Full Text PA-96-037
NIH GUIDE, Volume 25, Number 11, April 5, 1996
PA NUMBER:  PA-96-037
P.T. 34

  Health Promotion 
  Risk Factors/Analysis 
  Community/Outreach Programs 

National Institute of Nursing Research
The National Institute of Nursing Research (NINR) is interested in
facilitating investigator-initiated research into the clinical
application of intervention strategies designed to reduce health
risks at the community level.  Community-based strategies targeting
health problems of rural residents and of underserved minority groups
are of particular interest to NINR.
The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of "Healthy People 2000,"
a PHS-led national activity for setting priority areas.  This Program
Announcement (PA), Health Risk Reduction:  Community-Based
Strategies, is related to all of the special populations targets.
Potential applicants may obtain a copy of "Healthy People 2000" (Full
Report:  Stock No. 017-001-00474-0 or Summary Report:  Stock No.
017-001-00473-1) through the Superintendent of Documents, Government
Printing Office, Washington, DC 20402-9325 (telephone 202-512-1800).
Research applications may be submitted by domestic and foreign, for-
profit and non-profit organizations, public and private, such as
universities, colleges, hospitals, laboratories, units of State and
local governments, and eligible agencies of the Federal government.
Foreign institutions are not eligible for First Independent Research
Support and Transition (FIRST) (R29) awards.  Racial/ethnic minority
individuals, women, and persons with disabilities are encouraged to
apply as Principal Investigators.
The mechanisms of support will be the National Institutes of Health
(NIH) research project grant (R01) and FIRST (R29) award.
Responsibility for the planning, direction, and execution of the
proposed project will be solely that of the applicant.
Major relocations and transitions are occurring in health care.  New
forms of health care delivery and financing are creating the need to
review the efficacy and effectiveness of wellness and risk reduction
protocols, clinical treatments and intervention strategies, and
rehabilitation efforts, many of which were previously tested through
carefully controlled studies in hospitals.  The major emphasis today
is on providing health care in the community, frequently to groups of
patients rather than to individuals.  There is little indication that
this change will reverse itself.  There is also little evidence that
community-based health care strategies have been tested in a
systematic and ongoing manner.
The NINR convened a panel of scientific experts to examine the status
of research on community-based health care models, with a particular
focus on those that involve nursing strategies.  The report of the
panel is available from NINR (See Inquiries section below).  The
panel reviewed a variety of community-based models and intervention
strategies, many of which have not been fully evaluated, nor tested
for appropriateness.  In general, however, the panel determined that
community-based intervention strategies which directly involve
community participation are more likely to be successful and to
continue overtime than those relying solely on practitioner-patient
relationships.  Such an approach should enhance the chances that the
risk reduction and health restoration activities will be maintained
and their effect seen in the long term.
The panel recommended that the perspective of primary health care be
used as an organizing framework for community-based models.  In the
public health/community health context, primary health care includes
primary, secondary, and tertiary prevention of health risks and
disease onset and extension.  Primary prevention includes health
promotion and protection (such as immunizations of children and
elders, nutrition counseling, and life style alterations) aimed at
risky behaviors and at intervening before disease arises.  Secondary
prevention measures aim to prevent disease and disability through
screening, early detection of risks, and prompt treatment of pre-
symptomatic or early clinical disease (such as obesity,
hypercholesterolemia education, and cardiac risk reduction
strategies) of populations thought to be at-risk.  Tertiary
prevention measures seek to limit disease progression and the onset
or extension of disabilities in persons in various stages of disease
and rehabilitation (such as those with obstructive pulmonary disease,
hypertension, coronary artery disease or diabetes mellitus).
The lack of cultural specificity in the design of community-based
programs is thought to be a potential major factor in the less
frequent participation of certain groups, especially ethnic
minorities.  Several current studies indicate that identifying and
incorporating unique cultural factors into intervention strategies
may result in increased acceptability, use, and adherence.  Other
studies have  identified intervention strategies that were
efficacious but which had only limited continued use after the
controlled circumstances of a specific study were withdrawn.  Rural
residents usually have more intimate knowledge of each other than is
possible in more densely populated areas resulting in the potential
for some residents avoiding care from fear of neighbors finding out
they have a health problem even when the health problem may be
unknowingly shared by a number of their neighbors.  Community member
participation in planning and designing intervention strategies may
assist in resolving this phenomenon.
There is evidence that certain population groups use health care
services only in crises and may choose not to use preventative,
restorative, or rehabilitative measures even when strongly advised to
do so.  For example, those with known HIV risk factors are strongly
urged to use condoms or other safety measures, but many do not follow
this advice.  Those with chronic conditions frequently have
medications prescribed to control their disease or its related
symptoms, such as those taking medication for seizures or for
hypertension, and who may or may not take the medication as
instructed.  After several types of surgery or after stroke,
rehabilitative protocols such as exercises are prescribed to assist
in restoring function or to increase various physiological
capacities; however, there is great variation in patient adherence to
these exercise protocols.  There are indications that the explanation
for this lack of use of prescribed or advised treatments and safety
measures may be less the characteristics of the population groups
themselves than the approaches and design of health care systems
available to them. Our understanding is further clouded by a tendency
to uniformly stereotype the health-related behaviors of all
population groups when indeed they relate to only one or some part of
the groups.  An example is the over-generalization that all minority
groups have poor pregnancy outcomes, when this is true for many
African-Americans, but not for most Hispanic-Americans.  Another
example is the prescriptive telling to do treatments rather than a
collaborative planning approach to treatment choices.
It is not known to what extent the limited inclusion of cultural
factors represents a barrier to health care participation in general
or to the use of prevention strategies in particular.  The inter-
relationship of cultural factors and economic factors on the use and
acceptability of health care among rural minority groups is also
unclear.  Some investigators have found that certain ethnic minority
groups and rural residents use health care services differently than
others, have illnesses diagnosed at a later stage than other groups,
and seek care later in a disease process than others.  Intervention
studies with subsets of minority groups, such as certain rural Native
Americans, migrant Hispanics, southern Black churchgoers, and rural
pregnant women indicate that use of prevention strategies increases,
involvement in prenatal care starts earlier, and chronic illness risk
factors are modified when the clinical care is modified according to
cultural expectations.
Research Objectives and Scope
Interest is in research targeted on identifying and reducing risk
factors and disease occurrence at the community level.  Individuals,
families and other community groups as well as clinical practitioners
and other providers may be included as foci of research questions.
If questions are included about practitioners/providers in a study
design, they should be secondary rather than the primary questions in
the study.  Contextual and system issues, such as environmental
factors, specific aspects of community participation or ethnic group
involvement, non-health care cultural, social and economic issues may
be addressed as components of studies.
The major purpose of this program announcement is to stimulate
studies that directly test community-based intervention strategies
and models.  However, preliminary studies that will lead to such
research are encouraged, if such work is necessary to achieve the
central purpose.  These studies may take the form of epidemiological
inquiries, qualitative investigations such as ethnographies, or
initial testing of intervention strategies on a smaller scale.
Preliminary studies examining aspects of cultural sensitivity of
intervention strategies or measures are also encouraged, if needed.
Other methodological studies crucial to the successful conduct and
analysis of community-level studies are also encouraged.  Testing of
strategies that may be unique in providing community level care, such
as computer linkages and interactive television, may be tested if
they are targeted to health problems or clinical conditions.
The focus of research questions that could be addressed under this
initiative include the examples noted in the narrative above and the
questions noted here, but are not limited to these:
o  Do community-based health care models result in improved health
of, or in health-related behavioral changes among community members?
Do targeted, culturally relevant health care strategies change
participation, timeliness of health seeking behaviors, frequency of
crisis-oriented care seeking behaviors, appropriateness and
acceptability of care, and o  costs?
o  Are there unique requirements for community-based interventions or
models in rural areas?  How are they met? How can primary prevention
as well as the restorative and rehabilitative interventions be
implemented at the community level in rural areas?
o  What are the effects of health care strategies targeted to
particular age groups of populations, such as pre-school and school-
age children or middle age adults?  Are they different when family
and community participation are included in the planning, design, and
implementation?  Are differences seen when such strategies are
targeted to those of different socioeconomic levels? Are they
different when targeted to rural or minority populations?
o  Are there differences in health status, risk factors, clinical and
cost outcomes between community-based programs and the more
traditional individual patient-focused, episodic health care
programs?  Note: NINR is not interested in studies that propose cost
analyses alone.
It is the policy of the NIH that women and members of minority groups
and their subpopulations must be included in all NIH supported
biomedical and behavioral research projects involving human subjects,
unless a clear and compelling rationale and justification is provided
that inclusion is inappropriate with respect to the health of the
subjects or the purpose of the research.  This new policy results
from the NIH Revitalization Act of 1993 (Section 492B of Public Law
103-43) and supersedes and strengthens the previous policies
(Concerning the Inclusion of Women in Study Populations, and
Concerning the Inclusion of Minorities in Study Populations), which
have been in effect since 1990. The new policy contains some
provisions that are substantially different from the 1990 policies.
All investigators proposing research involving human subjects should
read the "NIH Guidelines For Inclusion of Women and Minorities as
Subjects in Clinical Research," which have been published in the
Federal Register of March 28, 1994 (FR 59 14508-14513) and reprinted
in the NIH Guide for Grants and Contracts, Volume 23, Number 11,
March 18, 1994.
Investigators also may obtain copies of the policy from the program
staff listed under INQUIRIES.  Program staff may also provide
additional relevant information concerning the policy.
Applications are to be submitted on grant application form PHS 398
(rev. 5/95) and will be accepted at the standard application
deadlines as indicated in the application kit.  Applications kits are
available at most institutional offices of sponsored research and may
be obtained from the Grants Information Office, Office of Extramural
Outreach and Information Resources, National Institutes of Health,
6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone
301/435-0714, email:  ASKNIH@odrockm1.od.nih.gov.  The title and
number of the program announcement must be typed in Section 2 on the
face page of the application.
Applications for the FIRST Award (R29) must include at least three
sealed letters of reference attached to the face page of the original
application.  FIRST Award (R29) applications submitted without the
required number of reference letters will be considered incomplete
and will be returned without review.
The complete original application and five legible copies must be
sent or delivered to:
6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for express/courier service)
Applications will be assigned on the basis of established PHS
referral guidelines.  Applications will be reviewed for scientific
and technical merit by  study sections of the Division of Research
Grants, NIH in accordance with the standard NIH review procedures.
Following scientific and technical review, the applications will
receive second-level review by the appropriate national advisory
Review Criteria
o  Scientific, technical, or clinical significance and originality of
proposed research;
o  Appropriateness and adequacy of the experimental,
quasi-experimental or qualitative approach and methodology proposed
to carry out the research;
o  Qualifications and research experience of the Principal
Investigator and staff, particularly, but not exclusively, in the
area of the proposed research;
o  Availability of the resources necessary to perform the research;
o  Appropriateness of the proposed budget and duration in relation to
the proposed research;
o  adequacy of plans to include both genders and minorities and their
subgroups as appropriate for the scientific goals of the research.
Plans for the recruitment and retention of subjects will also be
The initial review group will also examine the provisions for the
protection of human and animal subjects and the safety of the
research environment.
Applications will compete for available funds with all other approved
applications assigned to that institute or center.  The following
will be considered in making funding decisions: Quality of the
proposed project as determined by peer review, availability of funds,
and program priority.
Inquiries are encouraged.  The opportunity to clarify any issues or
questions from potential applicants is welcome.
For general scientific questions and those related to secondary and
tertiary prevention and/or chronic conditions, and for copies of the
expert panel report on Community-Based Health Strategies contact:
Dr. Patricia Moritz
Email:  pmoritz@ep.ninr.nih.gov
For questions related to primary prevention and other health behavior
strategies contact:
Dr. J. Taylor Harden
Email:  tharden@ep.ninr.nih.gov
For questions related to reproductive and infant health contact:
Dr. Laura James
Email:  ljames@ep.ninr.nih.gov
For questions related to cancer, HIV and other infectious diseases
Dr. June Lunney
Email:  jlunney@ep.ninr.nih.gov
For questions related to cardiopulmonary health and trauma contact:
Dr. Hilary Sigmon
Email:  hsigmon@ep.ninr.nih.gov
For questions related to neurological conditions contact:
Dr. Mary Leveck
Email:  mleveck@ep.ninr.nih.gov
All of the above may be contacted at:
Division of Extramural Programs
National Institute of Nursing Research
Building 45, Room 3AN-12
45 Center Drive MSC 6300
Bethesda, MD  20892-6300
Telephone:  (301) 594-6906
FAX:  (301) 480-8260
Direct inquiries regarding fiscal matters to:
Jeff Carow
Grants Management Office
National Institute of Nursing Research
Building 45, Room 3AN-32
6300 Center Drive MSC 6301
Bethesda, MD  20892-6301
Telephone:  (301) 594-6869
FAX:  (301) 480-8256
Email:  jcarow@ep.ninr.nih.gov
This program is described in the Catalog of Federal Domestic
Assistance No. 93.361, Nursing Research.  Awards are made under
authorization of the Public Health Service Act, Title IV, Part A
(Public Law 78-410, as amended by Public Law 99-158, 42 USC 241 and
285) and administered under PHS grants policies and Federal
Regulations 42 CFR 52 and 45 CFR Part 74.  This program is not
subject to the intergovernmental review requirements of Executive
Order 12372 or Health Systems Agency review.
The PHS strongly encourages all grant and contract recipients to
provide a smoke-free workplace and promote the non-use of all tobacco
products.  In addition, Public Law 103-227, the Pro-Children Act of
1994, prohibits smoking in certain facilities (or in some cases, any
portion of a facility) in which regular or routine education,
library, day care, health care or early childhood development
services are provided to children.  This is consistent with the PHS
mission to protect and advance the physical and mental health of the
American people.

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