The Behavior Change Wheel: A framework for improving cardiovascular treatment adherence

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The Behavior Change Wheel: A framework for improving cardiovascular treatment adherence



Improving patient adherence requires an actionable framework

Previous articles in this series have established that non-adherence to cardiovascular disease medication is a significant public health issue.1, 2 Adherence problems and their impact on health, costs, and mortality are exacerbated by socio-economic conditions in developing countries.3 Non-adherence is a behavioral problem, and we have discussed a number of frameworks to help understand what drives non-adherence and other patient behaviors. Numerous support initiatives have been developed to help patients with chronic diseases change their behavior, and many of these programs have demonstrated positive outcomes. However, there remains significant room to improve interventions by incorporating better and more applicable behavioral frameworks.4, 5 While behavioral frameworks focusing on improving patient knowledge provide some insight, their incomplete conceptualization of the problem tends to result in interventions that demonstrate limited behavior change. For example, the Health Belief Model, which was previously discussed in this series, does not address certain behavioral factors that can influence adherence, such as impulsivity, habit, and self-control,5 and application of the Theory of Planned Behavior had mixed success in patient support programs

The Behavior Change Wheel (BCW) was developed to address this need for a comprehensive, validated framework for evaluating behavior, designing interventions, and evaluating intervention efficacy.6 The BCW incorporates many of the other frameworks discussed in this series, and it is the most comprehensive and inclusive framework available for healthcare professionals who wish to take concrete action to support their patients.


The BCW is a comprehensive and actionable framework

Proposed in 2011 by Susan Michie, Maartje M van Stralen, and Robert West, the BCW is a comprehensive but straightforward framework that can be applied to almost any human behavior. At the heart of this dynamic tool are three fundamental components, known as COM-B, that explain or influence a given behavior (B): capability, opportunity, and motivation (COM).6

  • Capability is understood as the psychological and physical capacity of an individual to perform a specific behavior or activity.7 For example, a heart failure patient suffering from comorbid depression may have a reduced psychological capacity to be adherent.
  • Opportunity consists of objective social and physical factors that hinder, enable, or elicit the specific behavior externally.7 For example, patients with heart disease may be non-adherent due to physical or social factors, such as the location or the cost of therapy.  
  • Motivation incorporates automatic processes, involving emotions and impulses, and reflective processes; it includes making and evaluating plans.7 For example, patients with hypertension may not be adherent to therapy in the absence of symptoms because the intermittent nature of their condition means they lack the automatic stimuli that encourage adherence. Automatic stimuli correspond to Kahneman’s “System 1” process while the reflective processes correspond to his “System 2.”

The BCW is made up of various layers. One enumerates several intervention functions, including education and training, which are also common components of most medication adherence interventions. Another includes policy categories such as guidelines and legislation. The BCW framework’s components combine to interact in a non-linear fashion.5 The BCW has been successfully applied to the development of interventions to improve adherence.


The BCW develops a comprehensive understanding of adherence behavior

Use of the BCW’s COM-B format to create a medication adherence behavioral model* demonstrates the frameworks’ potential value in characterizing cardiovascular disease adherence behavior. As an example of the model’s utility, consider psychological factors that limit a heart failure patient’s capability of adhering to their treatment. Heart failure patients experience high levels of uncertainty regarding their condition, which can affect their medication-taking decisions.8 The proposed adherence model addresses this uncertainty through comprehension of the disease and treatment.6 To take another example, myocardial infarction survivors risk recurrent events and have an annual death rate of 5%,9 yet patient adherence is estimated to be only slightly greater than 50% despite this significant risk. The BCW addresses this by examining patients’ beliefs about treatment through the reflective processes encompassed under motivation drivers.6 These two examples demonstrate that the BCW may be used to create a plausible, comprehensive adherence model as the basis for evidence-based interventions to improve cardiovascular disease medication adherence.


The BCW framework is a simple, comprehensive approach to improving adherence

Compared to alternative behavioral models, the BCW provides a streamlined, actionable approach for understanding non-adherence. It creates an adherence model that indicates how behavior may best be influenced. The examples presented here demonstrate that effective adherence interventions to improve cardiovascular disease adherence would need to address patients’ understanding of and beliefs regarding their condition and treatment, which are highly specific. Additional research has used the BCW framework to identify strategies for improving cardiovascular adherence interventions for sociodemographic sub-populations having particular behaviors and needs.3 While the literature does not indicate significant limitations of the framework, an understanding of alternative behavioral theories and their application to adherence will be informative.

*Note: Validation of the behavioral model by external sources was not found in the literature.


1. Shalini Lynch (2019). “Adherence to drug treatment,” MSD Manual Consumer Version, August 2019.

2. Ian M. Kronish & Ye Siqin (2013). “Adherence to cardiovascular medications: Lessons learned and future directions,” Progress in Cardiovascular Diseases, (55):6, pp. 590–600. https://doi:10.1016/j.pcad.2013.02.001

3. Tracey-Lea Laba et al. (2013). “Strategies to improve adherence to medications for cardiovascular diseases in socioeconomically disadvantaged populations: A systematic review,” International Journal of Cardiology, (167):6, pp. 2430–2440. https://doi:10.1016/j.ijcard.2013.01.049

4. Bart J.F. van den Bemt, Hanneke E. Zwikker, & Cornelia H.M. van den Ende (2012). “Medication adherence in patients with rheumatoid arthritis: A critical appraisal of the existing literature,” Expert Review of Clinical Immunology, (8):4, pp. 337–351. https://doi: 10.1586/eci.12.23 

5. Susan Michie et al. (2011). “The behaviour change wheel: A new method for characterising and designing behaviour change interventions.” Implementation Science, (6):42. https://doi:10.1186/1748-5908-6-42

6. Christina Jackson et al. (2014). “Applying COM-B to medication adherence: a suggested framework for research and interventions,” The European Health Psychologist, (16):1, pp. 7–17.

7. Thekla Brunkert et al. (2020). “A contextual analysis to explore barriers and facilitators of pain management in Swiss nursing homes.” Journal of Nursing Scholarship, (52):1, pp. 14–22. https://doi:10.1111/jnu.12508

8. Rebecca Meraz (2020). “Medication nonadherence or self-care? Understanding the medication decision-making process and experiences of older adults with heart failure,” Journal of Cardiovascular Nursing, (35):1, pp. 26–34. https://doi:10.1097/JCN.0000000000000616 

9. Jan Keenan (2017). “Improving adherence to medication for secondary cardiovascular disease prevention,” European Journal of Preventive Cardiology, (24):3 Supp., pp. 29–35. https://doi:10.1177/2047487317708145