The Changing COVID-19 Landscape: A Feasibility Study to Capture Momentary Residential Environmental Exposures and Asthma Symptoms in Adults
Conditions: Asthma, Environmental Exposure, Home Environment Related Disease
Sponsor: University of Kansas Medical Center

 
The Changing COVID-19 Landscape: A Feasibility Study to 
Capture Momentary Residential Environmental Exposures and 
Asthma Symptoms in Adults 
 
NCT05224076 
 
March 13, 2025 

SPECIFIC AIMS 
 
The global pandemic of coronavirus 2019 (COVID-19) has rapidly impacted the United States (US) 
population and is a substantial cause for concern among individuals with chronic respiratory diseases. Asthma 
is a complex, multi-faceted respiratory disease that affects over 19 million US adults (18 years or older).1 
Further, it is estimated that more than 60% of US adults with asthma have uncontrolled symptoms.2 This 
represents a substantial health and economic impact; uncontrolled asthma in the US results in the loss of 
approximately 15 million quality-adjusted life years among adults and a total economic burden (both direct and 
indirect costs) of greater than $960 billion over a 20-year span.3 In addition, adults appear to be nearly five 
times more likely to die from asthma than children and the asthma-related death rate is highest among those 
65 years and older.2 Viral infections are a prominent risk factor for asthma exacerbation4 and, thus, SARS-
CoV-2, the virus responsible for COVID-19, is cause for alarm among those diagnosed with asthma. 
Sheltering-in-place orders and recommendations, physical distancing, wearing face coverings, hand hygiene, 
and increased cleaning and disinfecting are primary COVID-19 preventative measures advocated by public 
health experts.5 What is not known are the effects of these preventive measures, specifically increased 
residential exposure to cleaning/disinfecting agents and other environmental exposures on adults with asthma. 
 
As individuals are sheltering at home for longer periods of time, those with asthma may increasingly 
contend with household asthma triggers and new chemical exposures as they sanitize their home 
environments to prevent COVID-19. Household asthma triggers may include air pollutants6,7 such as air 
particulate matter in the form of combustible pollutants such as secondhand smoke8 and use of different 
chemical cleaning/disinfecting products.9,10 Tight housing construction results in less well-ventilated homes and 
enhanced exposure to household air pollutants. Ordinarily, adults can spend as many as 15 hours per day 
indoors11,12 which further contributes to their risk for environmental exposures. The current COVID-19 crisis 
has altered usual cleaning practices and amount of time spent at home. It is unknown how these changes 
impact adults with asthma. 
 
We will assess the feasibility and usability of ecological momentary assessment (EMA) to capture the 
context of real time behaviors and environmental exposures that impact indoor environments. In addition, we 
will assess the feasibility and usability of providing participants with a readily available indoor air quality monitor 
(Awair Omni®) to continuously capture total volatile organic compounds (VOCs) and particulates (PM2.5). This 
design will allow us to alert participants of high levels and collect real time data on exposures and asthma 
symptoms. Daily and exposure-related lung function will be measured with a low-cost home spirometer. 
Finally, we will examine the effect of residential environmental exposures that may be related to increased time 
spent at home due to COVID-19 and the associations between these exposures and asthma control. 
 
Our team is comprised of three nurse-scientists and a physician-scientist, each of whom have research 
focused on asthma experienced in a range of age groups from adolescent to older adult. Our team has 
established community partners (Chicago Asthma Consortium) and our research team members are situated 
in three different midwestern US areas. Our long-term goal is to characterize the impact of COVID-19 on 
existing asthma risk factors so as to develop tailored, home-based asthma interventions that takes into account 
COVID-19 and are responsive to the changing home environment and change in home routines resulting from 
this pandemic. For adults with sub-optimally controlled asthma, this study will: 
Aim 1. Determine the feasibility and usability of (1) EMA to assess self-report residential environmental 
exposures and asthma symptoms, (2) home monitoring of environmental exposures (VOCs, PM2.5), and lung 
function (home spirometry, FEV1% predicted). 
Aim 2a. Assess the frequency and degree of residential environmental exposures (e.g., disinfectants/ 
cleaners, second-hand smoke) via (1) self-reported data, and (2) home monitoring objective measures. 
Aim 2b. Assess the level of asthma control as indicated by self-reported asthma symptoms and lung function.  
Aim 3. Explore associations of self-reported and objective measures of residential environmental exposures 
with self-reported and objective measures of asthma control. 
 
Findings from this study will provide preliminary data for a powered study to develop innovative intervention 
strategies for those with asthma addressing the impact of changes in environmental exposures related to 
COVID-19 and enhancing our preparedness for future infectious disease outbreaks. This has implications for 
risk reduction in individuals with asthma to help improve asthma self-management using personal monitors and 
sensors for individually tailored exposure profiles.  
 

SIGNIFICANCE 
 
Asthma is a disease of chronic airway inflammation and affects 1 in 12 adults in the US.1 Despite effective 
treatments for asthma, it is estimated that more than 60% of adults with asthma have uncontrolled symptoms.2 
Poorly controlled asthma increases the risks of severe asthma exacerbations which may result in missed work 
days, emergency room visits, and hospitalizations.13 The 20 year direct costs related to uncontrolled asthma 
exceed $300 billion thus the burden of uncontrolled asthma is substantial.3  
 
Presenting to a healthcare facility with symptoms of wheezing and shortness of breath can initially 
complicate diagnosis and treatment for asthma exacerbation or COVID-19.4 Currently, the available case study 
evidence is unclear whether those with asthma are at greater risk or overrepresented among cases with 
severe COVID-19 outcomes.14-17 Recent US data has shown higher rates of asthma in hospitalized COVID-19 
patients compared to COVID-19 patients in the ambulatory setting.18 Further, in one US cohort study, asthma 
was the second most common co-morbidity after obesity among those 18-49 years old with COVID-19.19 It is 
also unclear if individuals with asthma are overrepresented among those currently seeking testing for COVID-
19 across the nation. While cardiovascular disease, kidney disease, and diabetes have been associated with 
greater COVID-19, mortality20 pulmonary conditions such as asthma, which is exacerbated by respiratory 
viruses, have not been well studied in COVID-19. 
 
Residential asthma triggers. Adults ordinarily spend about 15 hours/day indoors11,12 and since COVID-19, 
those hours have largely been spent in their homes. Environmental asthma triggers in residential settings 
include dust mites, animal dander, mold, moisture, tobacco smoke, particulates, cockroach allergen, mouse/rat 
allergens, VOCs, and nitrogen dioxide.13,21,22 Indoor residential air quality has been associated with decreased 
general health, asthma symptoms, airway inflammation, asthma exacerbations and decreased lung function in 
adults with asthma.23-26 We will focus on residential VOCs, specifically disinfectants/cleaners, and particulates 
as potential asthma environmental triggers exposures increased during the COVID-19 pandemic.  
 
Disinfectants. The CDC recommends initially cleaning residential surfaces with soap and water followed 
by disinfecting surfaces with an EPA-registered household disinfectant.5 As of August, 2020 the EPA includes 
482 products that meet the EPA criteria for use against SARS CoV-2 virus. Information listed by the EPA 
includes product name, active ingredients, contact times required, formulation types (e.g., ready-to-use, wipes, 
dilatable), and use sites (residential, institutional, healthcare). There are 305 products listed for use in any 
setting, 16 products listed only for residential use, 33 for institutional/residential use, and 4 for 
healthcare/residential use. Many of the products listed as appropriate for residential use have active 
ingredients shown to be asthmagenic such as quaternary ammonium (195 products) and sodium hypochlorite 
(56 products).27 The EPA list provides no guidance regarding potential respiratory impacts of these products.  
 
The effects of disinfectants on adults with asthma have been widely explored in the occupational context; 
research specific to residential exposures and disinfecting/cleaning products is limited. Exposure to cleaning 
agents, disinfectants, and hand sanitizers at worksites has been shown to increase asthma related symptoms 
and exacerbations.28-36 In residential settings, weekly use of spray cleaners was associated with asthma in 
adults9,37,38 and with decreased FEV1 and FVC in European adults.39 The odds of current asthma for women 
using bleach 4-7 times per week were 3.0 (1.5-7.1) compared to never using bleach.10 Specific chemicals in 
cleaning/disinfecting products shown to impact asthma include d-limonene 40 terpenes, formaldehyde,41,42 
chloroform,43 quaternary ammonium compounds,31,44 amine compounds, and aldehydes.45 Other VOCs 
commonly found in cleaners/disinfectants include ethanol, acetone, propanol, and a-pinene.46 Our work in 
asthma and older adults revealed that, compared to those with well controlled asthma, participants with very 
poorly controlled asthma cleaned their bathrooms more often with products determined to have respiratory 
impact (p=002).47  While cleaners and disinfectants are known asthma triggers, the extent asthma is impacted 
when use is increased during a pandemic is unknown.  
 
Gharpure et al.48 reported that since the COVID-19 pandemic, 60% of respondents to an online US survey 
had increased cleaning/disinfecting since the pandemic. Over a third of survey respondents indicated they had 
engaged in at least one high-risk practice involving a disinfectant such as bleaching food, using a household 
disinfectant on their hands, or misting themselves with a cleaner/disinfectant.48 What is not known is the extent 
that adults with asthma engage in these types of practices, how often they clean/disinfect, and what impact 
these practices have on their asthma. 
 
Particulates. Particulate matter (PM) are small particles/liquid droplets that include acids, organic 
chemicals, metals, soils, dust, and allergens.49 Common indoor sources of particulates include outdoor 
sources, vacuum cleaner bags, printers, cooking, secondhand smoke, wood combustion in fireplaces/stoves, 
dust, pet hair, mold, candles, and biological sources.25,50 PM2.5 concentrations were found to be highest indoors 

in homes (vs. outdoors or in offices) on weekends when participants wearing personal air quality monitors were 
home for longer periods,51 thus supporting the increased potential exposure to particulates during the COVID-
19 pandemic. PM2.5, or particulates less than 2.5 micrometers, have been shown to affect cardiovascular 
health, anxiety, cognitive function, and respiratory health.50 The effects of PM2.5 on asthma are unclear. When 
nighttime particulates were monitored for 12 weeks in individuals with asthma sensitized to house dust mites 
(N=26), no consistent relationship was found between PM exposure and daily clinical outcomes (peak 
expiratory flow, FeNO, symptoms).52 In contrast, increased indoor particulates were significantly related to 
reduced lung function, specifically with candle burning.25 Increased frequency and severity of asthma 
exacerbations, asthma symptoms, hospitalizations, and asthma mortality were associated with increased 
ambient PM2.5.53-56 Polivka et al.,57 found that older adults with poorly controlled asthma had significantly 
greater maximum PM2.5 counts over a 24-hour period (p=.03). 
 
In summary, the impact of home disinfectant use and particulate matter on adult asthma outcomes, 
particularly during the COVID-19 pandemic, demands further investigation. The home environment is an 
unregulated space where individuals and families make 
unique purchasing and cleaning decisions driven by 
tradition, finances, social and media influences. Existing 
research on VOCs and particulate matter provides a strong 
scientific premise for further exploration of these exposures 
in the home as the COVID-19 pandemic continues to 
actively unfold. This research can provide evidence-based 
guidance for home disinfectant use during a pandemic for 
those with asthma. Research efforts focused on indoor 
home environments are essential to understand the 
possible extent of exposures that can impact asthma 
outcomes in a time when home and healthcare resources 
(social and financial) continue to be strained. To describe 
our research trajectory, we illustrate the goals of our 
feasibility study and the impacts we intend to accomplish 
using the Translational Research Framework.58,59 This 
feasibility study will assess residential exposures of 
disinfectants and particulates with the goal of reducing 
exposures and improving asthma outcomes (Figure 1).   
INNOVATION  
 
The proposed feasibility study is innovative in several ways. First, the study addresses how increased 
cleaning and disinfecting practices associated with a novel virus could impact asthma control in those with 
asthma. Second, we uniquely use EMA to examine the effects of environmental triggers on adult asthma 
symptoms in real time, allowing us to capture participant engagement in their own home environment. Third, 
we will use and integrate innovative technologies to collect self-report and objective residential exposure data 
(VOCs, PM2.5) in real time and link these data with self-report (EMA) and objective data on asthma control 
(spirometer). Fourth, this study focuses on adults with sub-optimal asthma control, a population also at higher 
risk for complications from COVID-19. 
APPROACH 
 
Preliminary work - Global COVID-19 and Asthma 
Study (GCAS). The proposed study builds on data 
collected from the GCAS, an ongoing cross-sectional 
online survey we launched in May 2020 to examine how 
the COVID-19 pandemic affected the prevalence of 
disinfectant use among adults with asthma and to assess 
the associations of the frequency of disinfectant use with 
asthma control as measured by the Asthma Control Test 
(ACT). To date, over 1000 individuals have responded. Of 
those, 92% are based in the US, 80% are female, about 
21% indicated minority race/ethnicity, and 625 agreed to 
be contacted for follow-up research. Of those willing to be contacted about, 40% had ACT≤19. About 95% of 
respondents reported increased hand washing, 88% increased use of alcohol-based hand sanitizer since the 

COVID-19 pandemic (Figure 2); about one-third noted increased smoking behaviors by household members. 
The percentage of participants reporting household use of disinfectant wipes, disinfectant sprays, and a bleach 
and water solution to disinfect objects ≥5 times per week more than doubled since COVID-19. We observed 
statistically significant associations of the increased frequency of household disinfectants use since COVID-19 
with reduced asthma control (ACT score ≤19).   
 
Chicago Asthma Consortium (CAC) was formed in 1996 by American College of Chest Physicians and 
Respiratory Health Association to coordinate the activities of the asthma community in Chicago. One priority of 
the CAC is the coordination of the Community Advisory Board (CAB), which was formed in 2014 with support 
from several grants. The CAB is comprised of community health workers, parents, patients, and pastors from 
the communities that have the highest asthma rates in Chicago. The research team met with the 5 members of 
CAC on Wednesday August 5, 2020. The study was briefly explained to CAC members and feedback was 
received related to all aspects of the proposed protocol including adding an instructional video, reducing the 
routine EMA notifications from 3 to 2X/day, the 14-day data collection length, and assuring a research team 
member was available for troubleshooting. Suggestions were incorporated into the study procedures. Once 
funded, we will meet with the CAC semi-annually for input and feedback on study protocols, measures, 
recruitment, and interpretation of findings.  
 
Research Design. This study will evaluate the feasibility and usability of assessing real-time residential 
environmental exposures (VOCs/PM2.5), asthma symptoms, and lung function using an innovative combination 
of commercially available technology (Aim 1).60 In addition, we will use observational design to explore the 
unintended effects of these residential environmental exposures on adults with poorly controlled asthma in the 
era of COVID-19 (Aims 2 & 3).  
 
Sample. Eligibility criteria include GCAS participants who: (1) indicated willingness to be contacted for 
future research, (2) reported high use of disinfectant/cleaning products since COVID-19 (≥5 per week), and 
current ACT≤19. Non-US residents and non-English speakers will be excluded. We will strive to have at least 
20% of the sample representing minority populations. Fifty individuals meeting these criteria will be randomly 
selected and invited to participate in this study using their preferred contact method (94% indicated email). 
Interested individuals will be directed to a REDCap survey link to confirm willingness to participate, verify 
eligibility, and provide current contact information. We will randomly select replacements if no response is 
received after 2 contact attempts over two weeks or lack of interest is indicated.  
 
Data collection methods. Three innovative data collection methods will be integrated in this feasibility 
study: Ecological Momentary Assessment (EMA) downloaded to participants’ smartphone, Awair Omni Indoor 
Air Quality Monitor®, and Zephyrx Spirometer.  
 
EMA is a survey approach which uses repeated sampling of participants to capture behaviors and 
experiences in a real time context. This methodological approach maintains the ecological validity of reported 
behaviors and decreases the impact of recall bias as surveys are sent periodically to participants through 
electronic devices.61 EMA is particularly useful when trying to understand the context around symptoms or 
behaviors. Available literature that combines the EMA methodology with asthma research focuses primarily on 
asthma-related outcomes such as symptoms, control, quality of life, history, and medication adherence and 
their relationship with stress (perceived stress, mood, hassles, social support).62-64 None of the published 
literature to date pairs EMA with indoor air quality and asthma symptoms. The ability to timestamp behaviors, 
events, experiences, whether they present a positive or negative health impact, is valuable when seeking to 
understand the complexity of multiple risk factors and multiple environmental and behavioral interactions.  
 
Awair Omni Indoor Air 
Quality Monitor® continuously 
monitors about 1,000 square feet of 
indoor air for 7 air quality factors: 
total VOC, PM2.5, temperature, 
humidity, CO2, ambient light, and 
ambient noise. This feasibility study will only focus on VOCs and PM2.5 levels (Table 1). The Awair Omni 
measures about 4"X4”X1.3", is wi-fi and Bluetooth enabled, plugs into a standard AC outlet, and includes an 8-
hour battery back-up. An air quality reading is taken every 10 seconds and real-time data are uploaded to a 
dashboard accessed only by research personnel. The display on the Awair Omni will be limited to VOCs and 
PM2.5 data. Our preliminary work with Awair indoor air quality monitors indicates that increased VOC levels are 
detected when disinfectants are used and increased PM2.5 levels are detected when vacuuming without a 
Exposure 
Sensor 
Range/ Accuracy 
Optimal range 
VOCs 
Multi-pixel metal oxide 
semiconductor gas sensor 
0-60,000 ppb/ ±10% 
<333ppb 
PM2.5 
Laser-based light 
scattering particle sensor 
0-1,000µg/m3/±15 
µg/m3 or 15% 
<15 µg/m3 

HEPA filter. The Awair proprietary dashboard provides secure communication between the Awair Omni and its 
dashboard. Data will be exported from the dashboard to a .CSV file.65-71 
 
Zephyrx Spirometer72 system allows for laboratory quality pulmonary function tests (PFTs) at home (FVS-
forced vital capacity, FEV1-forced expiratory volume in 1 second, FEV1/FVC, flow-volume loop). The system 
consists of an FDA approved handheld Bluetooth spirometer (MIR Spirobank Smart), and a mobile application 
that works on a smartphone or tablet device. The MIR Spirobank bank measures 49x109x21 mm and weighs 
60.7 g. Participants share PFT results through their app and researcher team members will access a HIPAA 
compliant portal to view participants’ PFT results in real time. An in-App video coaching feature guides the 
participant through the PFT maneuver. Each maneuver conducted by the participant creates a time and date 
stamped American Thoracic Society standard PFT report accessible through the portal. Data will be exported 
from the dashboard to a .CSV file.  
Procedures (Figure 3) 
1. Randomly selected individuals from the CGAS study who meet eligibility criteria will be invited to participate 
in the current study. Those interested will be 
directed to a REDCap link to complete an E-
consent form and baseline questionnaire.  
2. An Awair Indoor Air Quality Monitor and a 
ZephyrX Spirometer will be mailed to each 
participant along with a quick start guide, 
written instructions with a link to an 
instructional video, and research team contact 
information. Once received, a research team 
member will conduct a live chat with each 
participant to enable the devices, download 
apps (EMA, ZephyrX), setup and test the 
devices and apps, review the protocol, and 
address questions. Participants will be instructed to place the portable Awair air quality monitor in the room 
where they spend the most time during the day and at night where they sleep.  
3. A 3-day run-in period will be completed during which the participants will become familiar with the devices 
and troubleshoot issues (Awair requires 24-48 hours to calibrate VOC sensors). Study personnel will be 
available to answer questions/address technical issues. After the run-in period, a research team member 
will contact the participant to launch the 14-day data collection period.  
4. During the 14-day data collection period, data from the EMA will be collected using EMA software platform 
on a personal smartphone (iOS or Android) and EMA software platform.73 Each morning, participants will 
receive an EMA survey concerning asthma symptoms and a reminder to use their spirometer. Additionally, 
EMA surveys addressing disinfectant use, asthma symptoms, and spirometry will occur randomly twice/day 
(6am – 10pm) or tailored for those working off hours (Appendix).  
5. A custom interface between the EMA platform and the Awair indoor air quality monitor will alert participants 
when levels of indoor VOCs or particulates are detected outside the optimal range (Table 1). The air quality 
monitor will communicate with the EMA platform using publicly available application programming interface 
(api). Upon notification from the Awair, the EMA will signal the 
participant to complete a brief survey on disinfectant use/air particulate 
exposure (depending on the alert), current asthma symptoms, and 
proximity to the Awair (Appendix). The EMA will then direct participants 
to use the spirometer. Participants experiencing symptoms will be 
guided to follow their asthma action plan/provider instructions. 
6. Thirty minutes after VOC/PM2.5 notification, a second EMA notification 
will be sent for participants to complete a survey on mitigation 
strategies, respiratory outcomes, and spirometry use if not already 
completed (Figure 4).  
7. Research personnel will monitor use of these devices/apps and contact 
participants if a 24-hour gap in data is noted to address concerns and 
determine acceptability. Research team members will check-in with 
each participant at about the 7-day mark to address technical concerns 
and ease of use. 

8. At the end of the 14 days, participants will complete a short acceptability, appropriateness, and feasibility 
REDCap survey. A random sample of 20 participants will be interviewed to provide further insights.  
9. Participants will be asked to return the Awair in the provided mailer. The Awair will be fully disinfected per 
manufacturer’s directions. Participants will keep the ZephyrX spirometer as an incentive.  
Baseline Measures 
 The following measures will be administered at baseline via REDCap:  
1. Adult Asthma History includes 5 items adapted from the Behavioral Risk Factor Surveillance System 
Survey.74 Four items address participants’ recent contact with healthcare professionals for asthma since 
COVID-19. The final item addresses changes in routine work/activities due to asthma since COVID-19. 
2. Asthma Control Test (ACT). The ACT includes 5 items addressing: asthma symptoms, use of rescue 
medications, and effect of asthma on daily functioning. Responses are summed for total ACT score.75,76 
3. Airborne Exposures. The 7 items from the PROMIS℠ Pool V1.0 Dyspnea Airborne Exposure address 
airborne allergens, pollutants, smoke, pets, and use of pesticides using Yes:No response 
options.77  
4. Adult Asthma Adherence Questionnaire,™ includes 5 items on following their prescribed asthma 
medication plan and barriers to following that plan.78 
5. Health and Demographics includes items such as self-rated physical health, comorbidities, 
height/weight, age, education, ZIP code, smoking status, and COVID-19 prevention practices, and 
COVID-19 exposure/infection status. 
6. Home Environmental Exposure data will be gathered including home type, # of occupants, vacuum with 
HEPA filter, cleaning practices, cleaning products, air filter, heating, ventilation, smoke exposures, hand 
washing practices, pests, hobbies, odors, indoor plants, printers, flooring, and stove type.79,80  
We will also measure the following psychometrically valid measures as potential confounders: 
7. Emotional Distress-Anxiety and Depression PROMIS Short Forms 4a assess anxiety and depression 
levels within the last 7 days (4 items). Higher scores indicate higher severity of anxiety or 
depression.81,82 
8. Emotional Support, PROMIS_SF_V2 Short Form 4A measures perceived feelings of support. being 
cared for and valued (4 items).83 Higher score indicating a higher perceived emotional support. 
9. Perceived stress scale includes 4 items measuring the degree to which situations in one’s life are 
appraised as stressful.84-86 Higher scores indicate an increased level of perceived stress. 
EMA survey items (See Appendix).  
• Asthma symptoms (trouble breathing, wheezing, coughing, other symptoms [Yes:No]) assessed each time 
participants are asked to complete an EMA survey. 
• Random EMA surveys (twice/day) assess use of disinfectants/cleaners in last 2 hours (Yes:No) if Yes, the 
type, brand, and asthma symptoms are queried. 
• EMA survey triggered by VOCs/PM2.5 greater than optimal range as detected by the Awair will query 
asthma symptoms, lists of probable sources of elevated VOCs or PM2.5. 
• EMA survey 30-minutes after Awair air quality notification queries mitigation strategies used (from lists) and 
asthma symptoms. 
• Home spirometer use (Yes:No) queried in each EMA survey 
Home spirometer. FEV1% predicted– a standard metric of lung function for those with asthma. 
Seven-Day check-in. Open-ended questions to identify any trouble-shooting areas, determine if adjustments 
need to be made, and assess ease of use of the app/devices. Interactions will be recorded and reviewed by 
the research team for patterns and to identify any adjustments that are needed.   
Participant feasibility assessment. At the end of the 14-day data collection period, participants will be asked 
to respond to a short REDCap survey assessing acceptability, appropriateness, and feasibility of the indoor air 
quality monitor, EMA notifications, and the home spirometer with response ranging from 1=completely 
disagree to 5=completely agree. A random sample of 20 participants will be interviewed to further explore 
these factors using open-ended questions such as “Tell us what you liked/didn’t like about the indoor air quality 
monitor”, “Describe the strengths/concerns about the survey you received about your home indoor air quality”.  
Data Analysis 
 
Each day of observation will be divided into four 4-hour periods between 6 a.m. and 10 p.m. Data from a 
given period will be considered as follows: 

1. Period specific data from all event-contingent EMA prompts [prompts triggered by high indoor air 
VOC/PM2.5 readings] will be analyzed. If multiple event-contingent prompts were answered, data will be 
averaged across all event-contingent prompts during that period.  
2. Data from all answered baseline and random [signal-contingent] EMA prompts will be considered.  
Aim 1. For this aim, we will assess: 
1. Compliance with the EMA prompts as indicated by the frequency of responses to prompts, specifically:   
a. # of responses (complete:incomplete)/number of prompts 
b. # times spirometer used/number of prompts   
c. # times environment modified/number of event-contingent prompts 
2. Compliance as described in 1a-1c by 4-hr each period.  
 
We will also assess the duration the indoor air quality monitor is used by each participant. The quantitative 
participant feasibility assessment of acceptability, appropriateness, and feasibility will be analyzed 
descriptively. In addition, we will examine differences in use/acceptance by participant characteristics (e.g., 
age, asthma symptoms, overall health, education, etc). Qualitative interview data will be transcribed, uploaded 
into Dedoose qualitative analysis software for content analysis.  
 
Aim 2a: We will collect baseline data on the current frequency and degree of disinfectants/cleaners and 
exposure to environmental triggers (e.g., secondhand smoke). We will capture real-time self-reported data on 
disinfectant use throughout the study period. We will determine the prevalence of disinfectant/cleaner use and 
frequency (% EMA prompts at which disinfectant/cleaner use is reported). We will obtain data from the Awair 
dashboard to determine the number of times VOCs and PM2.5 levels exceed optimal levels, average daily 
levels, average levels per time period, and fluctuations in VOC and PM2.5. We will identify possible 
environmental triggers that contribute to high levels of VOCs and PM2.5 leading to event-contingent prompts.     
 
Aim 2b: We will determine baseline level of asthma control as measured by the ACT. We will use EMA to 
determine the level of asthma control over the study period as indicated by (a) asthma symptoms reported at 
each prompt and over the 14 days; (b) number of time-periods during which an EMA prompt is sent and 
participants report asthma symptoms; and (c) lung function as measured by FEV1% predicted at each prompt. 
Asthma control will also be evaluated using EMA by exploring differences in variability in lung function. 
 
Aim 3: Data collected using the EMA approach are multilevel with time windows (level 1) nested with 
individuals (level 2). The exposure variables will include: (1) Baseline self-reported use and frequency of 
disinfectant/cleaner use and PM2.5 exposures; (2) Number of times VOC and PM2.5 levels exceed the threshold 
for the optimal readings per week; and (3) Average scores of VOC and PM2.5 levels in the time windows 
considered in the analysis. The outcome variables we will consider include occurrence of any asthma 
symptoms, inhaler use, and FEV1% predicted (within 30 minutes of each EMA prompt).  
 
We will use multi-level binary logistic regression to examine the associations of the exposure variables with 
the binary outcome variables. We will use multilevel linear regression to examine the associations of the 
exposure variables with FEV1% predicted. We will control for level 1 variables (time of day, day of week) and 
level 2 variables (baseline asthma symptoms, demographic characteristics, and psychosocial characteristics). 
Using available time stamps from the indoor air quality monitor, EMA, and the spirometer, we will also explore 
average lag time between an event-contingent prompt and self-reported asthma symptoms using multilevel 
survival analyses.   
Summary 
The proposed study has several 
strengths. First, our study is 
innovatively addressing the 
increased use of disinfectants during 
COVID-19 in adults with asthma. The 
study builds on an ongoing study and 
will be conducted with individuals 
who have agreed to be recruited for 
future studies and facilitate recruitment. Furthermore, participants will be drawn from a wide geographic area in 
the US which increases broad representation of participants. Moreover, we will uniquely gather real time 
environmental exposure data and indicators of asthma control in unregulated indoor residential space without 
actual in-person contact. Finally, findings from this study have the potential to impact recommendations for 
indoor use of disinfectants/cleaners for those with asthma and will guide further research.  

 
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