Impact of Sleep, Mental Health, and Health Literacy on Health-Related Quality of Life in Patients with Allergic Rhinitis: A Secondary Analysis of the 2023 Korea National Health and Nutrition Examination Survey
Article information
Abstract
Purpose
This study aimed to identify the impact of sleep, mental health, and health literacy on health-related quality of life in patients with allergic rhinitis.
Methods
A descriptive secondary analysis design was used. The participants were 771 adults aged 19 to 64 years with allergic rhinitis whose raw data were available from the 2023 Korea National Health and Nutrition Examination Survey. Data were analyzed using complex sample descriptive statistics, frequency, x2 test, t-test, and multiple regression using SPSS 29.0.
Results
Gender (t=4.90, p<.001), smoking habits (t=2.14, p=.034), perceived health status (t=5.83, p<.001), physical activity limitation (t=5.11, p<.001), stress (t=6.19, p<.001), depressive mood (t=4.48, p<.001), anxiety (t=5.43, p<.001), and health literacy (t=3.45, p<.001) showed statistically significant associations with health-related quality of life, accounting for 44.8% of the total variance.
Conclusion
Community health nursing should prioritize the early identification of psychological issues and provide tailored education to improve health literacy in patients with allergic rhinitis. Health promotion programs for smoking cessation and physical activity are necessary, particularly for vulnerable groups.
INTRODUCTION
Allergic rhinitis (AR) is a chronic respiratory condition characterized by repeated episodes of sneezing, nasal congestion, rhinorrhea, and nasal itching, triggered by an immunoglobulin E (IgE)-mediated response to environmental allergens [1]. In Korea, the prevalence of AR among adults ranges from approximately 15% to 25%, and its incidence has been steadily increasing in recent years, likely resulting from climate change and worsening air pollution [2,3]. According to data from the Health Insurance Review and Assessment Service, there will be approximately 5.8 million outpatient visits for AR in 2023, with total healthcare expenditures reaching around 252 billion KRW, indicating a substantial economic burden for both individuals and the healthcare system [4]. AR is not limited to nasal symptoms; it is also associated with absenteeism from work or school and diminished functional performance in daily life, which ultimately contribute to reduced productivity and increased socioeconomic costs [1,4]. Thus, AR represents a growing public health concern that warrants continuous attention at both the individual and societal levels.
The etiology of AR is multifactorial, involving both genetic predisposition and a variety of environmental triggers such as indoor and outdoor allergens and air pollutants [1,5]. Fine particulate matter (PM) and related pollutants exacerbate symptoms by inducing oxidative stress at the cellular level [5]. The prevalence of AR varies according to sociodemographic factors such as gender, age, and socioeconomic status. In adults, environmental influences tend to outweigh genetic factors, and AR symptoms are more likely to persist or progress to severe forms [1,6]. If not appropriately treated or effectively managed, AR may lead to complications, such as chronic sinusitis or asthma. Adults with AR are approximately three times more likely to develop asthma than those without AR [7,8].
In addition to nasal symptoms, AR has been associated with a range of comorbidities that negatively affect overall health, including sleep disturbances, emotional distress such as anxiety and depression, and reduced physical activity [9]. Given that adults are typically responsible for fulfilling various roles in the occupational, familial, and social domains, the impact of AR on daily functioning may be more pronounced, potentially leading to deterioration in health-related quality of life (HRQoL) [10]. Despite this, AR management often focuses predominantly on pharmacological treatments aimed at symptom relief, while preventive education and promotion of self-management capabilities are frequently overlooked. This symptom-centered approach fails to improve patients' quality of life and may contribute to the escalation of healthcare costs.
Previous studies have identified several factors that influence the HRQoL in patients with AR. Among these, sleep-related variables have been emphasized because AR is commonly associated with reduced sleep quality, sleep latency, and other disturbances [11]. These sleep issues may lead to decreased sleep duration, daytime fatigue, impaired cognitive functioning, and reduced ability to perform daily tasks, all of which adversely affect HRQoL [9,11]. Furthermore, AR has been linked to a range of mental health issues, including stress, anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD), with stress, anxiety, and depression consistently reported as major contributors to decreased quality of life [12,13].
Health literacy, the capacity to comprehend health-related information and make appropriate decisions based on that understanding, plays a vital role in the self-management of chronic diseases [14]. Limited health literacy has been associated with poor self-care practices, inefficient use of healthcare services, and reduced quality of life [8,14]. The ability to interpret and apply health information accurately is particularly important for adults who are largely responsible for managing their health. However, many patients with AR tend to rely on general medical consultations rather than specialized care, which may result in inadequate self-management and suboptimal use of health services [14]. This highlights the need for approaches that not only enhance self-care abilities but also improve health literacy among individuals with AR.
Sociodemographic characteristics such as gender, age, educational attainment, economic status, and marital status also significantly influence the HRQoL in patients with AR [2,6,8]. Additionally, health behaviors, including regular physical activity and smoking, are associated with HRQoL and are influenced by both individual attributes and external factors, such as living environment, accessibility to health information, social engagement opportunities, and availability of community resources [9,15,16].
However, much of the existing literature on AR has been limited to small sample sizes or focused on specific populations, such as children, older adults, or inpatients, often emphasizing the identification of physiological markers relevant to diagnosis or severity prediction [17-19]. Moreover, many instruments used to assess the HRQoL have limitations in terms of comprehensiveness and validity [13]. Consequently, studies centered on isolated physiological or sociodemographic factors may have limited applicability in nursing practice and fall short of informing holistic health management. Particularly, there is a lack of comprehensive research examining the combined effects of sleep, mental health, and health literacy on the HRQoL of community-dwelling adults with AR.
Accordingly, this study aimed to investigate the impact of sleep quality, mental health status, and health literacy on HRQoL among community-dwelling adults with AR. The novelty of this study lies in its use of raw data from the 2023 Korea National Health and Nutrition Examination Survey (KNHANES Ⅸ-2, 2023), which includes a nationally representative adult sample. By addressing the limitations of previous studies that relied on small or specific subgroups, this approach enhances the representativeness and generalizability of the findings. The results of this study are expected to provide empirical evidence to inform nursing interventions aimed at improving the quality of life of patients with AR and serve as foundational data for developing systematic community-level health management and prevention strategies. This study examined the impact of sleep, mental health, and health literacy on HRQoL in adults with AR using raw data from the KNHANES Ⅸ-2 (2023).
METHODS
1. Study Design
This descriptive and secondary data analysis study aimed to examine the effects of sleep, mental health, and health literacy on HRQoL among adults with AR. The analysis utilized raw data from the KNHANES Ⅸ-2 (2023).
2. Participants
The study population consisted of community-dwelling adults aged 19∼64 years who were diagnosed with AR. Among the 6,929 individuals who participated in the 2023 KNHANES, 771 adults who (1) were aged between 19 and 64 years; (2) self-reported having AR; and (3) had no missing values for key variables such as sleep, mental health, health literacy, and HRQoL were included in the final analysis (Figure 1).
Flow chart showing the selection of participants.
A power analysis was conducted using G*Power to determine the sample size required for multiple regressions. With an assumed medium effect size of .15, significance level of .05, a power of .95 and 19 predictors, the minimum required sample size was calculated to be 217. As this study analyzed secondary data from the Korea National Health and Nutrition Examination Survey, all eligible cases were included, yielding a final sample of 771, which exceeded the minimum requirement and ensured robust statistical validity.
3. Measurements
1) Health-related quality of life
HRQoL was measured using the Health-Related Quality of Life Instrument (HINT-8), developed by the Korea Institute for Health and Social Affairs [20]. It comprises eight items that assess stair climbing, pain, energy, work, depression, memory, sleep, and happiness. Each item is rated on a 4-point Likert scale, with reverse-coded scores used in this study; higher scores indicate better HRQoL. The reliability of this tool was Cronbach's ⍺=.80, based on raw data from KNHANES Ⅸ-2 (2023).
2) Sleep
Sleep duration was measured as the average number of hours of sleep per weekday. Based on the participants' responses, this variable was categorized as a binary variable using the mean sleep duration as a reference point.
3) Mental health
Mental health variables were selected based on previous research [12,13] and included perceived stress, depressive mood, and anxiety. Responses to perceived stress were recoded as "low stress=0" and "high stress=1." based on the criteria established in a previous study [21]. Participants reporting persistent depressive mood for at least 2 weeks were coded as "yes=1" and "no=0." Anxiety was assessed using the Generalized Anxiety Disorder-7 (GAD −7), developed by Spitzer et al. [22]. This tool includes seven items rated on a 4-point scale (0∼3). Higher scores indicate greater anxiety severity, with score ranges interpreted as follows: 0∼4 (normal), 5∼9 (mild), and ≥10 (severe anxiety). The reliability of this tool was Cronbach's ⍺=.90, based on raw data from KNHANES Ⅸ-2 (2023).
4) Health literacy
Health literacy was measured using the Health Literacy Index developed by Yoon et al. [23]. The tool consists of 10 items: three on disease prevention, one on health promotion, four on health management, and two on resource utilization. Each item is scored on a 4-point Likert scale, with higher scores reflecting greater health literacy. Scores were categorized as follows: ≤28 (inadequate), 28∼31(moderate), and ≥31 (adequate) [23]. The reliability of this tool was Cronbach's ⍺=.91, based on raw data from KNHANES Ⅸ-2 (2023).
5) General characteristics
Sociodemographic and health-related variables (n=14) included gender, age, marital status, living alone (yes/ no), residential area, economic activity status, educational attainment, smoking status, alcohol consumption, perceived health status, engagement in aerobic physical activity, participation in health screenings, presence of chronic illness (defined as having at least one of the following: hypertension or diabetes), and physical activity limitations. All variables were recategorized for analytical purposes.
4. Data Analysis
Data were analyzed using SPSS version 29.0 with the complex samples analysis module to account for the complex sampling design of the KNHANES Ⅸ-2 (2023), which included weights, clusters, and strata. Descriptive statistics and frequency analyses were used to examine the participants' general characteristics, sleep, mental health, health literacy, and HRQoL. Differences in HRQoL according to key variables were analyzed using a general linear model. Multiple regression analysis was performed to identify the factors influencing HRQoL.
5. Ethical Considerations
This study was exempt from ethical review by the Institutional Review Board of C University (IRB No. 202505-SB-090-01). This study used anonymized secondary data from KNHANES Ⅸ-2 (2023), which was conducted with the approval of the Institutional Review Board of the Korea Disease Control and Prevention Agency (IRB No. 2023-01-03-P-A, 2024-01-03-C-A). As the data were publicly available and no direct contact with participants occurred, additional informed consent was not required. All procedures complied with relevant ethical guidelines and data protection regulations. Before data access, the researcher submitted the required user agreement and confidentiality pledge in accordance with data usage guidelines. All data were stored in a secure folder with password protection on a desktop computer located in a restricted-access office, accessible only to the principal investigator and research staff. In compliance with the Personal Information Protection Act and relevant regulations, the data will be destroyed three years after the completion of the study.
RESULTS
1. General Characteristics, Sleep, Mental Health, Health Literacy, and Health-Related Quality of Life
Of the 771 participants, 505 (65.5%) were women and 266 (34.5%) were men. Most (65.6%) participants were aged between 19 and 44 years. Married individuals accounted for 507 (58.8%) and those living alone accounted for 96 (12.0%). The smoking rate was 103 (15.6%), and 428(57.8%) of the participants reported alcohol consumption. Most participants perceived their health status as fair or better, and 59 (7.7%) reported limitations in physical activity (Table 1).
Differences in Health-related Quality of Life according to General Characteristics (N=771)
The mean score for HRQoL was 26.72, indicating a moderate level. The average sleep duration was 6.68 hours on weekdays, with 350 (45.7%) reporting below-average sleep. Regarding mental health, 254 (34.0%) perceived high stress, and 103 (14.0%) had experienced a depressive mood lasting at least 2 weeks. The mean anxiety score was 2.74, which falls within the normal range; however, 165 (22.2%) scored 5 or higher, indicating a potential risk group. The average health literacy score was 31.46, indicating adequate health literacy, although 161 (20.7%) were classified as having inadequate health literacy (Table 2).
Differences in Health-related Quality of Life according to Sleep Health, Mental Health, and Health Literacy (N=771
2. Differences in Health-Related Quality of Life by Variables
Statistically significant differences were observed in HRQoL based on gender (F=22.96, p<.001), living alone (F=4.60, p=.034), smoking habit (F=6.04, p=.015), perceived health status (F=29.28, p<.001), and physical activity limitation (F=24.72, p<.001)(Table 1). No significant differences were found in other sociodemographic characteristics.
Significant differences in HRQoL were also observed according to stress levels (F=44.70, p<.001), depressive mood (F=23.18, p<.001), anxiety (F=32.20, p<.001), and health literacy (F=8.54, p=.004). However, no statistically significant differences were observed in sleep duration (Table 2).
3. Factors Influencing Health-Related Quality of Life
Multiple regression analysis identified the following variables as statistically significant predictors of HRQoL: gender (t=4.90, p<.001), smoking habit (t=2.14, p=.034), perceived health status (t=5.83, p<.001), physical activity limitation (t=5.11, p<.001), stress (t=6.19, p<.001), depressive mood (t=4.48, p<.001), anxiety (t=5.43, p<.001), and health literacy (t=3.45, p<.001). Specifically, higher HRQoL was associated with being male, being a non-smoker, having a fair or good perceived health status, not having physical activity limitations, perceiving less stress, not experiencing depressive mood in the past 2 weeks, having normal anxiety levels, and having adequate health literacy. The final model explained 44.8% of the variance in the HRQoL among adults with AR (Table 3).
Factors Influencing Health related Quality of Life (N=771)
DISCUSSION
This study aimed to identify the effects of sleep, mental health, and health literacy on HRQoL among community-dwelling adult patients with AR using raw data from KNHANES Ⅸ-2 (2023). The main findings are as follows.
In this study, mental health factors, such as stress, depression, and anxiety, were found to have a significant effect on the HRQoL of adult patients with AR. Anxiety was identified as the most influential factor, followed by depression and stress. These results are consistent with those of previous domestic and international studies that have reported a close relationship between mental health and quality of life in patients with AR [12,13]. Notably, the fact that anxiety and depression had a relatively greater influence than stress suggests that mental health assessments for patients with AR should be conducted more thoroughly rather than remaining at a superficial level.
AR is a chronic respiratory disease with an increasing prevalence in Korea. Symptoms tend to persist throughout the year, depending on indoor and outdoor environmental factors, in addition to seasonal symptoms in spring and autumn [1,5]. When such symptoms become prolonged, patients continuously experience not only physical fatigue but also psychological burden, which can ultimately lead to mental health deterioration. Rodrigues et al.[24] also reported that the severity and control status of rhinitis symptoms affect patients' mental health, with a tendency for anxiety and depression levels to increase when symptoms are severe or poorly controlled. Domestic studies have also reported that mental health problems occur more frequently in patients with AR than in the general population [12], showing that AR should be approached as a complex health issue directly related to mental health, and not merely as a physical condition.
Therefore, in community health nursing practice, it is necessary to regularly assess the mental health status of patients with AR and intervene early to prevent a decline in the quality of life. In particular, a multidisciplinary cooperative system should be established so that mental health services can be provided promptly when anxiety or depressive symptoms are detected, in cooperation with public health centers, home-visit health management programs, and mental health welfare centers. It is also necessary to develop and apply an integrated assessment tool that can evaluate both the severity of rhinitis symptoms and disease control status. Based on this, individualized nursing interventions should be implemented.
In this study, health literacy was identified as a significant factor affecting HRQoL among adults with AR. This finding aligns with the results of Zhang et al. [14], who reported that higher health literacy is associated with improved quality of life. Notably, 20.7% of participants were classified as having inadequate health literacy, despite 73.5% possessing a college degree or higher. This underscores that health literacy is not solely dependent on educational attainment but rather reflects an individual's capacity to access, interpret, and effectively apply health information in daily life.
Considering that AR frequently coexists with other chronic conditions such as asthma, sinusitis, and thyroid disorders [7], and is influenced by environmental factors including allergens, fine dust, and climate change [1,5], adequate health literacy is crucial for effective symptom management. Furthermore, because AR symptoms can vary in severity and persist over extended periods [8,25], individuals with limited health literacy may face challenges in understanding treatment plans, medication regimens, and environmental management strategies, potentially leading to reduced self-care ability and lower HRQoL.
Therefore, to promote the health of patients with AR, it is necessary to move beyond simply delivering health information to provide customized nursing interventions based on the patients' health literacy levels. Education should be carried out considering "understandability" and "applicability" rather than just the amount of information, thereby improving both self-care capabilities and the appropriateness of healthcare service use. For patients with multiple chronic diseases, an integrated health management approach that includes health literacy is required.
Health literacy must be actively addressed in nursing practice as a core intervention element to improve patients' quality of life. The results of this study support the idea that strengthening health literacy is an important strategy to improve the HRQoL of patients with AR. It is necessary to establish a practice-based system in the community nursing field to regularly assess health literacy levels, especially among vulnerable groups, and provide education and support appropriate to these levels.
In this study, gender, smoking status, perceived health status, and physical activity limitation were found to significantly affect the HRQoL of adults with AR. These results suggest that when developing nursing interventions to promote health and improve the quality of life among community residents, individuals' health behaviors and physical functioning should be comprehensively considered. First, there was a significant difference in HRQoL according to gender, with females having lower HRQoL than males. This may be related to the burden of social roles, emotional stress, and differences in depression levels, suggesting the need for gender-specific nursing interventions.
Moreover, smokers had a lower HRQoL than non-smokers, which is consistent with previous research indicating that smoking negatively affects not only physical but also psychosocial health [15]. Smoking is a major environmental factor that exacerbates allergic symptoms and is considered an important target for interventions in rhinitis self-management. The finding that individuals with positive health perceptions had significantly higher HRQoL demonstrates the positive impact of subjective health perceptions on health behaviors and emotional well-being, which is consistent with the findings of previous research. As such, individuals' attitudes and perceptions about health significantly affect not only their actual health status but also their overall quality of life, showing its value as an assessment and educational indicator in nursing practice. In addition, the finding that those without physical activity limitations had significantly higher HRQoL shows that maintaining the ability to perform daily activities plays a key role in maintaining and improving quality of life. This underscores the need for preventive nursing interventions that promote physical activity and functioning in aging communities.
However, this study found that sleep did not have a significant effect on HRQoL. This contrasts with some previous studies [9,11] that reported that sleep affects the quality of life and may result from the limitation of using only sleep duration, which may not fully reflect the overall impact of sleep health. In patients with AR, sleep quality may vary greatly depending on the symptoms. Therefore, future research should include sleep quality, the presence of sleep disorders, the frequency of nighttime symptoms, disease severity, and treatment status to allow for a more comprehensive analysis. This will enable a more accurate determination of how sleep-related factors affect the quality of life.
This study analyzed the factors affecting HRQoL in community-dwelling adult patients with AR using data from the KNHANES. Although the topic has been previously studied, this study strengthens the evidence base by conducting a more precise and reliable analysis using large-scale, representative data, contributing to the validity and applicability of the findings in community nursing practice. In particular, various individual characteristics, including mental health factors and health literacy were considered, providing evidence applicable to community nursing practice.
This study found that anxiety, depression, and stress had significant effects on the quality of life, with anxiety having the greatest impact. In addition, higher levels of health literacy and perceived health, as well as the absence of physical activity limitations, were associated with a significantly higher HRQoL. Gender and smoking status have also been identified as influential factors. These results suggest that nursing interventions to improve the quality of life of patients with AR should integrate emotional health, health information utilization capacity, and physical function.
Accordingly, the following approaches are required in community nursing practice. First, an early detection and management system for mental health problems should be established. Second, tailored education should be provided to improve health literacy, and strategic interventions should target individuals with limited access to information. Third, community-based programs to improve health behaviors, including smoking cessation and promotion of physical activity, should be implemented. Nurses must connect with community resources to implement these interventions and practice integrated management strategies that consider health equity.
This study has several limitations. First, its cross-sectional design restricts the ability to infer causal relationships between variables. Second, data on health and mental health, including sleep were collected through self-reported measures, which may introduce reporting bias and limit the clinical sensitivity of the findings. Depressive symptoms were assessed using a single-item measure, and anxiety was measured using the GAD-7. However, these tools may not sufficiently capture the severity or variability of symptoms. In addition, information on the clinical severity and treatment status of allergic rhinitis was not included, potentially limiting the interpretation of health outcomes.
To address these limitations, future studies should adopt longitudinal designs to strengthen causal inference and incorporate objective clinical data, such as medical records or diagnostic assessments, alongside self-reported information. It is also important to use multidimensional tools to evaluate not only sleep duration but also sleep quality and the presence of sleep disorders. More comprehensive instruments or in-depth interviews are recommended to assess the severity and progression of mental health symptoms. Furthermore, the development of community-based nursing interventions that integrate mental health, sleep health, and health literacy-supported by multidisciplinary approaches-will be essential for improving self-care and health outcomes in individuals with allergic rhinitis.
CONCLUSION
This study identified gender, smoking status, perceived health, physical activity limitations, stress, depression, anxiety, and health literacy as key factors influencing the health-related quality of life in adults with allergic rhinitis. These findings suggest important clinical, educational, and research implications. Clinically, early screening and targeted management of psychological symptoms-including stress, depression, and anxiety-are essential to improve patient outcomes. Educational efforts should focus on developing tailored health literacy programs that enhance patients' ability to understand their condition and adhere to treatment. In community nursing practice, priority should be given to the prompt identification of psychological difficulties and the delivery of customized education aimed at improving health literacy. Furthermore, health promotion initiatives, such as smoking cessation and physical activity programs, should be actively implemented, especially for vulnerable populations. From a research perspective, this study's use of nationally representative data highlights the need for longitudinal studies and intervention trials to clarify causal relationships and assess the effectiveness of community-based nursing interventions. Overall, these results contribute valuable evidence to guide nursing practice and health promotion strategies for adults with allergic rhinitis.
Notes
CONFLICTS OF INTEREST
The authors declared no conflict of interest.
AUTHORSHIP
Conceptualization or/and Methodology - Gang M and Kim G; Data curation or/and Analysis - Kim G; Funding acquisition - Gang M; Investigation - Kim G; Project administration or/and Supervision - Gang M; Resources or/and Software - Kim G; Validation - Gang M and Kim G; Visualization - Kim G; Writing: original draft or/and review & editing - Gang M and Kim G.
DATA AVAILABILITY
Please contact the corresponding author for data availability.