IMPROVING CONTRACEPTIVE PRACTICE AND DELIVERY Release Date: June 7, 2001 RFA: RFA-HD-01-015 National Institute of Child Health and Human Development (http://www.nichd.nih.gov) Letter of Intent Receipt Date: July 31, 2001 Application Receipt Date: September 11, 2001 THIS RFA USES THE MODULAR GRANT AND JUST-IN-TIME CONCEPTS. IT INCLUDES DETAILED MODIFICATIONS TO STANDARD APPLICATION INSTRUCTIONS THAT MUST BE USED WHEN PREPARING APPLICATIONS IN RESPONSE TO THIS RFA. PURPOSE To address the many public health and other concerns associated with unplanned pregnancies, the National Institute of Child Health and Human Development (NICHD) seeks to foster research that can result in improved contraceptive use in the United States. This initiative complements other efforts of the NICHD to support research on delaying the onset of sexual activity and reducing risky sexual behavior, and is aimed at contributing to knowledge that could be directly applied to feasible and sustainable strategies to improve contraceptive use in the United States. The initiative has three main aims: 1. Conduct basic research that will directly inform strategies to support effective contraceptive use among individuals and couples seeking to prevent or delay pregnancy, 2. Conduct research to identify and evaluate innovations in clinical practice and family planning service delivery that will lead to measurable improvements in contraceptive practice, and 3. Support basic and applied research addressing the influence of policy and the structure and financing of reproductive health services on effective contraceptive use, and the cost-effectiveness of alternative approaches to structuring and financing contraceptive services. Serious disparities exist in contraceptive failure rates among minority and non-minority populations, and between poor and non-poor populations. Accordingly, this initiative especially encourages research that can help to reduce these disparities. This initiative has been planned in consultation with the Centers for Disease Control and Prevention and the DHHS Office of Population Affairs. HEALTHY PEOPLE 2010 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2010," a PHS-led national activity for setting priority areas. This Request for Applications is related to one or more of the priority areas. Potential applicants may obtain "Healthy People 2010" at http://www.health.gov/healthypeople. 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) individual research project grant (R01) award mechanism. Responsibility for the planning, direction, and execution of the proposed project will be solely that of the applicant. The total project period for an application submitted in response to this RFA may not exceed five years. 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. The earliest anticipated award date is April 1, 2002. Specific application instructions have been modified to reflect MODULAR GRANT and JUST-IN-TIME streamlining efforts being examined by the NIH. Complete and detailed instructions and information on Modular Grant applications can be found at http://grants.nih.gov/grants/funding/modular/modular.htm. FUNDS AVAILABLE The NICHD intends to commit approximately $2 million in total costs [direct plus Facilities and Administrative (F&A) costs] in FY 2002 to fund four to eight new and/or competing continuation grants in response to this RFA. An applicant may request a project period of up to five years. Because the nature and scope of the research proposed may vary, it is anticipated that the size of each award will also vary. Although the financial plans of the NICHD provide support for this program, awards pursuant to this RFA are contingent upon the availability of funds and the receipt of a sufficient number of meritorious applications. RESEARCH OBJECTIVES Background One out of eight U.S. women using a method of contraception to avoid pregnancy can expect to experience an accidental pregnancy within the first year of method use. Rates of accidental pregnancy vary by age, marital status, and especially poverty and minority status. About one in five poor women and one in six African-American or Hispanic women are affected in the first year of method use. However, all groups of American women experience nontrivial problems in using contraception effectively. One in ten married women experiences an accidental pregnancy in the first year of method use, and the rate is nearly one in ten among women whose incomes exceed 250 percent of the Federal poverty standard. Unplanned pregnancy is associated with a host of public health concerns: lack of preconception counseling, less adequate prenatal care, and higher levels of low birthweight infants, infant mortality, and maternal morbidity and mortality. Over one-half of unintended pregnancies are ended by abortion. Further, research suggests that some children born as a result of unintended pregnancy are at greater risk for disadvantages such as poorer mental health and delayed cognitive development. About 57 percent of births that result from unintended pregnancy are born to unmarried women, and many of these children experience unstable family arrangements during their growing-up years. Improving contraceptive use is one of several strategies that can help to reduce unplanned and unwanted pregnancies. Complete abstinence from sexual intercourse is the most effective method to avoid pregnancy. However, rates of unintended pregnancy are nontrivial even among married women, who report nearly one out of three pregnancies as unintended. The need for all people to effectively manage their reproductive lives in accordance with their life goals mandates a multi-faceted approach to reducing unintended pregnancy, and underscores the need for research to improve contraceptive practice and delivery. While the ideal contraceptive for all couples at all ages does not exist, and may never exist, there is a menu of methods currently available. The evidence from other western countries strongly suggests that these methods can be used effectively to prevent unintended pregnancy. Research in the United States has documented a number of factors that contribute to inconsistent or ineffective contraceptive use, including ambivalence about pregnancy, lack of communication between partners, lack of planning for sexual activity, unfavorable attitudes towards contraception, and method characteristics that make effective use difficult. In addition, research in the United States and other developed and developing countries suggests that the way in which contraceptive services are delivered can make a difference in contraceptive use. However, limited support has been available within the United States for research that directly addresses strategies for improving contraceptive use, either through the improvement of service delivery, changes in cultural attitudes surrounding contraception, or changes in practices and policies related to the financing and organization of systems through which individuals and couples have access to contraception. This initiative seeks to encourage research that will provide knowledge that is directly applicable to improving the success with which people in the United States use contraception. Research Scope This initiative invites applications that address one or more of the following general areas: 1. Basic research that will directly inform strategies to support effective contraceptive use among individuals and couples seeking to prevent or delay pregnancy, 2. Research to identify and evaluate innovations in clinical practice and family planning service delivery that are affordable and sustainable, and will lead to measurable improvements in contraceptive practice, and 3. Basic and applied research addressing the influence of policy and the structure and financing of reproductive health services on effective contraceptive use, and the cost-effectiveness of alternative approaches to structuring and financing contraceptive services. NICHD particularly encourages research that can help to reduce disparities among minority and non-minority populations, and between economically advantaged and disadvantaged groups, in the successful use of contraceptive methods. Studies in racial and ethnic minority communities should be designed to involve community members in various aspects of the research, including the framing of research questions, the development of research approaches, and the interpretation and application of research findings. Plans should also be included to assure the dissemination of research findings to the communities affected by the research. These principles should ideally be applied to all studies that focus on particular communities or groups. All applicants are encouraged take into account the social, economic, and cultural characteristics of the populations they propose to study, and to consider approaches that are client-centered, i.e., that design and evaluate strategies to improve contraceptive use in the context of the values, needs, and constraints of the user and the communities that he/she/they move in. The goal of this initiative is to produce knowledge that can be directly applied to improving contraceptive use in the United States. Proposed basic research projects must be designed to produce knowledge that can be translated into realistic steps that could be taken by programs, policy-makers, and others to improve people"s ability to use contraception effectively. Applicants proposing to test innovative strategies for delivering contraceptive services or improving communication about contraception should ensure that such strategies are affordable and sustainable over time. Although the focus of this initiative is on the improvement of contraceptive use as a strategy for reducing unintended pregnancy, applicants should also consider risks of HIV and other sexually transmitted diseases (STDs) in developing their approaches. Investigators proposing innovative approaches to improving contraceptive use must take account of, and find ways of preventing, potential adverse consequences for other aspects of reproductive health. Investigators are encouraged to develop approaches that have the potential to reduce risks for both unintended pregnancy and STD. Examples of research areas within the scope of this RFA include, but are not limited to, the following: (1) Basic Research: o Micro-behaviors of effective contraceptive use: what are the specific behaviors that contribute to the effective use of specific contraceptive methods in different populations of men, women, and couples? o How do people adopt and sustain regular health habits, in general, and how can this knowledge be applied to improving contraceptive practice? o How do people seek out, receive, retain, and act upon information about contraception? How do individuals form their beliefs, attitudes, and values about contraceptive methods, their use, and their health effects? What method characteristics and social or individual processes contribute to beliefs that interfere with effective contraceptive use (e.g., dissatisfaction with methods, inaccurate perceptions of health risks or efficacy)? o How do partners and the characteristics of relationships influence beliefs and attitudes about contraceptive methods as well as the choice and effective use of methods? How can this knowledge be applied to improving contraceptive practice? o What is the effect of contraceptive counseling on individuals" and couples" ability to use contraception effectively over time, and through what mechanisms does counseling work? What proportion of information provided to individuals or couples during counseling sessions is retained and/or utilized? What counseling strategies or approaches are most effective in supporting the retention of accurate information and continued effective use? o What causes individuals to stop using or switch contraceptive methods during periods when pregnancy is not desired? What factors increase risk of unintended pregnancy during such gaps and transitions? How can the risks associated with gaps and transitions in contraceptive use be minimized? o How do the social/cultural characteristics and dynamics of the groups individuals belong to (e.g., family, friends, neighbors) influence contraceptive choices and effective use? How can such knowledge be applied in efforts to support effective contraceptive use? o How do the characteristics of neighborhoods and communities (e.g., economic well-being, safety, access to health services and transportation) affect the ability to obtain appropriate contraception and use it effectively? (2) Clinical/Applied Research: o How might the service provider community communicate more effectively about contraception? What innovative communication strategies might be effective in assuring that accurate information about contraception is available and accessible to all those who may potentially need it? o How can service providers and others bridge barriers in communication that result from differences in status, culture, and language between clients and providers, in order to assure that individuals have accurate information about contraception upon which to act? o How can existing research findings on the factors influencing contraceptive risk-taking be translated into interventions, and evaluated for effectiveness? o What innovative approaches might improve the delivery of contraceptive services and contraceptive counseling in clinical settings, how can these be tested and evaluated, and how can they be scaled up for widespread adoption in a way that is sustainable over the long term? o How can providers adapt service delivery to client-centered values and needs, e.g., flexible hours, rapid appointments, over-the-counter emergency contraception, changes in clinic protocols? o What alternative approaches to the delivery of new methods of contraception could improve contraceptive practice, e.g., one-month injectables, the new IUD/progestin releasing method, and new ways of providing emergency contraception? o How can contraceptive service providers develop effective coalitions with other community organizations and institutions to address barriers to, and provide support for, effective contraceptive practice within the social and cultural context of specific communities? (3) Research on Policy and Health Care Organization/Financing: o How do the features, structures, and practices of health care providers, organizations, and institutions affect the experiences of individuals and couples seeking contraceptive services? How do these features, structures, and practices influence effective contraceptive use and through what causal pathways? Examples include: - availability of services, e.g., at private sectarian hospitals and clinics with conscience clauses, - breadth of services available, including counseling and followup, range of methods available, provider preferences for or against specific methods, STD screening, etc., - client access to different types of providers for contraceptive care, including physicians, nurse-midwives, nurses, or other staff, - client access to different types of health services from the same provider source, - management practices that constrain the flow of resources to clients (e.g., scheduling sterilizations only at particular times, or requiring appointments or overscheduling clinics), and - practices that may undermine confidentiality (e.g., sending utilization reports to parents or partners). o How do employer policies regarding health benefits affect contraceptive use, and how does this influence employee productivity, days lost from work, etc.? o How do the coverage and structure of third party reimbursement for contraceptive services (e.g., insurance, health plans, Medicaid) affect contraceptive choice, effectiveness, and continuity of use? o How have trends in the funding and policies of federal programs supporting contraceptive services affected use? o How do alternative policies, structures, practices, etc. differ in cost- effectiveness, considering the monetary costs and benefits of providing effective contraceptive care and the consequences associated with providing such care? SPECIAL REQUIREMENTS Principal Investigators will be expected to attend an annual Investigators meeting to share research approaches, findings, and the application and dissemination of research findings. Investigators supported by the Centers for Disease Control and Prevention and the Office of Population Affairs will also participate in these meetings. Applications should include in the budget request sufficient funds to support travel for the Principal Investigator to attend one three-day meeting in Washington, DC, in each of the requested years of support. Investigators should also address plans, if any, for sharing research data from supported projects. Plans should be justified in relation to the potential utility of research data generated by the project for use by other investigators and the need to protect the privacy of study participants. 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 sub-populations must be included in all NIH-supported biomedical and behavioral research projects involving human subjects, unless a clear and compelling rationale and justification are provided indicating that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. This policy results from the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43). All investigators proposing research involving human subjects should read the UPDATED "NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical Research," published in the NIH Guide for Grants and Contracts on August 2, 2000 (http://grants.nih.gov/grants/guide/notice-files/NOT-OD-00-048.html), a complete copy of the updated Guidelines are available at http://grants.nih.gov/grants/funding/women_min/guidelines_update.htm. The revisions relate to NIH-defined Phase III clinical trials and require: a) all applications or proposals and/or protocols to provide a description of plans to conduct analyses, as appropriate, to address differences by sex/gender and/or racial/ethnic groups, including subgroups if applicable, and b) all investigators to report accrual, and to conduct and report analyses, as appropriate, by sex/gender and/or racial/ethnic group differences. INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS It is the policy of NIH that children (i.e., individuals under the age of 21) must be included in all human subjects research, conducted or supported by the NIH, unless there are scientific and ethical reasons not to include them. This policy applies to all initial (Type 1) applications submitted for receipt dates after October 1, 1998. All investigators proposing research involving human subjects should read the NIH Policy and Guidelines on the Inclusion of Children as Participants in Research Involving Human Subjects, published in the NIH Guide for Grants and Contracts, March 6, 1998, and available on the Internet at: http://grants.nih.gov/grants/guide/notice-files/not98-024.html. Investigators also may obtain copies of these policies from the program staff listed under INQUIRIES. Program staff may also provide additional relevant information concerning the policy. URLS IN NIH GRANT APPLICATIONS OR APPENDICES All applications and proposals for NIH funding must be self-contained within specified page limitations. Unless otherwise specified in an NIH solicitation, Internet addresses (URLs) should not be used to provide information necessary to the review because reviewers are under no obligation to view the Internet sites. Reviewers are cautioned that their anonymity may be compromised when they directly access an Internet site. LETTER OF INTENT Prospective applicants are asked to submit 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 this RFA. 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 NICHD staff to estimate the potential review workload and plan the review. The letter of intent is to be sent to Dr. Susan Newcomer at the address listed under INQUIRIES, below, by July 31, 2001. APPLICATION PROCEDURES The research grant application form PHS 398 (rev. 4/98) is to be used in applying for these grants. These forms are available at most institutional offices of sponsored research, on the Internet at http://grants.nih.gov/grants/funding/phs398/phs398.html, and from the Division of Extramural Outreach and Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301-710-0267, E-mail: Grantsinfo@nih.gov. Application Instructions The modular grant concept establishes specific modules in which direct costs may be requested as well as a maximum level for requested budgets. Only limited budgetary information is required under this approach. The just-in- time concept allows applicants to submit certain information only when there is a possibility for an award. It is anticipated that these changes will reduce the administrative burden for the applicants, reviewers, and NIH staff. The research grant application form PHS 398 (rev. 4/98) is to be used in applying for these grants, with the modifications noted below. Modular Grant applications will request direct costs in $25,000 modules, up to a total direct cost request of $250,000 per year. (Applications that request more than $250,000 direct costs in any year must follow the traditional PHS 398 application instructions.) The total direct costs must be requested in accordance with the program guidelines and the modifications made to the standard PHS 398 application instructions described below: o FACE PAGE: Items 7a and 7b should be completed, indicating Direct Costs (in $25,000 increments up to a maximum of $250,000) and Total Costs [Modular Total Direct plus Facilities and Administrative (F&A) costs] for the initial budget period. Items 8a and 8b should be completed indicating the Direct and Total Costs for the entire proposed period of support. o DETAILED BUDGET FOR THE INITIAL BUDGET PERIOD: Do not complete Form Page 4 of the PHS 398. It is not required and will not be accepted with the application. o BUDGET FOR THE ENTIRE PROPOSED PERIOD OF SUPPORT: Do not complete the categorical budget table on Form Page 5 of the PHS 398. It is not required and will not be accepted with the application. o NARRATIVE BUDGET JUSTIFICATION: Prepare a Modular Grant Budget Narrative page. (See http://grants.nih.gov/grants/funding/modular/modular.htm for sample pages.) At the top of the page, enter the total direct costs requested for the project year. This is not a Form Page. o Under Personnel, list ALL project personnel, including their names, percent of effort, and roles on the project. No individual salary information should be provided. However, the applicant should use the NIH appropriation language salary cap and the NIH policy for graduate student compensation in developing the budget request. o For Consortium/Contractual costs, provide an estimate of total costs (direct plus F & A), rounded to the nearest $1,000. List the individuals/organizations with whom consortium or contractual arrangements have been made, the percent effort of all personnel, and the role on the project. Indicate whether the collaborating institution is foreign or domestic. The total cost for a consortium/contractual arrangement is included in the overall requested modular direct cost amount. Include the Letter of Intent to establish a consortium. o Provide an additional narrative budget justification for any variation in the number of modules requested. o BIOGRAPHICAL SKETCH: The Biographical Sketch provides information used by reviewers in the assessment of each individual"s qualifications for a specific role in the proposed project, as well as to evaluate the overall qualifications of the research team. A biographical sketch is required for all key personnel, following the instructions below. No more than three pages may be used for each person. A sample biographical sketch may be viewed at: http://grants.nih.gov/grants/funding/modular/modular.htm. - Complete the educational block at the top of the form page, - List position(s) and any honors, - Provide information, including overall goals and responsibilities, on research projects ongoing or completed during the last three years, - List selected peer-reviewed publications, with full citations. o CHECKLIST: This page should be completed and submitted with the application. If the F&A rate agreement has been established, indicate the type of agreement and the date. All appropriate exclusions must be applied in the calculation of the F&A costs for the budget period. o The applicant should provide the name and telephone number of the individual to contact concerning fiscal and administrative issues if additional information is necessary following the initial review. Submission Instructions The RFA label available in the PHS 398 (rev. 4/98) application form must be stapled to the bottom of the face page of the application and must display the RFA number HD-01-015. A sample RFA label is available at http://grants.nih.gov/grants/funding/phs398/label-bk.pdf. Please note this is in the pdf format. 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 photocopies, in one package to: CENTER FOR SCIENTIFIC REVIEW NATIONAL INSTITUTES OF HEALTH 6701 ROCKLEDGE DRIVE, ROOM 1040, MSC 7710 BETHESDA, MD 20892-7710 BETHESDA, MD 20817 (for express/courier service) At the time of submission, two additional copies of the application should be sent to: Director, Division of Scientific Review National Institute of Child Health and Human Development 6100 Executive Boulevard, Room 5E03F, MSC 7510 Bethesda, MD 20892-7510 Bethesda, MD 20852 (for express/courier service) Applications must be received by September 11, 2001. If an application is received after that date, it will be returned to the applicant without review. The Center for Scientific Review (CSR) 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 CSR 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 the CSR and for responsiveness to this RFA by the NICHD. Incomplete applications will be returned to the applicant without further consideration. If the application is not responsive to the RFA, NICHD staff may 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 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 NICHD in accordance with the review criteria stated below. As part of the initial merit review, all applications will receive a written critique and may undergo a process in which only those applications deemed to have the highest scientific merit will be discussed, assigned a priority score, and receive a second level review by the National Advisory Child Health and Human Development Council. Review Criteria The goals of NIH-supported research are to advance our understanding of biological systems, improve the control of disease, and enhance health. In the written comments, reviewers will be asked to discuss the following aspects of the application in order to judge the likelihood that the proposed research will have a substantial impact on the pursuit of these goals. Each of these criteria will be addressed and considered in assigning the overall score, weighting them as appropriate for each application. Note that the application does not need to be strong in all categories to be judged likely to have major scientific impact and thus deserve a high priority score. For example, an investigator may propose to carry out important work that by its nature is not innovative, but is essential to move a field forward. (1) Significance: Does this study address an important problem? If the aims of the application are achieved, how will scientific knowledge be advanced? What will be the effect of these studies on the concepts or methods that drive this field? How adequate is the proposed plan to share data, if one is offered. (2) Approach: Are the conceptual framework, design, methods, and analyses adequately developed, well integrated, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative tactics? (3) Innovation: Does the project employ novel concepts, approaches or methods? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies or technologies? (4) Investigator: Is the investigator appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the Principal Investigator and other researchers (if any)? (5) Environment: Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed experiments take advantage of unique features of the scientific environment or employ useful collaborative arrangements? Is there evidence of institutional support? In addition to the above criteria, in accordance with NIH policy, all applications will also be reviewed with respect to the following: o The adequacy of plans to include both genders, minorities and their subgroups, and children as appropriate for the scientific goals of the research. Plans for the recruitment and retention of subjects will also be evaluated. o The reasonableness of the proposed budget and duration in relation to the proposed research. o The adequacy of the proposed protection for humans, animals or the environment, to the extent they may be adversely affected by the project proposed in the application. SCHEDULE Letter of Intent Receipt Date: July 31, 2001 Application Receipt Date: September 11, 2001 Peer Review Date: November 2001 Council Review: January 2002 Earliest Anticipated Start Date: April 2002 AWARD CRITERIA Criteria that will be used to make award decisions include: o scientific merit (as determined by peer review) o availability of funds o programmatic priorities. INQUIRIES Inquiries concerning this RFA are encouraged. The opportunity to clarify any issues or answer questions from potential applicants is welcome. Direct inquiries regarding programmatic issues to: Susan Newcomer, Ph.D. Demographic and Behavioral Sciences Branch National Institute of Child Health and Human Development 6100 Executive Boulevard, Room 8B07, MSC 7510 Bethesda, MD 20892-7510 Telephone: 301-435-6981 E-mail: Snewcomer@nih.gov Direct inquiries regarding fiscal matters to: Kathy Hancock Grants Management Branch National Institute of Child Health and Human Development 6100 Executive Boulevard, Room 8A17, MSC 7510 Bethesda, MD 20892-7510 Telephone: 301-496-5482 FAX: 301-402-0915 E-mail: hancockk@nih.gov AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.864 (Population Research). Awards are made under authorization of Sections 301 and 405 of the Public Health Service Act as amended (42 USC 241 and 284) and administered under NIH grants policies and Federal Regulations 42 CFR 52 and 45 CFR Parts 74 and 92. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. The PHS strongly encourages all grant recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care, or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people.


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