A Multicomponent, Multi-Trigger Intervention to Enhance Asthma Control in High-Risk African American Children

Mark H. Ebell, MD, MS; Stephanie Patrice Hall, PhD, MPH; R. Chris Rustin, DrPH; Kia Powell-Threets, MS; Luis Munoz; Kia Toodle; (Mary) Lu Meng, PhD; Jean O'Connor, JD, MPH, DrPH


Prev Chronic Dis. 2019;16(5):e69 

In This Article

Abstract and Introduction


Introduction: We evaluated the effectiveness and feasibility of implementation of a multicomponent, multi-trigger (MCMT) intervention through a public health department in a high risk population of African American children.

Methods: This was a pragmatic quasi-experimental pretest–posttest study. The population consisted of African American children enrolled in Medicaid and Children's Medical Services who had poorly controlled asthma. The MCMT intervention included 4 educational sessions and home asthma trigger reduction. Parents reported outcomes at baseline and at 1 to 3 months, 6 months, and 12 months after the MCMT intervention. Analysis used the McNemar χ 2 test and Student t test for paired observations. Data were collected during 2014 through 2016 in Augusta, Georgia.

Results: The number of children with asthma that was assessed as well controlled increased from 4 to 17 out of 20 (P < .001). Compared with baseline, at 12 months parents reported fewer days of school missed (6.4 vs 4.2, P = .01), fewer emergency department visits (1.7 vs 0.6, P = .02) and fewer hospitalizations (0.59 vs 0.18, P = .05). The most common environmental interventions were dust mitigation, getting a mattress or pillow protector, and cockroach mitigation.

Conclusion: An MCMT intervention in high risk African American children with poorly controlled asthma administered through the health department was associated with significant improvements in asthma control, days of school missed, and emergency department visits. Broader implementation of these strategies is warranted.


Asthma is a common chronic condition characterized by bronchospasm and inflammation, typically accompanied by intermittent exacerbations. Asthma may impair quality of life and function, may result in hospitalization, and rarely can cause death. African American children have a 60% greater prevalence of asthma than non-Hispanic white children. They also have a 4.5-fold greater likelihood of hospital admission and a 7.1-fold greater likelihood of death attributable to asthma, with 9.2 deaths per million African American children per year. When limiting the population to children aged 14 years or younger, mortality was 10 times higher for African American children.[1]

A group at especially high risk is children who live in poverty, who may have greater exposure to dust and other allergens in the home, and who may be less likely to have an asthma action plan, less likely to have a regular source of primary care, and less likely to have ready access to inhalers. Social determinants such as poverty and living situation adversely affect asthma-related outcomes.[2–7]

Approximately 1 in 10 children in Georgia have asthma. In 2016, approximately half of these Georgia children with asthma were African American, and over 60% lived in households with an annual income less than $50,000. Also in 2016, nearly 18% lived in a household where at least 1 parent smoked. In 2015, the State of Georgia identified pediatric asthma as a public health priority, with focus on elimination of pediatric asthma mortality and reduction of repeat hospitalization and emergency department visit rates among its Medicaid population.[8]

The Georgia Department of Public Health's Chronic Disease Prevention Section sought a means to address the pediatric asthma priority and to improve asthma outcomes for high-risk children with poorly controlled asthma in an area known for very high risk of uncontrolled asthma and higher than expected pediatric asthma mortality, especially among African American children. The department undertook a pilot project to test the delivery of a multicomponent, multi-trigger (MCMT) intervention in an area of the state with a high burden of pediatric asthma. A systematic review concluded that MCMT interventions were effective in improving overall quality of life and productivity in children with asthma[9] and were cost-effective.[10] These interventions were also recommended in 2008 by the Community Guide for Preventive Services for implementation.[11]

However, before this pilot project, MCMT interventions had not been implemented in the Medicaid population or by the public health system in Georgia. The purpose of this project was to assess the feasibility and outcomes that could be achieved through implementation of an MCMT intervention in a high-need, hard-to-reach population. MCMT interventions are directed at reaching, engaging, and educating children with poorly controlled asthma and their families, with the aim of reducing asthma-related emergency department visits and hospitalizations. This approach entails 1) identifying children with poorly controlled asthma, 2) linking them to health care providers who follow National Asthma Education and Prevention Program Expert Panel Report 3 guidelines–based care,[12] 3) educating them on asthma self-management, 4) providing a supportive school environment, and 5) referring to or providing home trigger assessments and reduction services by environmental health specialists. We report the results of this pilot project.