A Vision for the Prevention Research Centers Program
THE CHALLENGE AHEAD
The challenges now faced by the PRC program are similar to those faced by universities, especially academic health centers, everywhere in North America. These challenges involve the financial pressures in most of this country's institutions, joined by the need to become visibly contributing partners in their home communities. Universities are being called upon to “reinvent” themselves as close partners with the greater communities they serve. These are opportunities to transform the educational process by using new educational and communication technologies to respond to the unique training and research needs of communities. These challenges suggest an opportunity for the PRC program to place much greater emphasis on its outreach, dissemination, technical assistance, and implementation roles. Collaborative funding of community and state or regional dissemination and implementation efforts must also be pursued so that the responsibility of funding and staffing community, state, and regional programs is shared by all public and private stakeholders— health care providers, public health departments, private businesses, and others. Responding to these challenges, the committee has developed a vision for the PRC program that is described in this chapter. Its purpose is to provide ideas for the PRC leadership as they evolve the system, and to clarify the standard to which the committee held the PRCs and the program as a whole.
Purpose of the PRC Program
The committee's review and discussions with some of those associated with the development of the PRC program indicate that there are at least three ways in which the PRC program can serve CDC's purposes. First, in fulfillment of its mission as the nation's prevention agency, CDC could use the PRC program to undertake the research and development that any successful, forward-looking science-based agency must have. The PRC program could generate new knowledge, from fundamental concepts to practical approaches, and could support prevention practice at CDC, as well as at state and local public health agencies, in communities, and in health service delivery settings. CDC has an organizational focus on community health and has both a unique interest and experience to bring to public health practice research. Increasing numbers of researchers are recognizing the importance of community factors among the determinants of health and the consequent potential for community-based interventions, as well as the value of community involvement in the conduct of health research—that is, setting the research goal or question, developing community-appropriate methodology, interpreting results, and disseminating findings. Through the PRC program, CDC could lead the way in generating needed knowledge about this new community-based approach to research. Although other approaches to health promotion and disease prevention research remain important, addressing community-based interventions would allow CDC to distinguish itself from other research sponsors, develop a promising area of work, and most important, create a field program that reflects the reality of the communities CDC is intended to serve.
Second, CDC could use the PRC program as a way to build capacity for public health practice outside its Atlanta headquarters. The university-based PRCs, which have collaborative relationships with state and local health departments, community organizations, and other entities, might serve as extensions of CDC's activities based in Atlanta and state health departments to field settings that would otherwise be beyond the agency's reach. In this model, the PRCs would function as field laboratories for research and development relevant to CDC's mission and would provide the staff and connections to the community necessary to respond to public health issues that may arise in those communities. More generally, if CDC viewed schools of public health and similar academic institutions as important components of the nation's capacity to address public health problems, a research program could strengthen the institutions, just as National Institutes of Health (NIH) research support since World War II has increased and improved the capacity of American medical schools to address the nation's medical problems (IOM, 1984).
Finally, CDC could use the PRC program as a way to work with disadvantaged communities on critical public health problems. Taking
advantage of their locations and the connections that some academic health centers already have with minority communities, CDC-sponsored centers could provide an opportunity to address some of the pressing public health needs of these communities. By focusing its research efforts on issues relevant to particular disadvantaged communities associated with the PRCs, the PRC program could develop new knowledge appropriate to similar communities nationwide.
A Vision for the Future
As any complex program must, the PRC program needs to establish a vision for the future to enable its success as it moves into its second decade. Many options are available. The vision should encourage PRCs, and others who work in health promotion and disease prevention, to expand their activities, moving toward centers characterized by:
focus on risk conditions and social determinants of health;
an orientation toward the community;
a means for dissemination research in public health;
an interactive process for establishing research priorities;
a role in setting national research priorities.
A Focus on Risk Conditions and Social Determinants of Health
The last several decades have witnessed a resurgence of interest in broader models of health and its determinants, in part as a response to the growing realization that investments in clinical and personal preventive health care were not leading to commensurate gains in the health of populations. McGinnis and Foege (1993) found, for instance, that approximately half of the deaths in the United States were related to behavioral risks. More than half of the recommendations of the U.S. Preventive Services Task Force (1995) dealt with patient counseling interventions to address these behavioral factors. The Lalonde Report introduced a “new perspective” that recognized four elements as critical determinants of health: lifestyles, environment, human biology, and health care organizations (LaLonde, 1974). A broadening interest in health promotion in the United States has been evident in the “Healthy People” initiative since 1979. Healthy People 2000: National Health Promotion and Disease Prevention Objectives (USDHHS, 1991) has been officially adopted to guide Public Health Service programs. Unlike the traditional biomedical model
that views health as the absence of disease, the new models of health count the presence of good health, full functional capacity, and a positive sense of well-being as outcomes of interest. General factors that affect many diseases or the health of large segments of the population, rather than specific factors accounting for small changes in health at the individual level, are emphasized (Evans and Stoddart, 1994). The new models take a multidisciplinary approach, uniting biomedical sciences, public health, psychology, statistics and epidemiology, economics, sociology, education, and other disciplines.
The importance of considering the origins of health and the underlying risk conditions of disease in individuals and populations is emphasized in these new models. They underscore the interdisciplinary and multisectoral efforts often required to achieve health improvement in communities. Social, environmental, economic, and genetic conditions, in addition to behavioral risk factors, are seen as contributing to differences in health status, and therefore presenting opportunities to intervene.
Through the PRC program, research support and technical assistance can be provided to communities as they strive to improve the health of their populations. Guidance from academia and governmental agencies will be needed to improve the health status of Americans and to achieve healthy communities. The PRC program can play an important role in the adoption of new, broad models for how communities should approach health improvement.
An Orientation Toward the Community
During the decade since the PRC program was begun, there have been substantial changes in the public health establishment's understanding of the importance of the community to the health of the public. Following on The Future of Public Health (IOM, 1988), more recent IOM reports (IOM 1996a,b) have stressed the relationship between public health agencies and other community entities and public health's leadership role in improving the community 's health. Community health is now seen as a product of many factors, and many segments of the community have the potential to contribute and share responsibility for its protection and improvement. Changes in public policy, in public and private sector roles in health and health care, and in public expectations are presenting both opportunities and challenges for communities as they address health issues.
Contributing to this change of perspective is a wider recognition that health embraces well-being as well as the absence of illness. For both individuals and populations, health can be seen to depend not only on medical care but also on other factors, including individual behavior and genetic makeup and the social and economic conditions affecting individuals and communities. As described
by Evans and Stoddart (1994), the multiple determinants of health are best understood in a dynamic relationship, with feedback loops linking social environment, physical environment, genetic endowment, an individual's behavioral and biologic responses, disease, health care, health and function, well-being, and prosperity. This model makes it clear that a wide range of actors, many whose roles are not within the traditional domain of “health activities,” both affect and have a stake in a community's health. These include individual health care providers, public health agencies, health care organizations, purchasers of health services, local governments, schools, community organizations, policymakers, and the public.
Because of the importance of the social context in which health-related behavior is determined, community interventions have been the subject of a great deal of interest in the public health community in the last few years. Settings for community interventions include schools, and work sites, as well as whole communities. Approaches to these activities can take passive or active forms. Passive approaches change the physical or social environment and can be oriented toward control by police actions or restriction of substance availability, or toward incentives through taxes, prices, and the like. Active approaches to influence behavior can be targeted directly to individuals through screening and counseling programs, or to groups through the media or educational programs.
Community interventions include, but go beyond, the mass media to include community organization and control. Community interventions also differ in important ways from the medical model; rather than treatment for specific conditions, community interventions focus on knowledge and behavior of individuals and policymakers and aspects of the social and physical environment that influence them. Because of this focus, attitudes and culture as well as personal decisions take on increased prominence. Correspondingly, the science base for community interventions has roots in the social and behavioral sciences as well as in the biomedical sciences. The issue in many cases is not with the evidence of the importance of behavior change, or even the basic social and behavioral science, but with translating this knowledge into action in the community.
As the development of this new understanding about health and the community proceeds, many universities are contemplating major transformations that include forming partnerships with industry, public agencies, and other community organizations to enhance the economic, physical, and social well-being of the institutions, their students, and their surrounding communities. The breakdown of traditional boundaries allows universities to form true partnerships with community organizations for research, service, and teaching activities. The PRCs could serve as leaders in building partnerships, if they are able to progress to a second phase that involves
research and dissemination projects that are jointly planned and produced with community partners who have joint ownership of the programs.
Enthusiasm and optimism about getting universities directly involved in the solutions to social problems, however, should not be allowed to overwhelm them with demands beyond their capacities. A major concern is that increased responsibilities may be thrust upon the universities without commensurate increases in resources and that the educational and research missions of the universities will be jeopardized. Even if resources are increased, however, the risk remains that interests and attention of faculty, staff, and students in the universities will be diverted and that dilution of other activities will be inevitable. The PRCs are not intended to substitute for or replace the excellent service implementation partnerships that CDC has with state and local health departments. The PRCs are not intended to substitute for or replace the excellent service implementation partnerships that CDC has with state and local health departments. Public and other social agencies should limit their expectations of the role of universities in directing interventions to ameliorate social ills, and universities should be wisely, if selectively, resolute in resisting both the demands, which are obvious, and the temptations, which may not be.
Another extension of the conventional research approach is the active and collaborative engagement of multiple disciplines in prevention and health promotion research. This goal cannot be achieved if core faculty from various disciplines pursue separate research agendas on multiple, parallel, discipline-based tracks. A true interdisciplinary approach to research involves the active synthesis of disciplinary perspectives in defining a single research problem, the active merging of methodologies and methods in measuring and analyzing the phenomena under study, and the active reconciliation of multiple levels of analysis in the interpretation of results (Campbell, 1987; Vertinsky and Vertinsky, 1990).
Interdisciplinary research is one of the defining features of research centers that distinguishes them from most academic departments and justifies their existence within a university. One view of interdisciplinary research organizations is that their creation depends on uncertainty about a single approach to solve or research the problems they address, and that “a prime danger to the survival of interdisciplinary research organizations (IDROs) stems from strategies initiated by their management to reduce external and internal uncertainties” (Vertinsky and Vertinsky, 1990). The development of an IDRO often depends on identifying an area for research that is important and has been neglected or unsolved by the mainstream disciplines. IDROs that retreat to
bureaucratic modes of behavior and specialization to reduce uncertainty or to insure greater security often fall prey to the very limitations of disciplinary departments that justified their creation (Vertinsky and Vertinsky, 1990).
Interdisciplinarity also seeks to consolidate knowledge in ways that are more meaningful to communities' residents and practitioners (Beam, 1982). Public health as an interdisciplinary field has grounded its scientific foundations in epidemiology, biostatistics, social and behavioral sciences, administration, and environmental sciences. Indeed, the development of a cohesive body of knowledge for public health brings together these disciplines in a variety of combinations, depending on the research problem at hand. The development of knowledge in applied fields usually requires some degree of interdisciplinarity (Klein, 1985). This need becomes increasingly clear as emerging health problems are found to be complex, multicausal, and protracted in their duration and their latency period.
A Means for Dissemination Research in Public Health
A systematic, planned approach to dissemination can facilitate the PRCs' integration of research and programs that have been tested or evaluated into practice at the community or clinic level. The CDC has a tradition of working with state health agencies in the prevention of disease and the promotion of health. State and local health agencies play a critical role as linking agents in the process of diffusion of research in public health practice. A recommendation from CDC's First National Conference on Chronic Disease Prevention and Control (CDC, 1987) stated, “if it is true that effective clinical techniques should move quickly to the bedside, it is equally true that new prevention techniques should rapidly reach the community. ” Prevention centers, in conjunction with state and local health agencies, may enhance that diffusion process.
The universities that provide the institutional base for PRCs can facilitate the dissemination of findings from research and demonstration. This can be accomplished by incorporating research findings into teaching programs, assisting in publication of work in scholarly journals, bringing results to the attention of disciplines beyond public health (e.g., medicine, nursing, social work, pharmacy, and the like), and influencing policymakers. As universities have moved toward more interaction with communities, as is the case among many national and local institutions, they have increased the potential to provide findings to a broad range of community constituencies. They can also generate from their constiutuencies relevant needs and problems deserving exploration in research and demonstration.
An Interactive Process for Establishing Research Priorities
One way to characterize the options facing the PRCs in their relationship to public health practice communities (for example, state and local health departments, nonprofit community organizations, and so on) is as an evolving process for setting research priorities. PRCs adopting this approach must evolve through three steps: (1) the current proactive practice of academically driven research initiatives, (2) a more reactive practice for designing research in response to the needs and input of community agencies, and (3) the development of interactive research practices that involve both academic researchers and the community as equal partners in all phases of a research project.
The interactive model, an ideal to which some PRCs might aspire, focuses on building relationships with communities that represent true partnerships and conducting research that addresses local needs. The current literature refers to the interactive model of applied research as “participatory research” (Fals-Borda and Rahman, 1991; Green et al., 1995) and “empowerment evaluation” (Fetterman, 1994; Fetterman et al., 1995). These are variations on earlier models and traditions of “action research” (Lewin, 1953), “participatory evaluation” (Cousins and Earl, 1995), “developmental evaluation” (Patton, 1994), and “participatory action research ” (Park et al., 1993; Whyte, 1991). These approaches to research and evaluation have sought to improve on university-based or even community-based models of research by adding education and action as essential components of the research process. They fit logically and strategically with the legislative mandate of the PRC program and the dissemination and outreach objectives of the PRCs.
A Role in Setting National Research Priorities
National priorities for research are established regularly by federal bodies and agencies. In its allocation of funding to specific research institutes and programs, Congress establishes research priorities. In their selection of specific research initiatives to be included in annual budgets, federal agencies establish research priorities.
Federal agencies tend to establish their priorities for research independently of one another. As a consequence, allocations of interest and resources are quite uneven; some important problems may be neglected altogether because they fall in the bureaucratic cracks between the agencies. It is particularly difficult to bring to bear the resources of funding agencies and research recipients to provide for a concerted and integrated attack on a social problem. We do not, in relation to social problems, have any Manhattan Projects or moon shots.
In health promotion and disease prevention, the lack of coordination in establishing priorities and allocating funds means that problems are almost certain to be attacked piecemeal. The problem of adolescent smoking is unlikely to be dealt with in the context of a broad-scale program of research that should probably include nutrition, exercise, drug and alcohol abuse, dropping out of school, and many other issues. We know that adolescents who have weak attachments to school are more likely to drop out of school, to initiate smoking, to engage in risky sexual behavior, and so on, but we do not know whether increasing their attachment to school would also reduce their risks of other behaviors detrimental to their welfare. It might be that the best way to reduce adolescent smoking or other substance abuse would be to make changes in the educational system (Gerstein and Green, 1993), but under the present system of setting priorities, researchers may never be able to study that idea.
The public health community does not want and probably does not need a single agency to convene and establish higher-level research priorities to direct federal funding decisions. Nevertheless, public health research might benefit a great deal from higher-level multidisciplinary or interdisciplinary groups that would be convened, or otherwise created, to look at health issues in a more comprehensive way, to assemble information that cuts across problem boundaries, and to identify gaps in our knowledge base (Clark and McLeroy, 1995). The PRC program could play a leadership role in encouraging and establishing such groups.