5
Benefits and Challenges of Community-Based Collaboration for Researchers

A subtle smile, twinkling eyes, and Southern charm helped Selbert Wood, President and Chief Executive Officer of STEP ONE, a North Carolina-based drug and alcohol abuse treatment program, illustrate, the gulf between research and practice in the field of addictions treatment and prevention. He sought advice from friends and colleagues on what he ''ought to tell a bunch of Ph.D.s and policy folks" in Washington, DC. His community confidants proposed four tongue-in-cheek recommendations for researchers:

  • "We don't need no studies with long titles and with words more than three syllables."
  • "We don't need no studies about mice or monkeys-we just want to know better how to get drunk people sober and addicted people clean."
  • "We don't need no control groups or placebos floating around."
  • "We don't need no studies that cost more than you're giving us to take care of people."

In discussion with the panel, Mr. Wood explained that clinicians needed simple answers. A member probed, "What if the answers

This chapter was edited by Dennis McCarty with contributions by Benjamin P. Bowser and Joseph Westermeyer.



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5 Benefits and Challenges of Community-Based Collaboration for Researchers A subtle smile, twinkling eyes, and Southern charm helped Selbert Wood, President and Chief Executive Officer of STEP ONE, a North Carolina-based drug and alcohol abuse treatment program, illustrate, the gulf between research and practice in the field of addictions treatment and prevention. He sought advice from friends and colleagues on what he ''ought to tell a bunch of Ph.D.s and policy folks" in Washington, DC. His community confidants proposed four tongue-in-cheek recommendations for researchers: "We don't need no studies with long titles and with words more than three syllables." "We don't need no studies about mice or monkeys-we just want to know better how to get drunk people sober and addicted people clean." "We don't need no control groups or placebos floating around." "We don't need no studies that cost more than you're giving us to take care of people." In discussion with the panel, Mr. Wood explained that clinicians needed simple answers. A member probed, "What if the answers This chapter was edited by Dennis McCarty with contributions by Benjamin P. Bowser and Joseph Westermeyer.

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are not simple?" Mr. Wood suggested that investigators should provide practical and relevant studies. Another participant noted that many counselors read the research literature and respond to research findings but they too are looking for practical information. OVERVIEW Tensions between research and practice were evident in the testimony presented to the committee. Providers expressed concerns that managed care misused findings from controlled clinical trials to inappropriately justify reductions in the length and intensity of care. Policymakers hinted at discomfort with researcher-directed and -managed interventions. Both clinicians and investigators sought more value from the collaborative relationship. The folk wisdom found in the story above characterizes some of these tensions. Even readers who disagree with sentiments in the story should recognize the pragmatic, underlying attitudes. Practitioners and consumers want concrete results with clear applicability to clinical and personal needs. Investigators who seek to work closely and effectively with practitioners must be prepared to describe their research in straightforward language and must be able to explain the relevance for treatment and recovery. Similarly, because consumers and clinicians may not appreciate the need for experimental controls, researchers must be willing to teach practitioners and consumers about the importance of comparison groups. At the same time, investigators must learn to be sensitive to the treatment environment and to understand the culture of recovery. They should also respect the insights of experiential learning and be willing to explore non-experimental research opportunities. This chapter examines the benefits and challenges to working in a clinical environment from the perspective of the research investigator. The chapter also examines approaches that have been used successfully to build research/practice partnerships, and the lessons to be learned from prior federally sponsored demonstrations that linked practice and research in the field of drug abuse treatment. HISTORICAL APPROACHES TO COLLABORATION FOR RESEARCH Rapid development of community-based drug abuse treatment programs requires partnerships among investigators trained in theory and methods, clinical practitioners schooled in working with clients, administrators oriented toward problem resolution, and policymakers who fund and regu-

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late research, treatment, and prevention activities. Research investigators must embrace the challenge and complexity of working within clinical environments, just as clinical practitioners and consumers must be responsive to the burdens of research participation and become active partners in systematic data collection and investigation (see Chapter 4). Alliances between research and practice are required to develop empirically based clinical protocols and document improvements in clinical effectiveness. These alliances evolve slowly, however, as the theoretical underpinnings for research/practice linkages have evolved slowly in the study of prevention and treatment for alcohol and drug dependence. The origins include Kurt Lewin's formulation of action research, subsequent developments in applied social science and program evaluation methods, and the emergence of health services research. Action Research Researchers and practitioners have struggled for at least five decades to develop meaningful collaborations that simultaneously contribute to theory and knowledge development and to effective responses to social and clinical problems. Kurt Lewin was a pioneering and influential thinker on the nexus of application and theory. In the late 1940s, Lewin and his colleagues developed what they called action research to address gang-related anti-Semitism, monitor racial integration of work settings and housing projects, and explore the roots of racial and ethnic prejudices. During World War II, he applied science to management problems in a research partnership with the owners and employees at a furniture factory. This research collaboration documented the value of engaging workers in the design and collection of data, allowing them the opportunity to learn on their own and test the validity of their beliefs (Marrow, 1969). Today, many of these concepts and practices are central to the application of continuous quality improvement strategies: the importance of group participation, the value of self-management, and the use of data to test ideas and strategies. These early studies demonstrated the feasibility of conducting research in real-world settings and the potential to generate data that both solved problems and informed theory. As early as 1944, Lewin articulated four issues that must be addressed when conducting studies in applied settings: control, influence, education, and the need for theory (Lewin, 1951). He observed that investigators have relatively little control in organizational and community settings; consequently, they must seek active cooperation and must provide some value to the group in order to gain access and to introduce systematic change. Education about scientific methods is also essential in order to reduce resistance and to help participants understand

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the process. Finally, Lewin noted that effective study of social problems required both theory and application. [Collaboration can be achieved] if the theorist does not look toward applied problems with high brow aversion or with a fear of social problems, and if the applied psychologist realizes that there is nothing as practical as a good theory. Kurt Lewin in Theory in Social Science: Selected Theoretical Papers (1951), p. 169 Although he never studied treatment programs for alcohol and drug dependence, Lewin's observations remain clearly applicable to the integration of research and practice in substance abuse treatment programs. His exhortation on the value of research in industrial and community environments could have been written about many contemporary community-based substance abuse treatment programs: The organizational form of the existing factories, unions, political parties, community centers, associations-in short, of most groups-is based on tradition, on ideas of "a born organizer," on the non-survival of the unfit, or at best, on primitive methods of trial and error. Of course, much practical experience has been gathered and systematized to a degree. We know from other fields, however, that the efficiency of this procedure is far below what can be achieved with systematic scientific experimentation (Lewin, 1951). Applied Social Science Lewin's legacy is echoed in the work of social psychologist Leonard Bickman, who articulated the distinctions between laboratory and field settings and outlined the opportunities associated with conducting research in clinical environments (Bickman, 1980). His essays assert that investigators have much to gain when they enter clinical environments. For one thing, they are challenged to make a difference: concrete solutions for current problems become a central focus, rather than the more abstract development of knowledge. Research results may have visible influence on policy and practice. Clinical settings also stimulate urgency; timeliness is critical because policymakers and practitioners demand rapid results. Large, observable, and clinically meaningful effects are more valuable than small but statistically significant changes. And demonstrated effectiveness in com-

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munity treatment settings enhances adoption of clinical techniques and interventions and increases generalization of research findings. Bickman also recognized that clinical environments are challenging settings for research. Reduced statistical control and rival hypotheses can complicate interpretation of results. Discussion of results with clinicians and clients may be a critical step in the development of a full understanding of the findings and the articulation of subtle but real influences on the observed outcomes. A cadre of clinicians and data collectors is often required to implement investigations, so teamwork is essential to success and the management of the research process and personnel can be as important as the collection and analysis of data. The investigator must also be willing and able to negotiate access and procedures with a full range of stakeholders: clients, clinicians, administrators, policymakers, and funding agencies. Chilo Madrid's ten questions (Box 4.2) illustrate the importance of this negotiation. Ownership of the data and publication of the findings are issues that often generate controversy. Investigators should recognize that the participating treatment programs have a stake in the data and have claims to the findings. Investigators who make data available to the clinicians for treatment planning and evaluation and invite participation in data interpretation and publication may be encouraged to continue investigations. Those who demand autonomy and control, on the other hand, are likely to find inhibited access to programs and patients. Finally, the complexity of the research initiatives means that investigations that involve clinical settings may require a substantial investment of time and money. Funding should include incentives for patient participants (if primary data collection is required) and for treatment agencies that permit access. These influences and tensions have been apparent in the development of health services research. Health services research is a multidisciplinary field of inquiry, both basic and applied, that examines the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services to increase knowledge and understanding of the structure, processes and effects of health services for individuals and populations. Health Services Research: Workforce and Educational Issues, IOM (1995), p. 3.

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Health Services Research The study of health care delivery systems uses social science and economic analysis to span the gulf between research, practice, and policy. Health services research can be characterized in four general categories of investigations: 1.   clinical (studies of providers and patients and their influences on the process and outcome of care), 2.   institutional (studies that emphasize organizational and administrative aspects of service delivery), 3.   systemic (analyses of the interrelation among providers, institutions, and demands for care, including the financing and regulation of service), and 4.   environmental (assessments of the influence of social, political, and economic forces on the delivery and effects of health care). Services research often contributes to the development and implementation of health care policies through (a) documentation (health care indicators and markers specify and describe problems), (b) causal and correlational analyses (relationships are identified and policy influences are assessed often using demonstration programs), and (c) prescriptions (strategic models outline implementation requirements and provide guidelines for policy development) (Brown, 1991). Although the formal link between services research and policy formation can be traced most directly to the development, implementation, and analysis of Medicaid and Medicare during the 1960s, health services research evolved from descriptive and analytic investigations beginning in the first decade of the twentieth century (Ginzberg, 1991). The complexity of contemporary medical markets increases the importance of health services research and the dependence of policymakers on the data and results from these investigations. This complexity and need for data is strongly felt by community-based drug treatment organizations (CBOs) in their current environment. Only recently has services research been applied to the study of treatment services for alcohol and drug dependence. The ADAMHA Reorganization Act of 1992 (P.L. 101-321) separated the funding of research and practice in this field. The Act placed the research institutes (National Institute of Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and National Institute of Mental Health) under the auspices of the National Institutes of Health. At the same time, the service-focused agencies (Office for Treatment Improvement and the Office of Substance Abuse Prevention) were renamed the Center for Substance Abuse Treatment and the Center

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for Substance Abuse Prevention, respectively, and were located within the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services, along with the newly created Center for Mental Health Services. Concerns about the separation of research and practice led to language in the Act that required the three research institutes to allocate 15 percent of their research portfolio to health services research. The conference committee report on the legislation also requested a national plan for services research from the National Advisory Council on Alcohol Abuse and Alcoholism. The report identified eight areas where health services research was needed (Subcommittee on Health Services Research, 1997): 1.   analyses of the organization and financing of treatment for alcohol dependence; 2.   studies on the influence of managed care; 3.   investigations on access to care and utilization of services; 4.   assessments of treatment outcomes, effectiveness and the cost-effectiveness of care; 5.   studies of prevention services; 6.   development of improved research methods and databases; 7.   strategies for the dissemination of research results; and 8.   workforce analyses, reviews of training needs, and assessments of the peer review process. NIAAA's recommendations for health services research should facilitate continued development of research and practice collaborations. Another recent IOM report similarly stresses the importance of collaborative research linkages with managed care and community-based organizations to promote quality improvement in behavioral health care (IOM, 1997b). A similar set of priorities from NIDA would be helpful. Because services research is still emerging on treatment and prevention for alcohol and drug abuse and dependence, influences on policy and practice have been limited and there is much to be learned. MODELS FOR COLLABORATION Collaboration between research and practice takes many forms in the substance abuse treatment field and a number of collaboration models that impressed the committee are presented below. Arthur J. Schut, President of the Iowa Substance Abuse Program Director's Association, introduced the committee to the Iowa Consortium that brings together treatment providers, policymakers, and researchers based in each of the state's major universities to collaborate on research initiatives. The consortium facilitates the

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development, implementation, and interpretation of investigations that examine the need for substance abuse treatment and the effects of major policy initiatives in the state. Carol Leonard from the Navajo Nation and Philip May, Director of the University of New Mexico's Center on Alcoholism, Substance Abuse and Addictions (CASAA) offered another collaboration strategy. Their partnership illustrates a culturally sensitive approach to the combination of research and community oriented prevention and treatment. Importantly, the collaboration allows academic researchers to study a population (Native Americans) and service system (traditional practices) that would otherwise be difficult to investigate; the Navajo Nation gains through increased support from federal funding authorities and enhanced credibility of the findings from demonstration programs. The basis for partnerships between research and practice may be strengthened when treatment agencies employ investigators to develop assessment and monitoring protocols. Chestnut Health Systems in Illinois provides an example with its in-house research staff that collaborates with clinical and management staff to develop client information and outcomes monitoring systems. The researchers use the information not only to evaluate specific interventions but also to help practitioners improve the quality of care. The Community Clinical Oncology Program (CCOP), which has effectively linked cancer research and treatment for almost fifteen years, provides another model of collaboration. As described by Arnold Kaluzny from the University of North Carolina School of Public Health, this network, funded by the National Cancer Institute (NCI) brings together treatment providers and researchers in more than 30 states to get faster answers to research questions and bring state-of-the-art treatment to communities. Iowa Consortium for Substance Abuse Research and Evaluation The Iowa Consortium for Substance Abuse Research and Evaluation (the Consortium) provides a structure for communication and cooperation among policymakers, practitioners, and researchers. Representatives from the Iowa Substance Abuse Program Directors Association and investigators from four Iowa universities (University of Iowa, University of Northern Iowa, Iowa State University, and Drake University) joined with policymakers from the state agencies responsible for corrections, education, Medicaid, public safety, and public health to develop a forum to promote the collection of data and the use of research in policy formation and clinical practice. Convened in 1991 by the Governor's Alliance on Substance Abuse, the Consortium has become a vehicle for practical investigations, collaborative design and implementation of studies, multidisciplinary cooperation,

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and the application of research findings to practice and policy. Current membership includes the directors of community- and hospital-based treatment agencies; researchers trained in education, psychiatry, psychology, social work, and sociology; and women and men responsible for substance abuse treatment and prevention activities in state agencies. The Consortium uses newsletters, reports, meetings, and seminars to communicate and achieve three goals: 1.   encourage collaboration in research and evaluation studies, 2.   improve prevention and treatment services and contribute to public policy making, and 3.   educate students and professionals in substance abuse. Grants and contracts are the primary source of funding for Consortium activities. A small appropriation from the State of Iowa supports infrastructure and coordination. The Iowa Department of Public Health collaborates with Consortium members to apply for federal awards and state contracts. Funding from the Center for Substance Abuse Treatment and the Center for Substance Abuse Prevention supports needs assessment projects. Funding from NIDA supported investigations of case management strategies. Finally, Consortium affiliated investigators evaluated Iowa's implementation of a managed care approach for publicly funded substance abuse treatment services. Investigators who work through the Consortium structure may request letters of support from treatment providers and the state substance abuse authority when they apply for services research funds from federal, state, and local governments. The support letters strengthen applications and demonstrate a history of collaboration. The forum empowers treatment programs to participate in the design of investigations and to request support for necessary staff functions related to the research. Programs may also use the Consortium to discourage less clinically useful studies and to promote investigations that meet clinical priorities. The Consortium's goal of fostering discussion and cooperation among treatment providers, investigators, and policymakers has been difficult to articulate and implement. Individuals trained to conduct scientific research are not initially responsive to policymaker needs to review and comment on reports prior to public release. Practitioners do not always appreciate investigator requests for changes in clinical processes, and they can make demands for information and communication that investigators find intrusive. Policymakers are frustrated by the time required for investigators to collect and analyze data. Control and autonomy remain persistent concerns. Practitioners struggle with the added burdens of data collection and seek clarification around control and ownership of data.

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For some participants, the Consortium may be merely a vehicle to access data or clinical populations rather than a venue for collaboration. Nonetheless, the Iowa Consortium for Substance Abuse Research and Evaluation illustrates one way in which investigators, policymakers, and treatment providers can partner in the design and implementation of research. It provides an important example of an alliance between research, policy, and practice, and it suggests mechanisms that can be extended and applied to foster more local partnerships. Navajo Nation Community-based research now being undertaken by the Navajo Nation was initiated almost two decades ago by officials of the Navajo Nation (beginning with Mr. Gorman, a former tribal official) and a social science researcher, Philip May. After many years of patience and persistence, the research was finally undertaken with federal moneys, conducted under the aegis of the Navajo Nation with the collaboration of Dr. May and other researchers from the University of New Mexico's Center for Alcohol, Substance Abuse, and Addictions (CASAA), where Dr. May is now the director. CASAA worked with treatment providers in the Navajo Nation to evaluate an alcohol treatment program addressing the underlying cultural conflicts that contribute to high alcoholism rates among the Navajo. The approach was consistent with the high value the Navajo place on achieving balance and harmony with nature, family, and spirits. The collaboration provided the Navajo Nation with increased support from federal funding authorities and enhanced credibility for findings from demonstration programs. Obstacles to establishing this community-based research program included the following: initial suspicions within the tribe that the researchers were only interested in their own ends and did not have a long-lasting commitment to the tribe; a lack of familiarity by the tribe in addressing a major problem related to behavior, youth, health, family, law, and other social factors through research; absence of collaborative arrangements between nearby universities and the Navajo Nation; and insufficient awareness and trust in the funding agencies in working with the Navajo Nation. Five factors contributed to the eventual success of this community-based research:

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persistence of Tribal leaders and concerned Navajo leaders and community members; training and education of younger Navajo community members to participate actively in the administration and operation of a complex research endeavor; collaboration of Dr. Phillip May, a researcher with two decades of research experience with substance abuse among Native American people (see for example, May, 1992; May and Dizmang, 1974); the interest and flexibility of government officials in working with the tribe and local academics to bring about a funded project; and the capability to undertake convincing research across languages and cultures in a largely rural population, many of whom were unfamiliar with research methods or suspicious of the uses to which research might be put. Academicians, Navajo leaders, and Navajo collaborators in the research project had to cooperate in a variety of complex tasks to establish a state-of-the-art-and-science project. For example, materials had to be translated into Navajo using a standard, yet time-consuming and costly method of initial translation, back-translation, pilot study, renorming and restandardizing, and final acceptance (Brislin, 1986). Negotiations regarding data access were also important. Data that might result from such a study has the potential for embarrassing tribal officials, leaders, or members at large, while reputable researchers engage in such projects to foster the expansion of knowledge and understanding. Funding organizations wanted assurances that the findings would benefit the people for whom the project was intended, and not languish unused because they were unpalatable to one of the parties involved. After these issues were worked out to each party's satisfaction, projects were undertaken. Drug Outcome Monitoring System Two large community-based drug abuse treatment providers in Illinois designed and implemented a performance measurement system to monitor client outcomes and enhance their accountability with purchasers and consumers. Chestnut Health Systems and Interventions, operating 49 facilities, collaborated on a field trial of the Drug Outcome Monitoring System (DOMS). Clinical records, administrative information, and service utilization data are integrated and used for quality improvement and outcome monitoring initiatives. The system includes an assessment tool (Global Appraisal of Individual Needs—GAIN) that facilitates a diagnosis based on

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DSM-IV criteria, patient placement using the American Society of Addiction Medicine criteria for level of care, treatment planning consistent with Joint Commission for the Accreditation of Health Care Organizations standards, and compliance with federal and state data reporting requirements (Dennis et al., 1997). This monitoring during and after treatment is expected to enhance clinical processes and improve outcomes. Although still in development and testing, the emphasis on clinical needs and client outcomes increases the potential value for consumers, counselors, management, and payers. Developed with funding from NIAAA and CSAT, the Drug Outcome Monitoring System illustrates an important strategy for integrating services and research and meeting the needs for both sets of stakeholders. Because the data are of clinical value, counselors are likely to be more careful completing interviews and responding to data elements, thus enhancing data quality for research studies and policy analyses. Client subgroups are developed and benchmarks are established for levels of services and outcomes and postdischarge client tracking. The monitoring system engages clinicians and consumers in the process of tracking and recording clinical status and incorporates early reintervention protocols when postdischarge follow-up suggests that a client is in early relapse. The design of this system to be responsive to consumer and counselor needs contrasts with the top-down development of many administrative data systems that stress payer requirements and management needs. Community Clinical Oncology Program Initiated by the National Cancer Institute (NCI) in 1983, the goal of the Community Clinical Oncology Program (CCOP) has been to bring state-of-the-art cancer treatment, prevention, and control research to local communities. This is accomplished by involving community oncologists and community-based primary care physicians in NCI-approved clinical trials (Kaluzny et al., 1996). CCOP is a strategic alliance among existing organizations. The three main organizations are: (1) NCI, which provides overall direction, funding, and program management; (2) NCI-designated cancer centers and clinical cooperative groups, which develop protocols, analyze data, and provide quality assurance; and (3) the community oncology programs composed of community oncologists, primary care physicians, and their clinical staff who are involved with the accrual of patients to approved treatment, prevention, and control protocols. As of 1997, there were 51 CCOPs located in 30 states, with 300 participating hospitals where some 2000 physicians cooperate to enter patients and individuals at risk for cancer on NCI-approved clinical trials. An addi-

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tional 8 minority-based CCOPs are funded to enhance participation of minority populations in clinical trials research. This group adds 42 hospitals and 350 participating physicians to the alliance (NCI, 1997). The CCOP experience demonstrates certain general principles regarding community-based care. As well-described by Ann Greer (1988) some years ago, ''There are no magic signatories or formats which will cause knowledge to jump off the page and into practice." In CCOP, however, the creation of an infrastructure provided an opportunity to close the gap between state-of-the-art care and community practice patterns. For example, in the care of breast cancer, patients treated by CCOP physicians were the ones most consistently receiving state-of-the-art care as defined by current protocols. Moreover, changes in referral patterns among non-CCOP physicians within the community increased the likelihood that patients would receive appropriate adjuvant therapy—an important indicator of CCOP impact on quality of care delivered in participating institutions (Kaluzny et al., 1996). This approach has also demonstrated the necessity for protocols not only to be available but to be "user friendly," "feasible," and "relevant" in the local context. Moreover, it is necessary that data managers, nursing personnel, and other support personnel be involved in the effort and that CCOP physicians be able to link to primary care providers in the community. The role of support personnel is especially critical to the successful completion of day-to-day tasks involved in patient recruitment, protocol assignment, data collection, and follow-up (Kaluzny et al., 1993). CCOPs are not inexpensive and present a significant managerial challenge. The infrastructure alone at each clinical site can exceed $200,000. Interactions among community providers are often uneasy, and there is a need to maintain a working relationship between the cancer center (or university), the cooperative groups, and the community physicians. Local leadership of the CCOP is a particularly critical element. To be a clinician leader requires a commitment to a research perspective with a particular emphasis or at least an orientation to epidemiology and the social behavioral sciences. To meet the realities of a changing health care delivery system, partnerships with managed care organizations must be developed (Kaluzny, 1997). Such partnerships are in the process of development. For example, the American Association of Health Plans has recently adopted a new policy intended to encourage their member HMOs to participate in clinical trials sponsored by NIH, and there appear to be an increasing number of research partnerships between managed care organizations and cancer centers (Glass and Greenlick, 1989; Myers et al., 1997), as well as new partnerships for research developing among managed care organizations (Durham, 1998). The critical point is to close the gap between policy, research, and

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treatment and thereby assure "institutional learning" at the community level. This requires an infrastructure among a set of relevant organizations. The CCOP provides this infrastructure, permitting NCI, cancer centers, cooperative groups, and community-based physicians to achieve strategic objectives that were not possible for any single organization. LESSONS FROM DEMONSTRATION INITIATIVES The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) have long traditions of supporting demonstrations to develop and evaluate treatment and prevention interventions. The institutes used a variety of funding and management mechanisms to promote prevention programs, develop services for homeless men and women, and test strategies to reduce the risk of HIV infection among drug users. Three sets of demonstration initiatives are examined to identify lessons for research-practice collaborations in community-based drug treatment. Prevention Demonstrations NIAAA and NIDA prevention initiatives began in the 1970s. State Prevention Coordinators were supported to facilitate state planning, provide prevention training, manage state prevention contracts, and serve as liaisons with the federal Institutes (Williams and Vejnoska, 1981). NIAAA funded the development of prevention curriculum for children, adolescents, and college students. After the models were implemented, NIAAA used a demonstration replication program to test the generalizability of the three prevention models. Eight local communities and State Alcoholism Authorities were funded to replicate and evaluate one of the prevention programs. The replication highlighted the need for systematic documentation and illustrated the variations encountered as communities deviated from model frameworks (NIAAA, 1981). The two formal school-based curricula (Here's Looking at You and CASPAR) have evolved during more than 20 years of use and remain cornerstones of prevention activities in many school systems. The university-based model, however, faded as neither the original campus nor the replication campuses maintained the initiative for long after the termination of federal funding. Based on these experiences, NIAAA designed subsequent prevention projects to be "conceptually tighter, more skeptical, and careful in statements of objectives and intentions, more modest in whom they mean to reach and what they mean to do with people, and more deliberate in how they plan to go about it" (NIAAA, 1981). There was more emphasis on theory, and projects were more likely to be funded in public health depart-

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ments and research centers than in community-based schools and organizations. The prevention strategies evolved from an emphasis on individual change to an emphasis on policy and environmental interventions. These demonstrations illustrate both the value of building system capacity (there was a substantial need for educational curricula) and the challenges of collaborating with community groups to test applications. The replications enhanced curriculum development but appear to have contributed little to science. Projects for Homeless Individuals The 1987 Stewart B. Mckinney Homeless Assistance Act (P. L. 100-77) authorized initiatives to address the national problem of widespread homelessness. NIAAA and NIDA collaborated to support demonstration projects that implemented and evaluated interventions for homeless men and women with alcohol- and drug-related problems. Initially, nine projects were funded in eight cities. Each project was required to allocate at least 25 percent of the award for process and outcome evaluation. A separate contract was awarded for cross-site evaluation, coordination, assistance, and data analysis (Lubran, 1990; Orwin et al., 1993). A diversity of interventions was encouraged because there was little empirical data on effective services for alcohol and drug involved homeless individuals (Huebner and Crosse, 1991). The applicants tended to be community organizations or state or local health departments. The community organizations subcontracted with academic-based investigators for the evaluation research. Each site was unique. A special issue of the Alcoholism Treatment Quarterly (McCarty, 1990) and reports from NIAAA (Murray, 1993; Shane et al., 1993) provide more details. The evaluation report on the first round of demonstrations drew lessons, noted key findings, and made recommendations (Orwin et al., 1993). An obvious but often overlooked finding was that when working with homeless men and women, issues related to food, shelter, and security must be addressed before treatment can be initiated. Programs also learned that both program structure and flexible responses were necessary to engage and retain homeless participants. Start-up required substantial resources and persistence, especially when there was resistance to siting services in specific locations. Overall improvements in client functioning were modest. Generally, the services led to reductions in alcohol and drug use. Composite scores from the Addiction Severity Index suggested improvements in employment and economic security in some of the study sites. Housing stability was increased in a project that facilitated access to alcohol- and drug-free housing; psychiatric status improved in a different city. Substantial project variation made cross-site comparisons difficult, and

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only five of the nine sites provided useful outcome data (Huebner and Crosse, 1991; Orwin et al., 1993). The quality of the data submitted for cross-site analysis varied because the study sites tended to be community-based organizations with little research experience. Low follow-up rates compromised the integrity of the evaluation designs and threatened the validity of the findings. Finally, variability among the nine study sites and the relatively small number of study sites limited the ability to identify robust interventions and to generalize study findings. Based on these lessons and limitations, the cross-site evaluation has general implications for collaboration between community-based organizations and researchers (Huebner and Crosse, 1991; Orwin et al., 1993). The ability of seven of the nine sites to collect and submit standardized data suggested that research is feasible in community settings even when the population is difficult to serve. The evaluators also recommended longer funding periods, larger sample sizes, more rigorous evaluation designs, standardization of research tools and interventions, and more emphasis on follow-up data collection. First, research demonstrations require at least five years of funding for implementation, maturation, and the development of a sufficient sample. Second, programs should receive technical assistance as needed on evaluation design, data collection, and analysis. Finally, adequate follow-up rates are essential to provide scientifically valid data on the effects of the interventions. NIAAA applied these lessons to the design of a second round of community demonstration programs. Significantly, the funding mechanism was changed from grants to cooperative agreements to give NIAAA staff and its subcontractors more control and influence over development and implementation (Huebner et al., 1993). NIAAA provided guidelines for service interventions and site-level evaluations and mandated a core set of instruments. NIAAA also attempted to increase the consistency of the data collection and improve the potential for meaningful cross-site analyses. As a result of these modifications, the second round projects were primarily awarded to universities and research centers which subcontracted with community organizations for services. Details on the study sites are provided in a special issue of the Alcoholism Treatment Quarterly (Conrad et al., 1993) and an issue of New Directions for Program Evaluation (Conrad, 1994). The evolution of the Community Demonstration Project between the first set of grants to community organizations and the second set of cooperative agreements with academic research centers illustrates the challenges of building effective collaborations among practitioners, researchers, and policymakers. The funding agency and the external (cross-site) evaluators were disappointed with the level of control and influence in the initial investigations. In the subsequent awards, research expertise was empha-

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sized and specific research instruments were required. This was designed to improve the quality of the science, but changing the rules also changed the roles of the participants: service providers tended to be less directly involved, and investigators had a more dominant influence. National AIDS Demonstration Research Project The spread of HIV infection led Congress to ask NIDA to develop interventions that encouraged injection drug users to reduce HIV risk behaviors and enter treatment. During 1987 and 1988, the National AIDS Demonstration Research (NADR) Program funded demonstration outreach and intervention services in 47 cities (NIDA, 1996). These programs combined research and services to gather data on drug use and to test the efficacy of behavior change strategies. Individually and collectively, the study sites demonstrated that injection drug users were responsive to education and outreach interventions (NIDA, 1996; Needle and Coyle, 1997). NIDA encouraged state substance abuse prevention and treatment authorities to promote the adoption and continuation of the outreach and educational models that appeared to be most effective (NIDA, 1996). Three strategies for behavior change among injection drug users were disseminated: (1) a two-session risk reduction education intervention (Coyle, 1993); (2) a four-session psychoeducational intervention using behavioral counseling techniques (Rhodes, 1993); and (3) an outreach and community change strategy where recovering drug users provide education and support for behavior change (Wiebel, 1993). NIDA also used a cooperative agreement mechanism to support multisite studies to monitor HIV risk behaviors and test outreach interventions among out-of-treatment drug users. Collaboration among the 23 study sites permitted more rapid data collection on infrequent behaviors and small populations (NIDA, 1996). The Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program appears to have been an effective approach to multisite research collaborations with community-based services. These programs demonstrated that out-of-treatment drug users could be found and educated, and they also illustrated the value of collaborations between research and services. Involvement of multiple sites and varied teams of investigators increased the generalizability of the findings, and policymakers were able to be more confident in their programming recommendations. There appears to have been substantial teamwork among the outreach workers, counselors, and investigators. The initiatives document the feasibility of developing structures that support partnerships among consumers, clinicians, and researchers.

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GUIDANCE FOR GRANT REVIEW To participate in research, evaluation, and demonstration opportunities, treatment programs and investigators usually must respond to program announcements and requests for applications from the NIH research institutes and the SAMHSA service centers. The committee heard much apprehension about the application and review process—the competition is great, the review process is biased against clinically useful investigations, community-based agencies are not strong applicants, and controlled clinical trials are more likely to be funded than services research. Similar concerns were voiced in another IOM Committee report, Dispelling the Myths About Addiction: Strategies to Increase Understanding and Strengthen Research, (IOM, 1997a). The relatively small proportion of applications that are approved and funded attests to the difficulty of the process. But the widespread misgivings also suggest basic misunderstandings about the review process. More education and guidance about the application and review process may be useful, especially if it is pragmatic. An experienced perspective on the review process is provided by the former chair of a NIDA initial review group, who identifies ten common mistakes in grant writing (Oetting, 1990). Applicants should recognize their weaknesses and build a team that strengthens the proposal. Sufficient detail is required to convince reviewers that the study can be completed. If the proposal has been previously reviewed, the resubmission should respond to the prior critiques. The aims of the study must be important and address real needs and issues. Methods must be used appropriately and applicants should not make excuses for inadequate procedures. Three of Oetting's list of ten mistakes seem directly applicable to the challenge of research and practice collaborations. First, applications that seek research funds primarily to enhance treatment capacity are usually a mistake. While services can be funded through research applications (if the service is necessary to test specific hypotheses), reviewers evaluate the quality of the research plan and the potential for knowledge generation not the need for more treatment. In research applications, the quality of the research is the major determinant of the application score. Another common grant writing mistake is to attach analyses of drug use and abuse to programs and investigations with a different primary interest. Although drug abuse affects many facets of life, applications that fail to address drug use and abuse directly tend to be weak. Applicants must demonstrate a comprehensive understanding of the connections to drug abuse and not merely seek additional funding. Finally, Oetting (1990) suggests that the most critical mistake is not to apply. The process is difficult and the probability of funding is low. Agencies that never apply, however, can never be funded and can not benefit from the literature review and thinking required to

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develop an application and from the opportunity to receive reviewer feedback, revise and submit revised applications which have a higher probability of funding. Because community-based organizations receive few research grants, it appears to some observers that nonacademic applicants are disadvantaged in the application and review process. Significant changes may be required in the application and review process in order to increase awards to community-based applicants. If, however, the goal is research that is of high quality and applicable to treatment programs, the application and review process should stress the importance and quality of the proposed research. Applications with strong partnerships between practitioners and investigators should be encouraged and should be competitive in the current review process. Ultimately, the committee determined it was not appropriate to recommend changes in the general process for applying for and reviewing research applications. The committee felt strongly, however, that mechanisms must be created to stimulate and support effective alliances between research teams and treatment providers, and recommended a special grant program with a unique review process to achieve this end. SUMMARY The review of applied research and health services research suggests that research in clinical settings is not easy and has many unique aspects, views that were supported by many who spoke to the committee. Environmental control is reduced. Research teams are required. Access and funding issues must be negotiated. Data and results must be shared. Special skills and training are necessary for research collaboration in a community-based setting, but there are few, if any, programs that provide such training. Professional development programs are needed, similar to the NIH training programs and Robert Wood Johnson clinical scholars program. Services research in community-based substance abuse treatment settings requires investigators who can build meaningful partnerships with drug abuse treatment programs and who have the skills to design and implement high quality research studies that will contribute to the evolution and refinement of community-based treatment interventions. There is no single best approach to promoting collaborations. Strategies will vary depending on participant personalities, the issues and policies of interest, and the resources available. The Iowa Consortium works, in part, because policymakers help support the research infrastructure and provide a forum for communication. Chestnut Health Systems Drug Outcomes Monitoring System illustrates the advantages of working closely with investigators based in the treatment agency. CCOP also provides research infrastructure support and has the added benefit of having been

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developed and tested by NCI. The promise of enhanced consumer access to treatment innovations suggests an intriguing potential for application of the CCOP model within community-based drug abuse treatment services. Finally, the collaboration between CASAA and the Navajo Nation shows the importance of long-term relationships. This partnership promotes systematic study of populations and procedures that are often not open to research investigation. The culture of treatment and recovery requires investigators who are sensitive to its nuances. Demonstration programs funded through NIDA and NIAAA document that research collaborations with treatment programs, consumers, and investigators are feasible. The funding requirements appear to influence the nature of the collaborations: the homeless demonstrations and the HIV demonstrations were more service oriented when funding went to community-based providers who subcontracted for research and evaluation services, however, there was more emphasis on science when academic research centers controlled the funding and subcontracted for services. Both research and service must have adequate and specific funds. Adequate funding for both will empower services researchers and treatment providers alike. Practitioners and researchers must have a mutual understanding and appreciation for the other's role. Ultimately, research and practice alliances must balance scientific control and rigor with the realities of clinical environments. REFERENCES Bickman L. 1980. Applied Social Psychology, SPSSI, and Kurt Lewin. In: Bickman L ed. Applied Social Psychology Annual: 1. Vol. 1. Beverly Hills, CA: Sage Publications. Pp. 7-18. Brislin RW. 1986. The wording and translation of research instruments. In: Lonner JW, Berry JW eds. Field Methods in Cross-Cultural Research. Beverly Hills, CA: Sage. Brown LD. 1991. Knowledge and power: Health services research as a political resource. In: Ginzberg E, ed. Health Services Research: Key to Health Policy. Cambridge, MA: Harvard University Press. Pp. 20-45. Conrad KJ, ed. 1994. Critically Evaluating the Role of Experiments, Vol. 63. San Francisco, CA: Jossey-Bass. Conrad KJ, Hultman Cl, Lyons JS, eds. 1993. Treatment of the Chemically Dependent Homeless: Theory and Implementation in Fourteen American Projects (10)3/4. Coyle SL. 1993. The NIDA HIV Counseling and Education Intervention Model: Intervention Manual. NIH Pub. No. 93-3580. Rockville, MD: National Institute on Drug Abuse. Dennis NIL, Godley SH, Scott C, Foss M, Godley MD, Hagan R, Senay EC, Bailey J, Bokos PJ. 1997. Drug Outcome Monitoring Systems (DOMS): Developing a New Biopsychosocial Paradigm for Health Services Research. Bloomington, IL: Chestnut Health Systems. Durham NIL. 1998. Partnerships for research among managed care organizations. Health Affairs 17(1):111-122.

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NIDA (National Institute on Drug Abuse). 1996. National Institute on Drug Abuse Community-Based HIV Prevention Research. Rockville, MD : National Institute on Drug Abuse. Needle RH, Coyle SL. 1997. Community-Based Outreach Risk Reduction Strategy to Prevent HIV Risk Behaviors in Out-of-Treatment Injection Drug Users. Rockville, MD: National Institute on Drug Abuse. Oetting ER. 1990. Ten fatal mistakes in grant writing. In: Kazdin AE ed. Methodological Issues and Strategies in Clinical Research. Washington, DC: American Psychological Association. Pp. 739-748. Orwin RG, Goldman HH, Sonnefeld LJ, Smith NG, Ridgely MS, Garrison-Morgren R, O'Neill E, Luchese J, Sherman A, O'Connell ME. 1993. Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals: Final Evaluation Report. NIH Pub. No. 92-3541. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Rhodes F. 1993. The Behavioral Counseling Model for Injection Drug Users: Intervention Manual. NIH Pub. No. 93-3579. Rockville, MD: National Institute on Drug Abuse. Shane P, Ridgely MS, Sherman A, O'Neill E, Goldman HH, Wittman F, Smith NG. 1993. Community Demonstration Grants Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals: Case Studies of Nine Community Demonstration Grants . NIH Pub. No. 93-3539. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Subcommittee on Health Services Research, National Advisory Council on Alcohol Abuse and Alcoholism. 1997. Improving the Delivery of Alcohol Treatment and Prevention Services: Executive Summary. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Wiebel W. 1993. The Indigenous Leader Outreach Model: Intervention Manual. NIH Pub. No. 93-3581. Rockville, MD: National Institute on Drug Abuse. Williams M, Vejnoska J. 1981. Alcohol and youth: State prevention approaches. Alcohol Health & Research World 6(1):2-13.