Leadership matters: Strategies for local health department leaders to promote healthy built environments

The built environment is increasingly recognized as an important determinant of chronic disease, health inequities, and degraded environmental conditions, yet local health departments need more guidance on how to effectively influence it. In such important but ambiguous situations, leadership is particularly relevant. This study determined whether, and how, local public and environmental health leaders increase their departments' effectiveness creating health-promoting built environments, and what pitfalls they should avoid. It used mixed methods including a comparative case study and a survey of 159 (89% participation) health officers, health directors, and environmental health directors from 100% of California's local jurisdictions. The case-study encompassed 3 departments, 12 cases, and 36 health, planning, and private development professionals, plus 30 additional key informants. Multivariate linear and logistic regression were used to quantify the impact of leaders' attitudes, readiness, innovativeness, and staffing for built-environment actions on physical, policy, and procedural changes in the built-environment arena, and on levels of inter-agency collaboration. Departments with 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, strategy) tripled inter-agency and cross-sector collaboration (OR: 3.4). The case-study identified strong and weak leadership practices, using pattern-matching to relate them to successful and unsuccessful cases. Successful departments had consistently strong leadership that 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) built bridges leader-to-leader, and 6) leveraged their professional reputation. Inconsistency in these practices was twice as common among failure, versus success, cases (80%, 43%). Local health leadership underlies public and environmental health departments' successful community design efforts and should receive technical support and resources to effectively do so.