Full Text NR-95-001


NIH GUIDE, Volume 24, Number 1, January 13, 1995

RFA:  NR-95-001

P.T. 34

  Health Services Delivery 
  Disease Prevention+ 

National Institute of Nursing Research

Letter of Intent Receipt Date:  March 31, 1995
Application Receipt Date:  April 26, 1995


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.


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).


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.


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.


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



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.


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.


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.


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


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 301/435-0714; and from the NINR Information Office listed

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.


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

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.


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 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


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


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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