Assessment of knowledge on self-management and level of asthma control among patients attending a tertiary care center in Nepal: A cross-sectional study.

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Learn more: PMC Disclaimer | PMC Copyright Notice PLOS Glob Public Health . 2026 May 29;6(5):e0006563. doi: 10.1371/journal.pgph.0006563 Assessment of knowledge on self-management and level of asthma control among patients attending a tertiary care center in Nepal: A cross-sectional study Swojay Maharjan 1 , Rajesh Khatri Chhetri 2 , Ashok Basnet 2 , Sirapa Maharjan 3 , Kushal Shrestha 3, * , Shashwot Sedhain 3 , Helina Singh 3 , Kiran Dhonju 4 Editor: Julia Robinson 5 Author information Article notes Copyright and License information 1 Vayodha Hospital, Kathmandu, Nepal 2 Shree Birendra Hospital, Kathmandu, Nepal 3 Nepalese Army Institute of Health Sciences (NAIHS), Kathmandu Nepal 4 Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal 5 PLOS: Public Library of Science, UNITED STATES OF AMERICA ✉ * E-mail: shresthakushal2003@gmail.com The authors have declared that no competing interests exist. Roles Swojay Maharjan : Conceptualization, Formal analysis, Methodology, Resources, Writing – original draft, Writing – review & editing Rajesh Khatri Chhetri : Data curation, Investigation, Project administration, Resources, Supervision, Writing – review & editing Ashok Basnet : Conceptualization, Data curation, Investigation, Supervision, Writing – review & editing Sirapa Maharjan : Data curation, Investigation, Resources, Writing – original draft, Writing – review & editing Kushal Shrestha : Data curation, Formal analysis, Investigation, Resources, Writing – original draft, Writing – review & editing Shashwot Sedhain : Data curation, Writing – original draft, Writing – review & editing Helina Singh : Data curation, Writing – original draft, Writing – review & editing Kiran Dhonju : Data curation, Writing – original draft, Writing – review & editing Julia Robinson : Editor Received 2025 Aug 25; Accepted 2026 May 12; Collection date 2026. © 2026 Maharjan et al This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PMCID: PMC13221001  PMID: 42213688 Abstract Asthma is a major public health challenge globally and is characterized by recurrent attacks of breathlessness and wheezing that vary in severity and frequency from person to person. With a notable burden in Nepal, where prevalence ranges from 4.2% to 8.9%, effective asthma management requires both updated pharmacological treatments and robust self-management practices, which involve monitoring symptoms and preventing exacerbations. In settings like Nepal, where asthma prevalence and resource limitations are concerns, enhancing patient education and behavioral interventions is crucial for better disease control. An analytical cross-sectional study was conducted to find the relationship between asthma control levels and asthma self-management at a tertiary care center from 25th May 2024 to 15 th November 2024 in Nepal. The convenience sampling method was used. To evaluate differences in asthma self-management knowledge, a non-parametric statistical test was applied to the scores from the Asthma Self-Management Knowledge Questionnaire (ASMQ), which were categorized by independent variables. A p-value of < 0.05 was considered as statistically significant. A total of 145 patients had participated in our study. The mean (SD) transformed ASMQ score was 26.22 (13.32). Based on ACT scores, asthma control levels were classified as uncontrolled (40%), partially controlled (54.5%), and controlled (5%). The Kruskal-Wallis H test revealed a statistically significant difference in ASMQ scores across education levels (p = 0.047), occupation (p = 0.015) and subgroups of the asthma control test (p = 0.011). Post hoc analysis using the Dunn-Bonferroni test indicated a statistically significant difference in ASMQ scores between individuals with uncontrolled asthma and partially controlled asthma. The findings of our study suggest that asthma self-management knowledge is suboptimal and correlates with asthma control levels, emphasizing the critical importance of effective patient education and assessment in achieving optimal disease management. Introduction Asthma is a chronic, heterogeneous inflammatory airway disorder affecting individuals across the life course and remains a leading cause of morbidity globally. It is characterized by recurrent episodes of wheeze, shortness of breath, chest tightness, and cough that fluctuate in intensity over time and are associated with variable expiratory airflow limitation measurable through spirometry [ 1 , 2 ]. Common triggers such as upper respiratory tract infections, allergens, pollutants, medications, exercise, and psychological stress contribute to airway inflammation and symptom exacerbations [ 2 ]. The Global Burden of Disease (GBD) study (2019) estimated that asthma affected approximately 262 million people worldwide and accounted for 21.6 million disability-adjusted life years (DALYs), highlighting its substantial public health burden [ 1 ]. In Nepal, community-based studies report a prevalence of 4.2%–8.9%, with higher estimates observed among adult populations [ 3 ]. As Nepal undergoes an epidemiological shift towards non-communicable diseases (NCDs), increasing asthma burden poses a challenge to achieving the National Multisectoral Action Plan for NCDs (2021–2025), which targets a 25% reduction in premature NCD-related mortality, including chronic respiratory diseases, by 2025 [ 4 ]. Although pharmacotherapy particularly inhaled corticosteroids and bronchodilators delivered via metered-dose or dry-powder inhalers remains central to asthma management, optimal disease control depends heavily on patients’ self-management capacity [ 5 ]. Self-management encompasses adherence to treatment, correct inhaler technique, trigger avoidance, symptom monitoring, and timely medical consultation [ 6 ]. Evidence across diverse settings demonstrates that patient education targeting these domains can significantly reduce exacerbations and improve asthma control. Interventions such as structured inhaler-technique counseling, smartphone-based training tools for inhaler competency among students and allergen immunotherapy for prevention and control have shown beneficial outcomes [ 7 – 9 ]. The role of comorbidity-directed management is also notable. Omeprazole therapy among poorly controlled asthmatic children with gastroesophageal reflux led to improved asthma control [ 10 ]. Lifestyle-oriented strategies, including dietary intervention among obese children, have additionally been linked to reduced asthma risk and better disease control [ 11 ]. Beyond clinical outcomes, achieving asthma control is strongly associated with improved quality of life, as demonstrated in outpatient cohorts in Brazil [ 12 ]. Despite this growing body of evidence, asthma control remains suboptimal in low- and middle-income countries, where gaps in knowledge, adherence, inhaler technique, and health literacy persist. Studies consistently report that patients with inadequate understanding of self-management are more likely to have uncontrolled disease, frequent exacerbations, and poor therapeutic outcomes [ 5 , 6 ]. Nepal, with limited specialist access and relatively low awareness of chronic respiratory disease management, represents a context where patient-centered education and behavior-focused interventions could make substantial impact. However, data on asthma self-management knowledge among Nepali patients remain scarce, and literature linking knowledge with disease control in this setting is minimal. Generating such evidence is crucial for guiding context-responsive educational interventions and informing public-health strategies aimed at reducing preventable morbidity. The present study aims to assess the level of knowledge on asthma self-management among patients attending a tertiary care center in Nepal and evaluate its association with asthma control. By addressing an existing evidence gap in a resource-limited setting, this research contributes theoretically to understanding behavioral determinants of asthma outcomes in LMIC contexts and practically to informing strategies for patient education, clinical counseling, and community-level intervention design. Strengthening self-management capacity may serve as a cost-effective pathway to improve control and support national goals for reducing respiratory disease burden. Methods Study design This is an analytical cross-sectional study conducted to find the association between levels of asthma control with knowledge on asthma self-management, and also to relate demographic profiles with level of asthma control. Assessing asthma self-management using standardized methods and connecting it to disease control makes sense in a Low-and-Middle-Income-Country (LMIC) like Nepal, where the doctor-to-patient ratio is subpar and there is a significant intellectual divide between them [ 13 ]. Ethical approval This study was approved by the Institutional Review Committee of the Nepalese Army Institute of Health Sciences (NAIHS). By including the written informed consent form in the questionnaire itself, all participants were made aware of the study’s purpose. The consent was assumed to have been granted by the participants who filled out the form. Setting The teaching hospital of NAIHS, Shree Birendra Hospital (SBH), a tertiary care centre where all patients with military ties are given free treatment and medicines, was chosen as the suitable location for this study. The patient statistics of SBH show a variation in age groups, educational level and socioeconomic status, making this study as inclusive as possible. Study sample Patients with bronchial asthma for at least 6 months, aged 18 years and above, visiting the SBH Chest OPD, and who gave their written informed consent were selected for the study. A non-probability convenience sampling method was employed, whereby participants were selected based on accessibility, and data collection was conducted at times convenient to the researchers.. The patients with any major medical comorbidity, cognitive impairment, inability to communicate verbally, asthma-COPD overlap syndrome, and those who had symptoms similar to asthma but were not diagnosed were excluded from the study. All those patients who met the inclusion criteria were interviewed from 30th June 2024 to 1 st January 2025. Study instruments Asthma self-management behavior and asthma-related knowledge were assessed using the Asthma Self-Management Questionnaire (ASMQ) and the Asthma Control Test (ACT). Both instruments were translated into Nepali following standard translation and back-translation procedures to ensure linguistic accuracy and cultural relevance. The translated questionnaires were then reviewed by two pulmonologists and one public health expert. The Cronbach’s alpha for ASMQ was 0.513 and ACT was 0.554. The Asthma Control Test (ACT) is a validated five-item measure that evaluates the level of asthma control over the preceding four weeks. The items assess: (1) frequency of shortness of breath, (2) occurrence of nighttime asthma symptoms, (3) degree of functional limitation, (4) frequency of rescue inhaler use, and (5) the patient’s self-rating of overall asthma control. Each item is scored on a 5-point Likert scale, generating a total score ranging from 5 to 25. Higher scores indicate better asthma control: scores ≥20 represent well-controlled asthma, 16–19 partially controlled asthma, and ≤15 poorly controlled asthma. The ACT has demonstrated strong reliability and validity across diverse populations. The Asthma Self-Management Questionnaire (ASMQ) consists of 16 multiple-choice items that assess patient knowledge related to asthma triggers, preventive strategies, proper inhaler technique, and the appropriate use of rescue and controller medications, as well as peak flow monitoring. Each item has a single correct response. Total ASMQ scores are calculated by summing correct answers or converting them to a percentage scale; higher scores indicate greater asthma knowledge and more appropriate self-management practices. The ASMQ has been widely used in clinical and population-based research and exhibits good psychometric properties. Both questionnaires were administered through face-to-face interviews to accommodate varying levels of literacy among participants. Interviewers followed standardized administration procedures, providing instructions without offering clarifications that could bias responses. The average administration time for both tools combined was approximately 10–15 minutes per participant. In addition to these instruments, a structured interview schedule was used to collect sociodemographic and clinical data, including age, gender, occupation, educational level, family history of asthma, known allergens, cigarette smoking history, exposure to pets, dust, and dampness, and any recent history of asthma exacerbations. Data collection The data was collected through a closed-question interview with multiple-choice questions over a 7-month period (2024/06/30–2025/01/30) and analyzed by the authors. A written informed consent was taken before the respondents were assigned a printed questionnaire, both of which are attached as a single file in the annex section. Interviewees were assured that the questions had no fixed correct answer and that their response would not be judged as right or wrong to limit bias in the data collection process. Statistical analysis The data collected via the questionnaire was first cleaned in Microsoft Excel 2016 and imported into SPSS version 20 for the analysis. The statistical significance of the differences was ascertained from the p-value (<0.05). Firstly, normality was checked using Kolmogorov-Smirnov (K–S) test and the Shapiro-Wilk test. If the test’s significant value was higher than 0.05, the data distribution was considered normal; if it was less than 0.05, it was considered non-normal. Since the assumption of normality for the ASMQ score was not satisfied for all group combinations of independent variables, normality was rejected. Then we proceeded with the non-parametric tests using the median and Inter-Quartile Range (IQR) as measures of central tendency and dispersion, respectively. A Mann-Whitney U test was chosen as our study failed the assumption of independent samples t-test to determine if there were differences in ASMQ scores between two independent categorical variables like gender, occupation, family history of asthma, level of education, known allergy, history of time spent with pets, history of smoking, living in a damp and dusty environment, and exacerbations in the past 1 year. Effect sizes for each comparison were quantified using the rank biserial correlation (r₍rb₎), calculated from the U statistic and group sample sizes. Whereas, the Kruskal-Wallis H test was run to determine if there were differences in ASMQ scores between the three sub-groups of ACT and five groups of participants with different occupation categories and educational status as our study also didn’t meet the requirements of the parametric One-Way ANOVA test. When statistically significant results were obtained, post-hoc pairwise comparisons were conducted using Dunn’s test with Bonferroni correction. Effect sizes for Kruskal–Wallis tests were calculated using eta-squared (η²_H) to quantify the proportion of variance in ASMQ scores attributable to group differences. Results General characteristics Out of approximately 168 patients initially approached, 145 gave their consent to participate in the study. The majority of the participants in our study were female, 96 (66.2%), out of whom 65 were homemakers. Similarly, 45 (31%) had a family history of asthma, and 24 (16.6%) had an exacerbation in the last 1 year. Table 1 depicts the socio-demographic characteristics, ACT scores and level of asthma control based on the ACT and ASMQ scores of the study population. The distribution of transformed ASMQ scores among study participants is shown in Fig 1 . Table 1. Socio-demographic characteristics of the study population. S.N Characteristics Subgroups Values N (%) 1 Age, Mean (SD) 38.89 (11.60) 2 Gender Male 49 (33.80) Female 96 (66.20) 3 Occupation Army Personnel 34 (23.40) Homemaker 65 (44.80) Small business person 4 (2.80) Farmer 9 (6.20) Others 33 (22.80) 4 Family history of asthma Present 45 (31.00) Absent 100 (69.00) 5 Level of education Illiterate 9 (6.20) Literate 45 (31.00) Secondary 44 (30.30) Higher-secondary 37 (25.50) University 10 (6.90) 6 Known allergy Present 76 (52.40) Absent 69 (47.60) 7 Time spent with pets Present 33 (22.80) Absent 112 (77.20) 8 Smoking History Present 10 (6.90) Absent 135 (93.10) 9 Damp and dusty room Present 14 (9.70) Absent 131 (90.30) 10 Exacerbations in the past 1 year Present 24 (16.60) Absent 121 (83.40) 11 ACT score Mean (SD) 20.03 (3.12) 12 Level of Asthma control based on ACT Controlled 8 (5.50) Partially controlled 79 (54.50) Uncontrolled 58 (40.00) 13 ASMQ score Mean (SD) 26.22 (13.32) Open in a new tab SD: Standard deviation, N: Frequency, %: Percentage. Fig 1. Distribution of the ASMQ transformed score: possible range 0–100, with higher scores indicating more knowledge of asthma self-management. Open in a new tab Fig 2 demonstrates that item 7 has the largest percentage of correct responses (75.86%) (When using your inhaler, you should inhale slowly) and the lowest percentage of correct responses (4.83%) is item 13 (Asthma can be cured by, there is no known cure for asthma). Similarly, the highest percentage of incorrect answer is for the item 13. Whereas, the questions with the highest percentage of unknown or “Don’t know” answer is item 10 (Taking more rescue medicines than prescribed may mean you need more maintenance medicine). Similarly, Table 2 depicts the characteristics of incorrect responses in the ASMQ questionnaire. Fig 2. ASMQ frequency distribution among the study participants with asthma. Open in a new tab Table 2. Characteristics of incorrect responses to the ASMQ questions (N = 145 respondents) ASMQ. Misunderstandings about maintenance and rescue medications, and their proper use. S.N ASMQ Items Incorrect responses N (%) 1 A main method to prevent asthma flare up is to… Take medicines before meals 35 (24.1) Take steroids in pill form 11 (7.6) Go to the emergency room at the first sign of symptoms 33 (22.8) 2 Maintainence medicines… Don’t need to be taken every day 16 (11.0) Make you breathe better right after you take them 54 (37.2) Can only be taken in pill form 5 (3.4) Start exhaling and then put the mouth- piece in your mouth 28 (19.3) Put the mouthpiece in your mouth and then inhale and exhale 19 (13.1) 3 Rescue medicines… Help prevent future flare-ups 35 (24.1) Have no side effects 37 (25.5) Do not cause you to become tolerant to medicine 13 (9.0) 4 Taking more rescue medicines than prescribed… Is really not harmful 40 (27.6) Is a good way to manage symptoms caused by exercise 16 (11.0) May mean you can take less maintenance medicine 7 (4.8) Misconceptions about the correct techniques for using inhalers and peak flow meters and its benefits. 5 The correct way to use a peak flow meter is to... Take a deep breath and then blow into the mouthpiece slowly 35 (24.1) Start exhaling and then put the mouth- piece in your mouth 28 (19.3) Put the mouthpiece in your mouth and then inhale and exhale 19 (13.1) 6 When using your inhaler, you should… Take shallow breaths 2 (1.4) Inhale quickly 15 (10.3) Press your inhaler several times while you are inhaling 3 (2.1) 7 After you have used your inhaler, you should... Take the second puff as soon as possible after the first puff 16 (11.0) Keep taking puffs until you feel better 23 (15.9) Wash the inhaler in a tub of water 13 (9.0) 8 The benefit of using a peak flow meter every day is... It can tell you when you can decrease your medicines 28 (19.3) You can see how well you can inhale 33 (22.8) You can have a way to compare yourself to other people with asthma 12 (8.3) Misunderstandings regarding symptom management, flare-ups, the implications of not experiencing symptoms and others. 9 Taking the prescribed two puffs of your inhaler two times a day... Is the same as taking one puff four times a day 43 (29.7) Is the same as taking four puffs once a day 25 (17.2) Can be arranged in any way as long as you take a total of four puffs a day 9 (6.2) 10 If you are not having asthma symptoms... Your lungs are not sensitive to irritants 13 (9.0) It is OK to skip some doses of medicine 26 (17.9) You are probably cured of asthma 12 (8.3) 11 If you are having symptoms and don’t know why, the first thing you should do is... Take some doses of steroid medicine 8 (5.5) Call your doctor 65 (44.8) Count how fast you are breathing 17 (11.7) 12 For people with asthma, exercise... Is something that should not be done regularly 7 (4.8) Is only good if done for at least 30 minutes at a time 33 (22.8) Can trigger symptoms because the lungs are not taking in enough oxygen 13 (9.0) 13 Asthma can be cured by… Taking daily medicine 54 (37.2) Avoiding triggers, such as dust and cigarette smoke 51 (35.2) Using a peak flow meter 11 (7.6) 14 Asthma flare ups… Usually occur suddenly without warning 21 (14.5) Cannot be triggered by strong emotions 17 (11.7) Always cause wheezing 27 (18.6) 15 If you are prescribed a seven-day course of steroid pills... You don’t have to avoid triggers while you are taking the pills 10 (6.9) Your symptoms can’t get worse while you are taking the pills 41 (28.3) You don’t need to use your peak flow meter while you are taking the pills 24 (16.6) 16 Which of the following can help control asthma? Reducing stress levels 23 (15.9) Drinking plenty of water to stay hydrated 46 (31.7) Avoiding foods with sulfites, such as dried fruits and wine 17 (11.7) Open in a new tab N: Frequency, %: Percentage. Using the Mann-Whitney U test, the distributions of the ASMQ scores for males and females were assessed by visual inspection which were similar. Median ASMQ score for males (25) and females (25) was not statistically significantly different, U = 1,895, z = -1.926, p = 0.054, using an exact sampling distribution for U. The corresponding rank biserial correlation indicated a small effect size (r₍rb₎ = 0.194), with females showing slightly lower score variability. Similarly, the box-plots distributions were similar for family history and allergen history, however their respective median values were not statistically significantly different. The effect sizes of comparison between the ASMQ scores of the remaining dichotomous variables ranged from –0.154 to 0.162, indicating negligible to small effects. Using the Kruskal-Wallis H test, the differences in ASMQ score between five groups of participants with different occupation and educational status were assessed. Distributions of ASMQ scores were not similar for all groups in both categories, as assessed by visual inspection of a boxplot. However, the distributions of ASMQ scores were statistically significantly different between educational status, χ 2 (4) = 9.651, p = .047 and occupation χ 2 (4) = 12.392, p = 0.015. Subsequently, pairwise comparisons were performed using Dunn’s (1964) procedure with a Bonferroni correction for multiple comparisons. Adjusted p values are presented. This post hoc analysis revealed statistically significant differences in median ASMQ scores between Farmer-Others (p = 0.048) and Farmer-Army Personnel (p = 0.020) under the Occupation category and between the Literate-University (p = 0.033) under the Level of Education category. The associated effect sizes were η²_H = 0.040 for education and η²_H = 0.060 for occupation, indicating small-to-moderate effects. Further relationship between ASMQ scores and independent categorical variables are shown by Table 3 . Table 3. Relationship between ASMQ score and independent categorical variables. Characteristics ASMQ score Median (Interquartile range) P value Rank biserial correlation (r₍rb₎) and Kruskal-Wallis Effect Sizes (η²_H) Value Gender Male 25.00 (25.00) 0.054 0.194 Female 25.00 (16.04) Occupation Army Personnel 25.00 (25.00) 0.015 0.060 Homemaker 25.00 (17.27) Small business person 15.21 (21.41) Farmer 6.25 (15.63) Others 25.00 (18.75) Family history of asthma Present 25.00 (15.63) 0.115 0.162 Absent 25.00 (22.29) Level of education Illiterate 18.75 (25.00) 0.047 0.040 Literate 18.75 (17.27) Secondary 25.00 (25.00) Higher-secondary 25.00 (15.63) University 34.38 (14.06) Known allergy Present 25.00 (19.97) 0.883 0.014 Absent 25.00 (22.29) Time spent with pets Present 25.00 (17.40) 0.794 0.030 Absent 25.00 (22.29) Smoking History Present 21.88 (26.56) 0.640 0.088 Absent 25.00 (22.29) Damp and dusty room Present 18.75 (17.60) 0.601 -0.085 Absent 25.00 (22.29) Exacerbations in the past 1 year Present 18.75 (18.75) 0.231 -0.154 Absent 25.00 (22.29) Open in a new tab A Kruskal-Wallis H test was run to determine if there were differences in ASMQ score between three sub-groups of ACT scores. Distributions of ASMQ scores were similar for all groups, as assessed by visual inspection of a boxplot. The distributions of ASMQ scores were statistically significantly different between groups, χ 2 [ 2 ] = 8.972, p = 0.011 with an effect size of η²_H = 0.049, suggesting a small-to-moderate association between asthma control level and self-management knowledge. The post hoc analysis revealed statistically significant differences in median ASMQ scores between the uncontrolled (22.3284) and partially controlled (28.9004) ( p = 0.010). Adjusted p -value is presented in Table 4 . Table 4. Relationship between ASMQ and levels of asthma control based on the ACT category. ACT sub groups Mean Number Std. Deviation Grouped Median Interquartile range P value Kruskal-Wallis Effect size (η²ₕ) Value Controlled 28.0213 8 11.08958 26.5625 22.97 0.011* 0.049 Partially controlled 28.9004 79 13.50686 27.3148 18.75 Uncontrolled 22.3284 58 12.56868 19.0789 18.75 Total 26.2231 145 13.32476 24.1071 Open in a new tab * The p value represents the statistical test result comparing the ASMQ score across the three sub groups of ACT. Discussion The design and implementation of this study has allowed several inferences on the knowledge of self-management of asthma in relation to various socio-demographic factors and the extent of control of the disease. Despite different studies making modifications to the ASMQ by excluding questions about peak flow meter because of the tendency of high scores among its users, our study has adopted the original form by Mancuso et al.[ 14 ] The questionnaire assessed several components of asthma self-management. Only 32.41% participants correctly identified that flu vaccination prevents asthma flare-ups, while 54.48% responded incorrectly and 13.1% were unaware. Similarly, 44.83% had misconceptions regarding how flare-ups occur and 29.66% did not know the mechanism. Concerning dose regimen, 21.38% participants were aware that two puffs twice daily is not equivalent to other combinations; however, 53.10% considered other combinations the same and 25.52% did not know the correct regimen. When asymptomatic, 51.72% acknowledged the need to avoid triggers, whereas 35.17% responded incorrectly and 13.1% were unaware. Only 30.34% recognized the preventive purpose of maintenance medicines, with 51.72% responding incorrectly and 17.93% uncertain. Similar deficiencies were observed in understanding the mechanisms of asthma exacerbations, with a considerable proportion of participants either holding misconceptions or lacking knowledge altogether. Comparable trends have been reported in earlier studies, where inadequate disease understanding was associated with poor asthma control and increased exacerbation rates [ 13 , 15 ]. Knowledge related to peak flow meter use was particularly poor. Only 8.276% knew the correct technique and 11.72% recognized its benefit in identifying early lung function decline. In contrast, knowledge regarding inhaler technique was relatively better: 75.86% identified slow inhalation as correct and 49.66% knew breath-holding after actuation. Regarding rescue medicine usage, 19.31% knew it should not exceed 3–4 times/day and 12.41% knew that excessive rescue medicine use increases the requirement for maintenance therapy. Our findings of peak flow meter, inhaler technique, reliever and preventer medicines are consistent with the findings from a systematic review done by Alyas et al [ 15 ]. Our study showed a significant burden of poorly managed asthma, as just 8 patients (5.5%) had well-controlled asthma, while the majority had either uncontrolled asthma (40.0%) or moderately controlled asthma (54.5%). These results are in line with data from the Asthma Insights and Reality in Asia-Pacific Study, which showed that asthma control in the Asia-Pacific area is still not at its best, with many patients having chronic symptoms and inadequate treatment [ 16 ]. Similarly, data from the Asia-Pacific Asthma Insights and Management (AP-AIM) survey reported that nearly 90% of patients had partly controlled or uncontrolled asthma, with only a small minority achieving optimal control [ 17 ]. In this study, education level (p = 0.047) and occupation (p = 0.015) had significant association with ASMQ scores (p < 0.05). This aligns with Nguyen et al in Vietnam, where college-educated patients had higher ASMQ scores [ 18 ], and with Khor et al in Singapore, which also demonstrated a positive association between education and asthma knowledge [ 19 ]. Low educational attainment may hinder understanding of health messages and patient counselling. Studies from Pakistan and Egypt showed that structured educational interventions improve ASMQ scores, suggesting the benefit of patient education where clinical teaching time is constrained [ 20 , 21 ]. However, the present study did not measure the extent of prior patient education. ASMQ score also differed among ACT subgroups (p = 0.010), indicating better asthma control with higher self-management knowledge. While Nguyen et al reported a similar trend of high ACT corresponding with high ASMQ [ 18 ], Khor et al found no significant association between asthma knowledge and asthma control [ 19 ], suggesting that cultural, healthcare access, or medication adherence differences may affect this relationship. This study highlights the role of self-management knowledge in achieving better asthma control. However, certain methodological limitations need to be acknowledged. The use of self-reported data may introduce reporting bias, and the convenience sampling technique limits generalizability of the findings. Future research could incorporate objective measures of disease control, such as pulmonary function testing, adopt probability sampling to minimize selection bias, and include an educational intervention to more accurately evaluate the hypothesis. Evidence from other settings also supports the potential value of educational interventions. A quasi-experimental study in Nigeria reported that pharmacist-led interventions significantly improved asthma control through enhanced medication adherence and appropriate use of inhaler [ 22 ]. Similarly, a randomized clinical trial in Nigeria demonstrated better asthma control and improved adherence in patients who received educational intervention compared to who did not [ 23 ]. In the national context, Bhattarai et al. conducted an interventional study in a resource limited center from Nepal and observed improved compliance following an educational intervention, although a significant improvement in disease control was not reported [ 24 ]. Collectively, these findings suggest that while knowledge alone may not guarantee improved outcomes, structured educational interventions hold promise and warrant further investigation in larger, rigorously designed studies. There are some limitations of this study. First, the use of a non-probability convenience sampling method from a single tertiary care center may limit the generalizability of the results to the broader population. Second, the data were collected through interviewer-administered questionnaires, which may introduce reporting and social desirability bias. Third, the internal consistency of the translated instruments in this study was relatively low, with Cronbach’s alpha values of 0.513 for the ASMQ and 0.554 for the ACT. This may reflect cultural and linguistic differences, variation in patient understanding, or the multidimensional nature of the constructs being measured, and suggests potential measurement error that could affect the precision of the observed associations. Additionally, potential confounders such as prior exposure to asthma education, medication adherence, and objective measures of disease control (e.g., spirometry) were not evaluated. Finally, while several socio-demographic and environmental variables were included, their relationship with asthma control was not explored, which may have provided further insights into determinants of disease outcomes. Conclusion This study demonstrates that asthma self-management knowledge among patients in a tertiary care setting in Nepal is suboptimal, with a high proportion of patients exhibiting partially controlled and uncontrolled disease. The observed association between higher self-management knowledge and better asthma control highlights the clinical importance of patient education as a core component of asthma care. Strengthening self-management programs through structured educational interventions and objective assessment tools may therefore play an important role in improving long-term clinical outcomes, particularly in resource-limited settings. Supporting information S1 File. Questionnaire. a. The first page consists of the informed consent form. b. Second page consists of the socio demographic characteristics. c. Third page consists of the 5 items of the Asthma Control Test. d. The remaining ones consists of the 16 items of Asthma Self-Management Questionnaire. (DOCX) pgph.0006563.s001.docx (16.9KB, docx) S1 Data. Supplementary SPSS data file. (XLSX) pgph.0006563.s002.xlsx (39.8KB, xlsx) Data Availability All relevant data are within the paper and its Supporting information files. Funding Statement The authors received no specific funding for this work. References 1. Network GA. The Global Asthma Report 2022. Int J Tuberc Lung Dis. 2022;26:1–104. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Asthma [Internet]. [cited 2025 Feb 28]. Available from: https://www.who.int/news-room/fact-sheets/detail/asthma [ Google Scholar ] 3. Ekezie W, Jenkins AR, Hall IP, Evans C, Koju R, Kurmi OP, et al. The burden of chronic respiratory diseases in adults in Nepal: a systematic review. 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Patient Prefer Adherence. 2024;18:1395–408. doi: 10.2147/PPA.S460810 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] PLOS Glob Public Health. 2026 May 29;6(5):e0006563. doi: 10.1371/journal.pgph.0006563.r001 Author response to Decision Letter 0 Article notes Copyright and License information Collection date 2026. PMC Copyright notice Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. 25 Aug 2025 PLOS Glob Public Health. doi: 10.1371/journal.pgph.0006563.r002 Decision Letter 0 Katrien Janin Author information Copyright and License information Roles Katrien Janin : Staff Editor © 2026 Katrien Janin This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 31 Oct 2025 PGPH-D-25-01721 Assessment of Knowledge on Self-Management and Level of Asthma Control among Patients Attending a Tertiary Care Center in Nepal: A Cross-Sectional Study PLOS Global Public Health Dear Dr. Shrestha, Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The manuscript has been evaluated by two reviewers, and their comments are available below. The reviewers have raised a number of concerns. They request additional information on methodological aspects of the study and that the study acknowledges the limitations of self-reported data and selection bias. Could you please carefully revise the manuscript to address all comments raised? We note a reviewer requested citations. Please note that these request are optional. Please submit your revised manuscript by Dec 14 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. We look forward to receiving your revised manuscript. Kind regards, Katrien G. Janin, PhD Staff Editor PLOS Global Public Health Journal Requirements: 1.In the online submission form, you indicated that The data that support the findings of the study are available from the corresponding author upon reasonable request. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons by return email and your exemption request will be escalated to the editor for approval. Your exemption request will be handled independently and will not hold up the peer review process, but will need to be resolved should your manuscript be accepted for publication. One of the Editorial team will then be in touch if there are any issues. 2. Please amend your detailed Financial Disclosure statement. This is published with the article. It must therefore be completed in full sentences and contain the exact wording you wish to be published. If you did not receive any funding for this study, please simply state: “The authors received no specific funding for this work.” 3. We have noticed that you have uploaded Supporting Information files, but you have not included a list of legends. Please add a full list of legends for your Supporting Information files after the references list. 4. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions --> Comments to the Author 1. Does this manuscript meet PLOS Global Public Health’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.--> Reviewer #1: Partly Reviewer #2: Yes ********** -->2. Has the statistical analysis been performed appropriately and rigorously?--> Reviewer #1: Yes Reviewer #2: Yes ********** -->3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: No Reviewer #2: Yes ********** -->4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: No Reviewer #2: Yes ********** -->5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: Thank you for your submission. The manuscript addresses an important gap in asthma management in Nepal and presents promising data. However, significant revisions are needed to ensure methodological transparency, clarity, and compliance with PLOS editorial standards. I recommend major revision and encourage resubmission following the above guidance. A. Introduction: First of all, in the introduction part, it is necessary to emphasize the different aspects of the study from other studies in the literature. However, the theoretical and practical contributions of the research are not emphasized enough in the conclusion part. In addition, the relevant literature has not been adequately covered. I recommend that the following studies be included in the research. • Batard T, Taillé C, Guilleminault L, et al. Allergen Immunotherapy for the Prevention and Treatment of Asthma. Clin Exp Allergy. 2025;55(2):111-141. doi:10.1111/cea.14575 • Sikorska-Szaflik H, Połomska J, Sozańska B. The Impact of Dietary Intervention in Obese Children on Asthma Prevention and Control. Nutrients. 2022;14(20):4322. Published 2022 Oct 15. doi:10.3390/nu14204322 • Ghozali MT, Mutiara TA. Promoting knowledge of metered dose inhaler (MDI) usage among pharmacy professional students through a mobile app. J Asthma. 2024;61(8):835-846. doi:10.1080/02770903.2024.2306622 • Yagoubi A, Laid Y, Smati L, Nafissa Benhalla K, Benhassine F. Does omeprazole improve asthma-control in poorly-controlled asthmatic children with gastro-esophageal reflux. J Asthma. 2022;59(6):1169-1176. doi:10.1080/02770903.2021.1917606 • Jafari M, Sobhani M, Eftekhari K, Malekiantaghi A, Gharagozlou M, Shafiei A. The Effect of Oral Montelukast in Controlling Asthma Attacks in Children: A Randomized Double-blind Placebo Control Study. Iran J Allergy Asthma Immunol. 2023;22(5):413-419. Published 2023 Oct 29. doi:10.18502/ijaai.v22i5.13990 • Lourenco CB, Martins F, Fiss E, Grumach AS. Impact of asthma control on quality of life in an outpatient setting in Brazil. J Asthma. 2023;60(4):794-801. doi:10.1080/02770903.2022.2097092 B. Scientific and Methodological Rigor • The research question is relevant, and the study design is broadly appropriate. However, the use of convenience sampling introduces bias and limits generalizability. Please discuss this limitation more explicitly in the Discussion. • While the cross-sectional design is acceptable, the causal language in parts of the discussion and conclusion is overstated. The findings show association—not causation—and should be interpreted accordingly. C. Statistical Analysis • The use of non-parametric tests (Mann-Whitney U and Kruskal-Wallis) is appropriate given the non-normal distribution. • However, a more detailed justification for the selection of these tests, including the rationale for rejecting normality (e.g., test statistics), would improve transparency. • In Table 3, clarify if multiple comparisons were adjusted for when reporting multiple p-values. • Provide effect sizes (e.g., median differences, rank biserial correlation) where possible to contextualize statistical significance. D. Data Availability • As per PLOS policy, data underlying all findings must be publicly available. Currently, your Data Availability Statement notes that data are available “upon reasonable request.” This does not meet PLOS standards. • Please provide de-identified raw data (including ASMQ and ACT item-level scores) as supplementary files or deposit them in an open-access repository (e.g., Dryad, Zenodo). E. Language and Clarity • The manuscript contains several grammatical errors, redundancies, and non-standard phrasing that affect readability. • Examples include: o “Convenient method of sampling” → should be “convenience sampling method.” o “At researchers’ appropriate time” → unclear; please rephrase or remove. o “Median ASMQ score for males (25) and females (25)” → should include IQRs for clarity. • A thorough language and grammar revision is strongly recommended before resubmission. F. Presentation of Results • Tables and figures are helpful, but some formatting is inconsistent. For example, Table 2 could be better structured for readability (group similar misconceptions together). • Figures (esp. Fig 2) should include legends and clearer labeling for interpretation. G. Discussion and Literature Contextualization • The discussion fairly addresses previous studies but could be improved by: o Emphasizing context-specific implications for LMICs like Nepal. o Clearly acknowledging the limitations of self-reported data and selection bias. o Integrating additional recent literature to enrich the interpretation of findings. Wish you all the best! Reviewer #2: The manuscript reads well and highlights an interesting correlation between poor knowledge and poor control. Comments on specific sections: P6 'Refusal to participate' should be removed from the Study Sample section P7 A little too much information in the Statistical Analysis section eg detail on checking whether the data were distributed normally. In the study instruments section, please provide some more detail about the questionnaires (eg higher ASMQ score implies more knowledge) and their administration. P13 Table 4: It is unclear as to which comparison the p of 0.011 refers to P14 The current content of the Discussion could be trimmed a little and it would be good to hear more about how one might go about improving knowledge and whether this might affect control. ********** -->6. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public. For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No Reviewer #2: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] -->Figure Resubmissions: -->-->While revising your submission, we strongly recommend that you use PLOS’s NAAS tool ( https://ngplosjournals.pagemajik.ai/artanalysis ) to test your figure files. NAAS can convert your figure files to the TIFF file type and meet basic requirements (such as print size, resolution), or provide you with a report on issues that do not meet our requirements and that NAAS cannot fix.-->--> After uploading your figures to PLOS’s NAAS tool - https://ngplosjournals.pagemajik.ai/artanalysis, NAAS will process the files provided and display the results in the "Uploaded Files" section of the page as the processing is complete. If the uploaded figures meet our requirements (or NAAS is able to fix the files to meet our requirements), the figure will be marked as "fixed" above. If NAAS is unable to fix the files, a red "failed" label will appear above. When NAAS has confirmed that the figure files meet our requirements, please download the file via the download option, and include these NAAS processed figure files when submitting your revised manuscript.--> PLOS Glob Public Health. 2026 May 29;6(5):e0006563. doi: 10.1371/journal.pgph.0006563.r003 Author response to Decision Letter 1 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 19 Jan 2026 Attachment Submitted filename: Response to Reviewers.docx pgph.0006563.s005.docx (17.2KB, docx) PLOS Glob Public Health. doi: 10.1371/journal.pgph.0006563.r004 Decision Letter 1 Alejandro Torrado Pacheco Author information Copyright and License information Roles Alejandro Torrado Pacheco : Staff Editor © 2026 Alejandro Torrado Pacheco This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 19 Mar 2026 PGPH-D-25-01721R1 Assessment of Knowledge on Self-Management and Level of Asthma Control among Patients Attending a Tertiary Care Center in Nepal: A Cross-Sectional Study PLOS Global Public Health Dear Dr. Shrestha, Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The manuscript has been assessed by a third reviewer, who requests further clarification. Their comments are available below, please address all of them carefully. Please submit your revised manuscript by May 03 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. We look forward to receiving your revised manuscript. Kind regards, Alejandro Torrado Pacheco, PhD Staff Editor PLOS Global Public Health Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments (if provided): [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions --> Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #3: All comments have been addressed ********** -->2. Does this manuscript meet PLOS Global Public Health’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.--> Reviewer #3: Yes ********** -->3. Has the statistical analysis been performed appropriately and rigorously?--> Reviewer #3: Yes ********** -->4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #3: Yes ********** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #3: Yes ********** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #3: Comments Section comment Methods Study Design “Assessing asthma self-management using standardized methods and connecting it to disease control makes sense in a Low-and-Middle-Income-Country (LMIC) like Nepal where the doctor-to-patient ratio is subpar and there is a significant intellectual divide between them.” Provide reference of this line Study Sample “A nonprobability convenient sampling method was used – where the convenience to the researchers was in the process of data collection, which was done at researchers’ appropriate time.” Make this sentence grammatically correct Study Instrument Author written both ACQ and ASMQ were translated but did not report about validity and reliability check of translated instrument. Results Some sociodemographic characteristics like “time spent with pets” and “damp and dusty room” does not make much sense for checking association with asthma self-management knowledge Score (ASMQ), but this could make more sense if author check these variable association with asthma control test score as pet and damp, dusty room can affect Asthma control status. (But since author did not check association between sociodemographic and asthma control score, this is just suggestion) Any particular reason for not checking association between age and ASMQ. Discussion In the discussion the 2nd and 3rd paragraph is simply the replication of results. Author did not related these findings with existing literature, so it is suggested for author to related it to existing literature. Author could also include asthma control status and compare it with existing literature i.e. how many are having partially controlled, uncontrolled asthma etc. Conclusion “We found that patients’ attitudes and practices were closely linked to their knowledge of asthma self-management”. The study measure Asthma control and self-management knowledge. So how author concluded regarding attitude? ********** -->7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public. For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #3: Yes: Rabia Hussain ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] -->Figure Resubmissions: -->-->While revising your submission, we strongly recommend that you use PLOS’s NAAS tool ( https://ngplosjournals.pagemajik.ai/artanalysis ) to test your figure files. NAAS can convert your figure files to the TIFF file type and meet basic requirements (such as print size, resolution), or provide you with a report on issues that do not meet our requirements and that NAAS cannot fix.-->--> After uploading your figures to PLOS’s NAAS tool - https://ngplosjournals.pagemajik.ai/artanalysis, NAAS will process the files provided and display the results in the "Uploaded Files" section of the page as the processing is complete. If the uploaded figures meet our requirements (or NAAS is able to fix the files to meet our requirements), the figure will be marked as "fixed" above. If NAAS is unable to fix the files, a red "failed" label will appear above. When NAAS has confirmed that the figure files meet our requirements, please download the file via the download option, and include these NAAS processed figure files when submitting your revised manuscript.--> Attachment Submitted filename: Comments for Manuscript.pdf pgph.0006563.s004.pdf (69.3KB, pdf) PLOS Glob Public Health. 2026 May 29;6(5):e0006563. doi: 10.1371/journal.pgph.0006563.r005 Author response to Decision Letter 2 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 23 Apr 2026 Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx pgph.0006563.s006.docx (1.6MB, docx) PLOS Glob Public Health. doi: 10.1371/journal.pgph.0006563.r006 Decision Letter 2 Julia Robinson Author information Copyright and License information Roles Julia Robinson : Staff Editor © 2026 Julia Robinson This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 12 May 2026 Assessment of Knowledge on Self-Management and Level of Asthma Control among Patients Attending a Tertiary Care Center in Nepal: A Cross-Sectional Study PGPH-D-25-01721R2 Dear Mr. Shrestha, We are pleased to inform you that your manuscript 'Assessment of Knowledge on Self-Management and Level of Asthma Control among Patients Attending a Tertiary Care Center in Nepal: A Cross-Sectional Study' has been provisionally accepted for publication in PLOS Global Public Health. Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests. Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated. IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact globalpubhealth@plos.org. Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health. Best regards, Julia Robinson Executive Editor PLOS Global Public Health *********************************************************** Reviewer Comments (if any, and for reference): Reviewer's Responses to Questions --> Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #3: All comments have been addressed ********** -->2. Does this manuscript meet PLOS Global Public Health’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.--> Reviewer #3: Yes ********** -->3. Has the statistical analysis been performed appropriately and rigorously?--> Reviewer #3: Yes ********** -->4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #3: Yes ********** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #3: Yes ********** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #3: (No Response) ********** -->7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public. For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #3: Yes: Rabia Hussain ********** Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials S1 File. Questionnaire. a. The first page consists of the informed consent form. b. Second page consists of the socio demographic characteristics. c. Third page consists of the 5 items of the Asthma Control Test. d. The remaining ones consists of the 16 items of Asthma Self-Management Questionnaire. (DOCX) pgph.0006563.s001.docx (16.9KB, docx) S1 Data. Supplementary SPSS data file. (XLSX) pgph.0006563.s002.xlsx (39.8KB, xlsx) Attachment Submitted filename: Response to Reviewers.docx pgph.0006563.s005.docx (17.2KB, docx) Attachment Submitted filename: Comments for Manuscript.pdf pgph.0006563.s004.pdf (69.3KB, pdf) Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx pgph.0006563.s006.docx (1.6MB, docx) Data Availability Statement All relevant data are within the paper and its Supporting information files. 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