Outcomes associated with the BReATHE (Beating Regional Asthma Through Health Education) intervention among asthmatic children: A hospital-based quasi-experimental evaluation in Kenya

Outcomes associated with the BReATHE (Beating Regional Asthma Through Health Education) intervention among asthmatic children: A hospital-based quasi-experimental evaluation in Kenya | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outcomes associated with the BReATHE (Beating Regional Asthma Through Health Education) intervention among asthmatic children: A hospital-based quasi-experimental evaluation in Kenya Robai Linet Ayiela, Joseph Mukala, Bernard N Kanoi, Peter Mwaura, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9192384/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Asthma remains one of the most common chronic diseases in childhood worldwide and specifically in Kenya, where it contributes substantially to morbidity, impaired quality of life, and school absenteeism Methods A quasi-experimental evaluation involving 108 asthmatic children and their caregivers was conducted between January and June 2025. Participants were non-randomly assigned into intervention and control groups. Baseline, midline, and end line assessments evaluated asthma control and caregiver knowledge using structured questionnaires. The BReATHE intervention entailed monthly education sessions on triggers, medication use, and inhaler technique. Data were analyzed using paired and independent t -tests, Chi-square tests, logistic regression, and Difference-in-Differences (DiD) modeling. Results At baseline, both groups had similar asthma control, with comparable rates of exacerbations, hospital visits, and school absenteeism. Over the six-month follow-up, the intervention group demonstrated improved asthma control, evidenced by a reduction in the frequency of asthma exacerbations, fewer hospital visits, and decreased school absenteeism compared to the control group (p < 0.001) and fewer asthma episodes (mean 2.0 vs. 4.3, DiD = − 2.2, p < 0.001). These findings highlight the effectiveness of targeted interventions in improving clinical and functional outcomes for children with asthma. Severe asthma episodes (≥ 3) declined to 22.2% in the intervention group versus 70.4% in controls ( p < 0.001). Conclusion The BReATHE intervention significantly reduced asthma exacerbations. Integrating structured asthma education into routine pediatric care can enhance asthma control and overall outcomes in low-resource settings. Allergy & Immune Disorders Asthma BReATHE children caregiver education Thika Level 5 Hospital Kenya Background Asthma is one of the most common chronic childhood diseases worldwide and a major cause of disability-adjusted life years (DALYs) among school-aged children. Globally, approximately 262 million people are affected, leading to nearly half a million deaths annually [ 1 ]. In sub-Saharan Africa, asthma prevalence is increasing due to rapid urbanization, pollution, and limited access to inhaled corticosteroids [ 2 ]. In Kenya, asthma contributes to frequent hospital visits, school absenteeism, and impaired quality of life [ 3 ]. Despite the availability of effective treatments, asthma control remains poor in many settings due to low medication adherence, limited caregiver education, and mismanagement of triggers [ 4 , 5 ]. Educational interventions have been shown to improve symptom control, reduce exacerbations, and enhance quality of life [ 6 ]. While asthma education is a pillar of GINA guidelines, locally adapted curricula that account for African cultural contexts and health literacy levels are scarce. The BReATHE (Beating Regional Asthma Through Health Education) intervention was designed to address these gaps by enhancing caregiver knowledge, promoting correct inhaler use, and supporting adherence to evidence-based management practices. This study assessed the outcome of the BReATHE intervention on asthma control among children attending Thika Level 5 Hospital in Kiambu County, Kenya. Methods The results present baseline asthma morbidity among participating children and compare pre- and post-intervention asthma control outcomes between the intervention and control groups. Study design and setting This study employed a hospital-based quasi-experimental non-equivalent group design with intervention and control groups, using non-random assignment. A total of 108 known asthmatic children aged 3–17 years and their caregiver–child dyads (each consisting of an asthmatic child and the primary caregiver responsible for daily asthma management) were recruited. The design was chosen because it allowed for evaluation of the effectiveness of the BReATHE intervention in improving caregiver knowledge and reducing asthma exacerbations among children while working within the practical and ethical limitations of the hospital setting. The study was conducted at Thika Level 5 Hospital, a major referral facility in Kiambu County, between January and June 2025. Thika Level 5 Hospital is a county referral facility located in Thika Town, Kiambu County, approximately 40 km northeast of Nairobi along the Nairobi–Garissa highway. It is administered by the Kiambu County Government and is one of three Level 5 hospitals in the county. The hospital serves a large catchment population of about 1.5 million people from Thika Sub-County and neighboring regions, including Murang’a, Machakos, Garissa, and Nairobi. As the busiest Level 5 facility in the county, it handles a high patient load across outpatient and inpatient services. The study was conducted in the pediatrics department, which manages both outpatient follow-up of chronic conditions such as asthma and inpatient care for acute illnesses, including severe asthma exacerbations. Additionally, Thika’s highly industrialized environment exposes children to air pollution and allergens, increasing asthma risk, making the hospital an appropriate setting for evaluating the BReATHE intervention. Trial registration This study was not registered because it was a quasi-experimental program evaluation rather than a randomized clinical trial. Sampling and grouping A total of 108 caregiver–child dyads were recruited from the pediatric asthma clinic between January and June 2025, with 54 participants allocated to the intervention group and 54 to the control group. Group assignment was non-random, consistent with a quasi-experimental non-equivalent group design. Both groups received standard clinical asthma management, while only the intervention group participated in the structured BReATHE program. Exclusion criteria Caregiver–child dyads were excluded if the child had other chronic respiratory or systemic conditions that could influence asthma outcomes, if the dyad had participated in a similar asthma education program within the previous year, or if the caregiver had communication or cognitive limitations that could interfere with participation. Eligible dyads who provided written informed consent were enrolled consecutively until the target sample size of 108 was achieved. Intervention description The BReATHE intervention consisted of monthly educational sessions covering asthma symptoms and early acknowledgement of exacerbation, trigger avoidance, asthma medication and adherence, and proper inhaler use technique. Educational materials were provided in English and Kiswahili. Data collection instruments Data were collected using semi-structured questionnaires and the Asthma Control Test (ACT) adapted for children. Data were collected at three time points: baseline (pre-test), 3 months (post-test I), and 6 months (endline/post-test II) to assess asthma control outcomes. Data analysis Data were analyzed using SPSS version 31. Descriptive statistics were computed, and paired t -tests assessed within-group changes. Independent t -tests and Chi-square tests compared groups. Difference-in-Differences (DiD) modeling evaluated the net effect of the intervention, and multivariate logistic regression determined predictors of asthma control. Statistical significance was set at p < 0.05. Results Baseline characteristics At baseline, the majority of children presented with significant asthma-related morbidity. Overall, 71.3% experienced shortness of breath, 73.1% reported nighttime symptoms, and 50% had been hospitalized due to asthma within the past six months. Additionally, 52.8% had missed school in the preceding four weeks, indicating the negative impact of asthma on academic attendance and daily functioning. The distribution of baseline characteristics was comparable between the intervention and control groups (Table 1 ). Table 1 Baseline clinical characteristics of study participants (n = 108) Variable Category Intervention n (%) Control n (%) Total n (%) p-value Shortness of breath Yes 39 (72.2) 38 (70.4) 77 (71.3) 0.84 Missed school (past 4 weeks) Yes 29 (53.7) 28 (51.9) 57 (52.8) 0.85 Nighttime symptoms Yes 40 (74.1) 39 (72.2) 79 (73.1) 0.82 Hospitalized in past 6 months Yes 26 (48.1) 28 (51.9) 54 (50.0) 0.70 Controller medication use Yes 12 (22.2) 11 (20.4) 23 (21.3) 0.82 Use of SABA (reliever) Yes 48 (88.9) 47 (87.0) 95 (88.0) 0.77 SABA: Short-acting β₂-agonist. Table 2 Asthma control outcomes at baseline Parameter Intervention (Mean ± SD) Control (Mean ± SD) p-value Frequency of exacerbations (per month) 2.3 ± 1.1 2.4 ± 1.0 0.612 Hospital visits (past 3 months) 1.2 ± 0.7 1.3 ± 0.8 0.541 School absenteeism (days/term) 4.1 ± 2.2 4.0 ± 2.0 0.784 ACT score (0–5) 3.2 ± 0.9 3.3 ± 0.8 0.514 Post-intervention outcomes After six months, caregiver knowledge improved markedly in the intervention group (mean 7.8 vs. 5.6, p < 0.001). The proportion achieving high knowledge scores increased to 72% , compared to 38% in controls ( p = 0.002). Multivariate logistic regression indicated that high caregiver knowledge was significantly associated with good asthma control (AOR = 3.8, 95% CI: 1.9–7.5, p = 0.001) as shown in Table 3 below . Table 3 Multivariate logistic regression analysis of factors associated with good asthma control Variable Adjusted Odds Ratio (AOR) 95% CI p-value Intervention group (vs Control) 3.8 1.9–7.5 0.001 Frequency of exacerbations (per month) 0.42 0.25–0.71 0.001 Hospital visits (past 3 months) 0.51 0.30–0.86 0.012 School absenteeism (days/term) 0.63 0.45–0.88 0.006 ACT score (per unit increase) 1.92 1.30–2.84 0.001 Table 4 Post-intervention asthma control outcomes Parameter Intervention (Mean ± SD) Control (Mean ± SD) p-value Frequency of exacerbations (per month) 1.1 ± 0.6 2.2 ± 1.0 < 0.001 Hospital visits (past 3 months) 0.5 ± 0.4 1.2 ± 0.7 < 0.001 School absenteeism (days/term) 1.8 ± 1.2 3.9 ± 2.1 < 0.001 ACT score (0–5) 4.1 ± 0.8 3.4 ± 0.7 < 0.001 AOR for good asthma control (Intervention vs. Control) 3.8 (95% CI: 1.9–7.5) — 0.001 Asthma control improvements Children in the intervention group experienced significant improvements in symptom control. The mean ACT score rose from 3.2 to 4.1 ( p < 0.001), while the control group showed minimal change (3.3 to 3.4, p = 0.278). Nocturnal wheezing and activity limitation declined by more than 35% in the intervention group, demonstrating tangible clinical benefits. Table 5 Change in key asthma symptoms between baseline and end line (6-Month follow-up) Symptom Intervention Baseline n (%) Intervention endline n (%) Control Baseline n (%) Control endline n (%) p -value (Difference-in-Differences) Nighttime symptoms 40 (74.1) 19 (35.2) 39 (72.2) 35 (64.8) < 0.001 Shortness of breath 39 (72.2) 18 (33.3) 38 (70.4) 34 (63.0) < 0.001 Activity limitation 37 (68.5) 21 (38.9) 35 (64.8) 33 (61.1) < 0.001 Reduction in asthma exacerbations The mean number of asthma exacerbations decreased sharply in the intervention group from 4.9 ± 1.6 to 2.0 ± 1.2, compared to a smaller reduction in controls (5.0 ± 1.5 to 4.3 ± 1.4). The Difference-in-Differences (DiD) estimate of − 2.2 (p < 0.001) confirmed the significant net improvement attributable to the BReATHE intervention. Table 6 Change in frequency of asthma exacerbations Group Baseline Mean ± SD 6-Month Mean ± SD Mean Change DiD Estimate p -value Intervention 4.9 ± 1.6 2.0 ± 1.2 −2.9 −2.2 < 0.001 Control 5.0 ± 1.5 4.3 ± 1.4 −0.7 — — Severe asthma episodes At follow-up, only 22.2% of children in the intervention group experienced three or more severe episodes compared with 70.4% in controls ( p < 0.001). This represents a 68.5% relative reduction in severe exacerbations. The findings confirm the intervention’s clinical effectiveness in minimizing disease severity and healthcare utilization as shown in Table 6 below. Table 7 Distribution of severe asthma episodes at end line ( 6th month follow-up) Severity Category Intervention n (%) Control n (%) p -value ≥ 3 severe episodes 12 (22.2) 38 (70.4) < 0.001 < 3 episodes 42 (77.8) 16 (29.6) < 0.001 Discussion The BReATHE intervention significantly improved asthma control and reduced exacerbations among children attending Thika Level 5 Hospital. These findings align with prior studies demonstrating that structured asthma education improves self-management, inhaler technique, and treatment adherence [ 7 , 8 ]. In this population, the intervention was particularly effective because children presented with a high baseline burden of poorly controlled asthma, characterized by frequent exacerbations, hospital visits, and school absenteeism. At baseline, reliance on short-acting β₂-agonists with low use of controller medications was common, creating substantial opportunity for improvement through targeted education and behavior change. In addition, asthma management in this setting is largely caregiver-dependent, making caregiver-focused interventions especially relevant. The most impactful component of the BReATHE intervention appears to be caregiver education, as reflected by the nearly fourfold higher likelihood of achieving good asthma control among children whose caregivers attained high knowledge scores (AOR = 3.8). Improved caregiver knowledge likely translated into better adherence to controller medications, more appropriate use of relievers, earlier recognition of worsening symptoms, and timely healthcare seeking. These changes are consistent with observed reductions in asthma exacerbations, hospital visits, and school absenteeism, underscoring the importance of empowering caregivers in pediatric asthma management. BReATHE differs from many prior asthma education interventions in several key ways. Unlike programs that focus solely on the child or provide brief, one-off counseling sessions, BReATHE adopted a caregiver–child dyadic approach, recognizing shared responsibility in asthma management. The intervention combined clinical education, behavioral reinforcement, and environmental health messaging and was delivered within routine hospital care rather than as a standalone activity. Furthermore, BReATHE was contextually adapted to address common local challenges, including misconceptions about inhaled corticosteroids, inappropriate reliance on reliever medications, and exposure to environmental triggers prevalent in industrialized urban settings. These features distinguish BReATHE from earlier interventions that often lacked contextual tailoring. Similar reductions in asthma exacerbations, emergency visits, and hospitalizations have been reported in Ethiopia and Nigeria following structured asthma education programs [ 9 , 10 ], as well as in caregiver-focused interventions in Kenya, Ghana, and India, which demonstrated reductions in symptom frequency, nocturnal symptoms, and missed school days [ 15 – 17 ]. However, some studies have reported limited or inconsistent effects of asthma education interventions, particularly in low- and middle-income countries [ 11 – 14 ]. These contrasting findings have been attributed to short intervention duration, lack of follow-up reinforcement, inadequate caregiver involvement, or failure to integrate education into routine clinical care. In contrast, BReATHE incorporated repeated engagement over six months and emphasized practical skills and behavior change rather than knowledge alone, which may explain its superior outcomes. Although the findings demonstrate significant improvements in asthma control among children exposed to the BReATHE intervention, the quasi-experimental design limits the ability to establish definitive causal relationships. Because participants were not randomly assigned, unmeasured confounding factors may have influenced the observed outcomes. Nevertheless, the use of baseline comparability and Difference-in-Differences (DiD) analysis strengthens the inference that the improvements were associated with the intervention. Strengths This study has several notable strengths. First, it included caregiver–child dyads, which is rarely done in pediatric asthma research, allowing a more comprehensive assessment of both child outcomes and caregiver knowledge and practices. Second, the use of Difference-in-Differences (DiD) analysis provided a robust quasi-experimental approach to estimate the net effect of the BReATHE intervention while accounting for baseline differences between groups. Finally, the study achieved high follow-up completion rates, which strengthened the validity of the findings and minimized potential attrition bias. Limitations The quasi-experimental, single-site design introduced potential contamination between the intervention and control groups, as participants were recruited from the same hospital setting. Second, the follow-up period of six months was relatively short, which limits the ability to assess the long-term sustainability of the intervention effects. Third, several outcomes, including symptom frequency, school absenteeism, and caregiver knowledge, were self-reported, which may have introduced recall or social desirability bias. Fourth, although medication adherence and inhaler use are key components of asthma management, inhaler technique was not objectively measured, for example using validated tools such as the Morisky Medication Adherence Scale (MMAS), which may have provided a more precise assessment of adherence. Finally, the BReATHE intervention was multi-component, combining caregiver education, environmental control strategies, and adherence support. While this approach likely contributed to its overall effectiveness, it limits the ability to determine the relative impact of each individual component. Future studies could address these limitations by including multi-site designs, longer follow-up periods, objective adherence assessments, and component-specific analyses to better understand the mechanisms driving intervention success. Conclusion The BReATHE intervention demonstrated that low-cost, structured education delivered within a county referral hospital can reduce severe asthma episodes by over 60%. It also effectively decreased hospital visits and school absenteeism, thereby enhancing overall asthma control among children. These findings show that structured asthma education is both feasible and impactful in resource-limited settings. By enhancing caregiver understanding, correcting misconceptions, and promoting adherence to treatment and trigger avoidance, BReATHE achieved meaningful clinical benefits. Integrating structured, facility-based asthma education programs into routine pediatric care could improve outcomes, reduce hospitalizations, and contribute to better asthma control among children in Kenya and across sub-Saharan Africa. Recommendations Integration of Asthma Education : Incorporate structured asthma education programs into routine outpatient services. Continuous Caregiver Training : Reinforce correct inhaler use and medication adherence at each clinic visit. Policy Support : Develop national guidelines for asthma education and training for healthcare workers. Community Outreach : Extend asthma awareness to schools and communities to reduce environmental triggers. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Mount Kenya University Ethical Review Committee. Permission to conduct the study was also granted by the management of Thika Level 5 Hospital. Written informed consent was obtained from caregivers of all participating children prior to enrollment in the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Funding No external funding was received for this study. The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript. Competing interests The authors declare that they have no competing interests, financial or non-financial, related to this manuscript. Authors’ contributions RL worked alongside other fellow researchers in conceiving and designing the study and drafting the manuscript. KO assisted with data collection and analysis. JM, BK, PM, and DK provided mentorship, guided data interpretation, and critically reviewed the manuscript for important intellectual content. All authors read and approved the final version of the manuscript. Acknowledgements The authors express their sincere gratitude to the management and staff of Thika Level 5 Hospital for their support during data collection. Special thanks go to the caregivers and children who participated in this study. The authors also acknowledge Mount Kenya University, School of Clinical Medicine, for academic and ethical support. References WHO. Global Asthma Report 2023. Geneva: World Health Organization; 2023. Adeloye D, Chan KY, Rudan I, Campbell H. Global and regional estimates of asthma prevalence: Systematic analysis. BMC Public Health. 2019;19(1):1–15. 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Lancet Respir Med. 2022;10(4):348–360. Bwire GM, Ssetaala A, Mwanja M, et al. Implementation of asthma education and follow-up using community health workers in Uganda: A mixed-methods study. BMC Health Serv Res. 2023;23(1):765. Mutuku MW, Maina AN, Otieno PA. Determinants of asthma control among children attending Thika Level 5 Hospital, Kenya. East Afr Med J. 2021;98(6):256–263. Dharmage SC, Perret JL, Custovic A. Epidemiology of asthma in children and adults. Front Pediatr. 2023;11:1201452. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9192384","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610178868,"identity":"2d4b8d8d-4e89-489b-afb8-56ec8543c3fa","order_by":0,"name":"Robai Linet Ayiela","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACPmYIncDAzHzg4IcKIJOZuQGvFjaQlgNgLWyJjyXOgLQwEtDCANPCwKNswNsG4hLSws578PHHPTZ5/O08bBKS82qj+duBWn5UbMPjML5kgwPP0oolDvMekyjcdjx3xmHGBsaeM7fxaOExkzhw4HBiw2G+NAnJbcdyG4BamBnb8Gox/wHSMv8wUC/vnGO584nQYsYA0rLhMI+xAW9DTe4GIrQYS5w5kFZseBgUyMcO5G4EajmIzy/8/GcMP1QcsMmTO38YGJU1dbnzzh8++OBHBW4t6OAwmDxAtHogqCNF8SgYBaNgFIwQAAB3eFtL/4dvfQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0004-0519-9386","institution":"Mount Kenya University","correspondingAuthor":true,"prefix":"","firstName":"Robai","middleName":"Linet","lastName":"Ayiela","suffix":""},{"id":610178869,"identity":"169df862-1c92-4b13-925b-4b8576f0fb1e","order_by":1,"name":"Joseph Mukala","email":"","orcid":"","institution":"Mount Kenya University","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Mukala","suffix":""},{"id":610178870,"identity":"962d551a-4c94-4eec-8f7c-c90039192693","order_by":2,"name":"Bernard N Kanoi","email":"","orcid":"","institution":"Institute of Tropical medicine","correspondingAuthor":false,"prefix":"","firstName":"Bernard","middleName":"N","lastName":"Kanoi","suffix":""},{"id":610178871,"identity":"3cf811b6-f3f6-40d7-870a-86adbf32782c","order_by":3,"name":"Peter Mwaura","email":"","orcid":"","institution":"Mount Kenya University","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Mwaura","suffix":""},{"id":610178872,"identity":"f50ed1ad-5676-4ab7-a1f5-316d76f308e4","order_by":4,"name":"Ogweno Kennedy","email":"","orcid":"","institution":"Mount Kenya University","correspondingAuthor":false,"prefix":"","firstName":"Ogweno","middleName":"","lastName":"Kennedy","suffix":""},{"id":610178873,"identity":"8c0de874-6055-447d-964c-d1ddbd248346","order_by":5,"name":"Kamau Njoroge David","email":"","orcid":"","institution":"Mount Kenya University","correspondingAuthor":false,"prefix":"","firstName":"Kamau","middleName":"Njoroge","lastName":"David","suffix":""}],"badges":[],"createdAt":"2026-03-22 15:47:28","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9192384/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9192384/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105564801,"identity":"6a9af060-64b2-4da8-adb7-1d65c6db506e","added_by":"auto","created_at":"2026-03-27 12:50:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1010008,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9192384/v1/e848dd6d-dccc-4d44-a5ae-655c4e0a4436.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eOutcomes associated with the BReATHE (Beating Regional Asthma Through Health Education) intervention among asthmatic children: A hospital-based quasi-experimental evaluation in Kenya\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAsthma is one of the most common chronic childhood diseases worldwide and a major cause of disability-adjusted life years (DALYs) among school-aged children. Globally, approximately 262\u0026nbsp;million people are affected, leading to nearly half a million deaths annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In sub-Saharan Africa, asthma prevalence is increasing due to rapid urbanization, pollution, and limited access to inhaled corticosteroids [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Kenya, asthma contributes to frequent hospital visits, school absenteeism, and impaired quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the availability of effective treatments, asthma control remains poor in many settings due to low medication adherence, limited caregiver education, and mismanagement of triggers [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Educational interventions have been shown to improve symptom control, reduce exacerbations, and enhance quality of life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While asthma education is a pillar of GINA guidelines, locally adapted curricula that account for African cultural contexts and health literacy levels are scarce. The BReATHE (Beating Regional Asthma Through Health Education) intervention was designed to address these gaps by enhancing caregiver knowledge, promoting correct inhaler use, and supporting adherence to evidence-based management practices.\u003c/p\u003e \u003cp\u003eThis study assessed the outcome of the BReATHE intervention on asthma control among children attending Thika Level 5 Hospital in Kiambu County, Kenya.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe results present baseline asthma morbidity among participating children and compare pre- and post-intervention asthma control outcomes between the intervention and control groups.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis study employed a hospital-based quasi-experimental non-equivalent group design with intervention and control groups, using non-random assignment. A total of 108 known asthmatic children aged 3\u0026ndash;17 years and their caregiver\u0026ndash;child dyads (each consisting of an asthmatic child and the primary caregiver responsible for daily asthma management) were recruited. The design was chosen because it allowed for evaluation of the effectiveness of the BReATHE intervention in improving caregiver knowledge and reducing asthma exacerbations among children while working within the practical and ethical limitations of the hospital setting. The study was conducted at Thika Level 5 Hospital, a major referral facility in Kiambu County, between January and June 2025. Thika Level 5 Hospital is a county referral facility located in Thika Town, Kiambu County, approximately 40 km northeast of Nairobi along the Nairobi\u0026ndash;Garissa highway. It is administered by the Kiambu County Government and is one of three Level 5 hospitals in the county. The hospital serves a large catchment population of about 1.5\u0026nbsp;million people from Thika Sub-County and neighboring regions, including Murang\u0026rsquo;a, Machakos, Garissa, and Nairobi. As the busiest Level 5 facility in the county, it handles a high patient load across outpatient and inpatient services. The study was conducted in the pediatrics department, which manages both outpatient follow-up of chronic conditions such as asthma and inpatient care for acute illnesses, including severe asthma exacerbations. Additionally, Thika\u0026rsquo;s highly industrialized environment exposes children to air pollution and allergens, increasing asthma risk, making the hospital an appropriate setting for evaluating the BReATHE intervention.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTrial registration\u003c/h3\u003e\n\u003cp\u003eThis study was not registered because it was a quasi-experimental program evaluation rather than a randomized clinical trial.\u003c/p\u003e\n\u003ch3\u003eSampling and grouping\u003c/h3\u003e\n\u003cp\u003eA total of 108 caregiver\u0026ndash;child dyads were recruited from the pediatric asthma clinic between January and June 2025, with 54 participants allocated to the intervention group and 54 to the control group. Group assignment was non-random, consistent with a quasi-experimental non-equivalent group design. Both groups received standard clinical asthma management, while only the intervention group participated in the structured BReATHE program.\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eCaregiver\u0026ndash;child dyads were excluded if the child had other chronic respiratory or systemic conditions that could influence asthma outcomes, if the dyad had participated in a similar asthma education program within the previous year, or if the caregiver had communication or cognitive limitations that could interfere with participation. Eligible dyads who provided written informed consent were enrolled consecutively until the target sample size of 108 was achieved.\u003c/p\u003e\n\u003ch3\u003eIntervention description\u003c/h3\u003e\n\u003cp\u003eThe BReATHE intervention consisted of monthly educational sessions covering asthma symptoms and early acknowledgement of exacerbation, trigger avoidance, asthma medication and adherence, and proper inhaler use technique. Educational materials were provided in English and Kiswahili.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection instruments\u003c/h2\u003e \u003cp\u003eData were collected using semi-structured questionnaires and the Asthma Control Test (ACT) adapted for children. Data were collected at three time points: baseline (pre-test), 3 months (post-test I), and 6 months (endline/post-test II) to assess asthma control outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS version 31. Descriptive statistics were computed, and paired \u003cem\u003et\u003c/em\u003e-tests assessed within-group changes. Independent \u003cem\u003et\u003c/em\u003e-tests and Chi-square tests compared groups. Difference-in-Differences (DiD) modeling evaluated the net effect of the intervention, and multivariate logistic regression determined predictors of asthma control. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eAt baseline, the majority of children presented with significant asthma-related morbidity. Overall, 71.3% experienced shortness of breath, 73.1% reported nighttime symptoms, and 50% had been hospitalized due to asthma within the past six months. Additionally, 52.8% had missed school in the preceding four weeks, indicating the negative impact of asthma on academic attendance and daily functioning. The distribution of baseline characteristics was comparable between the intervention and control groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline clinical characteristics of study participants (n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eShortness of breath\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e77 (71.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissed school (past 4 weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e57 (52.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNighttime symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (74.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e79 (73.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospitalized in past 6 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e54 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eController medication use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse of SABA (reliever)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47 (87.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e95 (88.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSABA: Short-acting β₂-agonist.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAsthma control outcomes at baseline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of exacerbations (per month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital visits (past 3 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.541\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool absenteeism (days/term)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACT score (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePost-intervention outcomes\u003c/h2\u003e \u003cp\u003eAfter six months, caregiver knowledge improved markedly in the intervention group (mean 7.8 vs. 5.6, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The proportion achieving high knowledge scores increased to \u003cb\u003e72%\u003c/b\u003e, compared to \u003cb\u003e38%\u003c/b\u003e in controls (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Multivariate logistic regression indicated that high caregiver knowledge was significantly associated with good asthma control (AOR\u0026thinsp;=\u0026thinsp;3.8, 95% CI: 1.9\u0026ndash;7.5, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) as shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003ebelow\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis of factors associated with good asthma control\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted Odds Ratio (AOR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention group (vs Control)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.9\u0026ndash;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of exacerbations (per month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.25\u0026ndash;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital visits (past 3 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.30\u0026ndash;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool absenteeism (days/term)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.45\u0026ndash;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACT score (per unit increase)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.30\u0026ndash;2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-intervention asthma control outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of exacerbations (per month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital visits (past 3 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool absenteeism (days/term)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACT score (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAOR for good asthma control (Intervention vs. Control)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8 (95% CI: 1.9\u0026ndash;7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAsthma control improvements\u003c/h2\u003e \u003cp\u003eChildren in the intervention group experienced significant improvements in symptom control. The mean ACT score rose from 3.2 to 4.1 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the control group showed minimal change (3.3 to 3.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.278). Nocturnal wheezing and activity limitation declined by more than 35% in the intervention group, demonstrating tangible clinical benefits.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange in key asthma symptoms between baseline and end line (6-Month follow-up)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention Baseline n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003eendline n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl Baseline n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl endline n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value (Difference-in-Differences)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNighttime symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (74.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShortness of breath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34 (63.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity limitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33 (61.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eReduction in asthma exacerbations\u003c/h2\u003e \u003cp\u003eThe mean number of asthma exacerbations decreased sharply in the intervention group from 4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 to 2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2, compared to a smaller reduction in controls (5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 to 4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4). The Difference-in-Differences (DiD) estimate of \u0026minus;\u0026thinsp;2.2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) confirmed the significant net improvement attributable to the BReATHE intervention.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange in frequency of asthma exacerbations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6-Month Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Change\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiD Estimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSevere asthma episodes\u003c/h2\u003e \u003cp\u003eAt follow-up, only 22.2% of children in the intervention group experienced three or more severe episodes compared with 70.4% in controls (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This represents a 68.5% relative reduction in severe exacerbations. The findings confirm the intervention\u0026rsquo;s clinical effectiveness in minimizing disease severity and healthcare utilization as shown in Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e \u003cb\u003ebelow.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of severe asthma episodes at end line ( 6th month follow-up)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeverity Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3 severe episodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 episodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe BReATHE intervention significantly improved asthma control and reduced exacerbations among children attending Thika Level 5 Hospital. These findings align with prior studies demonstrating that structured asthma education improves self-management, inhaler technique, and treatment adherence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this population, the intervention was particularly effective because children presented with a high baseline burden of poorly controlled asthma, characterized by frequent exacerbations, hospital visits, and school absenteeism. At baseline, reliance on short-acting β₂-agonists with low use of controller medications was common, creating substantial opportunity for improvement through targeted education and behavior change. In addition, asthma management in this setting is largely caregiver-dependent, making caregiver-focused interventions especially relevant.\u003c/p\u003e \u003cp\u003eThe most impactful component of the BReATHE intervention appears to be caregiver education, as reflected by the nearly fourfold higher likelihood of achieving good asthma control among children whose caregivers attained high knowledge scores (AOR\u0026thinsp;=\u0026thinsp;3.8). Improved caregiver knowledge likely translated into better adherence to controller medications, more appropriate use of relievers, earlier recognition of worsening symptoms, and timely healthcare seeking. These changes are consistent with observed reductions in asthma exacerbations, hospital visits, and school absenteeism, underscoring the importance of empowering caregivers in pediatric asthma management.\u003c/p\u003e \u003cp\u003eBReATHE differs from many prior asthma education interventions in several key ways. Unlike programs that focus solely on the child or provide brief, one-off counseling sessions, BReATHE adopted a caregiver\u0026ndash;child dyadic approach, recognizing shared responsibility in asthma management. The intervention combined clinical education, behavioral reinforcement, and environmental health messaging and was delivered within routine hospital care rather than as a standalone activity. Furthermore, BReATHE was contextually adapted to address common local challenges, including misconceptions about inhaled corticosteroids, inappropriate reliance on reliever medications, and exposure to environmental triggers prevalent in industrialized urban settings. These features distinguish BReATHE from earlier interventions that often lacked contextual tailoring.\u003c/p\u003e \u003cp\u003eSimilar reductions in asthma exacerbations, emergency visits, and hospitalizations have been reported in Ethiopia and Nigeria following structured asthma education programs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], as well as in caregiver-focused interventions in Kenya, Ghana, and India, which demonstrated reductions in symptom frequency, nocturnal symptoms, and missed school days [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, some studies have reported limited or inconsistent effects of asthma education interventions, particularly in low- and middle-income countries [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These contrasting findings have been attributed to short intervention duration, lack of follow-up reinforcement, inadequate caregiver involvement, or failure to integrate education into routine clinical care. In contrast, BReATHE incorporated repeated engagement over six months and emphasized practical skills and behavior change rather than knowledge alone, which may explain its superior outcomes.\u003c/p\u003e \u003cp\u003eAlthough the findings demonstrate significant improvements in asthma control among children exposed to the BReATHE intervention, the quasi-experimental design limits the ability to establish definitive causal relationships. Because participants were not randomly assigned, unmeasured confounding factors may have influenced the observed outcomes. Nevertheless, the use of baseline comparability and Difference-in-Differences (DiD) analysis strengthens the inference that the improvements were associated with the intervention.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis study has several notable strengths. First, it included caregiver\u0026ndash;child dyads, which is rarely done in pediatric asthma research, allowing a more comprehensive assessment of both child outcomes and caregiver knowledge and practices. Second, the use of Difference-in-Differences (DiD) analysis provided a robust quasi-experimental approach to estimate the net effect of the BReATHE intervention while accounting for baseline differences between groups. Finally, the study achieved high follow-up completion rates, which strengthened the validity of the findings and minimized potential attrition bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe quasi-experimental, single-site design introduced potential contamination between the intervention and control groups, as participants were recruited from the same hospital setting. Second, the follow-up period of six months was relatively short, which limits the ability to assess the long-term sustainability of the intervention effects. Third, several outcomes, including symptom frequency, school absenteeism, and caregiver knowledge, were self-reported, which may have introduced recall or social desirability bias. Fourth, although medication adherence and inhaler use are key components of asthma management, inhaler technique was not objectively measured, for example using validated tools such as the Morisky Medication Adherence Scale (MMAS), which may have provided a more precise assessment of adherence. Finally, the BReATHE intervention was multi-component, combining caregiver education, environmental control strategies, and adherence support. While this approach likely contributed to its overall effectiveness, it limits the ability to determine the relative impact of each individual component. Future studies could address these limitations by including multi-site designs, longer follow-up periods, objective adherence assessments, and component-specific analyses to better understand the mechanisms driving intervention success.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe BReATHE intervention demonstrated that low-cost, structured education delivered within a county referral hospital can reduce severe asthma episodes by over 60%. It also effectively decreased hospital visits and school absenteeism, thereby enhancing overall asthma control among children. These findings show that structured asthma education is both feasible and impactful in resource-limited settings. By enhancing caregiver understanding, correcting misconceptions, and promoting adherence to treatment and trigger avoidance, BReATHE achieved meaningful clinical benefits. Integrating structured, facility-based asthma education programs into routine pediatric care could improve outcomes, reduce hospitalizations, and contribute to better asthma control among children in Kenya and across sub-Saharan Africa.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIntegration of Asthma Education\u003c/b\u003e: Incorporate structured asthma education programs into routine outpatient services.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eContinuous Caregiver Training\u003c/b\u003e: Reinforce correct inhaler use and medication adherence at each clinic visit.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePolicy Support\u003c/b\u003e: Develop national guidelines for asthma education and training for healthcare workers.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCommunity Outreach\u003c/b\u003e: Extend asthma awareness to schools and communities to reduce environmental triggers.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Mount Kenya University Ethical Review Committee. Permission to conduct the study was also granted by the management of Thika Level 5 Hospital. Written informed consent was obtained from caregivers of all participating children prior to enrollment in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this study. The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests, financial or non-financial, related to this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRL worked alongside other fellow researchers in conceiving and designing the study and drafting the manuscript. KO assisted with data collection and analysis. JM, BK, PM, and DK provided mentorship, guided data interpretation, and critically reviewed the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their sincere gratitude to the management and staff of Thika Level 5 Hospital for their support during data collection. Special thanks go to the caregivers and children who participated in this study. The authors also acknowledge Mount Kenya University, School of Clinical Medicine, for academic and ethical support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. \u003cem\u003eGlobal Asthma Report 2023.\u003c/em\u003e Geneva: World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eAdeloye D, Chan KY, Rudan I, Campbell H. 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Effectiveness of caregiver-focused asthma education on symptom control among children attending Kenyatta National Hospital. \u003cem\u003eAfr Health Sci.\u003c/em\u003e 2023;23(2):215\u0026ndash;223.\u003c/li\u003e\n\u003cli\u003eAgrawal A, Singh D, Sahoo RC. Impact of structured asthma education on disease outcomes and quality of life in children: A randomized trial. \u003cem\u003eIndian Pediatr.\u003c/em\u003e 2022;59(7):553\u0026ndash;560.\u003c/li\u003e\n\u003cli\u003eNkosi V, Wichmann J, Voyi K. Role of environmental exposures and caregiver education in childhood asthma control in sub-Saharan Africa. \u003cem\u003eBMC Pulm Med.\u003c/em\u003e 2021;21(1):345.\u003c/li\u003e\n\u003cli\u003eAddo-Yobo EO, Wilson N, Osei-Tutu E, et al. The burden and control of asthma among Ghanaian children: Lessons for intervention. \u003cem\u003eJ Trop Pediatr.\u003c/em\u003e 2020;66(3):261\u0026ndash;269.\u003c/li\u003e\n\u003cli\u003eEzeonwu BU, Onwuchekwa RC, Maduka IC. Outcomes of an asthma education program among pediatric patients in a Nigerian tertiary hospital. \u003cem\u003eWest Afr J Med.\u003c/em\u003e 2022;39(4):300\u0026ndash;307.\u003c/li\u003e\n\u003cli\u003eAlith MB, Cardoso TA, Rizzo LV. Adherence to inhaled corticosteroids and its determinants among children with asthma: Educational intervention outcomes. \u003cem\u003ePediatr Pulmonol.\u003c/em\u003e 2021;56(11):3694\u0026ndash;3702.\u003c/li\u003e\n\u003cli\u003eRosas-Salazar C, Beigelman A, Bacharier LB. Asthma education and management in low-resource settings: Evidence and strategies. \u003cem\u003eCurr Opin Pulm Med.\u003c/em\u003e 2023;29(1):43\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Byrne PM, Pedersen S, Schatz M. 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Trends in worldwide asthma prevalence: ISAAC Phase Three and beyond. \u003cem\u003eAllergy.\u003c/em\u003e 2021;76(5):1162\u0026ndash;1176.\u003c/li\u003e\n\u003cli\u003evan Dellen QM, van Aalderen WMC, Bindels PJE. Asthma education and self-management: Systematic review of long-term outcomes in children. \u003cem\u003eEur Respir Rev.\u003c/em\u003e 2020;29(156):190148.\u003c/li\u003e\n\u003cli\u003eBuelo A, McLean S, Julious S, et al. Effective interventions for reducing asthma hospital admissions in children: A meta-analysis. \u003cem\u003eLancet Respir Med.\u003c/em\u003e 2022;10(4):348\u0026ndash;360.\u003c/li\u003e\n\u003cli\u003eBwire GM, Ssetaala A, Mwanja M, et al. Implementation of asthma education and follow-up using community health workers in Uganda: A mixed-methods study. \u003cem\u003eBMC Health Serv Res.\u003c/em\u003e 2023;23(1):765.\u003c/li\u003e\n\u003cli\u003eMutuku MW, Maina AN, Otieno PA. Determinants of asthma control among children attending Thika Level 5 Hospital, Kenya. \u003cem\u003eEast Afr Med J.\u003c/em\u003e 2021;98(6):256\u0026ndash;263.\u003c/li\u003e\n\u003cli\u003eDharmage SC, Perret JL, Custovic A. Epidemiology of asthma in children and adults. \u003cem\u003eFront Pediatr.\u003c/em\u003e 2023;11:1201452.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Asthma, BReATHE, children, caregiver education, Thika Level 5 Hospital, Kenya","lastPublishedDoi":"10.21203/rs.3.rs-9192384/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9192384/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eAsthma remains one of the most common chronic diseases in childhood worldwide and specifically in Kenya, where it contributes substantially to morbidity, impaired quality of life, and school absenteeism\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA quasi-experimental evaluation involving 108 asthmatic children and their caregivers was conducted between January and June 2025. Participants were non-randomly assigned into intervention and control groups. Baseline, midline, and end line assessments evaluated asthma control and caregiver knowledge using structured questionnaires. The BReATHE intervention entailed monthly education sessions on triggers, medication use, and inhaler technique. Data were analyzed using paired and independent \u003cem\u003et\u003c/em\u003e-tests, Chi-square tests, logistic regression, and Difference-in-Differences (DiD) modeling.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAt baseline, both groups had similar asthma control, with comparable rates of exacerbations, hospital visits, and school absenteeism. Over the six-month follow-up, the intervention group demonstrated improved asthma control, evidenced by a reduction in the frequency of asthma exacerbations, fewer hospital visits, and decreased school absenteeism compared to the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and fewer asthma episodes (mean 2.0 vs. 4.3, DiD = \u0026minus;\u0026thinsp;2.2, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings highlight the effectiveness of targeted interventions in improving clinical and functional outcomes for children with asthma. Severe asthma episodes (\u0026ge;\u0026thinsp;3) declined to 22.2% in the intervention group versus 70.4% in controls (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe BReATHE intervention significantly reduced asthma exacerbations. Integrating structured asthma education into routine pediatric care can enhance asthma control and overall outcomes in low-resource settings.\u003c/p\u003e","manuscriptTitle":"Outcomes associated with the BReATHE (Beating Regional Asthma Through Health Education) intervention among asthmatic children: A hospital-based quasi-experimental evaluation in Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 11:27:47","doi":"10.21203/rs.3.rs-9192384/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5786f7f-682f-4eeb-910e-59dc6c773e90","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64923919,"name":"Allergy \u0026 Immune Disorders"}],"tags":[],"updatedAt":"2026-03-24T11:27:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 11:27:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9192384","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9192384","identity":"rs-9192384","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}