Allergic rhinitis (AR) is one of the most common chronic respiratory conditions worldwide, affecting individuals across all ages, socioeconomic groups, and geographic regions. It is characterized by symptoms such as sneezing, nasal congestion, rhinorrhea, nasal itching, and postnasal drip, resulting from an immunoglobulin E (IgE)-mediated hypersensitivity reaction to allergens. Although not life-threatening, AR has a profound impact on quality of life, sleep patterns, work productivity, school performance, and psychological well-being, making it a public health concern of considerable significance. According to the World Health Organization, allergic diseases including AR have been rising sharply over the past few decades, largely due to urbanization, lifestyle changes, environmental pollution, and altered immune responses in modern societies. The prevalence of AR varies widely, with studies estimating that approximately 10–30% of the global population is affected, and nearly 40% in certain highly industrialized nations. In India, the prevalence is estimated between 20–30% depending on region, yet significant differences exist between urban and rural populations owing to disparities in environmental exposures, socioeconomic conditions, healthcare accessibility, and awareness levels.^[1]

Urban populations are more frequently exposed to vehicular emissions, industrial pollutants, indoor allergens such as dust mites, and altered dietary patterns, all of which increase susceptibility to allergic diseases. Conversely, rural populations, though relatively shielded from urban pollutants, may face risks from biomass fuel smoke, agricultural allergens such as pollens and pesticides, and limited access to timely medical diagnosis or treatment. The "hygiene hypothesis" postulates that reduced exposure to infectious agents and increased use of antibiotics in urban populations might lead to a skewed immune response favoring allergic sensitization, thereby explaining higher prevalence of AR in cities compared to villages. However, rural areas may demonstrate underreporting due to poor awareness and lack of diagnostic facilities, creating a potential bias in existing prevalence data.^[2]

Quality of life (QoL) has emerged as an essential parameter in the assessment of AR, complementing traditional measures of clinical severity. Tools such as the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and Short Form-36 (SF-36) provide structured insights into the multidimensional burden imposed by AR, encompassing physical, psychological, and social domains. Patients with moderate-to-severe AR often report fatigue, poor concentration, irritability, and sleep disturbances, which cascade into reduced workplace or school productivity and absenteeism. Children with AR are particularly vulnerable, as it impacts learning outcomes and social interactions, while adults often face occupational challenges and diminished work efficiency. Studies have also established associations between AR and comorbidities such as asthma, sinusitis, otitis media, and conjunctivitis, further compounding the overall health burden.^[3]

Globally, several cross-sectional and population-based studies have highlighted the magnitude of Lambraki E et al. (2025)^[4] reported that AR significantly affects daily activities, with urban patients reporting more severe impairment due to higher exposure to pollutants and allergens. A study by Bauchau and Durham (2004) across European nations highlighted that nearly 25% of adults had AR symptoms, with substantial under-diagnosis and under-treatment. In India, Srivastava P et al. (2024)^[5] documented variable prevalence between rural and urban communities, reinforcing the need for population-specific studies. The Indian Council of Medical Research has repeatedly stressed the importance of evaluating allergic conditions in the context of rural versus urban disparities, since healthcare utilization, traditional beliefs, and accessibility differ markedly between these groups. Despite these observations, relatively few studies in India have systematically compared AR prevalence and its impact on QoL between urban and rural settings, leaving a critical knowledge gap that this study aims to address.

Aim

To evaluate the prevalence and impact of allergic rhinitis on quality of life in urban versus rural populations.

Objectives

1. To assess the prevalence and clinical profile of allergic rhinitis among urban and rural populations.
2. To evaluate the impact of allergic rhinitis on quality of life using standardized questionnaires.
3. To compare urban versus rural differences in symptom severity, triggers, and healthcare-seeking behavior.

Source of Data

The study included participants drawn from both urban and rural communities attending the outpatient departments of a tertiary care hospital and affiliated peripheral health centers.

 Study Design

The study was designed as a cross-sectional, observational analysis.

Study Location

The research was conducted at a tertiary care teaching hospital along with selected outreach health centers covering both urban and rural populations.

Study Duration

The study was conducted over a period of 12 months.

Sample Size

A total of 120 participants were included in the study, with equal representation from urban (n=60) and rural (n=60) populations.

Inclusion Criteria

• Adults and adolescents aged 15 years and above.
• Patients clinically diagnosed with allergic rhinitis based on ARIA guidelines.
• Willing participants who provided informed consent.

Exclusion Criteria

• Patients with chronic rhinosinusitis, nasal polyps, or deviated nasal septum.
• Individuals with other chronic respiratory conditions such as asthma, COPD, or tuberculosis.
• Patients unwilling or unable to participate.

 Procedure and Methodology

Eligible participants were recruited consecutively during their visit to the outpatient department. After informed consent, a detailed history was obtained including demographic data, residential background (urban or rural), duration of symptoms, environmental exposures, and family history of allergy. Clinical examination was conducted with emphasis on nasal mucosa, turbinates, and presence of allergic stigmata. The diagnosis of allergic rhinitis was confirmed using ARIA criteria, based on symptoms such as sneezing, rhinorrhea, nasal congestion, and nasal itching lasting for at least 4 days per week and for at least 4 consecutive weeks.

Participants were asked to complete a standardized questionnaire assessing quality of life, including the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), which covers domains such as activity limitation, sleep disturbances, nasal symptoms, eye symptoms, practical problems, and emotional impact. Symptom severity was assessed using a Visual Analog Scale (VAS). Data on healthcare-seeking behavior, use of medications, and awareness about AR were also recorded.

 Sample Processing

No invasive biological samples were required. Data were collected using structured case record forms and validated questionnaires administered by trained investigators.

 Statistical Methods

Data were compiled and analyzed using SPSS software version 25. Descriptive statistics (mean, standard deviation, and percentages) were calculated for demographic and clinical variables. Differences between urban and rural groups were analyzed using Chi-square test for categorical variables and Student’s t-test for continuous variables. Logistic regression analysis was performed to identify predictors of poor quality of life. A p-value <0.05 was considered statistically significant.

Data Collection

Data collection was done prospectively during patient visits. All responses were checked for completeness at the point of collection to minimize missing data. Data were entered into an electronic database, verified by double-entry, and subjected to periodic quality checks. Confidentiality of participants was maintained throughout the study.

Table 1: Prevalence and overall QoL impact (N=120)

Table 1 presents the prevalence of allergic rhinitis (AR) and its impact on quality of life in the urban and rural populations studied. The prevalence of AR was significantly higher among urban residents (78.3%) compared to rural residents (48.3%), with a risk difference of 30% (95% CI: +14% to +46%, p<0.001). Quality of life, as assessed by the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), showed higher impairment in the urban group (mean score 3.2±1.0) compared to the rural group (2.6±0.9), with a mean difference of +0.60 (95% CI: +0.26 to +0.94, p<0.001). Sleep disturbance scores on the visual analogue scale (VAS) were also worse in urban participants (6.1±1.8) compared to rural (4.9±1.7), with a significant difference of +1.20 (95% CI: +0.57 to +1.83, p<0.001). The number of work or school days lost in the past three months was higher in urban participants (3.1±2.2 vs. 2.2±1.9; mean difference +0.90, 95% CI: +0.16 to +1.64, p=0.017). Although the EQ-5D visual analogue scale for current health status showed slightly lower scores in the urban group (71.3±11.9 vs. 74.8±12.4), this difference was not statistically significant (p=0.115).

Table 2: Prevalence & clinical profile of AR (calculated among AR-positive only)

Table 2 details the clinical characteristics of AR among those who were diagnosed positive (Urban n=47; Rural n=29). A higher proportion of urban AR patients reported persistent symptoms (59.6%) compared to rural (37.9%), though this difference did not reach statistical significance (p=0.060). Similarly, moderate-to-severe ARIA classification was more frequent in urban participants (66.0% vs. 48.3%, p=0.126). The mean age at onset was lower in the urban group (22.8±8.1 years) compared to rural (25.6±7.7 years), though not statistically significant (p=0.131). The duration of symptoms was slightly longer in urban participants (6.4±4.1 years vs. 5.7±3.8 years, p=0.449). Comorbid asthma and allergic conjunctivitis were somewhat more frequent in urban patients (19.1% vs. 10.3% and 44.7% vs. 31.0%, respectively), but differences were nonsignificant. A family history of atopy was reported in 55.3% of urban patients compared to 34.5% in rural patients, showing a trend toward significance (p=0.068). Laboratory parameters, including absolute eosinophil counts and total IgE levels, were higher in urban AR patients, though these differences were not statistically significant.

Table 3: QoL impact using standardized questionnaires (AR-positive only)

Table 3 analyzes the impact of AR on different domains of quality of life, as measured by the RQLQ among AR-positive patients. Across all domains, urban patients demonstrated significantly higher impairment compared to rural patients. Activity limitation scores were higher in the urban group (3.1±0.9) than rural (2.5±0.8), with a mean difference of +0.60 (p=0.002). Sleep disturbance was also more pronounced in urban AR patients (3.4±1.0 vs. 2.7±0.9, mean difference +0.70, p=0.002). Nasal symptoms showed a similar pattern (3.8±1.1 vs. 3.1±1.0, mean difference +0.70, p=0.004). Eye symptoms were significantly more frequent in urban participants (2.6±0.8 vs. 2.2±0.7, p=0.022). Emotional impact and practical problems were also worse among urban participants (3.0±0.9 vs. 2.4±0.8 and 3.5±1.0 vs. 2.9±0.9, both p<0.01). The overall RQLQ total score was significantly higher in urban patients (3.2±1.0) compared to rural (2.6±0.9), with a mean difference of +0.60 (95% CI: +0.17 to +1.03, p=0.007).

Table 4: Symptom severity, triggers, and healthcare-seeking behavior (AR-positive only)

Table 4 compares symptom severity, environmental triggers, and healthcare-seeking patterns among urban and rural AR patients. Urban patients reported significantly higher mean symptom severity scores (6.7±1.6 vs. 5.5±1.7; p=0.002), though the proportion with severe AR (VAS ≥7) was not significantly different (51.1% vs. 31.0%, p=0.075). Dust exposure was reported more frequently as a trigger in urban patients (74.5% vs. 51.7%, p=0.043), whereas smoke/biomass exposure was significantly higher among rural patients (72.4% vs. 29.8%, p<0.001). Pollen and pet dander triggers did not differ significantly between groups. Regarding healthcare behavior, a larger proportion of rural patients first sought care at pharmacies (58.6% vs. 40.4%, p=0.117), while urban patients more often visited specialists in the past year (57.4% vs. 34.5%, p=0.044). Adherence to intranasal steroids was better among urban patients (51.1% vs. 31.0%, p=0.075). Importantly, rural patients experienced a significantly longer delay from symptom onset to first consultation (11.2±6.1 months vs. 7.3±4.5 months, p=0.003). Urban patients reported more physician visits in the past year (2.1±1.3 vs. 1.5±1.0, p=0.024).

Data show a substantially higher current prevalence of allergic rhinitis (AR) in urban participants than rural counterparts (78.3% vs 48.3%; RD +30%, p<0.001), alongside significantly worse overall RQLQ scores, greater sleep disturbance, and more days lost from work/school among urban residents (Table 1). These findings align with global guidance and epidemiology indicating that urban exposures-particularly traffic-related air pollution (TRAP) and indoor allergens-inflate AR burden and impair quality of life (QoL). Recent ARIA/“next-generation ARIA” statements emphasize environment- and exposure-aware management and the use of validated PROs such as RQLQ for routine assessment, which directly supports our choice of outcomes and interpretation of clinically meaningful differences. Appiah-Thompson P et al. (2023)^[6]

At the population level, large multi-country networks have reported sizeable AR prevalence with urban–rural gradients. India-specific estimates from the Global Asthma Network (GAN) show symptomatic rhinoconjunctivitis in schoolchildren and adults, with notable geographic heterogeneity that plausibly reflects ambient pollution, allergen load, and healthcare access-patterns consonant with our higher urban prevalence and worse urban QoL. A recent meta-analysis synthesizing cohort data also finds higher risk of AR with urban living versus rural residence, reinforcing that our effect direction matches broader evidence. Brodowicz-Król M et al.(2020)^[7]

The QoL detriment we observed-elevations across RQLQ domains (activity limitation, sleep, nasal/eye symptoms, emotions, and practical problems) among urban AR-positive participants (Table 3)-is consistent with the measurement properties and sensitivity of the Rhinoconjunctivitis Quality of Life Questionnaire, which has robust validity and responsiveness across paper and electronic formats. Our mean differences (e.g., +0.6 to +0.7 in several domains) exceed typical thresholds for minimal important change in RQLQ, supporting that these are not trivial differences.

Environmental trigger patterns further contextualize the urban–rural split (Table 4). Urban AR patients reported more dust/TRAP-proximate triggers, whereas rural patients exhibited markedly higher smoke/biomass triggers (72.4% vs 29.8%, p<0.001). Contemporary reviews and primary studies link TRAP exposure-prenatal and early-life-to later AR, while household biomass fuel smoke remains a major driver of airway symptoms in rural South Asia, including India. The divergence in triggers we document mirrors these exposure ecologies and likely contributes to the phenotype differences we observed (e.g., symptom severity VAS, delayed first consult in rural patients). Alblewi SM et al.(2024)^[8]

In clinical profile comparisons among AR-positive participants (Table 2), urban patients trended toward more persistent patterns, higher ARIA severity classes, and higher markers of type-2 inflammation (eosinophils, IgE), though not all reached statistical significance at α=0.05-likely a function of subgroup size. Still, the overall pattern accords with national reviews that document rising allergic disease burden in India, urban clustering, and under-recognition/under-treatment in peripheral settings. Our healthcare-seeking data complement this: urban patients had more specialist visits and better intranasal steroid adherence, whereas rural patients more often initiated care via pharmacies and faced longer delays to first consultation. Such utilization gaps are a recurrent theme in Indian allergy care landscape assessments and are salient targets for system-level intervention (e.g., primary-care algorithms linked to ARIA severity, affordable controller access, and biomass-smoke mitigation). Pisithkul T et al (2024)^[9]

The productivity signal-more days lost among urban residents despite a nonsignificant EQ-5D VAS difference-echoes prior work that AR imposes large indirect costs through presenteeism and absenteeism, even when generic health status measures are less sensitive than disease-specific PROs. This strengthens the argument for routine RQLQ deployment in clinics and for public-health policies that curb urban pollution and reduce rural biomass exposure. Al Khalaf AB et al.(2025)^[10]

This cross-sectional evaluation highlights a significantly higher prevalence of allergic rhinitis in urban populations compared to rural counterparts, with urban residents reporting more severe symptoms, greater quality of life impairment, and increased absenteeism from work or school. Environmental exposures, particularly dust and traffic-related pollutants, were more strongly associated with urban cases, while biomass fuel smoke was a major trigger in rural populations. Healthcare utilization patterns also differed, with urban patients accessing specialist care more frequently and rural patients experiencing delays in consultation and relying more on pharmacy-based care. These findings underscore the dual burden of allergic rhinitis in both settings, shaped by differing environmental and healthcare access factors, and call for tailored public health strategies addressing urban pollution control and rural healthcare accessibility.

1. Being a cross-sectional design, causal inferences between environmental exposures and allergic rhinitis could not be established.
2. The sample size, though adequate for preliminary comparisons, may not be fully representative of wider urban and rural populations across diverse regions.
3. Diagnosis was based on clinical criteria and patient-reported outcomes without confirmatory allergy testing (e.g., skin prick test, specific IgE), which may have led to misclassification.
4. Recall bias in reporting symptom onset, triggers, and healthcare visits could have influenced accuracy.
5. Quality of life assessment, though based on validated tools, may have been influenced by participants’ subjective perceptions at the time of survey.

1. Sikorska-Szaflik H, Sozańska B. Quality of life in allergic rhinitis-children’s and their parents’ perspective in polish urban and rural population. Health and Quality of life Outcomes. 2020 Mar 10;18(1):64.
2. Song M, Hwang S, Son E, Yeo HJ, Cho WH, Kim TW, Kim K, Lee D, Kim YH. Geographical differences of risk of asthma and allergic rhinitis according to urban/rural area: a systematic review and meta-analysis of cohort studies. Journal of Urban Health. 2023 Jun;100(3):478-92.
3. Tizek L, Redlinger E, Ring J, Eyerich K, Biedermann T, Zink A. Urban vs rural–Prevalence of self-reported allergies in various occupational and regional settings. World Allergy Organization Journal. 2022 Jan 1;15(1):100625.
4. Lambraki E, Bouloukaki I, Margetaki K, Tzanakis N, Karatzanis A, Tsiligianni I. Differences between rural and urban primary care practices in asthma and allergic rhinitis control: the Greek experience. Rural and Remote Health. 2025 Sep;25(3):1-3.
5. Srivastava P, Patil SA. A review of the adverse impacts of allergic rhinitis on health-related quality of life and its evaluation. Annals of the National Academy of Medical Sciences (India). 2024 May 20;60(2):131-8.
6. Appiah-Thompson P, Amuquandoh A. Prevalence and socioeconomic impact of allergic rhinitis among ear, nose, and throat patients of a tertiary hospital. Cureus. 2023 Dec 1;15(12).
7. Brodowicz-Król M, Guz E, Hawryluk D, Kulbaka E, Panasiuk L, Lutomski P, Kaczor-Szkodny P, Choina P. Quality of life of patients undergoing specific allergen immunotherapy in allergic rhinitis. Annals of Agricultural and Environmental Medicine. 2020;27(4):657-63.
8. Alblewi SM, Alenazi LM, Alshahrani RS, Alharbi RT, Alotaibi NA, Albalawi HM, Albalawi DL, Alfaidi AA, Sabir DA. Prevalence of allergic rhinitis and its impact on quality of life among pediatric patients in Tabuk, Saudi Arabia. Oman Medical Journal. 2024 Nov 30;39(6):e696.
9. Pisithkul T, Pisithkul T, Lao-Araya M. Impact of air pollution and allergic status on health-related quality of life among university students in Northern Thailand. International Journal of Environmental Research and Public Health. 2024 Apr 8;21(4):452.
10. Al Khalaf AB, Aljerayed MK, Alsuliman M, Alkhalifah SN, Alghazal SF, Alhaddad HM, ALHADDAD HM. The Impact of Allergic Rhinitis on the Quality of Life Among Adult Patients in Alahsa, Saudi Arabia: A Case-Control Study. Cureus. 2025 Jul 11;17(7).