{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T18:00:33Z","timestamp":1787162433494,"version":"build-2736575974"},"reference-count":38,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2025,6,16]],"date-time":"2025-06-16T00:00:00Z","timestamp":1750032000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In a clinical trial of allergen\u2010specific immunotherapy for allergic rhinoconjunctivitis, the Combined Symptom Medication Score (CSMS) was utilized as the primary endpoint. This was aligned with the European Academy of Allergy and Clinical Immunology recommendation. However, participants wanted to elaborate on how their behaviour affected their score, so voluntary free text boxes were added to the CSMS questionnaire. This study aimed to evaluate the patient-reported outcomes registered in the free text boxes to identify and understand contexts and mechanisms that may affect the CSMS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>The realist evaluation methodology was followed in four iterative steps: 1) development of the initial programme theory and context-mechanism-outcome (CMO) configurations, 2) collection of evidence, 3) data analysis, and 4) interpretation and assessment of results.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Seven CMO configurations were identified, highlighting contexts and mechanisms that may affect the CSMS. These included CMO1 \u2013 decision on preventive relief medication dosage, CMO2 \u2013 exhibiting symptom-relieving behaviour, CMO3 \u2013 being exposed to different levels of grass pollen, CMO4 \u2013 mistaking other symptoms for grass pollen-induced symptoms, CMO5 \u2013 different exposure to grass pollen when travelling abroad, CMO6 \u2013 reporting of relief medication for other allergies in CSMS, and CMO7 \u2013 failure to report symptoms not included in CSMS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This realist evaluation contributes verified CMO configurations based on patient perspectives to understand how context and mechanisms may affect the CSMS. We recommend further investigation in quantitative studies, as awareness of these CMOs may increase the internal validity of future allergy trials using CSMS as an endpoint.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec005\">\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>ILIT.NU: EudraCT 2020-001060-28.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0326143","type":"journal-article","created":{"date-parts":[[2025,6,16]],"date-time":"2025-06-16T13:23:17Z","timestamp":1750080197000},"page":"e0326143","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Understanding the combined symptom medication score in the light of contexts and mechanisms"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-1375-5691","authenticated-orcid":true,"given":"Anne M\u00f8ller","family":"Lohmann","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne","family":"Poder Petersen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johannes Martin","family":"Schmid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hans J\u00fcrgen","family":"Hoffmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2646-0227","authenticated-orcid":true,"given":"Jeanette","family":"Finderup","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,6,16]]},"reference":[{"issue":"11","key":"pone.0326143.ref001","doi-asserted-by":"crossref","first-page":"3383","DOI":"10.1111\/all.15044","article-title":"Advances and highlights in allergic rhinitis","volume":"76","author":"Y Zhang","year":"2021","journal-title":"Allergy"},{"issue":"1","key":"pone.0326143.ref002","doi-asserted-by":"crossref","DOI":"10.1016\/j.anai.2018.03.028","article-title":"The burden of allergic rhinitis and allergic rhinoconjunctivitis on adolescents: a literature review","volume":"121","author":"MS Blaiss","year":"2018","journal-title":"Ann Allergy Asthma Immunol"},{"key":"pone.0326143.ref003","first-page":"422","article-title":"Co-morbidities of allergic rhinitis: ocular allergy.","volume-title":"Global atlas of allergic rhinitis and chronic rhinosinusitis","author":"M Cortes","year":"2015"},{"issue":"6","key":"pone.0326143.ref004","doi-asserted-by":"crossref","first-page":"549","DOI":"10.1111\/pai.12108","article-title":"The natural course of sensitization and allergic diseases from childhood to adulthood","volume":"24","author":"SP Nissen","year":"2013","journal-title":"Pediatr Allergy Immunol"},{"issue":"7","key":"pone.0326143.ref005","doi-asserted-by":"crossref","first-page":"1022","DOI":"10.1111\/all.13135","article-title":"Novel approaches and perspectives in allergen immunotherapy","volume":"72","author":"HJ Hoffmann","year":"2017","journal-title":"Allergy"},{"issue":"6","key":"pone.0326143.ref006","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1097\/ACI.0000000000000857","article-title":"Strengthening the case for intralymphatic immunotherapy","volume":"22","author":"HJ Hoffmann","year":"2022","journal-title":"Curr Opin Allergy Clin Immunol"},{"issue":"7","key":"pone.0326143.ref007","doi-asserted-by":"crossref","first-page":"854","DOI":"10.1111\/all.12383","article-title":"Recommendations for the standardization of clinical outcomes used in allergen immunotherapy trials for allergic rhinoconjunctivitis: an EAACI Position Paper","volume":"69","author":"O Pfaar","year":"2014","journal-title":"Allergy"},{"key":"pone.0326143.ref008","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1017\/CBO9780511996214.004","article-title":"Development of a measurement instrument","volume-title":"Measurement in Medicine: A Practical Guide. 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