National Advisory Council for Nursing Research Concept Clearances

Concept Clearance

Concepts represent an early planning stage for potential NINR initiatives and describe their basic purpose, scope, and objectives. Through the Concept Clearance process, NINR receives input from the National Advisory Council for Nursing Research regarding the merits of the concepts. This page provides information on recently cleared concepts. Council approval of a concept does not guarantee it will become a funded initiative; that decision is made based on scientific and programmatic priorities and the availability of funds.

This listing of potential future initiatives is meant to enhance transparency and make the NINR research community aware of potential initiatives that may be developed into published funding announcements. The titles and brief descriptions are consistent with the information available at the time of concept clearance. The resultant RFAs, RFPs, PARs, or PASs may differ from the concepts in the final wording of the titles or other aspects. Specific information on each initiative, including receipt date, set-aside funds, referral and review criteria, will be available once the announcement has been published in the NIH Guide.

Approved Concepts

September 2024: Building Capacity for Community-Partnered Nursing Research

Concept Purpose

The primary purpose of this initiative is to support the development of innovative research centers to foster nursing-led programs of community-partnered research that aim to improve community health by applying NINR’s research lenses. This initiative will capitalize on extant community partnerships and accelerate research infrastructure development in schools and colleges of nursing (SON/CONs), with an emphasis on SON/CONs with limited prior NIH funding. This initiative will enhance research capacity and provide opportunities for investigators to enhance their knowledge of and skills in community-partnered research to improve their competitiveness for future funding.

State of the Problem

To achieve health equity for communities that have been historically disadvantaged and experience health disparities, it is important to address the social and structural factors that underpin these disparities. Community engagement in the research process is critical to these efforts in order to ensure that their perspective, expertise, and priorities are well integrated. Community Based Participatory Research (CBPR) as well as other similarly partnered collaborative approaches, have in common a commitment to build on community strengths, co-learn, balance research and action, and share power and ownership of decision-making. Community engagement should occur throughout the research process from identifying the research question to planning and implementation to evaluation and dissemination. This partnership approach ensures alignment with community needs, priorities, and goals and serves to build trust and facilitate long-term sustainability of health-improving programs, practices, and policies.

Community partnerships have long been recognized by SON/CONs as central to both nursing education and service delivery. Many SON/CONs and their faculty have active educational and service collaborations with communities. Despite having strong pre-existing community relationships, it may be challenging for a SON/CON with limited prior NIH funding to conduct community-partnered, solutions-oriented research. It is critical to have support that can facilitate research activities, including resources to free investigator time for research and to pay for research support staff and other infrastructure. This initiative would seek to leverage the existing relationships of SON/CONs and their faculty to provide a foundation for advancing community-partnered nursing research.

The initiative would encourage participation from SON/CONs that have received limited prior NIH-funding (e.g., Research-Active Institutions, Minority-Serving Institutions and institutions in IDeA states). Supporting capacity building at SON/CONs with limited prior NIH-funding allows expansion of diversity in nurse scientists and expands opportunities for minority-serving institutions and organizations.

Developing or adapting and testing solutions to health issues that are a priority to the community is a complex endeavor, and one that would benefit from the expertise of scientists of several disciplines. Furthermore, nurse scientists can benefit from mentors in other disciplines to broaden their knowledge and perspectives. This initiative would provide support for developing nurse-led interdisciplinary teams to conduct solution-focused research with community partners. By building these teams to conduct pilot work, they are building a history of successful teamwork which increases their ability to successfully compete for future funding.

The central feature of this initiative would be research centers in SON/CONs, with an emphasis on those with limited prior NIH support. These centers would support planning for new research projects and conduct of pilot studies that offer potential solutions to problems of special significance to the community and NINR. Previous NINR-funded Research Centers (e.g., P20s, P30s) have been successful in supporting the development of nurse scientists and interdisciplinary research teams as evidenced by increased numbers of publications and subsequent NIH grant awards. However, since 2014, of the 144 accredited SON/CONs offering PhDs, only 15 SON/CONs have had NINR-funded Research Centers.

Research Objectives

To support the development of innovative research centers to foster nursing-led programs of community-partnered research, this initiative will focus on enhancing the capacity of scientists in SON/CONs, building experience leading interdisciplinary teams that conduct community-partnered research, and foster competitiveness for future NIH-funding.

This initiative will stimulate:

Research centers that propose pilot research that incorporates community priorities, needs, and preferences in the design, conduct, evaluation, and dissemination of the research.
Studies utilizing one or more of the NINR Research Lenses that focus on developing solutions.
Development of interdisciplinary teams, led by nurse scientists.
Developmental activities for investigators at different levels of experience and for community partners.

May 2024: Social Determinants of Health in Artificial Intelligence to Advance Health Equity

Concept Purpose

The purpose of this concept is to understand and address social determinants of health (SDOH) in artificial intelligence (AI) models and systems and use SDOH to improve AI models and systems to reduce health inequalities and advance health equity.

State of the Problem

Artificial intelligence, or AI, is the design and study of computer programs to be intelligent. AI applies traditional statistical forecasting methods using a wide range of techniques such as deep neural networks, natural language processing (NLP), random forest, and decision tree algorithms for predictive and analytical purposes. Currently, the use of AI is controversial due to concerns about fairness and transparency in model development, interpretation, and application. There is also a growing body of research on bias in AI and recognition that AI has perpetuated and even exacerbated inequalities across many aspects of society, including medicine, criminal justice (facial recognition and surveillance), and finance.

Many AI systems do not include SDOH though research shows including SDOH significantly improves model fit, outcomes, and predictions. In addition, some AI systems lack representative, diverse data, and fail to examine how the inclusion of SDOH may affect results and model interpretation. When SDOH are utilized in AI algorithms, data inputs rarely go beyond the inclusion of individual-level SDOH proxies such as race/ethnicity, sex, or age, which leads to missing data and skewed results. Inter/multi-disciplinary teams that include nurse scientists and other experts with a background in health equity can help address these issues, but these experts have largely been missing from research teams working in AI. To move the science of health equity forward in this area, research on developing and implementing AI systems that address implicit and explicit data biases and biases inherent in the inputs chosen to develop the algorithm is also needed. AI algorithms are built by humans and implemented in systems and institutions that have been marked by entrenched racism and discrimination – from the criminal legal system to housing, the workplace, and financial systems. Transparency issues in AI may be addressed by frequent monitoring of the system and data inputs, and providing information on data that were included/excluded/missing, how the system works, and what decisions AI is used to make. Many existing AI algorithms and systems are proprietary and independent evaluation is difficult.

In AI, additional work incorporating the conditions in which people are born, live, learn, work, play, and age is needed and will move the science of health equity forward. These SDOH (e.g., job opportunities, school quality, reliable and accessible transportation, social cohesion, green space), as well as individual and family social risk and protective factors (e.g., ability to get a good education, obtain adequate nutrition personal safety, and affordable and stable housing), can have a significant impact on health outcomes but are largely missing or incomplete in the medical record. Some of these SDOH and health-related social needs may be captured in clinical notes, but extraction for use in AI is a challenge. Research shows that without SDOH, AI algorithms reproduce implicit and explicit biases inherent in healthcare utilization, diagnostics, and clinical documentation, leading to inaccurate predictions, misallocation of resources, and the perpetuation or exacerbation of health inequities. For example, one study showed AI was implemented to reduce the health care costs of patients with complex comorbid conditions. The generated algorithm recommended patients with the highest health care costs for additional health and social services – assuming that these patients were the most medically complex. However, the highest cost patients were those with the most frequent health care use rather than those with the highest need. While Black patients were more likely than other patients to have complex comorbid conditions (47%), only 18% of Black patients were referred for additional care. AI biases disproportionately disadvantaging marginalized communities are similarly reported in heart failure risk assessments, skin and breast cancer diagnoses, and liver transplant candidate identification.

In sum, additional research on SDOH in AI is needed to move the science of health equity forward and reduce known AI biases that contribute to health disparities. This requires an understanding of how to use SDOH in AI, beginning with collecting and using representative and diverse data. This also requires inter/multi-disciplinary teams of experts in health and equity to inform development and implementation of AI systems; transparency in algorithm development, data used, methods, and model interpretation; and continuous oversight of the system and inputs.

Research Objectives

This concept promotes SDOH research utilizing a variety of methods and measures to understand and address known biases in AI and to understand how SDOH may be used in AI to optimize health and advance health equity.

Examples of Potential Initiatives:

Understand how to use SDOH in AI to improve health outcomes and reduce disparities which may include: developing AI systems using diverse, representative data and developing AI systems to elucidate and reduce implicit and explicit biases in data, results, and system implementation.
Utilize inter/multi-disciplinary teams with health, SDOH, and equity expertise to inform AI algorithm and system development and implementation to advance health equity and optimize health outcomes.
Promote transparency in AI by providing information on SDOH inputs and other data characteristics including representativeness, diversity, missing data, and other information critical to model results and interpretation.
Provide for the continuous oversight of AI systems with built in checks and balances on SDOH inputs, other data, and all factors relevant to interpreting and implementing findings.

January 2024: Advancing Health Equity Through Housing

Concept Purpose

The purpose of this concept is to support research to advance health equity through development, testing, and evaluation of interventions to prevent or address homelessness and other forms of housing insecurity.

State of the Problem

Homelessness and other forms of housing insecurity have been linked with adverse health outcomes, including higher rates of physical and mental illnesses, substance abuse, and mortality. Housing security and quality, along with their upstream determinants such as structural racism, historical redlining, and other policies, are key social determinants of health (SDOH) and drivers of homelessness and health disparities. Lack of adequate housing may lead to and/or interact with other adverse SDOH, including but not limited to poorer educational and employment opportunities and lack of access to healthcare. Collectively, these adverse SDOH may not only increase homelessness and housing insecurity, but also a myriad of other social risks such as low income, food insecurity, and inadequate healthcare. Through a variety of pathways and mechanisms, housing insecurity, together with concomitant adverse SDOH and social risks, leads to increased health risks and health disparities.

Given the strong associations between housing insecurity and negative health outcomes, interventions to prevent or address homelessness and other forms of housing insecurity have been hypothesized to have positive effects on health. While many housing interventions have been shown to improve housing outcomes, the impact of housing interventions on health outcomes is less clear. Rigorous trials of housing interventions are limited, and current studies examining the impact of these interventions have shown mixed effects on health outcomes.

To address limitations of current housing intervention research, researchers and policy-makers have asserted that more research is needed to rigorously examine which housing interventions are effective in improving health, which specific health outcomes they improve, and the mechanisms by which these interventions influence health. Additionally, more research is needed to identify for whom and in what contexts are these interventions effective in improving health, and more work may be needed to develop or tailor interventions to meet the unique needs of specific subpopulations of people experiencing homelessness or other forms of housing insecurity (PEH/HI). Finally, given that PEH/HI often experience multiple social risks, more research is needed to determine what types of complementary interventions additional may be necessary to enhance the health impact of housing interventions.

Research Objectives

To address the aforementioned research gaps, the proposed concept will advance research to develop, test, and evaluate interventions to improve health by preventing or addressing homelessness and other forms of housing insecurity.

Potential Initiatives

Examples of potential initiatives include funding opportunities to inviting studies that:

Examine the effect of homelessness/housing insecurity prevention on health outcomes
Examine health effects of housing interventions among people experiencing homelessness or other forms of housing insecurity (PEH/HI)
Examine the unique housing and social needs of subpopulations of PEH/HI (e.g. racial and ethnic minority groups, underserved rural communities, people with disabilities, immigrant populations, formerly incarcerated people, youth, unsheltered people) to inform the development of future interventions and/or the health effects of interventions designed to meet the unique needs of subpopulations of PEH/HI
Examine the impact of housing issues related to housing conditions, quality, and safety within homes on health outcomes

January 2024: Expanding Research Capacity in Firearm Injury Prevention

Concept Purpose

The purpose of this concept is to build the capacity in nursing science for conducting rigorous, high-impact research in firearm injury prevention through creation of infrastructure and research resources, and support of small research awards and investigator training.

State of the Problem

Firearm Injury Prevalence

As stated in the NINR concept on Firearm Injury Prevention in Community Healthcare Settings (2023):

Firearm injury and deaths are serious public health problems. In 2020 there were 45,222 firearm-related deaths in the U.S. Nonfatal firearm injuries are even more common; for each person killed, there are two wounded. In 2020, firearm-related injury became the leading cause of death in children and adolescents. Firearms are used in more than half of all suicides and suicidal acts using firearms have the highest fatality rate of any method, with nearly 90% ending in death. Firearm injury is a source of health disparities in the United States, and disproportionately impacts marginalized populations. Black individuals have firearm homicide rates ten times greater than White individuals (with rates of 29.0 per 100 000 vs. 2.9 per 100 000 respectively). According to recent data, homicides were up to 22.5 times higher among non-Hispanic Black men and up to 3.6 times higher among Hispanic men compared to non-Hispanic White men. According to the CDC, the firearm-related death rate in rural communities was 28% higher than the urban rate (17.01 deaths per 100,000 residents, compared to 13.19 deaths per 100,00 residents), due to higher rates of suicide in rural communities. Another example of the urban-rural disparity can be seen in hospitalizations for firearm injury in children, which are lower for urban than rural 5- to 9-year-olds and 10- to 14-year-olds. Unintentional firearm injuries are most common among these age groups. Firearm injury has ramifications beyond the individual, including the significant impact on families and communities, and the substantial costs related to care, lost income, and the legal system.

Firearm violence, and the disparities in firearm injury described above, are complex problems that are substantially influenced by social determinants of health, or the conditions in which people are born, grow, learn, work, play, live, and age, and the wider set of structural factors shaping the conditions of daily life. It follows that firearm injury prevention research aiming to influence policy and practice must hold these social determinants of health as its foundation and integrate community needs and perspectives at all stages.

Nursing Science and Firearm Injury Prevention

Nursing science, based on nursing’s perspective that considers health challenges within the context of social determinants of health, is well-situated to make important contributions to firearm injury prevention. However, there are few schools or colleges of nursing with programs focused on this topic, and only one NINR-funded institutional training grant includes mentors with funded research in firearm injury prevention. Few nurse scientists investigate firearm injury prevention (FIP). The small number of universities with Centers or Institutes on firearm violence or firearm injury prevention infrequently engage nurse scientists. Therefore, capacity building is needed in nursing science on firearm injury prevention. Yet, few opportunities in nursing science are available to build infrastructure to conduct research on firearm injury prevention or to prepare nurse scientists and scientists in aligned fields for competitive R01 applications.

Given firearm injury research opportunity gaps in nursing science, the purpose of this concept is to build the capacity in nursing science for conducting rigorous, high-impact research in firearm injury prevention through creation of infrastructure and research resources, and support of small research awards and investigator training. For this concept, capacity building is defined as enhancing the abilities of individuals, organizations, and systems to plan, undertake and disseminate quality research efficiently and effectively. Examples of activities related to capacity building include developing relationships and collaborating with local and community experts to identify community-specific challenges to firearm injury prevention, providing training for investigators in methods or strategies relevant to firearm injury prevention research to inform the design of future studies, or building multidisciplinary teams from schools and colleges within an institution to plan and conduct firearm injury prevention research.

Research Objectives

Objectives for this concept include:

Develop capacity for nurse scientists and scientists in aligned fields to conduct inter- and transdisciplinary research in firearm injury prevention. This could be accomplished through initiatives to support transdisciplinary, complementary, and synergistic research activities. Such initiatives would encourage and incentivize faculty partnerships/collaborations across academic disciplines including nursing, criminal justice, sociology, public policy, community psychology, and public health.
Strengthen the capacity for rigorous and high impact firearm injury prevention research by building and expanding research resources. One example would be to develop a library of outcome measures appropriate for firearm injury prevention research, or to build a community advisory or content expert committee that would be available for multiple investigators and studies on firearm injury prevention.
Enhance capacity to address firearm injury disparities through community-engaged research. One example would be a boots-on-the-ground mentored experience.
Support pilot and small research projects that will develop new multidisciplinary research teams leading to independent investigator research applications.
Foster diversity of the firearm injury prevention research workforce through initiatives to enhance the ability of nurses and other investigators from diverse backgrounds to develop programs of research in this area.

These objectives would support early-stage investigators, new investigators, and established/experienced investigators who are new to firearm injury prevention research.

January 2024: Expanding Research to Advance Health Equity in Rural Populations

Concept Purpose

The purpose of this initiative is to advance solutions-oriented research to improve health and promote health equity in rural populations, with a focus on social determinants of health.

State of the Problem

Nearly one in five, or more than 46 million Americans reside in rural areas. It is well-established that rural populations experience health disparities, including a higher incidence of disease and disability, higher mortality rates, and lower life expectancies than populations in more urbanized areas. Rural populations also have higher rates of chronic conditions such as diabetes, cancer, cardiovascular, and respiratory conditions. The COVID-19 pandemic highlighted and exacerbated these existing disparities in rural health, especially for people of color.

Health in rural populations is influenced by biological, social, behavioral, and environmental factors. Increasingly, researchers have recognized that social determinants of health (SDOH), or the conditions in which people are born, grow, learn, work, play, live, and age, and the wider set of structural factors shaping the conditions of daily life, are drivers of health disparities in rural communities. SDOH, including quality and affordability of available food and housing, healthcare coverage, employment opportunities that provide a living wage, and transportation infrastructure facilitating access to resources needed to support health, wellbeing, and economic prosperity, hinder health in rural populations and contribute to health inequities. These and other SDOH vary across rural subpopulations such as immigrant and migrant communities, and influence individual and family social risks like low income, inadequate healthcare, and food insecurity in rural communities. In turn, through a variety of pathways and mechanisms, these social risks lead to health disparities within rural populations.

Substantial observational research has documented the impacts of adverse SDOH on the health of rural populations. Researchers and policymakers emphasize a need to focus on solutions to improve rural health. Some effective interventions addressing some key health challenges in rural areas are available, but important gaps in their adaptation and implementation hinder their population-level impact. Further, few intervention studies, including NIH-funded studies, have focused on promoting health equity in rural communities, and intervention research particularly in the areas of maternal health, climate change, and firearm injury prevention is needed to address NINR priorities. Given the strong body of literature linking adverse SDOH and social risks to health disparities in rural communities, future rural health research should focus on interventions addressing SDOH and/or social risks.

Rural communities are not monolithic; interventions with demonstrated effectiveness require community-specific implementation approaches to achieve lasting health improvements and eliminate inequities across populations. More research is needed to elucidate the mechanistic pathways by which regional and community-specific adverse SDOH impact health disparities to inform the development of tailored interventions to reduce disparities. Such research should take into account how structural factors, such as public spending on social services and public health infrastructure, intersect with other social determinants of health to inform effective intervention approaches. Additionally, intervention approaches should aim to build upon the strengths and assets of rural communities, such as social-connectedness, self-reliance, resiliency, and shared history. When possible, researchers should partner with community-based rural organizations to conduct health research and implement interventions that are tailored to specific rural communities.

In addition to the research gaps described above, improving the health of rural communities is a priority of the White House and the Department of Health and Human Services with a specific focus on improving rural health care access. This priority requires sound evidence to support effective and sustainable solutions to address rural health disparities. NINR has led several initiatives to increase the rural health research portfolio in the last five years. It is an opportune time to build upon and extend these efforts to stimulate research that addresses the adverse SDOH and related social risks that lead to health disparities in rural populations.

Research Objectives

This concept encourages research that addresses social determinants of health to reduce health disparities and advance health equity among rural populations. Studies examining multi-level interventions and/or outcomes are highly encouraged.

Examples of Scientific Efforts of Interest Under this Concept

Observational and mixed-methods research to understand and assess how SDOH impact the variation in assets, needs, and health inequities of rural communities to inform the development of future interventions.
Intervention research to develop, implement, and evaluate innovative interventions to address rural health inequities.
Research examining mechanisms for effective interventions to address rural health disparities and ways to adapt intervention components to maximize efficacy and/or effectiveness.
Dissemination and implementation research to develop knowledge and methods for how to implement effective interventions to improve health in different rural communities and how to share these findings.

September 2023: Understanding and Addressing the Intersection of Social Inequities to Advance Health - The Axes Initiative

Council Date: September 12, 2023
NINR Staff: Shalanda A. Bynum, Maureen K. Akubu-Odero, Libbey Bowen

Purpose of the Concept

To advance research to understand and address the impact of social determinants of health at intersections of social statuses such as race, ethnicity, socioeconomic status, sexual orientation, immigration, ability, and/or other statuses that have been marginalized.

Definitions

Intersectionality: The complex, cumulative way in which the effects of interlocking forms of oppression and/or discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals, communities, and populations.
Social Determinants of Health: Social determinants of health (SDOH) are the conditions in which people are born, grow, learn, work, play, live, and age, and the wider set of structural factors shaping the conditions of daily life. These structural factors include social, economic, and legal forces, systems, and policies that determine opportunities and access to high quality jobs, education, housing, transportation, built environment, information and communication infrastructure, food, and health care; the social environment; and other conditions of daily life. Read more about the NIH SDOH Conceptualization.

State of the Problem

Social determinants of health (SDOH), including the wider set of structural factors shaping the conditions of daily life, play a key role in determining the health trajectory of individuals, families, communities, and entire populations. Simultaneous systems and forces of oppression and privilege are key determinants of good health and prosperity, but also of poor health and hardship. Systems of oppression manifest in higher incidence, prevalence, and severity of diseases and conditions and lower life expectancy. There is clear recognition that oppression does not operate independently but rather intersects across multiple conditions of risk to produce, sustain, and exacerbate poor health outcomes. To fully account for and sufficiently address the experiences of populations that are multiply marginalized, an intersectionality lens is necessary. However, to fully leverage its potential to advance health equity, key scientific gaps in our understanding of intersectionality must be closed.

First, there is an evidenced need to move beyond documenting that health disparities exist at axes of social statuses to elucidating the mechanisms and pathways through which structural and social factors, embedded within systems of racism, sexism, classism, ableism, homophobia, transphobia, xenophobia, and other discriminatory systems, overlap to impact health across and within intersections of marginalization. This line of research moves the field toward a more precise understanding of the combination of factors that contribute to health disparities at these intersections.

Second, much of the research to date has focused on a narrow set of intersectional social statuses, to the neglect of others, with the greatest proportion examining axes of race, ethnicity, sex, and socioeconomic status. This knowledge gap presents an opportunity to expand intersectionality research to be more inclusive of other historically marginalized groups and to expand our understanding of the health of people who hold those statuses.

Third, most of the intersectionality research conducted to date has used qualitative methods – providing important insights into the experience of living with simultaneous marginalized social statuses. However, these methods are limited in their ability to identify complex mechanisms and pathways through which structural and social factors determine the health of individuals and whole populations. Using nursing’s holistic perspective, focused on solutions for people in the context of their lives and living conditions, intersectionality research can reveal important processes that can be translated into policies, programs, and interventions to reduce health disparities and advance health equity.

Research Objectives

This concept encourages research employing a range of research designs and methods to expand the evidence base on how structural factors and social conditions impact health at intersections of social statuses such as race, ethnicity, sex, socioeconomic status, sexual orientation, immigration, ability, and/or other statuses that have been marginalized. Populations of focus for this concept include those who experience health disparities and intersectional marginalization.

Scientific Efforts of Interest Under This Concept

Observational research to elucidate the health impact of SDOH across social, economic, education, and/or criminal legal forces, systems, and policies at intersections of social statuses that have been marginalized.
Intervention research that applies intersectionality theory to address health inequities at intersections of social statuses that have been marginalized.
Training efforts to build scientific capacity to conduct rigorous intersectionality research.

January 2023: Integrating Social Determinants of Health into Education and Training for Nursing Scientists to Advance Health Equity

Council Date: January 31, 2023

Purpose of the Concept

In alignment with its mission and focus on a holistic, contextualized approach to optimizing health for all people, NINR prioritizes research that meaningfully incorporates social determinants of health (SDOH) as primary drivers of health. NINR believes that nursing research that applies a SDOH perspective to our most pressing health problems will lead to new scientific discoveries that positively impact practice and policy toward the long-term goal of eliminating health inequities. However, this approach requires specific foundational knowledge about the SDOH perspective, theoretical underpinnings, and methodological considerations.

Research Objectives

This initiative is intended to provide support for the development of education and training opportunities that will expand the capacity of a diverse scientific workforce equipped to conduct rigorous, innovative, and solutions-oriented nursing research to address SDOH and their systematic maldistribution on health and health equity.

Critical components of funding opportunities under this initiative include objectives related to the following:

Ensuring researchers have strong foundational knowledge about the core concepts and theories that drive our current understanding about SDOH and a solid understanding of the science upon which to build new knowledge.
Training in the methods and tools needed to address critical gaps in evidence on SDOH, their inequitable distribution across populations, and effective solutions.
Increasing diversity in the workforce conducting SDOH research.

January 2023: Firearm Injury Prevention in Community Healthcare Settings

Council Date: January 31, 2023

Purpose of the Concept

The purpose of this concept is to advance research to reduce firearm injury and related health sequelae through the development, evaluation, and translation into routine practice of primary and secondary preventive interventions in community healthcare settings. Prevention interventions are needed to address firearm morbidity and mortality due to both intentional injury (including suicide) and unintentional injury. Under this initiative, NINR is interested in novel approaches to firearm injury prevention, directed at multiple points along the primary and secondary prevention continuum, to identify risk factors; reduce exposure risk in individuals, families, and populations; and prevent injury or reoccurrence of injury.

In alignment with its mission and focus on a holistic, contextualized approach to optimizing health for all people, NINR prioritizes research that meaningfully incorporates social determinants of health (SDOH) as primary drivers of health. Effective and sustainable solutions to the challenge of firearm injury prevention in healthcare settings will demand the integration of an SDOH perspective. Nursing’s contributions to injury prevention in the varied settings where nurses practice will be emphasized.

For this concept, community healthcare settings include but are not limited to schools; primary care centers, including Federally Qualified Health Centers; non-hospital-based locations where walk-in and same-day services are available, including pharmacies, pharmacy-based clinics, vaccination clinics, and mobile health units; home health care; workplaces; and other local community settings where healthcare is provided (e.g., WIC centers). Acute healthcare settings, including but not limited to hospitals and emergency departments, are excluded.

Research Objectives

Research questions could include, but are not limited to:

What screenings, directed assessments, and brief education interventions can be customized for use in specific community healthcare settings?
What models of care best leverage nurses’ unique skills, perspectives, and relationships with people and organizations with whom they interact to normalize firearm injury prevention activities in community healthcare settings?
How do social determinants of health affect the efficacy or effectiveness of firearm injury prevention programs, their implementation in routine practice, and their sustainability?

January 2023: Clinical-Community linkages to Address Social Needs and Social Conditions to Advance Health Equity Among Population Experiencing Health Disparities

Council Date: January 31, 2023

Purpose of the Concept

To advance research that bridges clinical care with community resources to address unmet social needs of individuals and families and adverse social conditions in the community among populations who bear an excess burden of morbidity and mortality.

Research Objectives

This concept encourages research employing a range of research designs and methods to expand the evidence base on effective interventions involving healthcare and community linkages to address adverse structural and social conditions at the community level and social needs at the patient and family level among populations experiencing health disparities. These populations include racial and ethnic minority populations, less privileged socioeconomic status (SES) populations, underserved rural populations, and any subpopulations that can be characterized by two or more of these descriptions.

January 2023: Building Capacity for Firearm Injury Prevention Research Through Education and Training Nursing Science

Council Date: January 31, 2023

Purpose of the Concept

This concept aims to develop cohorts of trainees and investigators to pursue careers or partnerships in Firearms Injury Prevention Research, applying a nursing holistic, contextualized perspective; using NINR’s research lenses to identify solutions; and addressing the substantial health disparities in firearm injury risk and related health sequelae.

Research Objectives

The overall goal is to create educational and training initiatives to advance Firearm Injury Prevention Research, applying nursing’s holistic, contextualized perspective, using NINR’s research lenses, and addressing disparities in firearm injury and related health sequelae. These efforts must include content and experiences that prepare individuals to design and conduct rigorous research that builds on existing knowledge. Equally important is an emphasis on partnerships with other disciplines and communities.

May 2022: Chronic Pain Management in Rural Populations

Council Concept Clearance - Chronic Pain Management in Rural Populations

Sponsoring ICs: NINR, NCCIH
Council Date: May 25, 2022

Description of Concept

The goal of this concept is to accelerate implementation of evidence-based non-opioid interventions for chronic pain management in rural and remote communities that experience health disparities. While effective, non-opioid pain management therapies are available, they are not being used in rural communities. Discovering and addressing the barriers to implementation of evidence-based pain management interventions is critical to alleviating the disparities between rural and non-rural populations. This is particularly important with the increase in drug overdose deaths during the pandemic. Rural communities have been particularly hard hit by the opioid epidemic and are disproportionately impacted by prescription opioid-related overdose. In 2017, of the 15 counties in the US with the highest opioid prescribing rates, 14 of them were in rural areas. However, patients with chronic pain are present across all geographic areas, and recent evidence indicates that percentage of adults with chronic pain increases as the place of residence became more rural. Furthermore, many patients with chronic pain have comorbidities, including mental health, and opioid and/or alcohol abuse disorders that complicate appropriate pain management. There are known disparities in management of chronic pain in rural areas, with rural residents having a greater likelihood of being prescribed an opioid analgesic than those in non-rural areas. Rural residents are also less likely to use self-management interventions for pain than those in non-rural areas.

Pain, like other health conditions, is shaped by both biological and social determinants of health. To fully address the factors affecting quality chronic pain management, the interrelationships between health policy, healthcare services, biology and genetics, individual behavior and social factors must be examined. Development and implementation of sustainable, effective non-opioid chronic pain management in rural and remote areas requires attention to the social determinants of health that affect overall health.

In rural settings, primary care practitioners, including physicians, nurse practitioners and physician assistants are responsible for addressing patients’ needs for chronic pain management while reducing opioid use. Limited community resources and/or long distances to reach specialists such as behavioral health, pain specialists, and physical therapists, increase the challenges of chronic pain management in rural communities. While there have been some promising studies integrating evidence-based chronic pain management in rural settings, there is still a need for a coordinated approach to identify and reduce barriers and accelerate the implementation of high-quality chronic pain care to optimize health and advance health equity.

Projects addressing multiple levels of NIMHD’s research framework would be encouraged. Stakeholder engagement including community groups, primary care practitioners, patients, caregivers, clinicians, community health workers, emergency medical service providers, and researchers is needed to support implementation of evidence based interventions that will be feasible, acceptable, and sustainable.

Examples of possible projects include:

Assessing the impact of establishing mobile vans traveling across multiple communities to provide physical therapy for individuals with chronic pain related to orthopedic issues to address the limited number of specialty care providers available in these communities. The intervention could include both pre- and post-surgical therapies to address both chronic and acute pain.
Multi-level education of primary care providers, pharmacists, patients, families, and the community in appropriate use of evidence based non-opioid medications (including anti-inflammatories, muscle relaxants, topicals, neuropathic pain agents, SSRIs, SNRIs, gabapentinoids, etc.) and implementation of use of these medications, with appropriate self-management and monitoring.
Utilizing a hub and spoke strategy for providing training to partnering community centers in rural regions to provide training of local providers or when possible, community members for evidence- based interventions including movement, self-management therapies, and/or mindfulness.

This concept aligns with the HEAL goals of improving chronic pain management, and appropriate prescribing of analgesics including opioids across populations. Additionally, the NIH HEAL portfolio has limited projects focusing on implementation of evidence-based interventions, especially in populations with known disparities, such as those in rural and remote areas. This initiative will enable integration of pain, rural health, social determinants of health, and clinical implementation expertise to promote use of evidence-based solutions to chronic pain management where such solutions are most needed.

January 2022: Research in NINR Areas of Emphasis

Council Concept Clearance - Research in NINR Areas of Emphasis

Program Lead/Presenter: David Tilley
Council Date: January 25, 2022

Purpose of the Concept

To stimulate research in NINR’s areas of research interests. This initiative will encourage research specifically relevant to NINR’s broad research interests as detailed in the forthcoming new NINR Strategic Plan (2022-2026). The goal of this initiative is to simplify the application process for investigators seeking NINR funding for applications of high relevance to NINR and to broadcast the Institute’s research priorities to the research community.

Research Objectives

The initiative specifically aims to encourage research on:

Health Equity: Studies aimed at producing evidence needed to reduce and ultimately eliminate the systemic and structural inequities that place some population groups at a disadvantage in attaining their full health potential.
Social Determinants of Health: Research examining the conditions in which people are born, live, learn, work, play, and age-identifying effective approaches to address social risk factors, social needs, and/or to capitalize on positive social factors (e.g., strengths, assets) in order to improve health outcomes.
Population and Community Health: Studies that address critical health challenges at a macro level by focusing on interventions that affect groups of people with shared characteristics or who live within a shared area.
Prevention and Health Promotion: Projects studying how to prevent disease and promote health through the continuum of prevention-from primordial prevention that targets the underlying factors that increase risk of illness, to tertiary prevention that aims to reduce disease severity, symptoms, and progression - with a particular emphasis on eliminating health disparities.
Systems and Models of Care: Research that addresses clinical, organizational, and policy challenges through the development, dissemination, and implementation of new systems and models of care, including those that bridge clinical and community care with social factors and needs.

January 2022: Addressing Nurse Burnout Amidst the COVID-19 Pandemic

Council Concept Clearance - Addressing Nurse Burnout Amidst the COVID-19 Pandemic

Program Lead/Presenter: Shweta Singh, Kris Bough, Rebekah Rasooly
Council Date: January 25, 2022

Purpose of the Concept

The purpose of this concept is to provide opportunities for researchers to develop, implement, and/or evaluate effective system-level interventions to prevent and reduce nurse burnout, which has been greatly exacerbated by the COVID-19 pandemic.

Research Need/Challenge to be Addressed

Burnout is an occupational phenomenon fundamentally characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment. The COVID pandemic has shined a spotlight on another epidemic impacting the nation’s largest health care workforce: nurse burnout. Nurse burnout is a healthcare crisis now affecting over half of U.S. nurses and has wide-ranging consequences.

At the nurse level, burned out individuals have been found to exhibit many health problems including sleep disturbances, fatigue, exhaustion, substance abuse, cardiovascular disease, as well as delayed recall and impaired general cognitive processing.

As a consequence, at the patient level, research has linked nurse burnout to higher odds of patient mortality, failure to rescue, longer length of stay, poor quality of care, preventable adverse events, increased hospital-acquired infections, and decreased patient satisfaction. Research has shown RNs with burnout were five times more likely to leave necessary patient care undone.

In addition, at the system-level, nurse burnout negatively impacts other providers, healthcare organizations, healthcare costs, and most alarmingly, the quality and safety of care. Furthermore, nurse burnout increases absenteeism and turnover. In turn, this reduces access to care and increases the nursing workforce shortage, adding even more stress on an already overburdened system. Marginalized populations have reduced access to safe, high-quality care, and nurse burnout exacerbates these inequities. Furthermore, a 2020 survey by the American Nurses Foundation found that Black and Hispanic/Latinx nurses were more likely to be in roles providing direct care to COVID-19 patients than White nurses, and twice as likely to have been diagnosed with COVID-19. These findings highlight existing disparities and inequities in healthcare systems that are further exacerbated by the pandemic.

Research Objectives

Expand research on the development, implementation, and evaluation of system-level interventions that can prevent and reduce nurse-, individual-, and/or system-level impacts of burnout. Examples of system-level interventions include improvements to modifiable components of the work environment such the management and support of nurses, nurse participation, team collaboration, staffing adequacy, and resources. Applications should not include individual-level nurse burnout interventions (e.g., mindfulness, yoga, etc.)
Understand the mechanisms and conditions under which these system-level interventions succeed or fail to improve outcomes.
Encourage research in healthcare systems where care or services are provided to underserved populations. This might include safety net providers - such as Federally Qualified Health Centers (FQHCs), Rural Health Centers, Disproportionate Share Hospitals (DSH), and Community Health Centers - that are disproportionately impacted by COVID-19. This also includes other community-based settings such as long-term care facilities, homes, nursing homes, justice settings, workplaces, and schools.

September 2021: Algorithmic Bias Workshop

Council Concept Clearance - Algorithmic Bias Workshop

Program Lead/Presenter: Rebekah Rasooly
Council Date: September 14, 2021

Goal

Develop a workshop to bring together panelists to discuss ways nursing science can help to detect and prevent unintended or undetected bias that result from machine learning (ML) algorithms (a subset of artificial intelligence or AI) used in biomedical research.

Rationale

In healthcare settings, ML-based algorithms are frequently used in medical devices, diagnostic platforms, and clinical risk assessment applications. As the use of ML continues to gain popularity in healthcare systems, there is growing concern about algorithmic bias that leads to or exacerbates health disparities. Algorithmic bias may arise from issues within the data used to train and evaluate the algorithms or reflect and perpetuate structural inequalities in the form of measurement/label choice bias.

Several new NIH-wide activities are seeking to strengthen and diversify the AI workforce, including the NINR 2020 and 2021 Methodologies Boot Camp focused on Artificial Intelligence, the ODSS-led "Developing Experts for Better Biomedical and Behavioral Research Data: FAIR and AI/ML-Ready Data" initiative, and”¯the NIH AIM-AHEAD Initiative, which is working to increase the participation and representation of researchers and communities currently underrepresented in the development of AI/ML models. Other NIH efforts are focused on specific aspects of ML/AI, such as the "NLM Research Grants in Biomedical Informatics and Data Science" initiative, which is focused on research to reduce or mitigate gaps and errors in health data sets.

However, as ML algorithms continue to be integrated into nursing practice and research, it is critical to address algorithmic bias that exacerbates health disparities. There are no existing NIH-wide activities focused in this area.

Nursing scientists need to understand ML thoroughly enough to consider and mitigate risks of developing and using ML.

Objectives and Scope

Create an advisory group with co-chairs with related expertise to plan the workshop
Gather and synthesize information about research gaps and training needs via a workshop and other activities

September 2021: Addressing Long-Term Social Impacts of the COVID-19 Pandemic on Health and Health Disparities

Council Concept Clearance - Addressing Long-Term Social Impacts of the COVID-19 Pandemic on Health and Health Disparities

Program Lead/Presenter: Amanda Price, Karen Huss, Lois Tully
Council Date: September 14, 2021

Purpose of the Concept

To identify and address the ongoing and long-term impacts of the COVID-19 pandemic, focusing specifically on policies and policy changes that addressed two specific social determinants of health: nutrition/food security and housing security and the resulting effects on health. The initiative will examine the impact of these pandemic mitigation efforts on health disparities and health in populations who experience health disparities, especially racial/ethnic minority and socioeconomically disadvantaged individuals, families, and communities.

Rationale

The COVID-19 Pandemic and Health - Although the US is traversing the worst pandemic in 100 years, the long-term effects on the health and well-being of the nation, beyond the enormous morbidity and mortality due to viral infection itself, are just beginning to be realized. Both pandemic prevention efforts such as social distancing and isolation policies and the related social and economic consequences of the pandemic such as increased food insecurity and widespread unemployment have had adverse effects on public health which will persist for years. Of particular concern is the impact of the pandemic and prevention efforts on health disparity populations, including racial and ethnic minority groups and those of lower socioeconomic status/position. The pandemic vividly highlighted ongoing social problems that influenced health and health equity before the onset of the pandemic, and then exacerbated many of these problems.

Food Insecurity - Food insecurity is a well-known health risk factor for both children and adults. Children who are food insecure, for example, are twice as likely to report fair or poor health and adults with lower food security have a higher likelihood of chronic disease in general. The impact of the pandemic on nutrition was striking. It is estimated that the prevalence of food insecurity has risen sharply from an estimated 11% of US households to an estimated 18-35% of US households. Correspondingly, use of food banks has risen dramatically during the pandemic.

Housing - Housing is also an important social determinant of health, a central component of the relationship between poverty and health. Substandard housing increases the risk of chronic diseases such as asthma and lead poisoning, reduces the availability of recreation and groceries, and is often associated with reduced employment opportunities. The pandemic caused significant financial hardship, with Census Bureau data showing 42% of working-aged adults experiencing household financial hardship by December 2020, leading to 51.7% of renters reporting a high likelihood of being evicted. In addition to being impacted by the pandemic, housing has also played a key role in the spread of COVID in two ways. First, COVID transmission has been associated with crowded households, and researchers have found a strong association between poor housing and a high incidence of and mortality from COVID. Second, public health officials have recognized that stable housing is also a critical part of the response to the pandemic, as it allows individuals who become ill or who are at risk of transmitting COVID to self-isolate, a major rationale for the national eviction moratorium.

Policies Aimed at Mitigating the Pandemic’s Effects - Major policy and programmatic initiatives attempted to blunt the pandemic’s effects by addressing key social determinants of health, such as nutrition security and housing security. The effects of these initiatives are poorly understood and their long-term consequences remain to be studied. Deeper understanding of the effects of pandemic mitigation policies that were aimed at reducing social risk factors will contribute both to lessons for dealing with future pandemics as well as for addressing persistent structural factors influencing health equity. This is directly related to the research interests of NINR, which include supporting studies that address the realities of people’s daily lives and living conditions and that aim to identify solutions that improve health in the many clinical and community settings where nurses practice including people’s homes, schools, and communities.

Research Objectives

Analyze two areas where policy and programmatic interventions were aimed at reducing the pandemic’s effects on health, quantifying the costs and benefits of such interventions as potential approaches to addressing long established determinants of health inequity.

Food insecurity and nutrition security interventions such as changes in subsidized/free meal programs (e.g., in schools), food assistance programs (e.g., SNAP, WIC)
Risky housing and housing displacement interventions, such as the moratorium on evictions, emergency rental assistance, elimination of single family zoning

September 2021: Advancing Integrated Models (AIM) of Care to Address Racial/Ethnic Disparities in Maternal Health Outcomes

Council Concept Clearance - Advancing Integrated Models (AIM) of Care to Address Racial/Ethnic Disparities in Maternal Health Outcomes

Program Lead/Presenter: Shalanda Bynum
Council Date: September 14, 2021

Purpose of the Concept

To characterize and develop integrated models of maternal care delivery to improve maternal health outcomes among women of color and reduce racial/ethnic disparities in maternal mortality and morbidity. For this concept, integrated maternal care is defined as care that incorporates pregnancy support such as through the use of a doula and/or social service providers to address healthcare access, healthcare quality, and social factors impacting maternal health outcomes.

Rationale

Maternal mortality, defined as "death of a woman while pregnant or within 1 year of the end of pregnancy regardless of the outcome, duration, or site of the pregnancy - from any cause related to or aggravated by the pregnancy or its management" has steadily increased over the years. The rate increased from 17.4/100,000 maternal deaths per live births in 2018 to 20.1/100,000 in 2019. Black women bear a disproportionate burden at 44.0/100,000 maternal deaths per live births versus 17.9 for non-Hispanic White women and 12.6 for Hispanic women. American Indian/Alaska Native and Pacific Islander women also have higher rates of maternal mortality compared to White and Hispanic women. Severe maternal morbidity, defined as "unexpected outcomes of labor and delivery that results in significant short- or long-term consequences for a woman’s health", has increased over the years and also disproportionately impacts racial/ethnic minority women.

To eliminate these racial/ethnic disparities in maternal morbidity and mortality, research is needed to identify new models of care that improve outcomes. In addition, research on the factors that contribute to maternal health disparities is especially needed for American Indian/Alaska Native and Native Hawaiian/Pacific Islander communities, where less is known about root causes.

Factors Contributing to Adverse Maternal Health Outcomes - Data from 13 state maternal mortality review committees identified a conceptual framework outlining drivers of adverse maternal outcomes, with factors encompassing 1) unstable housing, availability of healthy foods, and clinical care and transportation access; 2) obstetrics emergency inexperience and lack of personnel or services to attend to such emergencies; 3) patient awareness and knowledge of warning signs, pre-existing chronic conditions, age, and medication adherence; 4) provider missed/delayed diagnosis, implicit bias, and lack of care continuity; and 5) inadequate access to care and poor case coordination. The National Academy of Sciences reports similar contributors to maternal morbidity and mortality. Despite the complexity of the problem, research suggests that approximately 60% of pregnancy-related deaths and a large proportion of maternal morbidity are preventable.

Improving Maternal Health Outcomes - Many of the contributing factors point to the need for improved healthcare access and quality and the need to address women’s social risk factors and needs. Integrated models of care may be an effective approach to address those factors and improve maternal health outcomes among racial/ethnic minority women based on the limited existing research:

Healthcare Access - Health system access related to appointment scheduling, care coordination, and health insurance status are longstanding barriers to women’s health. Research suggests that patient navigators can improve access to services and continuity of care.
Health Care Quality - Implicit bias and healthcare discrimination contribute to patient-provider communication lapses and unequal provision of care. Continuous support especially from a doula or midwife, has been shown to improve pregnancy outcomes. Moreover, birthing centers and group-based prenatal care have also resulted in positive outcomes.
Social Care - Research documenting the influence of housing, healthy food availability, and transportation access on pregnancy outcomes highlights the importance of integrating approaches that address social risk factors and social needs into maternal care delivery models.

This concept seeks to fill existing scientific knowledge gaps in understanding the impact of integrated supportive care on improving maternal health outcomes among racial/ethnic minority women by carrying out rigorous studies.

Research Objectives

Formative
Among racial/ethnic minority populations about which little is known:

Conduct qualitative, quantitative, or mixed-methods research to inform development of integrated models of maternal care delivery to improve maternal health outcomes.
Develop partnerships and conduct pilot studies of integrated models of maternal care that utilize supportive care to address healthcare access, healthcare quality, and social risks and needs.

Intervention
Conduct studies among racial/ethnic minority women to evaluate the impact on maternal health outcomes of integrated models of maternal care that utilize supportive care to address healthcare access, healthcare quality, and social risks and needs.

January 2020: Strengthening the Impact of Community Health Workers on HIV Care Continuum in the US

Council Concept Clearance - Strengthening the Impact of Community Health Workers on HIV Care Continuum in the US

Program Lead/Presenter: Rebecca Henry
Council Date: January 15, 2020

NINR and OAR Strategic Plan Relevance

This concept fits with NINR’s Self-management of HIV/AIDS and related co-morbidities priorities and with the following NIH OAR (Office of AIDS Research) and EHE (Ending the HIV Epidemic) research priorities: Decrease the incidence of HIV transmission and decrease and/or mange HIV-associated comorbidities, coinfections, and complications

Purpose

The purpose of this concept is to promote research on the use of community health workers (CHW) to improve care engagement leading to durable antiretroviral (ARV) medication adherence in U.S. populations with the poorest HIV treatment outcomes. The concept is intended to support research on the effectiveness and real-world translation of local and regional CHW strategies, as well as integration of mHealth and virtual reality tools to strengthen CHW’s ability to improve HIV care among people living with HIV (PLH). This program of research is geographically aimed at US counties, states and territories with the highest concentrations of HIV disease identified in the President’s plan to End the HIV Epidemic (EHE).

Rationale

Despite the availability of highly effective HIV-targeted medicines, many of the approximately 1.2 million PLH living in the United States are not benefitting from them. The causes for lack of engagement in HIV care that leads to durable viral suppression are complex, rooted in poverty and the social stigma attached to HIV illness itself, compounded by a person’s sex, race, class, and sexual identity. Acceptance and integration of the realities of a serious health condition and developing a realistic daily management strategy takes time and support and is always vulnerable to a person’s changing circumstances. Given the limited time of clinicians, the fragmented condition of the US health care and insurance system, and the challenges inherent in the lives of poor or stigmatized groups, the development of a robust, diverse, community-savvy cadre of health workers in the US holds promise for addressing some of these ongoing challenges. As part of a provider team in the US, CHW have been successfully deployed to support people living with a variety of chronic conditions, including hypertension, diabetes, cancer and infectious illness such as TB (CDC). In the context of the US HIV epidemic, "patient navigators" have had some success in improving HIV health outcomes in research settings

In recognition of the importance of this research question, the NIH Office of AIDS Research (OAR) is supporting an NINR-led initiative on CHWs and the HIV Care Continuum. As a first step, on September 16-17, 2019, NINR led an NIH conference, funded by the NIH Office of AIDS Research (OAR) on "Strengthening the Impact of Community Health Workers on HIV Care and Viral Suppression in the U.S." The issues and gaps identified by the attendees were used in the development of this concept.

Public Health Relevance/Impact

Research on how community health workers and programs impact HIV care engagement, ARV adherence and other HIV health-related outcomes, and their value to improving the quality of health care to under-resourced communities, will provide guidance for bringing CHW to scale as a significant force in solving the large gaps in care engagement and between ARV prescription and viral suppression in the US. In addition, impactful CHWs strategies and programs, backed by clinical-evidence and, over time, supported through training, supervision and pay, could be an effective resource to addressing HIV comorbidities and many other clinical and public health problems in areas targeted by EHE initiative.

Research Objectives

Community-based participatory methods including thorough assessment of the policy and clinical practice context preliminary work to set the stage for scale up
Pragmatic trials of active (or augmented) CHW programs in EHE locations that study the impact of CHWs on HIV care and adherence health outcomes
Implementation research that translates CHW strategies with demonstrated efficacy in other locales and regions, to ETH locations
Development and testing and/or expansion of existing mHealth and Virtual approaches that strengthen work of CHWs, CHW/CBO programs or extend the geographic reach of CHW activities to support care engagement and medication adherence to EHE locations
Study of factors that influence how CHW draw from and impact social cohesion and program success;
Characterization of how, why and which specific program elements or combination of elements provide the highest impact on targeted HIV-related medication adherence and other health outcomes;

Potential Collaborators: NIDA, NIMH, NIMHD, NIDCR, OBSSR