Answer. It is important to balance the research which is individual investigator initiated and may not focus on the National Nursing Research Agenda priorities with the studies which are guided by the defined priorities. In any one year, approximately 30 to 35 percent of the competing funds are expected to be expended for the research priorities. In FY 1992, 30 percent of the competing funds would allow approximately $2.7 million for the support of these two new initiatives: studies on Long-Term Care of the Elderly and the Management of Acute Pain.

Question. I understand that the Institute of Medicine recommended that we fund 320 nurse training slots for 1991. is their recommendation for 1992?

What

Answer. Actually, the Institute of Medicine (IOM) recommendation was to fund 320 trainees/fellows in nursing research by 1990. The new 1990 IOM Report does not speak specifically to training needs in nursing research. The suggestion of 320 trainees/fellows for nursing will need to be used until a more definitive recommendation is available.

INTRAMURAL RESEARCH PROGRAM

Question. In 1990, intramural research was only 0.7 percent of your total budget. In 1992, you propose $486,000 for intramural research or 1.1 percent of the total. Is this the right balance? Most institutes have 7 to 8 percent of their total budget focused on intramural research.

Answer. Continued development of the NCNR's Intramural Research Program is one of the Center's major priorities. However, it is difficult to predict what percentage of the total budget should go into intramural research, because we do not know how quickly the science base will move forward. The growth of the science, relative to other NCNR program priorities will dictate what percentage of the total budget should be allocated to Intramural Research. The ability of NCNR's Intramural Program to make a significant contribution toward the mission of the NCNR and the health of the Nation will be enhanced by gradually increasing its resources within the next few years. The NCNR Intramural Program has moved rapidly to identify crucial scientific issues and health problems conducive to intramural study, as well as to identify opportunities for addressing these concerns and developing organizational approaches.

At the present time, the bulk of NCNR Intramural Program efforts are concentrated on HIV infection/AIDS. Ongoing research regarding HIV infection is focused on three prime areas: (1) symptom management, which includes disease symptoms and treatment side effects; (2) compliance with therapeutic regimens; and (3) health-related quality of life. One large study underway in the symptom management area investigates the occurrence of nutritionrelated problems during treatment for HIV infection, and the relationship of nutritional status to immune function. The findings from this study will help in the development of interventions, as well as predicting who is at greatest risk of nutrition-related problems so that those interventions can be best

directed.

Non-AIDS research related to quality of life also constitutes a portion of our Intramural Research Program. For example, the NCNR is conducting a sub-study to the Honolulu Asian Aging Study in Honolulu to examine the quality of life and burden of care in caregivers of aging demented male participants of the Honolulu Heart Study.

Question. Please describe the areas of research to be pursued over the next few years by your intramural research program.

Answer. At the present time, the bulk of NCNR Intramural Program efforts are concentrated on HIV infection/AIDS. Ongoing research regarding HIV infection is focused on three prime areas: (1) symptom management, which includes disease symptoms and treatment side effects; (2) compliance with therapeutic regimens; and (3) health-related quality of life. One large study underway in the symptom management area investigates the occurrence of nutrition-related problems during treatment for HIV infection, and the relationship of nutritional status to immune function. The findings from this study will help in the development of interventions, as well as predicting who is at greatest risk of nutrition-related problems so that those interventions can be best directed. Another protocol scheduled to begin within the next month is designed to study muscle weakness that occurs during treatment of HIV infection with AZT and other antiretrovirals. Additional symptom management studies to be developed in the future include those aimed at common and debilitating problems such as diarrhea, night sweats, and pain. In addition to expansion into new areas of investigation, intramural studies will be conducted at additional sites in order to reach subject populations, conditions, or a spectrum of disease not currently available at the NIH Clinical Center. The second area of focus, compliance with therapeutic regimens, will include administration issues, such as administration techniques and patient education. The third area, health-related quality of life, is currently under development and will include improvement of the techniques for measuring health-related quality of life as an outcome in clinical studies.

The NCNR anticipates future expansion of its Intramural Program to include Non-AIDS populations. Non-AIDS research relative to quality of life that constitutes a primary outcome measure is already underway. This NCNR study is a sub-study to the Honolulu Aging Asian study in Honolulu. The study examines the quality of life and burden of care in caregivers of aging demented male participants of the Honolulu Heart Study.

Additional expansion is anticipated in the three major research programs, symptom management, compliance with therapeutic regimens, and health related quality of life to a focus on cancer populations.

NEW CENTERS

Question. The Senate, in the 1991 report, called for the establishment of two exploratory centers focused on behavioral research. What specific areas of behavioral research will these centers focus on?

Answer. The National Center for Nursing Research, the National Institute of Child Health and Human Development, and the National Institute of Mental Health have issued a request for applications from interested institutions to establish multidisciplinary exploratory centers to investigate health behavior development in children and adolescents. Recent reports highlight the significance of behaviors which compromise health in the short term and have major long-range implications for the onset of chronic diseases. These patterns of behaviors include diet, physical activity, alcohol and tobacco use, risk taking, and sexual behaviors, which if begun in childhood and adolescence may continue into adulthood. The specific areas of behavioral research on which these centers will focus will be dependent upon the outcome of the peer review process.

Question. What is their status?

Answer. The Request for Applications (RFA) was published on March 1, 1991 in the NIH Guide. NCNR has received many questions from interested investigators about the Exploratory Centers for Health Behavior Research with Children and Adolescents. The RFA requested that letters of intent to submit applications be sent to NCNR by April 15, 1991. The receipt date for applications is May 20, 1991 with scientific merit review and Advisory Council consideration completed in time for potential funding in September, 1991.

PREVENTION OF LOW BIRTHWEIGHT

Question. What is the progress of the National Nursing Research Agenda (NNRA)?

Answer. The National Nursing Research Agenda is progressing as planned with two to three new priorities being initiated every one to two years. The NNRA priorities address important public health issues, such as prevention and care of low birthweight infants, prevention of the HIV condition and care of individuals and families who are experiencing the disease, long-term care of the older individual, symptom management of acute pain, health promotion with children and adolescents, and technology dependency issues for patients and families.

Question. What has been the response of the research community to the first critical priority--Prevention and Care of Low Birthweight Infants?

Answer. The nursing research community and its interdisciplinary colleagues have responded very strongly to the low birthweight infant initiative with a number of high quality applications. In FY 1991, NCNR will support over 20 studies on the care of low birthweight infants in Neonatal Intensive Care Units and the prevention of such a condition prenatally. This represents an investment of approximately $3.8 million in relation to $450,000 in FY 1986.

Question. What is needed next to accelerate progress in the prevention of low birthweight?

Answer. Progress in the prevention of low birthweight could be accelerated through the initiation of clinical trials to definitively test the nursing interventions for the care of low birthweight infants in the Neonatal Intensive Care Units (NICUs) and promote effective prevention strategies prenatally.

QUESTIONS SUBMITTTED BY SENATOR QUENTIN N. BURDICK RESEARCH INITIATIVES

Question. Health promotion and disease prevention has been a major focus of the National Center for Nursing Research (NCNR), and one of your branches is devoted to such studies. What current and future research initiatives do you anticipate developing and supporting?

Answer. Several program initiatives in health promotion and disease prevention will be supported in FY 1992. These include prevention of low birthweight infants; prevention of transmission of HIV; and health promotion and prevention of frailty in older adults. We also expect to collaborate with the Office of Research for Women's Health in targeting health promotion research for midlife and older women.

FUNDING RATE

Question. Dr. Hinshaw, the estimated funding rate for the NCNR has dropped significantly each year since the inception of the Center. What will be the award rate for NCNR in FY 1992, and how does this compare to the estimated NIH average? How do you explain this precipitous decline?

Answer. The estimated success rate for the NCNR in FY 1992 is 10.3 percent; the NIH average in FY 1992 is estimated to be 26.3 percent. The declining success rate experienced by the Center is a result of the fact that the number of applications being reviewed has increased substantially since the inception of the Center--from 160 in FY 1987 to an estimated 438 in FY 1992. The Center has been extremely successful in attracting high quality research grant applications from the nursing research community, and efforts to increase the cadre of well-trained nurse researchers through an expanded NRSA training program have also been extremely effective. In spite of the increased number of high quality applications received, the number of competing research project grants funded has remained relatively constant, resulting in the sharply declining success rate.

RURAL HEALTH

Question. In both FY 1990 and FY 1991, Congress encouraged NCNR to enhance its research efforts in rural health care, and in both years funds were allocated for the program. Describe the developing research program in this area. Do you expect the need for rural health care research to increase?

Answer. Recognizing the growing seriousness of the health problems in rural areas, NCNR began its rural health initiative in

These

FY 1990 through the publication of an RFA to develop, implement and evaluate nursing practice models designed to provide community-based health care to rural minority residents. practice models include specific nursing interventions that are focused on health problems in such a manner that the quality of patient outcomes and the effectiveness of the interventions can be determined. Through this initial effort NCNR funded two research demonstrations, both of which are studying nursing practice models targeted to improving prenatal care and pregnancy outcomes among Native American, Hispanic, and Pacific Island women residing in rural areas of Oregon and Hawaii.

Building on this earlier initiative, NCNR began a formal research program on rural health in FY 1991 when it announced to the scientific community its intent to support research on rural health care specifically focused on impacting the health of vulnerable populations. These populations include those with chronic illness or who are in jeopardy of becoming chronically ill, those who may become disabled due to health threatening behaviors, childbearing women, infants, children, adolescents, and persons over 65 years of age. It is anticipated that clinical studies funded under this program will assist in increasing our understanding of the specific health needs of vulnerable rural residents and in developing effective intervention strategies to improve their health and well being.

In addition to the rural health research program, NCNR will provide assistance to investigators in rural areas in the technical aspects of the grants process, so they can develop better grant applications related to those areas of research relevant to rural populations. NCNR staff will participate in a rural health workshop for investigators from the upper Midwest which will be held in North Dakota in April and is assisting in planning a workshop for investigators from Appalachia that will be held in West Virginia.

There is considerable evidence that the health issues occurring in rural America will require research to be conducted over time and in a manner that builds a scientific base on which to make sound clinical practice, care delivery, and policy decisions. In certain areas descriptive studies are needed that will lead to the development of clinical interventions, in others there is sufficient information to implement and test intervention strategies, but it will be some time before there is sufficient information to resolve the health problems of people residing in rural areas. To assist NCNR in understanding changes occurring in rural areas and in evaluating its rural health research program, NCNR will convene an advisory group whose members are from rural areas and who have first-hand knowledge of rural health care and the needs of these communities.

MINORITY HEALTH RESEARCH

Question. What percentage of your research portfolio is directed toward examining health problems that disproportionately affect minority populations?