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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.

Objectives: In 1996, California proposed regulations to eliminate publicly funded prenatal care for undocumented immigrants. Prenatal treatment of sexually transmitted infections (STIs) can prevent STI-related adverse outcomes of pregnancy (AOP). The study assessed the STI-related health and economic impact of the proposed regulations in Los Angeles County (LAC)., Methods: We modeled excess STI-related AOPs and associated costs that would occur in LAC as if the regulations were implemented in 1995. Using attributable fractions in the exposed for five STIs and their associated AOPs, we calculated excess STI-related AOPs and their costs that would result from the regulations and the degree to which excess morbidity would offset gross savings., Results: The model indicates that, depending on regulatory level, 74, 110, or 132 excess AOPs would occur subsequent to the regulations, representing lost prevented morbidity. These excess AOPs would cost $5.1, $7.6, or $9.2 million dollars in direct medical expenses, offsetting anticipated savings by 19.2%, 29.0%, or 34.9%. This analysis does not include other costs of these STIs or costs associated with non-STI-related sequelae of diminished prenatal care, all of which could further offset anticipated savings., Conclusions: The proposed regulations would likely lead to increased STI-related morbidity and costs, thereby offsetting anticipated savings. Health departments are in a special position to promptly respond to policy issues affecting vulnerable populations. The development of a practical and rational framework for local-level policy assessment can be important for encouraging good scientific approaches that respond to calls for reductions in basic preventive health services.