In recent years, community health centers have seen a rise in the rate of chronic health conditions, such as diabetes, among the populations they serve. The CDC estimates the prevalence of diagnosed diabetes among Americans rose from 2.5% to 6.9% between 1980 and 2010.[i]  Obesity, which is linked to diabetes, has also sharply increased. The rates of obesity doubled for adults and tripled for children from 1980 to 2008.[ii] More than a third of adults are obese and 17% of children ages 2-19 are obese.[iii] As many of these health conditions are directly impacted by an individual’s lifestyle, health centers need to be prepared to help their patients treat and monitor these diseases by encouraging and supporting healthy behavior.

Chronic conditions, such as diabetes, often require personal lifestyle changes for successful treatment and management. For example, one change might include eating more fruits and vegetables and consistently exercising. Providing education about the condition and needed behavior change is one strategy for helping patients. However, many health center staff mistakenly assumes that patients will make healthy choices once appropriate education is provided. In practice, changing one’s behavior is often quite difficult for a number of reasons. These reasons can range from personal motivation to barriers created by living and/or working in unhealthy environments and the lack of availability of resources such as healthy, fresh foods or reliable transportation. Behavior change is a gradual process that may require time, persistence, and access to additional resources and support, while also understanding the context in which people live. Outreach workers and other health center staff play an important role in supporting individuals with lifestyle changes. 

The Pathway to Change is a framework for understanding how change happens at an individual level. Outreach workers and other health center staff members can use the framework to help identify patient readiness and motivation for change. Understanding readiness is critical for successfully helping patients move toward embracing new behavior. By meeting the patient where they are at, health center staff can select appropriate tools and offer strategies that are matched to the needs of each person. This article will discuss the Pathway to Change and how outreach workers can use it to support new, healthy behaviors among the populations they serve. 


What is the Pathway to Change?

There are five “steps” or stages along the Pathway to Change.  These steps are the process an individual follows in order to move toward a desired behavior. The pathway has many steps and each individual moves through the steps at his or her own pace. The five steps are the following:

  1. Clued-Out. When an individual is clued-out, he or she has little or no understanding of the ways in which a particular behavior is damaging. The person does not intend to change the damaging behavior. For example, a patient may not know he or she is at risk for developing diabetes and does not recognize the need to monitor his or her diet.
  1. Clued-In. When the individual reaches the clued-in stage, he or she acknowledges that a damaging behavior is a problem. Yet the individual takes no action. For example, a patient with a family history of diabetes takes a screening test and discovers he or she has high blood sugar levels. The patient acknowledges that he or she should avoid eating sugar but does not change or modify any behavior at this point. 
  1. Motivated.  At this stage, the individual is willing to explore ways to change, or to incorporate a new behavior into his or her life. For example, a diabetic patient wants to try eating sugar-free cookies instead of regular cookies.   
  1. Action. During the action stage, the individual practices a new behavior. For example, a diabetic patient finds a recipe for sugar-free cookies, makes the cookies, and starts eating the sugar-free cookies instead of sugary ones.
  1. Maintenance. The individual consistently practices the new behavior while in the maintenance stage. For example, a diabetic patient stops eating sweets and only occasionally indulges in sugar-free cookies for dessert after dinner. 

It is important to note that the Pathway to Change is dynamic and individuals can move back and forth along the pathway. For example, stress, availability of resources, or other social and economic factors may cause an individual in the maintenance stage to go back to being clued-in. Patients, and those that support them, should know that this does not mean the patient has failed. It is often normal to go back and forth along the pathway. Providing continual support and encouragement helps prevent a patient from feeling overwhelmed and giving up. 


Why should outreach staff know about the pathway to change?

Outreach staff members play an important role in health education and supporting healthier lifestyles. They are especially well-positioned to support behavior change because they understand the culture, strengths, needs and barriers faced by the populations served by health centers. These factors greatly influence behavior change and must be taken into consideration in order to successfully help someone form and maintain healthy habits. For example, if a diabetic patient needs help understanding which foods they can eat, an outreach worker can help them identify culturally-appropriate recipes for low-sugar foods and where the ingredients can be purchased locally.             

By understanding the Pathway to Change, outreach staff can use it to determine an individual’s readiness for change. Outreach workers can use this information to determine the best way to provide support to an individual and select appropriate resources. The way that an outreach worker approaches someone that has little understanding of diabetes who just found out he or she is diabetic versus someone who has managed diabetes successfully for a number of years can be quite different. For example, approaching a patient at the “clued-out” stage with strategies on maintaining a healthy diet may not be very effective. Instead, outreach workers can try to gently guide patients at their own pace. Outreach staff can provide continual support and encouragement while working with patients to troubleshoot barriers to maintaining healthy behaviors.



Understanding where an individual is on the Pathway to Change helps outreach staff and other health center staff members tailor information, tools, strategies, and resources to the patient’s needs. Working with a patient to change behavior is not always easy, as well as for the individual. Using the Pathway to Change can help outreach workers better work within the context of each individual. By doing so, the likelihood of success increases.  

[i] The Centers for Disease Control and Prevention. Crude and Age-Adjusted Percentage of Civilian, Noninstitutionalized Population with Diagnosed Diabetes, United States, 1980–2010 . Accessed May 24, 2012:

[ii] The Centers for Disease Control and Prevention . Halting the Epidemic by Making Health Easier
At A Glance 2011
. Accessed May 24, 2012: 

[iii]The Centers for Disease Control and Prevention.  Overweight and Obesity Facts. Accessed May 24, 2012: