Reliability and validity of a newly developed self-administrated online questionnaire assessing the quality of life for allergic rhinitis in China: The QoLAR

Abstract

BACKGROUND:

There are a few effective tools in China to assess the geography, diet, and symptoms of allergic rhinitis (AR) patients. Existing generic tools need cultural adaptation better to evaluate AR’s impact on quality of life. This study aimed to develop the Quality-of-Life Questionnaire for AR patients (QoLAR), adapt it to Chinese, and assess its reliability and validity.

MATERIALS AND METHODS:

The present study was conducted in the following five phases: 1) Phase 1, item generation based on the literature review on AR and questionnaire development; 2) Phase 2, cultural adaptation and translation forward and backward from English to Chinese and vice versa; 3) Phase 3, pretest on 61 respondents via online messaging platform WeChat and revision of the questionnaire based on input from respondents and experts; 4) Phase 4, pilot study on 169 respondents via online messaging platform WeChat; and 5) Phase 5, statistical analysis for descriptive, reliability tests using item-total correlations and Cronbach’s ɑ coefficient, and validity test using item and scale content validity indices (I-CVI, S-CVI/Ave, and S-CVI/UA).

RESULTS:

The final version of QoLAR comprises 44 items in four domains: sociodemographic, health status and history of AR, dietary habits, and environmental exposure. The value for Cronbach’s ɑ is 0.903, and all three validity indices scored 1.00.

CONCLUSIONS:

A specific quality-of-life questionnaire for AR, known as QoLAR, has been created with acceptable validity and reliability. It is appropriate for an online self-reported survey and could be helpful to Chinese healthcare professionals like nurses and clinicians.

Introduction

Allergic rhinitis (AR) is triggered by immunoglobulin E, leading to nasal mucosa dysfunction and impacting quality of life.[1] Globally, 10%–40% of people, including both adults and children, suffer from AR, with increasing concern in China due to industrialization and urbanization.[2] Pollen has become a significant public health issue in China, particularly with ongoing urbanization and global warming.[1,3,4,5] A meta-analysis by Pang et al. reported AR prevalence ranging from 9.6% to 23.9% in adults and an average of 9.8% in children across different regions of China, highlighting regional variations due to diverse climates, economic development, and lifestyles.[1,6,7]

The etiology of AR remains elusive, though known risk factors in China encompass exposure to allergenic pollens, dietary patterns, asthma history, sociodemographic characteristics, and overall health status as suggested by several epidemiology studies and two health policies which are Chinese guidelines for diagnosis and treatment of AR and Chinese Guideline on Allergen Immunotherapy for Allergic Rhinitis.[1,4,5,8,9,10,11] Despite AR’s substantial health burden in China, comprehensive evaluations of quality of life and associated risk factors are scarce. The only validated instrument available, the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), was developed in Korea and employed in a limited study at West China Hospital, Sichuan University, to evaluate the quality-of-life impact of AR through face-to-face interviews.[12,13]

Recently, Li et al.[14] introduced a questionnaire in simplified Chinese. However, its purpose is confined to assessing parental burden due to traditional Chinese food allergies rather than addressing AR-related quality of life and risk factors. Thus, a culturally relevant, accessible self-reported questionnaire tool is urgently needed to determine the AR risk factors tailored to the Chinese population. This study proposes developing an online self-reporting questionnaire to evaluate the specific risk factors and quality-of-life impacts of AR in China. This approach aims to provide a robust, population-specific tool to facilitate more accurate assessments of AR’s impact, contributing to improved healthcare strategies for managing AR within China.

Materials and Methods

Study design and setting

The study was designed based on different procedures to develop and verify a quality-of-life questionnaire related to food allergies and other allergic rhinitis risk factors following the Chinese guidelines for diagnosing and treating AR.[4,5,13,14] The development, reliability, and validity of the Quality-of-Life Questionnaire for AR patients (QoLAR) were conducted in five phases, as shown in Figure 1.

Figure 1.

Phases in developing, reliability, and validity of the QoLAR

Study participants and sampling

Different samples were used in each study phase. In Phase 1 (Questionnaire Development), subjects aged 18 and older in China were recruited for pretesting. In Phase 2 (Cultural Adaptation and Translation), the pretest and pilot study were conducted via WeChat using snowball sampling to reach a broad audience across China.

Data collection tool and technique

Phase 1: Development of the questionnaire QoLAR

The development of the QoLAR questionnaire involved five phases: 1) item generation and expert review, 2) cultural adaptation and translation, 3) pretesting and revision (Version 1), 4) a pilot survey (Version 2), and 5) statistical analysis.

Item generation

The QoLAR questionnaire items were developed through a thorough literature review using keywords like “allergic rhinitis,” “quality of life questionnaire,” and “Chinese” or “Mandarin.” The review focused on sociological factors, medical issues, and other risk factors. Of 186 articles reviewed, only five were relevant for the initial draft for the Chinese population.

Expert committee review

Six experts in AR reviewed the preliminary QoLAR to ensure it was appropriate, clear, and understandable. They evaluated clarity to avoid confusion or jargon, assessed comprehension to ensure items were easily understood, and checked appropriateness to meet the QoLAR objectives. A consensus was reached when over 70% of the experts agreed on these criteria. The final QoLAR questionnaire contained 29 nonscaled items.

Phase 2: Cultural adaptation and translation

The preliminary questionnaire was translated into Chinese as part of the cultural adaptation to accommodate the target respondents in China. Researchers from Malaysia and China who speak English and Chinese, as well as MFFA and MR, performed forward and backward translations and information calibrations of the preliminary QoLAR questionnaire from English to Chinese and vice versa.

Phase 3: Pretest and revision of the first version of the QoLAR questionnaire

Pretesting of QoLAR version 1 was conducted via WeChat to assess item comprehensibility. Using a snowball sampling technique, 61 participants aged 18 and older completed the questionnaire online. This method ensured the questionnaire’s authenticity, minimized the influence of the administrator, and allowed respondents to complete it voluntarily and at their own pace.

Item revision for QoLAR questionnaire version 2

Items with interpretation issues were revised after the expert committee had reached a consensus. Technical challenges, including low reliability and inability to analyze high-value questions, were noted among the 61 respondents. Therefore, further revision, a second expert review, and a new questionnaire version are necessary.

The second expert committee review

Six experts evaluated version 2 of the QoLAR questionnaire over two consultation rounds. They recommended adding a response scale to improve reliability. The 44 items were categorized into four domains: sociodemographic, health status and medical history, dietary habits, and environmental exposure.

Phase 4: A pilot survey of QoLAR questionnaire version 2

A pilot survey was conducted to ascertain the usability of the revised QoLAR Questionnaire in Version 2 (44 items). Participants were recruited for an online pilot survey using a snowballing technique. The questionnaire was sent to 169 adults aged 18 and older via the WeChat messaging platform. They were contacted based on their history of visiting the hospital for AR and related health conditions.

Ethical consideration

Ethics approval was obtained from the First People’s Hospital of Yinchuan (KYLL-2021-1052) and Universiti Teknologi MARA (UiTM), Malaysia (R1/FERC/FSG/003). The procedures adhered to the ethical standards of the responsible institutional or regional committee on human experimentation and complied with the Helsinki Declaration of 1975, as amended in 2000. Only consented participants were recruited and could withdraw from the study without prejudice.

Phase 5: Statistical analysis method

Respondents’ demographics were described using median, 95% confidence intervals, standard error mean for continuous variables, and count and percentage for categorical variables. SPSS Version 28 assessed internal reliability through item-total correlations and Cronbach’s ɑ. Correlations were categorized as low (<0.3), moderate (0.3–0.7), and high (>0.7). A higher Cronbach’s alpha indicates greater reliability, which may improve by removing items with low item-total correlations (<0.30).[15] Open-ended questions were excluded from these assessments.

The content validity of the QoLAR questionnaire was assessed using the item-level content validity index (I-CVI), scale-level CVI average (S-CVI/Ave), and S-CVI universal agreement (S-CVI/UA). Experts rated each item’s relevance on a 4-point scale: 1 (not relevant), 2 (somewhat relevant), 3 (quite relevant), and 4 (highly relevant).[16,17,18,19] Ratings were dichotomized as 0 (disagreed) for ratings of 1 or 2 and 1 (agreed) for ratings of 3 or 4. The item-level content validity index (I-CVI) was calculated by dividing the number of experts who agreed by the total number of experts. Items with I-CVI > 0.79 were considered significant, those with I-CVI 0.70–0.79 required revision, and those with I-CVI < 0.70 were removed. The scale-level CVI average (S-CVI/Ave) was the average of I-CVI scores, with a score > 0.90 indicating excellent content validity.[18,19] For S-CVI/UA, items with 100% expert agreement scored 1, while those without received 0. The S-CVI/UA was calculated by dividing the sum of universal agreement scores by the total number of items [S-CVI/UA = (sum of UA)/(number of items)].[16,17,18]

Results

Demographic details of participants

A total of 61 subjects and 169 subjects participated in the testing of Version 1 (Phase 3) and Version 2 (Phase 4) QoLAR questionnaires, respectively [Table 1]. In Phase 3, 62.3% of the subjects were women, and 37.7% were men, with a mean age of 32.6 ± 8.4. However, during the pilot study in Phase 4, 50.37% of the subjects were women, and 49.73% were men, with a mean age of 29.4 ± 7.3. The other characteristics, such as height, body weight, and BMI index, are described in Table 1.

Table 1.

Demographic and clinical characteristics of participants in developing QoLAR

Details	Phase 3: Pretesting, QoLAR questionnaire Version 1, 21 items (n=61)	Phase 4: Pilot study, QoLAR questionnaire Version 2, 44 items (n=169)
Gender
Women	38 (62.3%)	85 (50.3%)
Men	23 (37.7%)	84 (49.7%)
Ethnic
Han	28 (45.9%)	63 (37.5%)
Hui	32 (52.5%)	104 (61.9%)
Manchu	1 (1.6%)	1 (0.6%)
Age	32.6±8.4 (20-45)	29.4±7.3 (18-45)
Height (cm)	164.1±12.9 (100-182)	165.0±0.1 (108-195)
Weight (Kg)	62.0±16.8 (21-123)	64.2±15.5 (20-110)
BMI	23.2±5.4 (15.82-46.87)	22.6±4.3 (15.3-41.1)

The data are presented in median, upper, and lower limits and standard error mean (SEM)

Expert panel

Six experts contributed to creating QoLAR: three from Universiti Teknologi MARA Malaysia, two from the First People’s Hospital of Yinchuan, and one from Tongxin County People’s Hospital, all in China. The panel included three nutrition, biology, and microbiome experts and three clinicians. During the review of QoLAR version 1, 36 items were evaluated, with 21 items reaching a 58.3% consensus. The 15 items that did not reach consensus, mainly related to micronutrient and calorie intake, were excluded. The final QoLAR questionnaire, with 29 nonscaled items, was deemed appropriate, comprehensible, and clear by over 70% of the experts.

Item generation and revision for the final version of QoLAR

A second version of QoLAR with 44 items was generated after the second expert review. Based on the expert responses, concerns were raised regarding the potential impact of pork on AR due to variations in dietary structures among individuals. More detailed questions on daily dietary patterns were also revised. More details on the AR symptoms, such as sneezing, runny nose, shedding tears, nasal congestion, and nosebleeds, were also added. The expert panels recommended using a response scale when responding to specific items in the QoLAR questionnaire version 2 to improve the reliability of the questions and answers provided later.

The final version of the QoLAR questionnaires was prepared in Chinese and English, creating 44 items. The English version of the QoLAR is provided in Table 2, whereas the Chinese version is provided in S1 Table 1. Five of the items were created as open-ended questionnaires (items 1 to 5) based on the demographics of the respondents. On the other hand, responses to six items (items 7 to 12) were intended to be either Yes/No or Yes/No/I do not know. On increasing rating scales of five, the responses to the remaining 33 items were to be submitted as three distinct options: Option 1 (None = 1/Short = 2/Medium = 3/Long = 4/Very long = 5), Option 2 (None = 1/Less = 2/Medium = 3/Many = 4/A lot = 5), and Option 3 (None = 0/Lighter = 1/Medium = 2/Serious = 3/Very serious = 4), respectively, depending on the suitable of the questions and domain [Table 2].

Table 2.

A QoLAR questionnaire version 2 for medical information in English

Question	Option for Responses
Domain 1: Sociodemographic
Age	Open-ended question
Ethnic group	Open-ended question
Height (cm)	Open-ended question
Weight (kg)	Open-ended question
Occupation	Open-ended question
Gender	Male/Female
Domain 2: Health Status, Medical History, and Burden of Allergic Rhinitis
Are you taking antibiotics currently?	Yes/No
Do you have a known disease? disease? (asthma, cancer, cerebrovascular disease, or myocardial infarction)	Yes/No/I do not know
Do you have a known metabolic disease? (Hypertension, hyperglycemia or dyslipidemia)	Yes/No/I do not know
Are you a smoker?	Yes/No
Are you currently breastfeeding a child?	Yes/No
Do you have any other diseases besides allergic rhinitis?	Yes/No
The time of year when you have allergies	None/Short/Medium/Long/Very long
Number of known allergens that will trigger your AR	None/Less/Medium/Many/A lot
The cost of drugs for AR (when bought without a doctor’s prescription)	None/Less/Medium/Many/A lot
The severity of your stuffy nose	none/lighter/medium/serious/very serious
The severity of your sneezing	none/lighter/medium/serious/very serious
The severity of runny nose during an attack of allergic rhinitis	none/lighter/medium/serious/very serious
The severity of teary eyes during an attack of allergic rhinitis	none/lighter/medium/serious/very serious
The severity of dry nose during an attack of allergic rhinitis	none/lighter/medium/serious/very serious
The severity of nasal bleeding during the attack of allergic rhinitis	none/lighter/medium/serious/very serious
The main diagnosis is “allergic rhinitis caused by pollen” and the impact on you	none/lighter/medium/serious/very serious
The main diagnosis is “other causes of seasonal allergic rhinitis”, and the impact on you	none/lighter/medium/serious/very serious
The main diagnosis is other allergic rhinitis (with a clear cause), and the degree of impact on you.	none/lighter/medium/serious/very serious
The main diagnosis is the cause of allergic rhinitis is not clear, and the impact on you	none/lighter/medium/serious/very serious
For how long has your family been suffering from allergy?	None/Short/Medium/Long/Very long
What is your degree of allergy to other medications?	none/lighter/medium/serious/very serious
The cost of treatment for AR (prescription drugs, treatment etc., prescribed by a doctor)	None/Less/Medium/Many/A lot
Cost of other health products for AR	None/Less/Medium/Many/A lot
Cost of consumables for AR (related masks, nose washers etc.)	None/Less/Medium/Many/A lot
The frequency of receiving treatment in a formal medical facility	None/Less/Medium/Many/A lot
The number of times of cleaning the nasal cavity each year	None/Less/Medium/Many/A lot
Domain 3: Dietary Habits
Frequency of consumption of other meats (not pork)	None/Less/Medium/Many/A lot
The frequency of eating rice	None/Less/Medium/Many/A lot
The frequency of eating pasta	None/Less/Medium/Many/A lot
Frequency of edible bean products	None/Less/Medium/Many/A lot
Frequency of eating pork and its products	None/Less/Medium/Many/A lot
The frequency of drinking wine	None/Less/Medium/Many/A lot
Domain 4: Environmental Exposure
How long have you lived in the countryside as an adult?	None/Less/Medium/Many/A lot
The length of time of working in the countryside	None/Less/Medium/Many/A lot
How long have you lived in the countryside as a child (1-6 years old)?	None/Less/Medium/Many/A lot
The length of time spent working indoors in the city	None/Less/Medium/Many/A lot
The length of time spent working outdoors in the city	None/Less/Medium/Many/A lot
The length of time living in Ningxia	None/Less/Medium/Many/A lot

Reliability analysis of the QoLAR questionnaire

The reliability analysis using item-total correlations and Cronbach’s ɑ coefficient for 21-item QoLAR versions 1 and 2 is provided in Supplementary Tables 1 and 2, respectively. The QoLAR version 1 had a lower Cronbach’s ɑ value (0.40) with 94.7% (n = 18/19) of items having a moderate (0.308–0.686) and one item, “Have you been fed by chewing” having a low (0.247) multiple correlations [Supplementary Table 1]. However, the QoLAR version 2 had a higher Cronbach’s ɑ value (0.903) than the first version of the questionnaire [Supplementary Table 2]. For the item-total correlation analysis, out of 32 items with rating scale responses, 11 items (34.4%) had a strong correlation (0.730–0.864), 19 items (59.4%) had a moderate correlation (0.325–0.658), and two items had a low correlation coefficient, which is “The length of time spent working outdoors in the city” (0.196) and “The length of time living in Ningxia” (0.268) [Supplementary Table 2]. However, these two items were not excluded from the questionnaire [Supplementary Table 2].

Supplementary Table 1.

A QoLAR questionnaire Version 2 in Chinese

Supplementary Table 2.

A QoLAR questionnaire Version 2 in English

Question	Option for Responses
Age	Open-ended question
Ethnic group	Open-ended question
Height (cm)	Open-ended question
Weight (kg)	Open-ended question
Occupation	Open-ended question
Gender	Male/Female
Are you taking antibiotics currently?	Yes/No
Do you have a known disease? disease? (asthma, cancer, cerebrovascular disease, or myocardial infarction)	Yes/No/I do not know
Do you have a known metabolic disease? (Hypertension, hyperglycemia or dyslipidemia)	Yes/No/I do not know
Are you a smoker?	Yes/No
Are you currently breastfeeding a child?	Yes/No
Do you have any other diseases besides allergic rhinitis?	Yes/No
The time of year when you have allergies	None/Short/Medium/Long/Very long
Number of known allergens that will trigger your AR	None/Less/Medium/Many/A lot
The cost of drugs for AR (when bought without a doctor's prescription)	None/Less/Medium/Many/A lot
The severity of your stuffed nose	none/lighter/medium/serious/very serious
The severity of your sneezing	none/lighter/medium/serious/very serious
The severity of runny nose during an attack of allergic rhinitis	none/lighter/medium/serious/very serious
The severity of teary eyes during an attack of allergic rhinitis	none/lighter/medium/serious/very serious
The severity of dry nose during an attack of allergic rhinitis	none/lighter/medium/serious/very serious
The severity of nasal bleeding during the attack of allergic rhinitis	none/lighter/medium/serious/very serious
The main diagnosis is "allergic rhinitis caused by pollen" and the impact on you	none/lighter/medium/serious/very serious
The main diagnosis is "other causes of seasonal allergic rhinitis", and the impact on you	none/lighter/medium/serious/very serious
The main diagnosis is other allergic rhinitis (with a clear cause), and the degree of impact on you.	none/lighter/medium/serious/very serious
The main diagnosis is the cause of allergic rhinitis is not clear, and the impact on you	none/lighter/medium/serious/very serious
For how long has your family been suffering from allergy?	None/Short/Medium/Long/Very long
What is your degree of allergy to other medications?	none/lighter/medium/serious/very serious
The cost of treatment for AR (prescription drugs, treatment etc., prescribed by a doctor)	None/Less/Medium/Many/A lot
Cost of other health products for AR	None/Less/Medium/Many/A lot
Cost of consumables for AR (related masks, nose washers etc.)	None/Less/Medium/Many/A lot
The frequency of receiving treatment in a formal medical facility	None/Less/Medium/Many/A lot
The number of times of cleaning the nasal cavity each year	None/Less/Medium/Many/A lot
Frequency of consumption of other meats (not pork)	None/Less/Medium/Many/A lot
The frequency of eating rice	None/Less/Medium/Many/A lot
The frequency of eating pasta	None/Less/Medium/Many/A lot
Frequency of edible bean products	None/Less/Medium/Many/A lot
How long have you lived in the countryside as an adult?	None/Less/Medium/Many/A lot
The length of time of working in the countryside	None/Less/Medium/Many/A lot
How long have you lived in the countryside as a child (1-6 years old)?	None/Less/Medium/Many/A lot
The length of time spent working indoors in the city	None/Less/Medium/Many/A lot
The length of time spent working outdoors in the city	None/Less/Medium/Many/A lot
The length of time living in Ningxia	None/Less/Medium/Many/A lot
Frequency of eating pork and its products	None/Less/Medium/Many/A lot
The frequency of drinking wine	None/Less/Medium/Many/A lot

Validity analysis of the QoLAR questionnaire

All four domains and 44 items of the QoLAR Questionnaire were assessed for validity using I-CVI, S-CVI/Ave, and S-CVI/UA [see Supplementary Table 3]. Each item had an I-CVI and S-CVI/Ave score of 1.00, and the S-CVI/UA score was also 1.00, indicating universal agreement on the questionnaire’s validity among experts.

Discussion

This study developed the QoLAR questionnaire in Chinese, the first self-administered QoL measure for AR. It includes 44 items across four domains: sociodemographic, dietary habits, environmental exposure, health status, and medical history. These domains address key AR risk factors in China.[1,4,5,8,9]

There are large regional differences in allergen exposure and lifestyle due to China’s heterogeneous topography, climate, and economic conditions. These variables, along with changes in socioeconomic status and urbanization, may impact the prevalence of AR.[1,4,5] Due to geographic and vegetation variations throughout China, there are significant regional variations in the distribution of pollen species and counts.[6,7] In the western and northern parts of China, airborne pollen is the most common and seasonal cause of allergic reactions (AR). As a result, in the northern Yangtze River region of China (Beijing, Xinjiang, Shanxi, Shandong, Shenyang, Lanzhou, and Ningxia), Artemisia pollen is the most prevalent allergenic pollen.[4,5] However, studies on the quality of life in the impacted area of China still need to be made available.

Recent studies outside China also highlight similar risk factors for allergies and asthma. In Tigray, Ethiopia, a case-control study by Gebresillasie et al.[12] found elevated asthma risk linked to urbanization, low income, allergic disease history, indoor smoke or dust, firewood use, pet ownership, and a sedentary lifestyle. These findings confirm that sociodemographic factors, dietary habits, environmental exposure, health status, and medical history are key AR risk factors. Our online self-reported QoLAR questionnaire offers culturally relevant access for the diverse population in China, enabling individuals to report their risk factors and burdens in real time, particularly related to environmental allergens. QoLAR supports comprehensive public health monitoring and aligns with Chinese guidelines for diagnosing and treating AR, emphasizing the need to identify high-risk exposures and the role of allergen immunotherapy (AIT) in managing the AR health burden.[4,5]

By implementing QoLAR, we enhance the effectiveness of monitoring AR risk factors and burdens, informing public health strategies, and improving resource allocation. This proactive approach ultimately leads to better health outcomes for those impacted by AR in China. Thus, the QoLAR questionnaire’s four domains and 44 items are valuable for assessing AR risk factors and quality of life, especially in China.

The QoLAR questionnaire offers several advantages for evaluating AR-related quality of life in China. Developed with input from experts in medicine, nutrition, biology, and microbiome from China and Malaysia, it ensures content validity and cultural relevance. The large sample size (n = 169) of Chinese respondents and balanced representation of Han (45.9%) and Hui (52.5%) ethnic groups, with an even gender distribution (women, 50.3%; men, 49.7%), further supports its validity and reliability.

Since the QoLAR questionnaire was tested by interacting with respondents through an online messaging platform, it also has the advantage of being appropriate for self-administered online surveys. Despite being an online study, several recent self-reported online surveys demonstrate good usability and reliability for gathering insightful feedback. A successful online survey on allergy disorders revealed important risk factors for students in the Japanese cities of Oyama and Tochigi.[20] Another self-reported online survey on the incidence of food allergy in 3- to 16-year-old children in Wuhan, China, was also reported, with details on the prevalence of food allergy.[21]

Self-reported online surveys became more popular after the COVID-19 pandemic, particularly in cases where official data are hard to come by and testing capacity is limited.[22] The prevalence and impact of an illness can be swiftly, easily, and affordably assessed using online population surveys distributed through social media and online messaging services, as Oliver et al. and Coppock and McClellan proposed.[22,23]

The QoLAR version 2 was designed and rated using a range of answer and response formats, such as open-ended questions and answers and questions rated on a five-point response scale based on the question’s appropriateness. This set of responses ensures the validity of the question and answers as it was discovered that version 2’s total Cronbach’s ɑ coefficient (0.903) was higher than the first version (0.40).

Regarding the item-total correlations, two items with a low correlation coefficient, “The length of time spent working outdoors in the city” (0.196) and “The length of time living in Ningxia” (0.268), were not excluded from the questionnaire because the exclusion of these items would not increase in the Cronbach’s ɑ value if the item were deleted [Supplementary Table 2]. Three content validity indices (I-CVI, S-CVI/Ave, and S-CVI/UA) gave all 44 items a high score of 1.00. Following the content experts’ review, the high scores for these items and the scale content validity demonstrate the questionnaire’s high validity.[16,17,18,19] Thus, items have not been amended or eliminated to QoLAR version 2.

This study introduces a novel approach by developing an online, self-administered questionnaire to assess AR risk factors and quality-of-life impacts within the Chinese population. By addressing existing gaps in AR assessment tools, this study successfully created a culturally relevant, accessible instrument that can yield more precise insights into AR’s impact on daily life via an online self-reported questionnaire. This innovative tool will support the development of targeted healthcare strategies for AR management in China, potentially setting a new standard for AR assessment in the region.[4,5]

Besides that, our study supports multiple United Nations Sustainable Development Goals (SDGs).[24,25] Specifically, it aligns with SDG 3: Good Health and Well-Being by contributing to targets focused on reducing premature mortality from noncommunicable diseases (Target 3.4) and promoting universal health coverage (Target 3.8). With AR affecting the quality of life, QoLAR serves as a vital tool for enhancing management strategies and minimizing the burden of AR, particularly in underserved areas like Ningxia.[4,5,26]

Additionally, QoLAR aligns with SDG 9: Industry, Innovation, and Infrastructure enhancing scientific research and innovations (Target 9.5). The culturally specific assessment strengthens health research infrastructure and supports data-driven policymaking. A multidisciplinary team of clinicians, scientists, and nutritionists collaborated to develop the QoLaR. The questionnaire also addresses health disparities following SDG 10: Reduced Inequalities, Empowering Diverse and Underserved Populations (Target 10.2). Its culturally tailored approach helps close health gaps in AR management.

Moreover, the study relates to SDG 11: Sustainable Cities and Communities by capturing how environmental factors, like air pollution, affect AR sufferers.[27] This information can guide policies to address environmental triggers and promote healthier urban settings. Last, QoLAR supports SDG 17: Partnerships for the Goals by enhancing data collection capacity (Target 17.18). It is a model for culturally relevant data tools, fostering partnerships to address AR and related health issues. This study establishes a new standard for AR assessment in China while advancing global health and equity goals. It provides a framework for culturally sensitive, evidence-based healthcare strategies that align with national and international priorities.

Limitation and recommendation

One limitation of this study is its reliance on online self-reported data, which may introduce biases such as self-selection bias and inaccuracies in participant responses due to survey question misunderstandings or misinterpretations. To address potential biases, pilot testing with a snowballing technique was used to identify and resolve potential question ambiguities.

Additionally, although the sample size was considerable and diverse, it may not fully represent the wider Chinese population, particularly in regions characterized by different socioeconomic statuses or environmental conditions. Future research should aim to utilize larger and more regionally representative samples to enhance the generalizability of the findings.

Furthermore, conducting longitudinal studies could facilitate an evaluation of the consistency and predictive validity of the QoLAR over time. Expanding the questionnaire to encompass a broader range of environmental and lifestyle factors, along with the incorporation of objective clinical measurements, would further augment its utility as a comprehensive tool for assessing and managing the risk of allergic responses.

Conclusions

This study establishes a new benchmark in health policy for AR in China by introducing a culturally tailored, online self-administered questionnaire to assess risk factors and quality-of-life impacts in the Chinese population. By filling critical gaps in current assessment tools, this instrument offers valuable insights into the daily burden of AR and improves assessment accuracy. The data generated can inform targeted healthcare strategies and support the development of culturally relevant health policies, particularly in regions like Ningxia and China’s local health policies, such as the Chinese Guideline for Diagnosis and Treatment of Allergic Rhinitis and the Chinese Guideline on Allergen Immunotherapy for Allergic Rhinitis. Furthermore, this initiative aligns with five key WHO Sustainable Development Goals: SDG 3 (good health and wellbeing), SDG 9 (Industry, Innovation, and Infrastructure), SDG 10 (reduced inequalities), SDG 11 (sustainable cities and communities), and SDG 17 (partnerships for the goals), ultimately enhancing quality of life for individuals with AR.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.