The World Health Organization’s (WHO) Ottawa Charter for Health Promotion (1986) states that health is created and lived w'ithin the settings of everyday life. A healthy settings approach employs a “whole systems” view to integrate action across sectors, determinants, and risks. Changing w'hole socio-ecological systems can be a daunting task given their complex and dynamic nature. The literature on leading change in socio-ecological systems dictates that complex systems cannot be changed by the top-down, command and control forms of management but instead needs a collaborative, inclusive and participatory action and that the capacity of individuals to act independently and make their own free choices is critical for systems change (Westley et al., 2013). The frequent disconnect between what we know about the biology and epidemiology of a health issue and program success has led to a growing realization that political, social, or economic conditions are often the primary determinants of success of health interventions. Health promotion and harm reduction, therefore, need to influence change at the personal, interpersonal, institutional, community, systems, and policy levels to successfully implement and sustain change.

Organizational Change

Lewin’s Theory of Change describes three stages of change in organizations: (i) people are ready to alter the status quo (unfreezing); (ii) a new state of affairs is created and customized to a setting through trial and error (changing); and (iii) new behaviours are implemented, creating a new' organizational system

(refreezing) (Kritsonis, 2005). Internal forces (such as an organization’s structure, leadership, strategy, and personnel) and external factors (such a public policy or market forces) encourage or impede movement through these changes.

Diffusion Theory addresses how new ideas and practices spread (Dearing, 2009). Firstly, new ideas are generated. Secondly, advocacy and screening help evaluate if an idea matches core beliefs of an organization and compares its advantages and risks. Thirdly, the idea is incrementally implemented, tested, and adjusted to fit the organization. Fourthly, change is implemented with ongoing assessment of its usefulness. Finally, the change is institutionalized. Diffusion Theory has been used to study the adoption of a wide range of health behaviours such as condom use, smoking cessation, and use of new tests and medical technologies.

Kotter’s eight steps to change (as described in Appelbaum et al„ 2012) (Table 9.3) has been used to lead change in the private and public sectors. For example, it was used in Canada in 2018 to lead provincial, territorial, and federal government ministers to adopt a new Pan-Canadian Approach to Wildlife Health (Stephen, 2019). It has been used by hospital managers, clinicians, and nurses to change clinical practices in hospital settings. It has guided the implementation of conservation practices. Kotter’s eight steps need to be adopted and adapted to meet where the organization is in its readiness for change and with the organization’s culture. Like all theories of change, its use does not guarantee success, but it can help plan change management process in an explicit and systematic fashion.


Steps Leading to Change



Create a sense of urgency

People will not change if they cannot see the need to do so

Create a guiding coalition

Assemble and support a group with energy and influence in the organization to lead the change

Develop a vision and strategy

Tell people why the change is needed and how it will be achieved. Change is more likely to happen if people know not just how but also why

Communicate the vision

Tell people, through multiple modes of communication and at every opportunity, about the why, what, and how of the changes

Empower broad-based action

Involve other people in the change effort. Help them see the advantages of change and how to achieve it rather than thinking about why they do not like the change and how to stop it

Make short-term wins

Seeing progress towards the larger vision and seeing that change is happening and having effects helps sustain involvement

Consolidate gains and produce more change

Building on successes of small changes invigorates people and helps them see themselves as agents of change

Solidify the changes in the organization’s culture

Institutionalize the changes through advocacy and re-enforcement to prevent reversion to the old and comfortable ways of doing things


Critical Questions to Answer When Promoting Organizational Change

Is the proposed change better than what it is meant to replace? (the criteria forjudging better may differ from person-to-person and organization-to-organization)

Is the proposed change compatible with the organization’s mandate, and does the organization have the capacity to change?

How easy will it be to implement the proposed change?

Can the change be tried and tested for being fit for the organization before it is fully implemented?

Will the change result in tangible results that are observable and easy to measure?

Source: Adapted from USDHHS, 2005.

The answers to some questions in Table 9.4 will affect whether change will be adopted and spread in an organization. Understanding who says what, in which ways, to whom, and with what effects as well as who are the formal and informal leaders in an organization can help tailor communications within an organization to disseminate the answers to these questions.

There are three essential elements needed to ensure an organization can act to promote health: (i) a mandate to act, (ii) a framework for action, and (iii) the capacity to act. It is worth remembering that it is people who change and not organizations. The concepts and theories described above for supporting individual change are also relevant to supporting community and organizational change.

Community Chance

A community can be defined in geographical terms as a group connected by shared interests, as a community of collective identities, or as a group of interacting organisms that live in a shared habitat. Community structures and norms constrain individual health behaviours. The state, the market, the social environment, and the local environmental conditions establish the texture of daily life. Not all communities are the same, so there is no one-size-fits-all approach to community interventions. It takes time and effort to understand a community, especially if you are not a member of it. But that effort will help you build trust with the community as well as understand the community’s strengths, challenges, and prevailing attitudes and opinions. Time, effort, and resources can be misdirected without understanding the underlying reasons behind the problem and the opportunities and willingness to change.

Community change happens when local people work together to transform the conditions and outcomes that matter to them. A key to community change is finding out what is important to people in the community and helping them reach their goals rather than organizing people to do something you think should be done. This principle underlies the harm reduction approach described in Chapter 6. Those wishing to enable community change need to understand the community


Five Stages of Community Change Described by the U.S. Centers for Disease Control and Prevention (USCDC, 2018)




A coalition of community members is assembled and partnerships with other agencies are established to give participants ownership of the process and to create a pool of fiscal and human resources to support change strategies


Data and input on what the community needs are gathered in a manner that gives the community a voice in the process. This stage helps to organize the community around the issue and can significantly influence program design


The community coalition works with key partners to collectively develop a plan to implement the change


Stakeholders and partners in collaboration with the community team implement and maintain the change by securing commitment and ownership of the actions needed to lead to the desired change


Evaluation runs throughout the entire change process. It serves to determine if you are implementing the right strategies and if the desired impacts are being realized

context, be adept at inspiring and maintaining collaborative and participatory planning, and have the leadership skills to attract and sustain participation.

The Centers for Disease Control and Prevention in the United States described five phases in the process of community change (Table 9.5) (USCDC, 2018).

A good community action plan maps a clear course of action, including roles and responsibilities and specific outcome and output targets. There can be an unlimited number of possible deterrents and motivators for behaviour change within a community. The more that are included as targets for an action plan, the more complex and complicated it will be to achieve the plan’s goals. Working with community partners can help identify those actions that are feasible within what we know and the resources at hand that are acceptable to the community and are technically feasible. While it is reasonable to include recommendations to make fundamental changes in knowledge, governance, or regulations, few of such changes come to fruition in a timely manner. Threats of harms can prevail and action on shared goals can be delayed if actions wait until new knowledge, regulations, or technology can be secured. Strategic collaborations are needed in community action plans to promote actions to reduce the more immediate harmful consequences of an activity through pragmatic, realistic, and low-threshold programs feasible under current conditions.

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