Milwaukee Day Cares Indoor Air Quality Assessment and Educational Response Study
Phase: NA
Conditions: Pollution; Exposure
Sponsor: Medical College of Wisconsin

 
 
 
 
 
 
 
 
 
 
 
 
 
Milwaukee Day Cares Indoor Air Quality Assessment and Educational Response Study 
 
 
 
 
 
Full study protocol and statistical analysis plan 
 
 
 
 
 
August 11, 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Funded by the Clinical and Translational Science Institute of Southeastern Wisconsin 
Award Numbers UL1TR001436, TL1TR001437, and KL2TR001438 
 
 
 

Protocol Summary  
Purpose  
A research and community service partnership, comprising the Medical College of Wisconsin 
(MCW), UWM College of Nursing, and the non-profit asthma coalition Fight Asthma Milwaukee 
(FAM) Allies, proposes to describe and improve health-relevant indoor air quality (IAQ) conditions 
within diverse urban Milwaukee child day care environments. Inferior IAQ could contribute 
significantly to the development and exacerbation of asthma6,7,8 which affects 1 in 10 children in 
the State9. Day care IAQ has been assessed in few studies 1,10,11,12,13,14,15,16,17, 18,19 and is largely 
unregulated by Wisconsin state law20.  
This project aims to understand the levels of indoor organic pollution and fine particles in the air, as 
well as temperature and humidity, using inexpensive, consumer-grade, Internet cloud- enabled 
continuous indoor air quality monitors. These air quality variables are established risk factors for 
both the development and exacerbation of asthma  
Aims  
1) Assess baseline IAQ characteristics in urban Milwaukee daycare settings.  
 
Objective 1.1: Deploy 36 IAQ monitors in 36 childcare settings by November, 
2018.  
 
Objective 1.2: Collect 36 IAQ monitors from 36 daycare settings by February, 
2019.  
 
Objective 1.3: Identify trends based on subtype analysis of IAQ baseline 
findings between large facility based, small home based and unlicensed 
daycare settings through data analysis by March 2019.  
2) Determine the efficacy of the Green Cleaning for Asthma educational curriculum 
to alter IAQ and daycare staff cleaning/pest control behaviors objectively.  
 
Objective 2.1: Deliver Green Cleaning for Asthma classes for staff in 36 
daycare organizations by January, 2019.  
 
Objective 2.2: Implement and collect IAQ pre and post surveys from 1 
designated staff member in each of 36 daycare organizations by February, 
2019.  
 
Objective 2.3: Identify trends in relationship to the educational intervention 
with regards to monitoring device variables including tVOC, PM2.5 and 
relative humidity variables and composites through data analysis by March 
2019.  
 
Objective 2.4: Identify behavior changes of daycare staff with regards to 
cleaning practices, VOC generation as a result of the educational intervention 
through data analysis by March 2019.  

3) Determine the feasibility of a future daycare oriented educational and research 
program to alter development of asthma and/or asthma exacerbations by 
improving IAQ.  
 
Objective 3.1: Assess the feasibility of educational training and community 
deployment of the educational curriculum.  
 
Objective 3.2: Develop proposals to investigate child health within daycare 
environments to determine future efficacy of IAQ interventions upon health 
outcomes such as asthma incidence, severity and exacerbations and daycare 
staff knowledge about asthma and recognition of symptoms of concern.  
Research Design  
A prospective randomized stepped-wedge trial is proposed. The partnership will engage day 
care facilities in a 4-month intervention. Half of the facilities will receive education at the 
second month, allowing the team to assess pre- and post-education air quality readings. 
The rest of the facilities will receive education at the third month. Devices will be removed 
from the day cares after the 4th month.  
Enrolled day cares will be provided with IAQ monitoring and continuing education-eligible 
educational programs for day care staff. Nursing students from UWM, an Americorp worker, 
and MCW community health workers will be trained to provide the curriculum. The groups 
will be block randomized to start the educational program at either 1 month or 2 months 
after initial baseline IAQ measurements. Summaries of the findings from the assigned 
devices will be shared with day care staff at the conclusion of the study.  
Two intervention schedules will be implemented:  
Group A  
 
Group B  
Month Outreach  
Month Outreach  
1  
IAQ monitors deployed, pre survey  1  
IAQ monitors deployed, pre survey  
2  
IAQ education delivered  
2  
 
3  
 
3  
IAQ education delivered  
4  
IAQ monitors collected, post survey 4  
IAQ monitors collected, post survey 
Within each intervention group, two cohorts will be determined by licensure per the WI 
Dept of Children and Families’ licensing for the program. Specifically, Licensed Family 
Child Care Centers provide care for up to eight children (to be referenced as home 
daycare), Licensed Group Child Care Centers provide care for nine or more children. Other 
data to be obtained from the daycare will include age of facility, type of heating, presence 
of air conditioning, type of air filtration, presence of gas ranges/stoves, usual cleaning 
regimen and cleaners, typical pesticide regimen, whether windows are typically opened, 
the State Youngstar rating (if a participant), # of children under 5, and over 5 years of age.  
Procedures  

Educational curriculum: A day care-specific modification of the FAM Allies “Green Cleaning for 
Asthma” curriculum will be provided to each facility by UWM nursing students, an AmeriCorps 
worker, FAM Allies volunteers, or MCW staff. Surveys of present cleaning/pesticide practices and 
air quality inventory will be obtained before and after the educational intervention. One person 
from each daycare will fill out the pre and post surveys and will receive a $25 gift card upon 
completion of the post survey. Each daycare organization will receive a $25 gift card for 
coordinating the training and housing the indoor air quality device.  
IAQ monitoring: Portable IAQ devices will be deployed within the day care facility to measure 
variables pertinent to asthma such as total volatile organic compounds (tVOC), particulate matter 
(PM2.5), temperature, and relative humidity. These consumer-grade montiors are inexpensive, 
silent, unobtrusive, and upload data continuously via a cellular WiFi hotspot device provided by the 
study. Continuous data will be tagged with date of the educational intervention, and statistical 
analysis for trends over time as a result of the intervention will be conducted. Secondary analyses 
will evaluate which variables and practice changes are associated with improved IAQ.  
Timeline providing details of each organization’s role:  
April – May, 2018  
 
Public Allies (AmeriCorps) hiring process  
 
Flier development and marketing to day care organizations  
 
Recruitment of day care organizations  
 
Purchase supplies and contracts: IAQ monitors and hotspots  
June, 2018  
 
FAM Allies volunteer training  
 
MCW staff training  
 
FAM Allies/MCW: Deploy 14 IAQ/hotspots in 14 day care organizations (Groups A and  
B)  
 
FAM Allies/MCW: Collect IAQ pre surveys from designated staff member in each of 14  
day care organizations (Group A and B)  
July, 2018  
 
FAM Allies/MCW: Teach educational intervention in 7 day care organizations (Group A) 
August, 2018  
 
 FAM Allies/MCW: Teach educational intervention in 7 day care organizations (Group B)  
September, 2018  
 
FAM Allies/MCW: Collect 14 IAQ/hotspots from day care organizations (Groups A and B)  

 
FAM Allies/MCW: Collect IAQ post surveys from designated staff member in each of 14 day 
care organizations (Group A and B)  
 
FAM Allies/MCW: Compile data (Groups A and B)  
 
Public Allies (AmeriCorps) onboarding and training  
 
UWM nursing student training  
 
UWM Nursing: Deploy 6 IAQ/hotspots in 6 day care (Groups A2 and B2)  
 
UWM Nursing: Collect IAQ pre surveys from designated staff member in each of 6 day care 
organizations (Group A2 and B2)  
October, 2018  
 
UWM Nursing: Teach educational intervention in 3 day care organizations (Group A2)  
 
Public Allies (AmeriCorps): Deploy 16 IAQ/hotspots in 16 day care organizations (Groups A3 
and B3)  
 
Public Allies (AmeriCorps): Collect IAQ pre surveys from designated staff member in each of 
14 day care organizations (Group A3 and B3)  
November, 2018  
 
UWM Nursing: Teach educational intervention in 3 day care organizations (Group B2)  
 
Public Allies (AmeriCorps): Teach educational intervention in 8 day care organizations 
(Group A3)  
December, 2018  
 
UWM Nursing: Collect 6 IAQ/hostpots from 6 day care organizations (Groups A2 and B2)  
 
UWM Nursing: Collect IAQ post surveys from designated staff member in each of 6 day care 
organizations (Group A2 and B2)  
 
UWM Nursing: Compile Data (Groups A2 and B2)  
 
Public Allies (AmeriCorps): Teach educational intervention in 8 day care organizations 
(Group B3)  
January, 2019  
 
Public Allies (AmeriCorps): Collect 16 IAQ/hotspots from 16 day care organizations (Groups 
A3 & B3)  
 
Public Allies (AmeriCorps): Collect IAQ post surveys from designated staff member in each 
of 16 day care organizations (Group A3 and B3)  
 
Public Allies (AmeriCorps): Compile data (Groups A3 and B3)  
February, 2019  
 Data compilation and submission to biostatisticians  
March, 2019  
 
Final data reports and reporting to Funder  
 
Share data reports with all participating day care organizations 
 

 
References  
1. Biedrzycki PA. An indoor air quality investigation within a central city daycare by a local 
public health agency; Emerging trends and challenges for environmental health. November 
2013. https://apha.confex.com/apha/141am/webprogram/Paper283363.html.  
2. Peden DB. The epidemiology and genetics of asthma risk associated with air pollution. 
Journal of Allergy and Clinical Immunology. 2005;115(2):213–9–quiz220. 
doi:10.1016/j.jaci.2004.12.003.  
3. Burbank AJ, Sood AK, Kesic MJ, Peden DB, Hernandez ML. Environmental determinants of 
allergy and asthma in early life. J Allergy Clin Immunol. 2017;140(1):1-12. 
doi:10.1016/j.jaci.2017.05.010.  
4. Rumchev KB, Spickett JT, Bulsara MK, Phillips MR, Stick SM. Domestic exposure to 
formaldehyde significantly increases the risk of asthma in young children. Eur Respir J. 
2002;20(2):403-408.  
5. Clark NA, Demers PA, Karr CJ, et al. Effect of early life exposure to air pollution on 
development of childhood asthma. Environ Health Perspect. 2010;118(2):284-290. 
doi:10.1289/ehp.0900916.  
6. Gold DR, Adamkiewicz G, Arshad SH, et al. NIAID, NIEHS, NHLBI, and MCAN Workshop 
Report: The indoor environment and childhood asthma—implications for home 
environmental intervention in asthma prevention and management. Journal of Allergy and 
Clinical Immunology. 2017;0(0). doi:10.1016/j.jaci.2017.04.024.  
7. Caudri D, Wijga A, Scholtens S, Kerkhof M. Early daycare is associated with an increase in 
airway symptoms in early childhood but is no protection against asthma or atopy at 8 years. 
American journal of .... 2009. doi:10.1164/rccm.200903-0327OC.  
8. Bernstein JA, Alexis N, Bacchus H, et al. The health effects of nonindustrial indoor air 
pollution. Journal of Allergy and Clinical Immunology. 2008;121(3):585-591. 
doi:10.1016/j.jaci.2007.10.045.  
9. Wisconsin Department of Health Services. Burden of Asthma in Wisconsin 2013. 
https://www.dhs.wisconsin.gov/publications/p4/p45055-2013.pdf.  
10. Hoang T, Castorina R, Gaspar F, et al. VOC exposures in California early childhood education 
environments. Indoor Air. 2017;27(3):609-621. doi:10.1111/ina.12340.  
11. Air pollution and contaminants at child-care and preschool facilities in California. 
arb.ca.gov. https://www.arb.ca.gov/html/fact_sheets/preschool_exposure.pdf. Accessed 
June 30, 2017.  
12. Carreiro-Martins P, Papoila AL, Caires I, et al. Effect of indoor air quality of day care centers 
in children with different predisposition for asthma. Pediatr Allergy Immunol. 
2016;27(3):299-306. doi:10.1111/pai.12521.  
13. St-Jean ML, St-Amand A, Gilbert NL, et al. Indoor air quality in Montr?al area day-care 
centres, Canada. Environmental Research. 2012;118:1-7. 
doi:10.1016/j.envres.2012.07.001.  
14. Zuraimi MS, Tham KW. Indoor air quality and its determinants in tropical child care centers. 
Atmospheric Environment. 2008;42(9):2225-2239. doi:10.1016/j.atmosenv.2007.11.041.  
15. Bröms K, Svärdsudd K, Sundelin C, Norbäck D. A nationwide study of indoor and outdoor 
environments in allergen avoidance and conventional daycare centers in Sweden. Indoor 
Air. 2006;16(3):227-235. doi:10.1111/j.1600-0668.2005.00420.x.  
16. Ruotsalainen R, Jaakkola N, Jaakkola JJK. Ventilation and indoor air quality in Finnish 
daycare centers. Environment International. 1993;19(2):109-119. doi:10.1016/0160- 
4120(93)90362-L.  

17. Clausen G, Høst A, Toftum J, et al. Children's health and its association with indoor 
environments in Danish homes and daycare centres - methods. Indoor Air. 2012;22(6):467-
475. doi:10.1111/j.1600-0668.2012.00777.x.  
18. Branco P, Alvim-Ferraz M, Martins FG. Indoor air quality in urban nurseries at Porto city: 
Particulate matter assessment. Atmospheric .... 2014.  
19. Roda CL, Barral S, Ravelomanantsoa H, et al. Assessment of indoor environment in Paris 
child day care centers. Environmental Research. 2011;111(8):1010-1017. 
doi:10.1016/j.envres.2011.06.009.  
20. WI Department of Children and Families. DCF 251 LICENSING RULES FOR GROUP CHILD 
CARE CENTERS With Commentary. dcf.wisconsin.gov/cclicensing/lcc- directories. 
http://dcf.wisconsin.gov/files/publications/pdf/4024.pdf. Accessed June 30, 2017.  
21. Wisconsin Department of Health Services. Health Disparities in Wisconsin Hospitalizations 
for Asthma. 2017. https://www.dhs.wisconsin.gov/publications/p01727.pdf.  
22. Grineski S. Incorporating health outcomes into environmental justice research: The case of 
children's asthma and air pollution in Phoenix, Arizona. Environmental Hazards. November 
2007. doi:10.1016/j.envhaz.2007.09.007.  
23. Salo PIM, Sever ML, Zeldin DC. Indoor allergens in school and day care environments. 
Journal of Allergy and Clinical Immunology. 2009;124(2):185-192.e189. 
doi:10.1016/j.jaci.2009.05.012.  
24. Johnson L, Ciaccio C, Barnes CS, et al. Low-cost interventions improve indoor air quality and 
children's health. Allergy and Asthma Proceedings. 2009;30(4):377-385. 
doi:10.2500/aap.2009.30.3257.  
25. Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a Home-Based Environmental 
Intervention among Urban Children with Asthma. New England Journal of Medicine. 
2004;351(11):1068-1080. doi:10.1056/NEJMoa032097.  
26. Seltenrich N. Environmental exposures in the context of child care. Environ Health Perspect. 
2013;121(5):a160-a165. doi:10.1289/ehp.121-a160.  
27. Arizona Dept. of Environmental Quality. Indoor Air Quality Issues for Child Care Facilities. 
legacy.azdeq.gov. http://legacy.azdeq.gov/function/about/download/indoorair.pdf. 
Accessed June 30, 2017.  
28. National Institutes of Health. PRISMS: NIH Funding Opportunity. 
https://www.nibib.nih.gov/funding/funding-opportunities/prisms. Accessed August 23, 
2017.  
29. The National Training Institute for Child Care Health Consultants, Department of Maternal 
and Child Health. Environmental Health in Child Care.  
30. Sousan S, Koehler K, Hallett L, Peters TM. Evaluation of consumer monitors to measure 
particulate matter. Journal of Aerosol Science. 2017;107:123-133. 
doi:10.1016/j.jaerosci.2017.02.013.  
31. Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster 
randomised trial: rationale, design, analysis, and reporting. BMJ. 2015;350:h391.  
32. Taljaard M, Lilford R, Girling A, Hemming K. The stepped wedge cluster randomised trial: an 
opportunity to increase the quality of evaluations of service delivery and public policy 
interventions. Trials. 2015;16(S2):P4. doi:10.1186/1745-6215-16-S2-P4.