Early public health efforts in the United States addressed social conditions that contributed to poor health, with public health workers playing a role in large scale societal reforms, such as passing housing and sanitation laws, which led to diminishing deaths from infectious diseases. As chronic diseases became leading causes of death, public health research and practice became more focused on individual behaviors, widely thought to be the primary cause of chronic diseases. However, health inequities along the lines of place, race, class, and other forms or marginalization are still prevalent. A substantial body of research illustrates how social, political, economic, and environmental factors affect multiple health outcomes, including chronic diseases, and contribute to health inequities.

In public health practice, some local health departments (LHDs) and organizations that support their work have called for broader public health interventions that address social policies that contribute to health inequities in addition to providing direct services to individuals. With continued research and support, the approximately 2,800 LHDs nationwide can play a central role in reducing health inequities. However, engaging in this complex work necessitates new approaches, skills, frameworks, and organizational infrastructures for LHDs. The recent foreclosure crisis, which stands to increase racial and health inequities, provides a lens to examine whether and how LHDs can move from a rhetorical commitment to addressing social determinants of health (SDH) into actual public health interventions that reduce health inequities.

Through this dissertation, I examine LHDs’ role in the foreclosure crisis through three related papers. My aim is provide insight into how LHDs responded to the deep and fundamental shifts in access to stable and quality housing and wealth created by the foreclosure crisis that disproportionately impacted African-American, Latino, and some Asian/Pacific Islander communities. Through all three papers, I incorporate a focus on challenges and approaches to addressing the racialized causes and outcomes of the foreclosure crisis. My overall aim is to help advance local public health practice within LHDs to more effectively target the causes of health inequities, including gaining a better understanding of LHD approaches and needs related to addressing SDH through local policy.

In the first paper, A National Survey on Local Health Department Engagement in Addressing the Foreclosure Crisis, I describe the results of a national survey on LHD engagement in the foreclosure crisis, which includes LHD approaches to addressing foreclosure and barriers to engagement. Responses followed a diffusion of innovation pattern, with innovator, early adopter, early majority, late majority, and lagging LHDs. Respondents expressed a high level of interest in adopting innovative approaches to addressing SDH and described a need for models of how other LHDs are preventing or mitigating the impacts of foreclosure, especially through local policies.

In the second paper, Adopting an Innovative Public Health Practice to Address Foreclosure: A Case Study of Alameda County Public Health Department, and the third paper, Policy Entrepreneurs, Agenda-Setting, and Communication: An Exploration of How a Local Health Department Engaged in Addressing the Foreclosure Crisis, I describe findings from qualitative interviews with current and former ACPHD staff and partners. In the second paper, I identify factors that 1) differentiate ACPHD’s innovative approach from traditional LHD activities; and, 2) contributed to ACPHD being an innovator among LHDs.

Finally, in the third paper, I focus on ACPHD’s role as a policy entrepreneur in agenda-setting, including their communication approach. While the second paper focuses on how ACPHD developed into an innovative LHD in the area of local housing policy, the 3rd paper focuses on how in this role, ACPHD interacted in the local policymaking process. This case study also examines how the role of policy entrepreneur can be shared across two organizations (ACPHD and Causa Justa::Just Cause) and provides another way to conceive of entrepreneurism.