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Health Promotion International Advance Access published November 14, 2014

Health Promotion International # The Author 2014. Published by Oxford University Press. All rights reserved.
doi:10.1093/heapro/dau098 For Permissions, please email:

Organizational change theory: implications for health

promotion practice
School of Public Health and Preventive Medicine, Monash University, Level 3 Burnet Tower (Alfred
Hospital), 89 Commercial Road, Melbourne, Victoria 3004, Australia and 2School of Psychological

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Sciences, Monash University, Building 17, Clayton Campus, Wellington Road, VIC, 3800 Australia
*Corresponding author. E-mail:

Sophisticated understandings of organizational dynamics is allocated to truly institutionalize change; the ability of
and processes of organizational change are crucial for the the agents of change to build short-term success deliberately
development and success of health promotion initiatives. into their implementation plan; whether or not the shared
Theory has a valuable contribution to make in under- group experience of action for change is positive or negative
standing organizational change, for identifying influential and the degree to which agencies that are the intended recipi-
factors that should be the focus of change efforts and for ents of change are resourced to focus on internal factors.
selecting the strategies that can be applied to promote In reviewing theories of organizational change, the article
change. This article reviews select organizational change also addresses strategies for facilitating the adoption of key
models to identify the most pertinent insights for health theoretical insights into the design and implementation of
promotion practitioners. Theoretically derived considera- health promotion initiatives in diverse organizational settings.
tions for practitioners who seek to foster organizational If nothing else, aligning health promotion with organizational
change include the extent to which the initiative is modifi- change theory promises insights into what it is that health pro-
able to fit with the internal context; the amount of time that moters do and the time that it can take to do it effectively.

Key words: organizational change; innovation; capacity building; organizational development

INTRODUCTION Commission on the Social Determinants of

Health, emphasized the need to assess and build
There is broad international consensus that build- the capacity of health systems and other sectors.
ing the capacity of communities, organizations Capacities for policy advocacy, development, im-
and systems is a critical area of action for tackling plementation and evaluation were highlighted as
the public health challenges of the 21st century. important. Most recently, in the Helsinki State-
At the 7th Global Conference on Health Promo- ment on Health in all Policies issued at the 8th
tion in Nairobi, Kenya, a renewed call was made Global Conference on Health Promotion in
to build sustainable capacity and infrastructure to Helsinki, Finland, there was recognition that buil-
achieve the effective implementation of health ding institutional capacity and skills will play a
and development strategies (World Health central role in achieving the implementation of
Organization, 2009). Ziglio and Apfel (Ziglio and Health in All Policies (World Health Organisation
Apfel, 2009), commenting on the actions required and Ministry of Social Affairs and Health
to address the priorities outlined by the WHO Finland, 2013). The Helsinki statement emphasized

Page 1 of 11
Page 2 of 11 D. Batras et al.
capacity building in relation to the structures, pro- leadership and internal management processes.
cesses and resources required for policy implemen- The employment of a project officer with skills to
tation across sectors. engage senior managers and to facilitate collabora-
Capacity building is understood to involve tive planning within the councils was found to be a
actions to improve knowledge and skills, support feature of those councils that were successful in
and infrastructure within organizations, and part- achieving the programmes objectives.
nerships for action (New South Wales Health The creation of healthy settings and the devel-
Department, 2001; Smith et al., 2006). The purpose opment of partnerships to tackle the determi-
of these actions is to create new approaches, values nants of health are areas of practice where
and structures for addressing health issues (Crisp organizational development is a strategic prior-
et al., 2000) and ultimately sustainable systems for ity. This places health promotion practitioners in
the ongoing execution of programmes (Potter and the role of policy entrepreneurs and change
Brough, 2004). This situates organizations, their agents, operating in organizational contexts that
objectives and the way they conduct their day-to- are often structurally, culturally and politically
day business, as a foremost concern in health diverse. Devine et al. (Devine et al., 2008) report
promotion. that the use of independent people in worksite

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The settings approach, which has a central health promotion initiatives is fundamental for
place in contemporary health promotion, has achieving mutually beneficial health and well-
been described as essentially about developing a being outcomes through a change initiative.
commitment to health within the cultures, pro- Health promotion practitioners may need to
cesses and routine life of organizations (Dooris, work with staff, managers and researchers, and
2006). In support of this, DeJoy and Wilson consider the dynamics of the setting, the position
(DeJoy and Wilson, 2003) argue that the creation of the change initiative within it, and then influ-
and maintenance of healthy workplaces is deter- ence context, structure and culture. This raises
mined by organizational culture and leadership, the question about whether practitioners are
reflected in practices, policies and values, and ul- equipped with an understanding of organization-
timately workplace climate, job design and job al dynamics and processes of change, to enable
security. Whitelaw et al. (Whitelaw et al., 2012) their work to be effective. Theory has a valuable
have discussed the critical role of organizational contribution to make in this regard, for identify-
capacity building in the development of Health ing influential factors that should be the focus of
Promoting Health Services (HPHS) in the UK, change efforts and for selecting the strategies
which involved creating a supportive policy that can be applied to modify these (Green,
context and alignment of HPHS with the under- 2000; Lee et al., 2014). Theory also has an im-
lying governance and appraisal mechanisms of portant role to play in guiding the evaluation of
health services. Efforts to develop healthy sport- organizational change strategies and building the
ing settings have also given priority to organiza- evidence base for this work (Birckmayer and
tional change (Crisp and Swerissen, 2003), so that Weiss, 2000). Little is known about knowledge
policies and structures are put in place to enable and use of organizational change theory by
the routinization of health promotion strategies. health promotion practitioners, but one survey
The scaling up of health promotion strategies, undertaken in Australia found that this was ex-
and the engagement of partners within and outside tremely low (Jones and Donovan, 2004).
the health sector in programme delivery, is another As de Leeuw (de Leeuw, 2011) has argued,
area of practice where organizational capacity there is great scope for health practice innovation
building is of prime importance (Hanusaik et al., and improvement through interdisciplinary theor-
2010; Hearld et al., 2012). Joffres et al. (Joffres etical engagement. The purpose of this article is to
et al., 2004), investigating the involvement of orga- review a selection of theories from management,
nizations in heart health promotion in Nova Scotia, education and social psychology disciplines that
Canada, found that leadership, management prac- identify determinants of organizational practice
tices and sustained funding were determinants of and describe methods that can be used to instigate
the nature and extent of strategies that were change. Models reviewed in this article include
implemented. In an evaluation of physical activity Diffusion of Innovations, Organizational Learning,
strategies by local councils in Melbourne, Victoria, Organizational Culture and Leadership, Action
Thomas et al. (Thomas et al., 2009) reached Research, the Three-step model and Field Theory
similar conclusions about the influence of senior and Receptive Contexts for Change. Following a
Organizational change theory Page 3 of 11
description of each, the theories are compared and of the conditions of change [(Lewin, 1997b),
contrasted, and their applications to current chal- p. 201]. The field is the culmination of a number of
lenges in health promotion practice are considered. interrelated factors in the environment; it is time
dependent and maintained by varying forces
(Lewin, 1997b, c). These forces may include intern-
ORGANIZATIONAL CHANGE THEORIES al characteristics of the organizations structure,
strategy, management and personnel, or external
A targeted literature search was conducted to iden- characteristics, for example, the market and/or
tify influential organizational change models in policy context. Lewin (Lewin, 1997c) argued that
the field of organizational development. Given the the analysis of these forces would enable practi-
extent of this literature, the authors agreed on the tioners to understand why groups act as they do
following three inclusion criteria. Preference was and what forces would need to be diminished or
given to theorists whose work appeared to have a strengthened to bring about planned change.
foundational influence on the field. Additionally, Lewin (Lewin, 1997c) also wrote about group dy-
theories that were explanatory in nature and there- namics, noting that individuals are influenced by
fore could provide interpretive value for health group norms and pressures to conform such that

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promotion were included. And lastly, theory devel- group behaviour should be the target for change.
oped from empirical research in settings to guide This is because group decision-making is powerful
organizational change for health was included. with respect to bringing about lasting behavioural
The table below summarizes the key bodies of change among group members.
work that met these criteria, Table 1. The lessons from field theory and Lewins work
The review that follows will concentrate on in group dynamics have been incorporated into the
common aspects across these organizational development of practical approaches that could
change models. For example, each perspective be applied by health practitioners to facilitate the
involves analysis of the setting, views change as a process of change. These approaches include
process and recognizes that each environment is Lewins formulation of action research and the
unique. Additionally, each organizational per- three-step model. An action research approach
spective in the review that follows offers generic involves analyzing the current situation of an or-
considerations applicable to any setting, and sug- ganization, identifying the range of possible change
gests that some conditions impinging on a setting solutions and choosing the one that is most appro-
can be manipulated to bring about a planned priate (Burnes, 2004). Concurrently, there needs
outcome. to be a felt-need for change, a realization by the
group that change is necessary. Furthermore,
success through action research involves a partici-
Lewins theories of change patory process at a group level rather than indivi-
The work of Kurt Lewin has profoundly influenced dual level, which is consistent with the view about
the field of organizational development. He is group behaviour being the target for change.
most famously known for the development of field Devine et al. (Devine et al., 2008) have described
theory, group dynamics, action research and the the use of an action research approach to address
three-step model of change. Burnes (Burnes, 2004) workplace health and safety issues at a mine in
argues that the unification of these themes in Queensland, Australia, whereby university re-
Lewins work is necessary to understand and searchers, management and staff worked together
create change, and thus should be viewed by as agents of change to identify and address promin-
change practitioners in their totality rather than as ent health and safety concerns. The use of this ap-
separate theories. Field theory is a way of learning proach led to staff agency and ownership over
about group behaviour in a particular setting; it health and well-being and improvements in work-
involves mapping the field in its entirety and con- site conditions.
sidering its complexity and influence on the Lewin acknowledged that change can often be
observed behaviours (Lewin, 1997a; Burnes, 2004). short lived in the face of setbacks, leading to the
Lewins analysis proceeds from the conviction that design of a three-step model to guide practi-
individual behaviour is a function of the group en- tioners in this process:
vironment or field. Field theory is a method of
analyzing causal relations and of building scientific (1) Unfreezinginvolves creating dissatisfaction
constructs; a focal point for analysis is the nature with the status quo, benchmarking against
Page 4 of 11 D. Batras et al.
Table 1: Summary of key perspectives on organizational change

Change theorist/s Explanatory factors Change strategy

Kurt Lewin The status quo is the product of a number of forces Create the appropriate conditions for
in the social environment that govern individuals sustained change to occur through a group
behaviour at a given point in time. As such causal process of trial and error until an
relations can be analyzed. Change initiatives need appropriate fit is found.
to destabilize the status quo, implement the
alternative and restabilize the environment. The
implementation process involves research and
performs a learning function.
Everett Rogers Messages about new ideas are communicated within Innovations follow a sequential course within
an organization and this brings about uncertainty. organizations, and attention to each stage is
An organizations propensity for innovation required for an innovation can fail before it
relates to structural factors within the has begun to diffuse.
organization, characteristics of individuals and
external factors in the environment.
Chris Argyris and The learning type of the organization and its To promote a culture of learning, attention

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Donald Schon members influences the acceptance of change. needs to be given to enabling room for
Organizational environments with a propensity higher learning to occur by effort to bring
towards defending existing norms have different about congruence between what is said and
capacity for learning and growth compared with what is donethe talk and the walk.
organizational environments that are open and
Edgar Schein Culture can be observed and studied through the To embed a change it needs to become
behaviour of groups and their beliefs, values and cultural. Repeated experiences of success or
assumptions. The culture of the organization failure for a group undertaking an action
determines its actions. Culture is formed over will lead to them forming an assumption
time through shared experiences within groups. about the value of that action. Values,
beliefs and behaviours in support of that
action indicate that it has become part of
the culture of the group.
Andrew Pettigrew, The degree to which a public sector institution is Use the variables identified as part of a
Ewan Ferlie and amenable to change depends on a combination of criteria for selecting settings that are likely
Lorna Mckee variables that are associated with the process and to be receptive to change, and within those
setting for change. These include quality and settings identify and manipulate the
coherence of policy, availability of key people variables that are not static.
leading change, long-term environmental
pressure, supportive organizational culture,
effective managerial-clinical relations,
cooperative inter-organizational networks,
simplicity and clarity of goals and priorities, and
fit between the districts change agenda and its

other organizations, internal performance support the continuation of the change. For
barrier diagnosis and survival anxiety that example, aligning pay and reward systems, re-
exceeds learning anxiety (a realization that engineer measurement systems, create new
the potential benefits of change outweigh the organizational structures (Lewin, 1997c).
potential negatives associated with the
process) (Schein, 2010). Heward et al. (Heward et al., 2007) described
(2) Movingis the implementation and trialling how the work of Lewin has been applied in the
aspect of change, involving research, action Victorian public service (Australia) to analyze
and learning. Actions may include redesign- the forces resisting change to health promotion
ing roles, responsibilities and relationships, capacity building. Lewins organizational change
training and up-skilling, promoting supporters/ theory was used in two of the case studies of re-
removing resisters. search undertaken in health promotion: in one
(3) Refreezingorganizational norms, culture, case study, it was used to assist with conceptual
practices and policies becoming realigned to analysis of capacity building implementation
Organizational change theory Page 5 of 11
Table 2: Rogers (2003) characteristics of organizational structure

Variable Description

Size Size of the organization is related to propensity for innovation, generally the larger the organization
the more innovative.
Centralization Centralization in an organization involves the concentration of power to a few individuals; this has a
negative effect on how innovative an organization is. However, centralization can encourage the
implementation of an innovation once a decision has been made to adopt.
Complexity Complexity is the degree to which an organizations team members have a range of specialties and
high level of knowledge and expertise. This is positive for the valuing of innovations, but consensus
about implementation can become a challenge with complexity.
Formalization Formalization through rules and procedures makes an organization bureaucratic; this acts as an
inhibitor for organizations to consider innovations but encourages the implementation.
Interconnectedness Interconnectedness involves groups and individuals within an organization being interpersonally
linked; new ideas can flow more easily in organizations that have higher degrees of network
Organizational slack Organizational slack is a factor that relates back to organizational size in that slack is the degree of
resources that an organization has available that have not been committed elsewhere. This may be

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something that larger organizations have more freely available; therefore, there is more opportunity
to be able to focus on innovation.

strategies. The second case study was about the an innovation is to a large degree determined by
implementation of health promotion technology how compatible it is with the values, beliefs and
in which Lewins work was used as the basis for a past experiences of individuals in the organiza-
selective coding framework for content analysis tion or social system, Figure 1.
of qualitative data that were gathered (Heward Later stages in the innovation process cannot be
et al., 2007). Analysis of each case study indicated undertaken until earlier stages have been com-
that efficiency, effectiveness and sustainability pleted, either explicitly or implicitly. A change
can be maximized by incorporating organization- focused initiative/innovation also requires a cham-
al change as a central component of health pro- pion to advocate for the change. Champions
motion practice and research. should have influence within the organization in
which change is taking place, to energize the initia-
Diffusion theory tive, and should possess negotiation skills (Steckler
Diffusion theory describes the communication and Goodman, 1989; Rogers, 2003). Champions
of messages about an innovation within a social are key for sustainability of health promotion
system. Rogers (Rogers, 2003) identifies three initiatives (OLoughlin et al., 1998), particularly in
key characteristics that relate to an organizations instances in which they share personal and social
propensity for innovation: individual (leader) characteristics with the recipients of innovation.
characteristics, internal characteristics of organ- Gates et al. (Gates et al., 2006) utilized diffusion of
izational structure and external characteristics of innovations theory to inform planning for a work-
the organization. Within these broad categories, place programme to increase healthy eating and
there are sub-variables such as organization size physical activity among manufacturing company
and leadership for change, which positively or employees. Focus group discussions were held
negatively impact an organizations capacity for with managers and staff to explore perceptions
innovation. concerning the relative advantage, compatibility
The variables identified by Rogers (Rogers, and complexity of actions to address these beha-
2003) as characteristics of organizational struc- viours. These revealed individual and workplace
tures are described in Table 2. factors that needed to be addressed to reduce bar-
Organizations go through five stages as part of riers to adoption.
the diffusion of innovation process. The initi-
ation and implementation phases are separated
by the decision to adopt or not to adopt. An Organizational learningtheories of action
adopted innovation proceeds through the three Argyris and Schons organizational learning
stages in the implementation phase. According provides a valuable foundation for understanding
to Rogers (Rogers, 2003), the rate of adoption of the behaviour of individuals and groups in
Page 6 of 11 D. Batras et al.

Fig. 1: Stages of the innovation process in organizations. Adapted from Rogers (Rogers, 2003).

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organizations as well as organizational behaviour Those elements are governing variables, action
modification through change initiatives. Argyris strategies and consequences:
and Schons (Argyris and Schon, 1996) theories
Governing variables are beliefs, philosophies
of action describe how the thinking of indivi-
of the organization and workers within the or-
duals and subgroups in organizations translates
ganization. Model 1 has defensive governing
into behaviours that either encourage or inhibit
variables such as maximize winning and min-
organizational learning. Theories-in-use are
imize losing, whereas model 2 theory-in-use
motives, values and beliefs that are translated into
has more open governing variables such as
action and are implicit in what people do as man-
free and informed choice.
agers and employees. Theories-in-use govern indi-
Action strategies are actions that will be exe-
viduals behaviour, because they are implicit
cuted depending on the governing variables.
assumptions that tell group members how to per-
Consequences of action are broken down into
ceive, think and feel (Argyris, 1976; Argyris and
two categories: consequences for the behav-
Schon, 1996). On the other hand, espoused theory
ioural world and consequences for learning.
of action refers to the concept to which managers
and employees give allegiance if they are asked The ultimate aim for an organization interested
to communicate their actions to others. However, in change is to move from Model 1 to Model 2
the theory that actually governs individuals theories-in-use with their double-loop learning.
actions is their theory-in-use. For example, a man- Single-loop learning involves the detection and
agers espoused theory may be that health promo- correction of error. Where something goes wrong,
tion strategies should be based on a review of the an initial port of call for many people is to look for
current evidence of what is best practice. But her an action that will address and work within the
theory-in-use is our team is abreast of what good existing governing variables (beliefs and philoso-
practice is, and thus, a small group of practi- phies of the organization). Double-loop learning
tioners discuss plausible strategies, begin imple- is learning that occurs when an organizations gov-
mentation and in later reports link their actions to erning variables are subjected to critical scrutiny.
the evidence in the literature that supports their This type of learning may lead to an alteration of
choice of strategies. existing governing variables and ultimately shift
Effectiveness in organizational learning results the way in which strategies and consequences are
from developing congruence between theory- framed. For example, this may involve the modifi-
in-use and espoused theory. Argyris and Schon cation of an organizations underlying norms, pol-
(Argyris and Schon, 1996) describe two separate icies and objectives. Organizations that promote
models (Model 1 and Model 2) of theories-in-use double-loop learning are likely to be more favour-
that lead to two different types of organizational able settings for health promoters who are seeking
learning. For both Model 1 and Model 2 theor- to influence the values, beliefs and actions of an
ies-in-use, three elements influence the type of organization. This is because health promotion
learning that an organization will experience. ideologies such as health equity may be viewed as
Organizational change theory Page 7 of 11
an innovative change to strategy, practice and good eventually transfers to a shared assumption
structure. To achieve this kind of change, Rogers within the organization. Assumptions within an
(Rogers, 2003) argued that proponents of innov- organization are difficult to change as they are
ation need to be granted some creative freedom often regarded as non-negotiable values. These
and protection to agenda set and match, fol- values, and the behaviours that are subsequently
lowed by a decision to implement. exhibited by employees and leaders, form the
The value of theory that informs an open and culture of the organization.
reflective learning culture within organizations Within an organization, there may be more than
was highlighted in the SPEC: Learning and one dominant culture, and the combination of cul-
Changing by Doing project (Evans et al., 2011). tures defines regimes that make up the overall
To achieve its community health and justice goals, political context of an organization (Douglas,
the project adopted an internal organizational 1982; Wildavsky, 1987). Health promoters who are
learning lens to identify the conditions needed to seeking to influence change in their own organiza-
support external community engagement and mo- tions need to analyze the culture of the targeted
bilization. These conditions included critical cap- subgroup, as well as the broader culture of the or-
acity and consciousness, shown by an awareness of ganization, to identify the most conducive settings

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the role of power dynamics, an orientation for change. In a Pennsylvanian study of organiza-
towards justice, an ecological approach and collab- tional culture in nursing homes, Scalzi et al. (Scalzi
orative practice (Evans et al., 2011). et al., 2006) found that positive cultural changes
occurred when residents, family members and fa-
cility staff worked towards a shared goal and with
Theories of organizational culture a critical mass of champions for the change.
Scheins work exploring organizational culture
provides valuable insight for change practitioners
seeking to modify culture, that is, to make an in- Receptive contexts for change
novation central to what is believed and done. Pettigrew et al. (Pettigrew et al., 1992) refer to re-
Schein (Schein, 2010) presents a model identify- ceptive contexts for change as those that enable
ing different levels of organizational culture, the progression of a change initiative within the
using case studies from two multinational cor- environment and non-receptive contexts as those
porations. The organizational cultures of the two that hinder the progress of a change initiative.
settings were then analyzed in three categories: Their work is relevant to change within the public
(i) artefacts are visible things about the group, sector and bureaucratic organizations in particu-
such as the physical environment, organizational lar. For example, Pettigrew et al. (Pettigrew et al.,
structures, clothing and language; (ii) espoused 1992) identified eight key variables linked to an
beliefs and values are philosophies, goals and organizations receptiveness to change. These vari-
strategies that have become socially validated ables were derived from studies of change in the
and confirmed through a shared experience by a National Health Service (NHS) in the 1980s and
group and (iii) underlying assumptions are taken include quality and coherence of policy, availabil-
for granted with little variation, because they ity of key people leading change, long-term envir-
have come about from continued success in the onmental pressure, supportive organizational
implementation of certain beliefs. Underlying culture, effective managerial-clinical relations, co-
assumptions can be so strong within groups that operative inter-organizational networks, simplicity
behaviours based on any other values or beliefs and clarity of goals and priorities and fit between
are unthinkable. the districts change agenda and its locale.
According to Schein (Schein, 2010), culture is The authors reported that a shared vision that
formed through the beliefs and values of organiza- could be adopted by a stable workforce was crucial,
tional leaders. These values inform the implemen- so too was a sense of crisis in the broader context
tation of certain actions, and the view that any for adding pressure for change. Furthermore, a
subsequent success of those actions is a result of setting that values learning, evaluation and skill
effective organizational leadership and the culture over status with workers who had a foot in both
and values it sustains. As a result, the perceived clinical and managerial camps was an enabler for
benefits of those actions lead to them being leading change. Other variables that were found to
repeated, and after continual success of those be enablers for change included networking and
actions the idea that those particular actions are sharing information across agencies, having simple
Page 8 of 11 D. Batras et al.
goals, patience and persistence in implementation, function that is inherent in capacity building.
and understanding external agendas, obstacles and Organizational learning theory (Argyris and
opportunities for making the change fit for purpose Schon, 1996) states that the way organizations per-
(Pettigrew et al., 1992). ceive and address problems is determined by their
Pettigrew et al. (Pettigrew et al., 1992) provide governing beliefs or theories-in-use. The capacity
a point of reference for assessing the organiza- building task is to influence these beliefs to facili-
tional context of a proposed health innovation. tate progression by organizations from single-loop
Consider one of the eight variables that influence learning, concerned with solutions to immediate
change receptivity (that is, the Fit between the problems, to double-loop learning, which entails
districts change agenda and its locale) as an critical reflection on established values and prac-
example of how their work may be used in health tices to bring about openness to innovation and
promotion practice. A health promotion practi- reform. A challenge that practitioners face is iden-
tioner may identify unmanipulable variables in a tifying those organizations with preparedness for
proposed pilot site for an initiative and instead double-loop learning, which may in turn become
opt for a more receptive context for the pilot. catalysts for change within their broader sector.
The aim is to design a health initiative to fit A common theme across the organizational

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within a receptive organizational context by en- change theories described above is that there
suring that it accommodates the needs of that or- needs to be a degree of elasticity in the shape and
ganization. This may involve a health promotion pace at which the change takes as well as within
practitioner working to modify aspects of the the host organization. Rogers (Rogers, 2003)
organizational context (internally or externally describes a matching phase in the innovation
as required or feasible) to achieve an agreeable process. OLoughlin et al. (OLoughlin et al., 1998)
fit between the goals of the health intervention found in a study of heart disease prevention initia-
and that organizational context (Pettigrew et al., tives implemented in Canada that sustainability
1992; Rogers, 2003). was linked to the degree in which organizations
could reinvent the initiative and the fit or appro-
DISCUSSION priateness within the host organization. Similarly,
Steckler and Goodman (Steckler and Goodman,
Recent discussions in the international literature 1989) found that when an innovation is able to find
have emphasized the changing policy context for a fit within the organization, it was more likely to
health promotion, the challenges that this pre- be institutionalized and hence sustainable.
sents for the field and the need to strengthen the The theories reviewed in this article highlight the
foundations for practice. Sparks (Sparks, 2013) need to take account of the uniqueness of settings,
has argued that the recent history of health pro- through situational analysis, which will often re-
motion has seen waves of new priorities (e.g. quire an iterative process. Steckler and Goodman
obesity, social determinants of health, chronic (Steckler and Goodman, 1989) have observed that
diseases), each with its own silo of activity that change is a process that often takes longer than
generally achieves a low level of integration allocated funding timelines allow for. Hanni
within established programmes and infrastruc- et al. (Hanni et al., 2007) evaluated a 5-year
ture. The focus on activities needed to tackle chronic disease intervention in a low socio-eco-
these new priorities often fails to recognize that nomic area in California, concluding that sustain-
health promotion offers principles, approaches able community and environmental change is
and strategies with applications across a broad difficult to achieve within this time frame. The
range of issues. Organizational change repre- limitations associated with short-term funding
sents one such cross-cutting area of action that is include problems of staff retention and loss of
needed to build the infrastructure and capacity corporate memory, which can delay and stifle im-
required to address contemporary health chal- plementation (Pettigrew et al., 1992).
lenges. The ability of the field to act strategically Progression to longer funding cycles to achieve
in this work, by drawing upon the broad body of institutionalized change puts greater onus upon
theory and research available, will to a large managers and policymakers to identify organiza-
degree determine the scale and sustainability of tions that are prepared (or able) to embark on
the health impacts that it can achieve. this change process. Organizational change the-
The organizational change theories examined in ories draw attention to the sorts of questions
this article can be applied to the problem-solving practitioners need to ask in making assessments
Organizational change theory Page 9 of 11
of readiness for change. Examples include the fol- 1995). This draws attention to the need for
lowing: Can a previously identified problem for health promoters to seek to influence group
the organization be addressed through health norms as opposed to just individuals in leader-
promoting change? Does the sector which the ship roles. Schein (Schein, 2010) argues that
organization operates in pose a threat to innov- when new actions are matched to existing operat-
ation? Is the structure and culture of the organi- ing environments of teams, continued positive
zation conducive to innovation? Does the experiences will lead to a shared team experi-
organization have a history of questioning the way ence that validates the benefit of the adopted
things are done and seeking solutions that may actions, and influence values and practices. It
challenge their governing variables? Is there an should be acknowledged that health promotion
opportunity for short-term group success that can agencies have their own group dynamics, values
be leveraged from? and To what extent is the or- and culture that will often differ from those of
ganization interconnected?. In addition to these the organizations with which they are working.
key considerations, the quality of the process This focuses attention on the valuable role that
undertaken is critical to success, including simple, policy entrepreneurs and champions can play,
clearly defined and agreed goals, elasticity of the who share values and ambitions with the recipi-

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initiative for the organization, sufficient external ents of change within organizations, can balance
environmental pressure such as market or political the diverse needs of groups, and exercise strategic
forces, and the existence of internal proponents leadership (Pettigrew et al., 1992; OLoughlin
for the change (Douglas, 1982; Wildavsky, 1987; et al., 1998; Rogers, 2003; Hoeijmakers et al., 2007;
Pettigrew et al., 1992; Lewin, 1997c; St Leger, Oakland and Tanner, 2007; de Leeuw, 2011).
1997; Rogers, 2003; Kotter, 2007; Schein, 2010). Studies in the field of occupational health
In examining the reasons why organizational psychology have investigated the impacts of or-
transformation efforts fail, Kotter (Kotter, 2007) ganizational change on workers health and well-
stresses that the agents of change often declare being and have offered strategies for achieving
success too early. He added that there may be adherence to change. Staff self-efficacy to cope
political pressure on funders and funding recipi- with the demands of job change, staff having an
ents of short-term health promotion projects to active approach towards problem solving, ad-
declare success at the end of their funding cycle. equate provision of information to staff about
Premature declarations of success in health pro- change to aid predictability and clarity, and a high
motion are problematic for all stakeholders and degree of readiness to change have been linked to
the discipline. The organizational change theor- well-being outcomes in organizations undergoing
ies reviewed above indicate that time and contin- change (Parker et al., 1997; Cunningham et al.,
ued effort are required to embed change well 2002; Jimmieson et al., 2004).
beyond the life of the initial project. This further Pettigrew et al. (Pettigrew et al., 1992) empha-
suggests that health promotion should be viewed sized the importance of the external environment
in a similar light to long-term institutional change. in their Receptive Contexts for Change theory,
In the fixed-term, temporary funding environment similarly external forces (Lewin 1997a) receive at-
(the status quo for health promotion) practitioners tention in organizational change theory in general.
may be best placed to focus their efforts on analy- However, it is arguable that the primary opportun-
zing the culture of the intended recipients of ities for health promoters to influence the function-
change, beginning with visible artefacts (Schein, ing of organizations is through addressing internal
2010) and aiming for early success (quick wins) variables. Steckler and Goodman (Steckler and
to engender stakeholder support. Contrary to Goodman, 1989) found that funding brokers to
funding objectives that are set within a political institutionalize health promotion initiatives in
calendar, Schein (Schein, 2010) points out that a other agencies was ineffective and concluded that
health promotion programme is most likely to in- funds should be directed to the host agency to
fluence the culture of the host agency with repea- bring about change from within. Riley et al. (Riley
ted success over time. et al., 2003) reported that changing internal organ-
Lewin (Lewin, 1997c) would add that group izational factors was most influential in facilitating
experience plays a significant role in determining the adoption of heart health initiatives by public
the behaviours, beliefs and values of its mem- health agencies in Canada. This does not discount
bers, and subgroups within organizations often the valuable leadership role that health promotion
have distinct cultures (Grendstad and Selle, agencies can play (Riley et al., 2003) but highlights
Page 10 of 11 D. Batras et al.
the fact that funding and equipping workers who Crisp, B., Swerissen, H. and Duckett, S. (2000) Four
are located within external organizations and approaches to capacity building in health: consequences
for measurement and accountability. Health Promotion
can work with teams internally to instigate change International, 15, 99107.
may be the most effective use of health promotion Cunningham, C. E., Woodward, C. A., Shannon, H. S.,
resources. MacIntosh, J., Lendrum, B., Rosenbloom, D. et al. (2002)
Readiness for organizational change: a longitudinal study
of workplace, psychological and behavioural correlates.
CONCLUSION Journal of Occupational and Organizational Psychology,
75, 377.
de Leeuw, E. (2011) Theory and policy innovation for
The centrality of organizational change in health health: where has the creativity and fun gone? Health
promotion capacity building is clear. Therefore, Promotion International, 26, 1 3.
theory-informed research is needed to identify de Leeuw, E. (2013) Health promotion research: war on
suitable targets of change, and effective strategies health, battle of bulge or conflict of confidence? Health
Promotion International, 28, 1 3.
and implementation processes are needed to DeJoy, D. M. and Wilson, M. G. (2003) Organizational
address these. It has also been argued that atten- health promotion: broadening the horizon of workplace
tion needs to be paid to factors that characterize health promotion. American Journal of Health Promotion,

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unsuccessful change efforts (Biron et al., 2010). 17, 337341.
Devine, S. G., Muller, R. and Carter, A. (2008) Using the
Nielsen et al. (Nielsen et al., 2010) recommend an Framework for Health Promotion Action to address staff
evaluative focus in organizational change research perceptions of occupational health and safety at a fly-in/
that uses mixed-methods approaches to examine fly-out mine in north-west Queensland. Health Promotion
how and why health interventions succeed (or not). Journal of Australia, 19, 196202.
Traditional controlled studies are not usually Dooris, M. (2006) Healthy settings: challenges to generating
evidence of effectiveness. Health Promotion International,
feasible or adequate for these types of investiga- 21, 5565.
tion (Nielsen et al., 2010). Douglas, M. (1982) In the Active Voice. Routledge &
Debate in this journal has highlighted the risks K. Paul, Boston, MA.
associated with the changing political discourse Evans, S. D., Prilleltensky, O., McKenzie, A., Prilleltensky,
I., Nogueras, D., Huggins, C. et al. (2011) Promoting
away from health promotion (de Leeuw, 2013). strengths, prevention, empowerment, and community
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the health, social and economic benefits that research, theory, and practice. Journal of Prevention and
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A. (2006) Changing the work environment to promote well-
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