Full Text NR-95-001 COMMUNITY PREVENTION MODELS: RURAL MINORITY GROUPS NIH GUIDE, Volume 24, Number 1, January 13, 1995 RFA: NR-95-001 P.T. 34 Keywords: 0730075 Health Services Delivery Disease Prevention+ National Institute of Nursing Research Letter of Intent Receipt Date: March 31, 1995 Application Receipt Date: April 26, 1995 PURPOSE The National Institute of Nursing Research (NINR) invites research grant applications on comprehensive, community-based health care strategies aimed at primary, secondary and tertiary prevention of disease and disabilities in rural populations lacking adequate health care services. The purpose is to determine the impact of comprehensive, community-based strategies incorporating culturally specific approaches on the health of underserved, rural, minority population groups. Targeted populations include ethnic minority groups such as Native Americans, Asians and Pacific Islanders, Hispanic Americans, and African Americans. HEALTHY PEOPLE 2000 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 Request for Applications (RFA), Community Prevention Models: Rural Minority Groups, 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 "Healthy People 2000" (Summary Report: Stock No. 017-001-00473-1) through the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325 (telephone 202-783-3238). ELIGIBILITY REQUIREMENTS 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. Racial/ethnic minority individuals, women, and persons with disabilities are encouraged to apply as Principal Investigators. MECHANISM OF SUPPORT This RFA will use the National Institutes of Health (NIH) research project grant (R01). Responsibility for the planning, direction, and execution of the proposed project will be solely that of the applicant. Collaboration of investigators funded under this RFA is planned, see SPECIAL REQUIREMENTS section below. The total project period for an application submitted in response to this RFA may not exceed five years. The anticipated award date is September 30, 1995. Because the nature and scope of the research proposed in response to this RFA may vary, it is anticipated that the size of an award will vary also. This RFA is a one-time solicitation. Future unsolicited competing continuation applications will compete with all investigator-initiated applications and be reviewed according to the customary peer review procedures. FUNDS AVAILABLE Approximately $1.8 million in total costs for the first year will be committed to fund applications submitted in response to this RFA. It is anticipated that four to five applications will be funded. This level of support is dependent on the receipt of a sufficient number of applications of high scientific merit. Although this program is provided for in the financial plans of the NINR, awards pursuant to this RFA are contingent upon the availability of funds for this purpose. RESEARCH OBJECTIVES Background The NINR, in its ongoing development of the National Nursing Research Agenda, convened a panel of scientific experts to examine the state of the science on community-based health care models, focusing on those that involve nursing practice. This panel has recommended strategies that respond to the growing number of programs that focus on community-based health care and preventive health strategies. The panel has specifically recommended studies of comprehensive community-based health care models for rural populations from the perspective of primary health care, which focuses on promoting health and preventing disease across the continuum of care. In their review of existing research, the panel determined that further study of community-based models for rural residents was a very promising area for expansion of our scientific knowledge. In the public health/community health context, primary health care includes primary, secondary, and tertiary prevention. Primary prevention includes health promotion and protection (such as immunizations of children and elders, nutrition counseling, and life style alterations) aimed at intervening before disease arises in individuals. Secondary prevention measures aim to prevent disease and disability through screening, early detection and diagnosis, and prompt treatment of pre-symptomatic or very early clinical disease (such as obesity, hypercholesterolemia) of populations thought to be at-risk. Tertiary prevention measures seek to limit disabilities in persons with various stages of disease and rehabilitation (such as those requiring restorative care or those with chronic illness). Different definitions of "community" arise from the different types of settings (worksites, senior centers, ambulatory clinics) and types of populations (those with low-incomes, frail elderly, children and adolescents) that are appropriate for community studies. The major defining element of community-based care, however, is the involvement of clients and other community members in (a) assessing environmental influences, health status, and health care use; (b) determining related-health priorities; (c) designing and implementing health programs; (d) encouraging participation in the resulting health programs; and (e) evaluating the impact of the health programs. The panel's review of the research on community-based models revealed the existence of many categorical health care programs, but found that the effect of these programs on specific population groups has not yet been scientifically well established. There are also indications that some fundamental factors thought to be needed for community-based health care success (accessibility, appropriateness, availability, adequacy, affordability, and acceptability) have not been included in programs and that the unique cultural requirements of groups such as ethnic minorities have not been part of the design. The lack of cultural specificity in the design of prevention programs is thought to be a potential major factor in the infrequent participation of ethnic minority groups in these programs. Several current studies indicate that identifying and incorporating unique cultural factors into intervention strategies may result in increased acceptability, use, and adherence. Other prevention 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. There is evidence that certain population groups use health care services only in crises and may choose not to use prevention measures even when strongly advised to do so (for example, known HIV risk factors and use of condoms or other safety measures). At the same time, there are indications that the explanation may be less 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. Including cultural factors unique for specific populations in the design of community-based health care programs has been shown to increase participation in these programs, the use of certain interventions or treatments, and earlier recognition of risk factors. It is believed but not well tested that prevention strategies and interventions developed with the involvement of community participants and implemented through partnerships between community members and practitioners may achieve a higher participation rate and may be maintained for longer periods of time. Some studies have shown, for example that members of specific cultural groups, including indigenous health workers and ethnic healers, should be involved in (a) designing of actual health care practices and services so as to assure acceptance; (b) establishing methods for gaining participation in health promoting behaviors and self care, use prevention techniques, and adherence to treatments; (c) understanding individual, family and community decision making processes; and (d) gaining acceptance of practitioners who are not group members. Understanding the lifestyle and unique needs of a community appears to be essential for successful collaboration in such settings, and some have speculated that these factors themselves may play a determining role in the understanding of health status across various population groups. It is not known to what extent the limited inclusion of cultural factors represents barriers to health care participation generally and the use of prevention strategies in particular. The inter- relationship of these 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 African American churchgoers and rural pregnant women indicate that use of prevention strategies increase, 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 The objective of this initiative is to examine the effect of comprehensive community-based primary health care models designed to include culturally appropriate approaches. The specific populations of focus are rural, minority groups. Applicants should focus on models targeted to populations as a whole, such as rural residents including a specific focus on minority groups, or to specific subpopulation groups, such as ethnic minority groups. Individuals, families and other community participants as well as clinical practitioners and other providers may be included as foci of research questions. Contextual and system factors, such as environmental factors, specific aspects of community involvement or ethnic group involvement, non-health care cultural, social and economic factors should be addressed. Where appropriate, it is preferred that primary, secondary and tertiary prevention strategies be included in the models examined. It is not required that all three prevention foci be included in the proposed model. The term rural has several definitions. This diversity has been problematic because of a lack of precision in defining rural for research purposes. For example, subcomponents of rural could represent population groups that were relatively close to urban centers, moderately distant, or far away and, therefore, more frontier-like in nature. As there is no one agreed-upon definition of rural for research purposes, those applying in response to this RFA must use one of two definitions of rural. These are: (1) the U.S. Bureau of the Census (1987) designation that an area with 2,500 or more persons is urban and that those areas not classified as urban are rural; or (2) the U.S. Office of Management and Budget (1983) identification of metropolitan statistical areas (MSA) as cities of 50,000 or more persons, or an urbanized area with at least 50,000 persons that is part of a county or counties having at least 100,000 in its populations, therefore, non-MSAs are rural. In addition, applicants should indicate: (a) the total number of persons in the geographic area of the proposed study; (b) the distance of the geographic area in the proposed study from a MSA; and (c) the population density of the area. The focus of research areas and questions that could be addressed under this initiative include, but are not limited to: o Do comprehensive, culturally specific, community-based primary health care models targeted to rural, minority groups result in improved health of, or health-related behavioral changes among community members? Does a culturally specific approach effect participation in the prevention strategies incorporated in the model? o What are the effects of culturally specific prevention strategies targeted to particular age groups of populations, such as rural, minority pre-school and school-age children, that include family and community participation in the planning, design, and implementation? Such strategies targeted to those of different socioeconomic level? o What are the differences among subpopulations in the use of, and effects of, targeted primary, secondary and tertiary prevention strategies? What factors can be differentiated as most influential? To what extent are they culturally driven? o What, if any, behavioral changes result from implementing primary, secondary and tertiary strategies targeted for specific cultural groups when there is direct family/community involvement? o Are there differences in health status, risk factors, clinical and cost outcomes between comprehensive community- based prevention programs and the more traditional practitioner-individual patient- focused, episodic primary care programs? o 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 costs? A variety of research designs could be proposed. However, research designs should include: a prospective, experimental or quasi- experimental approach; a well defined, specified rural population or subpopulation group(s); clear access to such a population/group(s); a theoretical basis for the model or organizing subcomponents; and demonstration of community involvement. The terms used to identify ethnic minority groups can vary in many ways. Some note traditional identifiers of origin, such as Mexican Americans; others refer to linguistic identifiers, such as Hispanics; and still others are more self descriptors, such as Latinos. It is important for population(s) targeted in a study to be clearly identified and their relationship to community boundaries described. SPECIAL REQUIREMENTS Applicants are asked to plan for an annual meeting of investigators. A meeting will be held early in the first year of funding to facilitate collaboration among the funded investigators and to determine the feasibility of coordination of aspects of research designs and of holding regular meetings. The cost of attending these meetings, which will be held in Bethesda, Maryland, should be included in the applicant's budget request. INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS 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. LETTER OF INTENT Prospective applicants are asked to submit, by March 31, 1995, a letter of intent that includes a descriptive title of the proposed research, the name, address, and telephone number of the Principal Investigator, the identities of other key personnel and participating institutions, and the number and title of the RFA in response to which the application may be submitted. Although a letter of intent is not required, is not binding, and does not enter into the review of a subsequent application, the information that it contains allows NINR staff to estimate the potential review workload and avoid conflict of interest in the review. The letter of intent is to be sent to: Dr. Ernest Marquez Chief, Office of Review National Institute of Nursing Research Building 45, Room 3AN-24 45 Center Drive, MSC 6302 Bethesda, MD 20892-6302 Telephone: (301) 594-5965 FAX: (301) 480-8256 APPLICATION PROCEDURES The research grant application form PHS 398 (rev. 9/91) is to be used in applying for these grants. These forms are available at most institutional offices of sponsored research; from the Office of Grants Information, Division of Research Grants, National Institutes of Health, 5333 Westbard Avenue, Room 449, Bethesda, MD 20892, telephone 301/710-0267; and from the NINR Information Office listed under INQUIRIES. The RFA label available in the PHS 398 (rev. 9/91) application form must be affixed to the bottom of the face page of the application. Failure to use this label could result in delayed processing of the application such that it may not reach the review committee in time for review. In addition, the RFA title and number must be typed on line 2a of the face page of the application form and the YES box must be marked. Submit a signed, typewritten original of the application, including the Checklist, and three signed, photocopies, in one package to: Division of Research Grants National Institutes of Health Westwood Building, Room 240 Bethesda, MD 20892** At the time of submission, two additional copies of the application must be sent to: Dr. Ernest Marquez Chief, Office of Review Building 45, Room 3AN-24 45 Center Drive, MSC 6302 Bethesda, MD 20892-6302 Telephone: (301) 594-5965 FAX: (301) 480-8256 Applications must be received by April 26, 1995. If an application is received after that date, it will be returned to the applicant without review. The Division of Research Grants (DRG) will not accept any application in response to this RFA that is essentially the same as one currently pending initial review, unless the applicant withdraws the pending application. The DRG will not accept any application that is essentially the same as one already reviewed. This does not preclude the submission of substantial revisions of applications already reviewed, but such applications must include an introduction addressing the previous critique. REVIEW CONSIDERATIONS Upon receipt, applications will be reviewed for completeness by DRG and for responsiveness by NINR staff. Incomplete applications will be returned to the applicant without further consideration. If the application is not responsive to the RFA, NIH staff may contact the applicant to determine whether it should be returned or submitted for review in competition with unsolicited applications at the next review cycle. Applications that are complete and responsive to the RFA will be evaluated for scientific and technical merit by an appropriate peer review group convened by the NINR in accordance with the review criteria stated below. As part of the initial merit review, a process (triage) may be used by the initial review group in which applications will be determined to be competitive or non-competitive based on their scientific merit relative to other applications received in response to the RFA. Applications judged to be competitive will be discussed and be assigned a priority score. Applications determined to be non- competitive will be withdrawn from further consideration and the Principal Investigator and the official signing for the applicant organization will be notified. Review Criteria o The review criteria for this RFA are essentially the same as those for unsolicited research project grant applications: o Scientific, technical, or clinical significance and originality of proposed research; o Appropriateness and adequacy of the experimental or quasi-experimental 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 In addition, applicants are expected to address the issues identified under "SPECIAL REQUIREMENTS," as well as criteria specific to the objectives of this RFA. These criteria include: o Applicants must be specific in defining the rural areas to be included in the study. o The applicant must provide documentation supporting access to the population(s) and community involved in the proposed study. The initial review group will also examine the provisions for the protection of human and animal subjects and the safety of the research environment. AWARD CRITERIA Awards will be made based on scientific merit determined by peer review and expressed in the priority score, availability of funds, and programmatic priorities. Award decisions will also take into consideration the extent of diversity of approaches among the primary health care models proposed. INQUIRIES Inquiries concerning this RFA are encouraged. The opportunity to clarify any issues or questions from potential applicants is welcome. Direct requests for copies of the RFA or other NINR documents to: NINR Information Office Building 31, Room 5B13 Bethesda, MD 20892 Telephone: (301) 496-0207 FAX: (301) 480-4969 Direct inquiries regarding scientific/programmatic issues to: Dr. Patricia Moritz Nursing Systems Branch National Institute of Nursing Research Building 45, Room 3AN-12 45 Center Drive MSC 6300 Bethesda, MD 20892-6300 Telephone: (301) 594-5956 FAX: (301) 480-8260 Email: pmoritz@ep.ninr.nih.gov Direct inquiries regarding fiscal matters to: Ms. Sally Nichols Grants Management Officer National Institute of Nursing Research Building 45, Room 3AN-32 45 Center Drive MSC 6301 Bethesda, MD 20892-6301 Telephone: (301 594-6869) FAX: (301 480-8256) Email: snichols@ep.ninr.nih.gov AUTHORITY AND REGULATIONS 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 Public Health Service (PHS) strongly encourages all grant recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people. References U.S. Bureau of the Census. (1987). Statistical abstract of the United States: 1988 (108th ed.). Washington, D.C.: U.S. Government Printing Office. U.S. Office of Management and Budget. (1983). Metropolitan statistical areas (NTIS No. PB83-218891). Washington, D.C.: U.S. Government Printing Office. .
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