Prevalence, severity, and risk factors of allergic rhinitis among schoolchildren in Saudi Arabia: A national cross-sectional study, 2019

Abstract

Background

Allergic rhinitis is a significant public health concern worldwide, affecting both developed and developing countries, with prevalence rates ranging between 10% and 30% in adults and over 40% in children. However, there are limited studies on allergic rhinitis prevalence in Saudi Arabia.

Objective

To explore allergic rhinitis among schoolchildren in Saudi Arabia in terms of prevalence, severity, and risk factors.

Methods

This study was conducted between March and April 2019, covering 20 regions. The study employed a multistage, stratified cluster sampling approach and selected 137 primary and 140 intermediate schools. The research utilized the methodology and questionnaires recommended by the Global Asthma Network (GAN). Data analysis was carried out using IBM SPSS Statistics (Version 23).

Results

The completed questionnaires in the analysis comprised 3614 children aged 6–7 years old and 4068 adolescents aged 13–14 years old. The study found that 5.6% of children and 14.0% of adolescents reported current rhinoconjunctivitis, with 0.5% of children and 1.3% of adolescents experiencing severe symptoms. Several risk factors were significantly associated with rhinoconjunctivitis. In children 6–7 years old, eating cooked vegetables was inversely associated with rhinoconjunctivitis, while prematurity, wheezing in infancy, and a history of pneumonia were positively associated with the condition. In adolescents, vigorous physical activity, current exposure to cats, and frequent use of paracetamol were found to be the main risk factors associated with rhinoconjunctivitis, while high consumption of pulses and eggs was found to have a protective effect.

Conclusion

In Saudi Arabia, the prevalence of rhinoconjunctivitis in children is lower than average globally, but among adolescents, it is within the global average range. However, the prevalence of severe rhinoconjunctivitis among adolescents is twice the global average. Further research is required to examine regional differences, track trends over time, and explore risk factors that contribute to allergic rhinitis.

Introduction

Atopic diseases, including allergic rhinitis, eczema, and asthma, are among children's most common chronic diseases.^1,2 These diseases primarily affect the nose, eyes, skin, and lungs.³ They are marked by an abnormal immune response in individuals with a predisposition to generate immunoglobulin E (IgE), upon exposure to environmental allergens that are usually harmless to the general population, such as dust mites, animal dander, molds, and pollen.^3,4

Allergic rhinitis, also known as hay fever, is a significant public health concern worldwide, affecting both developed and developing countries. Globally, allergic rhinitis affects more than 400 million people, with prevalence rates between 10% and 30% among adults and over 40% among children.¹

The prevalence of allergic rhinitis in the Kingdom of Saudi Arabia (KSA) has been assessed in a few studies.^5,6 In a study conducted in Madinah among 6–9 years old children, 24.2% reported ever experiencing rhinitis, and 18.2% reported having current rhinitis symptoms.⁷ Among adolescents aged 16 to 18, a remarkably high prevalence of allergic rhinitis was found in Riyadh, reaching 43.8% for participants who said they had ever experienced rhinitis symptoms and 38.6% for participants who reported current symptoms.⁸ In Najran, the overall lifetime prevalence of rhinitis, rhinoconjunctivitis, and physician-diagnosed rhinitis was 34.6%, 14.8%, and 6.3%, respectively, among schoolchildren aged 7–19 years.⁹

Epidemiological studies demonstrate that the prevalence of allergic rhinitis has continued to rise over recent decades, with substantial variation between countries.^1,10 However, the disease has so far been underestimated, as patients with less severe symptoms are less likely to seek medical advice and consult a doctor; thus, they are often under-recognized and undertreated.^1,10,11

Additionally, several studies have established the coexistence of atopic diseases, including the significant role of allergic rhinitis in the development of asthma in children.^12,13 A recent meta-analysis reported that a history of allergic rhinitis increases the likelihood of developing asthma over threefold.¹³ Furthermore, in asthmatic patients, asthma severity is significantly influenced by the presence of allergic rhinitis.^14,15

Allergic rhinitis can significantly affect an individual's quality of life, leading to physical, psychological, and social consequences. Patients and their families may suffer from sleep disturbance, fatigue, poor academic performance, reduced productivity at work, depression, and anxiety.14, 15, 16 Therefore, the declaration of the World Allergy Organization (WAO) encourages countries to promote and support more research in the field of atopic diseases, including allergic rhinitis, to determine and identify their actual burden accurately.¹

The International Study of Asthma and Allergies in Childhood (ISAAC), a globally recognized initiative that utilizes standardized methodology to collect data on the prevalence, severity, and risk factors of childhood atopic diseases,^17,18 found that atopic diseases, including allergic rhinitis, have been influenced by various modifiable and non-modifiable determinants^1,17 that involve a complex interplay between genetic, environmental, and lifestyle factors. While genetic predisposition and family history of allergies are significant risk factors, exposure to allergens, indoor and outdoor pollution, and dietary factors can also contribute to the development and severity of these conditions.19, 20, 21

Building on the success achieved by the ISAAC, the Global Asthma Network (GAN) was established in 2012 to evaluate the prevalence and severity of asthma, allergic rhinitis, and eczema in schoolchildren and adults (the parents of those children) in various parts of the world. It also explores factors that contribute to the development of atopic diseases and monitors trends in their prevalence over time.²² This study aims to explore the prevalence, severity, and factors associated with allergic rhinitis in the KSA and establish a benchmark for evaluating future trends.

Materials and methods

Study design, setting and population

An analytical cross-sectional study was conducted based on secondary data obtained from the KSA nationwide survey²³ accomplished by the National Asthma Control Program in 2019, as part of the GAN phase 1 study, which uses a standardized methodology to monitor the prevalence, severity, and risk factors of atopic diseases.^22,24 The study was carried out across all twenty health regions, encompassing the entirety of the KSA's 13 geographical administrative regions, from March to April 2019. Schoolchildren in 2 age groups participated in the study: children aged 6–7 years and adolescents aged 13–14 years.

Sample size and sampling technique

Based on a 95% confidence interval (CI), a conservative prevalence estimates of 50% as a starting point, a 1.5% margin of error, and a 10% allowance for nonresponse, the sample size was estimated for each group. The sample size for the 6- to 7-year-old schoolchildren was 4669, and for the 13- to 14-year-old adolescents was 4666.²³ The study adhered to the GAN protocol,²⁴ which recommends a minimum of 3000 participants per age group (Fig. 1).

Fig. 1.

Study flow diagram. Adopted from: Alomary SA, Althagafi WA, Al Madani AJ, Adam IF, Elsherif OE, Al-Abdullaah AA, et al. The burden of asthma among children and adolescents in Saudi Arabia: A national cross-sectional survey. Journal of Allergy and Clinical Immunology: Global. 2022 Nov 1;1(4):241-7. https://doi.org/10.1016/j.jacig.2022.07.006, reused with permission.²³

A proportional, multistage, stratified cluster-sampling approach was employed using region, sex, and type of school (public or private) to ensure representativeness. An online random picker was used to select 277 schools (137 primary schools and 140 intermediate schools) based on their unique Ministry of Education identification codes. Public schools from all 20 health regions were selected, and due to their limited distribution in certain areas, private schools were selected from only 7 regions. We assigned a cluster size of 40 schoolchildren to public schools and 30 to private schools. Within each school, participants were recruited through simple random sampling.²³

The questionnaires

The standardized GAN questionnaires for children 6–7 years old and adolescents 13–14 years old were used to collect data after developing and validating Arabic versions following GAN manual recommendations.²⁴ Along with sociodemographic information such as age, sex, and date of birth, the questionnaires included questions aimed at determining the prevalence, severity, and factors linked to allergic rhinitis. The questionnaires were self-administered: 13- to 14-year-old students completed the questionnaire for adolescents, whereas a parent or guardian completed the questionnaire for children aged 6–7 years.

The prevalence and severity of rhinitis symptoms were estimated based on positive responses to the following questions:^24,25 “Rhinitis symptoms ever” was evaluated based on the question, “Have you (has your child) ever had a problem with sneezing or a runny or blocked nose when you (he or she) did not have a cold or the flu?” “Hay fever ever” was evaluated based on the direct question, “Have you (has your child) ever had hay fever?” “Current rhinitis symptoms” was based on the question, “In the past 12 months, have you (has your child) had a problem with sneezing or a runny or blocked nose when you (he or she) did not have a cold or the flu?” “Current rhinoconjunctivitis symptoms” was evaluated based on the respondent having current rhinitis plus a positive answer to the question, “Has this (has your child's) nose problem been accompanied by itchy-watery eyes?” “Severe rhinoconjunctivitis” was based on the respondent having current rhinoconjunctivitis symptoms plus an answer of “a lot” to the question, “In the past 12 months, how much did this nose problem interfere with your (your child's) daily activities?”

Data analysis

The data were coded and entered into Microsoft Excel 2019 in accordance with the guidelines outlined in the GAN manual.²⁴ The coding procedure for variables in our study followed a systematic and standardized approach. The questionnaires were coded by assigning a unique number to each school and participant, and then a numerical code was assigned to each variable based on the predefined criteria provided in the manual. Observations with missing values for all variables or main symptoms were excluded from the analysis. Analysis was performed with IBM-SPSS Statistics (Version 23). Categorical data are presented as percentages and numbers, and continuous data as mean and standard deviation. Prevalence and 95% CI for rhinitis symptoms were calculated and compared between the 2 age groups. This was done by calculating the proportion of participants with positive symptoms out of those who completed the questionnaire.

A large set of covariates, including socio-demographics, lifestyle, nutrition, and environmental factors, were then evaluated separately for each age group to identify potential risk factors for current rhinoconjunctivitis. Chi-square and Fisher's exact tests were used to compare proportions among categorical variables, and logistic regression was used to predict potential risk factors. Initially, we performed a bivariate logistic regression analysis to evaluate the association between individual predictor variables and the dependent outcome (current rhinoconjunctivitis). Subsequently, we constructed a multiple logistic regression model based on the selection of factors that exhibited a statistically significant difference at a p-value of less than 0.05 at the bivariate level. This model was intended to determine the impact of all of these variables on the current rhinoconjunctivitis while adjusting for potential confounding factors. The odds ratio (OR) with 95% CI was reported for both bivariate and multivariable analyses. Statistical significance was set at P < 0.05.

Ethical considerations

We obtained the data for this study from the Saudi Arabian Ministry of Health after receiving the required approvals from both the Data Management Office and the Central Institutional Review Board (Approval reference number: 22–47 M). In order to maintain confidentiality, all data collected were kept anonymous, and no contact was made with the participants.

Results

A- characteristics of participants

In this study, questionnaires were self-administered by parents of 6- to 7-year-old children and adolescents aged 13–14 years, with overall response rates of 81.8% and 88.7%, respectively. After excluding incomplete questionnaires, 3614 and 4068 questionnaires, respectively, were included in the analysis (Fig. 1). The background characteristics of the participants are presented in (Table 1).

Table 1.

Background characteristics of the participating schoolchildren.

Characteristic	Children 6–7 years old N= (3614)	Adolescents 13–14 years old N= (4086)
Age (years)
Mean ± SD	6.86 ± 0.5	13.4 ± 0.6
Sex, n (%)
Male	1673 (48.7%)	1973 (49.5%)
Female	1764 (51.3%)	2015 (50.5%)
Birthweight (kg)
Mean ± SD	3.3 ± 0.4	NA
Weight (kg)
Mean ± SD	21.7 ± 4.4	48.7 ± 11.7
Height (cm)
Mean ± SD	119.2 ± 6.4	154.8 ± 8.4
Number of siblings, n (%)
No siblings	86 (2.7%)	71 (1.9%)
1-2	1268 (39.1%)	3063 (79.9%)
3 or more	1889 (58.2%)	701 (18.3%)
Twins, n (%)
Yes	96 (2.8%)	114 (2.9%)
No	3329 (97.2%)	3839 (97.1%)
Born in KSA, n (%)
Yes	3203 (92.7%)	3730 (92.9%)
No	252 (7.3%)	284 (7.1%)
Years lived in KSA, n (%)
1–5 years	128 (3.6%)	79 (2.3%)
6–10 years	3421 (96.4%)	207 (6.1%)
11–15 years	–	3104 (91.6%)

Abbreviation: NA, not available for this age group

B- prevalence and severity of rhinitis symptoms

Table 2 summarizes the overall and sex-stratified prevalence and severity of rhinitis symptoms among schoolchildren in the 2 age groups. Overall, adolescents aged 13–14 years had a significantly higher prevalence of rhinitis symptoms than children aged 6–7 years. The lifetime prevalence rate for rhinitis symptoms was 18.7% in children and 38.5% in adolescents, and the prevalence of rhinitis within the previous 12 months was 14.3% and 30.3%, respectively. Moreover, 5.6% of children and 14.0% of adolescents reported current rhinoconjunctivitis symptoms (P < 0.01). While girls aged 6–7 years had a significantly higher prevalence of “hay fever ever symptoms” and “physician-diagnosed hay fever” than boys, there was no significant difference between girls and boys in rhinoconjunctivitis symptoms. Among adolescents, however, girls showed a significantly higher prevalence of current rhinoconjunctivitis symptoms than boys (15.6% vs. 12.4%). Concerning symptom severity, 0.5% of the children and 1.3% of adolescents had nasal symptoms that interfered with daily activities. The prevalence of severe rhinoconjunctivitis symptoms did not differ significantly between boys and girls at both age groups.

Table 2.

The prevalence and severity of rhinitis symptoms among schoolchildren.

				Age Group
	6–7 years				13–14 years
Symptom	Overall	Male n = 1673	Female n = 1764	P value	Overall	Male n = 1973	Female n = 2015	P value
Rhinitis symptoms ever
No.	675	320	332		1574	759	773
(%) of all participants	(18.7%)	(19.1%)	(18.8%)	0.951	(38.5%)	(38.5%)	(38.4%)	0.100
Hay fever ever
No.	170	67	95		531	268	253
(%) of all participants	(4.7%)	(4.0%)	(5.4%)	0.009a	(13.0%)	(13.6%)	(12.6%)	0.072
Current rhinitis symptoms
No.	515	246	248		1237	588	613
(%) of all participants	(14.3%)	(14.7%)	(14.1%)	0.532	(30.3%)	(29.8%)	(30.4%)	0.639
Current rhinoconjunctivitis symptoms
No.	203	93	102		574	244	314
(%) of all participants	(5.6%)	(5.6%)	(5.8%)	0.777	(14.0%)	(12.4%)	(15.6%)	0.003a
(%) of those with current rhinitis	(39.4%)	(37.8%)	(41.1%)	0.450	(46.4%)	(41.5%)	(51.2%)	0.001a
Severe rhinoconjunctivitis in past 12 months
No.	18	8	9		55	28	26
(%) of all participants	(0.5%)	(0.5%)	(0.5%)	0.894	(1.3%)	(1.4%)	(1.3%)	0.725
(%) of current rhinoconjunctivitis	(8.9%)	(8.6%)	(8.8%)	0.956	(9.6%)	(11.5%)	(8.3%)	0.205
Hay fever confirmed by a doctor
No.	85	29	53		177	95	77
(%) of all participants	(2.4%)	(1.7%)	(3.0%)	0.029a	(4.3%)	(4.8%)	(3.8%)	0.123
(%) of hay fever ever	(50.0%)	(43.3%)	(55.8%)	0.100	(33.3%)	(35.4%)	(30.4%)	0.224

^aSignificant

C- allergic rhinoconjunctivitis and associated factors

In the bivariate analysis, a comprehensive investigation of a wide range of variables was carried out to examine their association with current rhinoconjunctivitis symptoms. Table 3, Table 4 illustrate the association between current rhinoconjunctivitis and related factors in children and adolescents. However, to maintain clarity and relevance in our results and to focus on the most relevant and informative variables included in the multiple logistic regression analysis, we have presented only those variables that exhibited statistical significance in the bivariate model and were then incorporated into the multiple regression model. In children aged 6–7 years, multiple logistic regression analysis revealed that current rhinoconjunctivitis was positively associated with a history of pneumonia diagnosis (OR, 2.07; 95% CI, 1.12–3.83), prematurity (OR, 2.32; 95% CI, 1.14–4.71), and wheezing during the first year of life (OR, 3.79; 95% CI, 2.13–6.73). However, high consumption of cooked vegetables was negatively associated with current rhinoconjunctivitis (OR, 0.52; 95% CI, 0.30–0.91). Among adolescents, current rhinoconjunctivitis was significantly associated with the use of paracetamol at least once a month (OR, 1.83; 95% CI, 1.25–2.68), having a cat living at home in the past year (OR, 1.44; 95% CI, 1.05–1.97), and vigorous physical activity once or twice a week (OR, 1.70; 95% CI, 1.23–2.33). On the other hand, the consumption of pulses once or twice a week and eggs once or more per week were inversely linked with current rhinoconjunctivitis.

Table 3.

Logistic regression analysis of factors associated with current allergic rhinoconjunctivitis symptoms among schoolchildren aged 6–7 years (N = 3614).

Associated factor	No. (%)	Bivariate Model		Multivariable Model
		Crude OR (95% CI)	P value	Adjusted OR (95% CI)	P value
Cooked vegetables
Never or only occasionally	60 (8.2%)	Reference		Reference
Once or twice per week	59 (4.7%)	0.55 (0.38–0.80)	0.002a	0.43 (0.25–0.73)	0.002a
Most or all days	56 (5.5%)	0.65 (0.45–0.95)	0.026a	0.52 (0.30–0.91)	0.023a
Burgers
Never or only occasionally	71 (4.6%)	Reference		Reference
Once or twice per week	80 (6.6%)	1.45 (1.04–2.01)	0.027a	1.17 (0.68–2.02)	0.563
Most or all days	19 (9.3%)	2.11 (1.24–3.57)	0.006a	1.56 (0.47–5.16)	0.469
Fast food
Never or only occasionally	75 (4.9%)	Reference		Reference
Once or twice per week	65 (6.0%)	1.23 (0.87–1.73)	0.240	0.93 (0.55–1.60)	0.802
Most or all days	15 (9.5%)	2.03 (1.14–3.62)	0.017a	0.95 (0.27–3.27)	0.931
Soft drinks
Never or only occasionally	93 (4.7%)	Reference		Reference
Once or twice per week	50 (7.3%)	1.58 (1.11–2.25)	0.012a	1.44 (0.84–2.48)	0.184
Most or all days	16 (8.5%)	1.87 (1.08–3.25)	0.027a	1.32 (0.51–3.41)	0.563
Weekly vigorous physical activity
Never or occasionally	148 (5.8%)	Reference		Reference
Once or more per weekb	33 (9.3%)	1.67 (1.12–2.47)	0.011a	1.22 (0.66–2.24)	0.530
Daily Computer Time
Less than 1 h	69 (4.6%)	Reference		Reference
1 h but less than 3 h	45 (5.8%)	1.28 (0.87–1.88)	0.215	0.71 (0.38–1.32)	0.277
3 h or more	61 (7.8%)	1.74 (1.23–2.48)	0.002a	1.37 (0.82–2.30)	0.233
Paracetamol use in the last 12 months
Never	6 (1.1%)	Reference		Reference
At least once a year	62 (4.6%)	4.20 (1.81–9.77)	0.001a	1.77 (0.50–6.27)	0.375
At least once per month	121 (8.5%)	8.13 (3.56–18.57)	0.000a	2.95 (0.85–10.32)	0.090
Ever diagnosed with pneumonia
No	136 (4.3%)	Reference		Reference
Yes	51 (21.7%)	6.20 (4.35–8.84)	0.000a	2.07 (1.12–3.83)	0.021a
Trucks passing near home
Never	48 (4.3%)	Reference		Reference
Seldom (not often)	109 (5.8%)	1.35 (0.96–1.92)	0.088	0.96 (0.57–1.63)	0.881
Frequently or almost the whole day	31 (7.5%)	1.79 (1.12–2.85)	0.015a	0.99 (0.46–2.13)	0.973
Mother used paracetamol during pregnancy
Never	44 (3.5%)	Reference		Reference
At least once in pregnancy	43 (6.6%)	1.97 (1.28–3.03)	0.002a	1.05 (0.55–1.99)	0.883
At least once a month	35 (8.0%)	2.43 (1.54–3.84)	0.000a	1.27 (0.64–2.50)	0.496
More often	40 (10.6%)	3.29 (2.11–5.14)	0.000a	0.86 (0.39–1.91)	0.712
Don't know	32 (4.5%)	1.31 (0.83–2.09)	0.249	1.01 (0.50–2.04)	0.983
Mother had regular contact with farm animals during pregnancy
No	184 (5.5%)	Reference		Reference
Yes	11 (11.1%)	2.14 (1.12–4.07)	0.021a	2.53 (0.90–7.05)	0.077
Child born prematurely
No	164 (5.2%)	Reference		Reference
Yes	31 (14.9%)	3.22 (2.13–4.86)	0.000a	2.32 (1.14–4.71)	0.020a
Paracetamol use during the first year of life
No	14 (1.8%)	Reference		Reference
Yes	185 (6.9%)	4.05 (2.34–7.02)	0.000a	2.59 (0.97–6.90)	0.057
Chest infection during the first year of life
No	75 (3.2%)	Reference		Reference
Yes	120 (11.3%)	3.87 (2.87–5.22)	0.000a	1.19 (0.68–2.08)	0.536
Antibiotics used in the first year of life
No	86 (4.1%)	Reference		Reference
Yes	108 (7.9%)	2.00 (1.49–2.67)	0.000a	0.76 (0.47–1.24)	0.270
Wheezing or whistling in the chest during the first year of life
No	111 (3.8%)	Reference		Reference
Yes	84 (17.5%)	5.45 (4.03–7.37)	0.000a	3.79 (2.13–6.73)	0.000a
Regular contact with farm animals during the first year of life
No	178 (5.5%)	Reference		Reference
Yes	17 (9.6%)	1.83 (1.08–3.08)	0.024a	0.57 (0.19–1.76)	0.330
Ever attended day care
No	62 (4.1%)	Reference		Reference
Yes	114 (6.8%)	1.715 (1.25–2.36)	0.001a	1.59 (0.97–2.59)	0.065

Abbreviations: OR, odds ratio; CI. confidence interval.

Note: This table only presents results for variables that achieved statistical significance based on the bivariate logistic model and were included in the multivariable regression model. Variables not meeting this criterion are not shown.

^aSignificant.

^bVariable categories were combined and transformed into dichotomous values due to zero frequency

Table 4.

Logistic Regression Analysis of Factors Associated with Current Allergic Rhinoconjunctivitis Symptoms Among Schoolchildren aged 13–14 years (N = 4086).

Associated factor	Number (%)	Bivariate Model		Multivariable Model
		Crude OR (95% CI)	P value	Adjusted OR (95% CI)	P value
Sex
Male	244 (12.4%)	Reference		Reference
Female	314 (15.6%)	1.31 (1.09–1.57)	0.003a	1.02 (0.77–1.36)	0.872
Pulses (peas, beans, lentils)
Never or only occasionally	233 (16.4%)	Reference		Reference
Once or twice per week	213 (12.6%)	0.74 (0.61–0.91)	0.003a	0.70 (0.52–0.95)	0.020a
Most or all days	73 (14.6%)	0.87 (0.66–1.16)	0.349	1.07 (0.71–1.62)	0.731
Eggs
Never or only occasionally	144 (17.2%)	Reference		Reference
Once or twice per week	233 (14.3%)	0.80 (0.64–1.01)	0.060	0.67 (0.48–0.92)	0.015a
Most or all days	140 (12.2%)	0.67 (0.52–0.86)	0.002a	0.53 (0.36–0.77)	0.001a
Sugar
Never or only occasionally	86 (12.4%)	Reference		Reference
Once or twice per week	200 (12.6%)	1.02 (0.78–1.34)	0.877	1.04 (0.70–1.55)	0.847
Most or all days	243 (17.1%)	1.46 (1.12–1.91)	0.005a	1.43 (0.94–2.18)	0.093
Burgers
Never or only occasionally	146 (12.8%)	Reference		Reference
Once or twice per week	268 (14.9%)	1.20 (0.97–1.49)	0.101	0.99 (0.69–1.43)	0.957
Most or all days	124 (16.0%)	1.30 (1.01–1.69)	0.045a	0.76 (0.45–1.27)	0.292
Fast food
Never or only occasionally	143 (12.7%)	Reference		Reference
Once or twice per week	257 (14.3%)	1.14 (0.92–1.42)	0.245	0.96 (0.67–1.39)	0.835
Most or all days	123 (16.6%)	1.37 (1.05–1.77)	0.019a	1.20 (0.72–2.02)	0.483
Weekly vigorous physical activity
Never or occasionally	356 (12.6%)	Reference		Reference
Once or twice per week	141 (20.9%)	1.83 (1.47–2.27)	0.000a	1.70 (1.23–2.33)	0.001a
Three or more times per week	52 (20.4%)	1.78 (1.29–2.46)	0.000a	1.54 (0.92–2.57)	0.098
Daily television time
Less than 1 h	157 (12.8%)	Reference		Reference
1 h but less than 3 h	140 (12.7%)	1.00 (0.78–1.27)	0.965	0.97 (0.68–1.37)	0.847
3 h or more	264 (17.0%)	1.40 (1.13–1.73)	0.002a	1.07 (0.78–1.48)	0.680
Daily computer time
Less than 1 h	63 (10.5%)	Reference		Reference
1 h but less than 3 h	50 (9.1%)	0.85 (0.57–1.25)	0.406	0.88 (0.54–1.44)	0.620
3 h or more	284 (14.6%)	1.46 (1.09–1.95)	0.011a	1.21 (0.82–1.79)	0.329
Paracetamol use in the last 12 months
Never	69 (8.6%)	Reference		Reference
At least once a year	185 (11.7%)	1.41 (1.06–1.89)	0.020a	1.02 (0.69–1.53)	0.906
At least once per month	297 (20.5%)	2.75 (2.08–3.63)	0.000a	1.83 (1.25–2.68)	0.002a
Had a cat at home last 12 months
No	416 (13.1%)	Reference		Reference
Yes	142 (18.3%)	1.49 (1.21–1.83)	0.000a	1.44 (1.05–1.97)	0.023a
Trucks passing near home
Never	61 (9.4%)	Reference		Reference
Seldom (not often)	321 (13.7%)	1.53 (1.15–2.04)	0.004a	1.20 (0.79–1.83)	0.400
Frequently or almost the whole day	176 (18.6%)	2.21 (1.62–3.01)	0.000a	1.54 (0.97–2.44)	0.064

Abbreviations: OR, odds ratio; CI, confidence interval.

Note: This table only presents results for variables that achieved statistical significance based on the bivariate logistic model and were included in the multivariable regression model. Variables not meeting this criterion are not shown.

^aSignificant

Discussion

To our knowledge, this was the first study on a nationwide scale exploring the prevalence, severity, and determinants of rhinoconjunctivitis among schoolchildren in the KSA.

Prevalence and severity of allergic rhinitis

Our analysis revealed that lifetime rhinitis was 18.7% and 38.5% for children and adolescents, respectively. Interestingly, we expected the difference in the prevalence of hay fever between children and adolescents to be similar to the difference observed between them in the prevalence of rhinitis symptoms, as seen above. However, reported hay fever prevalence was only 4.7% in children and 13.0% in adolescents. We believe that these mismatched results could have resulted from a language barrier, as the term “hay fever” in Arabic, used in the questionnaires, is not widely used in the region.

Results show that 5.6% of children and 14.0% of adolescents reported experiencing rhinoconjunctivitis symptoms in the past 12 months. Prevalence rates for children are lower than the mean global prevalence, while rates for adolescents are similar to those observed in both the GAN phase I study (7.7% and 13.3% in children and adolescents, respectively),²⁵ and the ISAAC phase III (8.5% and 14.6%, respectively).²⁶ At the regional level, a recent study conducted in the United Arab Emirates revealed prevalence rates of 8.0% and 13.8% for children and adolescents, respectively.²⁷ However, the GAN study for the India region reported the lowest prevalence rates, with only 2.0% of children and 8.4% of adolescents reporting symptoms.²⁸ Based on these findings, it is evident that rhinoconjunctivitis prevalence varies across geographical regions.

In our results, girls were significantly more likely to develop rhinoconjunctivitis during adolescence compared with boys. This finding is in line with results from previous studies^25,27,29,30 and may be linked to hormonal changes that occur in girls after puberty.^29,31,32

Regarding the severity of rhinitis symptoms, severe rhinoconjunctivitis was reported by 0.5% of children aged 6–7 years. This is consistent with global estimates for this age group.²⁵ However, among adolescents, 1.3% reported severe rhinoconjunctivitis symptoms, consistent with a study conducted in Kuwait³³ but twice as high as global figures.²⁵ These findings suggest that environmental or behavioral factors may contribute to the higher prevalence of severe rhinoconjunctivitis among adolescents in our region. This highlights the need for further research to identify the specific factors contributing to this trend. In addition, it is necessary to develop targeted interventions to address this issue.³⁴

Risk factors for rhinoconjunctivitis in children

We investigated the potential risk factors associated with rhinoconjunctivitis in each age group separately. For children, the findings showed a positive association between rhinoconjunctivitis and preterm birth. This is consistent with previous studies by Barne et al²⁸ and Mitselou et al³⁵ However, the results conflict with those of Kansen et al³⁶ and Schäfer et al,³⁷ who reported that prematurity was protective against atopic diseases. The present study also found that children who reported ever experiencing pneumonia had a twofold higher prevalence of rhinoconjunctivitis. This is consistent with the GAN phase I study conducted in India.²⁸

While previous studies^38,39 have reported an inverse relationship between vegetable consumption and allergic rhinoconjunctivitis, our study distinguished between raw and cooked vegetables. Remarkably, our results revealed that high consumption of cooked vegetables had a protective effect against current rhinoconjunctivitis symptoms. On the other hand, Garcia-Marcos et al⁴⁰ did not find a significant association between vegetable intake and rhinoconjunctivitis symptoms in children between 6 and 7 years of age.

Risk factors for rhinoconjunctivitis in adolescents

Our results reveal that adherence to a lifestyle of vigorous exercise was linked to an increased risk of rhinoconjunctivitis symptoms in adolescents. Foliaki et al⁴¹ and Chinratanapisit et al reported similar findings.⁴² However, the GAN study for Greece reported an inverse relationship between an active lifestyle and rhinoconjunctivitis.⁴³ Moreover, a number of studies also investigated the association between cat exposure and atopic disease. Results, however, are conflicting. While our study, along with others, has found that owning a cat increases the likelihood of developing atopic disease,44, 45, 46 some studies have found a preventive effect from exposure to cats against allergic disease.^36,47,48 Our study suggests that exposure to cats may be a risk factor for allergic rhinitis in adolescents. Additionally, the association between cat exposure and atopic disease has been examined in several studies, but the findings have been conflicting. The conflicting evidence on this topic highlights the need for further research to clarify the relationship between cat exposure and atopic disease. Furthermore, our study supports other studies regarding the correlation between regular paracetamol use and an increased risk of atopic diseases.^{19,28,29,41,49} This could be due to paracetamol's inhibitory effect on glutathione production, an antioxidant enzyme essential in the prevention of oxidative stress. Oxidative stress has been identified as one of the underlying factors in the development of atopic diseases.⁴⁹ Our results provide further evidence supporting the association between paracetamol use and atopic diseases, emphasizing the importance of judicious use of this common medication. The cross-sectional nature of our study, however, limits our ability to establish causal relationship. Therefore, future prospective studies should be conducted to identify the underlying mechanisms and establish causality.

Strengths and limitations

This study has several limitations to consider. Firstly, the study was conducted using a questionnaire, which is subject to recall and reporting bias. Additionally, no clinical or laboratory tests were carried out to confirm rhinitis diagnosis. Moreover, our analysis did not account for potential cluster effects, which may have affected the accuracy and generalizability of the estimates. Lastly, due to the cross-sectional design, causal relationships cannot be established. These limitations should be considered when interpreting the findings. The study also has several notable strengths, including the large and diverse sample, which is representative of all regions in the KSA, and the use of standardized methods for estimating prevalence, which enables comparability with other studies in different countries. Moreover, our study provides essential baseline data that can be used to guide future research efforts. These strengths enhance the generalizability of the findings and contribute to the significance of the study.

Conclusion

Our research provides comprehensive epidemiological information on rhinoconjunctivitis prevalence, severity, and determinants among schoolchildren. It indicates that current rhinoconjunctivitis in the KSA falls below the worldwide average for children. However, among adolescents, the prevalence is within the global average range, with a twofold higher occurrence of severe rhinoconjunctivitis. The study also highlights several factors associated with rhinoconjunctivitis, indicating that external influences could play a crucial role in the development of rhinitis during childhood and adolescence.

Recommendations

While this study provides valuable insights into the prevalence, severity, and factors associated with allergic rhinitis in the KSA, further research should be conducted to examine regional differences, track trends over time, and explore risk factors that contribute to allergic rhinitis, while considering clinical confirmation to minimize recall bias and enhance accuracy. Lastly, the impact of allergic rhinitis on patients' quality of life should be investigated, including its effects on work and school performance, social activities, and psychological well-being. These studies will assist in the development of public health policies and interventions for the prevention, early detection, diagnosis, and management of atopic diseases to reduce their burden and improve patients’ quality of life.

Abbreviations

CI, confidence interval; GAN, Global Asthma Network; ISAAC, International Study of Asthma and Allergies in Childhood; KSA, Kingdom of Saudi Arabia; OR, odds ratio.

Acknowledgments

I would like to express my heartfelt gratitude to every individual and department at the Saudi MOH who has contributed to the facilitation and approval of this study. The General Directorate of Health Programs and Chronic Diseases deserves special recognition for its tremendous support in providing the data necessary to conduct our research. Without their assistance and contributions, our research would not have been possible. I would like to express my gratitude to my supervisors for their invaluable guidance and support. Their expertise and insightful feedback have been instrumental in shaping the design, methodology, and analysis of this research. I would like to acknowledge the invaluable guidance that Dr. Afnan Younis from King Saud University, Dr. Nehad Mahdy, and Dr. Marwan Zidan from Dubai Health Authority provided in the statistical analysis process. Finally, I would like to thank my family for their constant support and encouragement throughout my academic journey. Their unwavering support motivated and inspired me.

Funding

The initial survey was funded by the Ministry of Health, Saudi Arabia.

Availability of data and materials

Interested individuals may obtain the datasets utilized in this study from the corresponding author upon reasonable request and with permission from the data owners.

Author contributions

Sawsan AL NAHAS: The main author of the manuscript, concept and design of the study, analysis and interpretation of data, writing and editing the manuscript, visualization, final approval of the submitted version.

Noura ABOUAMMOH: Concept and design of the study, supervision, critically reviewed and edited the manuscript, final approval of the submitted version.

Wael ALTHAGAFI: Concept and design of the study, data acquisition, provided guidance throughout the research process, critically reviewed and edited the manuscript, final approval of the submitted version.

Eman ElSayed ABD-ELLATIF: Concept and design of the study, supervision, critically reviewed and edited the manuscript, final approval of the submitted version.

Ethics statement

This manuscript presents secondary data obtained from the National Asthma Control Program of the General Directorate of Health Programs and Chronic Diseases, a department of the Saudi Arabian Ministry of Health. Participant information was kept confidential since the data was completely anonymous. All necessary permissions and approvals were obtained prior to use of the data. The study was approved by the Saudi Ministry of Health (Approval reference number: 22–47 M). This research does not involve any conflicts of interest.

Competing interest

The authors declare that they have no relevant conflicts of interest.

Submission declaration

As of this writing, the manuscript has not previously been published, nor has it been considered for publication elsewhere. Additionally, we confirm that all authors have reviewed and approved the manuscript prior to submission.