Section 1. Overview of Developing and Improving Community Services

Learn how to develop and improve public services in your community.

 

It all started on the day that two of the emergency room doctors at St. Mary’s Community Hospital happened to have coffee together as their shifts overlapped. Dr. Kowalski, who was just coming off duty, was tired. “I must have seen 45 kids today,” he told his colleague, Dr. Liu. “I know what you mean,” she answered. “I’ve been seeing an enormous number of children, too, and often for routine medical issues. Doesn’t anyone take their kids to a pediatrician any more?”

As the conversation continued, the two decided to check on the numbers, and to confer with area pediatricians about their caseloads. It turned out that far too many parents – particularly the uninsured and those on Medicaid – used the emergency room as the primary care physician for their children. This was bad for the hospital, since it meant that the emergency room staff was overworked. It was bad for other ER patients, since they often had to wait long periods in pain for treatment. And it was bad for the children, who weren’t being treated by doctors who specialized in child development, and who could spot problems that a non-pediatric physician might miss.

A core group of pediatricians and ER doctors contacted agencies that worked with children or health – Head Start, SPCC, the St. Mary’s Youth Development Corps, the St. Mary’s branch of the Public Health Service, and others – to discuss possible solutions to the problem. Ultimately, out of their discussions grew the St. Mary’s Child and Parent Health Clinic, staffed by pediatricians and family practitioners, which provided free or affordable health care to families with children. The establishment of this clinic is an example of the development of a community service that improved life for a significant number of people.

This chapter is about ways to develop and improve public services in your community. That can mean anything from getting a streetlight bulb replaced to starting a community-wide initiative that involves several new programs. Either might be effective in solving a problem and improving the quality of life in a neighborhood. An improvement in services in a community may or may not be an intervention in itself, but it may be an important part of the foundation for community change.

Developing and improving services also lays groundwork that can lead to larger changes down the road, and make other interventions easier. In some sections of this chapter, that groundwork appears as working relationships with other organizations and different parts of the community. In others, it takes the form of actual interventions in core areas that are basic to individuals’ and communities’ well-being.

This opening section discusses what we mean by improving services, and some ways in which an organization can use its community setting to address that improvement. It provides a context for the more specific information in the rest of this chapter and in others to come.

What do we mean by developing and improving community services?

In a healthy community, people have access to the services they need in order to live decent lives. There are really three kinds of public services in most communities, although there may be quite a bit of overlap among them. Let’s call them A-level, B-level, and C-level.

• A-level are the services that most people see as essential to community life, that make it possible for a community to exist as such – fire, police, schools, public works, local government. The existence of these services can be taken for granted. They are considered necessary to the well-being of any community.
• B-level are services that exist to prevent problems and to maintain the quality of life in a community. They usually address issues which, if left unattended, may lead to problems or deficiencies in the future, such as health, adult literacy, employment training, housing, and the development of youth. They also often include such quality-of-life services as recreation programs and support for the arts.  These services may vary from one community to another. A community coalition in a South Carolina industrial town, for instance, found that the most important issue there was water pollution. For that coalition, B-level services included instituting limits on pollution, cleaning up local water sources, and monitoring to make sure that the community’s drinking water was safe.
• C-level services specifically exist to solve current problems and correct deficiencies. They are often short-term, narrowly focused, and may treat the symptoms of community problems – food for the hungry or shelters for the homeless, for instance – but may or may not get at the underlying causes of those symptoms – poverty, a shortage of affordable housing, lack of mental health services, and the disconnectedness of people in modern society.

While A-level services are automatically funded in some amount in the budget of virtually every community, no matter how large or small, B- and C-level services, though they may be equally important, seldom are. Therefore, we will primarily focus on services that would be considered B-level and C-level, although sometimes A-level services need to be improved as well to meet the needs of the target population and of the community as a whole.

A community with excellent preventive (i.e., B-level) services may need far fewer corrective or emergency (C-level) services, so part of improving services should involve establishing, maintaining, and expanding B-level services until they are obtainable by all who need them. Equally important, however, is making sure that people don’t starve or freeze to death – or get shot – while working to gain basic skills or job competencies. Corrective and emergency services also have to be available when needed.

Corrective and preventive services are sometimes combined. The best homeless shelters, for instance, provide, either through collaboration or through their own resources, adult basic education, job training, parenting classes, budgeting instruction, and other supports to help residents gain the skills and strategies to keep them independent and housed when they leave the shelter.

All too often, however, these exemplary programs are only able to serve small numbers of people at a time. If there are several hundred homeless people in a community, working with ten of them will only address the homeless problem for those ten. Improving services in that community may mean extending the shelter program to a much larger portion of the homeless population.

In this context, developing and improving community services may mean establishing services where they didn't exist before; making existing services more effective; making existing services more widely available; improving access to effective services; and/or coordinating services so that all the providers in a community are working together, rather than at cross purposes. Each of these comes with its own priorities and its own set of issues.

Establishing services that didn’t exist before

The emphasis in this case has to be on planning and finding resources.

If you’re starting from scratch, you should:

• Put together an organization or work with an existing organization or coalition, each of which brings its own challenges
• Do a careful community assessment to understand exactly what services need to be delivered
• Plan out your initiative or intervention – involving the target population and other segments of the community – so that you’ll actually be making the services accessible and providing them to the right people in the best way possible
• Find the money and the people to make all this possible

There are a number of roles you might have in this situation. One would be as a leader or member of a coalition, initiative, or other group working to obtain a new service for the community. Another might be as the director or a staff member of an existing organization that wants to expand to provide this needed service, in addition to what it does already. Or you might be the director or a staff member of a new organization founded to provide the service in question. Obviously, depending upon your role, what you actually have to do can range from participating in planning meetings to taking responsibility for all or most of the process.

Making existing services more effective

Here, the needed services exist, but are inadequate, because they don’t do what the target population needs. Improving services in this circumstance is very different from starting a new service, not least because of the amount of resistance you might meet.

Change is always difficult, and many staff people who are actually delivering services won’t recognize the need for it. The community, or some elements of the community –perhaps even those who stand to benefit from improving the service – may not see the need, or have reasons for opposing change. Planning for change needs to involve the people who’ll have to make it work, and will probably take more time than you anticipate. It will also take some time to determine whether the changes you’ve made have, in fact, made the service better (i.e. to evaluate your work), and to make adjustments.

Making existing services more widely available

In this circumstance, service is inadequate because the volume of services isn’t great enough to serve the people who should benefit from them. Trying to increase the amount of service available may be largely a matter of finding funding, or it may depend on finding and training more volunteers, or even on finding a different way to offer services.

For example, a Boston English as a Second or Other Language (ESOL) program aimed at Cantonese speakers had a three-year waiting list.  In order to try to reach some of those waiting for classes, the program distributed instructional videotapes, and enlisted enrolled learners and graduates as tutors.  The system didn’t take the place of the classes, but it did give those on the waiting list an opportunity to get started, and helped the student tutors practice their own newly-learned skills.  Waiting list learners who participated in the program entered classes eventually as intermediates, rather than as beginners, and the tutors earned new respect in the community.  Out of frustration, the program was able to create a positive situation for everyone.

Increasing access to services

This could refer to making services physically and otherwise accessible to disabled participants (ramps, accessible bathrooms, TTY phones for the hearing impaired, etc.), but it could also involve accessibility of other kinds. Transportation may be a major issue for participants. The location of services may exclude a group that doesn’t feel comfortable or safe in that area or neighborhood. The times when services are available may create difficulties for a large number of people. All of these may be factors in trying to increase access.

Coordinating services

Another facet of improving services is trying to make the whole service system as seamless as possible. That means that even if there are many different organizations providing a variety of services to a number of different target populations, they should be coordinated enough that a participant in one program who needs other services will get them quickly and appropriately. It also means that organizations are aware of what others are doing, and that they work together as much as possible to assure a range of services for everyone who needs them.

All four of these ways of improving services also involve advocacy, public education, and reaching out to the community.  It is important that the community at large – not to mention legislators, local officials, and other policy makers – understand the need for services, the benefits they confer on the community as a whole, and the fact that those using the services are their neighbors (or, potentially, themselves).  Community support translates into funding, volunteers, and a voice in local policy-making for both service providers and the target population.

Who should be involved in developing and improving community services?

Improving services, as is obvious from the above, isn’t just a job for a single person, or even a single organization. It works best when the largest number of individuals and groups possible is involved.

The target population

Involving those who stand to benefit most directly from services makes sense in a number of ways.

• It helps to assure, through first-hand information, that the services provided meet the needs of those for whom they are intended
• It gives members of the target population a voice in deciding what’s appropriate for them, and establishes them as part of a policy-making team
• It can cement the support of the target population by giving them a sense of ownership of the services in question
• It provides communication channels to those who need to know about services and their availability
• It can ease the impact of cultural differences, and give service providers an entry to the target community

Other agencies, community-based organizations, and grass roots groups

Working with other service providers and organizations can significantly improve services.

• It allows for the coordination and articulation of community services into a coherent whole
• It makes it possible for a number of organizations to focus on one issue from different angles, and thus to approach it more effectively
• It enables you to form cooperative relationships, coalitions, collaborations, and partnerships with other organizations
• It facilitates the sharing of information and resources

Local and state officials

Involving local elected and appointed officials, state legislators, and state agency staff in improving services in your community can have far-reaching consequences.

• It gives you the opportunity to educate officials about your community’s issues
• State legislators and other officials may be able to help you get funding, or to increase funding for your issue across the board
• Helping you improve services gives them partial ownership, thereby ensuring their political support for those services in the future
• It can put legislators and others in your debt by giving them opportunities for positive public relations, or – as in the case of police, for instance – by making their jobs easier

The business community

Employers are often well aware of at least some of the needs in the community, because those needs show up in their workforce. They can be creative planners and effective advocates for services.

• Their standing in the community can help to provide community support for services
• Improving conditions for individuals and groups in the community also improves conditions for business, since it provides a better and more skilled workforce, more taxpayers, more potential customers, and a better environment in which to do business
• They can often be effective fundraisers, and have access to other resources – in-kind donations, volunteers, space – as well

The community at large

Reaching out to the community as a whole for help in planning and improving services can be important for a number of reasons.

• It can provide a broader range of ideas and information
• It may help in understanding community history, which may, in turn, have an effect on how services can be successfully structured and delivered
• It can generate community support for services
• It may generate resources – money, volunteers, etc.
• It can increase understanding among community members about what is needed to create a healthy community in which to live and work

When should you seek to develop and improve community services?

Trying to improve services should be an ongoing effort in any community, and a strategic plan will do much to tell you when to act. There are, however, times when it’s either particularly urgent or particularly favorable to try to make positive changes.

• At the start of a wide-ranging, long-term community initiative. Building the improvement of services into the plan for your initiative will both make sure that services are attended to, and improve the chances of the initiative’s success.

An initiative to end homelessness, for instance, might include, in addition to short-term solutions such as increased outreach and more shelter beds, either new programs or increased capacity for existing programs offering employment training, basic skills, physical and mental health services, substance use treatment, and life skills (budgeting, parenting, etc.).  It might also include the development of affordable housing, as well as programs and education aimed specifically at homeless youth.

• When a need makes itself clear. When it’s obvious that services in a particular area are inadequate, or when a new problem suddenly becomes apparent – a large increase in HIV infection rates, for instance – it’s often possible to garner community support for change and improvement.
• When what you’ve been doing isn’t working. If it’s clear that current services aren’t having the desired effect, it’s time to take action to improve them.
• When the community asks for a service. A community planning group – a coalition, a community council, the Chamber of Commerce – may identify a need and ask that the need be met, or a concerned public may create a groundswell for particular services.
• When funding becomes available for something that’s been needed for a long time. The winds of political change and the attention of the media sometimes “uncover” issues that have been problems for years. When that happens, funding often becomes available, and it makes sense to take advantage of it to improve services for those issues in your community.

In 1984, the publication of Jonathan Kozol’s book, Illiterate America, made headlines of a fact that educators and others had been aware of for decades: that there was a large population of Americans who couldn’t read or write well enough to function fully in a complex, late-20th century society.  Suddenly, it seemed that every major publication and every government agency had discovered illiteracy as an issue, and a long-neglected issue had its moment in the spotlight.  Studies were undertaken, funding was increased, and many communities finally had the means to create or improve their education services for adults.

Options for developing and improving community services

The options outlined in the rest of this chapter cover both some general guidelines for improving services, and some ways to address the improvement of specific core services in your community. We’ll briefly describe each of them here, and discuss how you might apply them in your community.

Developing and implementing programs to help people set and attain personal goals

These programs may range from employment training to substance use treatment (including smoking cessation), from wellness (exercise and weight targets) to parenting to overall life change. Whatever their particular focus, their aim is to enhance individual lives and, by so doing, to enhance as well the overall quality of life in the community.

Just as there is a broad spectrum of programs of this type, the possibilities for the shape of such programs are broad as well. Some really require professional intervention (most substance use treatment); others may be implemented through mutual support (many wellness and some parenting programs), volunteer assistance (helping elders stay in their own homes), and/or media campaigns. What kinds of programs you might develop depends upon the needs and nature of your community.

Promoting coordination, cooperative agreements, and collaborative agreements among agencies

It is almost universally true that services will be better in a community where agencies and organizations are in close contact, and, at the very least, coordinate their services. In cases where a program or intervention requires multiple services, or where a program participant is working with more than one organization, it’s absolutely necessary that organizations and agencies communicate and work together with the same plan toward the same goals.

A community coalition may help to encourage relationships and mutual arrangements among agencies, as may regular meetings, a central health and human service coordinator, or funders’ requirements for collaboration. Whether the original cooperative impulse is initiated by you, by the agencies, or by external necessities (such as a funder’s specifications), nurturing and maintaining it is a key to improving community services.

In a rural county in western Massachusetts, a group of more than 20 health, education, and human service agencies came together, as required by the funder, to apply for a grant to serve young children and their families.  When the grant was awarded, many agencies that had barely known of one another’s existence started working together.  As time went on, they found that there was a great deal of common ground in areas other than those covered by the grant.  A number of cooperative and collaborative agreements resulted from their association, many of them unrelated to serving the families the grant covered.  The quality of service, particularly in family health, in the area was vastly improved as a result of the relationships developed.

Developing multisector collaborations

Just as the relationships and agreements among agencies improve services, so do relationships and agreements among entire sectors of the community. Even though the services in question may be provided by particular agencies, community support will help publicize them and attract participants, and make funding easier. The cooperation of the business community, for example, might result in on-site services in workplaces (wellness, adult basic education, employment training), release time for employees to take advantage of services, or the provision of space or funding. Youth-oriented services can benefit greatly from coordination and collaboration among youth development agencies, the police, recreation organizations, the schools, and local businesses.

Developing employment programs

One of the building blocks of a stable community is the availability of decent work that pays enough to support a family. Employment programs can involve a number of different approaches:

• Employment readiness. Resume writing, getting along with co-workers and supervisors, getting to work on time every day, etc. This may also involve interagency or multisector coordination to help participants gain other, more general skills and credentials necessary for employment (reading and math, money management, a driver’s license, etc.)
• Employment training. Training potential employees for jobs, sometimes in specific industries or businesses (e.g., working in the local auto factory), sometimes in more general ways (secretarial skills, sheet metal work, computer skills, etc.)
• Employment matching. Finding specific jobs for specific people.
• Employment development. Working with employers to create jobs for, or to hire certain groups of people (recent welfare recipients, for instance, or employment training graduates).

Developing programs for physical activity and recreation

Physical activity – sports, walking, bike-riding, swimming, etc. – is important for people’s well-being, but recreation of various kinds is also an integral part of a decent life. It relieves tension, affords opportunities for families to play together and bond, fosters relationships among people from diverse backgrounds, and provides the fun and relaxation everyone needs to live a balanced life.

Community recreation can encompass much more than sports or the places to engage in them. Some other possibilities include free or inexpensive public performances of theater, music, and dance; after-school and summer supervised programs for children and youth; community theater, bands, and choirs where community members receive instruction and the opportunity to perform; and preservation of green space and the natural environment for all to enjoy.

Recreation is often a hard sell in communities that struggle with a host of problems. It may be seen as a frill, but, like other basic services, it’s important in enhancing the quality of community life.

Developing and increasing access to health and community services

The best services in the world are useless if no one takes advantage of them. Lack of access can be at least partially a matter of funding, i.e. having the money to start or expand programs to respond to a community need. In addition, however, access is also lacking if the service is ineffective, if – justifiably or not – it has a bad reputation in the community; if outreach is inadequate or badly implemented; if service is delivered at a hard-to-reach or intimidating location; if potential and actual participants are treated with disrespect; or if the service is not accessible to specific groups – disabled individuals, those who don’t speak English, etc.

Regardless of the services offered, access is an important issue, and increasing access to them is a cornerstone of improving community services.

Establishing peer education programs

Sometimes the best way to inform particular groups – youth, for instance, or a cultural or linguistic group – is through the use of community members from that same group. Training teens to educate other teens about safe sex or substance use, for instance, or teaching Hispanic women to help their peers learn about breast self-examination and mammograms are two of many ways to develop a peer education program.

By reaching people in their own neighborhoods, with community educators who are familiar to them, you can often increase both participation and the likelihood that a service will accomplish its purpose.

Enhancing supervised alternative activities for youth

In many communities – particularly in rural areas or in low-income inner-city neighborhoods – there is little for pre-teens and teens to do. Kids of that age gravitate to one another, and without supervision may display poor judgment, and engage in dangerous or illegal behavior. Especially in urban areas, they are at risk of falling prey to substance use, gang enticements, and the lure of the streets.

Supervised activity – activity that’s actually fun and/or compelling, and seen by the youth as better than the alternatives the street has to offer – can do a great deal to change the dynamic of the relationship between kids and the community. It can provide teens with caring adults, who also act as role models, and help the community see its youth as a resource, rather than as a nuisance or a danger.

Many such programs teach self-reliance and problem-solving, civic engagement, or interpersonal skills (conflict resolution and peer mediation). They may involve youth in the arts, in sports, or in work internships and employment. Whatever their shape, enhanced services for youth benefit the community, and contribute to a climate conducive to improving services across the board.

Planning youth programs should be approached with the full participation of the young people you’re aiming at.  All too often, adults create programs that are the products of minds that have seemingly never been adolescent.  Kids avoid these programs in droves, because they don’t speak to the realities of their lives, and try to pour them into adult molds that are simply the wrong shape.  With a participatory planning process, you can avoid this problem, and develop activities that teens will want to take part in.

Establishing school-linked health programs

Middle- and high-school age youth, including dropouts, often slip through the cracks of the health care system. Unless their parents are oriented toward regular medical checkups and wellness, they may visit health professionals only sporadically, if at all. At the same time, these youth are often at risk for sexually transmitted diseases (STD’s), pregnancy, substance use, violence, and poor nutrition.

School-linked health programs reach out to this population by establishing relationships with the schools, and addressing the teens’ needs. These centers avoid school committee and state regulation (which often restrict access to contraceptives, mental health and drug treatment, and other necessities of adolescent health care) by operating off school grounds. They and the schools act as referral agents for one another, but may be connected only informally. School-linked health services are generally cost-effective (one clinic usually serves students from several schools, as well as dropouts and homeless teens), and reach a difficult population to reduce teen pregnancy, the incidence of STD’s, and other serious adolescent health problems.

School-linked health services don’t all come out of one mold: each is designed specifically for its community. A school-linked health center can be an important part of improving health services in your community, if adolescent health is a concern.

Implementing home visitor programs

One way of improving services is by bringing them directly to those who need them. Home visitor programs – for newborns and their parents, for the elderly, for those with disabilities, for children with special needs – provide services in people’s homes, without the attendant problems of transportation, child care, and time away from home. In addition, they give the visitor an opportunity to see how a mother interacts with her child, or how well a senior or person with a disability can get around his house and take care of himself. The visitor can then intervene immediately with a suggestion, with equipment, with a demonstration, etc. to improve the situation on the spot.

Home visitor programs – especially those that act to enhance parenting skills and keep seniors and people with disabilities independent – can have a profound effect on community life by preventing potential problems, saving public and private money, and enriching social life helping people stay in the community who might otherwise be institutionalized.

Planning and establishing an adult literacy program

Adult literacy can be not only an educational, but a social and economic concern for communities. Literacy is actually a requirement for job training, parenting and health education, and other services. By offering an adult literacy program, a community can greatly increase the chances that people with reading, writing, or math problems will be able to take advantage of these services, helping them to gain and keep jobs that will support them and their families, enhance their roles as parents and family members, and encourage their participation as citizens.

Something to think about as you plan a program in your own community is what kinds of educational needs are most important, and what kinds of programs will best serve learners. Some communities with significant numbers of immigrants might have more need for an ESOL (English as a Second or Other Language) program than for one that teaches reading, writing, and math for native English speakers, for instance. Programs that give learners control over their own learning are very different in form and content, not to mention philosophy, from those that use a school-like format, where the teacher is firmly in charge. Assess the real needs of your community to see what kind of program might work best.

Enhancing developmental assets for children

The work of the Search Institute and others has shown that there are a number of community, family, and personal factors that help children toward healthy development and a successful adulthood. By assessing itself, a community can find out which of these developmental assets it is already providing or supporting adequately, and which need to be improved upon. In some cases, improvement may involve instituting or expanding services. In others, it may mean encouraging public support or disapproval for particular modes of behavior, changing policies or laws, or changing the environment to make it safer or healthier for children. Whatever the situation, the concept of developmental assets is based on the assumption that, as in the African proverb quoted by former First Lady Hillary Rodham Clinton, it takes a village to raise a child.

Enhancing resources for youth development

This is similar to, but not the same as, encouraging the improvement of developmental assets. It could entail providing resources for that activity – funding, volunteers, ideas, curricula, jobs, etc. It could also include the activities of such organizations as America’s Promise, a youth service organization founded by Colin Powell that promises five things to America’s youth: caring adults; safe places to live, learn, work, and play; a healthy start in life; marketable skills to enable them to support themselves; and opportunities to serve. Various affiliated funders and communities provide resources for programs and initiatives aimed at one or more of these five promises.

With or without a program like America’s Promise, a community can make a commitment to providing resources for services aimed at the development of youth. Such services might include after-school programs, paid community-service internships, midnight basketball, school-to-work efforts, etc. As mentioned above, resources need not be financial: community members volunteering to mentor at-risk youth, for instance, might constitute a valuable tool for improving services in this area.

Enhancing child care programs

Safe, reliable, and loving child care is a basic need for families seeking to use community services or to work. For those on welfare, who are required to work or volunteer, it is often the biggest stumbling block to fulfilling their obligations and to gaining independence. For working parents, particularly single parents, it can represent real financial hardship, and even threaten their ability to continue working. Making safe, competent, and affordable child care readily available to all who need it is one of the most important things a community can do to reduce stress and improve its citizens’ quality of life.

Enhancing child care programs may require funding for more slots and the hiring of trained workers, training of new workers or providers, furnishing space, or convincing – or subsidizing – employers to sponsor on-site programs, among other possibilities. As we’ve emphasized repeatedly here and elsewhere in the Community Tool Box, the best services are useless if people can’t take advantage of them. Acceptable child care is absolutely basic to improving services for the community as a whole.

Each of the remaining sections in this chapter discusses one of these options more fully. The last point to be made here is that made at the end of nearly every section of the Tool Box: you have to keep at whatever you do for the long term. While these options will improve services, that improvement won’t sustain itself. These are not short-term or one-time undertakings: each is meant to be carried out indefinitely once it reaches the level the community needs.

Think of it as literally building a community. Once each building in a community is completed, it needs maintenance and upkeep to remain standing. Leaks have to be fixed, roofs and sills replaced from time to time, broken windows mended, the walls repainted. Without this care, the building will weaken and collapse. Without the maintenance they need, community programs and initiatives will do the same. Developing and improving services and keeping them improving take work…for as long as those services are needed.

In Summary

Every community provides, or has the potential for providing, three kinds of public services: essential services, such as water, fire, police, and schools, that can easily be taken for granted; preventive services, such as health, employment training, housing, and adult literacy, that address needs that could lead to serious problems in the future; and corrective and emergency services, such as food banks, homeless shelters, and needle exchanges, that exist to correct specific community problems or address emergencies. Developing and improving public services involves dealing with all three types (although with more emphasis on the second and third, which are less likely to be fully funded or supported than the first), and choosing options for doing so that have the most effect on the long term quality of life in the community.

Everyone – the target population; health, human service, and community organizations and groups; activists; local officials; the business community; and citizens at large – should be involved in planning and implementing options. Developing and improving services ought to be part of a community’s long-range plan, but is especially important when needs arise. The start of a new initiative, the discovery of a need, the realization that previous efforts haven’t worked, a public outcry, or the availability of funding to fill a gap – any or all of these might be good reasons to embark on improving services.

Some of the most common and effective options for developing and improving services are discussed in the rest of the sections in this chapter. They focus on different areas, but they all have one thing in common: they require sustained effort over the long term if they are to have any real effect.