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


This was a pretest–posttest quasi-experimental trial. The Institutional Review Board of the Georgia Department of Public Health reviewed the study and approved it as exempt. Data were collected during 2014 through 2016 in Augusta, Georgia.

Population and Recruitment Measures

Eligible children had English-speaking parents or guardians, were aged from 0 to 17 years, and resided in a high-burden health district in the state of Georgia. The district was selected on the basis of historical data regarding pediatric asthma mortality, pediatric asthma hospitalizations, and use of emergency departments for pediatric asthma. The district also had infrastructure available for implementation of the intervention. For inclusion in the study, children had to be dually enrolled in Children's Medical Services (CMS), a case management program for children with special medical needs operated by the Georgia Department of Public Health for Medicaid, and Fee-for-Service Medicaid, and had to have diagnosed asthma that was either not well controlled or very poorly controlled. Not well controlled or poorly controlled was defined for the purposes of this project as having a hospitalization or multiple emergency department visits in the last 6 months, confirmed via an asthma control questionnaire that assessed symptoms more than 2 days a week; night time awakenings (one or more per month or week depending on age); interference with normal activity (some limitation); and an Asthma Control Test score of 19 or less.[13] CMS was selected as the vehicle for enrollment because the program provides funding for certain durable medical supplies and other remediation materials, such as mattress and pillow covers, that might be needed to fully implement the intervention.

Children were identified by using existing lists of CMS enrollees who had their CMS Asthma Questionnaires on file, and their asthma status was ascertained by a public health nurse based on the existing CMS Asthma Questionnaires completed before the intervention. No children were excluded. The nurse then contacted the child's parent or guardian to inform them of the opportunity to participate and to receive consent from interested families. On consenting to enroll in the program, the nurse then scheduled 4 education sessions on asthma self-management and 2 asthma healthy home assessments by environmental health specialists.

Intervention and Data Collection

The MCMT intervention was 4 education sessions, using the Wee Breathers asthma curriculum,[14] and 2 healthy home assessments (initial assessment and follow-up assessment). Education sessions were delivered in a group format from May through August 2016. At the first group session, parents and guardians signed the consent form and were given the Asthma Experience Questionnaire.[15] The survey included questions about the child's asthma (control, symptoms, quality of life for parents and guardians and children, number of emergency department visits, school and workdays missed because of asthma, asthma medications, school environment, and household information). They were then provided Lesson 1: Asthma Basics and Lesson 5: Asthma Action Plan from the Wee Breathers curriculum. Delivering Lesson 5 earlier is to make sure participants can set up their asthma action plans with their health care providers as soon as possible. The second session covered Lesson 2: Asthma Triggers and Lesson 3: Controlling Asthma Triggers from the Wee Breathers curriculum. The third session covered Lesson 4: Asthma Medicines and Lesson 6: Communication with the Asthma Team. In the last session (session 4), they were provided Lesson 7: Asthma Management Goals and a thorough review of the entire curriculum, and given the Asthma Experience Questionnaire and CMS asthma questionnaire again.

At each self-management education session, participants were assessed on proper use of medication devices and given pretests and posttests to assess knowledge they gained in each session. The pretests and posttests for the asthma self-management education sessions consisted of questions about the basics of asthma, triggers that make asthma worse, the importance of an asthma action plan, how to talk to the child's health care team about asthma, and asthma medicines and devices. Children who assented participated in the education session along with their parents. After finishing the program, participants completed follow-up surveys at 1 to 3 months, 6 months, and 12 months by telephone or in person at the health department. Participants received a $25 gift card for completing the enrollment interview and a $50 gift card for completing the exit interview.

As part of the intervention, the Asthma Healthy Home Assessments were conducted to reduce asthma triggers at home. The assessments consisted of an initial assessment and a follow-up assessment conducted by environmental health specialists employed by the local health department in Augusta and trained by the Georgia Department of Public Health. In the initial assessment, the asthma triggers at home were documented by using a Healthy Homes assessment tool,[16] and an In-Home Action Plan to improve the home environment was established with the parents or guardians. During the follow-up assessment, an environmental health specialist walked through the home to follow up on areas of concern identified during the first visit to determine if the recommendations were implemented and noted barriers to implementation.

On enrolling in the program, parents or guardians had the option of consenting to continued case management by the CMS nurse. If they agreed, the CMS nurse sent a letter to the child's regular health care provider updating them on the child's asthma and provided the child's asthma action plan to the child's school nurse. The nurse also helped to establish bidirectional communication with the child's provider, reinforced self-management education lessons, and assessed guidelines-based care.


Numerous variables had a large amount of missing data; therefore, our analysis was limited to variables where most respondents provided data. Categorical data were dichotomized based on a review of the distribution of each variable, to increase statistical power given the small number of observations. The McNemar χ 2 test for paired observations was used to test significance. Continuous data were analyzed by using the Student t test (one sided) for paired data, based on the hypothesis that there would be improvement in outcomes at follow-up. A P value of less than .05 was considered significant, and Stata version 14.0 (StataCorp LLC) was used for all analyses.