To help fulfill its role as the nation’s health protection agency, HHS’s CDC conducts and supports research, including prevention research. Prevention research includes applied public health research that develops and evaluates health promotion and disease prevention and control strategies that are community- and population-based. Through legislation enacted in 1984, Congress authorized, and CDC later established, the PRC program to fund health promotion and disease- prevention research. The legislation mandated that the PRCs to be funded be located at academic health centers capable of providing a multidisciplinary faculty with expertise in public health, relationships with professionals in other relevant fields, graduate training and demonstrated curricula in disease prevention, and a capability for residency training in public health or preventive medicine. The PRCs, the first of which were funded in 1986, also serve as demonstration sites for the use of new and innovative applied public health research and activities for disease prevention and health promotion. The PRC program is administered by CDC’s NCCDPHP. CDC makes its PRC awards through a competitive process; there are currently 26 PRCs, located in 24 states, funded for fiscal years 2014 through 2019. Funded PRCs are able to compete for SIPs, which were created by CDC in 1993 to provide supplemental funding to the PRCs to design, test, and disseminate effective applied public health prevention research strategies. According to CDC, eligibility for SIPs is limited to PRCs because the centers are “uniquely positioned to oversee, coordinate, and perform applied public health research that promotes the field of health promotion and disease prevention research due to their established relationships with multidisciplinary faculty and community partners.” Subject matter experts (SME) within CDC sponsoring units propose potential SIPs each year, depending on unit needs—e.g., particular research gaps that have been identified—and available funding. After being approved by the leadership of the sponsoring unit, the sponsoring units’ proposals are reviewed internally by NCCDPHP and others before being included in a SIP FOA. The SIP FOA is assembled by NCCDPHP’s extramural research group, and when complete, is posted publicly on the grants.gov website. SIP applications are subject to an external peer review process, as well as a secondary internal review by CDC officials. SIP awards are generally made on the last day of the fiscal year. Sponsoring units fund both individual SIPs, which are awarded to one or more PRCs to work independently on a particular research topic, and thematic network SIPs, which are awarded to multiple PRCs to work collaboratively on a research agenda related to a specific health issue, such as cancer prevention or brain health. In fiscal years 2014, 2015, and 2016, CDC announced the availability of 51 SIPs—of which 43 were funded. The 43 funded SIPs resulted in a total of 76 awards to 22 of the 26 PRCs. (See appendix 1 for detailed information on the SIPs awarded in fiscal years 2014 through 2016, including information on SIPs awarded by sponsoring unit, SIP funding by PRC, and a complete listing of all SIPs awarded during this period.) CDC publicly discloses information on SIP awards on its website. Specifically, CDC has a PRC project database on its website that, as of July 2017, included information on SIPs from fiscal years1999 through 2015, as well as other information related to the PRCs. The project database includes the SIP number, project title, principal investigator, PRC funded, and the CDC sponsoring unit. It does not include the amount of the funding. In general, CDC officials we spoke with told us they will choose the SIP mechanism when seeking to fund prevention research that is community- based and would benefit from having access to a multidisciplinary group of researchers. Specifically, CDC officials from most of the sponsoring units we spoke to told us that they use the SIP mechanism when community participation is important to the research. For example, one sponsoring unit used a SIP for the development and testing of an integrated comprehensive communication strategy to promote vaccination for the human papilloma virus in the United States. The SIP was focused on developing strategies that engaged local or regional health systems, community-based organizations, and state health departments as key community partners, in order to enhance the acceptability of the vaccination among parents with vaccine-eligible children and to increase the likelihood that a provider would recommend the vaccination. CDC officials from one sponsoring unit also told us they use the SIP mechanism when they need to engage community leaders and members of the public in order to answer the research questions. For example, CDC used the SIP mechanism to fund a research project focused on enhancing the knowledge, skills, and capacity of community health advocates and leaders from community-based organizations, with the goal to provide participants with the skills necessary to assess local community health needs in order to improve community health. According to CDC, an important aspect of the research was the evaluation of whether there was an increase in the skills and leadership capacities of participants and their influence on local improvements in their communities. In addition, CDC officials told us that they choose the SIP mechanism to conduct research when seeking to access researchers who have established partnerships with diverse population groups across the country. PRCs are located across the United States and are expected to have cultivated relationships with their local communities. For example, one sponsoring unit used a SIP to fund research on the barriers to colorectal cancer screening among South Central Asian immigrants, primarily Indians and Pakistanis, who have been shown to have low screening rates. The purpose of the research was to inform the development of culturally relevant strategies to increase colorectal screening. As such, to be awarded the SIP, a PRC had to demonstrate that it had established relationships within the South Central Asian community and an ability to recruit from these populations. In contrast, CDC officials explained that they would not choose the SIP mechanism if the desired research would be better suited for an entity other than an academic health center. For example: Officials from one sponsoring unit told us that a different mechanism was used for a project testing obesity prevention and management strategies because the project required working directly with health care service providers in the community, such as federally qualified health centers. Officials from another sponsoring unit chose not to use a SIP for a project to evaluate vaccine impact on recurrent respiratory papillomatosis (a disease in which tumors grow in the respiratory tract). This research was being conducted by the providers who care for the patients, as opposed to academic researchers. CDC officials provided examples of other instances when they would not use a SIP, and instead choose another mechanism to support the desired research. Specifically, officials from one sponsoring unit told us that when conducting a research project related to cervical cancer, they did the work through a contract in order to allow the SME to direct the research protocol, which included collaboration with organizations that maintained cancer data, as well as the deliverables and timeline for completion of the work. Sponsoring unit officials also told us that they will not choose the SIP mechanism when the research they want to fund is not focused on public health prevention, such as when the research is clinical or laboratory based, or when the timing of the research does not align with the PRC funding cycle (e.g., a longitudinal study or a study that would cross two PRC funding cycles). CDC officials told us that CDC SMEs’ relationships and collaboration with experts in the field—including federal and nonfederal experts—help inform the development of the research funding opportunities made available through SIPs, as well as other mechanisms. In our prior work, we found that interagency collaboration, which can include information sharing and communication among federal experts, may reduce the likelihood of unnecessary duplication. According to officials from all of the sponsoring units we spoke with, SMEs have developed collaborative relationships with federal and nonfederal experts in their fields; these relationships develop through SMEs’ participation in workgroups, advisory committees, and joint projects, as well as through informal interactions at in-person meetings and conferences. (See table 1 for examples of the workgroups and advisory committees in which CDC SMEs participate.) These interactions, as well as the SME’s review of the scientific and nonscientific literature, are used to determine gaps in knowledge and inform the research proposed to be funded through SIPs or other mechanisms. CDC SMEs’ collaboration with federal and nonfederal experts may lead to the development of specific research projects that are funded through a SIP. For example: SMEs from one sponsoring unit identified a series of research gaps that existed within skin cancer prevention while working on the Surgeon General’s Call to Action to Prevent Skin Cancer Report with multiple federal agencies, including the Food and Drug Administration, the National Institutes of Health’s (NIH) National Cancer Institute, the Environmental Protection Agency and the Office of the Surgeon General. CDC developed a SIP to address one of these gaps— assessing the knowledge, attitudes and beliefs about skin cancer in order to develop and test communication strategies for skin cancer prevention, specifically for adults aged 18 to 49. SMEs from another sponsoring unit participate in the Interagency Coordinating Committee on the Prevention of Underage Drinking with 15 federal partners, including the Substance Abuse and Mental Health Services Administration, Federal Trade Commission, Department of Justice, and NIH’s National Institute on Alcohol Abuse and Alcoholism. According to CDC, this group meets regularly to discuss their work and efforts to address prevention of underage drinking. Based on this collaboration and the review of other resources, including research projects and reports by committee members, CDC SMEs determined there was a gap in knowledge related to monitoring youth exposure to alcohol marketing on the Internet, and developed and awarded a SIP in 2014 to address this issue. In 2011, CDC SMEs hosted an expert conference—including federal and nonfederal researchers, health care providers, and representatives from advocacy groups—to discuss how patients and health care providers can communicate effectively before, during, and after prostate cancer screenings. Recommendations from this conference resulted in a 2014 SIP focused on the development of a multimedia decision aid to help patients and their family members understand treatment options after a positive prostate cancer diagnosis. Collaboration with experts may also increase the resources available for a specific research project. For example, officials from the CDC unit that sponsors the National Cancer Prevention and Control Research Network SIP told us that the network is jointly funded with NIH’s National Cancer Institute. This joint funding allows for an expanded pool of resources, and officials stated that the network is able to achieve more than any individual PRC could achieve on its own. CDC officials told us that the knowledge gained through coordination and information sharing also mitigates the potential for duplication of research efforts. For example, officials from one sponsoring unit told us that as a part of their ongoing discussions with NIH on sexually transmitted disease prevention, they learned of research NIH was conducting that was related to a SIP that CDC planned to fund. CDC decided not to fund the SIP and instead entered into a joint funding arrangement with NIH to address its research needs. The joint funding arrangement allowed CDC and NIH to expand the number of sites involved in the research NIH already had underway. The main advantage of limiting eligibility for SIPs to the PRCs is the ability to rapidly initiate high-quality research, due to the infrastructure and relationships the PRCs have in place, according to officials from CDC, outside organizations, and PRCs. For example, officials we spoke with from one PRC told us that they typically learn from CDC if their application for a SIP has been successful in August of a given year, and awards are made at the end of September, with the expectation that the research should begin shortly thereafter. These officials added that because many SIPs are only providing funds for one or two years, there is no time to waste in getting the research up and running. Officials from one outside organization noted that this faster turnaround in getting the research started can result in faster publication of results. Officials from CDC and others told us that PRCs have infrastructure in place to do multidisciplinary research, which an official from one outside organization told us includes the ability to manage federal funds and recruit study participants. This infrastructure contributes to the speed with which PRCs can start a SIP. For example, officials from one CDC sponsoring unit told us that a PRC’s existing infrastructure means that it is not starting from scratch when it conducts research through a SIP. In addition, a representative from one outside organization said that it is a good use of federal resources to continue to invest in federally supported infrastructure—as in the case of offering supplemental funding to PRCs in the form of SIP awards. In addition to research infrastructure, officials also told us that PRCs have established relationships with community partners. One outside organization told us that these relationships are particularly important for prevention research, which often involves working with populations who may be reluctant to participate in research. Research has confirmed the need for community engagement when studies include disadvantaged groups. Specifically, a systematic review of the literature on strategies for increasing participation of disadvantaged groups in research concluded that researchers need to operate via community partnerships, because they can increase trust among the study population. Similarly, one sponsoring unit told us about the importance of the PRCs’ credibility in the neighborhoods where the research is being done. Given this, for some SIPs, the FOA explicitly requires PRCs to outline their partnerships with community organizations in their applications or notes that descriptions of these relationships will be considered when applications are scored by reviewers. For example, the fiscal year 2015 FOA for a SIP that was to identify means for increasing screening rates for breast and cervical cancer in Muslim women asked that applicants “describe and provide evidence (such as supporting letters and publications) of sufficient institutional, community and other necessary support for carrying out this project.” In addition, officials from CDC and outside organizations noted that there are benefits of having eligibility limited to entities that have already been vetted, such as an increased likelihood of the research being successful. To become a PRC, the eligible academic institutions must go through a competitive peer review process, through which they are evaluated based on their ability to contribute to improved community and population health, impact public health programs and practice, and advance the field of public health promotion and disease prevention, among other things. Because of this vetting, an official from one outside organization told us that PRCs are likely to be successful in their work—mitigating the risk faced were an award to be made to an unknown entity. An official from another outside organization noted that CDC sponsoring units work closely with the PRCs on implementing the SIPs, and it is beneficial that the PRCs are “known entities” who have established relationships with CDC. Officials from CDC and outside organizations identified a few potential disadvantages to limiting eligibility for SIPs, including the potential for reduced access to expertise outside of the PRCs and the risk of being unable to conduct desired research at the desired time. Specifically, officials from outside organizations told us that there may be reduced access to the expertise of researchers from other universities or other entities. CDC officials and officials from PRCs said that PRCs have the ability to bring in the expertise from outside the PRC institution through subcontracts with other entities, which could help alleviate this concern. For example, for a SIP on skin cancer prevention messaging, the PRC officials at the University of Pennsylvania told us they had multiple subcontracts, including one with a researcher at another university with expertise on indoor tanning. Officials from two outside organizations stated that there is a missed potential for innovation and new approaches if new entities are not eligible for SIPs or added to the pool of PRCs. Although there is a competition for PRCs every 5 years, the PRCs have been fairly stable in recent years—2 new PRCs were added in fiscal year 2014, while more than half (15 of 26) of the current PRCs have been continuously funded by CDC for at least 15 years. Because SIPs are only announced once per year and are awarded at the end of the fiscal year, one other potential disadvantage of SIPs’ limited eligibility is the risk that CDC’s desired research may not be conducted, or may not be able to be conducted at the desired time. If the research project is ultimately not funded through the SIP, there is not sufficient time within the fiscal year to pursue an alternative mechanism. CDC sponsoring unit officials described instances where they did not receive any applicants or did not receive enough qualified applicants for individual SIPs and thus were not able to fund a SIP or made fewer awards than planned. In fiscal years 2014 through 2016, 5 of 51 SIPs included in the FOAs were ultimately not funded because they received no applications or the applications received were not a good fit for the desired project. For an additional 2 SIPs, the sponsoring units funded fewer awards than planned because they did not receive enough quality applications. We provided a draft of this report to HHS for review. HHS provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the Secretary of the Department of Health and Human Services, the Director of the Centers for Disease Control and Prevention, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. Appendix I: Information on Centers for Disease Control and Prevention (CDC) Special Interest Projects (SIPs) Tables 2, 3, and 4 below present data on SIPs awarded in fiscal years 2014 through 2016. In addition to the contact named above, Michelle B. Rosenberg (Assistant Director), Julie T. Stewart (Analyst-in-Charge), and Romonda McKinney Bumpus made key contributions to this report. Also contributing were Sam Amrhein and Jacquelyn Hamilton.

Summary: CDC, an agency within HHS, created the SIP program in 1993 as a supplemental funding mechanism to support health promotion and disease-prevention research being done at its PRCs. Currently, there are 26 PRCs. In fiscal years 2014 through 2016, CDC awarded more than $40 million for SIPs. SIP topics vary from year to year but are to be aligned with public health priorities, such as the Healthy People 2020 Objectives—HHS's 10-year national objectives for improving Americans' health. SIPs are sponsored and primarily funded by CDC organizational units, referred to as sponsoring units. House Report 114-195 included a provision for GAO to review the SIP program. This report describes (1) what research CDC chooses to fund through the SIP mechanism, and (2) what have been identified as advantages and disadvantages of SIP eligibility being limited to PRCs. GAO reviewed documents from CDC and analyzed CDC data on SIPs awarded in fiscal years 2014 through 2016. GAO also interviewed CDC officials, including officials from 5 of the 10 sponsoring units that together accounted for over 90 percent of SIP funding during this time period, officials from 4 PRCs with varying experience with SIPs, and 4 organizations with knowledge of prevention research. The Centers for Disease Control and Prevention (CDC) uses the Special Interest Project (SIP) mechanism to fund community-based prevention research that would benefit from a multidisciplinary group of researchers. SIPs are supplemental funding awards that focus on topics of interest or gaps in knowledge or research and can also support the development of state and local public health interventions and policies. SIPs are only available to CDC's Prevention Research Centers (PRC)—selected academic health centers at universities with schools of public health or medical schools with residency programs in preventive medicine. CDC officials said that they would choose the SIP mechanism when the research they want to fund is intended to involve community-based organizations or members of the community. They also use SIPs when they seek access to researchers who have established partnerships with diverse population groups across the country. They would not choose the SIP mechanism when the research they want to fund is not focused on public health prevention, including research that is clinical or laboratory-based; would be better suited for an entity other than an academic health center; or would be better funded through a contract to allow CDC to direct the research protocol. CDC's collaborations with experts in the field—including those at other federal agencies—help to inform its development of the research funding opportunities offered through SIPs. For example, CDC officials use information they learn through participation in multiagency workgroups and advisory committees to identify gaps in knowledge that SIP funding could help to address. CDC officials also stated that this collaboration can also help to avoid potential duplication of research. The key advantage of SIPs being limited to PRCs is the ability to rapidly initiate research, according to officials with whom GAO spoke—including officials from CDC, PRCs, and organizations with knowledge of prevention research. Factors cited as contributing to this ability included the research infrastructure and community relationships already established at the PRCs. Officials from CDC and outside organizations also identified a few potential disadvantages to limiting eligibility for SIPs, including the potential for reduced access to expertise from researchers or others who are not affiliated with the universities in which PRCs are located, although some noted that PRCs may bring in outside expertise through subcontracts with other entities. The Department of Health and Human Services (HHS) provided technical comments on a draft of this report, which GAO incorporated as appropriate.