Health promotion and disease prevention are central priorities in the Centers for Disease Control and Prevention (CDC) vision, Healthy People In A Healthy World Through Prevention (CDC, n.d.). To advance research in these areas, Congress authorized and CDC established a program of university-based Centers for Research and Demonstration of Health Promotion and Disease Prevention. Congress authorized the program to “undertake research and demonstration projects in health promotion, disease prevention, and improved methods of appraising health hazards and risk factors, and shall serve as demonstration sites for the use of new and innovative research in public health technique to improve public health” (PL 98-551). The prevention research centers (PRC) program 1 began in 1986 with funding to three universities. With periodic competitive renewals and expansions of the program, there are now 13 PRCs. 2
Multidisciplinary faculty at these PRCs, located at schools of public health and academic health centers, focus on a series of related projects on a public health theme defined in terms of special populations, risk factors, or specific health conditions. The PRCs are expected to form partnerships to develop
Public Law 98-551 created Centers for Research and Demonstration of Health Promotion and Disease Prevention. Throughout this report, the committee refers to these university-based centers as prevention research centers, or PRCs. In referring to the administration of the program by CDC, the committee uses the terminology “the PRC program. ”
A 14th PRC grant was awarded after the committee completed its final meeting.
innovative ways to prevent disease and promote health, focus on high-priority public health issues, and conduct research and demonstration activities that result in improved public health practice. The PRCs are intended to serve as bridges between science and practice, and from academia to state and local health departments, health care providers and provider organizations, and community organizations, as well as with CDC. Evaluation research is embedded in many of the PRC interventions, and the centers also train public health professionals in applied prevention research.
PL 98-551 authorized the Secretary of Health and Human Services to provide annual funding at the level of $1 million per center for a total of 3 centers in 1985, 8 centers in 1986, and 13 centers in 1987. The actual annual appropriations from Congress, however, have fallen short of these authorization levels. Since the program was established, Congress has expanded the core PRC program from a total budget of $1.5 million to a total budget of approximately $7 million in fiscal year 1995. 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. The PRCs received a total of $9.5 million through SIP funding in 1995.
CHARGE TO THE COMMITTEE
In 1995, CDC asked the Institute of Medicine (IOM) to review the PRC program to examine the extent to which the program is providing the public health community with workable strategies to address major public health problems in disease prevention and health promotion. IOM established a 10-member committee to evaluate the PRC program. CDC asked the committee to evaluate (1) the overall quality and appropriateness of the health promotion and disease prevention research and demonstration projects being carried out at the PRCs and (2) CDC's management and oversight of the PRC program. The committee has not assessed the quality of the health promotion and disease prevention research and demonstration projects of individual PRCs. No comprehensive evaluation of the individual PRCs has ever been done. Rather, the focus is on CDC's plans, actions, evaluation and support of the overall PRC program.
A VISION FOR THE PREVENTION CENTERS RESEARCH 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. An increasing number 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.
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 Atlanta-based activities in field settings that would otherwise be beyond the agency 's reach.
Finally, CDC could use the PRC program as a way to work with disadvantaged communities—those with high proportions of poor and underserved individuals —on critical public health problems. By focusing its research efforts on issues relevant to particular disadvantaged communities associated with the PRCs, the program could develop new knowledge appropriate to similar communities nationwide.
As any complex program must, the PRC program needs to establish a vision for the future to allow it to succeed 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, evolving 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.
THE RESEARCH AND DEMONSTRATION PROJECTS CONDUCTED BY THE PREVENTION RESEARCH CENTERS
The value of the PRC program is largely determined by the content and the quality of the research and demonstration projects conducted by the PRCs. The
committee assessed the contribution of the PRCs' efforts in innovation, setting priorities, and dissemination and implementation activities.
A research project could be judged innovative if it addressed an underserved or previously unreached population, or if it were to test previously tested methods on a different but important health problem. In these terms, the committee found that the research and demonstration projects conducted by the PRCs were indeed innovative.
The PRCs were less innovative in the area of research methodology and the development of new interventions. One way to enhance a PRC 's ability to develop new interventions and research methods is to establish a methodology unit or otherwise identify a group of PRC personnel that is responsible for methodological development. Methodology units of this sort are also likely to increase the PRC's ability to raise research funding from sources other than CDC. Thus, the committee recommends that
PRCs should include methodology units or assigned personnel in support of research methods development as a core activity.
Setting Priorities in the PRCs
In its interviews, site visits, and record reviews, the committee found little evidence of explicit criteria for selecting research projects in the individual PRCs. Specific criteria can help any research center set a coherent direction, and they can also improve the quality of the individual research projects selected. Thus, the committee recommends that
PRCs should clearly state their criteria for project selection and evaluation.
The committee's review of the research portfolios of the individual PRCs suggests that the quality of research and demonstration projects that are being conducted is highly variable. Most of the PRCs do not have a well-defined process for evaluating the results of their research projects. The quality of research and demonstration projects may be enhanced by an internal quality control mechanism for reports, publications, research proposals, and other PRC products. Thus, the committee recommends that
PRCs should have an internal quality control mechanism such as a review panel for reports, publications, research proposals, and other PRC products.
Peer-reviewed publications are an important means of reviewing the quality of projects as well as an important means of disseminating new knowledge in professional communities. The committee finds that, as a group, the PRCs produce too few peer-reviewed research publications relative to their resources and their maturity; PRCs should be encouraged to publish their findings in the peer-reviewed literature. Therefore, the committee recommends that
More of the findings of the PRCs should be published in the peer reviewed scientific literature.
There are examples of projects that have had a clear impact on the community's health, as well as policies and practices in public health agencies, health service delivery systems, and other community organizations concerned about public health. The committee's impression, however, is that relatively few of the research efforts have produced an impact that reaches beyond the immediate community. To clarify the impact of the PRCs' research, the committee recommends that
PRCs should document the impact of their activities on public health research, practice, and policy, both locally and nationally.
CDC has an opportunity to advance the science of community-based research through the PRC program. The committee's review of the individual PRCs, however, indicated that some are more oriented to this approach than others. Thus, the committee recommends that
The PRCs should adopt a community-based approach to their research and demonstration efforts.
Dissemination and Implementation Activities
Research findings and products from the PRCs and CDC should be disseminated to all PRCs, their communities, and their regional populations; to the research and professional communities through scientific and professional literature; to the public health practice community; and to the general public. Thus, the committee recommends that
The PRC program, as a whole, should increase its focus on dissemination efforts.
The impact of the PRC program can be enhanced through cooperative dissemination activities among the PRCs and between the network of PRCs and other health promotion organizations such as state and local health departments in the United States and elsewhere. Thus, the committee recommends that
PRCs should seek to be part of regional and national networks for prevention that include CDC, the public health practice community, and other relevant parties.
In reviewing the activities of the PRCs, the committee found many instances of dissemination activities, but few projects focused on dissemination research. Since the university-based PRCs are attempting a variety of dissemination approaches to a wide array of public and professional audiences, and because academic institutions have some research capacity, they are in a unique position to carry out dissemination research. Thus, the committee recommends that
The PRCs should increase their dissemination research efforts.
MANAGEMENT AND OVERSIGHT OF THE PREVENTION RESEARCH CENTERS PROGRAM
Vision and Goals
Through their research and demonstration activities, the PRCs can —and have—made significant contributions toward meeting some of the national goals and objectives of Healthy People 2000 (USDHHS, 1991). CDC's strategic plan (CDC, 1994) makes mention of the PRC program, but it does not appear to feature the program as a resource or asset. 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.
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.” This definition, however, should not be interpreted as limiting the scope of research to disease prevention priorities, and it should include health promotion. In order that the PRC program remain consistent with current theory and 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 that is 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).
An academic center is 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. 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. 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.
CDC's Role in Networking, Communication, and Dissemination
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 what it has learned that is new and warrants replication or adaptation and evaluation in other PRCs that serve different populations. 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 projects, and provide mutual support, especially from strong PRCs to fledgling centers.
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. 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.
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 various 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 Prevention Research Centers
The PRCs vary considerably in the extent to which they publish research, disseminate their findings, and interact with local and state programs and agencies. 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. One option for improving the quality assurance procedures at CDC is a modification in the format of the PRCs' annual progress reports. Thus, the committee recommends that
CDC should require PRC progress reports to include information on research findings and publications.
External peer review is a time-tested mechanism for evaluating a research program and identifying areas for improvement. 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, build and maintain strong working relationships with community organizations, and establish better-informed public health practice and research communities. 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.
Funding for the PRC Program
Funding for the PRC program has never equaled the amounts initially authorized by Congress in 1986, and the current inadequate level of funding for PRCs seems to be a critical barrier to the program 's long-term success. 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.
Peer review has been largely responsible for the remarkable quality, productivity, and originality of U.S. science and technology. In order to ensure the quality and relevance of the research carried out by the PRC program, 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.
In the SIP funding mechanism, CDC has found a creative means of supporting PRC research activities beyond the level provided by congressional
appropriations. Nevertheless, as a funding mechanism it lacks a systematic approach to setting priorities, calling for proposals, reviewing proposals, and funding the accepted proposals (initial and continuing). Thus, the committee recommends that
Priorities for the 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 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.
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 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 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.
SUMMARY AND CONCLUSIONS
By forging links with academia, CDC has created a gateway for access to a cadre of well-trained, university-based researchers who could serve to inform and collaborate with the agency and the public health community regarding
health promotion and disease prevention. The PRC program also fosters the development of academic research in questions related to public health practice, community interventions, and the development of community links for translating research findings into practice.
Overall, the committee finds that the PRC has made substantial progress and is to be commended for its accomplishments in advancing the scientific infrastructure in support of disease prevention and health promotion policy, programs, and practices. The committee's review of the efforts of the individual PRCs has indicated that each of the centers has made some contributions toward one or more of the goals of the program, and in the committee's judgment, many of these activities would not have been undertaken in the absence of the PRC program. There are, however, substantial differences among the PRCs in the kinds of activities they have undertaken and the success realized, and only a few centers have made substantial progress on all fronts: research, dissemination, and developing connections with the community and public health practitioners. Given the breadth of the PRC program's goals, the limitations on core funding, and the relative newness of some of the PRCs, the program 's successes have been genuine and important.
The committee's review indicates that CDC's management of the program has been creative in the face of limited resources relative to its mandate, dogged in pursuing the mandate over a 10-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.