For children growing up in Philadelphia and similar urban areas across the U.S., asthma is more than a common chronic illness—it is a life-threatening challenge. Decades of research have established stark racial disparities in chronic asthma, with Black children experiencing hospitalization rates three times higher and death rates seven times higher than their white counterparts. These disparities are worsened by poor air quality, aging buildings, and limited access to coordinated asthma care, particularly in under-resourced communities.

Recognizing these urgent challenges, Senior Fellows Tyra Bryant-Stephens, Chén Kenyon, and colleagues led a first-of-its-kind randomized clinical trial to test a community-wide intervention to improve asthma control for low-income school-aged children. Their study, conducted over four years across 36 public and charter schools in West Philadelphia, examined whether community health workers (CHWs) could help bridge the gap between doctors’ offices, homes, and schools—three critical settings where asthma management often remains disconnected.

About 630 children were enrolled in the study, nearly all of whom identified as Black and non-Hispanic. The trial used a 2×2 factorial design that randomized participants into one of six intervention groups involving a school-only intervention, a primary care-only intervention, and a combination intervention (school + primary care). Schools were also cluster-randomized to either receive the school-based intervention or not. CHWs were embedded in each setting—home, school, and clinic—working with families, educators, and providers to improve asthma management through education, home trigger reduction, and better care coordination.

After 12 months, all intervention groups showed significant improvements in asthma control. However, the primary analysis found no major differences between groups, meaning no single intervention stood out as significantly more effective. However, children who received the intervention before the COVID-19 pandemic and participated in both school and clinical interventions experienced the greatest improvement in asthma control. These findings demonstrate that integrating asthma care across home, school, and clinical settings is feasible and promising.

Read our Q&A with lead author Dr. Tyra Bryant-Stephens below to learn more.

What inspired your work to improve child asthma care through CHWs and home visits?

Bryant-Stephens: For more than 20 years as a pediatrician leading asthma care in our network, my team and I focused on how we could improve clinical care, and we found that connecting asthma CHWs to care in the clinic improved self-efficacy and outcomes and reduced asthma-related emergency room visits and hospitalizations. Similarly, we found that home visits alone improved health outcomes. However, we know that children with asthma live, play, and sleep in multiple environments, and we wanted to understand the best way to tackle improving asthma care in all settings. During the year of planning, we conducted focus groups with parents, children, primary care providers, school professionals, and payors to hear about the barriers and potential solutions. The results of these focus groups led to mapping those results to evidence-based interventions by connecting CHWs to each care setting.

CHWs are community residents with lived experience and, therefore, expertise in navigating barriers and stressors in their community. We know that peer-to-peer education is more likely to result in a change in self-management behaviors.

How did you design your asthma study to assess the impact of CHWs across homes, schools, and clinics?

Bryant-Stephens: We surveyed parents, teens, primary care providers and nurses, school nurses, and other professionals, as well as community members. We found that although children live, learn, and play in multiple environments, asthma care was not coordinated. We heard from parents that they often felt they were in the middle of school and provider communications, and no one was listening to them about the barriers to ensuring that their child’s asthma had appropriate care in all environments. We decided to implement evidence-based programs in all settings and put CHWs in the home, school, and clinical settings as connectors between the environments. We used a factorial design to understand the most effective combination of care in improving asthma control. We had a usual care group, a group where only school interventions were conducted, a group that only received primary care (clinical/home) interventions, and a group that received both school and clinical/home interventions.

What were the key findings, especially given the impact of the COVID-19 pandemic?

Bryant-Stephens: School closures during the pandemic significantly impacted our study. Even after the schools began hybrid operations, it was too burdensome to implement the school interventions as initially designed. However, about one-fifth of the 626 children received the interventions as designed. In a secondary analysis of that cohort, we found that those children who received home/clinical/school interventions had greater asthma control than those who received usual care.

What policy recommendations do you propose to overcome practical challenges in implementing CHW-led asthma interventions across various settings?

Bryant-Stephens: 

• CHWs should be used as connectors for all settings children with asthma occupy to improve care coordination.
• CHWs should be employed by school systems to deliver this care for asthma and other chronic diseases.
• Delivering asthma controller medications at schools improves adherence for children with asthma.
• There has been a lot of activity in having a Pennsylvania Medicaid state plan amendment that allows CHWs to bill for their services. This will be essential to scale the use of CHWs across all settings.

What are your future research plans on child asthma and CHW-led programs?

Bryant-Stephens: We are now focusing on the school’s sustainability and connection with primary care services. We have successfully sustained CHWs in the clinical setting. We are working closely with the Philadelphia School District and the City of Philadelphia and plan to train CHWs for deployment in additional schools in 2025.

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The study, “Community Health Workers Linking Clinics and Schools and Asthma Control: A Randomized Clinical Trial,” was published on October 21, 2024, in JAMA Pediatrics. Authors include Tyra Bryant-Stephens, Chen C. Kenyon, Colleen Tingey, Andrea Apter, Julie Pappas, Natalie Minto, Yvonne S. Stewart, and Justine Shults.

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