQ (11). Existence of the significant differences among BIPQ scores and observed parameters listed in Table 1 were tested by t-test. ANOVA was used when more than two groups were considered. The significance levels were set at 0.01 < P ≤ 0.05 (statistically significant) and P ≤ 0.01 (highly statistically significant).
Results Study group consisted of 93 adult AR patients (average age: 35.25 ± 12.42 years; female/male ratio: 0.79), 366
whose characteristics are showed in Table 1. While the analysis of the patients’ tobacco smoking status revealed 12 current smokers, 15 former smokers and 66 patients who never smoked, additional analysis showed that 44 patients have been exposed to environmental tobacco smoke (30/44 declared nonsmokers); furthermore, 83/93 have been exposed to other air pollution means at home or at the working place. The overall BIPQ score = 34.69 ± 11.89. The highest item-related scores were found for treatment control (8.17 ± 2.28), illness understanding (7.34 ± 2.96) and emotional representation (6.30 ± 3.45), and the lowest for identity (4.8 ± 2.78) and affection (4.83 ± 2.65) (Fig. 1). We found significant difference in overall BIPQ score between female and male patients (P = 0.04), which means that women perceive AR as a significantly more threatening disease (Fig. 2). Apart from this gender difference, no other significant correlation was found for any of the tested parameters.
Discussion Our study represents the first implementation of the BIPQ in the patients with AR and shows that IP in AR may vary. We found the questionnaire convenient for routine clinical practice because it takes only a few minutes to complete it. Before the Illness Perception Questionnaire (IPQ) was developed as ‘a pencil and paper measure for patients’, IP was not easy to assess and was obtained through the use of long and semistructured interviews with patients (18, 19). This method, however, produced quite variable patterns in terms of quantity and quality of responses, and lacked
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Pesut et al.
Illness perception in allergic rhinitis
Figure 2. Sex-related mean value of the total Brief Illness Perception Questionnaire (BIPQ) score in patients with allergic rhinitis (AR). The mean value of the total BIPQ score showed significant difference between men (31.82 ± 11.67) and women (37.09 ± 11.67). Independent samples t-test (two-tailed) (P = 0.04) showed that women perceive AR as more threatening disease compared with men.
psychometric validity. A later revised version of IPQ scale (the IPQ-R) extended the original scale by adding more items and subscales, including an assessment of patients’ perceptions of how well they understand their illness and patients’ emotional response to the illness (20). Its scale was long, and in many clinical and research situations there was a need for a shorter version, particularly when patients were very ill or when there was limited time available for assessment. In 2006, Broadbent et al. addressed this need by the publication of the BIPQ – a nine-item scale with good reliability and validity data (11). We found that the BIPQ is a convenient tool for fast assessment of IP and recommend its use in routine clinical practice, especially when assessment time is limited for any reason. The implementation of the BIPQ in our study shows that patients’ perceptions of AR are in concordance with the patients’ sex while no correlation has been found for patients’ rural/urban settlement, profession, air pollution or tobacco smoking. Having a higher overall BIPQ score, the female patients in our study perceive AR as a more threatening diseases comparing with male patients. Based on different methodology, similar results were reported for female patients in asthma while another study, which explored and compared psychosocial characteristics in the groups of patients with allergic and non-AR, has also appointed some gender differences in the studied groups (12). With regard to gender differences in AR, Klossek et al.
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
recently reported more ocular symptoms in female patients, but no evidence of AR gender differences in terms of overall perception of the disease as a more threatening than has been reported by now (21). Why do women in our study consider AR as being a more threatening disease then men do? The first explanation of our results on gender differences found in AR might be that, statistically, women suffer from anxiety more frequently than men. This is a mental health condition that prone women to worry about many issues, including health. The more symptoms they experience, the more they worry about them and perceive them as threatening. The anxiety thinking pattern (worry) lead women to anticipate very negative (catastrophic) consequences with these ‘loud’ symptoms. Apart from this, because the majority of AR symptoms affects the face (the look), women might perceive and anticipate more negative consequences than men regarding their look and beauty during the disease. Our study shows that patients with AR believing in treatment have the highest BIPQ item-related score for treatment control. Recent study on patients’ views showed that perception of inadequate efficacy was the leading cause of medication discontinuation or change (3), and another study has revealed some AR patients’ fears and misconceptions related to the treatment (22). The latter study appointed to lack of patients’ knowledge on AR. Low score for the item ‘identity’ in our study shows that the patients who do 367
Illness perception in allergic rhinitis
not know enough about the disease are not able to refer particular symptoms to the disease itself. The finding shows that further improvement of communication with AR patients and more efforts in their education are warranted. Further incorporation of IP assessment into clinical care for the patients with AR as routine may assist proper interventions design to change patients’ IPs. Further longitudinal studies of AR IP based on the BIPQ implementation could contribute to better coping strategies and to illness adaptation process with potential positive influence on patients’ quality of life and disease outcome.
Acknowledgements This study was supported by the Ministry of Science and Technology Development of Serbia through contract number 175095, 2011–2014. The authors would like to express their gratitude to Elizabeth Broadbent for providing useful piece of literature.
References 1. Salib RJ, Drake-Lee A, Howarth PH. Allergic rhinitis: past, present and the future. Clin Otolaryngol. 2003;28: 291–303. 2. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. Joint Task Force on Practice Parameters. J Allergy Clin Immunol. 2008;122: S1–S84. 3. Meltzer EO, Blaiss MS, Naclerio RM, Stoloff SW, Derebery MJ, Nelson HS, Boyle JM, Wingertzahn MA. Burden of allergic rhinitis: allergies in America, Latin America, and Asia-Pacific adult surveys. Allergy Asthma Proc. 2012;33(Suppl. 1): S113–41. 4. Mullol J. A survey of the burden of allergic rhinitis in Spain. J Investig Allergol Clin Immunol. 2009;19: 27–34. 5. Flemons WW, Tsai W. Quality of life consequences of sleep-disordered breathing. J Allergy Clin Immunol. 1997;99: S750–6. 6. Blaiss MS. Cognitive, social, and economic costs of allergic rhinitis. Allergy Asthma Proc. 2000;21: 7–13. 7. Lavie P, Gertner R, Zomer J, Podoshin L. Breathing disorders in sleep associated with ‘microarousals’ in patients with allergic rhinitis. Acta Otolaryngol. 1981;92: 529–33.
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8. Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108: S147–S334. 9. Bousquet J. Allergy as a global problem: ‘think globally, act globally’. Allergy. 2002;57: 661–2. 10. Scadding G, Walker S. Poor asthma control? – then look up the nose. The importance of co-morbid rhinitis in patients with asthma. Prim Care Respir J. 2012;21(2): 222–8. 11. Broadbent E, Petrie KJ, Main J, Weinman J. The Brief Illness Perception Questionnaire (BIPQ). J Psychosom Res. 2006;60: 631–7. 12. Rydén O, Andersson B, Andersson M. Disease perception and social behaviour in persistent rhinitis: a comparison between patients with allergic and nonallergic rhinitis. Allergy. 2004;59: 461–4. 13. Birch DS, Saleh HA, Wodehouse T, Simpson IN, Mackay IS. Assessing the quality of life for patients with chronic rhinosinusitis using the ‘Rhinosinusitis Disability Index’. Rhinology. 2001;39: 191–6. 14. Fell WR, Mabry RL, Mabry CS. Quality of life analysis of patients undergoing immunotherapy for allergic rhinitis. Ear Nose Throat J. 1997;76: 528–34. 15. Juniper EF. Measuring health-related quality of life in rhinitis. J Allergy Clin Immunol. 1997;99: S742–9. 16. 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. J Allergy Clin Immunol. 1994;94: 182–8. 17. Janssens T, Verleden G, Van den Bergh O. Symptoms, lung function, and perception of asthma control: an exploration into the heterogeneity of the asthma control construct. J Asthma. 2012;49: 63–9. 18. Bean D, Cundy T, Petrie KJ. Ethnic differences in illness perceptions, self-efficacy and diabetes self-care. Psychol Health. 2007;22: 787–811. 19. Weinman J, Petrie KJ, Moss-Morris R, Horne R. The Illness Perception Questionnaire: a new method for assessing illness perceptions. Psychol Health. 1996;11: 431–46. 20. Moss-Morris R, Weinman J, Petrie KJ. The Revised Illness Perception Questionnaire (IPQ-R). Psychol Health. 2002;17: 1–16. 21. Klossek JM, Annesi-Maesano I, Pribil C, Didier A. The burden associated with ocular symptoms in allergic rhinitis. Int Arch Allergy Immunol. 2012;158: 411–7. 22. Hellings PW, Dobbels F, Denhaerynck K, Piessens M, Ceuppens JL, De Geest S. Explorative study on patient’s perceived knowledge level, expectations, preferences and fear of side effects for treatment for allergic rhinitis. Clin Transl Allergy. 2012;2: 9.
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
The Clinical Respiratory Journal
Gender differences revealed by the Brief Illness Perception Questionnaire in allergic rhinitis Dragica Pesut1,2, Sanvila Raskovic1,3, Vesna Tomic-Spiric1,3, Milica Bulajic4, Mirjana Bogic1,3, Bogdana Bursuc5 and Aleksandra Peric-Popadic1,3 1 Internal Medicine Department, School of Medicine University of Belgrade, Belgrade, Serbia 2 Clinical Centre of Serbia, Teaching Hospital of Lung Diseases, Belgrade, Serbia 3 Clinical Centre of Serbia, Teaching Hospital of Immunology and Allergology, Belgrade, Serbia 4 Laboratory of Statistics, Faculty of Organizational Sciences, Belgrade, Serbia 5 Department of Psychotherapy, Mind Institute, Bucharest, Romania
Abstract Background: The increasing prevalence of allergic rhinitis (AR) is reported worldwide. Illness perception (IP) assessment is warranted in current routine clinical practice to assist communication between patients and medical staff, and improve adherence to treatment and disease outcome. Objective: To investigate a group of patients with AR in terms of their IP by the Brief Illness Perception Questionnaire (BIPQ) and to correlate the findings with demographic and clinical features. Methods: In this observational questionnaire-based study, a successive series of patients treated for AR at the Allergology and Immunology Teaching Hospital, Clinical Centre of Serbia in Belgrade, were enrolled from September 2010 to January 2011, and 93 valid questionnaires were analyzed. Each item of the BIPQ assessed one dimension of IP like the consequences, timeline, personal control, treatment control, identity, coherence, emotional representation and concern. Results: The patients’ average age: 35.25 ± 12.42; male/female ratio: 0.79; the overall BIPQ score = 34.69 ± 11.89. The highest item-related scores were found for treatment control (8.17 ± 2.28), illness understanding (7.34 ± 2.96) and emotional representation (6.30 ± 3.45), and the lowest for identity (4.8 ± 2.78) and affection (4.83 ± 2.65). Women compared with men perceive AR as a significantly more threatening disease (P = 0.04). No significant correlation between the BIPQ total or item-related scores was found for any other demographic or clinical feature. Conclusion: The BIPQ, which allows rapid assessment of IP and reveals gender differences in AR, is a convenient tool for use in routine clinical practice. Further investigation is needed to demonstrate how IP may influence patients’ behavior in AR, treatment adherence and disease outcome. Please cite this paper as: Pesut D, Raskovic S, Tomic-Spiric V, Bulajic M, Bogic M, Bursuc B and Peric-Popadic A. Gender differences revealed by the Brief Illness Perception Questionnaire in allergic rhinitis. Clin Respir J 2014; 8: 364–368.
Ethics The Ethical board of the Clinical Centre of Serbia, Belgrade, approved the study (12/4-B).
364
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Key words allergic rhinitis – Brief Illness Perception Questionnaire – gender – illness perception – questionnaire Correspondence Dragica Pesut, MD, PhD, University of Belgrade School of Medicine, Internal Medicine Department; Clinical Centre of Serbia, Teaching Hospital of Respiratory Medicine, Koste Todorovica 26, 11000 Belgrade, Serbia. Tel: +381 11 366 39 56 Fax: +381 11 2681 591 email: [email protected] Received: 15 June 2013 Revision requested: 24 October 2013 Accepted: 20 November 2013 DOI:10.1111/crj.12082 Authorship and contributorship All the authors have met the authorship criteria as follows: D. P. concepted the idea and together with B. B. developed study design. D. P. obtained approval for use of the Brief Illness Perception Questionnaire. A. P. P., S. R., V. T. S. and M. B. collected patients’ data. M. B. performed statistical analysis. All the authors analyzed and discussed the results, and B. B. contributed for important intellectual content. D. P. together with B. B. and M. B. drafted the manuscript. All the authors have read and approved the final version of the manuscript to be submitted. D. P. has taken responsibility for the paper as a whole from its conception to the final version to be submitted to the journal. The results of the study were presented at the 30th Congress of the European Academy of Allergy and Clinical Immunology (EAACI) 11–15 June 2011, Istanbul, Turkey.
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Pesut et al.
Introduction Allergic rhinitis (AR), the most frequent manifestation of atopic reaction on inhalatory allergens, affects about 10–30% of the world’s population (1, 2). It is considered a major chronic respiratory disease because of its dramatically increased prevalence during the last decade (3, 4), important influence on patients’ every day activities, productivity, learning, sleep and quality of life in general (5–7). AR is characterized by the clinical symptoms of sneezing, itching, rhinorrhea, and nasal congestion. Frequently, these are accompanied by eye, ear and throat symptoms, or postnasal drip. The symptoms arise as a result of inflammation induced by immunoglobulin E-mediated immune response to a specific allergen. About 30% of the patients with AR develop allergic asthma and aggressive whereas proper treatment of rhinitis may prevent asthma development (8–10). Assessment of IP is warranted in current routine clinical practice. How patients relate to the overall experience of their disease has a direct impact over their behavior, treatment adherence and disease outcome (11). While several studies focused on quality of life in chronic rhinitis (12–15), IP in AR has been studied only rarely, and semistructured questionnaires were the basic tools (16). IP assessment matters. Sometimes discrepancies between objective findings and subjective symptoms reporting or discrepancies between objective indicators of disease control and control perception may be present like in recently reported results in asthma patients (17). Identifying patients prone to such discrepancies may help to understand disease control problems. The aim of our study was to investigate a group of patients with AR in terms of their IP by means of the Brief Illness Perception Questionnaire (BIPQ) and to correlate the findings with demographic and clinical features.
Materials and methods In this observational questionnaire-based study, successive series of patients treated for AR at the Allergology and Immunology Teaching Hospital of the Clinical Centre of Serbia in Belgrade were enrolled from September 2010 to January 2011. Inclusion criteria were diagnosis of AR, the age of 18 years and above, and absence of comorbidity with similar/ overlapping symptoms with AR (asthma, chronic rhinosinusitis, otitis media and recurrent nasal polyposis) or/and mental disorder. The Ethical Board
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Illness perception in allergic rhinitis
Table 1. The AR patients’ demographic and social data and the correlation with BIPQ score Characteristic Age* (years) Mean Median Range Sex Male Female Residence Rural Urban Tobacco smoking status Current smokers Former smokers Nonsmokers Profession Worker Clerk Other Unknown Exposure to air pollution Yes No Unknown Number of previous medical None Up to three More than three
n = 93
P value
35.25 ± 12.42 34 18–68
N.S.
52 (56%) 41 (44%)
P = 0.04
8 (8.6%) 84 (90.3%)
N.S.
12 (12.9) 15 (16.1) 66 (71%)
N.S.
16 (17.2%) 16 (17.2%) 53 (57%) 8 (8.8%)
N.S
83 (89.2%) 9 (9.7%) 1 (1.1%) visits for AR 28 (30.1%) 25 (26.9%) 38 (40.9%)
N.S.
N.S.
The results are presented as absolute numbers and percentage of available data unless otherwise specified. *Mean ± standard deviation (SD). AR, allergic rhinitis; BIPQ, Brief Illness Perception Questionnaire; N.S., nonsignificant.
of the Clinical Centre of Serbia, Belgrade, approved the study (12/4-B). The questionnaire contained a self-created part to obtain demographic (sex and age) and social (marital status, profession and education) factors, tobacco smoking status, number of patient’s visits, etc. (the items are listed in Table 1). The other part was the original BIPQ. Having informed consent, all the patients voluntarily completed the BIPQ and the questionnaires for demographic and social data. The BIPQ is a nine-item questionnaire used to measure IPs along the following dimensions: identity (patient’s ability to refer particular symptom to the disease itself), consequences, timeline, personal control, treatment control, concern, understanding and emotional representations (11). Each dimension is measured by a single item scored on an 11-point Likert scale, with higher scores indicating stronger 365
Illness perception in allergic rhinitis
Pesut et al.
Figure 1. The Brief Illness Perception Questionnaire (BIPQ) – item-related scores. Each dimension of the BIPQ is measured by a single item scored on an 11-point Likert scale, with higher scores indicating stronger endorsement of that item. The highest score is found for treatment control and the lowest for identity.
endorsement of that item. According to the original instructions, summary score was also calculated by adding all of the BIPQ individual items to reflect the overall positivity or negativity of an individual’s IPs. Finally, the BIPQ included an open question aimed to assess patients’ opinion toward the three main causes of the disease in a rank order. The BIPQ forward and backward translation process caused no difficulties. After linguistic validation, BIPQ versions conceptually and linguistically equivalent to original instrument were offered to the patients in their native language. Implementation of the BIPQ in research on renal disease, type 2 diabetes mellitus, myocardial infarction, asthma and minor disturbances showed good test–retest validity (11), and the other study led to its intercultural validation (18). The calculated minimum number of the study group participants is 85 (11). The data were entered in Microsoft Excel worksheets (Microsoft, Redmond, WA, USA), and IBM SPSS Statistics for Windows, Version 19 (IBM Corp., Armonk, NY, USA) was used for the analysis. We used original instructions to score the BIPQ (11). Existence of the significant differences among BIPQ scores and observed parameters listed in Table 1 were tested by t-test. ANOVA was used when more than two groups were considered. The significance levels were set at 0.01 < P ≤ 0.05 (statistically significant) and P ≤ 0.01 (highly statistically significant).
Results Study group consisted of 93 adult AR patients (average age: 35.25 ± 12.42 years; female/male ratio: 0.79), 366
whose characteristics are showed in Table 1. While the analysis of the patients’ tobacco smoking status revealed 12 current smokers, 15 former smokers and 66 patients who never smoked, additional analysis showed that 44 patients have been exposed to environmental tobacco smoke (30/44 declared nonsmokers); furthermore, 83/93 have been exposed to other air pollution means at home or at the working place. The overall BIPQ score = 34.69 ± 11.89. The highest item-related scores were found for treatment control (8.17 ± 2.28), illness understanding (7.34 ± 2.96) and emotional representation (6.30 ± 3.45), and the lowest for identity (4.8 ± 2.78) and affection (4.83 ± 2.65) (Fig. 1). We found significant difference in overall BIPQ score between female and male patients (P = 0.04), which means that women perceive AR as a significantly more threatening disease (Fig. 2). Apart from this gender difference, no other significant correlation was found for any of the tested parameters.
Discussion Our study represents the first implementation of the BIPQ in the patients with AR and shows that IP in AR may vary. We found the questionnaire convenient for routine clinical practice because it takes only a few minutes to complete it. Before the Illness Perception Questionnaire (IPQ) was developed as ‘a pencil and paper measure for patients’, IP was not easy to assess and was obtained through the use of long and semistructured interviews with patients (18, 19). This method, however, produced quite variable patterns in terms of quantity and quality of responses, and lacked
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Pesut et al.
Illness perception in allergic rhinitis
Figure 2. Sex-related mean value of the total Brief Illness Perception Questionnaire (BIPQ) score in patients with allergic rhinitis (AR). The mean value of the total BIPQ score showed significant difference between men (31.82 ± 11.67) and women (37.09 ± 11.67). Independent samples t-test (two-tailed) (P = 0.04) showed that women perceive AR as more threatening disease compared with men.
psychometric validity. A later revised version of IPQ scale (the IPQ-R) extended the original scale by adding more items and subscales, including an assessment of patients’ perceptions of how well they understand their illness and patients’ emotional response to the illness (20). Its scale was long, and in many clinical and research situations there was a need for a shorter version, particularly when patients were very ill or when there was limited time available for assessment. In 2006, Broadbent et al. addressed this need by the publication of the BIPQ – a nine-item scale with good reliability and validity data (11). We found that the BIPQ is a convenient tool for fast assessment of IP and recommend its use in routine clinical practice, especially when assessment time is limited for any reason. The implementation of the BIPQ in our study shows that patients’ perceptions of AR are in concordance with the patients’ sex while no correlation has been found for patients’ rural/urban settlement, profession, air pollution or tobacco smoking. Having a higher overall BIPQ score, the female patients in our study perceive AR as a more threatening diseases comparing with male patients. Based on different methodology, similar results were reported for female patients in asthma while another study, which explored and compared psychosocial characteristics in the groups of patients with allergic and non-AR, has also appointed some gender differences in the studied groups (12). With regard to gender differences in AR, Klossek et al.
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
recently reported more ocular symptoms in female patients, but no evidence of AR gender differences in terms of overall perception of the disease as a more threatening than has been reported by now (21). Why do women in our study consider AR as being a more threatening disease then men do? The first explanation of our results on gender differences found in AR might be that, statistically, women suffer from anxiety more frequently than men. This is a mental health condition that prone women to worry about many issues, including health. The more symptoms they experience, the more they worry about them and perceive them as threatening. The anxiety thinking pattern (worry) lead women to anticipate very negative (catastrophic) consequences with these ‘loud’ symptoms. Apart from this, because the majority of AR symptoms affects the face (the look), women might perceive and anticipate more negative consequences than men regarding their look and beauty during the disease. Our study shows that patients with AR believing in treatment have the highest BIPQ item-related score for treatment control. Recent study on patients’ views showed that perception of inadequate efficacy was the leading cause of medication discontinuation or change (3), and another study has revealed some AR patients’ fears and misconceptions related to the treatment (22). The latter study appointed to lack of patients’ knowledge on AR. Low score for the item ‘identity’ in our study shows that the patients who do 367
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not know enough about the disease are not able to refer particular symptoms to the disease itself. The finding shows that further improvement of communication with AR patients and more efforts in their education are warranted. Further incorporation of IP assessment into clinical care for the patients with AR as routine may assist proper interventions design to change patients’ IPs. Further longitudinal studies of AR IP based on the BIPQ implementation could contribute to better coping strategies and to illness adaptation process with potential positive influence on patients’ quality of life and disease outcome.
Acknowledgements This study was supported by the Ministry of Science and Technology Development of Serbia through contract number 175095, 2011–2014. The authors would like to express their gratitude to Elizabeth Broadbent for providing useful piece of literature.
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