putting the community back in community health assessment
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This article was downloaded by: [Washington University in St Louis]On: 07 October 2014, At: 01:07Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK
Journal of Health & SocialPolicyPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wzhs20
Putting the Community Back inCommunity Health AssessmentRavi K. Sharma PhD aa Department of Behavioral and CommunityHealth Sciences, Graduate School of PublicHealth , University of Pittsburgh , 228 Parran Hall,Pittsburgh, PA, 15261, USAPublished online: 21 Oct 2008.
To cite this article: Ravi K. Sharma PhD (2003) Putting the Community Back inCommunity Health Assessment, Journal of Health & Social Policy, 16:3, 19-33, DOI:10.1300/J045v16n03_03
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Putting the Community Backin Community Health Assessment:A Process and Outcome Approach
with a Review of Some Major Issuesfor Public Health Professionals
Ravi K. Sharma, PhD
ABSTRACT. Community health assessment is a tool for allocating re-sources in a manner responsive to the community needs and conduciveto maximizing community input in decision-making. A process-focused,team approach that draws upon social and behavioral sciences, as well aspublic health and medical disciplines, is presented–in the context of defi-nitions of community and health and models of community health deter-minants–as a means of maximizing community involvement in localhealth issues. Such an approach requires that professionals function lessas “experts” than as resources to community members, who are engagedin every step of the process. [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com> © 2003by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Community assessment, health, policy, planning
Ravi K. Sharma is Assistant Professor, Department of Behavioral and CommunityHealth Sciences, Graduate School of Public Health, University of Pittsburgh, 228Parran Hall, Pittsburgh, PA 15261.
An earlier version of this paper was presented at the National Center for Health Sta-tistics, joint meetings of the Public Health Conference on Records and Statistics andthe Data Users Conference, July 28-31, 1997.
Journal of Health & Social Policy, Vol. 16(3) 2003http://www.haworthpress.com/store/product.asp?sku=J045 2003 by The Haworth Press, Inc. All rights reserved.
10.1300/J045v16n03_03 19
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INTRODUCTION
The health promotion and disease prevention goals enshrined inHealthy People 2000 and the subsequent formulation of communityhealth indicators for states have provided impetus to community healthassessment (CHA) at the local level (U.S. Department of Health andHuman Services, 1990; Centers for Disease Control and Prevention,1991). Further encouragement for these activities has been provided bythe APEX (National Association of County Health Officials, 1991) andPATCH (Centers for Disease Control and Prevention, 1992) initiatives.Community health assessment, unfortunately, is typically regarded as atop-down planning approach and as a technical exercise. It should, in-stead, be viewed within the broader framework of community healthdevelopment. Public health research has continued to identify the roleof communities and their members as central to improving health. To besuccessful, CHA must be viewed both as a process of getting communi-ties interested in assessing their own health–building upon and addingto the current body of theoretical and empirical evidence on the deter-minants of community health–and as a statistical process of assemblingand analyzing data. The most important aspect of CHA is that it is a pro-cess and not simply a technical-rational system of collecting and ana-lyzing statistical data. The latter, by itself, is of limited value.
The basic thesis of this paper is that CHA is a process of understand-ing the communities’ perception of priority health issues in conjunctionwith the objective collection and analysis of health status data. It is fur-ther proposed that the term “community health assessment” be limitedto those endeavors in which the community is an active agent in the con-duct of assessment. The process-focused approach to CHA has implica-tions for three specific elements in a CHA study:
Definition of a community;Definitions of health; andDevelopment of a model of community health determinants.
After an initial presentation of the various definitions of CHA, each ofthese elements is discussed, followed by a presentation of a conceptualmodel of a process-focused approach to community health assessment.
DEFINITIONS AND DIMENSIONSOF COMMUNITY HEALTH ASSESSMENT
Community health assessment has been defined in a variety of ways.The Institute of Medicine report (Institute of Medicine, 1988) describes
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assessment as “. . . all activities involved in the concept of communitydiagnosis, such as surveillance, identifying needs, analyzing the causesof problems, collecting and interpreting data, case-finding, monitoringand forecasting trends, research, and evaluating outcomes.” Need as-sessment has also been defined as “. . . the process of exploring the rela-tionship between health problems in a community and the resourcesavailable to address these health problems in order to achieve a desiredoutcome” (Pickin & St Leger, 1994). Another approach to assessment isfrom the perspective of community development, which is regarded as aprocess that promotes and utilizes human resources, leading to empow-erment of individuals and communities so that they can understand andsolve their problems (Martí-Costa & Serrano-García, 1983). In this pro-cess, assessment becomes an essential method for the social system sothat it is more responsive to community needs.
Community health assessment can be defined in terms of a series ofdimensions, adapted from Sadan and Churchman (1997), each repre-sented by a continuum that ranges from the autocratic (product-ori-ented) to the democratic (process-oriented) approach. Table 1 displaysthe seven dimensions and the end-points of the continuum for each.
The two ends of the continuum represent an ideal typical construct,which are constructed by emphasizing certain traits of a given socialitem. They illustrate two profiles of the practitioner, one whose orienta-tion is to product and the other whose orientation is to process. Howprofessionals view their roles in terms of these dimensions will deter-mine their approach to assessment. A product orientation results in anassessment that tends to be directive, objective, and expert-centered,whereas a process-focused assessment will lean toward the other end ofthe continuum. In theory, a process orientation clearly has the potentialfor involving community actively in the design and execution of a project,although there is no assurance that this will happen. On the other hand,product-oriented assessment, potentially more directive and expert-cen-tered, may nevertheless, in practice, offer opportunities to involve thecommunity in the CHA process. The purpose of this paper is to present amodel for introducing a process orientation into a CHA project.
DEFINING AND CHARACTERIZING A COMMUNITY
Defining a “community” is part of the process of community healthassessment. The word “community” is derived from the Latin communite,meaning “common” or “fellowship” as related to human populations.
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Beyond acknowledging that community involves human beings, thereis very little agreement on its definition. More than 40 years ago, Hillery(1955) uncovered 94 definitions of community that he noted had verylittle in common except for their focus on human beings. The defini-tions of community are dependent upon the academic disciplines of theauthors and the objectives of their studies.
For purposes of community health assessment, we recognize threerelevant classifications as enumerated in Newby (1980):
1. community as fixed and bounded reality,2. community as a local social system, and3. community as a type of social relationship.
The following discussion on communities is based on a lucid discussionby D. L. Patrick and T. M. Wickizer (1995).
Community as a Fixed and Bounded Reality
A longstanding school of thought traceable to the writings ofFerdinand Tönnies (1957) views community as a specific geographical
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TABLE 1. Dimensions of Community Health Assessment: A Continuum
Directive Assessment Nondirective Assessment
Goals and subject matter are defined bythe assessor.
Community members are involved in thedecision-making process.
Service Delivery-Focused Resident-Focused
Concerned primarily with development ofservices and resources according to theorganization’s policies and priorities.
Community members play a vital role indefining their priority health needs and intaking action to meet them.
Centralized Decision-Making Decentralized Decision-Making
Goals and solutions are determinedin advance by an outside agency.
Decision-making power is delegated tothe community, giving greater weight tolocal considerations.
Focused Task Definition Open-Ended Task Definition
The professional goes into the communitywith a specific task to accomplish.
The professional has the autonomy tomake decisions in the field about hows/he works and about the task itself.
Community as Object Community as Subject
The professional views the community asan object of professional activity.
The professional seeks to build under-standing with the community and to createjoint solutions to problems.
Expert Practitioner Reflective Practitioner
The practitioner sees him/herself as havingsole knowledge of the problem and soleresponsibility for results. S/he typicallyarrives with a ready-made assessment.
The practitioner devotes more time tostudying the problems and engaging thecommunity in a dialogue regarding theproblems and their possible solutions.
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place associated with a human settlement. Warren (1978) captures theessence of this viewpoint by defining community as “. . . the general fo-cus of shared living based on common locality . . . the meeting place ofthe individual and the larger society and culture.”
Some authors reject this geographically based definition of commu-nity. Nisbet (1970) considers the idea of community as dead or dying.The mobility of modern household units and their declining depend-ence on local areas for meeting the their basic needs has undermined thegeographical definition. Scherer (1972) has put forth the notion of“global village” that has emerged with the advent of new media that per-mits individuals to accept or reject place.
Human ecologists have extended and deepened the concept of place.In his classic work on human ecology, Hawley (1950) defined commu-nity spatially as “that area [whose] resident population is interrelatedand integrated with reference to daily requirements whether the con-tacts be direct or indirect.” Area can be defined in one of three differentdelimiting ways: administrative (arbitrary political subdivisions or au-thorities), community (fluid, heterogeneous areas that expand or con-tract with changes in the degree of human interdependence, and regional(homogeneous with respect to physical features, human occupancy, orboth). Hawley (1950) notes that “diversity is the stuff of which interde-pendence is made and is thus a basic to the community.”
Community as a Local Social System
In this classification, community is defined in terms of social interac-tions, including social support and shared perceptions, beliefs, knowl-edge, goals, and the like. In this sense, community may have no geo-graphic referents at all; a community spirit may exist among individualswho are widely scattered geographically.
Social support theory (Wellman, 1982) and social network studieshave defined communities in terms of social interaction and a networkof ties rather than locality and potential relationships. The theoreticalrationale and empirical evidence support a causal link between socialrelations and health and well-being (House, 1998). Social networks andsocial support can influence survival, psychological and physical func-tioning, and health perceptions. The relevance of this important work,however, is limited since it is not based on any explicit model of com-munity and, therefore, the relationship between spatially delimited com-munity and social relations remains poorly understood.
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Community as Political and Social Responsibility
Defining community in terms of political boundaries seems most rel-evant to health and social services and to community health assessment.The National Commission on Community Health Services has ad-vanced the notion of a “community of solution” to suggest that the mostefficient solution to health problems should dictate the size and shape ofcommunities (Gray, 1978).
Communities defined in terms of shared political and social responsi-bility will vary in the size of their physical boundaries. A communitymay be geographically proximal to a concern (such a local communityserving individuals with special needs) or more distal (such as a na-tional advocacy group for persons with disabilities). The boundariesshift according to the nature of the need and the extent to which individ-uals and social groups are involved. Keller (1988) defines essential as-pects of community in such a way as to encompass both a specific localeor social concern and the larger political community.
With respect to community health assessment, the most appropriatedefinition is based on a human ecologic perspective that includes both aspatial (geographic) aspect and the notion of social responsibility interms of the community’s role in health promotion and disease preven-tion. Hawley (1950) defines such a community as “that area [whose]resident population is interrelated and integrated with reference to dailyrequirements, whether the contacts be direct or indirect. In practice, thisresident population will be a politically organized unit with sociallyshared concerns and responsibilities. It is important to remember thatthe nature and character of these local communities, however defined,are influenced by the broader context of national as well as global socio-economic and political changes. As a consequence, the nature of com-munities where we live, their relative importance, and their relationshipto our health and well-being will be in a state of flux (Patrick & Wickizer,1995).
COMMUNITY DETERMINANTS OF HEALTH:A CONCEPTUAL FRAMEWORK
In order to fully appreciate the role that community characteristicsand community processes play in determining health status, a system-atic conceptual framework is needed to guide the CHA process. Thisframework is particularly important because of the tenuous nature of
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the existing evidence elucidating pathways and processes by which acommunity either directly influences health or acts as a mediator betweencommunity risk factors and health outcomes. Several attempts havebeen made to develop comprehensive models of the determinants ofhealth for purposes of health policy and epidemiological research andof community health analysis (Blum, 1974; Lalonde, 1974; Hancock,1985; Evans & Stoddart, 1990; and Green & Ottoson, 1994). Thesemodels vary in the manner in which they categorize the determinants ofhealth status and the importance attached to each determinant, espe-cially health care. As the following summaries indicate, however, allmodels distinguish among the environmental, behavioral, genetic, andhealth care determinants.
Models of Health Determinants
Lalonde (1974). Providing much of impetus in recent thinking aboutthe health status determinants, this model classified the determinantsinto four major categories: lifestyle, environment, human biology, andhealth care organizations. This approach symbolizes the shift in the un-derstanding of health from a reductionist, biomedical view to a com-plex, holistic and ecologic viewpoint.
Hancock (1985). A further development of the ecologic approach,this model is called the “mandala of health.” The mandala is a circularsymbol of the universe in which the individual–comprising body, mind,and spirit–is viewed as the center that coexists within enveloping circlesof family, community, and culture. The four factors that affect the healthof individuals and families are modified versions of the Lalonde catego-ries. They include:
a. human biology (genetic traits and predispositions; the biochemi-cal, physiologic, and anatomic state of the person and the family);
b. personal behavior (dietary habits; general risk-taking and preven-tive behaviors);
c. psychosocial environment (socioeconomic status, peer pressure,exposure to advertising, social support systems); and
d. physical environment (adequacy of housing; work and home envi-ronment).
According to the mandala model, lifestyle is considered to be per-sonal behavior that is shaped, molded, and constrained by a lifelong so-cialization process as well by a psychosocial environment. The medicalcare system, which is a relatively less important determinant of health,
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is considered part of the community and is wholly dedicated to biologi-cal and personal behavioral issues. The work environment is an impor-tant determinant of health, both physical and mental. In this model, acommunity’s physical and human-made environment, along with itsvalues, social support, and network systems, also exerts a major influ-ence on health.
Evans and Stoddart (1990). An extension of Lalonde’s approach, thismodel distinguishes physical and social environment from the individ-ual behaviors and biology that constitute the “host” response. Determi-nants of health outcomes include physical and social environment, ge-netic endowment, and individual response, both behavioral and biologi-cal. Prosperity influences both environment and health-related outcomes,leading to trade-offs in investment in health, especially between healthcare itself and other health producing activities such as income redistri-bution programs and subsidization of education.
A conceptual model of community health is essential to understand-ing the major determinants of health and aids in the identification ofrisks factors and indicators of health status when conducting a commu-nity health assessment. It also shows that a community’s health status isa function of the dynamic interaction of many variables and that a sim-ple listing of outcomes will leave out an important component of the as-sessment.
We propose a multilevel model of the determinants of health, basedon the social ecological framework. The main thesis of the social eco-logical approach is that health of the individuals is a function of the in-teraction of individuals with subsystems of the ecosystem, such asfamily, community, culture, and physical and social environment. Thisapproach emphasizes population-level thinking and rejects biologicalreductionism as the sole approach to understanding health determi-nants. Individuals are nested within successive layers of social organi-zation (families, households, neighborhoods, communities, nation-states,etc.) that are hierarchically arranged but are analytically distinguish-able. Evidence of the multilevel causation interactions is seen as the factthat physical, social, and behavioral influences are associated with arange of outcomes rather than specific diseases (Dean, 1993; Ory,1992). The dynamic processes influencing health are captured in theparadigm of age, period, and cohort according to which “health at anytime integrates the long-term influences arising from being born intoand growing up in a particular historical context along with contempo-rary influences of the social and physical environment” (Evans &Stoddart, 1990).
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DEFINING HEALTH
Although the search for “objective” measures of health status in agiven population has a long tradition in demography and public health,the concept of health is often ambiguous. It is inherently value-laden, andthe lack of recognition of this fact has complicated health status mea-surement and issues of health and illness. Health is usually defined neg-atively, in terms of the absence of disease, illness, or disability, ratherthan in positive terms such as wellness or normality.
Negative measures of health combine physiologic health and func-tional status: the presence or absence of disease, and biochemical mea-surements that reflect potential for future disease (i.e., blood cholesterollevels). Functional status measures include the degree to which an indi-vidual is able to perform socially defined roles free of physical limita-tions (Bowling, 1991) and the level of functioning of various organs(i.e., pulmonary function testing). Functional status is a proxy measureof disease, focusing on the effects of the disease.
Positive measures of health include both negative aspects, such as theabsence of disease or disability, and positive elements, such as ability tocope with stressful situations, maintenance of a strong social supportsystem, integration in the community, high morale and life satisfaction,psychological well-being, and levels of physical fitness as well as phys-ical health (Lamb et al., 1988; Green & Ottoson, 1994). The WorldHealth Organization (1985) provided impetus to the positive concept ofhealth when, in 1948, it stated in its constitution that “health is a state ofcomplete physical, mental, and social well-being and not merely the ab-sence of disease or infirmity.” Autonomy has since been added to thislist of positive attributes (World Health Organization, 1985). Debatecontinues to rage over whether the WHO approach was meant to de-scribe an ideal state of affairs or an attainable goal that all societiesshould strive to achieve. A broad consensus has emerged on the need toadopt the broader, more positive concept of health rather than the nar-row, negative, and disease-based concept.
The definition of health (including its multidimensional nature) isone issue with far-reaching policy and measurement issues for those in-volved in CHA. Another equally troubling issue involves the definitionof “equity” in health. This term commonly is limited to “input” eq-uity–equal access to health care. Some strong advocates, however, main-tain that it also means “output” in the sense that differentials in healthstatus among social groups (defined on basis of socio-economic or eth-nic characteristics) should be eliminated.
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Our preferred approach to defining the health status of a communityis the life cycle approach (Pickin & St Leger, 1994) that uses the “Con-sensus Set of Health Status Indicators” (Centers for Disease Controland Prevention, 1991). We supplement these indicators with a house-hold survey designed to assess health-related quality of life factors, be-havioral risk factors, and availability, coverage, accessibility, and accept-ability of health, environmental and social services. Our household sur-vey instrument incorporates standard national survey instruments, andthe SF-12 questionnaire (Ware, 1994) is used to measure health-relatedquality of life factors. Standardization of data collection instrumentspermit comparisons with the state and national data as well as local dataover time. We also use focus group interviews to gather in depth infor-mation on health perceptions and behaviors and priority health issues.
IMPLICATIONS FOR CHA:TOWARDS A PROCESS-FOCUSED CONCEPTUAL MODEL
OF COMMUNITY HEALTH ASSESSMENT
A model, as an abstraction of reality, cannot do justice to the numer-ous details involved in the actual conduct of a CHA. We hope, neverthe-less, that the following simplified model, based on our experiences, canbe replicated elsewhere by practitioners charged with conducting com-munity health assessments. Although we are committed to involvingthe community in a process-focused approach, our model stipulates avariety of tasks and incorporates some elements of a product-orientedstrategy because, in our experience, concrete results are important toboth professionals and members of the community. At the same time,this model presents community health assessment as a process experi-ence for both the professional and the community members, and it iden-tifies process outcomes that practitioners must look for at each stage.The stages serve as milestones for the professionals in gauging theirprogress in involving the community in the CHA process.
Stage 1. Know Thyself. It is critical for the professionals to believe inand value community control of the CHA process. This means educat-ing the sponsoring organization at the start about the process. Both theprofessional and the community members must keep the values ofshared responsibility and leadership in mind during their joint venture,and the professional must be ready to relinquish his or her power.
Stage II. Know Thy Community. A community assessment will yieldvaluable data for both the professional and the community, and it will
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assist in defining the boundaries of the community and identify majorproblems and concerns. An important goal of community assessment isto determine a community’s competence or ability to collaborate onidentifying issues, to agree on priorities, to agree on strategies to ad-dress these priorities, and to cooperate with others in implementing adesired intervention.
Since the assessment process is built upon community involvement,the professionals need to understand the composition of the community,its organization, and its capacities to act. Geographical information canbe a valuable aid in defining the community and its assets. The socio-eco-nomic and political data will provide information on existing opportu-nities and barriers for community action. The data on availability,coverage, accessibility and acceptability of health, environmental andsocial services will provide direct information on effectiveness of thecurrent service system and directions for change.
Stage III. Creating a Participatory Infrastructure. This stage buildsupon the professional understanding and knowledge gained from theprevious two stages through dialogue with key informants, major stake-holders, and opinion leaders and through the establishment of positiverelationships with the community. Formation of a “Community SteeringCommittee” (CSC) will provide the community members an opportu-nity to be partners in a socially valuable project and contribute their ex-pertise to the conduct of CHA. The CSC acts as the “eyes and ears” ofthe community and manages the conduct of CHA. The roles of all mem-bers, including the professionals, must be clearly specified.
Stage IV. Developing a Strategic Plan. The professional worksjointly with CSC members to prepare a plan for determining what dataare needed and how they will be gathered and analyzed, with deadlines,anticipated products, and personnel assignments clearly stipulated. Thisinvolves decisions on the following:
1. Objectives of assessment2. Definition of health status3. Specification of conceptual framework for CHA4. Specification of available resources5. Selection and collection of existing data on community health in-
dicators6. Primary data collection, based on household surveys and focus
group interviews7. Specification of standards for comparison8. Inventory and analysis of community health resources
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Stage V. Establishing Feedback Mechanisms. The CSC, by now,should be a fully functional body, capable of critiquing proposed plansand offering guidance and suggestions to the professional. Meetingsshould be regularly scheduled to present drafts of completed work foradditional community input and critique. This is also the stage at whichthe professional helps the CSC validate issues and concerns raised inthe previous stage.
Stage VI. Establishing Priorities. Analysis of quantitative as well asqualitative data in the previous stages will reveal a number of health de-ficiencies or problems. The professional working with the CSC shoulddevelop a list of criteria to prioritize health problems. One way to priori-tize is in terms of whether the problem is amenable to interventions atprimary, secondary, or tertiary levels. Some suggested criteria for prioritizinghealth deficiencies are given in Table 2.
Various group process approaches have been developed for encour-aging all members to participate equally in developing ideas, makingjudgments, bringing forward ideas, and exchanging information (Nutting,1984). A group process technique that has proven to be useful in rankingproblems and alternatives is the nominal group process (Killip, 1987).
Stage VII. Selecting Interventions. Once the problems have been pri-oritized, optimal intervention strategies need to be selected to addressthe problems identified in the previous stage. A list of suggested criteriais presented in Table 3.
Stage VIII. Presentation of a Joint Report. The presentation of theplan is the decisive stage, representing in essence the culmination of theassessment process. Community members experience a great sense ofreal accomplishment, and the synergistic relationship that has devel-oped among members of the community will assist in the project imple-mentation phase.
SUMMARY AND CONCLUSIONS
The rationale for a process-based approach to community health as-sessment is that, while the products (such as collection and publicationof data on CDC’s Consensus Set of Health Indicators) are important, theprocess by which they are produced is of equal, if not greater, impor-tance. Our approach expands the CDC’s approach by gathering addi-tional data through household surveys and focus group interviews andencapsulating this data gathering within a community health assess-ment process. The recent shift in focus of health policy from the federal
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to the state and local level underscores the need for greater communityparticipation, particularly in addressing such health problems as HIV-AIDSand teenage pregnancy which require community involvement from theoutset for designing effective intervention strategies.
CHA is a tool that can be used to allocate resources in a manner that isresponsive to the community needs and that can maximize communityinput in local decision-making. A process-focused approach, with par-ticular attention to definitions of community and health as well as to theselection of an appropriate model of community health determinants,was presented as a means of maximizing community involvement in lo-cal health issues. The process-focused approach must be viewed as ateam approach, incorporating not only the public health and medical dis-ciplines but also social and behavioral sciences. Because it is communitydriven, the process approach requires considerable re-education of pro-
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TABLE 2. Suggested Criteria for Prioritizing Health Problems
• Estimated burden of problem on the community
• Community, family, and individual financial losses
• Population impacted by the disease
• Years of potential life lost
• Potential worsening of the problem
• Urgency of the problem is known and accepted
• Expected health impact is measurable or action will produce benefits
• Problems perceived as serious by community leaders and residents
• Existing health care system is capable of responding to the problem
• Incentives exist for the health care system to respond to the problems
Source: Adapted from Zucconi et al. (1993)
TABLE 3. Suggested Criteria for Intervention Strategies
• Efficacy of intervention strategies has been demonstrated
• Potential for positive change can be demonstrated
• Cost-effectiveness of intervention strategies is known
• Strategies to address problem would have a positive or negative impact on other knownproblems
• Resources are available for specific program development and implementation
Source: Adapted from Zucconi et al. (1993)
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fessionals accustomed to thinking in an “expert” mode and to “being incharge.” In the process approach, the professional serves a resource tothe community to facilitate the conduct of CHA. Sustainability is morelikely if the community members engage in every step of the process.
If the current discussions about the community’s role in health ap-pear to be somewhat romantic, this is a reflection of the assumption thatcertain health and human needs can best be served by communal mech-anisms. The failures of federal health policy-making have led to a wide-spread belief that community-centered norms, such as interdependence,reciprocity, mutual benefit, and trust, offer a promising alternative ap-proach to designing policy at the local level (Aday & Linder, 1997).Whether they fulfill that promise remains to be seen.
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