1

Introduction

Health promotion and disease prevention are central priorities in the Centers for Disease Control and Prevention (CDC) vision, Healthy People In A Healthy World Through Prevention (CDC, n.d.). To advance research in these areas, Congress authorized and the CDC has established a program of university-based Centers for Research and Demonstration of Health Promotion and Disease Prevention. The program is intended to “undertake research and demonstration projects in health promotion, disease prevention, and improved methods of appraising health hazards and risk factors, and shall serve as demonstration sites for the use of new and innovative research in public health technique to improve public health” (PL 98-551). The prevention research centers (PRC) program 3 began in 1986 with funding to three universities. With periodic competitive renewals and expansions of the program, there are now 13 PRCs. 4

Multidisciplinary faculty at these PRCs, located at schools of public health and academic health centers, focus on a series of related projects on a public health theme defined in terms of special populations, risk factors, or specific health conditions. The PRCs are expected to form partnerships to develop innovative ways to prevent disease and promote health, focus on high-priority

3  

Public Law 98-551 created Centers for Research and Demonstration of Health Promotion and Disease Prevention. Throughout this report, the committee refers to these university-based centers as prevention research centers, or PRCs. In referring to the administration of the program by CDC, the committee uses the terminology “the PRC program. ”

4  

A 14th PRC grant was awarded after the committee completed its final meeting.



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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention 1 Introduction Health promotion and disease prevention are central priorities in the Centers for Disease Control and Prevention (CDC) vision, Healthy People In A Healthy World Through Prevention (CDC, n.d.). To advance research in these areas, Congress authorized and the CDC has established a program of university-based Centers for Research and Demonstration of Health Promotion and Disease Prevention. The program is intended to “undertake research and demonstration projects in health promotion, disease prevention, and improved methods of appraising health hazards and risk factors, and shall serve as demonstration sites for the use of new and innovative research in public health technique to improve public health” (PL 98-551). The prevention research centers (PRC) program 3 began in 1986 with funding to three universities. With periodic competitive renewals and expansions of the program, there are now 13 PRCs. 4 Multidisciplinary faculty at these PRCs, located at schools of public health and academic health centers, focus on a series of related projects on a public health theme defined in terms of special populations, risk factors, or specific health conditions. The PRCs are expected to form partnerships to develop innovative ways to prevent disease and promote health, focus on high-priority 3   Public Law 98-551 created Centers for Research and Demonstration of Health Promotion and Disease Prevention. Throughout this report, the committee refers to these university-based centers as prevention research centers, or PRCs. In referring to the administration of the program by CDC, the committee uses the terminology “the PRC program. ” 4   A 14th PRC grant was awarded after the committee completed its final meeting.

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention innovative ways to prevent disease and promote health, focus on high-priority public health issues, and conduct research and demonstration activities that result in improved public health practice. The PRCs are intended to serve as bridges between science and practice, and from academia to state and local health departments, health care providers and provider organizations, and community organizations, as well as with CDC. Evaluation research is embedded in many of the PRC interventions, the center also train public health professionals in applied prevention research. Funding for the PRCs includes three components: (1) core center funding from CDC, which must be used, in part, for at least one demonstration project with a state or local health department or board of education; (2) supplemental funding, also from CDC, to address special interest projects (SIPs) proposed annually and funded by various components of CDC each year; and (3) funding from other public and private sources. HISTORY OF THE PREVENTION RESEARCH CENTERS PROGRAM The PRC program was authorized by Congress in 1984 by Public Law 98-551. This legislation was supported by the Association of Schools of Public Health, which viewed the PRC program as a way to enhance health promotion activities by fostering better linkages between the schools of public health and the public health practice community and between academia and CDC. Congress mandated that the PRCs be located at academic health centers capable of providing multidisciplinary faculties with expertise in public health, relationships with professionals in other relevant fields, graduate training and demonstrated curricula in disease prevention, and a capability for residency training in public health or preventive medicine. The PRC program was established at the CDC in 1985, but no funding was appropriated until 1986, when the first three centers were established. CDC has evolved from an agency born of the need to control malaria in the United States during World War II to the nation's primary agency for the control of a broad spectrum of contemporary health hazards related to environmental and occupational exposures, chronic diseases, and behavioral risks (CDC, 1994). CDC's mission to “promote health and quality of life by preventing disease, injury and disability” (CDC, 1994) and its special relationship with state and local health departments make it a good institutional home for the health promotion and disease prevention content and the community-based focus of the PRC program. Because of the rapidly changing health care environment, CDC sees its role and relationship to the public health community changing significantly with prevention research and dissemination

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention of effective strategies and interventions becoming paramount. To foster the necessary research and development efforts, CDC has sought to develop the capacity to conduct and support prevention research that is recognized as innovative and effective. To address these goals, the scientific research that the CDC supports at academic centers must be innovative and of high quality, and it must include dissemination research and application. CDC sees the PRC program as (1) providing a sound basis for health promotion and disease prevention and (2) translating research findings into community-based interventions. It identifies four main goals for the program, all intended to help meet national health objectives: Maximize resources for complex public health research. Make communities accessible and amenable to prevention interventions. Increase collaboration among agencies and nontraditional partners. Train public health professionals (NCCDPHP, 1996). GROWTH OF THE PRC PROGRAM PL 98-551 authorized the Secretary of Health and Human Services to provide funding at the annual level of $1 million per center for a total of 3 centers in 1985, 8 centers in 1986, and 13 centers in 1987. The actual appropriations from Congress, however, have fallen short of these authorized levels. Congress has expanded the PRC program from 3 PRCs and a total budget of $1.5 million to 13 PRCs and a total budget of approximately $7.7 million. This growth is shown in Table 1-1. In 1993, CDC began providing supplementary funds to the PRCs as a way to increase the levels of research activity within the PRCs through a Special Interest Project (SIP) funding mechanism. The PRCs received a total of $1.3 million through SIP funding in 1993 (ranging from $10,000 to $408,000 per PRC). In 1994 and 1995, the amounts were $3.3 million (ranging from $30,000 to $864,000 per PRC) and $9.5 million (ranging from $82,000 to $1.615 million per PRC), respectively. In 1996, $9.6 million was available for SIPs. Figure 1.1 illustrates the growth of the core funding and SIP components of the PRC program budget. Most of the PRCs also receive funding from the National Institutes of Health, state health departments, private foundations, and other sources. Some receive additional funding from CDC that is not associated with the PRC program core grants or SIPs. In fiscal year 1996, core funding for the PRC program was about $7.7 million, but CDC estimates that the total funding for

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention TABLE 1-1 Annual Congressional Funding and Number of PRCs Year Core Funding ($ millions) Number of PRCs Range of Core Awards Made to each PRC ($ thousands) 1986 1.5 3 406–550 1987 1.6 3 430–579 1988 1.8 5 124–511 1989 2.1 5 187–511 1990 3.8 7 325–650 1991 4.1 7 400–725 1992 5.2 7 420–861 1993 4.8 9 400–581 1994 5.8 12 425–977 1995 7.4 13 360–1,000 a 1996 7.7 14 n.a. a This represents the PRC program recommendation for funding levels in 1995. the centers was around $30 million (including SIP funding and nonprogram funding). Some of this additional funding has come to the PRCs as the result of CDC's investment in an infrastructure for prevention research. In addition to the increasing number of PRCs, the program has broadened its geographic distribution and thematic areas. The expansion of the PRC program by geographic areas and thematic interests is shown in Table 1-2. CDC'S REQUEST FOR A REVIEW OF THE PRC PROGRAM In 1995, CDC asked the Institute of Medicine (IOM) to review the PRC program to examine the extent to which the program is providing the public health community with workable strategies to address major public health problems in disease prevention and health promotion. IOM established a 10-member committee to evaluate the PRC program. CDC asked the committee to evaluate (1) the overall quality and appropriateness of the health promotion and disease prevention research and demonstration projects being carried out at the PRCs; and (2) CDC's management and oversight of the PRC program. The specific charge to the committee can be found in Appendix B.

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention FIGURE 3.1 Prevention research centers program dollars. SOURCE: Centers for Disease Control and Prevention.

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention TABLE 1.2 Growth of the PRC Program Year Established University Theme 1986 University of North Carolina at Chapel Hill: Schools of Dentistry, Medicine, Nursing, Pharmacy, and Public Health Workplace health promotion: New approaches to improving worker health 1986 University of Washington, Seattle, School of Public Health and Community Medicine/Group Health Cooperative of Puget Sound Making prevention work with community partners/Health promotion in older adults 1986 The University of Texas School of Public Health From healthy children to healthy adults 1990 Columbia University School of Public Health Reduction of excess morbidity and mortality in Harlem 1990 The University of Illinois, Chicago, School of Public Health Health promotion and disease prevention across the lifespan 1993 The University of California at Berkeley School of Public Health Families, neighborhoods, and communities: A model for action in chronic disease 1993 The University of South Carolina School of Public Health Promoting health through physical activity 1993 The Johns Hopkins University School of Public Health Promoting health and preventing disease among urban and rural adolescents 1993 The University of Alabama, Birmingham, School of Public Health Risk reduction across the lifespan within African-American families 1993 Saint Louis University School of Public Health Chronic disease prevention in low-income, rural communities 1994 The University of Oklahoma College of Public Health Health behavior promotion and disease prevention in the Native American population

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention 1994 Robert C. Byrd Health Sciences Center of West Virginia University Risk factors in Appalachia, with emphasis on cardiovascular diseases 1994 University of New Mexico Medical Center Promoting healthy lifestyles in American Indian families SOURCE: The CDC Prevention Research Centers Program (D. Labarthe). Organization of the Study The committee's report is intended to assist CDC in supporting research in health promotion and disease prevention. The focus of the report is on the roles, functions, plans, actions, and performance of CDC in establishing and maintaining the overall PRC program. The committee's examination of individual PRCs has been for the purpose of understanding the experience and performance of PRCs under varying circumstances of participation, not for the purpose of evaluating the individual PRCs. The potential of the PRCs to contribute to the fulfillment of the goals of regional and national health promotion and disease prevention was debated, and a decision was rendered in favor of the program when the authorizing legislation was passed. The committee accepts this conclusion without difficulty and without conducting the extensive study that would be required to test the validity or, at this early stage, the achievement of this goal. As a first step in assessing whether the PRC program is providing the necessary support for the PRCs to perform appropriately and effectively, the committee addressed questions related to the directions the PRCs have staked out for themselves and how the PRC program has provided support for movement in those directions. The committee accomplished this, in part, by examining the circumstances that have allowed some PRCs to flourish in their progress and the circumstances under which other PRCs have waned. The committee has not assessed the quality of the health promotion and disease prevention research and demonstration projects of individual PRCs. Rather, the focus is on CDC's plans, actions, and support of the overall PRC program to facilitate the appropriate and effective functioning of the PRCs. The research and demonstration projects of the PRCs have been assessed through CDC's two-tiered review process, at the stages of making the initial proposal and reporting annual progress.

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention Methodology for Reviewing the PRC Program The committee met three times, in March, May, and July 1996. The PRCs and the CDC provided information about the PRC program to the committee, both at and between the meetings. The committee reviewed documentation about the PRC program, including: historic documents about the program, including its legislative history; annual funding applications, internal review documents, and peer-review materials about each center; applications from centers that did not receive initial or continuing funding; criteria given in requests for proposals for new center grants and competitive renewals; information about projects receiving SIP funding; PRC program vision statements; annual reports from each center for each year funding was received. As a second source of information about the PRC program, the committee developed a questionnaire for the directors of the 13 university-based PRCs. Responses to the questionnaires were followed by scheduled telephone interviews with nine PRC directors, site visits to three PRCs, and a meeting with one PRC director during the committee's July meeting. The telephone interviews, which involved the PRC directors and, quite frequently, key staff, lasted from 90 minutes to 2 hours. Protocols for the interviews and site visits and the questionnaire appear in Appendix C. The site visits were conducted during a single business day, from 10 a.m. to 4 p.m. The committee selected three PRCs for a site visit based on years of funding, relation to the academic health center, geographical distribution, and population diversity. Site visits were made to one “mature” PRC funded in 1986 (The University of North Carolina), one intermediate PRC funded in 1990 (Columbia University), and a young PRC funded in 1994 (the University of New Mexico). The committee 's meeting in July with a PRC director provided an opportunity to hear from a researcher who has been involved with the PRC program since its inception in 1986. 5 The committee also made one site visit to CDC to conduct discussions with the PRC program staff, as well as CDC staff who work outside the PRC program but who have provided funding to PRCs through SIPs. Committee staff attended the PRC annual meeting in Atlanta in February 1996. 5   One of the committee members also had been a director of one of the first three centers.

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Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention OVERALL IMPRESSIONS By forging links with academia, CDC has created a gateway for access to a cadre of well-trained, university-based researchers who could serve to inform and collaborate with the agency and the public health community regarding health promotion and disease prevention. The PRC program also fosters the development of academic interest in research questions related to public health practice, community interventions, and the development of community links for translating research findings into practice. Overall, the committee finds in this report that CDC has made substantial progress with its PRC program and is to be commended for its accomplishments in advancing the scientific infrastructure in support of disease prevention and health promotion policy, programs, and practices. By further strengthening the PRC program, the CDC can increase its capacity to contribute to local, state, and national efforts to improve the health of Americans. The PRC program is at a crucial turning point. In Chapter 2 the committee discusses the importance of crafting a vision for the future of the program at this stage in the program's history, and its suggests some elements of a vision for the program. The committee 's findings and recommendations appear in chapter 3 and chapter 4. Chapter 3 reviews the research and demonstration projects conducted by the individual PRCs, and Chapter 4 addresses CDC's management and oversight of the program as a whole. ADDITIONAL PERSPECTIVES ON THE PRC PROGRAM While the committee was carrying out its work, the PRCs prepared a report that described their progress during the past decade. A summary of the report is in Appendix D. Also during this time, the CDC program staff prepared an information sheet on the program, which is reproduced in Appendix E. The contents of these reports and the perspectives of the PRC directors and the CDC staff were helpful to the committee.

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