4

Management and Oversight of the Prevention Research Centers Program

In this chapter the committee presents its findings and recommendations regarding the management and oversight of the prevention research centers (PRC) program. The discussion focuses on management issues that are related to the quality of the research and demonstration projects undertaken by the individual PRCs, as discussed in the preceding chapter. These issues include the definition of prevention research, criteria for evaluating the PRCs, and procedures for mobilizing and allocating resources in their support. The committee also addresses the degree to which effective collaboration is occurring between PRCs and their communities, among the PRCs as a network, and beyond the PRCs to the national and international community of researchers, policymakers, planners, and practitioners in disease prevention and health promotion. The recommendations in this chapter suggest ways that CDC can help the center program evolve in the directions identified in chapter 2.

VISION AND GOALS

As an agency, the Centers for Disease Control and Prevention (CDC) focuses on public health practice rather than funding university-based research. Nevertheless, through its interviews and site visits, the committee found that the adoption and integration of the PRC program by CDC has been relatively smooth. Through their research and demonstration activities, the PRCs can make—and have made—significant contributions toward meeting some of the national goals and objectives of Healthy People 2000 (USDHHS, 1991),



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention 4 Management and Oversight of the Prevention Research Centers Program In this chapter the committee presents its findings and recommendations regarding the management and oversight of the prevention research centers (PRC) program. The discussion focuses on management issues that are related to the quality of the research and demonstration projects undertaken by the individual PRCs, as discussed in the preceding chapter. These issues include the definition of prevention research, criteria for evaluating the PRCs, and procedures for mobilizing and allocating resources in their support. The committee also addresses the degree to which effective collaboration is occurring between PRCs and their communities, among the PRCs as a network, and beyond the PRCs to the national and international community of researchers, policymakers, planners, and practitioners in disease prevention and health promotion. The recommendations in this chapter suggest ways that CDC can help the center program evolve in the directions identified in chapter 2. VISION AND GOALS As an agency, the Centers for Disease Control and Prevention (CDC) focuses on public health practice rather than funding university-based research. Nevertheless, through its interviews and site visits, the committee found that the adoption and integration of the PRC program by CDC has been relatively smooth. Through their research and demonstration activities, the PRCs can make—and have made—significant contributions toward meeting some of the national goals and objectives of Healthy People 2000 (USDHHS, 1991),

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention Whether CDC as a whole has recognized this asset is unclear. CDC's strategic plan (CDC, 1994) makes mention of the PRC program, but it does not appear to feature the program as a resource. As it recreates its vision for the future, CDC should consider the important and changing relationships between communities and universities discussed in Chapter 2. To ensure that the PRC program remains relevant to critical current public health issues, the committee recommends that CDC should ensure that the vision and goals of the PRC program are compatible, mutually supportive, and consistent with the agency's overall strategic plan and with Healthy People 2000. The PRC program's vision and goals should define, in a clear and comprehensive way, the contributions of the PRC program to national priorities. A strategic plan, developed collaboratively by the CDC staff and the PRC directors, might help to clarify the program's actual and potential contributions. Prevention Research CDC defines prevention research in the application guidelines for the PRC program as research designed “to yield results directly applicable to interventions to prevent occurrence of disease and disability, or the progression of detectable but asymptomatic disease”. In the context of the broad spectrum of research defined by the National Institutes of Health (NIH) (Moskowitz, et al., 1981), CDC has described the research conducted under its PRC program as applied research. The definition, however, should not be interpreted as limiting the scope of research to disease prevention priorities, as it sometimes appears to do in CDC documents—it should include health promotion. Health promotion requires a scope of research that may not have a direct application to prevention of specific diseases or disabilities, at least in the short run. Health promotion research, for instance, addresses risk-taking among adolescents, which indirectly affects lifelong patterns of tobacco, alcohol, and substance use, as well as sexual behaviors that affect teen pregnancy, sexually transmitted diseases, and AIDS. At least three of the PRCs (Hopkins, Illinois, and Texas) are addressing these issues. Health promotion research, generally encompasses the examination of underlying risk conditions, which may not have an immediate influence on the incidence of diseases and disability, as well as more proximal risk factors. Health promotion research also includes the examination of processes that build the understanding and skills, mobilize the resources, and reinforce the actions of individuals and communities to cultivate health and to improve the quality of life. In order for the PRC program to remain consistent with current theory and

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention practice in health promotion and disease prevention, the committee recommends that CDC should modify its definition ofprevention research as articulated in the application guidelines for the PRC program to encompass the broader scope of health promotion research needed to address the underlying determinants of health (risk conditions) and to build the capacity of individuals and communities to “cultivate health,” rather than to focus solely on those determinants with immediate application to disease prevention (risk factors). THEMATIC FOCUS In the committee's experience, as discussed in chapter 2 , academic centers are more likely to build a cohesive program of research and to have a major impact on public health problems when the center develops a strong sense of its own identity. Integrating major research projects around a common theme is one of the best ways to build and maintain cohesiveness and continuity. Such an approach requires strategic planning for each five-year period of core funding and involves putting proposed efforts into research that is most reflective of a center's unique identity. CDC requires that each PRC adopt a thematic focus for its research and demonstration efforts. A theme is a useful concept for defining a PRC's central mission and its priorities in health promotion and disease prevention. Over time a center's identity can adapt in response to both internal initiatives and external needs. An example of such an approach is the University of Washington's original theme of elder health which later evolved into an additional theme of health for the disabled. Reactively responding to the multiple research topics of the Special Interest Projects (SIPs) can take a center in many directions at once, resulting in fragmentation rather than integration, and diminished focus on in-depth research that ultimately may have the greatest impact on the health of the community. PRCs, however, are faced with a dynamic tension between criteria based on their themes and those defined by the SIP program and other funding opportunities. Beginning in 1993, CDC has made supplementary funding available to PRCs through this mechanism, in which research topics are identified (and funds provided) by CDC program units, and only PRCs are eligible to compete for the funds. Current planning for SIP funding has been an ad hoc process of garnering funds remaining at end of the fiscal year from agencies, divisions, or offices of the federal government that can use the SIP funding mechanism to expedite spending for discrete research projects.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention Although the funding occurs in an expedient way, less encumbered by bureaucratic requirements than other means of government procurement, it has the disadvantage of being hurried and is an unstable funding mechanism. In addition, some of the PRC researchers have raised questions about the process of developing research topics and whether there is sufficient input from the research community and other experts in the public health practice community outside CDC. The resulting topics may not reflect state-of-the-art approaches to research. While SIPs have the potential to create innovative opportunities for the PRCs consistent with their themes, they also have the potential to present distractions from thematic research agendas. If the PRCs are to make progress in their self-identified thematic areas, they need to have a long-term commitment to a focused research agenda. Based on its interviews and document review, the committee finds that investigator-initiated research tends to be driven by PRC themes and demonstrates commitment to a focused research agenda, whereas SIP-initiated research is generally driven by CDC's internal interests and short-term needs. Although some SIPs have a clear association with the goals of the PRC program as a whole and the strengths and themes of some PRCs, others do not. PRC program staff at CDC need to address the disjoint between PRCs' themes and CDC's internal interests and short-term needs. It appears that CDC has not communicated whether themes should be paramount in the selection of projects. Guidance from CDC that clarifies the role of PRC themes in selecting projects would be beneficial to the PRCs. In addition, CDC has not specified whether it has expectations about progress toward national goals in the thematic areas, and if it does, the potential roles of the PRCs in achieving these goals. The guidance provided by CDC should be relevant to the selection of investigator-initiated core projects as well as SIPs. In order to clarify CDC's expectations regarding the PRC program's contributions, the committee recommends that CDC should provide guidance to the PRCs about the role of the PRCs' themes in selecting core research and demonstration projects and SIPs. NETWORKING, COMMUNICATION, AND DISSEMINATION Improved Communication and Interaction The PRC program has created a group of 13 PRCs with similar interests and goals. Several share a focus on similar health problems or populations. No individual PRC has the capacity, interest, or resources to cover the full range of

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention research, from epidemiologic research to research that assesses interventions at the community level and the dissemination and implementation of effective interventions across communities. Collectively, however, the PRCs have this capacity, which is necessary to reach the goals of the PRC program. The groups of researchers, their community constituents, and the circle of public health practitioners who collaborate in the PRCs' activities comprise a valuable network for exchanging ideas, disseminating results, and generating new projects. CDC serves as the fulcrum for networking and communication. Two of the recent SIP initiatives from CDC (on tobacco and adolescent health) have encouraged networking among the PRCs on specific issues. The committee's review has suggested that the interaction between the PRC program staff at CDC and the individual PRCs has realized some success in linking the efforts of the 13 PRCs. The tobacco network funded by a SIP initiative is an excellent example. Nevertheless, the links among PRCs and between an individual PRC and PRC program staff at CDC and/or other CDC efforts can be improved. In general, projects encouraged by PRC program staff at CDC are not always focused on topics that address the PRCs' central interests and capabilities. This can be attributed to some degree to a lack of communication between PRC program staff at CDC and other CDC units, as well as a lack of opportunity to identify mutually beneficial and innovative projects. The PRC program can enhance prevention research and the public's health through improved communication and networking mechanisms. To achieve this goal, each PRC should be called upon periodically to report on new knowledge gained that warrants replication or adaptation and evaluation in other PRCs that serve different populations. While some PRCs have generated interesting and significant findings, innovative research and demonstration projects have generally not been replicated within the PRC network. Annual reports to CDC describe activities that PRCs undertake, but not the lessons learned. They are therefore not a source of information that would allow individual PRCs, the PRCs as a group, or the PRC program staff at CDC to build on their own efforts. CDC should encourage the replication of promising studies at other PRCs (Campbell, 1987). The annual meetings provide an opportunity for the PRCs to discuss findings and their appropriateness for replication, multicenter trial, or broad dissemination to the public health practice community. In order to consolidate the information for public health policy being gained from the PRC program, the committee recommends that CDC should provide more opportunities for the PRCs to meet collectively, share lessons learned, exchange information related to findings, activate their collective communication channels on behalf of worthy

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention projects, and provide mutual support, especially from strong PRCs to fledgling centers. CDC efforts to this end could include: providing resources for periodic meetings of the PRCs' staff at both senior and junior levels for substantive discussion of research issues through presentation of papers, discussion of methods, planning for collaborative projects, and the like; using national meetings, such as the American Public Health Association 's annual meeting, to promote communication among PRCs and to reach the broader public health constituency; continued development of means for electronic communications among the centers using the Internet and the World Wide Web; developing mechanisms to involve individual PRC investigators in decisions related to SIPs and other special projects, strategies for dissemination of research results, and promising new research directions. Community Input The added value of the PRC program is its focus on community-based research, and CDC should encourage the public health practice community and other agencies and sectors to take greater advantage of the resource represented by the PRCs in their region and elsewhere. Another way for CDC to achieve greater involvement of the PRCs with the practice community would be to require, as a condition of funding, that the planning processes at PRCs involve representatives from their communities. This would be consistent with the funding conditions that CDC places on state and local health departments. The currently mandated community advisory boards are a step in this direction, but they do not seen to be effective in developing the kind of dialog between the PRCs and their communities called for in Chapter 2. Thus, to foster better connections between the PRCs and the communities they work with, the committee recommends that CDC should develop strategies for improving community input into the PRCs.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention Dissemination Research As discussed in Chapter 3 , the overall amount of research on dissemination and implementation appears to be very limited, whether viewed within individual PRCs or across the entire PRC program. PRCs have not exchanged information in a systematic way, and opportunities for replication of investigations into dissemination and implementation have not been exploited. PRCs have not regularly and systematically reported their findings concerning dissemination and implementation to CDC, and CDC does not have a mechanism for assembling findings from the PRCs in order to promote such activities. Thus, to improve the quality of dissemination research in the PRC program, the committee recommends that CDC should set specific expectations for dissemination research in the PRC program and encourage the PRCs to communicate their findings concerning dissemination and implementation methods among themselves and to the broader public health community. CRITERIA FOR EVALUATING PRCs The PRCs vary considerably in the extent to which they publish research, disseminate their findings, and interact with local and state programs and agencies. Based on its interviews, site visits, and document reviews, the committee believes that this is because CDC has not established clear expectations for the PRCs. In fact, CDC does not require that the PRC's results be evaluated, except in funding renewal applications, and no comprehensive evaluation of the individual PRCs has ever been done. The PRC program staff at CDC should, in consultation with the PRCs, set explicit performance expectations and establish a mechanism for periodic evaluation of the PRCs. In this way, CDC can influence the PRCs' output toward high achievements while avoiding micromanagement. The committee reviewed the quality of the PRCs' research and demonstration projects using standard academic criteria (peer-reviewed publications) and found that the quality of the PRCs ' research and demonstration projects is highly variable. In many of the PRCs there is no clear mechanism to eliminate low-quality projects that are unlikely to yield generalizable or clearly usable results worthy of dissemination through publication. A few PRCs produce research that consistently meets the traditional academic standards, but these PRCs are in the minority. Overall, the PRCs produce too few peer-reviewed research publications relative to the resources available and the life span of the PRCs. The committee recognizes

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention that the PRCs make other contributions to health promotion and disease prevention research, and does not believe that academic criteria should dominate the evaluation of the PRCs, but it had no objective or independent measure for the evaluation of the quality of non-peer-reviewed products. Progress Reports One option for improving the quality assurance procedures at CDC is a modification in the format of the PRCs' annual progress reports. At present, the annual progress reports do not include measures of project results such as data gathered and their importance and summaries of publications. Instead, they offer measures of what has been done such as meetings attended, and data collected. The annual progress report would be a better quality assurance tool if it contained both results and process measures. Thus, the committee recommends that CDC should require PRC progress reports to include information on research findings and publications. Peer Review There is currently no requirement for external peer review of PRCs. Only applicants for new grants and competitive renewals receive external reviews as part of the application process. External peer review is a time-tested mechanism for evaluating a research program and identifying areas for improvement, and it can help a research program to overcome obstacles to success. Ideally, the external peer review should consist of a review of publications and other PRC products along with a site visit. External peer review should occur sufficiently far ahead of an application for refunding to allow time to make needed changes, at the same time that it assists CDC in forming the basis of its eventual decision about renewal of a PRC (i.e., at least one year ahead of the refunding application). To ensure appropriate scientific review of the PRCs, the committee recommends that An external peer review of each PRC should be conducted in the year prior to the last year of its funding. The core funding of the PRCs is dedicated to developing community-based projects that enhance health, building and maintaining strong working relationships with community organizations, and establishing better-informed

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention public health practice and research communities. PRCs must demonstrate that they have used core funding successfully. The measures of success include demonstration programs, productive working relationships with community institutions, and dissemination of research findings. Most centers use core funding to enhance their capacity to do high-quality, investigator-initiated research and carry out community-based interventions. A key measure of success, therefore, is the amount of funds raised to support these projects. In order to set expectations clearly and treat all of the centers fairly, the committee recommends that CDC should establish criteria to evaluate the performance of a PRC over its five-year funding period. The criteria should enable one to measure performance in the following programmatic areas: development of innovative research and demonstration projects; success in conducting demonstration projects (the extent of implementation, proper evaluation, effective dissemination of research findings and lessons learned, altered health behaviors, practitioner functioning, program planning, policy decisionmaking in the population, and other measures); publication of research articles in peer-reviewed journals; other peer-reviewed products such as videotapes, curriculum, and intervention program guidelines that communicate research results to public health practitioners and the population that they serve; an effective working relationship with the public health practice community, including but not limited to official state and local health departments; success in disseminating research results to public health practitioners in the PRC's local area and elsewhere; a demonstrated role in enhancing public health resources in the community (measured by the number of trainees placed in local public health agencies, the impact on policy changes in the community, and similar activities); measures of sustained impact on the community, state, or nation; success in competing for other funding, including SIPs, foundation support, community and state funds, and federal grants.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention FUNDING FOR THE PRC PROGRAM Core Funding Perhaps the most consistent message the committee received from the PRCs was their great need for stable core funding and the perceived inadequacy of the level of core funding provided by CDC. Neither the funding level for individual PRCs nor the overall PRC program has ever equaled the amounts initially authorized by Congress in 1986. In several instances, the PRCs have been unable to pursue dissemination and evaluation activities for lack of adequate funding. The inadequate level of funding for PRCs seems to be a critical barrier to the program's long-term success. When CDC reduces awards from the proposed level, PRCs are unable to accomplish all the work originally planned. Dissemination and implementation efforts tend to be costly and labor-intensive, and are thus likely to be diminished in scope and intensity in response to reduced funding. Yet these are very important facets of PRC activities. These reductions in funding levels by CDC have adversely affected the quality of the PRCs' dissemination research, as well as the sharing of information between PRCs and the broader public health community. Green and Kreuter (1991) document this “poverty cycle” in the field of health education, and indicate how it can be overcome. The committee supports CDC's commitment to providing core funds on an ongoing basis to allow PRCs to undertake innovative community-based research activities that are difficult, if not impossible, to support through other funding sources. The committee emphasizes, however, that the CDC needs to encourage the use of core funding to support activities that are likely to produce generalizable research results that will advance the science of health promotion and disease prevention. Thus, the committee recommends that The Congress should increase the appropriation for the core PRC program to the level authorized in PL 98-551 to allow for 13 PRCs to be funded at the $1 million level, as originally intended. The committee believes that range of core activities expected of the PRCs (as described elsewhere in this chapter), especially given increased costs in the last decade, fully justifies a core funding level of $1 million per center, as originally authorized. The committee does not have enough information on the budgets of the individual centers, or the effectiveness of the the projects supported by core funds, to make any more specific funding recommendation.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention Open Competition One of the hallmarks of the U.S. research and development system since World War II has been the involvement of nongovernment scientists in setting the detailed scientific agenda of federal research agencies. Part of the social contract between science and government is that scientists should play major roles in providing advice about the scientific agenda, while policymakers should set broad strategic goals and provide the resources needed to reach them. This approach, implemented most clearly in the peer-review process of the National Science Foundation and the National Institutes of Health, is seen as one of the most important reasons that these agencies have been successful in harnessing scientific research to meet national needs in the last half-century. Reviewing this experience in the context of improving the process of allocating federal funds for science and technology, a recent National Academy of Sciences report (NAS, 1995) states that “because competition for funding is vital to maintain the high quality of [federal science and technology] programs, competitive merit review, especially that involving external reviewers, should be the preferred way to make awards.” The NAS report relies on the principle that the highest-quality projects and people should be supported with federal research funds, and finds that the best-known mechanism to accomplish this is some form of open competition involving evaluation of merit by peers. Competitive merit review requires the use of criteria that include technical quality, the qualifications of the proposer, relevance and educational impacts of the proposed project, and other factors pertaining to research goals rather than to political or other nonresearch considerations. Open competition means that, at some level within the framework of an agency's mission, researchers propose their best ideas and anyone may apply and be funded, regardless of institution or geographic location. In the case of highly targeted missions, however, quality can also be maintained by knowledgeable program managers who have established external scientific and technical advisory groups to help assess quality and to help monitor whether agency needs are met. The committee agrees that merit review—which emphasizes competition among ideas, diversity of funders and performers of research and development, and organizational flexibility —has been largely responsible for the remarkable quality, productivity, and originality of U.S. science and technology in the past. The PRC program was established to improve the capacity of schools of public health and academic health centers to conduct research that can be applied to public health practice, and this goal is to be lauded. This aim should be preserved, and high-quality research should not be hampered by restrictive application criteria.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention To further these aims, competition for PRC grants should focus on public health researchers, and CDC should be particularly responsive to applicants who demonstrate a capacity for multidisciplinary approaches to public health problems. Competition for PRCs should not be restricted to a single state; this is unnecessarily restrictive. The network of PRCs should strive to be a national resource that is responsive to all states and territories and that funds the most qualified research proposals. Thus, in summary, the committee recommends that Core funding for the PRCs should be determined as a result of open competition, using the peer-review approach that is standard in most federally-funded research programs. Special Interest Projects In 1993, CDC began providing supplementary funds to the PRCs through a Special Interest Project (SIP) funding mechanism as a way to increase the levels of research, activity within the PRCs, and simultaneously address CDC research needs. In 1995, PRCs received $9.5 million (ranging from $82,000 to $1.615 million per PRC) under this program, more than the total core funding. Funding for the community intervention portion of the NIH Women's Health Initiative recently has been channeled through the SIP program. In this funding mechanism, CDC has found a creative means of supporting PRC research activities beyond the level provided by congressional appropriations. The program also provides a simple means (in an agency not set up to fund research, as NIH is) for CDC units to fund university-based research to meet program needs. As a funding mechanism, however, it lacks a systematic approach to setting priorities, calling for proposals, reviewing proposals, and funding the accepted proposals (initial and continuing). To date, planning for SIP funding has been an ad hoc process of garnering funds at the end of the fiscal year from agencies, divisions, or offices of the federal government that use the SIP funding mechanism to expedite spending to complete discrete research projects. Although the funding is accomplished in an expedient manner, less encumbered than other means of government procurement by bureaucratic requirements that are inappropriate for a research program, it is neither a satisfactory nor a stable means of funding research. It tends to be rushed, confusing for those responding to the requests for applications (RFAs), and frustrating to funders when the responses to RFAs are insufficient. In addition, the process of developing research topics tends to be completed without the benefit of input from the research community and other experts in

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention the public health practice community outside CDC. The resulting topics often do not reflect state-of-the-art approaches to research. The committee encourages CDC to promote innovation by developing a process of research formulation that is more interactive than either the proactive process of most SIP funding or the reactive process of investigator-initiated grants that have not included consultation with either local or federal consumers of research. One option would be for CDC to institutionalize a triangulation process that would involve PRCs, state or local health departments, and CDC in a process of developing research topics. Thus, the committee recommends that Priorities for the Special Interest Projects (SIPs) should be set through a long-term, interactive process involving the PRCs, CDC, and the public health practice community. SIPs have the potential to create innovative opportunities for the PRCs that are consistent with their themes, but as currently structured, they are more likely to present distractions. By reflecting the capabilities and goals of the PRCs and the PRC program in SIPs, the SIPs are likely to produce innovative research and demonstration projects. Thus, the committee recommends that CDC should assure that the capabilities and goals of the individual PRCs and the PRC program are reflected in the SIPs. One of the most successful SIPs is a tobacco network project, which provided a small amount of funding to 10 PRCs to develop a collaborating network of projects. This SIP should be used as a model for developing other networking SIPs. Another way in which SIPs can advance the science of prevention research is through replication of promising studies in other regions and populations. Therefore, the committee recommends that CDC should make available a portion of SIP funds to encourage collaborative networks, multicenter studies, or replication of promising studies in other regions and populations. CDC assigns a staff liaison to each SIP project funded at a PRC, including projects funded under the NIH Women's Health Initiative. These assignments are made to provide guidance to the PRC researchers and to ensure that the funding unit's program goals are addressed. In some cases, the PRC staff are not experienced in the relevant research areas, and the assignment of a liaison is beneficial. In other cases, however, the university-based researchers are more knowledgeable about a subject area than the CDC staff. If CDC feels that the assignment of liaisons to all SIP projects must continue, the purpose should be

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention clarified, and liaisons used to help create integrated networks, as discussed above. Allocation of Core Funds CDC requires that PRCs use core funds for demonstration projects, collaboration with state and local health (or education) departments, and training, but it does not specify the proportion of funding that should be allocated to each activity. PRCs can expend core funds justifiably to help initiate a cohesive program of research, but such research should then be continued through regular research funding channels so that an adequate proportion of core funds can be devoted increasingly to outreach and technical assistance activities. The committee considered varying formulas for proportionate allocation and earmarking of PRCs' core funds for purposes of infrastructure support, research activity, and dissemination and evaluation functions. It concluded that the levels of development and other resources available to the PRCs vary so widely that any single prescription for the allocation of core funds would be inappropriate for some centers, and potentially counterproductive for others. This should not be interpreted as a recommendation for less oversight by CDC; the intent of the recommendation is to allow flexibility regarding the percentage of funds allocated across mandatory core activities. PRCs should have leeway in determining how they will achieve core objectives, but should be held accountable for demonstrating that objectives have been achieved. Thus, the committee recommends that CDC should allow the PRCs to determine how to spend their core funds most productively for their varying organizational circumstances. CDC, no doubt, wishes to attract strong, research-oriented institutions that will add to the nation's understanding of prevention and health promotion, work with communities, and disseminate promising results. There are several, somewhat obvious, benefits to an institution that becomes a PRC. For example, the program ensures the availability of funds that will remain reasonably stable over five years and offers the potential to leverage new funds, especially through access to the SIPs. Nevertheless, there are potential drawbacks to the PRC program that may cause hesitation or a decision not to compete. Consideration of these may suggest ways for CDC to strengthen the program. For some institutions, the amount of core funding available may not be adequate to cover the considerable amount of faculty and staff time needed to initiate and maintain a PRC. Faculty diverted from teaching or from research projects with larger budgets may generate costs not fully covered by core funds.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention In addition, much health-related research is funded by agencies that are not primarily interested in community-focused research emphasizing collaboration and, a PRC may not be the best mechanism for leveraging other large, non-CDC, grant support. Further, the process of formulating SIPs appears to exclude academia; that is, CDC determines the priorities, and these may not be central to the primary interests of a given PRC. The attraction of applying for SIPs could thus be diminished because a PRC may not be successful, and securing a SIP may divert faculty from the major work of the PRC. Many institutions, especially schools of public health, are interested in developing their ability to link with communities and engage in more participatory, partnership-oriented research. Creating and maintaining the interface and capacity for these activities is expensive. The PRCs represent a source for identifying shared community and academic interests and needs. Core funding expressly earmarked for linking and enabling community-focused structures and functions would be very attractive to these institutions. The relatively low level of core funding for the PRC program and the complications of the SIP funding mechanism, however, may, in the committee's judgment, have caused some of the more research-oriented schools of public health and academic health centers to decide not to apply for funding under the PRC program. CDC could structure the program to be more attractive to institutions that have intellectual and other resources to contribute to prevention research. Further, CDC could develop a process to involve PRCs in the formulation of SIPs. If some or all of the announcements for SIPs were focused on helping PRCs to build on current work or to move research programs forward, deans and faculty members might be more motivated to establish PRCs. SUMMARY AND CONCLUSIONS The committee's review indicates that CDC's management of the PRC program has been creative in the face of limited resources relative to its mandate; dogged in pursuit of the mandate over a ten-year period in a bureaucratic environment that was not created or structured for the management of university-based research programs; and skilled in enhancing a sense of community and networking among the funded centers in a time of disappointing funding levels. CDC has fulfilled its initial mandate of “establishing and maintaining centers collaborating through research and demonstration to help fulfill prevention goals consistent with regional and national priorities” (PL 98-551, 1984). 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.

OCR for page 49
Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention This page in the original is blank.