Full Text CA-92-11

APPALACHIA LEADERSHIP INITIATIVE ON CANCER

NIH GUIDE, Volume 21, Number 10, March 13, 1992

RFA:  CA-92-11

P.T. 34, BB

Keywords: 
  Cancer/Carcinogenesis 
  Risk Factors/Analysis 
  Disease Prevention+ 
  Community/Outreach Programs 
  Disease Control+ 


National Cancer Institute

Letter of Intent Receipt Date:  April 10, 1992
Application Receipt Date:  May 21, 1992

PURPOSE

The National Outreach Initiatives Branch (NOIB), Division of Cancer
Prevention and Control (DCPC), National Cancer Institute (NCI), invites
cooperative agreement applications from organizations to participate in
establishing a strong, cancer control outreach program in Appalachia
(as defined in the research objectives section below).  The long-term
goals of the program are to achieve reductions in cancer incidence and
mortality, increases in cancer survival, and increases in the diagnosis
of cancers at earlier stages within the Appalachian region.  This
Request for Applications (RFA) invites applications that propose
mobilization of community lay and professional leaders to develop and
support community cancer control coalitions throughout Appalachia.
These coalitions will design and implement long-range, comprehensive,
multi-disciplinary, and community-wide cancer control outreach projects
and stimulate greater cancer control data collection and research
efforts.  As a result, measurable improvements are expected in
knowledge about prevention and early detection of cancer and access and
utilization of diagnostic and treatment services for cancer.

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 RFA, the
Appalachia Leadership Initiative on Cancer, is related to the priority
area of cancer.  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 public and private, for-profit and
non-profit, organizations serving a substantial number of Appalachian
clients such as universities, public health departments, voluntary
organizations, research centers, hospitals, consortia of health
providers, units of State and local governments, and eligible agencies
of the Federal Government.  Teams of applicants are encouraged.  Among
a team of applicants, one institution must be proposed as the lead
institution to serve as the applicant and to assume responsibility for
the conduct of the project.  Note that awards will not be made to
foreign institutions and that applications from domestic organizations
may not include international components.

MECHANISM OF SUPPORT

Support for this program will be through the cooperative agreement
(U01).  The cooperative agreement is an assistance mechanism in which
substantial NCI programmatic involvement with the recipients during
performance of the planned activity is anticipated.  The nature of NCI
staff involvement is described in the Special Requirements section
below.  Awardees will be responsible for the planning, direction, and
execution of the proposed project.  The total project period for
applications submitted in response to the present RFA may not exceed
five years.  Except as otherwise stated in this RFA, awards will be
administered under PHS grants policy as stated in the Public Health
Service Grants Policy Statement, DHHS publication No. (OASH) 90-50,000,
revised October 1, 1990.

This RFA is a one-time solicitation.  Future unsolicited competing
continuation applications will compete as research project applications
with all other investigator-initiated applications and be reviewed
according to the customary peer review procedures.  If the NCI
determines that there is a sufficient continuing program need, the NCI
will invite recipients of awards under this RFA to submit competing
continuation cooperative agreement applications for review.  The
anticipated start date for the initial awards will be September 30,
1992.

FUNDS AVAILABLE

Approximately $1 million in total costs per year for five years will be
committed to specifically fund applications that are submitted in
response to this RFA.  It is anticipated that up to four awards will be
made.  The total project period of these awards may not exceed five
years.  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 NCI, the
award of cooperative agreements pursuant to this RFA is also contingent
upon the availability of funds for this purpose.

RESEARCH OBJECTIVES

Background

In 1986, the National Cancer Advisory Board (NCAB) and the NCI
established an outreach initiative for Black Americans because the
cancer incidence and mortality rates for Blacks were disproportionately
higher than those of the general population.  That initiative, known as
the National Black Leadership Initiative on Cancer (NBLIC), was the
first formal outreach initiative of the NCI to develop a national
network of concerned and active leaders to help organize, implement,
and support cancer prevention programs at national and local levels.

In 1989, the NCI funded a three-year follow-up phase of the NBLIC.  To
date, the NBLIC has established over 50 community cancer control
coalitions nationwide and has directly or indirectly reached 15-20
million Black Americans, representing 50-60 percent of the U.S. Black
population.

Under this RFA, a similar community-coalition approach to cancer
control outreach activities will be developed and implemented in a
specific region of the United States, namely, Appalachia.  For the 20.7
million Americans residing there, many of whom are medically
underserved and of low income, cancer has become an increasing problem.

Appalachia, as defined by the Appalachian Regional Development Act of
1965 and the Appalachian Regional Commission (ARC), follows the spine
of the Appalachian Mountains from southern New York to northern
Mississippi. It encompasses 398 counties and includes all of West
Virginia and parts of twelve other states:  Alabama, Georgia, Kentucky,
Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania,
South Carolina, Tennessee, and Virginia (1).  The region is
substantially homogeneous in racial composition, with whites making up
91.8 percent of the population.  Blacks are the second largest racial
group with 7.3 percent, and all other races account for less than 1
percent (2).

Appalachia is largely rural in nature with over 75 percent of its
counties classified as non-metropolitan and rural (3).  Among these
rural and non-metropolitan counties, a significant proportion (23
percent) appear to be particularly economically weak or "distressed"
(4).  Many counties also suffer from health service shortages.
According to the U.S. Health Resources and Services Administration,
over 85 percent of Appalachian counties contain one or more designated
Medically Underserved Areas (5) and over 65 percent contain one or more
Primary Medical Care Health Professional Shortage Areas (6).

Information on cancer incidence and survival in Appalachia is very
limited.  Since there are no standardized cancer registries covering
the region, cancer incidence data are unavailable.  However, death
registration data indicate that in major portions of Appalachia
mortality rates for the majority population from some cancers are
significantly higher than overall U.S. rates (e.g., cervical) and for
some cancers they are increasing significantly faster than overall U.S.
rates (e.g., female breast and ovarian, and male esophagal, laryngeal,
lung, bladder, and prostate) (7).  In addition, information from small
area cancer studies suggest high mortality rates from cancers of the
lung for both males and females and cancer of the cervix (8,9).

A number of surveys and small studies document very high levels of
tobacco use for males and females living in Appalachia and for many
states with populations living in Appalachia (10,11,12).  In some areas
tobacco use rates are even increasing.  For example, the rate of female
smoking in West Virginia increased from 27 percent in 1985 to 31
percent in 1989, and for the first time, the smoking rate for West
Virginian women ages 24 to 44 surpassed that for men in the same age
group (13).

This RFA is being initiated to encourage applicants to assist
Appalachian communities developing community coalitions that will use
existing resources and state-of-the art approaches to improve cancer
control efforts.  The NCI considers it essential that several key
community organizations and groups be involved in the development and
implementation of comprehensive, community-wide programs to prevent and
control cancer.

Although predominately white, Appalachia is a multi-cultural area that
includes a number of groups with different cultural heritages and
socioeconomic strata.  The geography and economics of the area are
diverse, ranging from coal-dependent areas to farming, forestry, and
metropolitan industrialized areas.  Important variations exist among
the people living in Appalachia that affect their cancer control needs,
services, behaviors, and risks.

Other

This program is intended to improve cancer prevention and control in
Appalachia through the formation of community coalitions to design,
implement, and support comprehensive cancer control outreach
activities.  These coalitions will promote systems change in
communities and facilitate the development, implementation,
maintenance, and evaluation of long-range, comprehensive,
multi-disciplinary, and community-wide projects.  For purposes of this
RFA, Appalachia is defined according to the ARC current definition that
includes 398 counties in 13 states.  A listing of these Appalachian
states and counties is provided in Appendix A.

The long-term goals of this program are:

o  reduce cancer incidence and mortality and improve cancer survival
rates in Appalachia;

o  prevent future cancer incidence and mortality rate increases;

o  reduce the barriers preventing Appalachians from gaining access to
quality cancer control services and referral to appropriate screening,
diagnostic, and therapeutic cancer programs; and

o  stimulate greater participation of Appalachians in community cancer
control outreach programs.

The specific objectives are:

o  create a network of cancer control community coalitions throughout
Appalachia;

o  develop, disseminate, and support effective cancer control
intervention programs and strategies in Appalachian communities;

o  mobilize community lay and professional leaders to develop and
support cancer control community coalitions and outreach activities;

o  stimulate cancer control data collection and research efforts in
Appalachia; and

o  evaluate the effectiveness of this initiative.

Program Implementation

The program has two broad, overlapping phases:  Phase I, Planning and
Coordination, includes the area-wide planning and coordination of
program resources and contacts; and Phase II, Implementation and
Evaluation, includes the implementation, evaluation, and documentation
of the program and its outreach activities.

A.  Phase I:  Planning and Coordination

During the first 12 months of the project, plans for identifying and
recruiting community leaders, developing and supporting community
coalitions within the geographic area defined by the Cooperative
Agreement, and evaluating the project will be developed.  Qualified
staff will be hired which may include a full-time community coordinator
and support staff.  In addition, key part-time and volunteer staff may
be recruited such as a well-known and respected person to serve as an
overall Area Chairperson.

Phase I will have the following objectives:

1.  To develop a comprehensive, strategic project plan with time
schedules and milestones to address all key aspects of the project.
The plan should address such things as:  the identity of target
communities, methods to identify and recruit organizations and local
leaders, strategies to establish and maintain productive relationships
with cancer-related groups, methods for communities to identify the
cancer control needs of the community and to design activities to meet
these needs, ways to ensure area-wide program support and visibility,
strategies for disseminating project findings, plans to provide on and
off-site technical assistance, and methods for quality assurance.

2.  To develop and implement a program management plan that includes a
description of the program structure, the roles and responsibilities of
key staff, and a communication system for the regular exchange of
information and ideas between key staff members and local area leaders,
organizations, and coalitions.

3.  To develop a plan for the development and dissemination of program
messages, materials, and products.  This will include target groups,
goals and objectives, methods of development and distribution, and
evaluation.  For example, public media campaigns and patient education
materials may be planned in response to community-identified needs.

4.  To develop a detailed evaluation plan that includes process,
outcome, and cost-effectiveness measures.  See "Phase II:
Implementation and Evaluation" below.

5.  To develop a long range plan for continued community activity and
institutionalization of this outreach initiative after the expiration
of the five-year cooperative agreement.  The plan may include such
things as obtaining in-kind contributions, fostering volunteerism,
pursuing cost-containment techniques, and establishing affiliations
with health care provider groups and non-profit organizations.

B.  Phase II:  Implementation and Evaluation

During the second year of the project, implementation and evaluation of
outreach activities will begin according to the program plans developed
in Phase I.  Progress towards planning, implementation, evaluation, and
documentation will be measured by milestones.  The third, fourth, and
fifth years will be a continuation of the activities created in years
one and two.  Coalitions and outreach activities will be monitored for
quality and outcome effects.  Special emphasis on data analysis and the
dissemination of program findings will occur in year 5.

The development of consortia or coalitions to achieve the objectives of
this RFA is encouraged.  If a consortium or coalition is proposed a
clear delineation of roles and administrative procedures must be
outlined in the application.  If the budget request includes support
for more than one unit, policies and procedures for financial and
program management must be outlined in the application.

A significant aim of the NCI is to improve the overall national cancer
prevention and control effort by creating cohesion among cancer
programs supported by the NCI and other public and private health
organizations.  To this end, applicants should strive to establish
relationships with relevant cancer programs (e.g. cancer information
programs, facilities providing cancer care, local organizations of
national cancer-related organizations, and  cancer or other incidence
registries) in areas where they exist.

C.  Project Evaluation

The NCI will only support projects that have well-developed,
comprehensive evaluation plans.  The evaluation plan must be
conceptually and procedurally integrated with the overall project.  It
must connect implementation and outcome and specify a time frame for
conducting all evaluation activities.  The evaluation plan must
describe the selection and development of sound measures and
instruments for data collection.  The application must include detailed
and clearly written descriptions of process and outcome evaluation.

D.  Process Evaluation

Process evaluation facilitates the replication of effective projects.
It consists of the periodic monitoring of project implementation to
document what actually was being done and to facilitate project
adjustments and corrections when needed over the course of the project.
It involves the collection of both quantitative and qualitative data to
describe the formation and ongoing functions of community coalitions
and the project as a whole.

Process evaluation may include descriptions of the methods used to
form, structure, and maintain community coalitions; the breadth of
coalition membership and the interaction patterns of organizations and
individuals in coalitions (e.g., patterns of communication, conflict,
conflict resolution, coordination, cooperation, and collaboration);
methods used to inform and involve the community in cancer control
outreach activities; ways used to sustain trust and credibility for the
program; and program costs.  Process evaluation may also include
detailed descriptions of project activities and their tracking.

E.  Outcome Evaluation

Outcome evaluation consists of assessing whether or not the project was
effective in meeting its objectives in ways that will lead to project
goals.  The design of the outcome evaluation and the resulting data
should be based on clear and measurable indicators of progress toward
project goals.  The outcome evaluation design should be rigorous enough
to result in valid conclusions concerning the effectiveness and
replicability of the project.

Baseline data pertaining to the target area are an essential component
of a meaningful outcome evaluation.  Proposed baseline data (e.g.,
cancer measures of the availability and utilization of cancer control
services, cancer rates, tobacco use rates, and indicators of knowledge
about the prevention and early detection of cancer) and methods for
obtaining data must be provided.  Additionally, plans for the periodic
collection of the same information must be described.  The importance
of external resources and the likelihood of the availability should be
estimated.  Although awardee researchers should obtain as much baseline
data as possible in the process of the preparation of the cooperative
agreement application, refinement and development of key elements can
occur at the beginning of the project period.

In conducting the analysis, researchers should consider features of the
setting (e.g., geographic, social, economic, demographic) that may
either facilitate or impede implementation of the project.  In
addition, recommendations should be made concerning the potential for
generalization of the project to other rural settings.

The PIs funded under these cooperative agreements are responsible for
collecting core data that are comparable across award sites.  The
definition of these data will be jointly decided by the Steering
Committee during the first year of the project (see SPECIAL
REQUIREMENTS, Terms of Cooperation).  These data may include, but are
not limited to:  measures of coalition effectiveness; characteristics
of coalitions and their numbers; descriptions of planned activities;
changes in utilization of cancer control services; and the extent of
media coverage and involvement.

SPECIAL REQUIREMENTS

Terms of Cooperation

Under the cooperative agreement, a partnership exists between each
recipient of the award and the NCI.  The role of the NCI will be to
provide program advice and technical assistance and to facilitate the
performance of the effort -- not to direct Appalachia Leadership
Initiative on Cancer activities.  The following terms and conditions
pertaining to the scope and nature of the interaction between the ALIC
Program Director and the awardees will be incorporated into the Notice
of Grant Award.  These agreements will be in addition to the customary
programmatic and financial negotiations that occur in the
administration of grants.  The Terms of Cooperation described in this
section are in addition to, and not in lieu of, otherwise applicable
OMB administrative guidelines; HHS grant administrative regulations of
45 CFR 74; other HHS, PHS, and NIH grant administration policy
statements; and other NCI administrative terms of award.

Responsibilities of the NCI ALIC Program Director:

1.  Data Management

The ALIC Program Director shall provide assistance to the awardees
regarding the quality and type of data to be used and its potential
value to the project and shall periodically review the use of such data
and provide assistance in potential further use.

2.  Program Coordination and the ALIC Steering Committee

The ALIC Program Director shall assist the awardees with coordination
of efforts with NCI programs and grants, including coordination of
efforts among other awardees funded under this RFA.  The ALIC Program
Director shall be a member or the ALIC Steering Committee (see
Responsibilities of Awardees, 2.) and shall actively participate in
meetings and will serve as liaison between the NCI and the ALIC
Steering Committee.

3.  Program Monitoring and Assistance

The ALIC Program Director will review and approve the implementation of
all project plans developed in Phase I and will develop a schedule for
the periodic on-site monitoring of each project.  Through telephone
contacts, written correspondence, site visits, and meetings, the ALIC
Program Director will provide appropriate advice, assistance, and
guidance in the design of activities, the recruitment of staff, and
selection of resource providers, and will monitor progress, review and
evaluate technical performance, provide technical assistance, and
assist in establishing new priorities.

4.  Personnel

The ALIC Program Director will review all key personnel recruitment and
changes during the project period and may approve or disapprove any
changes.  Key personnel are the Principal Investigator and others
specifically identified in the Notice of Grant Award.

5.  Program Materials

The ALIC Program Director will provide the awardee with specialized
technical assistance essential to the development and distribution of
effective, culturally sensitive program communication messages and
materials.

Responsibilities of Awardees:

1.  Participation in Meetings

The awardees will attend periodic NCI-coordinated meetings. These
meetings will serve as a forum to exchange ideas and information on
program progress.  The Principal Investigators (PIs) and other
appropriate project staff will attend these meetings.  "Appropriate"
project staff shall be identified by the ALIC Program Director and by
the nature of the agenda of each meeting.  Approximately two 2-day
meetings will be held in Washington, D.C each year. Up to three project
staff may attend, including the Principal Investigator.  Travel funds
for these meetings shall be included in the proposed budget.

2.  The ALIC Steering Committee

An ALIC Steering Committee, composed of the PI and Project Managers
(the awardees' senior-most project managers under the direction of the
PI) from each award, and the ALIC Project Director, will be established
to provide guidance and support for program activities and to identify
project-wide needs and resources.  The Committee will meet three times
the first year and approximately two times a year thereafter in
Bethesda, Maryland, for one day.  The Committee will elect a
chairperson from among the PIs or Project Managers.  As needed, the
ALIC Steering Committee may establish subcommittees, such as a data and
evaluation subcommittee, to focus on special issues.

3.  Reporting requirements

In addition to required annual progress reports, the awardees will
provide semi-annual reports and additional information as requested by
the ALIC Program Director.

4.  Publications and Presentations

It is expected that data and program findings will be presented and
published through a variety of mechanisms to reach health professionals
and the general public in Appalachia.  Publication of data findings and
process activities by the awardees is encouraged.  Copies of reports,
publications, and major presentations are to be provided to the ALIC
Program Director.  The awardees will acknowledge NCI support in
publications and oral presentations of work supported by this
cooperative agreement.

5.  Data Management

Although the awardees retain custody of and primary rights to the data
developed under these awards, consistent with current HHS, PHS, and NIH
policies, the ALIC Program Director will be provided access to all data
developed under these awards for periodic review of data management
procedures, data quality, and uses of such data.

6.  Program Materials

Program materials developed for training sessions, media campaigns,
community meetings, public education, and other presentations shall be
inventoried and copies provided to the ALIC Program Director.

Arbitration Procedures

These "Terms of Cooperation" require that the ALIC Program Director
make decisions concerning continuation of an award based on successful
performance of the awardees during the planning and developmental
period of the cooperative agreement.  Disagreements (e.g.,
programmatic, technical, and evaluation) arising pursuant to these
approvals will be arbitrated by a panel composed of one award recipient
designee, one NCI designee, and a third designee, with expertise in the
relevant area, chosen by the other two.  These special arbitration
procedures in no way affect the awardee's right to appeal an adverse
action in accordance with PHS regulations at 42 CFR, Part 50, Subpart
D and DHHS regulations at 45 CFR, Part 16.

Other

The applicants must define the geographic boundaries of the proposed
project and describe in detail the plan to establish community
coalitions, structural interactions among them, and interactions
between coalitions and other key public and private organizations
(e.g., the NCI, community health centers, hospitals, cancer centers,
departments of health, and Cooperative Extension Service).  Efforts to
ensure community acceptance must be described, and where specific
cultural barriers are important, the applicants must provide a plan for
addressing these barriers.

The applicants must identify the cancer prevention and control outcome
measures that will be uses to evaluate the project and describe in
detail the observations and records to be used.  Methods of data
accrual, coordination of data accrual, data analysis, and any
contemplated studies or publication plans must be described.

STUDY POPULATIONS

The targeted population intended under this RFA is the approximately 21
million Americans living in the Appalachian region, as defined by the
ARC.  (See Appendix A for a listing of the 398 counties that comprise
Appalachia.)  Applicants responding to this RFA are expected to
successfully access a significant portion of this population with the
intent to decrease cancer incidence and mortality, increase cancer
survival, and increase the diagnosis of cancers at earlier stages.

SPECIAL INSTRUCTIONS TO APPLICANTS REGARDING IMPLEMENTATION OF NIH
POLICIES CONCERNING INCLUSION OF WOMEN AND MINORITIES IN CLINICAL
RESEARCH STUDY POPULATIONS

NIH and ADAMHA policy is that applicants for NIH/ADAMHA clinical
research grants and cooperative agreements will be required to include
minorities and women in study populations so that research findings can
be of benefit to all persons at risk of the disease, disorder or
condition under study; special emphasis should be placed on the need
for inclusion of minorities and women in studies of diseases,
disorders, and conditions which disproportionately affect them.  This
policy is intended to apply to males and females of all ages.  If women
or minorities are excluded or inadequately represented in clinical
research, particularly in proposed population-based studies, a clear
compelling rationale should be provided.

The composition of the proposed study population must be described in
terms of gender and racial/ethnic group.  In addition, gender and
racial/ethnic issues should be addressed in developing a research
design and sample size appropriate for the scientific objectives of the
study.  This information should be included in the form PHS 398 in
Section 2 1-4 of the Research Plan AND summarized in Section 2, E,
Human Subjects.  Applicants are urged to assess carefully the
feasibility of including the broadest possible representation of
minority groups.  However, NIH recognizes that it may not be feasible
or appropriate in all research projects to include representation of
the full array of United states racial/ethnic minority populations
(i.e., Native Americans (including American Indians or Alaskan
Natives), Asian/Pacific Islanders, Blacks, Hispanics).

The rationale for studies on single minority population groups should
be provided.

For the purpose of this policy, clinical research includes biomedical
and behavioral studies of etiology, epidemiology, prevention (and
preventive strategies), diagnosis, or treatment of diseases, disorders
or conditions, including but not limited to clinical trials.

The usual NIH policies concerning research on human subjects also
apply.  Basic research or clinical studies in which human tissues
cannot be identified or linked to individuals are excluded.  However,
every effort should be made to include human tissues from women and
racial/ethnic minorities when it is important to apply the results of
the study broadly, and this should be addressed by applicants.

If the required information is not contained within the application,
the application will be returned.

Peer reviewers will address specifically whether the research plan in
the application conforms to these policies.  If the representation of
women or minorities in a study design is inadequate to answer the
scientific question(s) addressed AND the justification for the selected
study population is inadequate, it will be considered a scientific
weakness or deficiency in the study design and reflected in assigning
the priority score to the application.

All applications for clinical research submitted to NIH are required to
address these policies.  NIH funding components will not award grants
or cooperative agreements that do not comply with these policies.

LETTER OF INTENT

Prospective applicants are asked to submit, by April 10, 1992 a letter
of intent that includes a descriptive title of the proposed research,
the name and address of the PI, the names of other key personnel, the
participating institutions, and the number and title of the RFA in
response to which an application may be submitted.

Although a letter of intent is not required, is not binding, and does
not enter into the review of subsequent applications, the information
it contains is helpful in planning for the review of applications.  It
allows NCI staff to estimate the potential review workload and to avoid
possible conflict of interest in the review.  The letter of intent is
to be sent to:

Nancy K. Simpson, Sc.M.
ALIC Program Director
National Outreach Initiatives Branch
National Cancer Institute
Executive Plaza South, Room 400-C
9000 Rockville Pike
Bethesda, MD  20892
Telephone:  (301) 496-8680

APPLICATION PROCEDURES

The 9/91 revision of the research grant application form PHS 398 is to
be used in applying for cooperative agreements.  These forms are
available at most institutional business offices and from the Office of
Grants Inquiries, Division of Research Grants, National Institutes of
Health, Room 449, Westwood Building, 5333 Westbard Avenue, Bethesda, MD
20892, telephone 301/496-7441.

The RFA label available in the application form PHS 398 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 2 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, exact photocopies, in one package to the
address below.  The photocopies must be clear and single sided.

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 also be sent to:

Hernon H. Fox
Division of Extramural Activities
National Cancer Institute
Westwood Building, Room 838
5333 Westbard Avenue
Bethesda, MD  20892

All applicants must clearly define the geographic area within
Appalachia where they will target their program efforts and demonstrate
that the project team will be able to access the target population.
Where specific cultural barriers are important, the applicant must
provide a plan for addressing these barriers.  All applicants must
include in the application a succinct discussion of previous relevant
efforts and plans to meet the Terms of Cooperation.  Applicants are
encouraged to describe their ideas on how best to meet the goals of
this RFA and to identify in-kind contributions and/or co-sponsors for
specific personnel, activities, and facilities.

Applications must be received by May 21, 1992.  If an application is
received after that date, it will be returned to the applicant.  The
Division of Research Grants (DRG) will not accept any application in
response to this announcement 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

Review Procedures

Upon receipt, applications will be reviewed by NIH staff for
completeness.  Incomplete applications will be returned to the
applicant without further consideration.  If the application is not
responsive to the RFA, NCI program staff will contact the applicant to
determine whether to return the application to the applicant or submit
it for review in competition with unsolicited applications at the next
review cycle.

Applications may be triaged by an NCI peer review group on the basis of
relative competitiveness.  The NCI will remove from further competition
those applications judged to be non-competitive for award and notify
the applicant PI and institutional official.  Those applications that
are competitive will be evaluated in accordance with the criteria
stated below for scientific/technical merit by an appropriate peer
review group convened by the NCI.  The second level of review will be
provided by the National Cancer Advisory Board.

Review Criteria

Applications will be judged primarily on evidence of an understanding
of the Appalachian region and its cancer control needs; the ability to
access and obtain participation of Appalachian communities, to identify
and recruit formal and informal leaders, to establish community
coalitions, and to collaborate with Appalachian health care and other
organizations; discussion of considerations relevant to this RFA;
qualifications of the investigators, including community outreach
experience, Appalachian cultural competence, and cancer control and
communications expertise; capability to perform the work proposed; and
a demonstrated willingness to work together with other awardees and NCI
staff.  (See "Research Objectives:  Program Implementation" section
above.)

The following criteria will be used in the review:

o  Comprehensiveness, feasibility, and consistency of the proposed
project plan with the goals and objectives of the RFA, and the extent
to which the application demonstrates originality and an understanding
of cancer control outreach activities and community coalition
development;

o  Rationale for selection of the targeted geographic area and
documentation of its cancer control needs including cancer-related risk
factors, access and utilization of health care services, and cancer
rates;

o  Adequacy and soundness of the staffing and project management plans,
including evidence of the capability, experience, and qualifications of
the applicant and cooperating institution's technical staffs to
implement the project successfully, and an overall balance of the
program team in relation to the objectives of the project;
o  Appropriateness of the implementation plan and the extent to which
it demonstrates sensitivity to cultural and socioeconomic factors in
the community, including evidence that these factors are significant
targets of inclusion in community coalitions;

o  Evidence of program linkages to existing relevant Federal, State,
and local cancer control plans and activities in target communities,
and a strategy for improving existing plans and stimulating their
implementation;

o  Adequacy, appropriateness, feasibility, and comprehensiveness of the
evaluation plan including sufficient allocation of resources;

o  Feasibility of the project within the resources and time frames
proposed; appropriateness of the proposed budget and duration in
relation to the proposed initiative; and inclusion of specific written
agreements with cooperating institutions, including those agencies that
may be providing services and/or the settings for these services.

AWARD CRITERIA

The anticipated date of award is September 30, 1992.  Applicants will
compete for funding based on the quality and merit of the proposed
outreach program as determined by peer review.  It is the intent of
this program to cover the entire Appalachian region, and, therefore,
geographic needs will be considered in making funding decisions.

INQUIRIES

Written and telephone inquiries concerning this RFA are encouraged.
The opportunity to clarify any issues or questions from potential
applicants is welcome.  Direct inquiries regarding programmatic issues
to:

Nancy K. Simpson, Sc.M.
ALIC Program Director
National Outreach Initiatives Branch
National Cancer Institute
Executive Plaza South, Room 400-C
9000 Rockville Pike
Bethesda, MD  20892
Telephone:  (301) 496-8680

Direct inquiries regarding fiscal issues to:

Eileen Natoli, Team Leader
National Cancer Institute
Grants Administration Branch
Executive Plaza South, Room 243
9000 Rockville Pike
Bethesda, MD  20892
Telephone:  (301) 496-7800 Ext. 56

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance
No. 93.399, Cancer Control Science Program.  Awards are made under the
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 part 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.

REFERENCES

1.  Appalachian Regional Commission.  1990 Annual Report.

2.  Appalachian Regional Commission.  1990 PL-171 Census data.

3.  National Cancer Institute.  U.S. Department of Agriculture
Rural-Urban Continuum Codes, 1980 Census data.

4.  Appalachian Regional Commission.  FY 1988 Distressed Rural
Counties.

5.  U.S. Department of Health and Human Services, Health Resources and
Services Administration.  Designation of Medically Underserved Areas.
Federal Register, Vol. 41, No. 201, Friday, October 15, 1976;  Federal
Register, November 12, 1982;  and Bureau of Health Care Delivery and
Assistance (BHCDA) case by case updates.

6.  U.S. Department of Health and Human Services, Health Resources and
Services Administration.  List of Designated Primary Medical Care
Health Professional Shortage Areas (HPSAs).  Federal Register, Vol.56,
No. 188, Friday, September 27, 1991.

7.  Pickle, L.W.; Mason, T.J.; Howard, N.; Hoover, R.; Fraumeni, Jr.,
J.F.  Atlas of U.S. Cancer Mortality Among Whites: 1950-1980.  National
Cancer Institute.  DHHS Publication No. (NIH) 87-2900.

8.  Tucker, T.C.; Friedell, G.H.; Stallones, L.; Thompson, J. R.;
Bagby, J.W.  Cancer Mortality in Rural Appalachian Kentucky.
Appalachian Data Bank Report #6, November 1988.

9.  National Cancer Institute.  Cancer Statistics Review 1973-88.
Ries, L.A.G.; Hankey, B.F.; Miller, B.A.; Hartman, A.M.; Edwards, B.K.
(eds.)  DHHS Publication No. (NIH) 91-2789.

10.  Johnson, T.P; Frank, A.L.; Hougland, J.G.; Moore, R.W.; Ford, T.R.
Health Experience and Behavior Among Appalachian and Non-Appalachian
Kentuckians:  Results from the Kentucky Health Survey.  (In) Health in
Appalachia, Proceedings from the 1988 Conference on Appalachia,
November 3-5, 1988.  University of Kentucky.

11.  Shopland, D.R.; Niemcryk, S.J.; Marconi, K.M. Geographic and
Gender Variations in Total Tobacco Use.  NCI Report (undated).

12.  U.S. Department of Health and Human Services, National Heart,
Lung, and Blood, Institute (NHLBI).  NHLBI Data Fact Sheet:
Cardiovascular Disease Risk Factors, March 1991.

13.  State of West Virginia.  1990 State Health Plan.

APPENDIX A

APPALACHIAN STATES AND COUNTIES*

Alabama:
Bibb, Blount, Calhoun, Chambers, Cherokee, Chilton, Clay, Cleburne,
Clobert, Coosa, Cullman, De Kalb, Elmore, Etowah, Fayette, Franklin,
Jackson, Jefferson, Lamar, Lauderdale, Lawrence, Limestone, Madison,
Marion, Marshall, Morgan, Pickens, Randolph, St. Clair, Shelby,
Talladega, Tallapoosa, Tuscaloosa, Walker, Winston

Georgia:
Banks, Barrow, Bartow, Carroll, Catoosa, Chattooga, Cherokee, Dade,
Dawson, Douglas, Fannin, Floyd, Forsyth, Franklin, Gilmer, Gordon,
Gwinnett, Habersham, Hall, Haralson, Heard, Jackson, Lumpkin, Madison,
Murray, Paulding, Pickens, Polk, Rabun, Stephens, Towns, Union, Walker,
White, Whitfield

Kentucky:
Adair, Bath, Bell, Boyd, Breathitt, Carter, Casey, Clark, Clay,
Clinton, Cumberland, Elliott, Estill, Fleming, Floyd, Garrard, Green,
Greenup, Harlan, Jackson, Johnson, Knott, Knox, Laurel, Lawrence, Lee,
Leslie, Letcher, Lewis, Lincoln, McCreary, Madison, Magoffin, Martin,
Menifee, Monroe, Montgomery, Morgan, Owsley, Perry, Pike, Powell,
Pulaski, Rockcastle, Rowan, Russell, Wayne, Whitley, Wolfe

Maryland:
Allegany, Garrett, Washington

Mississippi:
Alcorn, Benton, Chickasaw, Choctaw, Clay, Itawamba, Kemper, Lee,
Lowndes, Marshall, Monroe, Noxubee, Oktibbeha, Pontotoc, Prentiss,
Tippah, Tishomingo, Union, Webster, Winston,

New York:
Allegany, Broome, Cattaraugus, Chautauqua, Chemung, Chenango, Cortland,
Delaware, Otsego, Schoharie, Schuyler, Steuben, Tioga, Tompkins

North Carolina:
Alexander, Alleghany, Ashe, Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Davie, Forsyth, Graham, Haywood, Henderson, Jackson, McDowell,
Macon, Madison, Mitchell, Polk, Rutherford, Stokes, Surry, Swain,
Transylvania, Watauga, Wilkes, Yadkin, Yancey

Ohio:
Adams, Athens, Belmont, Brown, Carroll, Clermont, Columbiana,
Coshocton, Gallia, Guernsey, Harrison, Highland, Hocking, Holmes,
Jackson, Jefferson, Lawrence, Meigs, Monroe, Morgan, Muskingum, Noble,
Perry, Pike, Ross, Scioto, Tuscarawas, Vinton, Washington

Pennsylvania:
Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Butler,
Cambria, Cameron, Carbon, Centre, Clarion, Clearfield, Clinton,
Columbia, Crawford, Elk, Erie, Fayette, Forest, Fulton, Greene,
Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lawrence, Luzerne,
Lycoming, McKean, Mercer, Mifflin, Monroe, Montour, Northumberland,
Perry, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan,
Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne,
Westmoreland, Wyoming

South Carolina:
Anderson, Cherokee, Greenville, Oconee, Pickens, Spartanburg

Tennessee:
Anderson, Bledsoe, Blount, Bradley, Campbell, Cannon, Carter,
Claiborne, Clay, Cocke, Coffee, Cumberland, De Kalb, Fentress,
Franklin, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock,
Hawkins, Jackson, Jefferson, Johnson, Knox, Loudon, McMinn, Macon,
Marion, Meigs, Monroe, Morgan, Overton, Pickett, Polk, Putnam, Rhea,
Roane, Scott, Sequatchie, Sevier, Smith, Sullivan, Unicoi, Union, Van
Buren, Warren, Washington, White

Virginia:
Alleghany, Bath, Bland, Botetourt, Buchanan, Carroll, Craig, Dickenson,
Floyd, Giles, Grayson, Highland, Lee, Pulaski, Russell, Scott, Smyth,
Tazewell, Washington, Wise, Wythe

West Virginia:
Barbour, Berkeley, Boone, Braxton, Brooke, Cabell, Calhoun, Clay,
Doddridge, Fayette, Gilmer, Grant, Greenbrier, Hampshire, Hancock,
Hardy, Harrison, Jackson, Jefferson, Kanawha, Lewis, Lincoln, Logan,
McDowell, Marion, Marshall, Mason, Mercer, Mineral, Mingo, Monongalia,
Monroe, Morgan, Nicholas, Ohio, Pendleton, Pleasants, Pocahontas,
Preston, Putnam, Raleigh, Randolph, Ritchie, Roane, Summers, Taylor,
Tucker, Tyler, Upshur, Wayne, Webster, Wetzel, Wirt, Wood, Wyoming

*  Defined by the Appalachian Regional Commission (ARC), 1990.

.

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