Implementation Lessons from a Randomized Trial Integrating Community Asthma Education for Children

Abstract

This study characterized and compared the implementation of clinically-integrated community health workers (CHWs) to a certified asthma educator (AE-C) for low-income children with asthma. In the AE-C arm (N=115), 51.3% completed at least one in-clinic education session. In the CHW arm (N=108), 722 home visits were completed. The median number of visits was seven (range 0–17). Scheduled in-clinic asthma education may not be the optimal intervention for this patient population. CHW visit completion rates suggest the schedule, location, and content of CHW asthma services better met patients’ needs. Seven to ten visits seemed to be the preferred CHW dose.

INTRODUCTION

In the United States, asthma is one of the most prevalent chronic diseases in the pediatric population, as demonstrated by a current childhood asthma prevalence rate of 8.4% (Centers for Disease Control and Prevention, 2017). Asthma prevalence and morbidity remain high for urban minority children despite decades of intervention development (Weiss et al., 2009; Akinbami, 2012; Moorman et al., 2012). National and international guidelines for asthma management clearly describe stepwise how clinicians need to assess and treat asthma (National Asthma Education and Prevention Program, 2007; Global Initiative for Asthma, 2019). Despite these guidelines, asthma disparities persist and are evident in Chicago, where some of the nation’s highest pediatric asthma prevalence and morbidity have been documented (Gupta et al., 2008; Whitman et al., 2004; Shalowitz et al., 2007). The reasons for asthma disparities are complex (Canino et al., 2009; Esteban et al., 2009; Willis-Owen et al., 2018; Celedon et al., 2004; Brauer et al., 2007). Effective interventions to improve cornerstone asthma self-management behaviors, including medication adherence and trigger avoidance, are critical to improving pediatric asthma outcomes (National Asthma Education and Prevention Program, 2007).

Certified asthma educators (AE-Cs) have asthma knowledge and skills that adhere to the National Asthma Education and Prevention Program Expert Panel Report 3 (EPR3) Guidelines (National Asthma Education and Prevention Program, 2007; Cataletto et al., 2011). Although AE-Cs are considered best practice and their services are reimbursable (To et al., 2010), many clinical practices do not include AE-C staffing. Community health workers (CHWs) have been proposed as a lower-cost approach to provide asthma education and support, especially for populations experiencing health disparities. CHWs define themselves as frontline public health workers who serve as liaisons between health and social services and community residents to facilitate access to services and improve the quality and cultural competence of service delivery (American Public Health Association). CHWs typically provide health education, information, assistance with services, and build individual and community capacity for health (American Public Health Association). CHW home visits have been demonstrated to reduce home triggers, asthma symptoms and urgent care utilization in children (Campbell et al., 2015; Postma et al., 2009; Crocker et al., 2011). Many health systems are exploring ways to implement asthma CHW services but challenges remain regarding how to translate these research findings effectively into real world systems (Payne et al., 2017). Outstanding questions include CHW hiring and field supervisory needs, workloads, accountability, critical asthma topic areas, and the number of visits needed for families.

The Asthma Action at Erie Trial (NCT02481986) is a randomized comparative effectiveness trial that compares clinically-integrated asthma CHWs to an AE-C (Mosnaim et al, 2019). The purpose of this manuscript is to characterize and compare the implementation of the CHW and AE-C interventions in an urban clinic system serving low-income minority families.

METHODS

Study Design and Sample

The Asthma Action at Erie Trial involves a partnership between the University of Illinois at Chicago (UIC) and Erie Family Health Center (Erie), a federally qualified health center with six clinical sites serving mainly low-income minority families in the Chicago area. Participants were enrolled as parent/child dyads and randomized to one of two community interventions: CHW home visits, or education in the clinic delivered by an AE-C. The inclusion criteria for children were as follows: 1) patient at Erie, 2) age 5–16 years, and 3) uncontrolled asthma defined as a score of less than 20 on the Asthma Control Test/childhood Asthma Control test or a 1.25 or higher on the Asthma Control Questionnaire, or self-report of at least one oral corticosteroid burst for asthma in the past year (Cloutier et al, 2012; Juniper et al, 2010; Liu et al, 2007; Mosnaim et al, 2019; Nguyen et al, 2014; Schatz et al, 2006). These inclusion criteria were chosen to capture impairment and risk (National Asthma Education and Prevention Program, 2007) in this community sample of children. From March 2016 to August 2017, 223 families were enrolled and randomized to AE-C or CHW services (Mosnaim et al, 2019). Table 1 presents the baseline demographics and asthma characteristics of the 223 randomized patients. The sample is primarily Hispanic (85%) with a mean age of 9.4 years (SD 3.0). Caregivers had a mean age of 36 years (SD 7.1). Forty-nine percent of the encounters were conducted in English, 31% in Spanish, and 20% mixed English and Spanish. Fifty-six percent of children (N=123) had current uncontrolled asthma symptoms (implying impairment) by combined Asthma Control Test/Childhood ACT (ACT/cACT) at the time of enrollment. The average number of oral corticosteroid bursts for asthma (implying risk) in the past 12 months was 2.1 (SD 1.6).

Table 1:

Asthma Action at Erie Participant Demographics and Asthma Characteristics

	Total (N=223)	AE-C Arm N=115	CHW Arm N=108
Child age, mean (SD)	9.4 (3.0)	9.5 (3.2)	9.3 (2.9)
Child race (%)a  Black  White  Other	39 (17.6) 63 (28.4) 120 (54.1)	21 (18.4) 30 (26.3) 63 (55.3)	18 (16.7) 33 (30.6) 57 (52.8)
Child Hispanic (%)	190 (85.2)	98 (85.2)	92 (85.2)
Child Hispanic ethnicity (%)b  Mexican  Puerto Rican  Other Hispanic	159 (83.7) 20 (10.5) 11 (5.8)	83 (84.7) 10 (10.2) 5 (5.1)	76 (82.6) 10 (10.9) 6 (6.5)
Caregiver is mother/father (%)	216 (96.9)	110 (95.7)	106 (98.2)
Caregiver is female (%)	216 (96.9)	111 (96.5)	105 (97.2)
Caregiver age, mean (SD)	36.3 (7.1)	36.5 (7.6)	36.0 (6.6)
Caregiver highest degree earned (%)  Less than high school  High school/GED  Some college  College graduate or more	64 (28.7) 84 (37.7) 54 (24.2) 21 (9.4)	33 (28.7) 42 (36.5) 28 (24.4) 12 (10.4)	31 (28.7) 42 (38.9) 26 (24.1) 9 (8.3)
Language of interview (%)  English  Spanish  Mixed English and Spanish	109 (48.9) 70 (31.4) 44 (19.7)	52 (48.2) 34 (31.5) 22 (20.4)	30 (28.0) 69 (64.5) 8 (7.5)
Current uncontrolled asthma by combined ACT/cACT (%)c	123 (55.7)	59 (51.3)	64 (60.4)
Days of activity limitation in the past two weeks, mean (SD)	3.6 (3.9)	3.4 (4.0)	3.7 (3.9)
Emergency department visits for asthma in past 12 months, mean (SD)a	2.1 (1.5)	2.2 (1.5)	1.9 (1.4)
Hospitalized for asthma in past 12 months, mean (SD)a	1.5 (1.1)	1.2 (0.5)	2.1 (1.8)
Oral corticosteroid bursts for asthma in past 12 months, mean (SD) a	2.1 (1.6)	2.1 (1.4)	2.1 (1.8)

^a: N = 222

^b: N = 190

^c: N=221

Certified Asthma Educator (AE-C)

AE-Cs are certified by the National Asthma Educator Certification Board to ensure asthma knowledge and skills that adhere to the EPR3 Guidelines (National Asthma Education and Prevention Program, 2007). The AE-C at Erie was bilingual (English and Spanish), had a bachelor’s degree, had prior experience providing asthma education and tobacco cessation counseling at a local safety-net hospital, completed a two day comprehensive workshop from the Respiratory Health Association, and passed the AE-C certification exam. The AE-C received research protocol training from the investigators and was supervised weekly by the manager of community programs. She met with UIC management staff and investigators every 2–4 weeks to review study protocols, data entry, intervention delivery, and other study operations.

The AE-C received participant contact information from UIC and had access to their information in Erie’s electronic medical record (EMR). The AE-C called families to invite them to two in-clinic education sessions at months one and six. The AE-C had a 60-day window to complete each session. At the first session, the AE-C assessed and provided education on asthma symptoms, control, triggers, medication technique, adherence, written asthma action plans, and addressed caregiver/child concerns (National Asthma Education and Prevention Program, 2007; McDonald et al., 2006). The AE-C followed-up with the family by telephone two weeks later to review and answer any questions. The six-month session was similar, with more emphasis on review and included another follow-up telephone call. All sessions and their components were documented in the Erie EMR and the study’s database (REDCap). The AE-C rotated between the six clinical sites on a fixed schedule. When not supervising the CHWs or seeing her own study patients, the AE-C was available at the clinic for general asthma education and support services.

Asthma CHWs

CHW candidates were recruited through Erie, community list-serves, and word of mouth. Priority was given to potential candidates who had been patients at Erie, were bilingual in English and Spanish, and had personal or professional experience with asthma. The principal investigator developed a comprehensive asthma CHW training curriculum (Martin et al., 2011) which she conducted in three phases. Phase 1 provided 18 hours of training on asthma basics (general epidemiology, physiology, symptoms, medications, devices, triggers, allergies, healthcare system navigation, and school navigation) and self-management (social support, problem-solving, self-monitoring, and environmental rearrangement). This training was delivered to 17 potential candidates, from which two CHWs were chosen and hired by Erie. They continued with Phase 2 training that served to familiarize them with the study protocol, Erie policies, home visitation strategies, and documentation. Medications and trigger remediation were reinforced through role-play and practical exercises. CHWs attended a course on emergency mental health and received basic training in motivational interviewing. The CHWs shadowed other CHWs and Erie clinicians to gain additional asthma education skills. Phase 3 continuing education throughout the intervention period was delivered by the investigators and through local educational seminars.

Families were offered ten CHW home visits over 12 months. CHWs educated families on the core curriculum (Table 2) which consisted of standard topics for asthma educators intended to reduce impairment (prevent chronic symptoms, reduce the use of quick-relief medications, maintain healthy activity levels) and risk (prevent exacerbations and reduced lung growth, and minimize emergency care and adverse effects of therapy) (National Asthma Education and Prevention Program, 2007; McDonald et al., 2006). The CHWs began each visit with a social discussion to strengthen relationships. They reviewed behavior change plans from previous visits, which involved exercises in setting and achieving small goals. The goal for each visit was to cover at least one of the core curriculum topics. Whenever a barrier was noted, the CHW incorporated a pertinent self-management skill. After each visit, the CHWs completed a report of the topics covered, the behavior change plan, and relevant issues in REDCap. CHWs were allowed to exceed ten visits if needed, or they could reduce the number of visits if families and the CHW felt they had accomplished all of their asthma goals.

Table 2:

Asthma Home Visit Topics

Asthma Core Curriculum*  1. General asthma facts  2. Asthma physiology  3. Controller medications  4. Inhalers and spacers  5. Symptom recognition  6. Triggers  7. Smoking  8. Allergies  9. Co-morbidities (obesity, ADHD)  10. Communicating with the doctor Self-Management Skills  1. Problem solving  2. Self-monitoring  3. Environmental rearrangement  4. Social support

^*Participants could receive extra visits for review if needed

CHWs were directly supervised by and attended weekly meetings with the AE-C. They also met with UIC data management staff and investigators every 2–4 weeks to review study protocols, data entry, intervention delivery, behavioral health issues, and other study operations. Although CHWs met with most of their study participants outside of Erie, they documented their encounters in the Erie EMR. They received referrals and communications from providers and also sent providers messages regarding their patients. The CHWs facilitated “warm handoffs” to the Erie behavioral health team and other support staff when indicated. The CHWs maintained an office space at one of the Erie sites and provided asthma education and support services for Erie patients when not working on study duties.

Analysis

Data were abstracted from the Erie EMR, AE-C and CHW notes and calendars, and REDCap. Free text fields were coded into categorical values. Descriptive statistics were performed to summarize the data. Visit amounts were compared within intervention arms using nonparametric independent two-sample t-tests for continuous variables and chi-squared tests for categorical variables. All analyses were performed on SAS 9.4.

Human Subjects

The University of Illinois at Chicago, Rush University Medical Center, and NorthShore University HealthSystem Institutional Review Boards and the Erie Research Committee approved the study protocol. Children ages seven and above, and caregivers provided signed assent/consent.

RESULTS

AE-C Intervention

The AE-C intervention (N=115) was delivered between 5/10/2016 and 12/11/2017. A total of 84 sessions and 38 follow-up calls were completed (Table 3). Forty-five percent of participants completed the initial education session, 20% the first follow-up call, 28% the six-month education session, and 13% the final follow-up call. Seven participants received the six-month education session but not the initial session. Six sessions were completed via phone (7%), and the remainder in person (93%). Visit completion rates were highest at the larger sites where the AE-C spent the majority of her time. Per the AE-C, the major barrier to session completion was participant availability. Another challenge affecting session completion was AE-C adherence to the study protocol. Despite close supervision, no contact attempts were documented for nine participants for the initial session and 64 participants for the six-month session.

Table 3:

Intervention Delivered over 12 Months

	AE-C Sessions Completed			CHW Visits Completed
		Initial Session (%)	6-month Session (%)		Median Number of Visits (IQR)	Range
Total (all sites)	N=115	52 (45.2)	32 (27.8)	N=108	7.0 (4.0)	0–17
Site 1	N=63	29 (46)	16 (25.4)	N=59	8.0 (5.0)	0–10
Site 2	N=19	10 (52.6)	10 (52.6)	N=22	7.0 (2.0)	0–17
Site 3	N=20	9 (45)	5 (25)	N=17	7.0 (3.0)	0–9
Site 4	N=4	1 (25)	1 (25)	N=5	10.0 (4.0)	7–11
Site 5	N=6	2 (33.3)	0	N=3	5.0 (6.0)	0–6
Site 6	N=3	1 (33.3)	0	N=2	4.0 (6.0)	1–7

The average duration for in-person sessions and follow up phone calls was 61.0 (SD 12.2) minutes and 2.9 (SD 1.6) minutes, respectively. The median number of attempts to schedule for those that completed sessions was 2.0 (inter-quartile range [IQR] 2.0). Children were present for 94% (N=79) of the sessions and were coded as actively participating in the majority of sessions (78.5%, N=62). The topics covered at more than 95% of the sessions were asthma pathophysiology, triggers, exacerbation warning signs, quick-relief medications, controller medications, inhaler/spacer technique, action plan use, tobacco, access to care, and communication with doctors and schools (Table 4).

Table 4.

Topics covered by AE-C during visits

Topics	Total number of times covered at any visit
	N= 84	%
Asthma pathophysiology	84	100.0
Quick relief medications	84	100.0
Controller medications	84	100.0
Inhaler/spacer technique	84	100.0
Triggers	84	100.0
Exacerbation warning signs	83	98.8
Access to care	82	97.6
Communicating with Doctors and Schools	82	97.6
Tobacco	81	96.4
Action plan use	80	95.2
Peak flow use	0	0.0

Participants that completed any or both AE-C sessions compared to none were not statistically different in terms of child age, race, ethnicity, asthma control, ED visits, or prednisone use. Caregiver education, depression, PTSD, and household chaos also did not differ.

CHW Intervention

The CHWs intervention (N=108) was delivered between 5/9/2016 and 8/8/2018. A total of 722 visits were completed, with a median of seven (IQR 4, full range 0–17) visits per participant (Table 3). Six families (5.6%) refused all CHW visits, 9% received 1–3 visits, 21% received 4–6 visits, 55% received 7–9 visits, and 9% received ten or more visits. Visit distribution was not equal by site. For 56.5% of families, the CHWs and families felt they had achieved all their predetermined asthma goals. This influenced the number of visits some families received since visits were stopped when all goals were met (Figure).

Figure 1:

Number of CHW Visits by Participants

The mean CHW visit duration was 65.1 (SD 16.3) minutes. Almost all visits (95.2%) occurred in the homes, but other locations included the clinics, schools, and homes of friends/family. The median number of contact attempts made to the participants that did not complete any visit was 21.0 (IQR 6.0), compared to 2.0 (IQR 2.0) for participants who completed one or more visits. Mothers were engaged in visits far more than fathers (91.6% vs 6.6%, respectively). Out of the 722 visits delivered, children participated in 87.1% and were coded as actively participating in the majority of visits (71.7%). The level of engagement by children varied according to age. Children 5–7 years old actively participated in 55.4% of their visits, compared to 85.8%, 76.5%, and 89.7% for children ages 8–10, 11–13, and 14–16 years old respectively.

A wide range of asthma topics were covered by the CHWs (Table 5). The topics covered at least once in more than 90% of visits included symptoms, medicines, general asthma facts, reducing home triggers, schools, inhaler/spacer technique, and allergies. Some topics were repeated many times. For example, symptoms were addressed in 73.8% of all 722 visits. The topic of schools included discussions of having asthma medicines available at schools (31.4%), having a documented asthma plan at school (28.1%), ensuring full participation in physical activity at school (27.0%), and having a 504 medical accommodation plan (25.2%). Parent and child well-being was covered in 74.5% of the families at least once and included behavioral health discussions and referrals. Within this category, discussions included caregiver stress (15.7%), child stress (11.2%), child anxiety and depression (9.7%), and caregiver anxiety and depression (5.4%). CHWs gave referrals to community resources for behavioral health to 20.6% of families and referred 33.3% of families to Erie behavioral health services. Other topics frequently covered included the roles of obesity in asthma (21.6% of families) and ADHD (12.7% of families).

Table 5.

Topics covered by CHW during visits

Topics	Covered at least once, N=102 (%)	Total times used, N = 722 (%)
Symptoms	101 (99)	533 (73.8)
Medicines	101 (99)	523 (72.4)
General asthma facts	101 (99)	349 (48.3)
Reducing home triggers	97 (95.1)	326 (45.2)
Schools	99 (97.1)	314 (43.5)
Inhaler/spacer technique	94 (92.2)	294 (40.7)
Allergies	93 (91.2)	269 (37.3)
Parents and child well-being	76 (74.5)	176 (24.4)
Health care providers and access	75 (73.5)	166 (23.0)
Tobacco exposure	64 (62.7)	112 (15.5)
Other health problems	44 (43.1)	65 (9.0)

CHWs helped families make specific behavior change plans in 600 of the 722 visits. Out of those, 61.5% of families achieved their plans and 26.2% partially achieved their plans. CHWs used a range of self-management skills to help families learn and achieve their goals. The most frequently used skill was self-monitoring which was employed in 98.8% (713) of the visits. Problem-solving was used in 94.7%, social support in 85.7%, and environmental rearrangement in 81.6% of visits.

Six participants refused all CHW intervention. The mean age of these participants was 9.4 (SD 3.2) years old, four reported Hispanic ethnicity, two claimed Black race and two claimed White race. Four were uncontrolled by ACT/cACT, the mean days of activity limitation was 4.7 (SD 2.7), and three had visited the emergency room in the last 12 month. Participants that completed (N=61) and did not complete the intervention (47) were not different by race, ethnicity, caregiver education, ACT score, prednisone use, or child or caregiver depression. Children that did not complete the intervention had more days of activity limitation (p=0.02) at baseline.

DISCUSSION

Asthma self-management education and support is an essential component of the asthma guidelines for clinical asthma management (National Asthma Education and Prevention Program, 2007). The goal of this study was to assess the implementation of two promising interventions for delivery of asthma self-management services: AE-C services in a clinical setting and clinically-integrated CHW services provided in homes. Although these two interventions are supported by a growing body of evidence and best practice recommendations, rigorously conducted research testing their effectiveness in real-world settings is limited. In our study, CHWs were much more effective at engaging participants and delivering intervention than the AE-C. CHWs had more flexibility in their scheduling and protocols, and they addressed family challenges that went beyond asthma.

Clinic-based AE-C services represent current best practice in asthma (Cataletto et al., 2011; To et al., 2010). Our AE-C session completion rates were low. The first reason is that families struggled to find time to meet with the AE-C. Families repeatedly told the AE-C that they were too busy, despite her efforts to be flexible. The other reason is related to the design of the AE-C position. Our AE-C was only responsible for asthma education and support; she had no clinical duties. However, she rotated between six clinical sites because of the study design and clinic needs. Her time at sites was predictable but limited. She spent more time at larger sites and session completion rates were higher at those sites. The AE-C was provided with multiple tools to help organize her time and participants. However, the frequent site movement, CHW supervision responsibilities, and pressures to provide asthma services in real-time to patients in the clinics limited her documentation and adherence to the study protocol. These issues are similar to those typically faced by health care providers. The majority of health systems serving low-income populations do not have adequate systems for prompting and tracking follow-up and routine preventive services (Cabana et al., 2001; Bailey et al., 2016).

Evidence to date on pediatric CHW asthma interventions is strong, with a clinical return on investment in one study of 1.9 (Campbell et al., 2015). Healthcare systems are continually trying to translate this evidence into clinical operations (Payne et al., 2017). Our CHWs were hired by Erie, not by the researchers. They identified mainly with the clinical system, communicating regularly with their supervisor (the AE-C) and with providers, the behavioral health team, and other support staff. CHWs took full responsibility for their participants. Their primary responsibility was the delivery of the intervention to participants and, unlike the AE-C, their time windows were extremely flexible. For example, a CHW might spend four months trying to find a participant by calling, stopping by their home, and checking the clinic schedule. Once the CHW found the participant, she could then accelerate the visit schedule to get the participant on track, whereas the AE-C could only call via phone or check the clinic schedule, and sessions out of window could not be made up. Going to homes helped ensure that visits occurred. Families appreciated not having to travel or arrange for childcare. Sometimes families were hesitant to participate in the visit but found it hard to refuse someone at their door. This flexibility contributed to the high completion rates for our CHW visits.

Studies to date have reported that a range of 4–10 asthma CHW visits are needed for asthma management among poorly controlled, inner-city children (Campbell et al., 2015; Krieger et al., 2005; Morgan et al., 2004; Parker et al., 2008; Martin et al., 2016). In our study, CHW visit completion rates varied greatly depending on participant need and availability. Most participants felt they had reached their asthma goals between 7–10 visits. Once the intervention impact on asthma outcomes is fully analyzed, we will have a better understanding of the optimal number of visits for achieving asthma control; however, the experiences of our CHWs to date suggest that this number should not be fixed. We could not identify specific predictors of who got more intervention, underscoring the need for a flexible and personalized approach. Patients have different challenges and resources. Some can achieve asthma goals with less CHW support than others. Healthcare providers titrate the dose of a medication to the needs of the patient; behavioral interventions such as CHWs should be approached similarly.

Topics covered during CHW visits included all those expected such as medications and triggers, but also some that have not been emphasized previously. For example, CHWs spent a lot of time discussing asthma management at schools. This is very important as children spend a tremendous amount of time in these settings. Nevertheless, asthma management plans at schools can be fragmented due to the general lack of communication between schools, families, and clinicians (Martin et al., 2018; Lemanske et al., 2016). Our CHWs also covered behavioral health issues in almost a quarter of their visits, which we have shown to be a key risk factor for asthma control [35]. In particular, our findings highlight the importance of family organization and routines for asthma control in this population – an area that CHWs are primed to address and improve through their work (Weinstein et al., 2019). Our CHWs were not specially trained in mental health but they were able to screen and refer patients to behavioral health services. Future analyses will determine if mental health issues changed with receipt of the CHW services and if they had any influence on asthma control.

LIMITATIONS

The greatest limitation of this preliminary report is that we do not yet know if the interventions are associated with any changes in asthma management behaviors, impairment, or risk. Those analyses will be conducted once a 12-month post-intervention observation period concludes. Our sample was mainly low-income, urban, and Hispanic, which limits generalizability. Because we had only one AE-C, we cannot know if the results of that group are due to her personal attributes or the intervention itself. Data collection in busy clinical settings is challenging. The AE-C and CHWs had to document both in the EMR (for clinical care purposes) and REDCap (for study management). We suspect some encounter documentation was missed during this process of double documentation.

CONCLUSIONS

In conclusion, these results fill a gap in our understanding of how to implement clinic asthma interventions that reach into community settings. Both the AE-C and CHWs integrated well into the clinical system. The AE-C was kept fully occupied delivering asthma education in the clinics, while the CHWs were able to be based in clinics successfully but spend the majority of their time in participant homes. Our AE-C visit completion rates were low, suggesting that scheduled in-clinic asthma education may not be the optimal route for delivery of asthma education and support services for this patient population. Our CHW visit completion rates were much higher and greatly varied depending on participant need and availability. For many, 7–10 visits seemed to be the optimal “dose” of the intervention. Our experiences highlight opportunities for health systems. Although certified asthma educators in the clinic setting are considered best practice for asthma management support, CHWs can provide education and support in a variety of settings at a lower cost. This may be of greater importance in low-income urban settings. Future trial results will determine if either intervention is associated with improvements in asthma control and self-management behaviors.