Addressing Pediatric Asthma Disparities through RI-AIR's Community Approach: A Randomized Trial

Rationale: Clustering of social and environmental risks in low-income neighborhoods is a key factor in racial and ethnic asthma disparities. Integrating school and in-home programs, with treatment tailored to disease risk, is a promising approach for children with high disease burden. Objectives: We evaluated the Rhode Island Asthma Integrated Response (RI-AIR) program in improving asthma outcomes at the individual and community levels. RI-AIR leverages existing community collaborations and technological advances to identify children with asthma at the highest risk for poor outcomes through a system of identification, screening, and intervention. Methods: We conducted a stepped wedge cluster randomized hybrid type II effectiveness-implementation study. School-based catchment areas (N = 32) of high asthma burden were identified using geospatial mapping of asthma-related urgent healthcare use from 2010 through 2018. Families received only school-based interventions if the child's asthma was categorized as "not well controlled" or school- and home-based interventions if the child's asthma was deemed "poorly controlled." Community health workers facilitated communication between families, schools, and healthcare providers. Follow up visits occurred every 3 months to 1 year after the intervention. Results: Individual level: At 3 months, asthma control (primary outcome) improved (d = 0.47; 95% confidence interval, 0.33-0.61) and symptom-free days increased (d = 0.37; 0.24-0.51); both improvements were sustained at 12 months. Community level: healthcare use remained the same or increased (rate ratio, 1.16; 1.00-1.36); however, sensitivity analyses indicated that healthcare use was slightly lower in areas with greater family participation (i.e., penetration; active intervention, 0.93 [0.87-0.99]; postintervention, 0.91 [0.86-0.97]). Conclusions: Intensive, multicomponent interventions and community engagement are needed to improve asthma outcomes in areas of high burden. Clinical trial registered with www.clinicaltrials.gov (NCT03583814).