Public Health

Behavioral and social science research and theories are relevant to promoting health and preventing disease in the population. This article discusses the major health challenges confronting developed and developing countries, the contribution of social and behavioral factors to current global health challenges, and current approaches to addressing health problems. Finally, it considers the importance of using social and behavioral theories and models to providing a comprehensive understanding of all the determinants and influences relevant to a particular health issue, and informing the development of efficacious, practitioner-delivered lifestyle–change interventions to address these issues at a public health and societal level.

Introduction

This article focuses on the extent to which behavioral and social science research and theories are relevant to the challenge of promoting health and preventing disease in the whole population. An overview is provided of the major health challenges confronting developed and developing countries, including a discussion of the contribution made by social and behavioral factors to these global health challenges. It is important to note some key differences between the so-called individual or high-risk approach to addressing health problems, and the whole-of-community or population approach. The ‘high-risk’ approach, used to develop efficacious, intensive, practitioner-delivered lifestyle–change interventions for individuals, needs to be integrated within a broader public health approach. The latter approach involves a consideration of the whole spectrum of sociobehavioral and environmental factors that are relevant determinants of health to promote health and prevent disease. The importance of the wider dissemination and uptake of interventions at an institutional or policy level is also discussed. Social and behavioral theories and models are very important in public health; they not only help provide a more complete understanding of all of the determinants and influences relevant to a particular health issue, but are also very important for informing how to address the health issue at a public health and societal level.

What Is Public Health?

Public health has been classically defined as

… the combination of science, skills and beliefs that are directed to the maintenance and improvement of the health of all people through collective or social actions. The programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities change with changing technology and values, but the goals remain the same: to reduce the amount of disease, premature death and disability in the population.

Last, 1995

Health was defined by the World Health Organization (WHO) more than 60 years ago as “a state of complete mental, physical, and social well-being, and not merely the absence of disease or infirmity.” By this definition, health is more than just a physical state and is inextricably linked to personal well-being and potential, and incorporates many other dimensions of human experience, such as quality of life, psychological health, and social well-being. Public health is different from other fields of health and medicine as it strongly emphasizes the promotion of health and well-being and the prevention of disease, illness, and disability at the population level. Populations are groups of individuals with some similar characteristic(s) that unify them in some way, such as people living in rural areas, older people, women, an indigenous group, or the population of a specific region or country.

Contemporary public health is particularly concerned with those sections of the population who are under- or poorly served by traditional health services and, consequently, are most disadvantaged and vulnerable in terms of their health. Because such disadvantage or vulnerability usually has its origins in the very early years of childhood and/or is related to an individual or a population subgroup’s social and economic circumstances, public health is therefore very concerned with the more upstream or distal (i.e., distant from the person), social, physical, economic, and environmental determinants of a person’s health, in addition to the more proximal determinants (i.e., closer to the person), such as lifestyle risk factors, health behaviors, and biological factors.

Preventing any disease is commonly grouped into three levels, named for the stages of disease that they target; primary (pre-disease), secondary (latent disease), and tertiary prevention (symptomatic disease). Primary prevention aims to reduce both the incidence and prevalence of a disease before it occurs. For example, encouraging people to protect themselves from ultraviolet radiation or tobacco prevention and health promotion programs which target young people are examples of this level of prevention. Secondary prevention (or early detection) refers to the situation after a disease has started to occur, but before the person has noticed anything is wrong. The goal of secondary prevention is to find and treat a disease early – such as cardiovascular disease or diabetes – and in many cases, the disease can then either be cured or the risk of progression can be significantly reduced. Tertiary prevention targets people who are already experiencing symptoms of a disease or diseases and thus aims to reduce the complications associated with poor health and minimizing disability and suffering, such as cardiac rehabilitation programs for patients after a heart attack. There is also a fourth level of prevention, primordial prevention, which involves actions and measures to prevent the emergence of risk factors in the form of environmental, economic, social, and cultural patterns of living. For example, many adult health problems, such as obesity and hypertension, have their origins in childhood, because this is the time when the determinants of lifestyle are developing. Subsequently, improving the social and economic circumstances of families during these early years can have a profound influence on later health. Sometimes the boundaries of prevention strategies are indistinct, and it can be common for a given intervention to address a combination of the primary, secondary, and tertiary levels.

The World Health Organization recommends the combined use of population (or mass) and high-risk strategies for prevention. The ‘high-risk’ strategy aims to provide preventive care to individuals at special risk; hence it requires the detection of individuals with high risk. The population strategy is directed at the whole population, or subgroups in the population, irrespective of their individual risk levels. For example, research has demonstrated even a small reduction in the average blood pressure or the serum cholesterol of a population can produce a large reduction in the incidence of cardiovascular disease. Health promotion strategies are often very important for prevention and the WHO definition for health promotion is “the process of enabling people to increase control over the determinants of health and thereby improve their health” (World Health Organisation, 2005). Successful prevention depends upon the following: a knowledge of causation and the determinants; an understanding of the dynamics of transmission; identification of risk factors and risk groups; availability of evidence-based preventive or early detection and treatment measures; an organization and systems for delivering their measures to appropriate persons or groups; and continuous monitoring and evaluation and further development of the strategies that have been implemented.

The application of behavioral and social science theories and methods to prevention can occur at multiple levels and in many different settings in the community. Many public health initiatives are aimed at the individual or interpersonal level, and are delivered through the primary care setting, workplaces, and schools. Such programs typically have a low reach, in that only a limited number of people are impacted on by, and/or have access to the programs. However, these programs can have high levels of exposure for the individuals and can be quite intensive. Other programs can be organized and implemented through whole organizations or systems. Finally, community-wide or societal-level interventions may involve mass or social media, policy, or legislative action at a national or governmental level, and these can have a very large reach. However, program exposure for any given individual is typically quite low.

The practice of public health is therefore very broad and can include the delivery of many different types of programs and services throughout the community. It can include efforts to reduce health disparities, increase access to health services, improve childhood rates of immunization, control the spread of HIV/AIDS, reduce uptake of smoking by young people, and implement legislation and policies to improve the quality of water and food supplies, reduce the occurrence of motor vehicle accidents, and reduce pollution. In fact, the overall health and well-being of the population is more directly related to the effective and widespread implementation of these kinds of efforts, than it is by the society’s direct investment in direct health-care delivery.

This article discusses the extent to which theories and models from the behavioral and social sciences can better underpin the understanding and practice of public health. The following sections of this article provide a brief overview of the major public health problems and challenges confronting both developed and developing countries; the contribution made by social and behavioral factors to many of these health problems; and how social and behavioral theories and models can be usefully applied to the development, implementation, and evaluation of public health programs.

Trends in the Global Burden of Disease

The past 100 years have seen substantial change in health and the patterns of disease burden around the world. The findings of the Global Burden of Disease Study 2010 resulted from the collaborative efforts of 486 scientists from 302 institutions in 50 countries and it has made a very important contribution to our understanding of present and future health priorities for specific countries and the global community (Horton, 2012). Expanded in scope since the first study of the global burden of disease completed in 1990, in which 107 diseases and injuries and 10 risk factors were assessed, the GBD 2010 included 235 causes of death and 67 risk factors. This has facilitated the comparison of diseases which cause early death with those that cause prolonged suffering or disability in any country or region of the world.

Disease burden refers to the impact of diseases, injuries, and risk factors as measured by financial cost, mortality, morbidity, and/or other indicators. It is often quantified in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs), both of which measure the number of years lost due to disease. One DALY can be thought of as 1 year of healthy life lost, and the overall disease burden can be thought of as a measure of the gap between current health status and the ideal health status. Such measures allow for a comparison of difference causes of disease burden, and they can also be used to evaluate the possible impacts of health intervention for similar or different causes. The WHO has now also provided a set of detailed guidelines for measuring disease burden.

The findings GBD 2010 (Horton, 2012) also allowed a comparison of health life expectancy, a summary measure which captures mortality and nonfatal outcomes in a single measure, between countries from 1990 to 2010. Contributions of changes in child mortality, adult mortality, and disability to overall change in population health between 1990 and 2010 were also considered. Findings revealed that in 2010, global healthy life expectancy at birth was 59 years for males and approximately 63 years for females, and across countries in 2010, life expectancy at birth ranged from almost 28 years in Haiti to 71 years in Japan for males, and 37 and 75 years for females in Haiti and Japan, respectively (Salomon et al., 2012). In the past 20 years healthy life expectancy has increased by 5 years or more for males in 48 countries compared with 43 countries for females. However, healthy life expectancy decreased for males in 22 countries compared with 11 countries for females. Worthy of note is that increases in life expectancy have corresponded with an increase in the number of healthy years lost to disability (YLDs) in most countries. This finding has implications for health planning and health-care expenditure. That is, although substantial progress has been made in terms of the reduction of mortality over the past two decades, comparatively little improvement has been made in reducing the overall effect of nonfatal disease and injury on population health. Of course, this provides a very strong argument for the importance of prevention.

GBD 2010 findings also reveal that although almost 53 million deaths occurred in 2010, up from approximately 46 million deaths in 1990, some very important progress has been made in global health and the health of the majority of countries. For example, life expectancies are increasing for men and women and a greater proportion of deaths are taking place among people aged 70 and older (Horton, 2012). The burdens of HIV and malaria are falling, and fewer children aged 5 years or less are dying (Horton, 2012). The number of deaths attributable to communicable, maternal, neonatal, and nutritional causes were also down from those attributed to these causes in 1990, due largely to decreases in mortality from diarrheal disease (2.5–1.4 million), lower respiratory infections (3.4–2.8 million), neonatal disorders (3.1–2.2 million), measles (0.6–0.13 million), and tetanus (0.3–0.06 million) (Horton, 2012). Furthermore, infectious diseases control is improving in most countries.

Despite this progress, old threats remain and new threats have emerged. In developing countries, major public health problems continue to include infectious diseases, undernutrition, and complications of childbirth, as well as the increasing prevalence of chronic diseases such as cardiovascular disease, cancer, and diabetes. In Sub-Saharan Africa communicable, maternal, neonatal, and nutritional causes still account for 76% of premature mortality in 2010, and newborn, and child mortality, and various vaccine-preventable and other communicable diseases remain urgent concerns (Horton, 2012). Furthermore, the considerable impact of HIV/AIDS on mortality and disability in most developing regions in 2010 is still of concern, as it is now the fifth leading cause of DALYs worldwide (up from 33rd in 1990; a 351% increase) (Murray et al., 2012).

The increasing prevalence of chronic disease is a significant new threat with blood pressure identified as the biggest global risk factor for disease, closely followed by tobacco, alcohol, and poor diet. Deaths attributable to noncommunicable diseases rose from approximately 8 million between 1990 and 2010, to account for two of every three deaths worldwide by 2010. Specifically, 8 million people died from cancer in 2010, 38% more than two decades ago, ischemic heart disease and stroke collectively accounted for one in four deaths worldwide, compared with one in five in 1990, and deaths due to diabetes (1.3 million) were double that in 1990. Deaths due to injuries (5.1 million) were marginally higher in 2010 compared with 1990, a figure driven by a 46% rise in deaths worldwide due to road traffic accidents. In short, ischemic heart disease, stroke, chronic obstructive pulmonary disease, lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010.

Other emerging areas of concern are the increasingly widespread and rising prevalence of diabetes in China and other low- or middle-income countries (Rawal et al., 2012), such as India, Russia, Brazil, Pakistan, Indonesia, and Bangladesh, and the very large unrecognized burden of mental illness in developed and developing countries (Murray et al., 2012). A recent systematic review revealed an increase in diabetes mellitus prevalence from 2.6 to 9.7% in China over the period of 2000–2010 (Li et al., 2012). This finding, combined with the increasing prevalence of undiagnosed, untreated, and suboptimally managed diabetes and prediabetes in China and a population of 1.3 billion people, is cause for concern. In regards to mental illness, results of the GBD 2010 revealed that mental and substance use disorders accounted for approximately 7% of DALYs globally, 8.6 million of all years of life lost (YLL), and are the leading cause of years lived with disability (YLD)s worldwide. The burden of mental and substance use disorders increased by approximately 40% between 1990 and 2010, a figure largely driven by population growth and aging (Whiteford et al., 2013). These findings suggest that mental and substance use disorders pose a significant challenge for health systems in developed and developing regions, and the prevention and treatment of mental and substance use disorders is vital if improvements in population health are to be achieved.

With more people spending more years of their lives with more illnesses, disability from disease and injury is also becoming an increasingly important public health issue. Women are impacted on especially hard by disability with those aged 15–65 years losing more healthy life to disability than men. Although global DALYs remained stable from 1990 to 2010, an important shift occurred in DALY composition with the contribution of deaths and disability among children (aged 5 years and younger) declining from 41% of global DALYs to 25%. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, Western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. Changes in DALYs over the past 20 years were observed for communicable, maternal, neonatal, and nutritional disorders, as well as noncommunicable diseases, and injuries. Furthermore, ischemic heart disease became the leading cause of DALYs worldwide in 2010, up from fourth in 1990, followed by lower respiratory infections (first in 1990), stroke (fifth in 1990), diarrheal diseases (second in 1990), and HIV/AIDS (33rd in 1990). Other significant contributors to global DALYs were major depressive disorder (up 37%) and road injuries (up 34%). In summary, the global disease burden has continued to shift away from communicable to noncommunicable diseases and from premature death to years lived with disability (YLDs). Furthermore, population aging has dramatically changed the global burden of illness worldwide, hastened by improvements in health related to increases in income and reductions in family sizes.

Publications which continually update the GBD estimates are an important source of information for framing health policies and objectives not just globally but also within specific countries (Murray et al., 2013). For example, the findings of GBD 2010 suggest rising burden chronic conditions and their comorbidities, and the shift away from communicable to noncommunicable diseases and from premature death to years lived with disability (YLDs), particularly in developing or low- and middle-income countries, are significant problems global public health needs to address. In short, disability from disease and injury has become an increasingly important consideration for all health systems as more people will be spending more years of their lives with more illnesses, and suggests a need to focus on the growing burden of noncommunicable diseases and to make a shift from preventing premature death to reducing years lived with chronic illnesses and debilitating conditions (Murray et al., 2012). However, the small evidence base from developing countries is underdeveloped which serves to highlight the need for appropriate cultural adaptation/ translation of programs based on social and behavioral models and theories, from more developed settings.

Public Health Theories and Models

Understanding the alterable causes of the burden of disease can help inform responses to these challenges nationally, regionally, and internationally, as well as within population subgroups. There are numerous factors which explain the changing patterns of morbidity, mortality, and the spread of disease, globally and between regions and countries, relating to population growth, aging and changes to family, social structures, education and reproductive patterns, and changes in ecological and living environments. An evidence base for these multilevel determinants of health has been extensively developed over the past decade (Roux, 2008), in particular, particularly the important relationships between behavior and health. Fisher et al. (2011) have recently reviewed the central role that behavior has in health and the importance of behavioral interventions to prevent disease, improve management of existing disease, increase quality of life, and reduce health-care costs.

Mokdad et al. (2004) demonstrated the relative contribution of alterable health behaviors and social factors to mortality and morbidity in the United States. They concluded that the primary causes of death in 2000 were tobacco and alcohol use, poor diet, and physical inactivity (World Health Organisation, 2005); however, the conditions of the society were also very important as more fundamental causes of health. More recently, the United States Centers for Disease Control and Prevention released a key report estimating that 14 of the top 15 causes of death in the United States are attributable to modifiable behaviors, including physical inactivity, diet, smoking, alcohol and other drug use, injury control, sun protective behaviors, appropriate use of medicines, immunization, sexual and reproductive health, oral hygiene, and mental health (Heron et al., 2009). An increased understanding of the social, economic, and environmental influences on behaviors leading to health (and ill health) from an individual to a neighborhood/community level and to a global level is consistent with a socioecological model of health that can also be used to understand the rapid increase in chronic NCDs reflected by tobacco, poor diet, physical inactivity, and sedentariness. These findings from a considerable amount of social and behavioral epidemiologic research conducted over the past 40 years demonstrate that a substantial part of the global disease burden is attributable to these multiple levels of influences from the society where we live. This underlines the importance of gaining more of an understanding of the social, environmental, and other determinants of human behavior and how these can be influenced and changed. Theories and models are very important for this improved understanding.

Theories and models from the social and behavioral sciences not only help to explain health-related behaviors and their downstream and more upstream determinants, they can also help guide the development of interventions to influence and change both the determinants of and health-related behaviors themselves and, thereby, improve health of individuals and populations. Theories can also help understand adherence to a health regimen, identify the kinds of information and other details needed to develop effective intervention programs, provide guidelines on effective communication, and identify barriers to be overcome in implementing an intervention.

This article adopts a widespread definition of theory (Glanz et al., 2008), by which a theory is seen as a set of related concepts, definitions, and assumptions about relations between concepts that allow understanding events or situations in a systematic way. The most important notions perhaps are that theories can be applied to multiple problems and they should also be testable, which means that we can generate and examine data that tells us something about how well a theory is suited to explain a specific public health problem. This means that we should select theories (or elements of theories) on the basis of the evidence of such tests of how well they explain and predict a specific problem rather than their face validity or what might appear plausible. Theories can be useful for understanding the determinants of behavior and how to improve health at multiple levels, that is, at an individual, interpersonal, institutional/organizational, community, and/or societal level.

Theories can also be used as basis for public health measures to specific populations to increase effectiveness. For example, target group-specific theories such as the Gelberg– Andersen behavioral model for vulnerable populations (Gelberg et al., 2000) explicitly include frequent behavioral problems in vulnerable populations as predisposing variables that impact on health-care utilization. On the other hand, demographic characteristics (e.g., age, sex, cultural background, behavioral characteristics) of the target group can be taken into account in identifying the most promising theory-based methods.

Furthermore, an important distinction can be made between theories that explain behavior (e.g., ‘The Theory of Planned Behavior,’ Ajzen, 1991) and theories that explain change in individuals and organizations (e.g., ‘Diffusion of Innovations,’ theory Oldenburg and Glanz, 2008). The former are useful in outlining factors that are for example responsible for engaging in a specific behavior, the latter are useful in identifying factors that promote change. On the level of individual behavior, a range of theories have been examined in the public health context. These include theories such as the Health Belief Model, the Theory of Planned Behavior, interpersonal theories such as Social Cognitive Theory, stage theories such as the Transtheoretical Model, or hybrid theories such as the Health Action Process Approach. These theories outline variables on the level of the individual that explain individual health-related behavior. For example, a very parsimonious approach, the Health Belief Model, proposes the more susceptible someone feels to a health problem, the more severe they see this health problem, and the more advantages as well as the less costs of a protective behavior they perceive, the more likely they are to engage in this protective behavior. Theories such as the Health Action Process Approach (Schwarzer and Luszczynska, 2008) are more sophisticated, include several stages of behavioral preparedness with different psychosocial influence factors, and assume different phases of behavior initiation, maintenance, and recovery. Practical approaches go beyond the application of one specific model and move toward the identification of effective behavior change techniques.

However, in public health, the scope of intervention usually goes beyond the individual and therefore needs to be based on theories that go beyond the individual. For example, interventions that target health at the workplace need to account for workplace factors that interact with individual health such as an imbalance between rewards and efforts (Siegrist, 1996) or workplace demands and control (Karasek, 1979). More integrative theories such as the Reserve Capacity Model (Gallo, 2009) can help to understand how socioeconomic factors interact with individual factors in determining health. There have also been recent efforts to integrate environmental factors with individual predictors of health behaviors, for example, the interactions between environmental factors such as district-level resources and attitudes, or self-efficacy and the built environment (Carlson et al., 2012) in predicting health behaviors such as physical activity.

Theories such as Social Cognitive Theory (for an overview, see McAlister et al., 2008) assume that health-related behavior is both shaped by the individual and the social environment within which individuals live. By observing others’ behavior and the results of others’ behaviors, we shape our own expectations, make learning experiences, and determine our capability to change health-related behavior (social learning). Theories that operate on this level of influence on health can help to understand and (potentially) modify the effects of interpersonal networks such as families, friends, or peers on behavior.

Finally, on the level of organizations and society more broadly, theories about the functioning of social systems consider factors that impact on change of institutions, organizations, or communities. For example, the Diffusions of Innovations Theory (Oldenburg and Glanz, 2008) proposes that the degree to which innovations (such as health initiatives) permeate a social group is determined by the communication channels available, the time since the innovation and properties of the social system. Understanding these parameters can help to identify access points for interventions to achieve wide-reaching distribution.

From a practical viewpoint, however, the interaction between environmental, social, and individual influences on behavior can be very complex, so that more integrative models or frameworks that operationalize health promotion and prevention as a process through multiple levels, from individual to policy level, are often employed as tools to develop, implement, and evaluate such programs.

One such framework, the PRECEDE–PROCEED model (Green and Kreuter, 2005) outlines eight steps that allow mapping a series of measures to promote health on different levels – from the individual to policy makers. The model includes a detailed needs assessment of the health problem on a social, an epidemiological, behavioral and environmental, an educational and ecological, and an administrative and policy level. More importantly, this model also includes a framework for evaluating the impact of interventions on these different levels and thus provides an integrative framework that allows including theories for individual and organizational change on different levels. Furthermore, Intervention Mapping (Bartholomew et al., 2011) has also been developed as a very comprehensive model that identifies theory as well as theory- and evidence-based methods to promote behavior change that can be integrated into the PRECEDE–PROCEED framework. It involves the specification of a series of matrices outlining the change objectives and determinants of change on various levels (e.g., determinants of individual increases of physical activity in a specific target population need to be linked with the determinants of an organization adopting a workplace health promotion intervention based on these individual determinants of physical activity). Such integrative and multilevel models are increasingly used as comprehensive frameworks to understand the determinants of a particular health issue or behavior and to develop effective public health interventions.

Implementation and Wider Uptake of the Social and Behavioral Science Evidence Base to Improve Public Health

With the development, implementation, and evaluation of a series of major community-based cardiovascular prevention trials during the 1970s and 1980s, widespread use was made of multilevel intervention or change strategies underpinned by behavioral and social science theories and research for the first time. Importantly, these strategies did not focus exclusively on change in the individual. Instead, preventive strategies using multiple approaches were directed at the media, legislation, and the use of restrictive policies, and involved specific settings such as schools, the workplace, health-care settings, and other key groups in the community, with the aim of reducing population rates of risk behaviors, morbidity, and mortality.

The North Karelia Project in Finland (Puska et al., 1985) was initiated in response to concern that the community, at that time, had the highest risk of heart attack worldwide. Strategies included tobacco taxation and restriction, televised instruction in skills for nonsmoking and vegetable growing, and extensive organization and networking to build an education and advocacy organization. After 10 years, results indicated significant reductions in smoking, blood pressure, and cholesterol, and a 24% reduction in coronary heart disease mortality among middle-aged males. The Stanford Three Community Study (Maccoby et al., 1977) demonstrated the feasibility and effectiveness of mass media-based educational campaigns and achieved significant reductions in cholesterol and fat intake. The Minnesota Heart Health Project (Mittelmark et al., 1986) used interventions aimed at raising public awareness of risk factors for coronary heart disease, and changing risk behaviors through education of health professionals and environmental change programs, such as grocery store and restaurant labeling.

Worksite intervention trials, such as the Working Well Trial (Sorensen et al., 1996), also utilized interventions aimed at favorably altering social and psychological factors known to influence health-related behaviors, including increased awareness of benefits, increased self-efficacy, increased social support, and reduced perception of barriers. Strategies in this setting can include promotion of nonsmoking policies, increasing the availability of healthy foods in canteens and vending machines, group education sessions, and access to exercise facilities. School-based interventions provide an established setting for reaching children, adolescents, and their families to address age-pertinent health issues such as smoking, teenage pregnancy, and substance use. Strategies have targeted social reinforcement, school food service, health-related knowledge and attitudes, local ordinances, peer leaders, and social norms.

In evaluating the effectiveness of such trials, Rose (1992) states that it is important to acknowledge the differences between clinical and more population-based approaches. Clinical approaches, while more likely to result in greater mean changes in individuals, are less significant at a population level because fewer individuals are involved. In contrast, the small mean changes achieved by population-based approaches, if applied to a large number of people, have the potential to impact much more significantly on population rates of disease and health. Furthermore, one of the difficulties in evaluating such population-based approaches is the length of time required to demonstrate changes in population rates of health outcomes. While researchers can readily measure changes in a behavioral outcome – such as the rate of smoking cessation – following a widespread and well-conducted program, the time required for such behavioral changes to impact upon long-term morbidity and mortality – such as lung cancer – is much more problematic. Nevertheless, many of the above-identified behavior-based trials demonstrate the value of social and behavioral theories and the feasibility of activating communities in the pursuit of health.

The ultimate value of this research must be determined by the extent to which the knowledge generated is widely disseminated, adopted, implemented, and maintained by ‘users’ and, ultimately, by its impact on systems and policy at a regional, state, and/or national level (i.e., institutionalization). While considerable effort and resources are devoted to developing effective interventions, relatively little attention has been given to developing and researching effective methods for the diffusion and implementation of their use. It is important to acknowledge that the availability of relevant research findings does not in itself guarantee good practice. Such knowledge transfer involves the development of formal research policies, formalized organizational structural support, appropriate and targeted funding, formal monitoring of activity, and ongoing training.

In essence, achieving the effective diffusion of innovations, both within the general community and in organizational settings, involves change, and the change principles which underpin the diffusion process are not so different to those previously identified for understanding change at the individual, organizational, or community levels. At the level of the individual, family, or small group, uptake of a health promotion innovation typically involves changes in behaviors or lifestyle practices which will either reduce risk factors or promote health. At an organizational level, such as the workplace, school, or the health-care setting, successful uptake of an innovation may require the introduction of particular programs or services, changes in policies or regulations, or changes in the roles and functions of particular personnel. At a broader community-wide or even societal level, the change process can involve the use of the media and changes in governmental policies and legislation, as well as coordination of a variety of other initiatives at the individual and the settings level.

However, in considering the principles that underpin the diffusion of innovations at a population level, further complexity arises from the need to consider change occurring at multiple levels, across many different settings, and resulting from the use of many different change strategies. This requires the application of multiple models and theories to develop frameworks with sufficient explanatory power.

Looking to the Future

It is difficult to be certain about the public health challenges that lie ahead in the twenty-first century. It is clear that in all countries, there is still a need to reduce preventable disease and premature death, reduce health inequalities, and develop sustainable public health programs. Much of the social and behavioral science research conducted with individuals is still relevant in the field of public health, as are many of the models and theories developed and tested over the past 40 years. To move to a population-based focus, we need innovative means of implementing such knowledge, and methodologies so as to increase the reach of such programs to more people, particularly the most disadvantaged individuals and sections of society.

Adopting preventive approaches to improve health, acknowledging and acting on the importance of social and environmental factors as major determinants of population health, and reducing health inequalities provides a substantial challenge to public health now and in the future. Furthermore, limited resources place an emphasis on evaluating the affordability and sustainability of public health interventions. Public health should be at the forefront of developing and researching effective intervention methods and strategies for current and future health challenges, with global sharing of information in terms of monitoring health outcomes and development of the evidence base. However, this research should not focus solely on developing strategies and testing their efficacy and effectiveness. There is an important need for research that examines larger scale implementation and diffusion of these strategies to whole communities and populations, through the innovative use of a variety of psychological, social, and environmental intervention methods, including evidence from the social and behavioral sciences.

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