Recognizing that health improvement activities and performance monitoring imply the need for change in communities, the committee sought to explore some of the theories of social change and how they might relate specifically to health and health care. It was noted that change is ubiquitous today in health care systems, health care policy, and social policy and is occurring in multiple dimensions. Emphasis is shifting from individual health to population-based health; from tertiary to primary care; from preventive care to health promotion. Tension between controlling costs and improving health complicates change in all dimensions.

Change is not linear. It occurs in a specific context and is subject to complicated interactions. Change is a process of transition; therefore, it is fruitful to study both the change process and its outcome. To determine whether an outcome is causally related to a particular intervention, it is necessary to study the process of change linking the intervention and the outcome. The suggestion was made that natural experiments provide unique opportunities to study change and deserve more scrutiny than they currently receive.

The committee was reminded that people frequently resist change and that change can both arise from and contribute to conflict and tension. Although admittedly uncomfortable, conflict and tension may be necessary prerequisites for constructive change.

Three theoretical constructs that can be used in formulating models of change were noted. Structural functionalism is a positivist approach and is consistent with an epidemiologic orientation. Conflict theory views change as subjective and value laden. Its naturalistic approach parallels community development and participatory action orientations. Symbolic interactionism involves developing consensus to produce change (Thompson and Kinne, 1990).