Overview of Notice of Funding Opportunity: Advancing Policy as a Public Health Intervention to Reduce Morbidity, Mortality and Disparities in HIV, Viral Hepatitis, STDs, and Tuberculosis; PS-23-0009

Science-based policymaking can improve health outcomes, increase efficiency, reduce costs, identify and eliminate ineffective programs and policies, and strengthen governmental accountability. By leveraging legal epidemiological methods, complex laws and policies can be distilled into data that can be used to evaluate their impact on a population’s health and determine the economic impact of policy approaches. This evidence can then be translated into actionable strategies and resources for leaders who make decisions in public health to advance impactful policy that saves lives, saves money, reduces health disparities, and protects all people.

Laws and policies to reduce morbidity and mortality from HIV, viral hepatitis, STDs, TB, and other health conditions are complex and applicable at every level of society; many of these laws and policies can be evaluated through the application of legal epidemiology. Legal epidemiology is the study of law as a factor in disease causation, distribution, and prevention. Legal epidemiology analyses can empower leaders who make decisions in public health to understand the effectiveness of policy changes and implement evidence-based law and policy interventions to inform public health practice.

This NOFO provides funding to conduct robust policy surveillance and legal mapping of priority and emerging policy levers, including cross-cutting syndemic topics (e.g., social determinants of health, infectious disease consequences of the opioid crisis, safe and supportive school environments, and other health conditions). The data collected will be used to evaluate the impact that laws and policies have on health and economic outcomes, including examining their impact on health disparities. In addition, these legal epidemiological activities will inform the development of specific tools and resources that leaders can use to advance evidence-based policy making and efforts to achieve health equity.

Additionally, this NOFO will fund the creation of a resource center for leaders who make decisions in public health to request technical assistance (TA) and other support in navigating complex law and policy issues in their jurisdictions. Law and policy-related issues and questions occur as state, tribal, local, and territorial jurisdictions develop, adopt, and implement policies. However, leaders who make decisions in public health often lack access to quality tools and resources to make evidence-based policy decisions. By providing TA and building public health capacity, this resource center will support leaders who make decisions in public health in advancing their understanding of how laws are developed, adopted, implemented, and enforced. It will also support jurisdictions and their partners in gaining comprehensive and critical knowledge on how to successfully achieve (1) reductions in morbidity, mortality, and disparities from HIV, viral hepatitis, STDs, and TB and (2) increased use of evidence-based policy decision-making.

Important Dates

NOFO Publishes: November 2, 2022
Applications Due: February 1, 2023
Awarding: May 1, 2023
Project start date: June 1, 2023

Upcoming Informational Call
References:
  1. Pew-MacArthur Results First Initiative. (2014). Evidence-Based Policymaking: A guide for effective government. Evidence-Based Policymaking: A Guide for Effective Government (pewtrusts.org)
  2. National Center for Chronic Disease Prevention and Health Promotion. (2021, May 12). Legal Epidemiology. Centers for Disease Control and Prevention. Legal Epidemiology | cdc.gov
  3. Wagenaar, A.C., & Burris, S. C. (Eds.) (2013). Public Health Law Research: Theory and methods.
  4. Rabarison, K. M., Bish, C. L., Massoudi, M. S., & Giles, W. H. (2015). Economic evaluation enhances public health decision making. Frontiers in Public Health, https://doi.org/10.3389/fpubh.2015.00164
Funding Strategy

Total program years: 5

Total period of performance funding: Approximately $7,500,000

Component 1: 1 recipient, $750,000/project year

Component 2: 1 recipient, $750,000/project year

This program notice is subject to the appropriation of funds, and is a contingency action taken to ensure that, should funds become available for this purpose, CDC can process applications and award funds in a timely manner. If future fiscal year appropriation or other statute fails to authorize this activity, no awards will be made. Final award amounts may be less than requested. Funding availability in subsequent fiscal years is subject to the availability of appropriated funds.

Applicants may apply for Component 1, Component 2, or both components. If you are applying for both components, one application should be submitted with two separate narratives, workplans, and budgets.

This NOFO is designed with no award ceiling and as funds are available and, where appropriate, may be added to this mechanism to support program goals on a variety of policy topics.

Components

Component 1 – Grow the breadth and depth of longitudinal law and policy surveillance data sets and conduct comprehensive health and economic outcome assessments

The recipient will use legal epidemiological methods to inform public health practice by identifying laws and policies, systematically collecting data, and conducting analyses to determine the potential or actual impact of laws and policies on health and economic outcomes, including health equity.

Component 2 – Conduct and facilitate policy and legal-related technical assistance (TA) among leaders who make decisions in public health

The recipient will inform public health practice by providing legal and policy-related TA and developing evidence-based resources and tools for leaders who make decisions in public health.

Strategies

Component 1

Strategy 1.1 – Conduct a data-driven landscape assessment to determine policy topics for legal epidemiological analyses
Strategy 1.2 – Systematically collect legal data on policy topics and develop publicly available legal data sets
Strategy 1.3 – Conduct analyses to determine the impact of laws and policies on health and economic

Component 2

Strategy 2.1 – Develop a process to address incoming legal TA requests to formulate evidence-based responses to address jurisdiction-specific policy and legal barriers
Strategy 2.2 – Identify solutions to policy and legal barriers by developing and using evidenced-based TA tools and resources
Strategy 2.3 – Proactively disseminate TA-related resources to leaders who make decisions in public health

Outcomes

There are two long-term outcomes for the entire NOFO

  1. Reduced morbidity, mortality, and health disparities from HIV, viral hepatitis, STDs, and TB.
  2. Increased evidence-based policy decision-making.

Component 1 Short-term and Intermediate Outcomes

Short-term:

  1. Increased knowledge of evidence-based laws and policies that reduce morbidity, mortality, and health disparities.
  2. Increased awareness of and access to longitudinal law and policy surveillance data sets.

Intermediate Outcomes

  1. Increased application of evidence-based laws and policies that are found to reduce morbidity, mortality, and health disparities.
  2. Increased breadth and depth of available evidence demonstrating the impact that laws and policies have on health and economic outcomes.

Component 2 Short- and Intermediate Outcomes

Short-term:

  1. increased knowledge of evidence-based TA resources to address policy and legal barriers.
  2. Increased awareness of and access to legal TA among leaders who make decisions in public health.

Intermediate Outcomes

  1. Increased nationwide capacity for addressing policy and legal barriers to inform public health practice.
  2. Increased application of legal TA tools and resources in advancing evidence-based laws and policies.

Table 1: Example of Law and Policy Analyses

Appendix 1 – List of Example Analyses
Topic Outcome Outcome Citation
Examples of Legal Epidemiology Publications
Syringe Services Programs (SSPs) Syringe Services Programs (SSPs) Developed cross-sectional data set of state laws and regulations in effect on August 1, 2019; compared data with previously collected data on laws as of August 1, 2014. Fernández-Viña MH, Prood NE, Herpolsheimer A, Waimberg J, Burris S. State Laws Governing Syringe Services Programs and Participant Syringe Possession, 2014-2019. Public Health Reports. 2020;135(1_suppl):128S-137S.
Prenatal syphilis screening Only six states (11.8%) do not require prenatal syphilis screening Targeted search terms were used to identify laws in legal research databases. The timing of the screening mandates for each state law was coded for: (1) first visit, (2) third trimester, and (3) delivery. Descriptive statistics were calculated to examine the number of states with each type of requirement Warren, H.P., Cramer, R., Kidd, S. et al. State Requirements for Prenatal Syphilis Screening in the United States, 2016. Matern Child Health J 22, 1227–1232 (2018). https://doi.org/10.1007/s10995-018-2592-0
Sexual orientation, gender identify & health status Local (county/city) laws prohibiting discrimination were less common. State laws differed significantly by US census region – West, Midwest, Northeast, and South. Future analyses of these data could examine the impact of these laws on various outcomes, including health among LGB populations. Collected laws that in 2013 prohibited discrimination based on sexual orientation;
coded certain aspects of laws to create a dataset. Generated descriptive statistics by jurisdiction type and tested for regional differences in state law using Chi-square tests
Cramer, R., Hexem, S., LaPollo, A. et al. State and local policies related to sexual orientation in the United States. J Public Health Pol 38, 58–79 (2017). https://doi.org/10.1057/s41271-016-0037-9
Hepatitis C Only three states had laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs. Existing state laws in all states related to access to clean needles and syringes by persons who inject drugs were reviewed using the legal database WestlawNext Existing state laws in all states related to access to clean needles and syringes by persons who inject drugs were reviewed using the legal database WestlawNext
Hand hygiene; animal exhibits Seven states require hand sanitation stations for certain animal contact exhibits through statute or regulation. A list of statutes and regulations was compiled using WestlawNext from March 17 to April 1, 2016. Hoss A, Basler C, Stevenson L, Gambino-Shirley K, Robyn MP, Nichols M. State Laws Requiring Hand Sanitation Stations at Animal Contact Exhibits—United States, March–April 2016. MMWR Morb Mortal Wkly Rep 2017;66:16–18. DOI: http://dx.doi.org/10.15585/mmwr.mm6601a4
Cytomegalovirus (CMV) State-level CMV laws have been enacted to increase CMV awareness and to implement CMV testing for infants at higher risk for infection. Systematic review and code legal texts for themes Yassine, Brianne B. PhD, MPH; Hulkower, Rachel JD, MSPH; Dollard, Sheila PhD; Cahill, Eric MA; Lanzieri, Tatiana MD, MPH. A Legal Mapping Assessment of Cytomegalovirus-Related Laws in the United States. Journal of Public Health Management and Practice: March/April 2022 – Volume 28 – Issue 2 – p E624-E629 doi: 10.1097/PHH.0000000000001401
Medicaid; ADHD Medicaid policies on ADHD medication treatment are diverse; some policies are tied to diagnosis and treatment guidelines. A 50-state legal assessment characterized ADHD prior authorization policies in state Medicaid programs Hulkower RL, Kelley M, Cloud LK, Visser SN. Medicaid Prior Authorization Policies for Medication Treatment of Attention-Deficit/Hyperactivity Disorder in Young Children, United States, 2015. Public Health Reports. 2017;132(6):654-659.
Other Examples of Law and Policy Publications
Naloxone Access Laws Naloxone access laws were associated with an average increase of 78 prescriptions dispensed per state per quarter.
Zoster vaccination rates for adults ages 60 and older were significantly higher in states that did not require a prescription order.
Regression analysis and a negative binomial estimator
Propensity score-matched multilevel logistic regression model
Xu J, Davis CS, Cruz M, Lurie P. State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies. Drug Alcohol Depend. 2018 Aug 1;189:37-41.
Tak CR, Gunning K, Kim J, Sherwin CM, Ruble JH, Nickman NA, Biskupiak JE. The effect of a prescription order requirement for pharmacist-administered vaccination on herpes zoster vaccination rates. Vaccine. 2019 Jan 21;37(4):631-636.
Vaccination Authority for Pharmacists Pharmacist authority laws were not statistically significantly associated with increased HPV vaccine initiation or completion. Difference-in-difference regression model Justin G. Trogdon, Paul R. Shafer, Parth D. Shah, William A. Calo, Are state laws granting pharmacists authority to vaccinate associated with HPV vaccination rates among adolescents, Vaccine, Volume 34, Issue 38, 2016, Pages 4514-4519.
Repeal of Comprehensive Background Check Policies No evidence of an association between the repeal of comprehensive background check policies and firearm homicide and suicide rates in Indiana and Tennessee. Synthetic control method Kagawa RMC, Castillo-Carniglia A, Vernick JS, Webster D, Crifasi C, Rudolph KE, Cerdá M, Shev A, Wintemute GJ. Repeal of Comprehensive Background Check Policies and Firearm Homicide and Suicide. Epidemiology. 2018 Jul;29(4):494-502.
Cannabis Use Disorder and Medical Marijuana Laws (MML) Overall, from 1991-1992 to 2012-2013, illicit cannabis use increased significantly more in states that passed MML than in other states. Differences in degree of change Hasin DS, Sarvet AL, Cerdá M, Keyes KM, Stohl M, Galea S, Wall MM. US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws: 1991-1992 to 2012-2013. JAMA Psychiatry. 2017 Jun 1;74(6):579-588.
Naloxone Access Laws and Outpatient Prescriptions The presence of any naloxone law was significantly associated with increases in outpatient naloxone reimbursed through Medicaid. State-level fixed effect models Gertner AK, Domino ME, Davis CS. Do naloxone access laws increase outpatient naloxone prescriptions? Evidence from Medicaid. Drug Alcohol Depend. 2018 Sep 1;190:37-41.
Texting Bans and Motor Vehicle Crashes Texting bans were associated with a 7% reduction in crash-related hospitalizations among all age groups. Pooled cross-sectional time series data, a difference-in-difference framework, and a count data model Ferdinand AO, Menachemi N, Blackburn JL, Sen B, Nelson L, Morrisey M. The impact of texting bans on motor vehicle crash-related hospitalizations. Am J Public Health. 2015 May;105(5):859-65.
Survival Gains from Revising State Laws Requiring Written Opt-in Consent for HIV Testing Potential survival gains of increased testing are substantial, suggesting that state laws requiring opt-in HIV testing should be revised. Model-driven projection of survival based on consent method April MD, Chiosi JJ, Paltiel AD, Sax PE, Walensky RP. Projected survival gains from revising state laws requiring written opt-in consent for HIV testing. J Gen Intern Med. 2011 Jun;26(6):661-7.
HIV Testing Regulations in Opioid Treatment Programs Opioid treatment programs in states whose laws do not require pretest counseling and that use opt-out consent were more likely to provide HIV testing and to test higher percentages of clients. Random-effects logit and interval regression analyses D’Aunno T, Pollack HA, Jiang L, Metsch LR, Friedmann PD. HIV testing in the nation’s opioid treatment programs, 2005-2011: the role of state regulations. Health Serv Res. 2014 Feb;49(1):230-48
Written Informed-Consent Statutes and HIV Testing Those living in a state with a requirement for written informed consent were significantly more likely to report a recent HIV test if they self-reported having an HIV risk factor compared to those who did not report such risk factors. Regression analysis Ehrenkranz PD, Pagán JA, Begier EM, Linas BP, Madison K, Armstrong K. Written informed-consent statutes and HIV testing. Am J Prev Med. 2009 Jul;37(1):57-63.
State Mandated Benefit Laws State laws had a significant impact on only the likelihood of outpatient mastectomy, which was reduced by five percentage points. Difference-in-difference model Bian J, Lipscomb J, Mello MM. Spillover effects of state mandated benefit laws: the case of outpatient breast cancer surgery. Inquiry. 2009-2010 Winter;46(4):433-47.
Medical Cannabis Legalization and Prevalence of Mental Illness Medical cannabis laws are likely related to state mental health, and a higher prevalence of cannabis use partially explains this relationship. Covariate-adjusted meta-regression Dutra LM, Parish WJ, Gourdet CK, Wylie SA, Wiley JL. Medical cannabis legalization and state-level prevalence of serious mental illness in the National Survey on Drug Use and Health (NSDUH) 2008-2015. Int Rev Psychiatry. 2018 Jun;30(3):203-215.
Immunization Mandates and Vaccination Coverage State policies that refer to Advisory Committee on Immunization Practices recommendations were associated with 3.5% and 2.8% increases in MMR and DTaP vaccination rates. Retrospective, longitudinal analysis Shaw J, Mader EM, Bennett BE, Vernyi-Kellogg OK, Yang YT, Morley CP. Immunization Mandates, Vaccination Coverage, and Exemption Rates in the United States. Open Forum Infect Dis. 2018 Jun 2;5(6):ofy130.
State Legal Restrictions and Prescription-Opioid Use among Disabled Adults No significant associations between opioid outcomes and specific types of laws or the number of types enacted. Logistic regression models Meara E, Horwitz JR, Powell W, McClelland L, Zhou W, O’Malley AJ, Morden NE. State Legal Restrictions and Prescription-Opioid Use among Disabled Adults. N Engl J Med. 2016 Jul 7;375(1):44-53.
Effects of State-Level Earned Income Tax Credit Laws on Birth Outcomes Across all subgroups, any level of state EITC is associated with better birth outcomes with the largest effects seen among states with more generous EITCs. Quasi-experimental multistate and multiyear difference-in-differences Komro KA, Markowitz S, Livingston MD, Wagenaar AC. Effects of State-Level Earned Income Tax Credit Laws on Birth Outcomes by Race and Ethnicity. Health Equity. 2019 Mar 12;3(1):61-67
Ignition Interlock Laws: Effects on Fatal Motor Vehicle Crashes State laws requiring interlocks for all drunk driving offenders were associated with a 7% decrease in the rate of BAC >0.08 fatal crashes. Multilevel modeling McGinty EE, Tung G, Shulman-Laniel J, Hardy R, Rutkow L, Frattaroli S, Vernick JS. Ignition Interlock Laws: Effects on Fatal Motor Vehicle Crashes, 1982-2013. Am J Prev Med. 2017 Apr;52(4):417-423.
State Laws and Influenza Vaccination of Hospital Personnel Facility-level mandates were estimated to increase mean influenza vaccination coverage among all healthcare personnel. Hierarchical linear modeling Lindley MC, Mu Y, Hoss A, Pepin D, Kalayil EJ, van Santen KL, Edwards JR, Pollock DA. Association of State Laws with Influenza Vaccination of Hospital Personnel. Am J Prev Med. 2019 Jun;56(6):e177-e183.
Minimum Wage Increases and Infant Mortality and Birth Weight Across all models, a dollar increase in the minimum wage above the federal level was associated with a 1% to 2% decrease in low-birth-weight births and a 4% decrease in post neonatal mortality. Quasi-experimental difference-in-difference models Komro KA, Livingston MD, Markowitz S, Wagenaar AC. The Effect of an Increased Minimum Wage on Infant Mortality and Birth Weight. Am J Public Health. 2016 Aug;106(8):1514-6.
Opioid-overdose Laws and Overdose Mortality States with naloxone access laws or Good Samaritan laws had a lower incidence of opioid-overdose mortality. Difference-in-differences and mixed-effects negative binomial regression models McClellan C, Lambdin BH, Ali MM, Mutter R, Davis CS, Wheeler E, Pemberton M, Kral AH. Opioid-overdose laws association with opioid use and overdose mortality. Addict Behav. 2018 Nov;86:90-95.

FAQs

How long can our application be?

  • CDC will review 19 pages of any application package received. This applies to applicants that are applying to one or both components of the NOFO. If an applicant is applying for both components, one application should be submitted with two separate narratives, workplans, and budgets.

What attachments are allowed or disallowed?

  • On page 53 of 58 in the full NOFO announcement, a review of required documents required for an application can be found. These additional uploads do not count towards the number of pages you may submit (19).
  • If any additional attachments are included (i.e., supporting evidence of prior experience), CDC program staff will determine which attachments are included for objective review.
  • Please ensure all attachments are clearly labeled when uploaded to grants.gov.

The NOFO states to upload “evidence” but it is not listed under “optional attachments” on page 53. What do we do? (

  • On pages 22-23 of 58 in the full NOFO announcement it states, “applicants must upload their organization capacity and prior experience (which will serve as evidence) to carry out the strategies and activities of the NOFO.”  Please upload this evidence as an attachment. Please ensure all attachments are clearly labeled when uploaded to grants.gov.

If our organization is applying to a component, can we be listed as a possibly sub recipient/write a letter of support for another organization applying to the same component(s).

  • Yes. NOTE: A recipient cannot be a recipient/awardee and a sub-recipient on the same NOFO. However, they can write a letter of support.

Are we allowed to apply our Negotiated Indirect Cost Agreement Rate?

  • There is nothing in the NOFO stating you cannot apply your current Indirect Cost Rate agreement.

Does my organization have to create and/or submit a new logic model with our application?

  • No, your organization should use the logic model in the NOFO (Pages 5-6) to develop a work plan. A sample work plan template is provided (Pages 24-25). All activities in the work plan should be aligned with the strategies and outcomes in the NOFO’s logic model. Applicants will be evaluated based on how consistently their approach aligns with the NOFO’s logic model (Pages 40-44).

How many CVs need to be included in the application, and are alternatives (e.g., a biographical sketch) acceptable?

  • The number of CVs will vary based on the number of key staff involved in carrying out the NOFO’s activities if funded. Applicants will be evaluated based on their organizational capacity, including staffing (Pages 40-44). The NOFO explicitly states (Pages 22-24) that CVs/resumes should be included in the organization’s application package. If an organization submits a CV/resume alternative (e.g., a biographical sketch), those documents will not be evaluated.

Should potential partner organizations be treated as sub-awardees?

  • Suppose your organization plans to leverage sub-awardees to carry out the work of the NOFO or fill a gap in organizational capacity. In that case, the applicant should treat potential partner organizations as sub-awardees and provide the required elements, which includes a detailed itemized budget for each sub-award.

If my organization applies for both components, how do we submit a budget?

  • Applicants will use section B of the 42A form to identify the funding amounts being applied for, and each component should be reflected in separate columns. The last column should reflect the total amount requested. If your organization is applying to one component, the total requested should be $750,000, and if your organization is applying to both components, the total requested should be $1.5 million.

Can the NOFO be submitted in a smaller font?

  • All NOFO text should be single-spaced, 12-point font, with one-inch margins and page numbers.

Can references and other documents be uploaded separately from the main application? 

  • Yes, references, CVs, organizational charts, letters of support, evidence of organizational capacity, etc., can be uploaded as separate files. These individual files do not count toward the 19-page application limit. Please clearly label each file and document, so it is explicitly clear what the file includes.
Contact Information

Michael D. Williams, MPH
Lead, Policy as a Public Health Intervention
Public Health Analyst
xkk3@cdc.gov

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