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Central Nervous System

The Behavior Change Wheel: A framework for improving adherence

  • Therapy adherence interventions for chronic conditions are only moderately effective; solutions are often designed without using an evidence-based approach.
  • The “Behavior Change Wheel” framework has been used to model and characterize adherence.
  • Adherence research using the Behavior Change Wheel demonstrates the importance of addressing patients’ specific concerns regarding their treatment.

Improving patient outcomes and adherence requires an actionable framework

Previous articles in this series demonstrate that non-adherence is a significant public health issue in patients with neurologic disease.

A study conducted in Europe in 2004 estimated that the annual economic cost of neurological disease (including dementia, epilepsy, migraine and other headaches, multiple sclerosis, Parkinson’s disease and stroke) amounted to €139 billion.1 Much of the burden for neurological disorders is in low and lower middle income countries.1 Despite the availability of medications that can often control symptoms, adherence in conditions such as Parkinson’s disease (10– 67%),2 epilepsy (30–50%)3 and bipolar disorder (~50%)4 is often poor.

The problem of non-adherence thus demands a solution. In as much as the issue is a behavioral one, targeted interventions are required. Adherence programs for chronic conditions have demonstrated positive outcomes, but there is significant opportunity to improve the impact of such interventions via the use of behavioral frameworks or similar analysis to characterize adherence and the mechanisms by which it may be achieved.5,6 Frameworks focusing entirely on patient knowledge provide insights on adherence but tend to be incomplete; thus, their use may not significantly improve adherence. 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, among others.6 The “Behavior Change Wheel” was developed to address this need for a comprehensive, validated tool for evaluating behavior and designing and vetting corresponding interventions. The framework provides the means to characterize adherence behavior and to identify factors that can improve it.6,7

The “Behavior Change Wheel” is a comprehensive, actionable framework

Proposed in 2011 by Susan Michie, Maartje M van Stralen and Robert West, the Behavioral Change Wheel framework is designed to be comprehensive, minimalist and applicable to all behaviors.6 Its structure is informed by existing behavioral theories in addition to input from a range of behavioral theorists.6 At the heart of this dynamic tool is a behavioral model, known as COM-B, comprising three fundamental components that may explain, or conversely be influenced by, a given Behavior (B): Capability, Opportunity and Motivation (COM).7

  • Capability is understood as the psychological and physical capacity of an individual to perform a specific behavior or activity.8 For example, patients with Parkinson’s disease or bipolar disease have reduced psychological capability to be adherent.
  • Opportunity comprises social and physical factors that hinder, enable, or elicit the specific behavior externally.8 Similarly, patients with Parkinson’s disease may be non- adherent due to physical factors such as the cost of therapy.  
  • Motivation incorporates automatic processes, involving emotions and impulses, and reflective processes, such as making plans and evaluations.8 For example, patients with epilepsy may not be adherent to therapy in the absence of seizures, which are automatic stimuli influencing adherence.

The second layer in this wheel are nine possible intervention functions, including Education, and Training, which are also common components of medication adherence interventions. The third and outer layer of this wheel are seven policy categories, which include Guidelines and Legislation. The framework’s components all interact in a non-linear fashion.6 The framework’s utility is demonstrated in the development of a medication adherence framework.

The Behavior Change Wheel enables a comprehensive understanding of adherence behavior

Initial use of the Behavioral Change Wheel to create a medication adherence model* demonstrates the frameworks’ potential value in characterizing adherence behavior.6,7

A study using COM-B identified different factors contributing to pain management in older patients, including fear of side effects and reluctance to take pain medication.8 The study identifies these factors as part of a general attitude towards pain in this population, as accounted for by the psychological component of the Capability behavioral driver (see definition above). This example demonstrates the Behavioral Change Wheel’s value in creating a plausible, comprehensive adherence model, which may be the basis for evidence- based interventions to improve adherence.8

The framework provides a simple yet comprehensive approach for improving  adherence

Compared to alternative behavioral models such as the intentional vs. unintentional framework discussed in previous articles, the Behavioral Change Wheel provides a streamlined, actionable, analytic approach for understanding adherence.6 The framework enables creation of an adherence model that indicates how behavior may be influenced; the example presented demonstrates that effective interventions for adherence should address patients’ understanding of and beliefs regarding their condition and treatment, which are highly specific.6,8 While the literature does not indicate significant limitations of the framework, an understanding of alternative behavioral theories and their application to adherence is informative. The articles in this series investigate different theories and approaches for understanding patient adherence.

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

References

  1. World Health Organization. Neurological Disorders: Public Health Challenges. 2006. Available at: https://www.who.int/mental_health/publications/neurological_disorders_ph_challanges/en/ [Accessed March 2021].
  2. Straka I, et al. Adherence to Pharmacotherapy in Patients With Parkinson’s Disease Taking Three and More Daily Doses of Medication. Frontiers in Neurology 2019;10:799.
  3. Ferrari CMM, et al. Factors associated with treatment non-adherence in patients with epilepsy in Brazil. Seizure 2013;22:384–9.
  4. Jawad I, et al. Medication nonadherence in bipolar disorder: a narrative review. Ther Adv Psychopharmacol 2018;8(12):349–63. 
  5. Van den Bemt BJF, et al. Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature. Expert Review of Clinical Immunology 2012;8(4):337–51.
  6. Michie S, et al. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42.
  7. Jackson C, et al. Applying COM-B to medication adherence: A suggested framework for research and interventions. Eur Health Psychol 2014;16(1):7–17.
  8. Brunkert T, et al. A Contextual Analysis to Explore Barriers and Facilitators of Pain Management in Swiss Nursing Homes. Journal of Nursing Scholarship 2020;52(1):14–22.