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This chapter reviews ways in which behaviour relates to the spectrum of health and disease determinants, from environmental to genetic, in shaping health outcomes. It builds on the previous chapters in recognizing the powerful influence of socioeconomic and cultural factors, especially poverty and discrimination, in influencing both behaviour and health. Many commentaries in the past four decades have attempted to correct the overemphasis on individual behavioural determinants of health by discounting and sometimes disparaging any focus on individual behaviour or personal responsibility in disease prevention and health promotion. This chapter seeks a middle ground, building on the growing understanding of the ecological and cultural context of the behaviour–health relationship. It seeks to integrate that knowledge in an approach to public health that acknowledges the reciprocal determinism of behavioural, environmental, and biological determinants rather than minimizing the importance of behaviour in these complex interactions.

The FluFIT program is an evidence-based intervention that leverages the time of annual influenza vaccination activities as an opportunity to offer colorectal cancer screening with fecal immunochemical testing to eligible adults between the ages of 50 and 75 years. Begun as a pilot program for a family medicine residency-based flu shot clinic in San Francisco in 2005, the FluFIT program has since been evaluated and implemented successfully in a wide variety of clinical settings throughout the United States. This case study describes the process of designing and testing a clinical intervention with the goal of implementation. Important steps included an initial needs assessment identifying the capabilities and opportunities for changing the behavior of clinical teams, as well as broadly conceived and continuously sustained stakeholder engagement at all stages of program design, evaluation, dissemination, and implementation.

This chapter raises questions about the reliability of much “evidence-based practice” disseminated from the original studies and systematic reviews of those studies, insofar as they were often conducted and reviewed with inadequate attention to external validity. Important issues are raised for dissemination and implementation researchers. Indeed, the pressure on investigators to provide for increasingly rigorous controls on threats to internal validity, and to exclude studies that fall below standards for internal validity, has made many such sources of evidence more suspect in their external validity and less credible to the practitioners or policymakers who would adopt them. Greater attention is needed to ways to incorporate considerations of external validity into studies and in systematic reviews of studies to produce more generalizable evidence, and greater attention to practice-based evidence that can complement the more formal evidence-based practices in the process of implementing and evaluating the dissemination and implementation process

The misuse of alcohol, tobacco, and illicit drugs by youth and young adults is a major public health challenge across nations and the world. This chapter reviews the extensive international research concerning the use of public policy approaches to reducing these problems associated with the use and misuse of alcohol, tobacco, and illicit drugs. In general, wide differences arise in public policies both in the type of research undertaken and the practical application of policy approaches to reduce harm. For illegal drugs and for alcohol, research concerning public health effects has been associated with policies addressing specific control mechanisms, whereas many public health policy approaches for tobacco harm prevention have been multifaceted. Overall, the cumulative international evidence offers public health policy approaches with demonstrated potential to reduce harm from and use of alcohol, tobacco, and illicit drugs and can have specific effects for adolescents and young adults.

Community intervention trials in high-income countries. This chapter summarizes results of combined mass media and community organizing methods used and evaluated during the past 40 years to achieve chronic disease prevention through changes in behaviour and risk factors. These studies are examples of experimental epidemiology and community-based participatory research, using cost-effective health promotion methods. The chapter also reviews earlier experiences in public screening, immunization, family planning, HIV/AIDS, and tobacco control, which provided useful theory and methods on which the later trials built. Major advances in theory development and intervention methods occurred in the 1970s from two pioneering community intervention projects on cardiovascular disease prevention from Stanford (USA) and Finland. These projects, followed in the 1980s and beyond in North America, Europe, Australia, and elsewhere, added many major lessons in both theory and practice. These lessons, considered ‘operational imperatives’, are: economic, social normative (or ‘denormalization’), informed electorate, public health, surveillance, comprehensiveness, formative, ecological, and logical sequencing of needs and action. Therefore, these recent decades of applying ‘total community’ health promotion in developed countries achieved considerable change at reasonable cost. Such communities were changed greatly through organizing and education; changes requiring advocacy, activism, partnership building, leadership, and regulations. This results in community transformation, creating ‘community efficacy’, a composite of enhanced self-efficacy of the community’s residents and leaders. Such transformed communities, as models, allow leverage in disseminating methods, including regulatory tactics. Such dissemination can lead to national changes analogous to those of the recent decade’s tobacco control successes.