THE USE OF THE REPERTORY GRID TECHNIQUE IN HEART FAILURE: A NOVEL METHOD TO DETERMINE PATIENTS’ UNDERSTANDING AND BELIEFS OF THEIR MEDICINES

In the management of chronic diseases, once the individual and healthcare professional have agreed on a treatment option, individuals can then decide whether they will follow the agreed course of action. This often requires them to take medicines and adopt self-care activities in the agreed manner, a process known as adherence. There are a number of factors that impact on adherence behaviour. One important factor is the individual’s belief in the necessity for a medicine, as reinforcing this belief increases the likelihood of adherence. Beliefs have been linked to adherence behaviour in patients with heart failure. Heart failure is a chronic disease in which non-adherence to drug therapy and self-care activities results in worsening symptoms and hospitalisation. Measuring beliefs has involved the use of questionnaires with researcher-generated statements, usually from pilot studies or the literature, or qualitative interviews. The former are prone to issues in interpretation, as the researchers’ intended meaning of the statement may not reflect the interviewees’ understanding and interpretation. Qualitative interviews, although providing rich individual data, are often lengthy, and it is not in keeping with the nature of qualitative data to present them quantitatively. A method that has been proposed to overcome these issues and which may be practical within clinical practice is the repertory grid technique. The overall aim of this thesis was to trial the repertory grid technique to improve understanding of the perception of patients with heart failure towards the risks from non-adherence with their medication and self-care activities. The first step was to conduct a feasibility study, the aim of which was to test the repertory grid technique to identify beliefs and understanding towards medication and self-care activities in patients with heart failure. An interview process was developed applying the repertory grid technique, and a total of 28 patients with heart failure, from two Brisbane hospitals, were interviewed. Analysis of individual grids generated from the interviews provided insight into individual patients’ interpretation of their medicines and self-care activities. In analysing the grids collectively, a series of themes were generated, the four most common being benefit to the heart, for fluid, necessary to do and would do. The grids were analysed using generalised Procrustes analysis and principal components analysis to produce a graphical representation of how the individuals interpreted their medicines and self-care activities. ACE-inhibitors and beta-blockers were interpreted as necessary to do, would do and benefit to the heart, whereas the self-care activities were interpreted as not important to do and for fluid by some patients, but also acknowledged to be a benefit to the heart. The diuretic was interpreted to be strongly for fluid. To further explore risks of medicines, patients were also asked to complete a risk/benefit graph on their perception of the harm of using a fictitious pain reliever (representing a non-steroidal anti-inflammatory drug) that could worsen their heart failure. Most patients (79%) rated the risk of using the pain reliever as ‘high with low benefit’ and would avoid taking it. The findings from the feasibility study suggested that the repertory grid technique generated statements that reflect individuals’ understanding of their heart failure management, and that these could be linked to beliefs towards medicines. The subsequent study applied the repertory grid technique to improve understanding of the perception of patients with heart failure towards the risks from non-adherence with their medication and self-care activities. A total of 92 patients with heart failure, in a single Brisbane hospital, were interviewed using the repertory grid technique, and their level of self-reported adherence to medicines and self-care activities measured. The majority of the patients reported ‘good’ adherence with a MARS score of 24 or 25 (maximum 25) (n=82, 89.1%) and Morisky scores reflecting ‘high’ adherence (n=84, 91.4%). When comparing the constructs between the MARS scores and the Morisky scores, there were non-significant differences in the construct frequencies. Comparison of the graphical representations of repertory grid groupings based on adherence scores suggested differences in the patients’ interpretation (understanding) of their medicines and self-care activities for their heart failure. When examined individually, the graphical representations in those patients with higher self-reported adherence scores suggested a more integrated understanding of their heart failure management in terms of the necessity and the benefit to the heart. The constructs, when analysed collectively, reflected beliefs of individuals towards their medicines, and these were related to their adherence. The repertory grid technique has the potential to be a practical method of eliciting, individually and collectively, patients’ understanding of, and beliefs towards, their medication and self-care activities, and the influence of these on their adherence. The technique has potential utility in other chronic disease states. Using the repertory grid to determine understanding and beliefs towards medicines could help identify patients at risk of non-adherence and allow strategies to change understanding and beliefs to be implemented