Context: The built environment is an important but less-recognized health determinant, and local health departments need expanded guidance to address it. In such situations, leadership is particularly relevant.
Objective: To assess whether and how local public and environmental health leaders increase their departments' health-promoting impact on built environment design, and what pitfalls they should avoid.
Design: Mixed-methods employing cross-sectional surveys and a comparative case study.
Setting: Local public and environmental health departments.
Participants Survey: A total of 159 (89%) health officers, health directors, and environmental health directors from all 62 local jurisdictions in California. Case-Study: Three departments, 12 cases, 36 health and land-use professionals, and 30 key informants.
Main Outcome Measures: The study measured the influence of leadership practices on health departments' built environment-related collaborations, land use activities, policy developments, and contributions to physical changes. Quantitative multivariate linear and logistic regression were used. Case-study content analysis and pattern-matching, which related strong and weak leadership practices to outcomes, were also employed.
Results: Departments having highly innovative leaders with positive attitudes had greater odds of achieving physical changes to the built environment (OR: 4.5, 3.4, respectively). Leadership that most prepared their departments for built environment work (by updating staffing, structure, and strategy) tripled interagency and cross-sector collaboration (OR: 3.4). Leadership of successful departments consistently (1) established and managed a healthy built environment vision, (2) cultivated innovation, (3) supported, empowered and protected staff, (4) directly engaged in land use and transportation processes, (5) established direct contacts with directors in other departments, and (6) leveraged their professional reputation. Inconsistency in these practices was twice as common among failure as success cases (80%, 43%).
Conclusions: Local health leadership underlies public and environmental health departments' community design efforts and should receive technical support and targeted resources to do so effectively.