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RESEARCH TRAINING

Senator HARKIN. Thank you very much, Dr. Hinshaw.
I had a question about rural health, but you covered that.
Let me ask you about research trainees.

Dr. HINSHAW. Yes.

Senator HARKIN. You are showing a decrease of 12 research training slots for the first time after several years of growth. The 1992 request is again for 245 research training slots or the same number as last year. The Institute of Medicine recommended we fund 320 slots for 1991.

What is happening here? Is this an area that is no longer a priority for your Institute?

Dr. HINSHAW. It's a very high area of priority for us. Our difficulty is we are also faced with an award rate of approximately 11.3 percent for competing research project grants in this next year.

Senator HARKIN. At what rate?

Dr. HINSHAW. It's 11.3 percent in fiscal year 1992. And because of this we are making some very hard choices around how to distribute our moneys.

Senator HARKIN. What was the Institute of Medicine's recommendation for this year? The same, 320?

Dr. HINSHAW. The recommendation was 320 for 1990. We did not have a further recommendation from the latest report, so we do not have updated numbers.

WOMEN'S HEALTH

Senator HARKIN. Dr. Hinshaw, we understand the nursing center has a sizeable portfolio of studies about women's health. You mentioned some of these in your opening statement. I do not want to go back over that again. I would just emphasize the need for that and encourage you in that direction.

Again, do you see this as a growing area that your Institute will be involved in?

Dr. HINSHAW. Yes; very much so. We are looking at what other initiatives we can take in this particular area. We have about 20 percent of our portfolio that is currently in women's health. Senator HARKIN. It's 20 percent now?

Dr. HINSHAW. About 20 percent which is in issues of women's health, and it is much broader than just the reproductive type of issues that one often sees with women's health. We are looking particularly at older women, at midlife and menopausal issues. So, it is a widespread type of program. We would see that continuing. Senator HARKIN. Thank you very much, Dr. Hinshaw. Dr. HINSHAW. Surely.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

Senator HARKIN. Thank you very much. There will be some additional questions which will be submitted for your response in the record.

[The following questions were not asked at the hearing, but were submitted to the Institute for response subsequent to the hearing:]

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

RURAL HEALTH

Question.

For this fiscal year the Committee provided an increase of $1,500,000 to support the establishment of a rural health care research agenda for vulnerable populations." Please tell the Committee what you are doing to implement this initiative.

Answer. Recognizing that those residing in rural areas have increased vulnerability to illness, disability, and poor pregnancy outcomes, NCNR has announced to the scientific community the initiation of a research program targeted to improving the health and well being of vulnerable populations in rural areas. Included in these vulnerable groups are those who have a chronic illness, 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 initial clinical studies will focus on more clearly determining the health needs of these populations, developing intervention strategies for improving health and maintaining wellness, and evaluating nursing practice models designed to provide effective interdisciplinary health care to these populations.

This new research program builds on NCNR's previous experience with a special initiative implemented in FY 1990 to establish and evaluate community-based nursing practice models designed to provide health care to minority groups living in rural areas. This research demonstration initiative, co-sponsored with the Division of Nursing, Health Resources and Services Administration, and the Agency for Health Care Policy and Research, resulted in three studies being funded, two by NCNR. The NCNR studies focus on improving prenatal care and pregnancy outcomes among Native American, Hispanic, and Pacific Island women and their infants. The specific Pacific Island groups are Hawaiian, Filipino and Japanese women living in rural Hawaii.

In addition to the new research program, NCNR will actively assist investigators in rural areas with 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 are working with investigators from the Appalachian region to plan a technical assistance workshop that will be held in West Virginia. NCNR staff will also participate in a rural health workshop for the upper Midwest to be held in North Dakota in April. There are regional nursing research conferences held throughout the year in which NCNR staff participate, and at each of these, NCNR staff will be discussing the rural health research program.

NATIONAL NURSING RESEARCH AGENDA

Question. The two research focus areas included in the National Nursing Research agenda which are scheduled to be implemented in 1992 are: 1) and 2) Management of pain. request do you expect to make

Long term care for the elderly, How much of your 1992 funding available for these two initiatives?

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. What is their recommendation for 1992?

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.

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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: 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.

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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. 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.

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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..

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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?

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