Leadership and public health
Historically, obesity prevention efforts have focused on individual behavior change, yielding marginal results and limited sustainability [1, 2]. To be effective, solutions will likely need to address the problem more broadly. From a social ecological perspective, it will be necessary to create change at multiple levels, including addressing environmental and policy factors that influence behavior [2–6]. Leadership is one of the major factors in creating change at these levels. For example, leadership has been a critical element in creating policy and shifting social norms around tobacco use and breastfeeding .
Leadership has been identified as a key component of community capacity building [8–16], which has emerged as an effective approach for achieving environmental and policy changes to improve health [10, 11, 17–19]. Within the public health realm, community capacity has been defined as the “characteristics of communities that affect their ability to identify, mobilize, and address social and public health problems” . Notably, enhancing leadership has been a successful strategy for increasing community capacity in underserved populations, including ethnic minority and rural communities [13, 15–17], implicating it as a promising approach for reducing health disparities.
In 1998, Goodman et al. reviewed the evidence related to leadership characteristics of individuals that contribute to community capacity in the context of public health. This review suggested that successful leaders have a democratic decision-making style; help make it possible for all members of a community to participate; are responsive and accessible; and are well-connected to other leaders . Three studies published subsequently were identified that specifically examine the leadership characteristics related to community capacity. A study of coalition factors that foster community capacity within the Fighting Back Initiative (which addressed substance abuse) used key informant interviews and surveys with project staff, advisory council members, project directors, and steering committee members to identify characteristics associated with greater organizational capacity among the study sites . In this study, higher performing sites had leaders with a more collaborative style, compared to lower performing sites where leaders had a more autocratic style.
In a qualitative study, Goodman  explored the components of capacity most relevant to public health initiatives in communities that were predominantly inhabited by racial and ethnic minorities. Group interviews with the core members of each initiative were conducted using an open-ended guide. Cross-site qualitative analysis identified the characteristics of leaders in initiatives that realized successful outcomes, such as improved and expanded health and social services, compared to those in initiatives that failed to achieve goals. Leaders at successful sites were visionary, selfless, persuasive, fearless, and respected. Leaders at sites where initiative goals were not attained were overloaded, overwhelmed, unresponsive, self-interested, and passive. Participatory and team-oriented leadership styles were also found to be more successful than top-down approaches.
A study of the community initiatives to increase physical activity that were part of the Active Living by Design Program defined successful partnerships by positive outcomes such as changes in the community physical environment or in policies related to physical activity . Synthesis of the lessons learned from the 25 communities that participated in the program indicated that leadership was important to success, and that local leaders in the most successful partnerships were visionary, flexible, willing to mentor others, and able to nurture effective partnerships.
Taken together, studies exploring community capacity paint a picture of effective community leaders as visionaries who have the skills to recruit others to a common goal, and to carry out a plan for realizing a vision using a collaborative and democratic leadership style. This is consistent with a transformational leadership model, described by Burns as a model in which leadership is not based on a charismatic personality or access to traditional sources of power, but rather occurs “when one or more persons engage with others in such a way that leaders and followers raise one another to higher levels of motivation and morality” . This type of leadership contrasts both with transactional leadership, which encompasses traditional management practices (setting goals, providing feedback, and exchanging rewards for achievement), and laissez-faire leadership, which is characterized by a lack of involvement in managing .
Consistent with the studies described above, social and interorganizational networks have been identified as a dimension of community capacity . Explorations of interorganizational work as part of the solution to the childhood obesity epidemic have begun . A body of work has examined an integrative leadership framework in public health, which can be defined as “fostering collective action across boundaries to advance the common good” . The focus is on leadership that cultivates collaboration among multiple levels of the social ecological model and multiple sectors within each level. Integrative leadership scholarship investigates the ways that leadership can foster collaborations that are most effective at creating synergy and change. Crosby and Bryson  suggest that eight capabilities are necessary for effectiveness, including an understanding of the social, political, and economic contexts; understanding and deploying personal assets on behalf of beneficial change; nurturing humane and effective organizations; and creating and communicating a shared vision.