The Behavior Change Wheel: A framework for improving menopause therapy adherence

  • Interventions designed to improve therapy adherence are often designed without any understanding of what drives patient behavior; as a result, they are only moderately effective. 
  • The Behavior Change Wheel (BCW) framework is a useful model for understanding and characterizing adherence behavior. 
  • The BCW highlights the importance of addressing patients’ specific concerns regarding their menopause therapy. 

Improving patient adherence requires an actionable framework

Previous articles in this series have established that menopause therapy adherence has important implications for women’s health. Non-adherence is a behavioral problem, and we have discussed different theories and frameworks to help understand what drives patient health behaviors regarding menopause, including non-adherence. While information on menopause interventions is limited in the literature, findings for chronic disease interventions may be a useful proxy, given the similarity of symptoms in terms of complexity, duration and variability. 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.1, 2 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.

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.2 The BCW is the most comprehensive and inclusive framework available for healthcare professionals who wish to take concrete action to support their patients.

Capability, Opportunity, Motivation – Behavior (COM-B) was developed from several behavior change frameworks, which were and are still used, such as Health Belief Model (HBM) and Theory of Planned Behavior (TPB). However, these frameworks do not address the important roles of impulsivity, habit, self-control, associative learning, and emotional processing, which is the case for BCW2.

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).3

  • Capability is understood as the psychological and physical capacity of an individual to perform a specific behavior or activity. 4 For example, a patient suffering from menopause symptoms and 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.4 For example, patients with menopause symptoms 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.4 For example, patients experiencing the menopause transition may not be adherent to therapy in the absence of symptoms because their intermittent nature 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.2 The BCW has been successfully applied to the development of interventions to improve adherence. Use of the BCW’s COM-B format to create a medication adherence behavioral model* demonstrates the frameworks’ potential value in characterizing menopause adherence behavior. As an example of the model’s utility, consider psychological factors that limit a menopause patient’s capability to adhere to their treatment. Patients may experience high levels of uncertainty or anxiety regarding the menopause transition, which can affect their symptoms as well as their therapy-related decisions.5,6 The proposed adherence model addresses this uncertainty through comprehension of the disease and treatment.3 This example demonstrates that the BCW may be used to create a plausible, comprehensive adherence model as the basis for evidence-based interventions to improve women’s experience during the menopause transition.

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

The BCW provides a streamlined, actionable approach for understanding patient adherence behavior. It allows for the creation of an adherence model that indicates how behavior may best be influenced. The examples presented here demonstrate that effective adherence interventions for menopause symptoms would need to address patients’ understanding of and beliefs regarding the transition and treatment, which are highly specific.

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

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Activating menopause patients to improve outcomes


  1. Bart J.F. van den Bemt, Hanneke E. Zwikker, & Cornelia H.M. van den Ende “Medication adherence in patients with rheumatoid arthritis: A critical appraisal of the existing literature,” Expert Review of Clinical Immunology, 2012, (8):4,. 337–351. 10.1586/eci.12.23
  2. Susan Michie et al. (2011). “The behaviour change wheel: A new method for characterising and designing behaviour change interventions.” Implementation Science, (6):42. 10.1186/1748-5908-6-42
  3. Christina Jackson et al. (2014). “Applying COM-B to medication adherence: a suggested framework for research and interventions,” The European Health Psychologist, (16):1, 2014.pdf 7–17.
  4. 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, 14–22. 10.1111/jnu.12508
  5. Hunter, Myra, and Melanie Smith in collaboration with the British Menopause Society. Cognitive Behaviour Therapy (CBT) for menopausal symptoms: Information for GPs and health professionals. Post Reproductive Health 2017;23(2):83-84.
  6. Santana L, Fontenelle LF. A review of studies concerning treatment adherence of patients with anxiety disorders [published correction appears in Patient Prefer Adherence. 2012;6:153]. Patient Prefer Adherence. 2011;5:427-439.