Understanding Stigma in Later Life Asthma: A Mixed Methods Scoping Review with an Intersectional Lens

Understanding Stigma in Later Life Asthma: A Mixed Methods Scoping Review with an Intersectional Lens | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Understanding Stigma in Later Life Asthma: A Mixed Methods Scoping Review with an Intersectional Lens Austin Swamy, Sanduni Madawala, Evelyne Dharmawan, Chris Barton This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9190215/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract Background: Asthma is a chronic respiratory condition with effective pharmacological treatments; however, poor adherence, particularly the overuse of short-acting β2-agonists (SABA) and underuse of inhaled corticosteroids, remains a persistent challenge. Stigma may influence self-management behaviours, yet its impact in asthma, especially among older adults, is underexplored. Health-related stigma, defined as stereotyping, prejudice, or discrimination directed toward individuals based on a health condition, may interact with age-related factors such as comorbidity, generational attitudes toward illness, and historical experiences of asthma stigma. Methods: We conducted a scoping review following the Joanna Briggs Institute methodology and PRISMA-ScR guidelines. Six databases (Medline OVID, Embase, Emcare, PsycInfo, Scopus, and CINAHL) were systematically searched for studies examining stigma in asthma, with a focus on older adults. Titles and abstracts were screened independently by two authors, followed by full-text review and data extraction using a customised template. Findings were synthesised narratively, and stigma and ageism were approached as sensitising concepts. Results: Sixteen empirical studies involving participants from diverse cultural contexts, and two reviews, were included. Stigma was commonly reported, particularly among individuals with severe asthma or frequent symptoms, and was primarily associated with medication use. Stigma manifested across four key domains: emotional impact, behavioural adaptations, identity disruption, and social withdrawal. While age-related considerations were evident, few studies explicitly examined these experiences in older adults. Intersectional influences including cultural background, age-related biases, and gender were acknowledged in some studies but rarely analysed in depth. Conclusion: Stigma influences asthma management across emotional, behavioural, and social domains, affecting adherence, wellbeing, and healthcare engagement. This review identifies a critical gap in understanding the lived experiences of older adults with asthma and underscores the need for age-specific, intersectional research and tailored interventions to address stigma and improve outcomes, with implications for health promotion, self-management support, and reducing stigma-related barriers to care in older adults. Asthma Stigma Older adults Self-management Medication adherence Intersectionality and ageism Patient-centred care Figures Figure 1 Figure 2 Introduction Asthma is a common chronic respiratory condition, typically characterised by airway inflammation and symptoms such as wheezing, breathlessness, chest tightness, and cough (1). Globally, approximately 300 million people live with asthma (1). While most can achieve good long-term control with appropriate treatment, particularly inhaled corticosteroids (ICS) (1), suboptimal adherence remains a persistent challenge, especially the overuse of short-acting β2 agonists (SABA) and underuse of ICS (2–4). Older adults represent a growing proportion of those living with asthma and experience disproportionately high rates of hospitalisation and mortality (5–7). The gap between the therapeutic potential of asthma medications and real-world outcomes underscores the importance of behavioural and psychosocial factors in disease management. One such factor is stigma (8). Health-related stigma, a powerful social determinant of health, can influence how individuals perceive their condition, interact with healthcare providers, and use their medications (9, 10). Stigma is commonly defined as the social discrediting, stereotyping, or discrimination directed toward individuals based on a health condition (11, 12). In asthma, stigma has historically been associated with perceptions of weakness, psychological instability, and nervousness (13). Treatments such as corticosteroids and nebulisers have also carried social stigma, visibly marking users as unwell or physically vulnerable (3, 14, 15). Despite its relevance, stigma in asthma remains underexplored, particularly among older adults (16). Older individuals face distinct challenges in asthma management. Age-related physiological changes, comorbidities, and polypharmacy complicate diagnosis and treatment (5, 6). Cognitive or physical impairments may hinder inhaler use, and spirometry may be less reliable in this age group. Beyond these clinical factors, older adults may also carry the legacy of historical stigma, having grown up in eras when asthma was poorly understood and often stigmatised. These experiences may shape attitudes and self-management behaviours, including underuse of ICS (17). Patient behaviour is a key determinant of asthma control, shaped by individuals’ perceptions of their condition and beliefs about treatment (3, 18). When symptoms worsen, many patients increase SABA use but are less likely to adjust their preventer medication, reflecting a reactive rather than preventative approach to management (3, 4). These behaviours may be further influenced by concerns or misconceptions about corticosteroids (19). Stigma may exacerbate these issues, contributing to delayed care-seeking, poor adherence, and reduced engagement with healthcare services, ultimately impacting outcomes (12). The concept of intersectionality provides a lens to understand how multiple social identities such as age, gender, cultural background, or socioeconomic status, interact with structural contexts to shape lived experience of stigma (8, 20). For older adults with asthma, overlapping experiences of ageism and chronic illness stigma may compound the challenges of managing symptoms and using medications consistently (21). Despite these concerns, most research on asthma-related stigma has focused on children and adolescents, particularly in school settings (16). While informative, these studies do not capture the distinct experiences of older adults, whose perceptions and behaviours may be shaped by decades of social and medical change. Understanding how stigma influences medication use and self-management in older adults could help build evidence for patient-centred asthma care in this group, who experience disproportionately high rates of hospitalisation and mortality (6). This scoping review aims to map existing literature on stigma in asthma, with a particular focus on older adults. By identifying conceptual gaps and synthesising current knowledge, it seeks to inform future research on the life-course experiences of stigma and its impact on asthma management. A scoping review is particularly suited to this purpose, allowing for comprehensive mapping of existing research, clarification of key concepts, and identification of gaps to inform future empirical work. Methods The scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews (22) and is reported following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines (23). Search Strategy A systematic search was conducted across six electronic databases: Medline (OVID), Embase, Emcare, PsycInfo, Scopus, and CINAHL. A subject librarian was consulted to refine and validate the search strategy. Additional searches were conducted using Google Scholar to identify citing studies, and the reference lists of included articles were hand-searched to ensure completeness. Searches were conducted in March 2026 covering literature from database inception to the search date. Grey literature was excluded. Key search domains included asthma, stigma, older adults and asthma medications and self-management . The initial strategy was developed in OVID Medline and adapted for use across other databases. The full search strategy is provided in Supplemental File 1. Eligibility Criteria and Study Selection All identified records were imported into Covidence™ for screening and duplicates removed (Fig. 1 ). Title and abstract screening were conducted independently by two authors from AS, ED, or CB. Because constructs such as attitudes, perceptions, and self-efficacy are related to but distinct from stigma, we implemented a brief, eligibility-focused concept check prior to full-text retrieval to re-confirm the stigma concept and older-adult population criteria. In this second pass, records were re-assessed against the stigma concept and the older-adult population criterion to ensure close alignment with the review question. Discrepancies were resolved through discussion between senior authors (CB and SM). Full-text review and data extraction were undertaken by one author (AS), with verification by a second author (CB) in accordance with JBI guidance for scoping reviews. All study designs were eligible, including qualitative, quantitative, mixed-methods designs and reviews. Commentaries, letters, editorials, and theses were excluded. Studies were excluded if they did not focus on stigma, did not include older adults (aged ≥ 55 years) within their sample, were not published in English, or primarily addressed chronic conditions other than asthma (Table 1 ). Studies addressing multiple chronic conditions were included if asthma-specific findings could be extracted or inferred. Table 1 Inclusion and Exclusion Criteria Used to Select Papers Population Inclusion Exclusion Asthma – any diagnosis of asthma (self-reported, doctor diagnosed, spirometry confirmed), Severity – any severity Age – sample includes older adults aged ≥ 55 years. Comorbidity where there are too few study participants with asthma Children, adolescents, young adults, students, youth, teenager, kids, baby, infant. Concept Social Stigma, internalised stigma, experienced, felt, anticipated, perceived, intersectional stigma, bias, ageism, discrimination, judgement, shame, embarrassment Not involving stigma Context Impact on treatment, medications, adherence, compliance, quality of life quality of care, management of asthma, self-management Other methods of impact unrelated to asthma management and treatment. The study selection process is summarised in the PRISMA-ScR flow diagram (Fig. 1 ). Data Extraction, Charting, and Synthesis Data were extracted using a customised template developed for this review (Supplemental File 2). Extracted variables included study characteristics (e.g., design, setting, publication year), sample details (e.g. age, severity of asthma), how stigma was assessed or conceptualised, and reported outcomes relevant to stigma and asthma management. Stigma and ageism were approached as sensitising concepts, informed by established frameworks such as the Health Stigma and Discrimination Framework (8) and definitions of ageism in healthcare (21). These frameworks guided data charting but were not applied as formal analytic models. A narrative synthesis was conducted to identify key themes and conceptual domains related to stigma in asthma, with a particular focus on older adults. These were developed through an inductive grouping of extracted findings, followed by iterative refinement and discussion among the author team to ensure conceptual clarity and alignment with scoping review methodology. Consistent with JBI guidance (22), no formal assessment of methodological quality or risk of bias was undertaken, as this is not required for scoping reviews. Results A total of 16 empirical studies and 2 systematic reviews (3, 13) were included in this scoping review (Fig. 1 ). The empirical studies were conducted across diverse geographical settings: the USA (24–26), Australia (16, 17, 27), UK (28), Canada (29), China (30), Malaysia (31–33), Saudi Arabia (34), Kenya and Sudan (35), Nigeria (36) and Iran (37). Study designs included qualitative (n = 8), quantitative (n = 6) and mixed-methods approaches (n = 2). Collectively, the empirical studies reported data from 1,591 participants. One study did not report age range but recruited across routine care settings (37); we retained it because the findings were adult-focused and conceptually aligned with the review question. The publications spanned over three decades, with noticeable increase in output and geographical diversity in the past ten years. Across the studies, a range of stigma-related concepts were described. Twelve of the sixteen empirical studies reported participants experiencing shame, embarrassment, or self-consciousness, particularly in relation to visible medication use (e.g., inhalers) in public settings (Supplemental file 2). Participants frequently reported feeling judged or singled out, and expressed discomfort at being seen using asthma medication (16, 26, 28–31, 33–36, 38). Internalised stigma was further exacerbated by perceived or actual side effects such as weight gain from oral corticosteroids - which contributed to embarrassment and self-consciousness (26, 38). Some participants described feeling devalued, or labelled as “different” or “handicapped” due to their asthma diagnosis (28, 38). Stigma was also perpetuated in healthcare settings, where some patients reported perceived discrimination, judgement, or not feeling heard, leading to frustration (27, 30, 31). Socio-cultural factors influenced stigma experiences and medication behaviours (31, 34, 36). For example in Ma et al (30), traditional Chinese health beliefs contributed to non-adherence, with over two-thirds of participants endorsing the saying “all medicine has du (poison) to some degree”. In Kenya, Sudan, and Arabic speaking communities’ asthma symptoms (like chronic coughing) are frequently mistaken for tuberculosis (TB), leading to enacted stigma where community members avoid the person with asthma for fear of infection (34, 35). Stigma was found to be associated with the severity, frequency, and overall functional burden of asthma. Quantitative studies demonstrated statistical associations between stigma and poor asthma control (25, 33), while qualitative studies highlighted stigma as a key concern among participants with severe or frequently symptomatic asthma (26, 28, 34, 38). Findings were synthesised into four overarching domains: Emotional Impact, Behavioural Adaptations, Identity Disruption, and Social Withdrawal. These domains are discussed below. Emotional Impact This domain captured the emotional burden associated with asthma related stigma. Participants reported anxiety, depression, fear and dissatisfaction, in relation to asthma complications or the possibility of potentially fatal outcomes (16, 26, 28, 32, 36, 38). Severe asthma was associated with emotional distress, including feelings of worthlessness, hopelessness, frustration, and self-directed anger (38). While most studies reported elevated emotional burden, one study (36) found no significant association between stigma of asthma treatment and presence of anxiety and depression. Behavioural Adaptations This domain included descriptions of the actions patients took to cope with symptoms or manage stigma, often resulting in non-adherent or mal-adaptive behaviours. Stigma led patients to conceal their asthma or avoid using inhalers in public to appear healthy or avoid being treated differently (26, 28–32, 34, 35, 38). Participants reported avoiding exercise or restricting social activities due to asthma (24, 28, 31, 35, 38). Stigma contributed to intentional non-adherence, particularly in public settings, reinforcing its impact on asthma management (16, 27, 33, 36). Some individuals sought alternative therapies to avoid corticosteroid-based treatments (24, 27, 30, 31, 34, 35). Identity Disruption Asthma was described as fundamentally affecting a person’s self-concept and sense of normalcy. Individuals reported feeling devalued, different, or “handicapped” (29, 30, 33, 35) and those with severe asthma described feeling deeply misunderstood (38). Stigma was linked to low health literacy, fear of judgement, and discouragement, which compounded feelings of inadequacy and self-doubt (25, 31, 34, 35). In some studies, coughing and inhaler use were viewed with prejudice, further impacting individuals’ social interactions and self-perception (29, 30, 34, 35, 38). Social Withdrawal This domain focused on the impact of stigma on social participation and relationships. Participants described social isolation, noting that symptoms such as coughing or breathlessness attracted unwanted attention (28–31, 34, 35, 38). Asthma limited participation in social activities, and insensitive comments from peers or the public negatively affected relationships (16, 26, 28, 32, 38). Some individuals described partners who lacked empathy or had become resentful of the long-term limitations imposed by asthma (38). Stigma also affected employment opportunities, with some participants forced to leave work, contributing to further isolation (29, 35). In some studies, participants wished to engage in activities such as sports, but felt excluded due to societal attitudes and assumptions about asthma (24, 27, 28, 31). Discussion The scoping review reveals a modest but conceptually diverse body of literature addressing stigma in adults with asthma, particularly older adults. Across the included studies stigma was common, and experienced most prominently in relation to medication use, and was across a range of cultural contexts. Among adults, particularly those with more severe or frequently occurring symptomatic asthma, stigma emerged as a pervasive, multi-layered barrier to self-management. It was driven by self-consciousness around visible medication use, anticipation of judgement, and longstanding narratives associating asthma with weakness. These experiences are frequently underpinned by low health literacy, where misconceptions influenced disclosure, hindered adherence, and contributed to emotional distress, identity disruption, and social withdrawal. Furthermore, stigma experiences were compounded by intersectional factors, where asthma-related judgment intersected with other social markers such as obesity or poverty, intensifying the internalised burden for certain populations. Stigma in asthma has several properties that make its experience and impact distinct from other chronic illnesses (12), including other respiratory conditions such as COPD (10). In some chronic conditions (e.g. mental health conditions or HIV), the stigmatising trait may be concealed (11), whereas in others like obesity, neurological disability, visible symptoms or physical markers make concealment difficult (39). Stigma in lung cancer and HIV is often moralised due to perceived behavioural risk factors (e.g. smoking, drug use, sexuality) (40). Asthma occupies a middle ground. Its symptoms (e.g., cough, wheeze, breathlessness) and treatments (inhalers, spacers) can be visible, yet its episodic nature means visibility fluctuates (41). This situational visibility may heighten self-consciousness and reinforce stigma through perceived loss of control or social disruption. Unlike conditions explicitly moralised due to behavioural risk factors (e.g., smoking in lung disease) asthma stigma tends to be less overtly judgement-laden but is nonetheless embedded in socio-cultural expectations around health, visibility and personal responsibility. A critical finding of this review is few studies explicitly examined stigma in older adults. Most included studies featured broad adult samples without age-disaggregated analyses, limiting the ability to isolate stigma experiences specific to later life. This reflects a broader gap in asthma research, where older adults are frequently underrepresented despite carrying disproportionate burden of morbidity and mortality (5). Where age related experiences were described, they highlighted factors unique to older adults, including historical stigma associated with asthma, generational attitudes towards illness, and concerns about medication side effects within the context of polypharmacy. These observations point to the importance of age-specific enquiry into how stigma influences adherence and self-management in later life. The review also identified four overarching domains—Emotional Impact, Behavioural Adaptations, Identity Disruption, and Social Withdrawal—that describe how stigma manifests and affects asthma management. These domains reflect commonalities across diverse settings and study designs, and align with established conceptualisations of health-related stigma (8). Although derived inductively from study findings, they provide a practical framework for understanding how stigma may impede optimal asthma care in older adults and adults more broadly. Intersectionality was introduced as a sensitising concept to acknowledge how multiple social identities and structural factors may shape stigma experiences (8, 20). However, few included studies examined intersectional dynamics in depth, and none provided analyses that considered ageism and asthma-related stigma concurrently. Instead, dimensions such as gender, ethnicity, or socioeconomic status were generally examined in isolation. These limitations underscore the need for future research that moves beyond univariate analyses to explore how age intersects with other identities and structural inequities to shape asthma-related stigma. Previous reviews have described stigma and treatment perceptions in children (42), adolescents (43), and adults with asthma (3, 13). While these reviews identified stigma as a barrier to adherence and self-management, they did not examine its impact in older adults or consider intersectional dimensions such as ageism. This review extends this literature by synthesising empirical studies focused on adults, identifying four distinct domains of impact, and introducing intersectionality as a critical framework for understanding how stigma shapes medication use in later life. Although some findings from earlier reviews may be extrapolated to older populations, our synthesis highlights the need for age-specific research that accounts for historical stigma, generational attitudes, and the unique challenges of ageing with asthma. Asthma severity and symptom frequency emerged as important contextual factors shaping stigma. Individuals with severe or frequently symptomatic asthma reported heightened emotional distress, greater social withdrawal, and more pronounced identity disruption. These participants often described feeling more visible, judged or misunderstood, particularly when symptoms were difficult to conceal or when treatment side effects (e.g., weight gain from corticosteroids) were physically apparent. In contrast, those with milder or intermittent symptoms tended to report stigma in more situational terms, such as embarrassment using inhalers in public or reluctance to disclose their condition. This gradient of experience suggests that asthma severity should be considered not only as a clinical variable but also as a contextual factor shaping stigma’s impact (44). It also raises important questions about whether stigma contributes to a feedback loop, similar to the bi-directional relationship observed in depression and physical illness (45), where poor asthma control exacerbates stigma, which in turn undermines adherence and self-management. Collectively, the findings emphasise the need for research that explicitly examines the lived experiences of older adults, incorporates intersectional frameworks, and develops interventions that address stigma-related barriers to medication use, self-management, and healthcare engagement. Strengths and Limitations A key strength of this review is its focused examination of stigma in older adults with asthma, a population largely overlooked in previous research. By synthesising empirical studies across diverse cultural contexts and identifying four distinct domains of stigma impact, the review provides a structured and clinically relevant framework for understanding how stigma affects self-management and medication use in later life. The integration of intersectionality and ageism as conceptual lenses offers a novel contribution to the literature and sets the stage for future research and intervention development. However, the review is limited by the relatively small number of studies that explicitly focus on older adults, reflecting a broader gap in the literature. Many included studies did not disaggregate findings by age, limiting insights into stigma among older populations. Consistent with scoping review methodology, no formal assessment of methodological quality of included studies was conducted, which limits the ability to comment on the robustness of individual findings. The heterogeneity of study designs and contexts may limit generalisability. Furthermore, most included studies relied on self-reported measures of stigma and adherence, which may be subject to recall or social desirability bias. Finally, the exclusion of grey literature and non-English language publications may have omitted relevant studies from non-English speaking regions. Implications for Practice The evidence highlights that stigma carries significant clinical implications for adults. It directly compromises therapeutic adherence and exacerbates psychological burden, thereby hindering optimal disease control. Clinically, stigma manifests through intentional non-adherence, concealment of medication use, and avoidance of healthcare engagement. These behaviours are shaped by cultural beliefs, misconceptions, and fear of medication side effects, particularly regarding corticosteroids. Stigma also contributes to emotional distress and social withdrawal, both of which are associated with both poorer self-management and reduced quality of life. Clinicians should be aware of the situational and episodic nature of asthma stigma, and adopt flexible, stigma-sensitive approaches that acknowledge variability in symptom visibility. This includes transitioning from paternalistic models toward shared decision making and a more holistic approach to asthma management that considers the patient’s social and psychological well-being alongside clinical symptoms (46). Conclusion Patient-centred care models that incorporate patient preferences, cultural beliefs, and the perceived stigma associated with asthma and its treatment are essential. Care that integrates empathic, stigma-aware communication can strengthen patient-provider relationships, build trust, foster medication acceptance, and help mitigate the clinical impacts of stigma. This review highlights that asthma stigma is distinct in its episodic variability, its social embeddedness, and its intersection with cultural and contextual factors that influence self-management. By synthesising the available evidence, this review highlights four key domains—Emotional Impact, Behavioural Adaptations, Identity Disruption, and Social Withdrawal—through which stigma appears to primarily impact adults with asthma, and underscores a critical gap in understanding how these experiences unfold in later life. Although few studies explicitly focused on older adults, the findings point to meaningful age-related considerations, including historical stigma, generational attitudes toward illness, and the added complexity of managing asthma within the broader context of ageing and comorbidity. Future studies should aim to develop and validate age and context specific frameworks for understanding stigma and its implications for medication use, self-management, and health care engagement. Approaches grounded in intersectionality offer a promising path forward for examining how age, cultural background, gender, and other social identities shape stigma experiences. Interdisciplinary work drawing from respiratory medicine, public health, behavioural science, and social theory, will be essential to advancing stigma-sensitive care and improving outcomes for older adults and all people living with asthma. Declarations AI Acknowledgement Statement Initial data extraction was undertaken by AS and CB. 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Ahmed R, Mulupi S, Taegtmeyer M, Ardrey J, Devereux G, Chinouya M, et al. “People here live in denial”: A qualitative study of the pervasive impact of stigma on asthma diagnosis and care in Kenya and Sudan. PLOS Glob Public Health. 2025;5(12):e0003935. Adewuya A, Adeyeye O. Anxiety and depression among Nigerian patients with asthma: Association with sociodemographic, clinical, and personality factors. Journal of Asthma. 2017;54(3):286 − 93. Hosseininia S, Mohammadikebar S, Motashakkeri L, Kamran A. Determinants of adherence to inhaler use in patients with asthma: the role of knowledge, self-efficacy, and perceived barriers. BMC Pulmonary Medicine. 2025;25(456). Foster J, McDonald V, Guo M, Reddel H. “I have lost in every facet of my life”: the hidden burden of severe asthma. Eur Respir J. 2017;50(3):1700765. Madawala S, Warren N, Osadnik C, Barton C. The primary care experience of adults with chronic obstructive pulmonary disease (COPD). An interpretative phenomenological inquiry. PloS One. 2023;18(6):e0287518. Stuber J, Galea S, Link B. Smoking and the emergence of a stigmatized social status. Soc Sci Med. 2008 67:420 − 30. Chau-Etchepare F, Hoerger J, Kuhn B, Zeki A, Haczku A, Louie S, et al. Viruses and non-allergen environmental triggers in asthma. J Investig Med 2019 67(7):1029-41. Kansra S, Calvert R, Jones S. Stigma from medication use: an under recognised burden of care. Breathe (Sheff). 2021 17(1):21000. Kaplan A, Price D. Treatment Adherence in Adolescents with Asthma. Journal of Asthma and Allergy. 2020;13:33–49. Global Initiative for Asthma. Difficult-To-Treat & Severe Asthma in Adolescent and Adult Patients, V5.0, 2024. 2024. Jang S. Temporal and bidirectional association of depression and physical illnesses: Analyzing the pooled data from independently conducted cross-sectional national surveys at three distinct time points. Journal of Psychosomatic Research. 2024;179. Barton C, Smith L, Bruzzese J-M. Asthma and mental health: novel insights to the experience, etiology, longitudinal course, and management of mental health in asthma and allergy Front Allergy. 2025;6(1559527). Additional Declarations No competing interests reported. Supplementary Files SupplementalFile1DatabaseSearchStrategies.docx SupplementalFile2dataextractiontable.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 12 May, 2026 Reviews received at journal 03 May, 2026 Reviews received at journal 02 May, 2026 Reviewers agreed at journal 07 Apr, 2026 Reviewers agreed at journal 04 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviewers invited by journal 02 Apr, 2026 Editor invited by journal 27 Mar, 2026 Editor assigned by journal 26 Mar, 2026 Submission checks completed at journal 26 Mar, 2026 First submitted to journal 22 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9190215","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":610404036,"identity":"5d0d3648-0b97-451f-a3ce-f6c7a0ce7456","order_by":0,"name":"Austin Swamy","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Austin","middleName":"","lastName":"Swamy","suffix":""},{"id":610404037,"identity":"6afc9ff6-1cd6-466f-9675-fe347466566d","order_by":1,"name":"Sanduni Madawala","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Sanduni","middleName":"","lastName":"Madawala","suffix":""},{"id":610404038,"identity":"10e29d4a-c356-43f4-8545-e135969222ef","order_by":2,"name":"Evelyne Dharmawan","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Evelyne","middleName":"","lastName":"Dharmawan","suffix":""},{"id":610404040,"identity":"55b68749-0cab-49d6-a25b-847490144cb8","order_by":3,"name":"Chris Barton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYBAC/hkMDAcYGP5AeB/AJA8Qs+HWInEDrOUYWBHjDGK0GESAqcNgRcw8RGmR7n148AfDMXnz+c3HHtvm2OTx9589wPCh7DBuLTLHDQ7zMPwxnHOMLd04d1tascSNvATGGefwaJFIA7nqGOMMNh4z6dxthxMbbvAYMPO24dcCdNhhe7AWS6CW+efPGDD/xaclIo3hAA/D4USwFkaglg0HcgyYGfFokbgBdBiPwbHkGWxpaZK929ISN97IMTjYcy4dpxb+GWnMH39U/LGdwXz4mMTPbTaJ886fMXzwo8wapxao89D4BwioHwWjYBSMglFAAAAALl1XiVScWYEAAAAASUVORK5CYII=","orcid":"","institution":"Monash University","correspondingAuthor":true,"prefix":"","firstName":"Chris","middleName":"","lastName":"Barton","suffix":""}],"badges":[],"createdAt":"2026-03-22 09:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9190215/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9190215/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105310834,"identity":"4a8e5f10-271d-42b7-838f-0e9a3fd41b68","added_by":"auto","created_at":"2026-03-24 15:12:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37157,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA-ScR flow diagram showing study selection. After initial title/abstract screening, an eligibility-focused concept pass (stigma and older-adult criteria) was conducted prior to full text retrieval.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9190215/v1/6f7356d3fb65e0113922bc9e.png"},{"id":105310812,"identity":"e9b6f284-d1c0-4c2c-b4c4-ac3ee4ae3e0c","added_by":"auto","created_at":"2026-03-24 15:12:29","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":655237,"visible":true,"origin":"","legend":"\u003cp\u003eStigma impacted outcomes for people living with asthma in four key domains – emotional/affective, behavioural, identity, social.\u003c/p\u003e","description":"","filename":"floatimage11.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9190215/v1/6f63c2ac716a1acbc6af3c0f.jpeg"},{"id":105310932,"identity":"10c356d0-91d1-4047-8573-681f60e6ba5f","added_by":"auto","created_at":"2026-03-24 15:13:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1315109,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9190215/v1/3735a90c-40c6-4d9b-b5ed-48b00db0104e.pdf"},{"id":105310782,"identity":"d920154d-d4aa-4e2e-80f5-f6f6f556a653","added_by":"auto","created_at":"2026-03-24 15:12:22","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":39679,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFile1DatabaseSearchStrategies.docx","url":"https://assets-eu.researchsquare.com/files/rs-9190215/v1/eef9cc608dd472b6750e97de.docx"},{"id":105310803,"identity":"de8a512d-8abc-4ca1-b675-a259ad20eb7a","added_by":"auto","created_at":"2026-03-24 15:12:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27020,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFile2dataextractiontable.docx","url":"https://assets-eu.researchsquare.com/files/rs-9190215/v1/84f9642b901287fcec053e01.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding Stigma in Later Life Asthma: A Mixed Methods Scoping Review with an Intersectional Lens","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAsthma is a common chronic respiratory condition, typically characterised by airway inflammation and symptoms such as wheezing, breathlessness, chest tightness, and cough (1). Globally, approximately 300\u0026nbsp;million people live with asthma (1). While most can achieve good long-term control with appropriate treatment, particularly inhaled corticosteroids (ICS) (1), suboptimal adherence remains a persistent challenge, especially the overuse of short-acting β2 agonists (SABA) and underuse of ICS (2\u0026ndash;4).\u003c/p\u003e \u003cp\u003eOlder adults represent a growing proportion of those living with asthma and experience disproportionately high rates of hospitalisation and mortality (5\u0026ndash;7). The gap between the therapeutic potential of asthma medications and real-world outcomes underscores the importance of behavioural and psychosocial factors in disease management.\u003c/p\u003e \u003cp\u003eOne such factor is stigma (8). Health-related stigma, a powerful social determinant of health, can influence how individuals perceive their condition, interact with healthcare providers, and use their medications (9, 10). Stigma is commonly defined as the social discrediting, stereotyping, or discrimination directed toward individuals based on a health condition (11, 12). In asthma, stigma has historically been associated with perceptions of weakness, psychological instability, and nervousness (13). Treatments such as corticosteroids and nebulisers have also carried social stigma, visibly marking users as unwell or physically vulnerable (3, 14, 15). Despite its relevance, stigma in asthma remains underexplored, particularly among older adults (16).\u003c/p\u003e \u003cp\u003eOlder individuals face distinct challenges in asthma management. Age-related physiological changes, comorbidities, and polypharmacy complicate diagnosis and treatment (5, 6). Cognitive or physical impairments may hinder inhaler use, and spirometry may be less reliable in this age group. Beyond these clinical factors, older adults may also carry the legacy of historical stigma, having grown up in eras when asthma was poorly understood and often stigmatised. These experiences may shape attitudes and self-management behaviours, including underuse of ICS (17).\u003c/p\u003e \u003cp\u003ePatient behaviour is a key determinant of asthma control, shaped by individuals\u0026rsquo; perceptions of their condition and beliefs about treatment (3, 18). When symptoms worsen, many patients increase SABA use but are less likely to adjust their preventer medication, reflecting a reactive rather than preventative approach to management (3, 4). These behaviours may be further influenced by concerns or misconceptions about corticosteroids (19). Stigma may exacerbate these issues, contributing to delayed care-seeking, poor adherence, and reduced engagement with healthcare services, ultimately impacting outcomes (12).\u003c/p\u003e \u003cp\u003eThe concept of intersectionality provides a lens to understand how multiple social identities such as age, gender, cultural background, or socioeconomic status, interact with structural contexts to shape lived experience of stigma (8, 20). For older adults with asthma, overlapping experiences of ageism and chronic illness stigma may compound the challenges of managing symptoms and using medications consistently (21).\u003c/p\u003e \u003cp\u003eDespite these concerns, most research on asthma-related stigma has focused on children and adolescents, particularly in school settings (16). While informative, these studies do not capture the distinct experiences of older adults, whose perceptions and behaviours may be shaped by decades of social and medical change. Understanding how stigma influences medication use and self-management in older adults could help build evidence for patient-centred asthma care in this group, who experience disproportionately high rates of hospitalisation and mortality (6).\u003c/p\u003e \u003cp\u003eThis scoping review aims to map existing literature on stigma in asthma, with a particular focus on older adults. By identifying conceptual gaps and synthesising current knowledge, it seeks to inform future research on the life-course experiences of stigma and its impact on asthma management. A scoping review is particularly suited to this purpose, allowing for comprehensive mapping of existing research, clarification of key concepts, and identification of gaps to inform future empirical work.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews (22) and is reported following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines (23).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy\u003c/h2\u003e \u003cp\u003eA systematic search was conducted across six electronic databases: Medline (OVID), Embase, Emcare, PsycInfo, Scopus, and CINAHL. A subject librarian was consulted to refine and validate the search strategy. Additional searches were conducted using Google Scholar to identify citing studies, and the reference lists of included articles were hand-searched to ensure completeness. Searches were conducted in March 2026 covering literature from database inception to the search date. Grey literature was excluded.\u003c/p\u003e \u003cp\u003eKey search domains included \u003cem\u003easthma, stigma, older adults and asthma medications and self-management\u003c/em\u003e. The initial strategy was developed in OVID Medline and adapted for use across other databases. The full search strategy is provided in Supplemental File 1.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility Criteria and Study Selection\u003c/h3\u003e\n\u003cp\u003eAll identified records were imported into Covidence\u0026trade; for screening and duplicates removed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Title and abstract screening were conducted independently by two authors from AS, ED, or CB. Because constructs such as attitudes, perceptions, and self-efficacy are related to but distinct from stigma, we implemented a brief, eligibility-focused concept check prior to full-text retrieval to re-confirm the stigma concept and older-adult population criteria. In this second pass, records were re-assessed against the stigma concept and the older-adult population criterion to ensure close alignment with the review question. Discrepancies were resolved through discussion between senior authors (CB and SM). Full-text review and data extraction were undertaken by one author (AS), with verification by a second author (CB) in accordance with JBI guidance for scoping reviews.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAll study designs were eligible, including qualitative, quantitative, mixed-methods designs and reviews. Commentaries, letters, editorials, and theses were excluded. Studies were excluded if they did not focus on stigma, did not include older adults (aged\u0026thinsp;\u0026ge;\u0026thinsp;55 years) within their sample, were not published in English, or primarily addressed chronic conditions other than asthma (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Studies addressing multiple chronic conditions were included if asthma-specific findings could be extracted or inferred.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInclusion and Exclusion Criteria Used to Select Papers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsthma \u0026ndash; any diagnosis of asthma (self-reported, doctor diagnosed, spirometry confirmed),\u003c/p\u003e \u003cp\u003eSeverity \u0026ndash; any severity\u003c/p\u003e \u003cp\u003eAge \u0026ndash; sample includes older adults aged\u0026thinsp;\u0026ge;\u0026thinsp;55 years.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComorbidity where there are too few study participants with asthma\u003c/p\u003e \u003cp\u003eChildren, adolescents, young adults, students, youth, teenager, kids, baby, infant.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial Stigma, internalised stigma, experienced, felt, anticipated, perceived, intersectional stigma, bias, ageism, discrimination, judgement, shame, embarrassment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot involving stigma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContext\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpact on treatment, medications, adherence, compliance, quality of life quality of care, management of asthma, self-management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther methods of impact unrelated to asthma management and treatment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe study selection process is summarised in the PRISMA-ScR flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eData Extraction, Charting, and Synthesis\u003c/h3\u003e\n\u003cp\u003e Data were extracted using a customised template developed for this review (Supplemental File 2). Extracted variables included study characteristics (e.g., design, setting, publication year), sample details (e.g. age, severity of asthma), how stigma was assessed or conceptualised, and reported outcomes relevant to stigma and asthma management.\u003c/p\u003e \u003cp\u003eStigma and ageism were approached as sensitising concepts, informed by established frameworks such as the Health Stigma and Discrimination Framework (8) and definitions of ageism in healthcare (21). These frameworks guided data charting but were not applied as formal analytic models.\u003c/p\u003e \u003cp\u003eA narrative synthesis was conducted to identify key themes and conceptual domains related to stigma in asthma, with a particular focus on older adults. These were developed through an inductive grouping of extracted findings, followed by iterative refinement and discussion among the author team to ensure conceptual clarity and alignment with scoping review methodology.\u003c/p\u003e \u003cp\u003e Consistent with JBI guidance (22), no formal assessment of methodological quality or risk of bias was undertaken, as this is not required for scoping reviews.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e A total of 16 empirical studies and 2 systematic reviews (3, 13) were included in this scoping review (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The empirical studies were conducted across diverse geographical settings: the USA (24\u0026ndash;26), Australia (16, 17, 27), UK (28), Canada (29), China (30), Malaysia (31\u0026ndash;33), Saudi Arabia (34), Kenya and Sudan (35), Nigeria (36) and Iran (37). Study designs included qualitative (n\u0026thinsp;=\u0026thinsp;8), quantitative (n\u0026thinsp;=\u0026thinsp;6) and mixed-methods approaches (n\u0026thinsp;=\u0026thinsp;2). Collectively, the empirical studies reported data from 1,591 participants. One study did not report age range but recruited across routine care settings (37); we retained it because the findings were adult-focused and conceptually aligned with the review question. The publications spanned over three decades, with noticeable increase in output and geographical diversity in the past ten years.\u003c/p\u003e \u003cp\u003eAcross the studies, a range of stigma-related concepts were described. Twelve of the sixteen empirical studies reported participants experiencing shame, embarrassment, or self-consciousness, particularly in relation to visible medication use (e.g., inhalers) in public settings (Supplemental file 2). Participants frequently reported feeling judged or singled out, and expressed discomfort at being seen using asthma medication (16, 26, 28\u0026ndash;31, 33\u0026ndash;36, 38). Internalised stigma was further exacerbated by perceived or actual side effects such as weight gain from oral corticosteroids - which contributed to embarrassment and self-consciousness (26, 38).\u003c/p\u003e \u003cp\u003eSome participants described feeling devalued, or labelled as \u0026ldquo;different\u0026rdquo; or \u0026ldquo;handicapped\u0026rdquo; due to their asthma diagnosis (28, 38). Stigma was also perpetuated in healthcare settings, where some patients reported perceived discrimination, judgement, or not feeling heard, leading to frustration (27, 30, 31). Socio-cultural factors influenced stigma experiences and medication behaviours (31, 34, 36). For example in Ma et al (30), traditional Chinese health beliefs contributed to non-adherence, with over two-thirds of participants endorsing the saying \u0026ldquo;all medicine has du (poison) to some degree\u0026rdquo;. In Kenya, Sudan, and Arabic speaking communities\u0026rsquo; asthma symptoms (like chronic coughing) are frequently mistaken for tuberculosis (TB), leading to enacted stigma where community members avoid the person with asthma for fear of infection (34, 35).\u003c/p\u003e \u003cp\u003eStigma was found to be associated with the severity, frequency, and overall functional burden of asthma. Quantitative studies demonstrated statistical associations between stigma and poor asthma control (25, 33), while qualitative studies highlighted stigma as a key concern among participants with severe or frequently symptomatic asthma (26, 28, 34, 38).\u003c/p\u003e \u003cp\u003eFindings were synthesised into four overarching domains: Emotional Impact, Behavioural Adaptations, Identity Disruption, and Social Withdrawal. These domains are discussed below.\u003c/p\u003e\n\u003ch3\u003eEmotional Impact\u003c/h3\u003e\n\u003cp\u003eThis domain captured the emotional burden associated with asthma related stigma. Participants reported anxiety, depression, fear and dissatisfaction, in relation to asthma complications or the possibility of potentially fatal outcomes (16, 26, 28, 32, 36, 38). Severe asthma was associated with emotional distress, including feelings of worthlessness, hopelessness, frustration, and self-directed anger (38). While most studies reported elevated emotional burden, one study (36) found no significant association between stigma of asthma treatment and presence of anxiety and depression.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBehavioural Adaptations\u003c/h2\u003e \u003cp\u003eThis domain included descriptions of the actions patients took to cope with symptoms or manage stigma, often resulting in non-adherent or mal-adaptive behaviours. Stigma led patients to conceal their asthma or avoid using inhalers in public to appear healthy or avoid being treated differently (26, 28\u0026ndash;32, 34, 35, 38). Participants reported avoiding exercise or restricting social activities due to asthma (24, 28, 31, 35, 38). Stigma contributed to intentional non-adherence, particularly in public settings, reinforcing its impact on asthma management (16, 27, 33, 36). Some individuals sought alternative therapies to avoid corticosteroid-based treatments (24, 27, 30, 31, 34, 35).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIdentity Disruption\u003c/h3\u003e\n\u003cp\u003eAsthma was described as fundamentally affecting a person\u0026rsquo;s self-concept and sense of normalcy. Individuals reported feeling devalued, different, or \u0026ldquo;handicapped\u0026rdquo; (29, 30, 33, 35) and those with severe asthma described feeling deeply misunderstood (38). Stigma was linked to low health literacy, fear of judgement, and discouragement, which compounded feelings of inadequacy and self-doubt (25, 31, 34, 35). In some studies, coughing and inhaler use were viewed with prejudice, further impacting individuals\u0026rsquo; social interactions and self-perception (29, 30, 34, 35, 38).\u003c/p\u003e\n\u003ch3\u003eSocial Withdrawal\u003c/h3\u003e\n\u003cp\u003eThis domain focused on the impact of stigma on social participation and relationships. Participants described social isolation, noting that symptoms such as coughing or breathlessness attracted unwanted attention (28\u0026ndash;31, 34, 35, 38). Asthma limited participation in social activities, and insensitive comments from peers or the public negatively affected relationships (16, 26, 28, 32, 38). Some individuals described partners who lacked empathy or had become resentful of the long-term limitations imposed by asthma (38). Stigma also affected employment opportunities, with some participants forced to leave work, contributing to further isolation (29, 35). In some studies, participants wished to engage in activities such as sports, but felt excluded due to societal attitudes and assumptions about asthma (24, 27, 28, 31).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe scoping review reveals a modest but conceptually diverse body of literature addressing stigma in adults with asthma, particularly older adults. Across the included studies stigma was common, and experienced most prominently in relation to medication use, and was across a range of cultural contexts. Among adults, particularly those with more severe or frequently occurring symptomatic asthma, stigma emerged as a pervasive, multi-layered barrier to self-management. It was driven by self-consciousness around visible medication use, anticipation of judgement, and longstanding narratives associating asthma with weakness. These experiences are frequently underpinned by low health literacy, where misconceptions influenced disclosure, hindered adherence, and contributed to emotional distress, identity disruption, and social withdrawal. Furthermore, stigma experiences were compounded by intersectional factors, where asthma-related judgment intersected with other social markers such as obesity or poverty, intensifying the internalised burden for certain populations.\u003c/p\u003e \u003cp\u003eStigma in asthma has several properties that make its experience and impact distinct from other chronic illnesses (12), including other respiratory conditions such as COPD (10). In some chronic conditions (e.g. mental health conditions or HIV), the stigmatising trait may be concealed (11), whereas in others like obesity, neurological disability, visible symptoms or physical markers make concealment difficult (39). Stigma in lung cancer and HIV is often moralised due to perceived behavioural risk factors (e.g. smoking, drug use, sexuality) (40). Asthma occupies a middle ground. Its symptoms (e.g., cough, wheeze, breathlessness) and treatments (inhalers, spacers) can be visible, yet its episodic nature means visibility fluctuates (41). This situational visibility may heighten self-consciousness and reinforce stigma through perceived loss of control or social disruption. Unlike conditions explicitly moralised due to behavioural risk factors (e.g., smoking in lung disease) asthma stigma tends to be less overtly judgement-laden but is nonetheless embedded in socio-cultural expectations around health, visibility and personal responsibility.\u003c/p\u003e \u003cp\u003eA critical finding of this review is few studies explicitly examined stigma in older adults. Most included studies featured broad adult samples without age-disaggregated analyses, limiting the ability to isolate stigma experiences specific to later life. This reflects a broader gap in asthma research, where older adults are frequently underrepresented despite carrying disproportionate burden of morbidity and mortality (5). Where age related experiences were described, they highlighted factors unique to older adults, including historical stigma associated with asthma, generational attitudes towards illness, and concerns about medication side effects within the context of polypharmacy. These observations point to the importance of age-specific enquiry into how stigma influences adherence and self-management in later life.\u003c/p\u003e \u003cp\u003eThe review also identified four overarching domains\u0026mdash;Emotional Impact, Behavioural Adaptations, Identity Disruption, and Social Withdrawal\u0026mdash;that describe how stigma manifests and affects asthma management. These domains reflect commonalities across diverse settings and study designs, and align with established conceptualisations of health-related stigma (8). Although derived inductively from study findings, they provide a practical framework for understanding how stigma may impede optimal asthma care in older adults and adults more broadly.\u003c/p\u003e \u003cp\u003eIntersectionality was introduced as a sensitising concept to acknowledge how multiple social identities and structural factors may shape stigma experiences (8, 20). However, few included studies examined intersectional dynamics in depth, and none provided analyses that considered ageism and asthma-related stigma concurrently. Instead, dimensions such as gender, ethnicity, or socioeconomic status were generally examined in isolation. These limitations underscore the need for future research that moves beyond univariate analyses to explore how age intersects with other identities and structural inequities to shape asthma-related stigma.\u003c/p\u003e \u003cp\u003ePrevious reviews have described stigma and treatment perceptions in children (42), adolescents (43), and adults with asthma (3, 13). While these reviews identified stigma as a barrier to adherence and self-management, they did not examine its impact in older adults or consider intersectional dimensions such as ageism. This review extends this literature by synthesising empirical studies focused on adults, identifying four distinct domains of impact, and introducing intersectionality as a critical framework for understanding how stigma shapes medication use in later life. Although some findings from earlier reviews may be extrapolated to older populations, our synthesis highlights the need for age-specific research that accounts for historical stigma, generational attitudes, and the unique challenges of ageing with asthma.\u003c/p\u003e \u003cp\u003eAsthma severity and symptom frequency emerged as important contextual factors shaping stigma. Individuals with severe or frequently symptomatic asthma reported heightened emotional distress, greater social withdrawal, and more pronounced identity disruption. These participants often described feeling more visible, judged or misunderstood, particularly when symptoms were difficult to conceal or when treatment side effects (e.g., weight gain from corticosteroids) were physically apparent. In contrast, those with milder or intermittent symptoms tended to report stigma in more situational terms, such as embarrassment using inhalers in public or reluctance to disclose their condition. This gradient of experience suggests that asthma severity should be considered not only as a clinical variable but also as a contextual factor shaping stigma\u0026rsquo;s impact (44). It also raises important questions about whether stigma contributes to a feedback loop, similar to the bi-directional relationship observed in depression and physical illness (45), where poor asthma control exacerbates stigma, which in turn undermines adherence and self-management.\u003c/p\u003e \u003cp\u003eCollectively, the findings emphasise the need for research that explicitly examines the lived experiences of older adults, incorporates intersectional frameworks, and develops interventions that address stigma-related barriers to medication use, self-management, and healthcare engagement.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA key strength of this review is its focused examination of stigma in older adults with asthma, a population largely overlooked in previous research. By synthesising empirical studies across diverse cultural contexts and identifying four distinct domains of stigma impact, the review provides a structured and clinically relevant framework for understanding how stigma affects self-management and medication use in later life. The integration of intersectionality and ageism as conceptual lenses offers a novel contribution to the literature and sets the stage for future research and intervention development.\u003c/p\u003e \u003cp\u003eHowever, the review is limited by the relatively small number of studies that explicitly focus on older adults, reflecting a broader gap in the literature. Many included studies did not disaggregate findings by age, limiting insights into stigma among older populations. Consistent with scoping review methodology, no formal assessment of methodological quality of included studies was conducted, which limits the ability to comment on the robustness of individual findings. The heterogeneity of study designs and contexts may limit generalisability. Furthermore, most included studies relied on self-reported measures of stigma and adherence, which may be subject to recall or social desirability bias. Finally, the exclusion of grey literature and non-English language publications may have omitted relevant studies from non-English speaking regions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Practice\u003c/h2\u003e \u003cp\u003eThe evidence highlights that stigma carries significant clinical implications for adults. It directly compromises therapeutic adherence and exacerbates psychological burden, thereby hindering optimal disease control. Clinically, stigma manifests through intentional non-adherence, concealment of medication use, and avoidance of healthcare engagement. These behaviours are shaped by cultural beliefs, misconceptions, and fear of medication side effects, particularly regarding corticosteroids. Stigma also contributes to emotional distress and social withdrawal, both of which are associated with both poorer self-management and reduced quality of life. Clinicians should be aware of the situational and episodic nature of asthma stigma, and adopt flexible, stigma-sensitive approaches that acknowledge variability in symptom visibility. This includes transitioning from paternalistic models toward shared decision making and a more holistic approach to asthma management that considers the patient\u0026rsquo;s social and psychological well-being alongside clinical symptoms (46).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePatient-centred care models that incorporate patient preferences, cultural beliefs, and the perceived stigma associated with asthma and its treatment are essential. Care that integrates empathic, stigma-aware communication can strengthen patient-provider relationships, build trust, foster medication acceptance, and help mitigate the clinical impacts of stigma. This review highlights that asthma stigma is distinct in its episodic variability, its social embeddedness, and its intersection with cultural and contextual factors that influence self-management.\u003c/p\u003e \u003cp\u003eBy synthesising the available evidence, this review highlights four key domains\u0026mdash;Emotional Impact, Behavioural Adaptations, Identity Disruption, and Social Withdrawal\u0026mdash;through which stigma appears to primarily impact adults with asthma, and underscores a critical gap in understanding how these experiences unfold in later life. Although few studies explicitly focused on older adults, the findings point to meaningful age-related considerations, including historical stigma, generational attitudes toward illness, and the added complexity of managing asthma within the broader context of ageing and comorbidity.\u003c/p\u003e \u003cp\u003eFuture studies should aim to develop and validate age and context specific frameworks for understanding stigma and its implications for medication use, self-management, and health care engagement. Approaches grounded in intersectionality offer a promising path forward for examining how age, cultural background, gender, and other social identities shape stigma experiences. Interdisciplinary work drawing from respiratory medicine, public health, behavioural science, and social theory, will be essential to advancing stigma-sensitive care and improving outcomes for older adults and all people living with asthma.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAI Acknowledgement Statement\u003c/h2\u003e \u003cp\u003eInitial data extraction was undertaken by AS and CB. Google NotebookLM was used to enhance the rigour and clarity of data extraction presented in Supplemental File 2. All outputs were critically reviewed and verified by the authors to ensure accuracy, relevance, and alignment with the study\u0026rsquo;s objectives.\u003c/p\u003e \u003c/div\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy conceptualisation (CB, SM), study design and search strategy (AS, CB, SM), data screening (AS, ED, CB), full text review and data extraction (AS, CB), analysis and synthesis (AS, SM, CB), drafting the manuscript (AS), all authors provided critical review of the manuscript and approved the final version for submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlobal Initiative for Asthma. Asthma management and prevention for adults, adolescents and children 6\u0026ndash;11 years (2024). A summary guide for healthcare providers. Published December 2024. Available from ginasthma.org. 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Patient-reported side effects, concerns and adherence to corticosteroid treatment for asthma, and comparison with physician estimates of side-effect prevalence: a UK-wide, cross-sectional study. NPJ Prim Care Respir Med. 2015;9(25):15026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalby S, Armstrong J, Strid S. Intersectionality: Multiple inequalities in Social Theory. Sociology. 2012;46:224\u0026thinsp;\u0026minus;\u0026thinsp;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFern\u0026aacute;ndez-Puerta L C-BA, de-Moya-Romero JR, Mart\u0026iacute;nez-Sabater A, Valera-Lloris R. Ageism and Associated Factors in Healthcare Workers: A Systematic Review. Nurs Rep. 2024;14(4):4039-59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeters M, Godfrey C, McInerney P, Munn Z, Tricco A, Khalil H. Scoping Reviews (2020). 2024. In: JBI Manual for Evidence Synthesis [Internet]. Joanna Briggs Institute. Available from: https://synthesismanual.jbi.global.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTricco A, Lillie E, Zarin W, O'Brien K, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation Ann Intern Med 2018;169(7):467\u0026thinsp;\u0026minus;\u0026thinsp;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTam-Williams J, Jones B. Closing the gap: Understanding African American asthma knowledge and beliefs.. Annals of Allergy, Asthma and Immunology. 2018;121(4):458\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung H, Kanchanasuwan S, Cox E, Moreno M, Havican N. Barriers to medication use in rural underserved patients with asthma. Research in Social \u0026amp; Administrative Pharmacy. 2015;11(6):909\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePersaud P, Tran A, Messner D, Thornton J, Williams D, Harper L. Perception of burden of oral and inhaled corticosteroid adverse effects on asthma-specific quality of life. ;():. Annals of Allergy, Asthma and Immunology. 2023;131(6):745\u0026thinsp;\u0026minus;\u0026thinsp;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis S, Tudball J, Flynn A, Lembke K, Zwar N, Reddel H. \u0026ldquo;You\u0026rsquo;ve got to breathe, you know\u0026rdquo; - asthma patients and carers\u0026rsquo; perceptions around purchase and use of asthma preventer medicines. Australian and New Zealand Journal of Public Health. 2019;43(3):207\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSvedsater H, Roberts J, Patel C, Macey J, Hilton E, Bradshaw L. Life Impact and Treatment Preferences of Individuals with Asthma and Chronic Obstructive Pulmonary Disease: Results from Qualitative Interviews and Focus Groups. Advances in Therapy. 2017;34(6):1466\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnadden D, Brown J. Asthma and stigma. Family practice. 1991;8(4):329\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa J, Sun X, Wang X, Liu B, Shi K. Factors Affecting Patient Adherence to Inhalation Therapy: An Application of SEIPS Model 2.0. Patient Prefer Adherence. 2023;17:531\u0026thinsp;\u0026minus;\u0026thinsp;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoh W, Abu Bakar A, Hussein N, Pinnock H, Liew S, Hanafi N, et al. Sociocultural influences on asthma self-management in a multicultural society: A qualitative study amongst Malaysian adults. Health Expectations. 2021;24(6):2078\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmad S, Ismail N. A qualitative study exploring the impact of stigma in the lives of adult asthma patients in Selangor Malayasia. Int J Pharm Pharm Sci. 2015;7(7):373-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmad S, Ismail A, Zim M, Ismail N. Assessment of Self-Stigma, Self-Esteem, and Asthma Control: A Preliminary Cross-Sectional Study Among Adult Asthmatic Patients in Selangor, Malaysia. Front Public Health. 2020;7(420).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlzayer R, Almansour H, Basheti I, Chaar B, Al Aloola N, Saini B. Asthma patients in Saudi Arabia \u0026ndash; preferences, health beliefs and experiences that shape asthma management. Ethnicity \u0026amp; Health. 2022;27(4):877\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed R, Mulupi S, Taegtmeyer M, Ardrey J, Devereux G, Chinouya M, et al. \u0026ldquo;People here live in denial\u0026rdquo;: A qualitative study of the pervasive impact of stigma on asthma diagnosis and care in Kenya and Sudan. PLOS Glob Public Health. 2025;5(12):e0003935.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdewuya A, Adeyeye O. Anxiety and depression among Nigerian patients with asthma: Association with sociodemographic, clinical, and personality factors. Journal of Asthma. 2017;54(3):286\u0026thinsp;\u0026minus;\u0026thinsp;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosseininia S, Mohammadikebar S, Motashakkeri L, Kamran A. Determinants of adherence to inhaler use in patients with asthma: the role of knowledge, self-efficacy, and perceived barriers. BMC Pulmonary Medicine. 2025;25(456).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoster J, McDonald V, Guo M, Reddel H. \u0026ldquo;I have lost in every facet of my life\u0026rdquo;: the hidden burden of severe asthma. Eur Respir J. 2017;50(3):1700765.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMadawala S, Warren N, Osadnik C, Barton C. The primary care experience of adults with chronic obstructive pulmonary disease (COPD). An interpretative phenomenological inquiry. PloS One. 2023;18(6):e0287518.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStuber J, Galea S, Link B. Smoking and the emergence of a stigmatized social status. Soc Sci Med. 2008 67:420\u0026thinsp;\u0026minus;\u0026thinsp;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChau-Etchepare F, Hoerger J, Kuhn B, Zeki A, Haczku A, Louie S, et al. Viruses and non-allergen environmental triggers in asthma. J Investig Med 2019 67(7):1029-41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKansra S, Calvert R, Jones S. Stigma from medication use: an under recognised burden of care. Breathe (Sheff). 2021 17(1):21000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan A, Price D. Treatment Adherence in Adolescents with Asthma. Journal of Asthma and Allergy. 2020;13:33\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal Initiative for Asthma. Difficult-To-Treat \u0026amp; Severe Asthma in Adolescent and Adult Patients, V5.0, 2024. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJang S. Temporal and bidirectional association of depression and physical illnesses: Analyzing the pooled data from independently conducted cross-sectional national surveys at three distinct time points. Journal of Psychosomatic Research. 2024;179.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarton C, Smith L, Bruzzese J-M. Asthma and mental health: novel insights to the experience, etiology, longitudinal course, and management of mental health in asthma and allergy Front Allergy. 2025;6(1559527).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Asthma, Stigma, Older adults, Self-management, Medication adherence, Intersectionality and ageism, Patient-centred care","lastPublishedDoi":"10.21203/rs.3.rs-9190215/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9190215/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eAsthma is a chronic respiratory condition with effective pharmacological treatments; however, poor adherence, particularly the overuse of short-acting β2-agonists (SABA) and underuse of inhaled corticosteroids, remains a persistent challenge. Stigma may influence self-management behaviours, yet its impact in asthma, especially among older adults, is underexplored. Health-related stigma, defined as stereotyping, prejudice, or discrimination directed toward individuals based on a health condition, may interact with age-related factors such as comorbidity, generational attitudes toward illness, and historical experiences of asthma stigma.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003e We conducted a scoping review following the Joanna Briggs Institute methodology and PRISMA-ScR guidelines. Six databases (Medline OVID, Embase, Emcare, PsycInfo, Scopus, and CINAHL) were systematically searched for studies examining stigma in asthma, with a focus on older adults. Titles and abstracts were screened independently by two authors, followed by full-text review and data extraction using a customised template. Findings were synthesised narratively, and stigma and ageism were approached as sensitising concepts.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eSixteen empirical studies involving participants from diverse cultural contexts, and two reviews, were included. Stigma was commonly reported, particularly among individuals with severe asthma or frequent symptoms, and was primarily associated with medication use. Stigma manifested across four key domains: emotional impact, behavioural adaptations, identity disruption, and social withdrawal. While age-related considerations were evident, few studies explicitly examined these experiences in older adults. Intersectional influences including cultural background, age-related biases, and gender were acknowledged in some studies but rarely analysed in depth.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eStigma influences asthma management across emotional, behavioural, and social domains, affecting adherence, wellbeing, and healthcare engagement. This review identifies a critical gap in understanding the lived experiences of older adults with asthma and underscores the need for age-specific, intersectional research and tailored interventions to address stigma and improve outcomes, with implications for health promotion, self-management support, and reducing stigma-related barriers to care in older adults.\u003c/p\u003e","manuscriptTitle":"Understanding Stigma in Later Life Asthma: A Mixed Methods Scoping Review with an Intersectional Lens","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 15:08:39","doi":"10.21203/rs.3.rs-9190215/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-12T18:31:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T11:24:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T16:33:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5478796009438121262341615712001202193","date":"2026-04-07T21:26:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84825774640451630729478237498710857774","date":"2026-04-04T17:52:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4245471488912330005349683150063323272","date":"2026-04-03T19:10:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T17:27:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-27T12:12:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-26T07:40:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-26T07:40:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-22T09:19:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"268a775c-2302-42af-9dff-b98d24f45008","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-12T18:31:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T11:24:34+00:00","index":58,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T16:33:39+00:00","index":57,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T18:39:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 15:08:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9190215","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9190215","identity":"rs-9190215","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}