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Family support and medication adherence among residents with

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ARTICLE
Family support and medication adherence among residents
with hypertension in informal settlements of Nairobi, Kenya: a
mixed-method study
✉
Shangzhi Xiong 1 , Nicholas Peoples 1,2
, Truls Østbye3, Michael Olsen4, Xuefeng Zhong5, Caroline Wainaina6, Shujun Fan1,
David Wambui and Lijing L. Yan1,3,8
6,7

© The Author(s), under exclusive licence to Springer Nature Limited 2022

Suboptimal medication adherence is a major barrier to hypertension control in Kenya, especially among informal urban settlement
areas (sometimes referred to as “slums”). The few studies that have specifically explored medication adherence among this
population have received discordant results, implying that additional factors which influence medication adherence merit further
investigation. This study explores the relationship between family support and medication adherence among people with
hypertension in informal settlements in Nairobi, Kenya. We conducted a quantitative survey followed up by semi-structured
qualitative interviews. The sampling frame comprised two health facilities in informal settlement areas of the Korogocho
1234567890();,:

neighborhood and participants were recruited via convenience sampling. We performed multiple logistic regressions for
quantitative data and thematic analysis for qualitative data. A total of 93 people participated in the survey (mean age: 57 ± 14.7,
66% female). Most participants reported high family support (82%, n = 76) and suboptimal medication adherence (43% by the
Morisky Scale; 76% by the Hill-Bone Scale), with no significant associations between family support and medication adherence.
During interviews, many participants reported they lacked health knowledge and education. We suggest that the lack of health
knowledge among this population may have contributed to a failure for family support to meaningfully translate into
improvements in medication adherence. Our results underscore the need for further research to improve hypertension control
among this uniquely disadvantaged population, especially with respect to the possible mediating influence of health education on
family support and medication adherence.

Journal of Human Hypertension; https://doi.org/10.1038/s41371-022-00656-2

INTRODUCTION [17–20]. With respect to medication adherence, a descriptive study

Hypertension control is a major global health challenge in low-
and middle-income countries (LMICs) such as Kenya [1, 2].
Estimates for the prevalence of hypertension among various
populations and settings in Kenya range from 18.4 to 32.6% [3–7],
with the nationally representative 2015 Kenya STEPS survey
finding an age-standardized prevalence of hypertension of 24.5%
[8]. The use of anti-hypertensive medication is an effective
strategy to control hypertension [9], and poor or non-adherence
to anti-hypertensive therapy can be a cause of failed hypertension
control. Therefore, suboptimal medication adherence is a key
barrier to hypertension control [10–14].
A particularly vulnerable population is the socioeconomically
disadvantaged residents of informal urban settlements (some-
times referred to as “slums”). UN-HABITAT estimates that around
60% of the urban Kenyan population live in such areas [15, 16].
The poor conditions which characterize informal settlements, such
as violence, stress, and insecurity, have long been linked to
increased risk of cardiovascular disease (CVD) and CVD risk factors
revealed particularly low adherence among hypertensive patients
in informal settlements in Nairobi because the medications are
unaffordable and there is a low perceived need to take them [13].
Since only about 25% of the population in Kenya are covered by
some form of private, public, or community-based insurance [21],
out-of-pocket expenses are high [22] and poverty thus acts as a
significant barrier to accessing medications. Other studies have
found that, in general, poor purchasing ability puts the urban poor
at higher risk for complications of untreated hypertension [23].
A handful of studies have explored the burden of hypertension
among this population [3, 4, 12, 13, 24]; however, only a couple
have specifically investigated medication adherence, and they
found discordant results with respect to adherence levels [12, 13],
implying additional factors may influence adherence levels. Given
the magnitude of the problem and relative lack of clarity among
existing evidence, improving medication adherence for people
with hypertension living in informal urban settlements merits
invigorated attention.

1
Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu Province, China. 2Baylor College of Medicine, Houston, TX, USA. 3Global Health Institute, Duke
University, Durham, NC, USA. 4Department of Internal Medicine, Holbaek Hospital, and Centre for Individualized Medicine in Arterial Diseases (CIMA), University of Southern
Denmark, Odense, Denmark. 5Philips Research China, Shanghai, China. 6African Population and Health Research Center, Nairobi, Kenya. 7Department of Public Health, Brody
School of Medicine, East Carolina University, Greenville, NC, USA. 8School of Health Sciences, Wuhan University, Wuhan, China. ✉email: shangzhi.xiong@alumni.duke.edu

Received: 9 September 2021 Revised: 22 December 2021 Accepted: 6 January 2022

 S. Xiong et al.
2
Family support is an important factor in health management of
people with chronic diseases [25–28]. This term refers to how
people perceive the support, information, and response from their
family [29, 30]. Limited studies, however, have focused on the
influence of family support on medication adherence. A study
conducted in western Nigeria showed that patients with strong
perceived family support were approximately five times more
likely to achieve blood pressure control than respondents with
weak or no family support [29]. Another study conducted in a
Nigerian tertiary hospital showed that hypertensive patients with
good family support had better adherence to anti-hypertensive
medications based on a pill-count measurement [31]. Other
studies have also shown that lack of family support was associated
with lower adherence to anti-diabetic regimens among diabetic
patients, which was further related to worse glycemic control
[27, 32]. These studies underscore the importance of family
support in chronic disease management and medication adher-
ence. Few, however, have used well-defined measurements for
key variables such as family support and medication adherence,
and none of them were conducted in Kenya, let alone specifically
among those living in informal urban settlements.
To bridge this knowledge gap, this study aimed to explore the
association between family support and medication adherence
among residents with hypertension who live in informal settle-
ments in Nairobi, Kenya. By using both quantitative and
qualitative methods, we hope to generate evidence-based
implications for improvements in hypertension control among
this population.
METHODS
We used a mixed-method cross-sectional study design with a ques-
tionnaire survey followed up by in-depth interviews. These were
conducted by local research assistants fluent in both English and Swahili.
Both survey instruments and in-depth interview guides were translated/
back translated and pilot tested prior to data collection.
The study population comprised people with hypertension who live in
informal settlements in Nairobi, Kenya. We chose two health facilities
located in selected informal settlement areas of the Korogocho neighbor-
hood as our study sites. Assisted by clinicians, we used convenience
sampling by approaching patients diagnosed with hypertension during
their visits to the clinics. We excluded patients who were (1) under 18 years
old, (2) pregnant, (3) unable to communicate with researchers due to
deafness or muteness, or (4) unwilling to participate.
Our questionnaire included two validated measurements of medication
adherence. The Morisky-Green Levine Scale measures general medication
adherence and consists of four “yes or no” questions. The overall score is
dichotomized into either: 0 for “high adherence” or 1–4 for “low to
medium adherence” [33]. The Hill-Bone Compliance to High Blood Pressure
Therapy Scale measures medication adherence specifically for hyperten-
sive patients and has nine questions. A score of 9 is labeled as “perfect
adherence” and scoring higher than 9 is “non-perfect adherence” [34]. The
primary independent variable is patients’ level of family support, measured
by the Perceived Social Support from Family Scale [35]. The scale includes
20 self-reported items with the overall score of ≥ 11 categorized as “strong
family support” and ≤10 as “no or weak family support.” We conducted
bivariate analysis and multiple logistic regressions for medication
adherence measured by both adherence scales, respectively, with Stata
SE 15 (Stata Corp, College Station, TX, USA).
For interviews, we followed up with a smaller number of survey
participants for inclusion based on willingness and ability to communicate.
We aimed to recruit 20 interviewees or until information saturation. We
asked open-ended questions about participants’ perceptions of their
family relationships, barriers in hypertension management, and the roles
that their families played in their hypertension management. We
performed thematic analysis for the verbatim transcripts of the interview
recordings using NVivo 12 (QSR International).
The study was approved by the ethical committees of Duke Kunshan
University, Africa Population Health Research Center (APHRC), and the
Ethics and Scientific Research Committee of African Medical and Research
Foundation (AMREF). Informed consent was obtained from each partici-
pant before they were involved in the study.
RESULTS
We collected 93 valid questionnaires and conducted 21 interviews
from July to September 2017. Among surveyed participants, the
majority were female (66%, n = 61) and the mean age was 57
years (standard deviation = 11 years). Sociodemographic data
indicated our sample of participants generally had low socio-
economic status (SES): 56% had no more than primary education,
48% were unemployed, and 40% had no formal family income. For
family support, 82% of all participants reported “strong family
support” (n = 76). Of note, the percentage of female participants
who reported strong family support (77%) was lower than males
(91%), although this difference was not found significant (p =
0.108). Regarding medication adherence, 57% of all participants
had “high adherence” as measured by the Morisky-Green Levine
Scale (n = 53), and 24% had “perfect adherence” as measure
by the Hill-Bone Compliance to High Blood Pressure Therapy Scale
(n = 26). No significant differences were found in either medica-
tion adherence measurements between male and female
participants (p = 0.437 and p = 0.530, respectively).
Table 1 shows the results of the logistic regressions assessing the
relationship between family support and medication adherence in
two models. Model 1 used the Morisky-Green Levine Scale as the
outcome variable; Model 2 used the Hill-Bone Compliance to High
Blood Pressure Therapy Scale. Both models suggested that a strong
perceived family support level was associated with higher medication
adherence, but neither result was statistically significant (Model 1:
OR = 1.67, CI = 0.45–6.20, p = 0.438; Model 2: OR = 1.80, CI =
0.38–8.52, p = 0.457). According to Model 1, having an education
higher than secondary school was significantly associated with higher
medication adherence (OR = 8.54, CI = 1.01–72.21, p = 0.049). Being
prescribed to take more than two pills per day (OR = 0.07, CI =
0.01–0.62, p = 0.018) and having comorbidities other than diabetes
(OR = 0.246, CI = 0.07–0.91, p = 0.035) were significantly associated
with lower medication adherence. In Model 2, there were similar
trends but no significant predictors were found.
Table 2 displays the results of the thematic analysis of the 21
interviews. Three major themes and nine sub-themes were
identified from these in-depth interviews. First, most interviewees
reported that they had very supportive and caring families. Second,
many participants reported a variety of barriers to medication
adherence, including lack of health knowledge, forgetfulness, and
unaffordability of medicines. One participant stated: “I don’t know
much (health knowledge) … Apart from the doctor, I have never
received information from another person.” Finally, many partici-
pants reported their families’ insufficiency of health knowledge
and lack of involvement for their hypertension care. One patient
mentioned: “No, my families are not aware of [hypertension]. Even
my sons, they have no knowledge about hypertension. They don’t
know the symptoms of hypertension.” However, some also
mentioned several ways their families were involved in their
hypertension care, such as giving medicine reminders, advising
lifestyle changes, and providing emotional support.
DISCUSSION
This mixed-method observational study investigated the relation-
ship between family support and medication adherence among
people with hypertension living in informal settlements (some-
times referred to as “slums”) in Nairobi, Kenya. We found high
levels of family support but low medication adherence levels
among the participants, with a trend toward but no significant
association between these two factors.
The low medication adherence that we found is concordant
with previous studies [13, 36]. We identified several factors
significantly associated with low medication adherence, such as
being prescribed more than two pills per day and having
comorbidities. Previous studies with similar findings have inter-
preted this as causing “medication-taking fatigue” among patients
Journal of Human Hypertension
 S. Xiong et al.
3
Table 1. Perceived family support and high medication adherence by two adherence measurements from multiple logistic regressions.
Model-1: Morisky-Green levine scalea Model-2: hill-bone adherence scaleb
Odds ratio (95% CI) P value Odds ratio (95% CI) P value
Perceived family support levelsc
Weak or medium (ref ) – –
Strong 1.68 (0.45–6.20) 0.438 1.80 (0.38–8.52) 0.457
Age 1.05 (0.99–1.10) 0.08 0.99 (0.94–1.05) 0.682
Gender
Male (ref) – –
Female 1.52 (0.45–5.15) 0.499 2.195 (0.55–8.81) 0.267
Education
No formal schooling (ref ) – –
≤Primary school 5.82 (0.96–35.35) 0.056 1.79 (0.24–13.59) 0.572
Primary school completed 6.53 (0.78–54.33) 0.083 0.32 (0.02–5.46) 0.428
≥Secondary school 8.54 (1.01–72.21) 0.049 2.81 (0.28–28.66) 0.384
Number of pills prescribed daily
One (ref ) – –
Two 0.36 (0.12–1.06) 0.063 0.41 (0.13–1.37) 0.148
More than two 0.07 (0.01–0.62) 0.018 0.28 (0.02–3.37) 0.314
Side effects
Don’t have side effects (ref ) – –
Have side effects 3.85 (0.75–19.90) 0.107 0.21 (0.02–1.97) 0.171
Comorbidities
No comorbidities (ref ) – –
Diabetes 1.30 (0.33–5.16) 0.706 1.81 (0.38–8.55) 0.452
Other comorbiditiesd 0.25 (0.07–0.91) 0.035 1.65 (0.41–6.64) 0.482
a
Model 1 used the Morisky-Green Adherence Scale as the adherence measurement, where scoring 0 were coded as “high adherence”, and scoring 1 to 4 as
“low to medium adherence”.
b
Model 2 used the Compliance to Hill-Bone Medication-Taking Adherence Scale as the adherence measurement, where scoring equal to 9 were coded as
“perfect adherence,” and scoring higher than 9 as “non-perfect adherence”.
c
Responses of the Perceived Social Support from Family (PSS-Fa) Scale is categorized as “strong family support” (scoring ≥11), “weak or medium family
support” (scoring ≤10).
d
Other comorbidities considered in this analysis include arthritis, ulcers, asthma, pneumonia, and kidney diseases.

[37–39]. Such “medication-taking fatigue” is modifiable and
should be addressed through health education and external
support to raise awareness and motivation for self-management.
Both the quantitative and qualitative data in our study showed
strong family support perceived by the study participants, which is
also consistent with previous studies conducted in similar settings
[29, 40]. However, the high family support was not significantly
associated with medication adherence, even though there was a
trend in that direction. This is incongruent with existing evidence,
which has suggested that strong family support has a widely
positive impact on chronic disease control through mechanisms
such as providing practical help, emotional support, and health
information support [27, 29, 31, 32, 41].
Our qualitative data provides a possible explanation: the
suboptimal level of health knowledge and health management
skills in this population may have contributed to a failure for
family support to translate into meaningful improvements in
hypertension management, including medication adherence. In
the interviews, many participants reported that their family health
knowledge was mainly comprised of their self-experience of
diseases, and that hospitals were their only source of health
education. Therefore, the strong family support that the patients
perceived might have failed to enhance their medication
adherence when the patients’ families were not empowered with
the awareness and capacity to help patients in health-related
issues. This, along with “medication-taking fatigue,” underscores a
clear need to provide better health education for this population,
which may potentially enable more successful translation of
strong family support into positive health effects.
The higher participation rate of women is also informative. We
found that 68.3% of our participants were female, and only 31.7%
were male. Our sample was produced via convenience sampling,
where we approached and recruited all patients with hypertension
who attended the clinics/healthcare centers during the research
period. Thus, the gender proportion in the study may roughly
reflect the gender distribution of people’s attendance for HTN care.
A higher number of women seeking HTN care is consistent with
previous studies in sub-Saharan Africa. The higher participation
rate of women in a study in Nigeria was attributed to women’s
higher likelihood to seek HTN care instead of higher prevalence of
HTN among women (29), and a study in Kenya found that women
had significantly higher rates of detection, treatment, and control
of HTN (7). Two explanations can be offered for this phenomenon.
First, in traditional African society, males are the major breadwin-
ners of the family, and are thus less likely to have clinic visits
unless urgent (7, 29). Second, hypertension among women is
more likely to be detected from their contacts with healthcare
facilities during their reproductive years (7, 29). The gender
disparity of care seeking behavior with respect to HTN therefore
provides insight into the serious issue of low awareness and
detection rates of HTN in Kenya, especially among its male
population.

Journal of Human Hypertension

 S. Xiong et al.
4
Table 2. Major themes of in-depth interviews.
Main themes
1. Family relationships and situations
1.1 Positive
1.2 Negative
2. Patient perceptions of hypertension and medication adherence
2.1 Patients’ hypertension knowledge
2.2 Patients’ perceived importance of adherence
2.3 Barriers to medication adherence
3. Patients’ family and hypertension management
3.1 Family’s awareness of patients’ hypertension condition
3.2 Family’s hypertension knowledge
3.3 Family’s roles in hypertension care
3.4 Expectations for family
Our study has both strengths and limitations. We are among the
only studies to specifically explore hypertension control among
people living in informal settlements in Nairobi, Kenya – especially
with respect to medication adherence. Likewise, our results are
based on well-defined, widely validated measures for all key
variables (e.g. Morisky-Green Levine scale for medication
adherence).
Our primary limitations include convenience sampling, use of
only two study sites, small sample size, and potential for
desirability bias. Within the limitations of being only two study
sites, the clinics in Korogocho neighborhood do portray char-
acteristic informal settlement areas of Nairobi, Kenya and serve
our purposes as an exploratory study. Second, it must be
acknowledged that a possible interpretation for the non-
significant result is that the study could be under-powered due
to small sample size and convenience sampling strategy, which
were a consequence of budget and timing restraints. While it is
true our sample of 93 participants is too small to act as a nationally
generalizable sample, the number was large enough to permit
statistical subgroup comparisons. Moreover, our qualitative data
provided an alternative plausible explanation for the non-
significant result, which is worthy of discussion. For qualitative
data, interviews reached information saturation, evidencing
sufficiency of the qualitative sample size for our purposes. Finally,
self-reporting of medication adherence is more prone to
desirability bias than objective measurements such as pill counts.
We attempted to mitigate by using two widely-used, widely-
validated adherence measurements within a mixed-method
design with in-depth interviews and variable triangulation
[33, 34, 42–61]. Taken together, these limitations do not invalidate
Key points
· Supportive and caring family members
· Poverty, lack of education
· Insufficient hypertension knowledge
· Reliance on self-experience for hypertension knowledge
· Unawareness of risk factors for hypertension
· Desire to receive more health information
· Hospitals being the only source of health education
· Acknowledging the importance of medication adherence
· Suffering from the consequences of non-adherence
· Forgetfulness
· Intentional stops when feeling good
· Unaffordability of medicines
· Awareness of the patients’ hypertension conditions
· Unfamiliarity with the hypertension treatment
· Overarching insufficiency
· Infrequent health knowledge exchange within the family
· Reminders of taking medicines, appointments, and refills
· Advising lifestyle changes (e.g. lower salt intake)
· Providing emotional support and motivation
· Increasing patients’ sense of responsibility
· More health knowledge
· Better technical skills (e.g. measuring blood pressure)
· Constant emotional support
our data. We are therefore able to draw conclusions appropriate to
the level of an exploratory study, using our results to highlight
evidence gaps and important areas of investigation.
In conclusion, even among those living in informal settlements in
Nairobi who are able to access healthcare, receive a diagnoses of
hypertension, and also access treatments, suboptimal medication
adherence still poses a major barrier to hypertension management.
Our study adds to the literature that family support and medication
adherence may not always exist in a direct relationship, but rather
may possibly be mediated by additional values such as health
education and awareness. We propose that when families are
empowered with greater health knowledge, this may enable family
support to then translate into more tangible benefits for medication
adherence. Therefore, we call for additional research to explore the
potential mediating effects of health knowledge on the relationship
of family support and medication adherence. We further call for
invigorated efforts to provide better health education for both
people with hypertension and their families living in informal
settlements in Nairobi, Kenya, and additional research to better
represent this population in the hypertension literature.
SUMMARY
What is known about this topic
● Suboptimal medication adherence is a major barrier to
hypertension control, both globally and in Kenya.
● Family support is an important factor in health management
of people with chronic diseases.
Journal of Human Hypertension

● People living in informal urban settlements in Kenya are an
underrepresented population in the hypertension literature,
and the few existing medication adherence studies with this
group have found discordant results.
What this study adds
● Improving medication adherence among people with hyper-
tension living in informal settlements in Nairobi, Kenya merits
invigorated attention.
● The relationship between family support and medication
adherence may potentially be mediated by additional
variables, such as health education and awareness.
DATA AVAILABILITY
The raw data supporting the conclusions of this article will be made available by the
authors, without undue reservation.
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Among Hypertensive Patients Post Health Education At Kenyatta National Hos- SX, SF, and LLY conceived the study design, drafted the study protocol, and obtained
pital (Doctoral dissertation, University of Nairobi). ethical approvals. CW and DW led the data collection and cleaning. SX and NP
51. Wang Y, Lee J, Toh MP, Tang WE, Ko Y. Validity and reliability of a self‐reported conducted data analysis, interpretation, and led the writing. NP, TO, MO, and XZ
measure of medication adherence in patients with type 2 diabetes mellitus in provided critical suggestions to the structure and writing of the manuscript. All
Singapore. Diabet Med. 2012;29:e338–44. Sep authors approved the submission for the final manuscript.
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SM. Descriptive study of patient compliance in pharmacologic antihypertensive This research was funded by Duke Kunshan University.
treatment and validation of the Morisky and Green test. Aten Primaria.
1992;10:767–70.
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ETHICAL APPROVAL
56. Yan LL, Gong E, Gu W, Turner EL, Gallis JA, Zhou Y, et al. Effectiveness of a primary
The study was approved by the ethical committees of Duke Kunshan University,
care-based integrated mobile health intervention for stroke management in rural
Africa Population Health Research Center (APHRC), and the Ethics and Scientific
China (SINEMA): A cluster-randomized controlled trial. PLoS Med. 2021;18:
Research Committee of African Medical and Research Foundation (AMREF). Informed
e1003582 https://doi.org/10.1371/journal.pmed.1003582
consent was obtained from each participant before they were involved in the study.
57. Teshome DF, Demssie AF, Zeleke BM. Determinants of blood pressure control
amongst hypertensive patients in Northwest Ethiopia. PloS One. 2018;13:
e0196535. May 2
58. Tefera YG, Gebresillassie BM, Emiru YK, Yilma R, Hafiz F, Akalu H, et al. Diabetic ADDITIONAL INFORMATION
health literacy and its association with glycemic control among adult patients Correspondence and requests for materials should be addressed to Shangzhi Xiong.
with type 2 diabetes mellitus attending the outpatient clinic of a university
hospital in Ethiopia. PloS One. 2020;15:e0231291. Reprints and permission information is available at http://www.nature.com/
59. Usman MN, Umar MD, Idris FA, Abdullahi Y. Medication adherence and its reprints
associated factors among hypertensive patients in a tertiary health facility in
Minna, North central Nigeria. Archives of Clinical. Hypertension 2019;5:003–7. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims
60. Tandon S, Chew M, Eklu-Gadegbeku CK, Shermock KM, Morisky DE. Validation in published maps and institutional affiliations.
and psychometric properties of the 8-item Morisky Medication Adherence Scale

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