CENTERS FOR POPULATION HEALTH AND HEALTH DISPARITIES RELEASE DATE: April 1, 2002 (see NOT-ES-02-012) RFA: ES-02-009 Update: The following update relating to this announcement has been issued: December 23, 2008 - This RFA has been reissued as (RFA-CA-09-001). National Institute of Environmental Health Sciences (NIEHS) (http://www.niehs.nih.gov/) National Cancer Institute (NCI) (http://cancer.gov/) National Institute on Aging (NIA) (http://www.nia.nih.gov/) Office of Behavioral and Social Sciences Research (OBSSR) (http://obssr.od.nih.gov/) LETTER OF INTENT RECEIPT DATE: July 29, 2002 APPLICATION RECEIPT DATE: August 29, 2002 THIS RFA CONTAINS THE FOLLOWING INFORMATION o Purpose of this RFA o Research Objectives o Mechanism(s) of Support o Funds Available o Eligible Institutions o Individuals Eligible to Become Principal Investigators o Special Requirements o Where to Send Inquiries o Letter of Intent o Submitting an Application o Peer Review Process o Review Criteria o Receipt and Review Schedule o Award Criteria o Required Federal Citations o References PURPOSE OF THIS RFA The purpose of Centers for Population Health and Health Disparities (CPHHD) is to support inter-disciplinary research leading to an understanding and reduction of health disparities in domestic populations. Applicants are invited to propose multi-level, integrated research projects that will elucidate the complex interactions of the social and physical environment, mediating behavioral factors, and biologic pathways which determine health and disease. CPHHD are expected to create an environment conducive to interdisciplinary and reciprocally beneficial collaborations among biomedical scientists, social scientists and affected communities with the common goal of improving population health and reducing health disparities. For the purposes of this proposed Centers Program, the physical environment includes the natural environment and built structures, as well as physical, chemical, and biological agents (e.g., radiation, pesticides, infectious agents, food supply, and pharmacological agents) to which individuals are exposed. The social environment includes individual, institutional, and community-level characteristics [e.g., socioeconomic status (SES), education, coping resources and support systems, residential factors, institutional and political forces, racial discrimination, and familial and cultural factors]. This RFA draws on the recommendations contained in the strategic plans of the sponsoring National Institutes of Health (NIH) institutes concerning health disparities , those submitted to NIH from the conference entitled "Toward Higher Levels of Analysis: Progress and Promise in Research on Social and Cultural Dimensions of Health" , and those highlighted by numerous recent National Academy of Sciences and Institute of Medicine Reports [3-11]. This is a trans-NIH RFA sponsored jointly by the National Institute of Environmental Health Sciences (NIEHS), the National Cancer Institute (NCI), the National Institute on Aging (NIA, and the Office of Behavioral and Social Science Research (OBSSR). Applicants are encouraged to propose research across disease outcomes or health-related issues relevant for these Institutes. RESEARCH OBJECTIVES Background Remarkable advances in understanding human biology and its interaction with behavior and social factors have been made in recent decades. The mapping of the human genome will undoubtedly provide a platform for further discovery and progress in disease prevention, early detection, diagnosis, treatment, and for increasing active life expectancy. However, these discoveries will not reach their full potential without an effective long-term strategy for gaining knowledge and preventing disease at the population level . This strategy must integrate research in the natural sciences with that in the behavioral and social sciences to create a more comprehensive understanding of disease pathways from a molecular to a societal level , and lead to effective measures to prevent disease occurrence and progression, and to enhance well-being in all population subgroups, especially those at higher risk. A. Social Determinants of Health Social determinants refer to factors in the social, cultural, and physical environment that interact to influence population health [8,12-13]. Most frequently, the impact of the social environment is represented by some measure of socioeconomic status. For almost any measure of SES, a gradient in health has been described wherein those at the bottom of the social scale fare worse than those at the top . There is no threshold at which SES begins to exert an influence, but rather an incremental decrease in morbidity and mortality as one ascends the social ladder. Science cannot fully explain this observation. The disparity in health between socioeconomically disadvantaged individuals and those more advantaged has existed for centuries and continues to this day. Disparities are most apparent and closely associated among populations with varying levels of socioeconomic status (SES). The most striking health disparities result in shorter life expectancy, as well as higher rates of most cancers, some birth defects, infant mortality, asthma, diabetes, dementia, impaired functional and cognitive abilities, behavioral and affective disorders, and cardiovascular disease. Disparate health outcomes in specific populations will require multi-level analyses to identify and describe the mechanisms by which social determinants of health interact with the physical environment to influence these adverse health outcomes. Socioeconomic status has been most often characterized by the complex interplay between income, education and occupation. Other concepts have been developed to reflect the influence of societal resources on health. Social capital, for example, refers to the network of societal institutions and relationships that together have a positive influence on the function of communities and individuals [5,8]. Examples include membership in faith-based organizations, civic organizations, neighborhood organizations, extended family relationships, and other social networks. Units of social capital for communities could include the overall affluence of the community, the quality and condition of schools, neighborhood housing, and quality of recreational facilities. There is a paucity of data concerning the interaction between social capital and SES in the causation of health disparities, and whether intervening upon social capital is feasible and has a potential for improving outcomes and reducing disparities. Psychosocial factors may also help explain the observed relationship between SES and health. For example, health and/or illness may depend less on the immediate physical effects of inferior material conditions than of the social meanings attached to those conditions, e.g., how people feel about their circumstances and how they feel about themselves. However, psychosocial factors are themselves strongly patterned by socioeconomic and other societal conditions. Therefore, considering physical infrastructure rather than its psychosocial consequences may be similarly valuable from a public policy perspective. For example, regions with wide economic disparity tend to have inadequate investment in human capital and have more adverse health outcomes. The relationships between psychosocial factors, social capital and health need further study, and targets for effective and feasible interventions need to be identified. Social gradients have been observed for overall mortality and disease- specific mortality, including cardiovascular diseases and exemplified by longitudinal studies of British civil servants . In addition, a longitudinal study of Atherosclerosis Risk in the Communities (ARIC) has recently reported that even after controlling for personal income, education, and occupation, living in a disadvantaged neighborhood is associated with an increased incidence of coronary heart disease (CHD). Although far less well studied than cardiovascular disease, inverse gradients in overall and specific cancer mortality can also be observed in relation to various measures of SES . However, there are important and interesting exceptions to this general observation, such as the case of breast cancer diagnosis, where the gradient is reversed such that those in the highest SES group are at highest risk of developing the disease. This highlights the fact that the relationship between cancer as a group of diseases, and social gradients can differ depending on the particular cancer. Consequently, studies of relationships between cancer and environmental variables contributing to social disparities may lead to important insights into the role of societal factors in health. For most chronic diseases and functional disabilities, more research is needed to understand the mechanisms by which SES affects health. An excellent example of the interaction between social and physical environments in determining children's health status is asthma. Statistics show that asthma prevalence and severity disproportionately affect socially disadvantaged populations, including African Americans, Mexican Americans, and residents of low-income inner-city neighborhoods. Although racial and ethnic differences in asthma prevalence are small nationally, African Americans have substantially higher rates of asthma mortality, hospitalization, and emergency department visits than Caucasians. Differences in indoor allergen (e.g. cockroach, dust mite and mold) sensitivity are consistent with racial differences in asthma morbidity. Similar recent results suggest that all children living in an urban setting (in contrast to rural setting) are at increased risk for asthma, regardless of race, ethnicity or low family income. Along with other data, these findings suggest that racial and ethnic disparities in housing, community environmental quality, or both may play a role in determining national patterns of asthma morbidity. Hence, there is an urgent need to address the complex relationship between both social and physical environments as major influences of asthma and other disorders affecting children. Other examples include Alzheimer's Disease, the dementias, and cognitive impairment at older ages, where the relationship between SES and these conditions is unresolved. Cardiovascular disease is the leading cause of death worldwide. Recent studies have demonstrated that living in a disadvantaged neighborhood is associated with an increased incidence of Coronary Heart Disease (CHD), even after controlling for measures of SES, e.g., personal income, education, and occupation. Additionally, this association remains intact after adjustment for CHD risk factors including smoking, hypertension, and body mass index. A social gradient has been observed for both blacks and whites with indications that environment is as important as genetics; SES characteristics of communities are related to the incidence of CHD and strategies for CHD prevention will need to consider community level SES in addition to individual-centered approaches. B. Bio-behavioral Mechanisms Although the mechanisms through which the social environment affects the biology of health and disease are not well understood, several such influences on neural, cognitive, endocrine and immune functions have been described. One theory, which is particularly relevant to cardiovascular diseases, suggests that cumulative wear and tear due to an organism's repeated need to adapt to external and internal stress, or allostatic load, may be an important link between the psychosocial environment and health, especially when demands are excessive or physiologic responses inefficient . In a longitudinal study of older Americans, lower allostatic load was linked to better physical and mental functioning and reduced probability of developing cardiovascular disease over time. However, it is not known whether it is possible to intervene on allostatic load, and whether such interventions will decrease somatic disease outcome. A bio-behavioral model of environmental stress and the disease course for cancer is still being developed, but parallels in principle the relationships postulated for other diseases: long term stresses from the social environment lead not only to adjustment difficulties related to cancer after it is diagnosed, but may have also influenced pre-clinical biological processes leading to incident cancer. Responses to stress are regulated by neuro-endocrine mechanisms, yet individual experience defines the content and conditions that give rise to particular responses. Thus, the context of human experience, the social environment, plays an influential role in the state of the biological environment. Specific mechanisms linking stress to down- regulation of natural killer cell activity (believed important to host anti-cancer defenses), to DNA damage and repair, and the inhibition of apoptosis are also under study. Mechanisms by which the social environment may contribute to sensitivity or resistance to infectious diseases are under investigation. Previous studies using animal models have demonstrated that animals occupying lower ranks in the dominance hierarchies of a colony are more susceptible to viral infections after exposure to viral pathogens compared to animals of higher rank. These studies and others validate the utilization of animal models in studies examining social status/rank and physical exposures. Age is a risk factor for many diseases, partly because disease reflects a developmental process that takes time to manifest clinically, and partly because of normal age changes in the ability of the organism to respond to stress, to recover from injury, and in the function of homeostatic mechanisms. Thus, it is important that risks conferred by social environment are studied within the context of age effects. The biologic pathways through which social determinants affect disease and functional outcomes remain to be determined. The answers will not be found by inquiry limited solely to biological or individual behavioral approaches. A broader perspective is required that integrates the social and biologic sciences to study diseases, chronic morbidity and disability in populations. Responses to stress are regulated by neuro-endocrine mechanisms. An interdisciplinary setting is essential so that biomedical, clinical, behavioral and social scientists can work together using a shared conceptual framework that integrates discipline-specific theories, concepts, and approaches to address common problems [17, 18]. Objectives and Scope The purpose of the RFA is to support interdisciplinary research leading to understanding and reduction of health disparities in domestic populations. To achieve this goal CPHHD will support three or more thematically linked research projects, facility cores that support two or more projects, an administrative core, and pilot projects. CPHHD will present opportunities to concurrently study biological, behavioral, psychological, cultural and social precursors of disease. A key objective is to generate a research program that embraces the concept of 'multiple levels of analysis'  in health sciences to examine factors operating at the social/environmental, behavioral/psychological, and biological (organ system, cellular, and molecular) levels. Centers should propose mechanistic and intervention studies across multiple levels of analysis and across diseases and conditions relevant to the mission of the sponsoring Institutes. The theme of a proposed CPHHD may be organized to examine: o A single condition for which a significant disparity in morbidity and/or mortality between populations has been demonstrated (e.g., obesity, infant mortality, low birth weight, diabetes, CHD, asthma, cancer), its relationship to multiple social and physical environmental determinants and their mechanistic pathways; or o A particular category of social environmental determinant (e.g., food supply, urban crowding, built environment, social support) and mechanistic pathways by which it affects multiple health outcomes for which disparities have been demonstrated between populations. Although not required, applicants are encouraged to take advantage of defined geographic areas of study and existing high-quality population-based disease registries in developing these investigations. This RFA supports research across multiple levels of analysis. Applicants must develop a thematic focus that can be carried across population(s), behavior, and biologic pathways for the diseases or conditions under study. At least two of the following levels must be addressed in proposed research projects. A. Social/Environmental Level More needs to be learned about the effects of social networks, social capital, racism and other forms of social injustice at the population level on risk factor behaviors, disease incidence, and stage of disease at diagnosis. This includes the influence of social policies, the impact of social hierarchies, and factors related to control in the workplace. Population health models  are needed for investigations that include: the community as a unit of analysis; measurements of cumulative social, physical and behavioral antecedents or exposures; the characteristics of "healthy communities" and health-promoting environments; characteristics of "toxic" community environments and interventions to remedy these conditions; protective factors and mechanisms promoting positive health outcomes and disease prevention; human resilience, resistance to disease, and factors supporting positive health behaviors. The role of the health care system in contributing to disparities in disease outcomes is important, but will be supported by this RFA only when integrated with studies of social and physical environmental factors. The relative impact of the health care system may be compared to underlying social and behavior characteristics of the population prior to diagnosis of disease. Although the focus of this RFA is on domestic populations, international comparisons of health systems combined with other sociocultural, economic or physical environmental factors may shed light on determinants relevant to domestic populations and are within the scope of this announcement. Studies of multi-generational patterns of social and physical exposures and their mediating biological and behavioral pathways on relevant health outcomes are encouraged. Analytic studies that elucidate the links between social relationships and gene expression , and longitudinal studies that link cumulative social relationship profiles with biological and pathophysiologic effects may be pursued. Examples of activities relevant to the sponsoring Institutes include but are not limited to: o Examining differential social gradients for specific cancer sites and the contribution of known risk factors to these gradients. o Identifying and elucidating pathways by which the built environment, which includes physical aspects such as streets, sidewalks, transportation systems, buildings, architecture, land use planning, signage and landscaping, exerts influence on persons with functional disabilities, and on diverse health outcomes such as infant morbidity and mortality, asthma, perturbations of the immune system, degenerative or developmental neurological disorders, cognitive disorders, behavioral disorders, sensory impairment, and cardiovascular disease. o Elucidating the role of the social and physical environments and behavioral and biologic pathways in explaining the persistent disparities in cervical cancer mortality. What is the interplay of social norms and culture in the sexual transmission of the human papilloma virus, the practice of pelvic examinations and Pap smears, and societal barriers to adequate treatment? o Evaluating whether social class or other social factors affect the availability and efficacy of therapeutic interventions for diseases such as sickle cell disease, which predominately affect specific population subgroups. o Increasing emphasis on the collection of biomarkers in epidemiological studies of social relationships and health. o Examining the consequences of retirement on health and functioning. Investigating the effects of public versus private retirement programs, income security of future retirees, and labor supply and demand for older workers on health disparities in elderly populations. o Characterizing differentials in income and wealth accumulation for sub-populations (such as elderly, racial and ethnic minorities, pre- retirement workers), and identifying the sources of these differentials and their impacts on health status. B. Behavioral/Psychological Level Individual risk behaviors (including poor diet, lack of exercise, smoking, alcohol abuse, saving and non-saving behaviors among the elderly) may be critical factors in the etiology and progression of chronic diseases. However, for purposes of this RFA and to advance our understanding of population health, applicants should focus on the factors that affect health disparities among population subgroups, rather than solely focus on high-risk individuals. The effectiveness of many interventions is related to social factors that determine group behaviors, such as affordability of drugs/foods, communication, trust, and cultural beliefs. Study of response to lifestyle and pharmacological interventions will be considered to be within the scope of this RFA only if studied in relationship to the context of social, cultural, or physical environmental influences on health at a population level. Likewise, studies of tobacco use and cancer will be considered within the scope of this RFA only when placed in the context of the multiple determinants of cancer and other diseases and when they use a multi-level analytic approach (social and physical environment, behavioral, and biological). Examples of relevant activities that involve this level of analysis include: o Elucidation of the pathways invoked by protective factors and mechanisms that act at a population level to result in positive health behavior and outcomes, such as the substantially lower incidence of certain cancers in Asian and Hispanic populations. o The extent to which the population prevalence of known risk factors such as tobacco use, altered cognitive function, suboptimal diet, low physical activity, personality, and inadequate screening practices explain observed social gradients in disease incidence, morbidity, and mortality, and disability. C. Biological Levels The biologic pathways through which social determinants might affect disease incidence, severity and outcomes may be studied in diseases for which a significant disparity exists. How do factors in biologic pathways, which include genetic, endocrine, and immunologic variables, interact with behavioral, psychological, and social influences prior to and after the diagnosis? For example, substantial age and racial/ethnic differences have been noted in variability in biological response to certain drugs and nutrients (e.g. dietary salt, chemotherapeutics, beta-agonists, beta- blockers, ACE inhibitors), and effectiveness of many interventions is related to social and behavioral factors, such as access to and quality of care, affordability of drugs/foods, communication, trust, cultural beliefs. Applicants are encouraged to propose studies that examine: genetic susceptibility in relation to social characteristics and exposures, and the connection to positive and negative health outcomes; and the relationship between social conditions and phenotype. Examples of activities of relevance to the sponsoring Institutes include but are not limited to: o Employing animal models, including application of methods to examine gene mutations and gene expression in relation to social and/or physical environmental exposures. o Identifying and characterizing the social and environmental factors that interact with genetic susceptibility to disease and pathophysiologic factors to contribute to variation in the prevalence of cancer, cardiopulmonary conditions and other chronic diseases. o Exploring the biological pathways by which various exposures (e.g., polychlorinated biphenyls, mercury, lead) and social and cultural conditions influence neuro-developmental and cognitive outcomes. o Evaluating genetic factors or pathophysiologic mechanisms by which social and physical environments contribute to disparities in the prevalence of, asthma, CHD, and diabetes in population subgroups. o Determining whether social factors are equally involved in differential cancer prevalence in various subgroups, and elucidate the implications to disparities in health. o Evaluating the interaction between social, cultural, educational or lifestyle factors and genetic variability on cognitive decline and dementia in older population subgroups. o Exploring the role of social/environmental factors in explaining observed biological variability in response to heart failure, cancer, asthma or other therapies. D. Methodological Research Integration of multiple levels of analysis, as previously described, may warrant the refinement of existing methodological approaches or the development of novel methodological approaches in the conduct of CPHHD research projects. Methodological research is supported by this RFA to the extent that it is requisite to the achievement of specific aims outlined in CPHHD applications. Research at various levels of analysis could be facilitated by methodologic advances in areas such as: o Development of methods to improve the assessment of physical, social, psychological, behavioral, and cultural environmental exposures. o Development of innovative and effective ways to integrate qualitative and quantitative research methods needed to investigate the complex, multi-layered nature of psychosocial, behavioral, and cultural influences on health and functioning. o Development of statistical methods to delineate relationships among behavioral, psychosocial, environmental, and biological levels of analysis. o Development of the most useful contextual measures of SES at the level of neighborhoods or census tracts, how these measures relate to individual SES, and how this relationship varies for different disease outcomes. o Development of design, implementation, and analysis strategies for multi-component interventions which include adaptive tuning of duration or intensity to achieve optimal effects. o Development of standardized approaches to assessing the collective health of communities. DESCRIPTION OF A CENTER Centers established under this RFA will have in common support for the following four basic elements: research projects, shared facility core resources, an administration core and pilot projects. For the purpose of this RFA, a Center is defined as an interdisciplinary collaborative arrangement among a group of scientists located at the same or different institutions, committed to conducting at least three individual but interrelated and interdependent research projects that address the goals of this RFA. Plans for interaction among the components within Centers must be explicitly described. A. Research Projects Each Center will minimally support three meritorious research projects with a conceptual theme focusing on social determinants of health, population health and significant disparate health outcomes. At least one of these research projects must be a community based participatory research project. Research projects must be inter-disciplinary and address at least two levels of analysis (i.e., social, behavioral, biological). Projects will bring together the skills of basic, clinical, and public health intervention research scientists with other population research scientists, such as anthropologists, demographers, economists, epidemiologists, psychologists, sociologists, historians, and political scientists to support multiple levels of analysis within and/or across research projects supported by Center funding. In addition, CPHHDs will be asked to explicitly describe a plan for the promotion and support of interdisciplinary planning, implementation and synthesis of research across and within individual projects. Hypotheses and specific aims developed and described in Center applications must demonstrate the thematic, inter-disciplinary and collaborative nature of the Center proposal. This requirement is meant to promote inter-disciplinary collaboration in the development and design of Center research projects as well as continued collaboration throughout the duration of Center support. B. Community-based Participatory Research Each Center must support one project that develops, implements, and evaluates a Community-based Participatory Research (CBPR) related to the central theme of the Center. These projects can be proposed in the following areas: community-based etiology studies of health concerns; community-based exposure assessment; and community based prevention/intervention research. CPHHD applicants are encouraged to propose CBPR intervention research where scientifically appropriate. It is a requirement of this program that academic researchers work together with community-based organizations, broadly defined to include environmental justice groups, faith-based organization coalitions, parent-teacher associations, or other such groups who have organized around environmental or health concerns of the community. Working with local affiliates of regional or national disease-based organizations in identifying research concerns is also appropriate. Applications lacking a demonstrable linkage to a community-based or local disease-based organization will be considered non-responsive and returned without review to the applicant. This CBPR project, like all other proposed research projects, must specifically address all of the following parameters: (a) scientific basis of the proposed research and the hypotheses to be tested; (b) sample size needed, power considerations, procedures for sample selection, and recruitment and retention of study population; (c) detailed description of a research design for the proposed intervention or etiologic or exposure assessment study; (d) measurement instruments and their reliability and validity, considering both process and outcome evaluation; and (e) data management and analysis methods. In addition, it must include the means of establishing effective interaction and collaboration with community members. Because this project is intended to be community-based and participatory, the application must demonstrate specific, existing linkages to community-based organizations and specific involvement of community members in development, conduct, and interpretation of the research. Appropriate activities for CBPR projects include but are not limited to the following examples: o Testing of worksite or community-based interventions to promote aggregate level changes in weight loss and physical activity in populations whose modal characteristics put them at higher risk of cardiovascular disease, cancer and other chronic diseases. o Intervention studies among disadvantaged populations that combine individual and community approaches to healthy lifestyles by integrating psychosocial interventions with traditional management of cardiovascular disease risk factors. o Design and implementation of community-based participatory prevention strategies to promote aggregate-level health by changing social and community environments (e.g., regulation of smoking in public places, institutional policies). o Research that identifies sources of health strengths and resilience, as well as health risks, among individuals, families, and communities of low SES and racial and ethnic minority groups. o Application of exposure assessment tools to study pathways through which behavioral and social factors affect pregnancy outcomes, low birth weight incidence, and infant morbidity/mortality and active life expectancy. C. Facility Cores Centers may support shared core resources common to two or more research projects. Each Center may support facility cores that provide a technique, service, or instrumentation to enhance ongoing research efforts. Examples of such facilities are: biostatistics, survey research and data analysis, pathology, molecular biology, neuropsychology, and exposure assessment. Budgeted Center projects as well as research projects external to the Center may have access to facility cores. The application should provide a total operational budget for each facility core together with the percentage of support requested from the Center grant. The application should explain the organization and proposed mode of operation of each core, including a plan for usage, priority setting, allocation of resources, and any applicable charge back system. Allocation among various components of the Center should be balanced and well justified. D. Administrative Core The administrative structure should include, in addition to the Center Director, a Co-Director, a business manager, an internal steering committee, and an external advisory committee. The external advisory committee should consist of a group of three to five scientists, having expertise appropriate for the Center's research focus, plus at least one representative from a community-based organization involved in the community-based participatory research. At least two-thirds of the external advisory committee members should be from outside the grantee institution. The membership of the advisory committee must be approved by the funding agency post review. Names should not be submitted in the application. Individuals in senior leadership positions should provide intellectual, administrative, and scientific leadership for the center and are critical to its overall effectiveness and evolution. These individuals should be in place and committed to a defined percent effort. The administrative core should promote joint planning and evaluation activities as well as collaborations and interactions among different research cores of the Center. The Center must have appropriate and adequate management capabilities to conduct research and to evaluate the performance of the Center in achieving the goals of the RFA. Objective criteria for evaluation including intermediate markers for the potential impact of the science conducted by each Center in improving population health and reducing health disparities are required as part of this core. It is anticipated that a Center will devote no more than 10 percent of its budget to the administrative core. Pilot Project Program Funds can be used to provide support for short-term research projects to explore the feasibility of new areas of study and to enable investigators to collect preliminary data for other funding mechanisms. Centers may provide up to $200,000 per year in direct costs for pilot projects, which based on internal peer review, are deemed to have a high potential to lead to more fully developed, competitive research projects. The process of internal peer-review must be specified. General conceptual examples of two proposed pilot studies should be given; but details of the content of pilot studies are not required. Scientific merit of pilot projects should be evaluated based on the potential to address research gaps in the scientific focus of the Center. Management of the program must include a means of announcing its availability, a mechanism of scientific merit review, and a record of results. This record must be available to NIH program directors for review post-award and final approval of pilot projects after internal review will be made by the NIH program director. MECHANISM OF SUPPORT Support of this program will be through the P50 Specialized Centers Grant. Applicants are encouraged to discuss this mechanism with the Program Representatives named below. As an applicant you will be solely responsible for planning, directing, and executing the proposed project. This RFA is a one-time solicitation. The anticipated award date is April 1, 2003. This RFA uses just-in-time concepts. FUNDS AVAILABLE The sponsoring Institutes intend to commit approximately $15,000,000 (NIEHS $5 million, NCI $8 million, and NIA $2 million) in FY 2003 to fund 7 to 8 new grants in response to this RFA. An applicant may request a project period of up to five years and a budget for direct costs of up to $1.3 million per year. This direct cost maximum includes F&A costs associated with consortial arrangements. Because the nature and scope of the proposed research will vary from application to application, it is anticipated that the size and duration of each award will also vary. Although the financial plans of the participating Institutes provide support for this program, awards pursuant to this RFA are contingent upon the availability of funds and the receipt of a sufficient number of meritorious applications. ELIGIBLE INSTITUTIONS You may submit an application if your institution has any of the following characteristics: o For-profit or non-profit organizations o Public or private institutions, such as universities, colleges, hospitals, and laboratories o Units of State and local governments o Eligible agencies of the Federal government o Domestic o Faith-based organizations Foreign organizations are not eligible to apply for this program, although an international partnership with a lead domestic institution is possible. Minority individuals, women, and persons with disabilities are encouraged to apply as principal investigators. Applications are encouraged from institutions holding other Center grants in population sciences from the National Institutes of Health (NIH), Centers for Disease Control (CDC), and foundations, since the skills and capabilities of these Centers may synergistically strengthen research on social determinants of health disparities. It is expected that consortia of institutions that might include medical schools, environmental health science centers, cancer centers, schools of public health and community-based organizations will best support interdisciplinary CPHHDs. INDIVIDUALS ELIGIBLE TO BECOME PRINCIPAL INVESTIGATORS Any individual with the skills, knowledge, and resources necessary to carry out the proposed research is invited to work with their institution to develop an application for support. Individuals from underrepresented racial and ethnic groups as well as individuals with disabilities are always encouraged to apply for NIH programs. SPECIAL REQUIREMENTS Interaction among different CPHHDs could contribute significantly to the objectives of this initiative. Centers are encouraged to describe creative strategies for fostering inter-center collaborations, and for identifying overarching scientific and methodological issues. CPHHD Principal Investigators and each research project and core facility leader from each Center will be required to attend an annual meeting in the Washington, DC metropolitan area, and Research Triangle Park, NC (in alternating years). The travel budget should therefore reflect appropriate allocation for this activity. The purpose of these annual meetings will be to share scientific information, assess progress, identify and solve common methodological problems, identify new research opportunities and consider possible strategies for evaluating progress. WHERE TO SEND INQUIRIES We encourage inquiries concerning this RFA and welcome the opportunity to answer questions from potential applicants. Inquiries may fall into three areas: scientific/research, peer review, and financial or grants management issues: o Direct your questions about scientific/research issues to: Suzanne Heurtin-Roberts, Ph.D. M.S.W. National Cancer Institute Division of Cancer Control and Population Sciences 6130 Executive Blvd., EPN 4054 Bethesda, MD 20892 Telephone: (301) 594-6655 FAX: (301) 435-7547 Email: email@example.com Frederick L. Tyson, Ph.D. Scientific Program Administrator Chemical Exposures and Molecular Biology Branch National Institute of Environmental Health Science P.O. Box 12233 111 T.W. Alexander Drive (EC-21) Research Triangle Park, NC 27709 Telephone: (919) 541-0176 FAX: (919) 316-4606 Email: firstname.lastname@example.org Georgeanne E. Patmios, M.A. National Institute on Aging Behavioral and Social Research Program 7201 Wisconsin Avenue Gateway Building, Suite 533 Bethesda, MD 20892-7936 Bethesda, MD 20892-7936 Telephone: (301) 496-3138 FAX: (301) 402-0051 Email: email@example.com o Direct your questions about peer review issues to: Linda K. Bass, Ph.D. Scientific Review Administrator Scientific Review Branch National Institute of Environmental Health Sciences P.O. Box 12233 (EC-30) 111 T.W. Alexander Drive 79 T.W. Alexander Drive, Bldg 4401, Room 3172 (express/courier service) Research Triangle Park, NC 27709 Telephone: (919) 541-1307 FAX: (919) 541-2503 Email: firstname.lastname@example.org o Direct your questions about financial or grants management matters to: Ms. Carolyn K. Mason Deputy, Grants Management Officer Grants Management Branch National Institute of Environmental Health Sciences P.O. Box 12233 (EC-22) 111 T.W. Alexander Drive Research Triangle Park, NC 27709 Telephone: (919) 541-1373 FAX: (919) 541-2860 Email: email@example.com Ms. Crystal Wolfrey Grants Administration Branch National Cancer Institute 6120 Executive Boulevard, Suite 243 Rockville, MD 20852 (for express courier service) Phone: (301) 496-8634 Fax: (301) 496-8601 Email: firstname.lastname@example.org Ms. Carol Lander Grants and Contracts Management Office National Institute on Aging 7201 Wisconsin Avenue, Suite 2N212, MSC 9205 Bethesda, MD 20892-9205 Telephone: (301) 496-1472 FAX: (301) 402-3672 Email: landerC@nia.nih.gov LETTER OF INTENT Prospective applicants are asked to submit a letter of intent that includes the following information: o Descriptive title of the proposed research o Name, address, and telephone number of the Principal Investigator o Names of other key personnel o Participating institutions o Number and title of this RFA Although a letter of intent is not required, is not binding, and does not enter into the review of a subsequent application, the information that it contains allows Participating Institute staff to estimate the potential review workload and plan the review. The letter of intent is to be sent by the date listed at the beginning of this document. The letter of intent should be sent to: Linda K. Bass, Ph.D. Scientific Review Administrator Scientific Review Branch National Institute of Environmental Health Sciences P.O. Box 12233 (EC-30) 79 T.W. Alexander Drive, Bldg 4401, Room 3172 (express/courier service) Research Triangle Park, NC 27709 Telephone: (919) 541-1307 FAX: (919) 541-2503 Email: email@example.com PRE-APPLICATION MEETING Participating Institutes plan to hold a pre-application meeting in the Summer 2002 to which interested prospective applicants are invited. Details of this meeting will be published in the NIH Guide to Grants and Contracts when they become available. SUBMITTING AN APPLICATION Applications must be prepared using the PHS 398 research grant application instructions and forms (rev. 5/2001). The PHS 398 is available at http://grants.nih.gov/grants/funding/phs398/phs398.html in an interactive format. For further assistance contact GrantsInfo, Telephone (301) 435-0714, Email: GrantsInfo@nih.gov. USING THE RFA LABEL The RFA label available in the PHS 398 (rev. 5/2001) application form must be affixed to the bottom of the face page of the application. Type the RFA number on the label. Failure to use this label could result in delayed processing of the application such that it may not reach the review committee in time for review. In addition, the RFA title and number must be typed on line 2 of the face page of the application form and the YES box must be marked. The RFA label is also available at: http://grants.nih.gov/grants/funding/phs398/label-bk.pdf. SENDING AN APPLICATION TO THE NIH Submit a signed, typewritten original of the application, including the Checklist, and three signed, photocopies, in one package to: Center For Scientific Review National Institutes Of Health 6701 Rockledge Drive, Room 1040, MSC 7710 Bethesda, MD 20892-7710 Bethesda, MD 20817 (for express/courier service) At the time of submission, two additional copies of the application must be sent to: Linda K. Bass, Ph.D. Scientific Review Administrator Scientific Review Branch National Institute of Environmental Health Sciences 79 T.W. Alexander Drive, Bldg 4401, Room 3172 (express courier) Research Triangle Park, NC 27709 Telephone: (919) 541-1307 FAX: (919) 541-2503 Email: firstname.lastname@example.org APPLICATION PROCESSING Applications must be postmarked by the application receipt date listed in the heading of this RFA. If an application is received after that date, it will be returned to the applicant without review. The Center for Scientific Review (CSR) will not accept any application in response to this RFA that is essentially the same as one currently pending initial review, unless the applicant withdraws the pending application. The CSR will not accept any application that is essentially the same as one already reviewed. This does not preclude the submission of substantial revisions of applications already reviewed, but such applications must include an Introduction addressing the previous critique. PEER REVIEW PROCESS Upon receipt, applications will be reviewed for completeness by the CSR and responsiveness by the NIEHS. Incomplete and/or non-responsive applications will be returned to the applicant without further consideration. Applications that are complete and responsive to the RFA will be evaluated for scientific and technical merit by an appropriate peer review group convened by the NIEHS in accordance with the review criteria stated below. As part of the initial merit review, all applications will: o Receive a written critique o Undergo a process in which only those applications deemed to have the highest scientific merit, generally the top half of the applications under review, will be discussed and assigned a priority score o Receive a second level review by the National Advisory Environmental Health Sciences Council, the National Cancer Advisory Board, or the National Advisory Council on Aging. REVIEW CRITERIA The goals of NIH-supported research are to advance our understanding of biological systems, improve the control of disease, and enhance health. In the written comments, reviewers will be asked to discuss the following aspects of your application in order to judge the likelihood that the proposed research will have a substantial impact on the pursuit of these goal. A. Overall Center Centers must include three or more research projects with a conceptual theme focusing on one of the two thematic areas outlined in the RFA. There must be evidence of the potential for a meaningful inter-disciplinary collaboration with an integrated identity relevant to population health, the social and physical environmental determinants of disease, and health disparities. 1. Evaluate the interdisciplinary nature of the proposed research activities, integration of the projects around an overarching theme, and plans to effectively pursue interdisciplinary research objectives. 2. Evaluate the plans for active participation of populations such as community or tribal groups in the conceptualization, planning, implementation, and handling and dissemination of research and findings whenever appropriate. B. Research Projects Reviewers will be asked to evaluate each research project using the criteria listed below. Reviewers are asked to judge the likelihood that the proposed research will have a substantial impact on the pursuit of the goals of this RFA as implied by the criteria below. Each criterion will be addressed and considered by the reviewers in assigning the overall score for each project: 1. Significance. Does this study address an important research objective related to social and physical environmental determinants of disease and health and disparate health outcomes in domestic populations? Will this study lead to a better understanding of factors influencing population health and health disparities? 2. Approach. Are the conceptual research framework, design, methods, and analyses adequately developed, well integrated, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative interdisciplinary approaches? Is there clear evidence of significant interdisciplinary interactions in the conception, design, and proposed implementation of the project? How well is collaboration with the community documented? Does the project show significant and meaningful evidence of attempts to cross and link levels of analysis in the conceptualization, design or methods of the project? Does this attempt show promise of being successful and productive? 3. Innovation. Does the project show promise in the development of the conceptualization of population health and health disparities? Does the project challenge existing paradigms or develop new methods or technologies that will move the area of study forward? Does the study reflect sufficient originality, novelty, and innovation to make it highly relevant to the overall goals and objectives of CPHHD? 4. Investigators. Are all investigators appropriately qualified with demonstrated competence to conduct the proposed research? Is the proposed work appropriate to the experience level of the principal investigator and other project researchers? Are the proposed time commitments for all key researchers reasonable and appropriately associated with the project? 5. Environment. Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed projects take advantage of unique and interdisciplinary features in the scientific environment and reach out to useful collaborative arrangements? Is there evidence of adequate institutional support? Is the project interactive with and supportive of other components of the CPHHD conceptually and experimentally? C. Community-based Participatory Research (CBPR) In addition to review criteria for the other research projects, CBPR projects will be evaluated on: 1. Demonstrate extent of community support and liaison. Rationale for selection of the targeted population and documentation of environmental health needs and risk factors. Evidence of access to, interaction with, and participation of community members and community leaders in development and conduct of the project. Establishment of collaborative interactions among all project participants. Extent to which the design demonstrates sensitivity to cultural and socioeconomic factors in the community. 2. Demonstration of effective communication channels between researchers and community members. Plans for useful and practical dissemination of project activities and findings within the affected community(ies). Active involvement of at least one community based organization is a minimal requirement for responsiveness to this RFA. 3. For intervention projects evaluate the extent to which findings can be translated into public health practice and/or policies. Are links to the community within which the research is framed well documented reflecting both appropriate levels of support and collaboration? D. Facility Cores 1. Evaluate overall use of each core by funded by proposed research projects. Determine whether projected use is sufficient to warrant establishment of the core. Determine if the usage is balanced and broadly based rather than being primarily for the research project(s) of only one or a few individuals. 2. Evaluate the core for its overall importance to research activities in the Center. Evaluate whether the core is likely to become of greater or lesser importance to center members in the future. Determine if the facility core can contribute to the expansion of research into new areas. 3. Evaluate whether there is sufficient institutional commitment to meet the requirements of the core. 4. Determine if the requests for equipment, supplies, and other items are appropriate for the activity of each core. 5. Evaluate the cost effectiveness and efficiency of use of the core in the context of the quality, breadth, and utility of service provided. 6. Assess the total operational budget of the facility core and the percentage of support requested from the Center grant and determine if the facility core usage by Center members is proportional to support requested. 7. Adequacy of qualifications and performance (if applicable) of core personnel to conduct high quality, reliable resource operations. 8. Adequacy of plans for oversight of resources and the prioritization of work. E. Administrative Core 1. Evaluate whether the lines of authority and the administrative structure are designed for effective center management. 2. Evaluate the qualifications, responsibilities, and effectiveness of senior leaders. Identify if the percent effort is appropriate. 3. Evaluate the duties and percent efforts of administrative staff of the center in terms of their qualifications and contributions to the specialized needs and conduct of the center's research activities. 4. Evaluate the effectiveness of the center's internal planning and evaluation activities. Determine who is involved and the mechanisms used. Determine if these activities are documented. Evaluate how well the administrative structure maximizes the Center's capability to take advantage of research opportunities. F. Pilot Project Program 1. Evaluate whether pilot project funds will be used to test innovative ideas of particular importance to the development of new ideas within the CPHHD. 2. Evaluate the overall plan for and potential effectiveness of the pilot project program in filling gaps in research areas relevant to the scientific focus of the CPHHD. 3. Evaluate the adequacy of the proposed process for continuously reviewing and funding a spectrum of pilot projects for their quality, innovativeness, interdisciplinary nature and importance to population health and health disparities research. 4. Evaluate the degree to which pilot project funds will be used to stimulate projects of an interdisciplinary nature that will promote collaborative interactions within the Center. 5. Evaluate the appropriateness of the budget relative to the scope of the proposed pilot project program and potential of the program to generate innovative pilot projects on a consistent basis. G. Institutional Commitment 1. Evaluate the effectiveness of the Center as a formal organizational component within the institution relative to other organizational components. Determine whether the reporting, accountability, and management structure of the CPHHD within the institution are equivalent to that of comparable organizations within the institution. Assess the adequacy of institutional procedures and plans for monitoring, evaluating, and assuming accountability for the general success of the CPHHD. 2. Evaluate the specific resources provided by the institution such as personnel, appropriate facilities, financial support, and other forms of support that reflect the level of the institution's commitment to the functional stability, continuing development, and success of the Center. 3. Appraise the adequacy of the institutional infrastructure for assessing progress and needs. ADDITIONAL REVIEW CRITERIA In addition to the above criteria, your application will also be reviewed with respect to the following: o PROTECTIONS: The adequacy of the proposed protection for humans, animals, or the environment, to the extent they may be adversely affected by the project proposed in the application. o INCLUSION: The adequacy of plans to include subjects from both genders, all racial and ethnic groups (and subgroups), and children as appropriate for the scientific goals of the research. Plans for the recruitment and retention of subjects will also be evaluated. (See Inclusion Criteria included in the section on Federal Citations, below) o BUDGET: The reasonableness of the proposed budget and the requested period of support in relation to the proposed research. RECEIPT AND REVIEW SCHEDULE Letter of Intent Receipt Date: July 29, 2002 Application Receipt Date: August 29, 2002 Peer Review Date: November 2002 Council Review: January/February 2003 Earliest Anticipated Start Date: April 1, 2003 AWARD CRITERIA Award criteria that will be used to make award decisions include: o Scientific merit (as determined by peer review) o Availability of funds o Programmatic priorities. REQUIRED FEDERAL CITATIONS INCLUSION OF WOMEN AND MINORITIES IN CLINICAL RESEARCH It is the policy of the NIH that women and members of minority groups and their sub-populations must be included in all NIH-supported clinical research projects unless a clear and compelling justification is provided indicating that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. This policy results from the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43). All investigators proposing clinical research should read the AMENDMENT "NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical Research - Amended, October, 2001," published in the NIH Guide for Grants and Contracts on October 9, 2001 (http://grants.nih.gov/grants/guide/notice- files/NOT-OD-02-001.html); a complete copy of the updated Guidelines are available at http://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_2001.htm The amended policy incorporates: the use of an NIH definition of clinical research; updated racial and ethnic categories in compliance with the new OMB standards; clarification of language governing NIH-defined Phase III clinical trials consistent with the new PHS Form 398; and updated roles and responsibilities of NIH staff and the extramural community. The policy continues to require for all NIH-defined Phase III clinical trials that: a) all applications or proposals and/or protocols must provide a description of plans to conduct analyses, as appropriate, to address differences by sex/gender and/or racial/ethnic groups, including subgroups if applicable; and b) investigators must report annual accrual and progress in conducting analyses, as appropriate, by sex/gender and/or racial/ethnic group differences. INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS The NIH maintains a policy that children (i.e., individuals under the age of 21) must be included in all human subjects research, conducted or supported by the NIH, unless there are scientific and ethical reasons not to include them. This policy applies to all initial (Type 1) applications submitted for receipt dates after October 1, 1998. All investigators proposing research involving human subjects should read the "NIH Policy and Guidelines" on the inclusion of children as participants in research involving human subjects that is available at http://grants.nih.gov/grants/funding/children/children.htm. REQUIRED EDUCATION ON THE PROTECTION OF HUMAN SUBJECT PARTICIPANTS NIH policy requires education on the protection of human subject participants for all investigators submitting NIH proposals for research involving human subjects. You will find this policy announcement in the NIH Guide for Grants and Contracts Announcement, dated June 5, 2000, at http://grants.nih.gov/grants/guide/notice-files/NOT-OD-00-039.html. HUMAN EMBRYONIC STEM CELLS (hESC) Criteria for federal funding of research on hESCs can be found at http://grants.nih.gov/grants/stem_cells.htm and at http://grants.nih.gov/grants/guide/notice-files/NOT-OD-02-005.html. Only research using hESC lines that are registered in the NIH Human Embryonic Stem Cell Registry will be eligible for Federal funding (see http://escr.nih.gov). It is the responsibility of the applicant to provide the official NIH identifier(s)for the hESC line(s)to be used in the proposed research. Applications that do not provide this information will be returned without review. PUBLIC ACCESS TO RESEARCH DATA THROUGH THE FREEDOM OF INFORMATION ACT The Office of Management and Budget (OMB) Circular A-110 has been revised to provide public access to research data through the Freedom of Information Act (FOIA) under some circumstances. Data that are (1) first produced in a project that is supported in whole or in part with Federal funds and (2) cited publicly and officially by a Federal agency in support of an action that has the force and effect of law (i.e., a regulation) may be accessed through FOIA. It is important for applicants to understand the basic scope of this amendment. NIH has provided guidance at http://grants.nih.gov/grants/policy/a110/a110_guidance_dec1999.htm. Applicants may wish to place data collected under this RFA in a public archive, which can provide protections for the data and manage the distribution for an indefinite period of time. If so, the application should include a description of the archiving plan in the study design and include information about this in the budget justification section of the application. In addition, applicants should think about how to structure informed consent statements and other human subjects procedures given the potential for wider use of data collected under this award. URLs IN NIH GRANT APPLICATIONS OR APPENDICES All applications and proposals for NIH funding must be self-contained within specified page limitations. Unless otherwise specified in an NIH solicitation, Internet addresses (URLs) should not be used to provide information necessary to the review because reviewers are under no obligation to view the Internet sites. Furthermore, we caution reviewers that their anonymity may be compromised when they directly access an Internet site. HEALTHY PEOPLE 2010 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2010," a PHS-led national activity for setting priority areas. This RFA is related to one or more of the priority areas. Potential applicants may obtain a copy of "Healthy People 2010" at http://www.health.gov/healthypeople. AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.113, 93.115 and 93.866, and is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. Awards are made under authorization of Sections 301 and 405 of the Public Health Service Act as amended (42 USC 241 and 284) and administered under NIH grants policies described at http://grants.nih.gov/grants/policy/policy.htm and under Federal Regulations 42 CFR 52 and 45 CFR Parts 74 and 92. The PHS strongly encourages all grant recipients to provide a smoke-free workplace and discourage the use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care, or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people. REFERENCES 1. Documents on the Institutes' Strategic Plans to Reduce or Eliminate Health Disparities are available at: http://healthdisparities.nih.gov/working/institutes.html 2. Office of Behavioral and Social Sciences Research. Toward Higher Levels of Analysis: Progress and Promise in Research on Social and Cultural Dimensions of Health. National Institutes of Health, Bethesda, MD 20892, NIH Publication No. 01-5020, September 2001. http://obssr.od.nih.gov/Conf_Wkshp/higherlevel/conference.html] 3. New Horizons in Health: An Integrative Approach. Singer BH, Ryff CD, Editors. Committee on Future Directions for Behavior and Social Sciences Research at the National Institutes of Health, National Research Council, 2001, National Academy Press, Washington, DC. 4. The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Medically Underserved. Haynes MA, Smedley BD, editors, Committee on Cancer Research Among Minorities and the Medically Underserved. 1999 Institute of Medicine, National Academy Press, Washington, DC. 5. Promoting Health: Intervention Strategies from Social and Behavioral Research. Smedley BD, Syme SL, editors. Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public's Health 2000, Institute of Medicine, National Academy Press, Washington, DC. 6. Hanna, K., Coussens, C. Rebuilding the Unity of Health and the Environment: A New Vision of Environmental Health for the 21st Century. Washington, DC: National Academy Press, 2001. 7. Stoto, M.A., Green, L.W., Bailey, L.A. Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention. Washington, DC: National Academy Press, 1997. 8. Institute of Medicine. Committee on Health and Behavior: Research, Practice and Policy Board on Neuroscience and Behavioral Health. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: National Academy Press, 2001. 9. The Aging Mind: Opportunities in Cognitive Research. Stern PC and Carstensen LL, Editors. Committee on Future Directions for Cognitive Research on Aging, Board on Behavioral, Cognitive, and Sensory Sciences, National Research Council, 2000, National Academy Press, Washington, DC. 10. Cells and Surveys: Should Biological Measures Be Included in Social Science Research? Finch CE, Vaupel JW and Kinsella K, Editors. Committee on Population, National Research Council, 2001, National Academy Press, Washington, DC. 11. Racial and Ethnic Differences in the Health of Older Americans. Martin LG and Soldo BJ, Editors. Committee on Population, National Research Council, 1997, National Academy Press, Washington, DC. 12. Rose, G. The Strategy of Preventive Medicine. New York: Oxford University Press, 1992. 13. Marmot, M., Wilkinson, R.G. Eds. Social Determinants of Health. 1999. Oxford University Press, Oxford. 14. Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, Syme SL. Socioeconomic status and health: the challenge of the gradient. Amer Psych 1994;49:15-24. 15. Brunner, E.J., Marmot, M.G., Nanchahal, K., et al. Social Inequality in Coronary Risk: Central Obesity and the Metabolic Syndrome. Evidence from the Whitehall II Study. Diabetologia 40: 1341-1349, 1997. 16. Faggiano F, Partanen T, Kogevinas M, Boffetta P. Socioeconomic differencesin cancer incidence and mortality. In Kogevinas M, Pearce N, Susser M, Boffetta P, eds. Social Inequalities and Cancer. IARC Scientific Publications No. 138. Lyon, France: International Agency for Research on Cancer; 1997:65-176. 17. Kahn RL, Prager DJ. Interdisciplinary collaborations are a scientific and social imperative. The Scientist. July 11, 1994, p 12. 18. Abrams DB. Transdisciplinary paradigms for tobacco prevention research. Nicotine Tob Res 1999;1:S15-S23.
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