‘You can sleep hungry just to buy the medicine’: Applying a patient-centred model of cumulative complexity to explore how patients manage the lifelong workload of hypertension care in Kenya

This research applies the Cumulative Complexity model to examine patient experiences of hypertension management following prescription of anti-hypertensive medication in the public health system in Kenya. Set in Kiambu County, central Kenya, it draws on abductive analysis of interviews with patients (n = 24), caregivers (n = 7) and non-participant observation in four purposively selected public facilities conducted between November 2022 and April 2023. Patients undertook three kinds of ‘work’ to reduce their blood pressure: processing work to accept hypertension diagnosis and its chronic dimension; practical work managing care and medications, and work of managing emotions. Four inter-related domains of patient capacity influenced patients' ability to do this work: individual financial resources; physical functioning; social support and religious faith. Variations in treatment cost and medicine availability increased patient workload. When workload overwhelmed capacity treatment adherence was interrupted. Interruptions in treatment resulted in negative feedback loops further reducing patient capacity. Recognising temporal variability in workload and capacity is key to understand treatment adherence in resource constrained settings. Consideration of adaptive counter-agency can strengthen treatment burden models. We encourage policy makers to prioritise addressing treatment burdens to support treatment adherence and sustained hypertension control. • Patients undertook three kinds of ‘work’ to reduce their blood pressure. • Four capacity domains influenced patients' ability to do this work. • Fluctuation in treatment cost and medicine availability increased patient workload. • When workload overwhelmed capacity treatment adherence was interrupted. • Consideration of adaptive counter-agency can strengthen treatment burden models.