1 Background

Asthma is a global burden. Over 339 million people around the world suffer from this chronic lung disease, which affects daily life activities and quality of life (QoL). People of all ages irrespective of geographic location can be affected [1]. The prevalence of asthma varies from country to country. In Southeast Asia, the prevalence of asthma was 3.4%, as reported in a previous study [2]. The prevalence of asthma was 4.4% in Bangladesh [3].

Depression is more common among asthma patients than among the general healthy population [4]. In fact, it is more common among asthma patients than among patients with other severe illnesses [5]. Studies suggested that asthma symptoms such as night awakening and breathing difficulty also increase depressive symptoms [4, 5]. However, few studies have examined the influence of depression on asthma outcomes, such as asthma control [6] and asthma severity [7]. Depression also has a negative effect on asthma management for many patients [4].

Stigma is another psychosocial factor that may influence asthma control [8, 9]. Internalized stigma, often termed self-stigma, is an individual’s negative feeling for themselves from experiences in society that are discrediting for them [10]. Stigmatized patients are secretive about their illness, as they feel ashamed for their illness, and stigma also affects their treatment outcome negatively [11]. Internalized stigma is negatively related to treatment adherence and positively related to psychiatric symptoms in patients with mental illness [10]. According to the Global Initiative for Asthma (GINA), asthma treatment adherence can also be challenging due to stigma [12]. In this study stigma is mentioned as the term ‘internalized stigma’.

Despite numerous efforts to improve asthma treatment and the availability of updated asthma guidelines, asthma control is still suboptimal for a significant number of patients [8]. Psychosocial factors such as depression and stigma can affect asthma patients in numerous ways such as QoL, and adherence to treatment. However, this topic is under-researched. Stigma is also associated with depression among many patients with different diseases [11].

Some sociodemographic characteristics may influence the association between depression and stigma associated with asthma. However, the results from the past studies have varied across different populations. For example, in a previous study of adult asthma patients in Korea (age > 20 years), older adult asthma patients were found to be less depressed [13]. However, in another study age and gender were not significantly associated for depression, although ethnicity, education, income, BMI, and comorbidity were significantly associated with depression among asthma patients. The coexistence of asthma and depression among elders increases the risk of ER visit, asthma episodes, and sleep disturbance [14]. In a different study, older age, female gender, comorbidities, and ER visits were significantly associated with depression among asthma patients [15].

Although stigma is another psychosocial factor that may affect asthma treatment outcome and quality of life of asthma patients, available research data on asthma-related stigma are very limited [16]. However, several sociodemographic factors were found to be associated with stigma among patients with other chronic diseases such as COPD [17], schizophrenia [18], depression [19], and epilepsy [20].

There is a research gap in the literature on depression and stigma in asthma patients studied together in a study, and the influence of sociodemographic factors on depression and stigma among asthma patients in Bangladesh. This study explored the level of depression and stigma among adult asthma patients in Bangladesh, collectively in a single study. These two psycho-social factors may influence asthma patients’ well-being in numerous ways. Furthermore, the risk factors associated with depression and stigma according to sociodemographic and asthma related medical variables were assessed.

2 Materials and methods

The study protocol was approved by the Research Ethics Committee, Faculty of Pharmacy, MAHSA University (ref. no. FP/BPhrm.PKUMF/001) followed by ethics approval from the Research Management Centre (RMC), MAHSA University, Malaysia. As the patients were recruited from the National Asthma Centre at the National Institute of Disease of Chest and Hospital (NIDCH), Bangladesh, ethics approval was also obtained from the Ethical Review Committee of NIDCH, Dhaka, Bangladesh.

A researcher-administered cross-sectional study was conducted in NIDCH, Bangladesh. The advantage of researcher-administered data collection is that participants with low literacy can participate [21]. Adult asthma patients who met the inclusion criteria (aged ≥ 18 years old, had stable asthma as specified by GINA, and good understanding of Bangla language) were recruited. Asthma patients who were terminally ill to participate, and patients with hearing and speech impairments were excluded from this study.

The sample size for this study was calculated by using the estimated number of asthma patients visited for check-up from the hospital records. A 50% response distribution, 95% confidence interval and 5% margin of error were used. The sample size was 325, as calculated by Raosoft®, an online sample size calculator.

The participants were selected by the convenience sampling method. This sampling method was adopted because it has several advantages over other sampling methods for recruiting participants who meet the inclusion criteria in terms of time constraints and geographic proximity [22]. Prior consent was obtained from all the participants.

2.1 Methodological framework

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2.2 Questionnaire (study instrument)

The instrument used for this study was researcher-administered questionnaire adapted from previous research, and modified for use with the Bangladeshi population. The first part of the questionnaire included sociodemographic data (age, gender, urban/rural residential status, highest education level, occupation and monthly family income), whereas the second part of the questionnaire included the asthma related medical data (years of asthma, ER visits, hospitalization or intubation for asthma in the last one year, triggering factors for asthma, asthma medications, devices such as home nebulizers used for asthma, body mass index (BMI), peak expiratory flow rate (PEF) and any other comorbidities). The PEF rate was assessed by a peak flow meter, 80%-100% was the green zone, 50%-80% was the yellow zone and < 50% was the red zone [23]. Asthma symptom control was examined by physicians as per GINA guidelines [1].

In the third section, the PHQ-9 was used to assess depression. The PHQ-9 is a screening tool for assessing criteria based depressive symptoms and severity based on DSM-4 criteria. These 9 items are the depression module of PHQ, which is a self-administered version of PRIME-MD [24]. This 9 item scale is widely used in research to measure depressive symptoms in various settings, although it is not a diagnostic tool for diagnosing depression clinically. The scale is also available in many languages [25], including Bangla. The score can range from 0 to 27. Each item can be scored from 0 (not at all) to 3 (nearly every day). Based on the score, the severity of depression is none if the score is 0–4, mild if the score is 5–9, moderate if the score is 10–14, moderately severe if the score is 15–19, and severe if the score is 20–27 [24]. The responses to the items are based on the last 2 weeks.

In the last section, the 22-item Stigma Scale (SS) that was used to assess the degree of stigmatization among asthma patients. The scale was adopted for this study from a past study [26] and translated into the Bangla language by standard procedure. The scale measures asthma related stigma, designed based on three domains of stigma- discrimination, disclosure and perceived positive feeling about asthma. The stigma related responses were based on how the asthma patients felt for having asthma. Each item was scored on a 5 point Likert scale, and responses for each item ranged from strongly disagree to strongly agree. Response set bias was considered by alternating negative and positive wording. A total score of 75% or more reflected severe stigma, 50–74% reflected moderate stigma and 49% or less reflected mild stigma [8]. This instrument was translated by the forward–backward-forward translation technique [27].

2.3 Translation of the study instrument

The Bangla version of the PHQ-9 was translated and validated earlier [28], so it was not translated. The SS was translated in this study. The translation process was performed by professional translators with experience in translating questionnaires for medical and health research. A translation committee was formed by a senior panel comprising three practicing respiratory physicians, two senior pharmacists, one social worker and one expert in questionnaire validation. The committee members were native language speakers and who are also fluent in English. The committee oversaw the entire translation process. The adapted English version of the SS was translated into Bangla by two translators. The committee checked the translated version and harmonized the instrument. The final version was re-translated to English by another different independent translator. After backward translation and harmonizing the translated versions, pretest cognitive debriefing of the instrument was performed to test the feasibility, interpretability, understanding, and cultural relevance among volunteer asthma patients (n = 10). Expert committee finalized the translated questionnaire after all the items in the instrument were checked and scrutinized. They ensured the items were relevant and understandable. They gave their comments on anything on the questionnaire that needed to be changed, whether to remove any item or add any item.

A pilot study (n = 10) prior to main study was performed to ensure that the statements conveyed the same meanings to the patients as the investigators intended. Modifications were made based on the feedback from the pilot study participants.

2.4 Data collection

Adult asthma patients who visited for check-up in NIDCH were approached to participate in this study. The data were collected with the participants’ prior consent. The data enumerator was one of the researchers who read the subject information sheet to potential participants. Those who agreed to participate provided their consent and signed the consent form. The questions about sociodemographic characteristics, asthma related medical data, depression, and stigma were asked by following the questionnaire, and the responses were recorded based on the participants’ answers. Depression was not diagnosed clinically in this study, but the depressive symptoms were assessed by using the PHQ-9 scale. The total score of PHQ-9 was the depression level. Stigma was also the total score of SS. The number of asthma medications and physician-assessed asthma symptom control were recorded from the patients’ files. Then, their height and weight were measured to calculate BMI. Then, PEF readings were recorded with a peak flow meter. Approximately 30 min was taken in an average to collect data from each of the participant.

2.5 Data analysis

All data were analyzed using the Statistical Package for Social Sciences (IBM SPSS® Software), version 22. The independent variables were the sociodemographic and the asthma related medical data descriptively analyzed. Monthly income was recorded in local currency, Bangladeshi taka, but reported in U.S. dollars after the approximate currency conversion rate during the data collection period. The PEF rate was assessed by comparing with normal values of EU scale [23, 29]. The influence of the sociodemographic and medical characteristics on internalized-stigma and depression was analyzed with suitable statistical tests based on the normality of the data after Shapiro–Wilk test was applied. The data distribution of the overall score of PHQ9 and SS were not normal. Therefore, the Kruskall-Wallis test and Mann–Whitney-U tests were applied where applicable to assess the significance of the differences. Furthermore, depression was categorized into 5 groups and stigma was categorized into 3 groups and the chi square test was applied with categorical data. Spearman’s correlation test was applied to test the correlation of continuous variables. Binary logistic regression analysis was performed to analyze the predictors for categorical variables of depression and internalized stigma.

3 Results

3.1 Sociodemographic and medical data

Table 1 displays the sociodemographic characteristics and medical data of the 325 participants in this study. The mean age of the participants was 41.9 years (± 15.4), ranging from 18 to 82 years. Of these, 151 (46.5%) were female, and 165 (50.8%) were hailed from rural areas. The majority of participants, specifically 251 (77.23%), reported a monthly family income ≤ 40,000 BDT (approximately ≤ USD$500). Only 75 (23.1%) had completed university education. The mean duration of asthma diagnosis among participants was 9.94 years (± 11.5), with 151 (46.5%) having been diagnosed for less than 5 years. Over the last year, 15 (4.6%) participants had been hospitalized for asthma, while 38 (11.7%) had experienced emergency visits for asthma. Additionally, 103 (24%) had other chronic diseases. The peak expiratory flow (PEF) rates were 83 (25.5%) for the red zone and 163 (50.2%) for the yellow zone.

Table 1 Differences between depression level, stigmatization degree across sociodemographic and medical data (n = 325)
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3.2 Depression level

The mean score for the Patient Health Questionnaire-9 (PHQ9) was 7.4 (± 6), suggesting that participants experienced mild depression. Participants were categorized into five groups based on their PHQ-9 scores: 129 (39.7%) had no depression, 90 (27.7%) had mild depression, 62 (19.1%) had moderate depression, 28 (8.6%) had moderately severe depression, and 16 (4.9%) had severe depression. The response distribution is shown in the Table S1 of Supplement 1.

The overall PHQ-9 score was not normally distributed analyzed by the Kolmogorov–Smirnov (K-S) test (K-S: 0.11, p < 0.01). Therefore, nonparametric tests were applied to analyze the data. Several sociodemographic and medical variables were found to be significantly associated with depression, as determined by the Mann–Whitney-U and Kruskal–Wallis tests. These included age, highest completed education, number of asthma medicines, nebulizer use, BMI, emergency visits, hospitalizations, PEF rate, comorbidity (p < 0.01), and stigma (p < 0.01). Additionally, depression differed across the categories of stigma (p < 0.01).

3.3 Internalized stigma

The participants in this study reported a mean score of 62.2 (± 10.3) on the Stigma Scale (SS), indicating a moderate level of stigma. The total score on the SS scale can range from 22 to 110. Among the participants, 215 (66.2%) experienced moderate stigma, while 17 (5.2%) reported high levels of stigma. The response distribution is shown in the Table S2 of Supplement 1.

The distribution of SS scores was not normal according to the the Kolmogorov–Smirnov (K-S) test (K-S: 0.14, p < 0.01). Therefore non-parametric tests applied, which revealed that stigma was significantly varied across age, occupation, years since asthma diagnosis, type of inhaler used, comorbidity (p < 0.01), as well as highest completed education, nebulizer use, BMI, and PEF rate (p < 0.05). Stigma was also significantly different across the categories of depression (p < 0.01).

3.4 Post-hoc pairwise comparison

Subsequent post-hoc tests were conducted for variables that showed significant differences according to the Kruskal–Wallis test, shown in Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. These tests aimed to identify which specific categories of those variables exhibited significant differences. Depression levels varied significantly between age groups) shown in Fig. 1. Those aged ≥ 65 years differed from those aged 18–40 years (p < 0.05) and 41–64 years (p < 0.01). Other significant differences were observed in depression levels based on the PEF rate shown in Fig. 2. The PEF rate < 50% was significantly different from PEF rate 50–80% (p < 0.05) and PEF rate > 80% (p < 0.01). Figure 3 shows that depression was significantly different for the patients with uncontrolled asthma symptoms were significantly different from those with well controlled asthma symptoms (p < 0.05). A significant difference in depression was also found between low stigma with moderate sigma and high stigma (p < 0.01) shown in Fig. 4.

Fig. 1
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Difference in PHQ-9 across age group

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Fig. 2
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Difference in PHQ-9 across PEF Rate

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Fig. 3
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Difference in PHQ-9 across Asthma symptom control

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Fig. 4
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Difference in PHQ-9 across internalized stigma

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There were also significant differences in stigmatization degree across various factors, including age (Fig. 5). The stigma score for the 18–40 year age group was significantly different from 41 to 64 year age group and ≥ 65 year age group (p < 0.05). The stigma score for the patients with years of asthma > 10 was significantly less than patients with years of asthma < 5 and patients with years of asthma 5–10 (p < 0.05), shown in Fig. 6. Figure 7 shows that the stigma score for MDI users was significantly different from the users who used two devices, MDI with spacer and DPI, both (p < 0.01). The stigma score for PEF rate of < 50%, the red zone was significantly different from the yellow zone (PEF rate 50%-80%), and the green zone (PEF rate > 80%) (p < 0.05) (Fig. 8). Stigma was significantly different between well-controlled asthma symptoms and uncontrolled asthma symptoms (p < 0.05) shown in Fig. 9. The difference in the stigma scores across the depression categories is shown in Fig. 10. The ‘no depression’ category was significantly different from moderate depression, moderate-severe depression and severe depression categories (p < 0.01). The mild depression category was significantly different from moderate depression, moderate-severe depression and severe depression categories (p < 0.01). The moderate depression category was different from the severe depression category (p < 0.05). Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 shows the posthoc analysis of pair wise comparison across PHQ-9 and SS.

Fig. 5
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Difference in SS across age group

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Fig. 6
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Difference in SS across years of asthma

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Fig. 7
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Difference in SS across type of inhaler used

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Fig. 8
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Difference in SS across PEF Rate

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Fig. 9
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Difference in SS across Asthma symptom control

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Fig. 10
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Difference in SS across depression

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3.5 Reliability

The Cronbach’s alpha values for the PHQ-9 and SS were 0.93 and 0.89, respectively, indicating good internal consistency for both instruments. Test–retest reliability was assessed among 50 participants who participated at least 2 weeks later. The ICC values were 0.87 for PHQ-9 and 0.89 for SS, indicating good reproducibility.

3.6 Test for relationship

Correlations between continuous variables and depression and internalized stigma scores were evaluated using Spearman’s rank test (Table 2). The results revealed a positive correlation between internalized stigma and depression, while age and years of asthma diagnosed exhibited negative correlations with stigma (p < 0.01). A graph (Fig. 11) was constructed to demonstrate the correlation between stigma and depression across age groups.

Table 2 Correlation among selected independent continuous variables with depression and stigma (n = 325)
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Fig. 11
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Age-based impact of stigma and depression

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Additionally, chi-square tests were performed to assess associations between depression, internalized stigma, and various sociodemographic and medical variables (Table 3). Notably, highest education qualification, occupation, emergency visits, hospitalizations, asthma symptom control, stigma, PEF, and comorbidity (p < 0.01), as well as age and BMI (p < 0.05) were significantly associated with the depression. On the other hand, internalized stigma was significantly associated with age, years of asthma, asthma symptom control, depression, type of inhaler, and comorbidity (p < 0.01).

Table 3 Depression and internalized stigma across sociodemographic and medical data (n = 325)
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3.7 Risk factors

Further binary logistic regression analysis was performed to examine the risk factors for depression and stigma (Table 4). The enter method was applied using a cutoff score > 9 for the PHQ-9 and a cut-off score > 55 for the SS. The Nagelkerke R2 was 0.524, explaining 52.4% of the variance in the depression model. The Nagelkerke R2 was 0.332, explaining 33.2% of the variance in the stigma model. The last category was the reference category for all the independent variables. The PEF rate, asthma symptom control and stigma were significant predictors of depression (p < 0.01), while, years of asthma and depression were significant predictors of internalized stigma (p < 0.01).

Table 4 Effect of independent variables on Depression and Stigma
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4 Discussion

The findings of this study shed light on the psychological and sociodemographic factors affecting adult asthma patients in Bangladesh. Notably, we observed that depression and stigma play significant roles in the lives of these patients, and there is a complex interplay between these two factors. Understanding these dynamics is essential for improving the overall well-being and healthcare management of asthma patients in the country. This study revealed a strong correlation between depression and stigma among Bangladeshi adult asthma patients. Several studies have explored the individual impact of depression on asthma patients [4, 5], as well as the impact of stigma on asthma patients8. However, the present study highlights that they are closely intertwined among asthma patients. A strong correlation between depression and stigma among Bangladeshi adult asthma patients was revealed. The presence of stigma appeared to be a significant predictor of depression, and vice versa. Stigma can exacerbate feelings of isolation and distress among patients, potentially leading to depressive symptoms. On the other hand, depression may amplify the perceived stigma associated with asthma, creating a cycle of negative emotions and experiences.

The findings regarding the coexistence of depressive symptoms and stigma among Bangladeshi asthma patients who participated in this study are noteworthy. Approximately one-third of the participants reported moderate to severe depression, which was lower than the rates observed in some other studies conducted in different countries. This variance may be attributed to cultural differences and variations in healthcare systems and access to mental health services. This finding aligns with existing literature that has explored the relationship between mental health and chronic illnesses, including asthma [30].

Similarly, the moderate level of stigma reported by participants suggested that while stigma is present, it may not be as pervasive as in other contexts. However, it is essential to consider that even moderate level of stigma can significantly impact individuals' mental health and quality of life. These findings underscore the need for tailored interventions to address stigma and depression within the Bangladeshi cultural and healthcare context.

Moreover, this study further explored the association between various sociodemographic factors and depression. Age, education, occupation, and income were identified as significant predictors of depression. Notably, older participants were found to have higher levels of depression, which is consistent with some previous studies in other Asian countries [13, 31]. This may reflect the unique cultural and societal pressures experienced by older individuals in Bangladesh.

The influence of education and income on depression highlights the socioeconomic disparities that affect mental health outcomes. Patients with lower education and income levels were more susceptible to depressive symptoms. Addressing these disparities and providing targeted support to individuals with limited resources are crucial in improving the mental well-being of asthma patients.

Depression was predicted by factors such as ER visits for asthma in some previous studies [32, 33]. Patients who visited the ER for asthma were likely to be more worried, and hence had depressive symptoms [33]. This study revealed that the incidence of having depressive symptoms was higher among patients with comorbidities. A past study revealed that comorbidity with asthma increases the risk of having depressive symptoms [34]. A lower PEF rate was associated higher level of depression. A lower rate of PEF indicates poor health status, and poor health increases depression, as found in a previous study, where PEF rate was inversely correlated with quality of life, depression and anxiety [35]. BMI was also associated with depression in this study. According to the post hoc analysis, underweight and overweight participants had higher level of depression, supports a past study. There was U-shape associate between BMI and depression, i.e. overweight or underweight patients are likely to be more depressed [36].

Although the moderate degree of stigma reported by participants in the present study suggests that while stigma is present, it may not be as pervasive as it is in some different contexts. For instance, a previous study conducted in another country revealed different scenarios [37]. However, it is worth mentioning that published literature on stigma among adult asthma patients was limited in the course of the literature search. An interesting finding was that stigma was less common among geriatric patients (aged ≥ 65 years), unlike in the findings for depression in this study. Disparity in stigma was evident among different occupations and highest education qualifications. It is noteworthy that the student participants in our study predominantly younger adults, aligning with our observation that younger adults tend to experience greater stigma. Another finding is that stigma is greater when asthma is recently diagnosed, and the SS score decreased as years of asthma increased. A possible reason for this relationship is that patients cope over the years of their diagnosed illness. GINA reported that stigma is a growing concern for asthma patients specially for using inhaler properly [12]. Interestingly, participants in this study who used spacers with inhalers and had a PEF rate less than 50% were less stigmatized. It is possible that they were elders and had more years of asthma. These factors contributed to the lower level of stigma in this study. It is essential to consider that even moderate levels of stigma can significantly impact individuals' mental health and quality of life. These findings underscore the need for tailored interventions to address stigma and depression within the Bangladeshi cultural and healthcare context.

4.1 Implications for healthcare and interventions

The findings of this study have several implications for healthcare providers and policymakers in Bangladesh. First and foremost, recognizing the interconnectedness of depression and stigma is essential. Healthcare professionals should consider screening patients for both conditions and providing comprehensive care that addresses both mental and physical health.

Additionally, interventions to reduce stigma and depression among asthma patients should be developed and implemented. These interventions should be culturally sensitive and tailored to the specific needs of the Bangladeshi population. Early counseling upon asthma diagnosis, especially for younger patients, may help mitigate stigma and prevent the development of depressive symptoms.

Furthermore, efforts to reduce socioeconomic disparities and improve access to education and employment opportunities can contribute to better mental health outcomes for asthma patients. Investing in mental health support services and raising awareness about the psychological aspects of chronic illnesses such as asthma are essential steps toward improving the overall well-being of individuals affected by these conditions.

4.2 Strengths and limitations

To the best of our knowledge, this study examined under-researched psychosocial factors such as depression and stigma together in patients with asthma. GINA reported stigma and depression need to be studied more thoroughly to better understand asthma management. This study will also contribute to the better understanding of asthma management in Bangladesh. The stigma scale was translated into Bangla language. In the social and cultural context of Bangladesh, it will help in future to design suitable interventions for better asthma management with considering the psychosocial aspects of the disease management. Another strength lies in the study setting. Asthma patients from all over the country visit the center for asthma treatment. Moreover, psychosocial factors associated with asthma are an essential research area, but are still under-researched especially in the developing world. Therefore, the findings of the present study are an important contribution to the newer knowledge. Many sociodemographic characteristics and variables from asthma related medical data were considered in this study to control for the confounding factors of depression and stigma as much as possible.

While this study provides valuable insights into the psychological well-being of asthma patients in Bangladesh, it is not without its limitations. This study was conducted in a single center, the study’s findings may not fully capture the diversity of experiences among asthma patients in the country. Additionally, the use of researcher-administered data collection methods could introduce biases. This study did not aim to diagnose depression clinically. PHQ-9 used in this study for screening depressive symptoms was not used for clinically diagnosing depression.

5 Conclusion

In conclusion, this study highlights the complex relationship between depression and stigma among asthma patients in Bangladesh. The presence of these psychological challenges underscores the need for holistic healthcare approaches that consider both physical and mental well-being. By addressing stigma, providing mental health support, and reducing socioeconomic disparities, healthcare providers and policymakers can enhance the quality of life and healthcare outcomes for asthma patients in Bangladesh. Further research is warranted to delve deeper into these issues and develop effective interventions tailored to the unique cultural context of the country.