Ethical Issues Raised by Patient Non-Adherence in the
Homeless Population
Joyce Do '25
Introduction: Health Disparities Among the Homeless
Population
This paper explores ethical questions raised by the
issue of patient non-adherence in the homeless
population. The homeless population includes those who
are chronically homeless, experiencing temporary housing
loss, escaping domestic abuse, or confronting various
challenges. In 2022, the Department of Housing and Urban
Development (HUD) counted around 582,000 Americans
experiencing homelessness. That is about 18 per 10,000
people in the US.
Between 2020 and 2022, there was a 16% increase among individuals experiencing chronic homelessness. Chronic homelessness is used to describe people who have experienced homelessness for at least a year—or repeatedly—while struggling with a disabling condition such as a serious mental illness, substance use disorder, or physical disability.
Homelessness is strongly linked to deteriorating physical and mental health. In March 2024, the measure known as Proposition 1, which includes $6.38 billion for treatment and housing of homeless individuals with severe mental illnesses and addiction, was passed by voters in California. Despite a narrow 50.2% approval rate, this significant proposition underscores California’s acknowledgment of the pivotal role mental health care plays in addressing homelessness.
Moreover, the 2022 Annual Homelessness Assessment Report (AHAR) to Congress and the Continuum of Care Homeless Populations and Subpopulations Report states that 21% of individuals experiencing homelessness reported having a serious mental illness, and 16% reported having a substance use disorder. Recently, in 2023, a wide-ranging study released by the Benioff Homelessness and Housing Initiative at University of California, San Francisco, found that about two-thirds of the homeless people interviewed had serious symptoms of mental illness, yet only about 18 percent had recently been treated. These health challenges arise from multiple factors, including inadequate access to food and shelter and limited availability of resources and social services. In addition, distrust of the healthcare system and past experiences of discrimination from providers can deter unhoused individuals from seeking treatment.
A 2022 study highlights the contrast in healthcare coverage between the general population and the homeless community. While 92.1% of people, or 304.0 million, had health insurance at some point during the year in the United States, only about 40% of homeless individuals were insured under Medicare and Medicaid. Shockingly, the remaining 60% lack any form of insurance, despite many being eligible due to their age or disability status., Health insurance allows access to free preventative healthcare services and mitigates the financial burden of healthcare expenses, both of which are crucial for unhoused and housed individuals.
Between 2020 and 2022, there was a 16% increase among individuals experiencing chronic homelessness. Chronic homelessness is used to describe people who have experienced homelessness for at least a year—or repeatedly—while struggling with a disabling condition such as a serious mental illness, substance use disorder, or physical disability.
Homelessness is strongly linked to deteriorating physical and mental health. In March 2024, the measure known as Proposition 1, which includes $6.38 billion for treatment and housing of homeless individuals with severe mental illnesses and addiction, was passed by voters in California. Despite a narrow 50.2% approval rate, this significant proposition underscores California’s acknowledgment of the pivotal role mental health care plays in addressing homelessness.
Moreover, the 2022 Annual Homelessness Assessment Report (AHAR) to Congress and the Continuum of Care Homeless Populations and Subpopulations Report states that 21% of individuals experiencing homelessness reported having a serious mental illness, and 16% reported having a substance use disorder. Recently, in 2023, a wide-ranging study released by the Benioff Homelessness and Housing Initiative at University of California, San Francisco, found that about two-thirds of the homeless people interviewed had serious symptoms of mental illness, yet only about 18 percent had recently been treated. These health challenges arise from multiple factors, including inadequate access to food and shelter and limited availability of resources and social services. In addition, distrust of the healthcare system and past experiences of discrimination from providers can deter unhoused individuals from seeking treatment.
A 2022 study highlights the contrast in healthcare coverage between the general population and the homeless community. While 92.1% of people, or 304.0 million, had health insurance at some point during the year in the United States, only about 40% of homeless individuals were insured under Medicare and Medicaid. Shockingly, the remaining 60% lack any form of insurance, despite many being eligible due to their age or disability status., Health insurance allows access to free preventative healthcare services and mitigates the financial burden of healthcare expenses, both of which are crucial for unhoused and housed individuals.
Moreover, in a retrospective analysis based on data from
615 homeless individuals, of whom 176 died in the analyzed
period of 2010-2016, the average lifespan of a homeless
individual was reduced by approximately 17.5 years
compared to the general population. This stark disparity
underscores the gravity of the health challenges faced by
those without stable housing. Furthermore, homeless males
have an average age at death of 56 years, while homeless
females have an average age at death of just 52 years.
Most deaths occurred in conditions of cold stress,
particularly from hypothermia. Deaths from hypothermia
occurred thirteen times more frequently among the homeless
population compared to the general population.
In addition, Black Americans have the highest rate of homelessness among the nation’s racial and ethnic groups. In 2018, 54 out of every 10,000 Black people in the United States were homeless. In New York, 208 out of every 10,000 Black people were homeless and Massachusetts is number one in the country in its rate of Hispanic/Latinx homelessness, with 107 per 10,000 unhoused. With these marginalized communities simultaneously facing disparities in wealth, education, employment, and higher rates of incarceration, the effects of homelessness will further exacerbate existing systemic issues.
The homeless population must navigate a multitude of challenges such as managing their physical and mental health, acquiring health insurance, avoiding death by the elements, and facing systemic racism. Homeless individuals, many who are victims of an unjust and unethical system, are worthy of justice and compassion, and their living situation does not define their inherent worth as a human being. Thus, society as a whole and communities with unhoused people have an obligation to alleviate the health disparities present within this vulnerable community, with a focus on the issue of patient non-adherence, which is closely tied to their unique living circumstances.
Overview of Patient Non-adherence Non-adherence, a complex phenomenon, includes both intentional and unintentional refusal by patients to follow prescribed treatment recommendations. Intentional non-adherence involves deliberate actions by patients and is typically linked to their motivation levels, whereas unintentional non-adherence stems from factors such as limited resources or capability to adhere to medication regimens.
Adherence varies throughout patients’ treatment journeys and may manifest in behaviors such as not filling prescriptions, not initiating treatment, using medication incorrectly, or prematurely discontinuing treatment. This multifaceted issue arises from factors related to patients, treatment complexity, and interactions with healthcare providers. Patients may question treatment necessity, encounter barriers to due complex regimens, or face communication challenges with providers. A meta-analysis of 569 studies found an average nonadherence rate of 25% in patients. While adherence rates are highest among patients with certain conditions like HIV infection or cancer, they tend to be lower among those with pulmonary disease, diabetes, or sleep disorders. The severity of illness often correlates with adherence, with patients facing more serious conditions typically adhering more closely to their prescribed medication regimens.
The issue of patient non-adherence is imperative to investigate as non-adherence rates have remained nearly unchanged in the last decades.
"This multifaceted issue arises from factors related to
patients, treatment complexity, and interactions with
healthcare providers."
Factors Contributing to Non-adherence
Non-adherence to medication regimes among homeless
individuals is influenced by a myriad of factors,
stemming from their unique socioeconomic status and
healthcare challenges. One example is the absence of
stable housing that prioritizes basic needs such as food
and shelter over healthcare. This prioritization, which
is sometimes misconceived as negligence or
non-adherence, reflects individuals’ fundamental fight
for survival.
Moreover, non-adherence to medication in homeless patients is common in behavioral health treatment, with around 42% of patients discontinuing their antidepressants within the first month and 72% stopping after three months. Reasons for this non-adherence include concerns about adverse effects, forgetfulness, lack of social support, insufficient knowledge, and poor communication between patients and physicians. This breakdown in communication can be attributed to various factors. Patients exhibit diversity in education, intelligence, and language proficiency, leading to potential misunderstandings. For instance, explanations comprehensible to native English-speaking college graduates may be entirely unintelligible to those who did not complete highschool or for whom English is a second language. This discrepancy underscores the importance of clear and accessible communication in and outside healthcare settings.
Moreover, the issue of health literacy further exacerbates communication barriers, especially within the homeless community. Research indicates that higher levels of health literacy were associated with being housed and with lower levels of drug use. In addition, a 2006 study conducted in central North Carolina, examining medication barriers among homeless women, revealed that those with low health literacy faced greater challenges in administering medication to their children compared to those with higher health literacy. This finding underscores the dangers of low health literacy, extending beyond individual consequences to affect the health and well-being of family members, particularly children. Finally, individuals with limited health literacy frequently struggle to comprehend health education materials provided by healthcare professionals or pharmacists. This difficulty may extend to monitoring their symptoms effectively. Also, they may have concerns about developing dependency on long-term medications and hold misconceptions about the efficacy of medications over prolonged use. With better health literacy education, knowledgeable patients could be more inclined to follow through with treatments and take control of their own health.
Furthermore, the homeless population faces additional
barriers contributing to non-adherence including limited
or no prescription insurance coverage, lack of storage
space for medications, limited privacy, and lack of
transportation to pick up their medications. More
factors include younger age, illicit drug use, and
depression or stress. These challenges underscore the
complex social, economic, and psychological factors
affecting medication adherence.
Finally, an overwhelmed patient often struggles with self-care, particularly when facing complex and stressful life situations such as homelessness. These situations can leave individuals feeling exhausted, unable to fully manage a chronic illness, and alone, with disaffiliation from social networks worsening non-adherence challenges among homeless individuals.,
Moreover, non-adherence to medication in homeless patients is common in behavioral health treatment, with around 42% of patients discontinuing their antidepressants within the first month and 72% stopping after three months. Reasons for this non-adherence include concerns about adverse effects, forgetfulness, lack of social support, insufficient knowledge, and poor communication between patients and physicians. This breakdown in communication can be attributed to various factors. Patients exhibit diversity in education, intelligence, and language proficiency, leading to potential misunderstandings. For instance, explanations comprehensible to native English-speaking college graduates may be entirely unintelligible to those who did not complete highschool or for whom English is a second language. This discrepancy underscores the importance of clear and accessible communication in and outside healthcare settings.
Moreover, the issue of health literacy further exacerbates communication barriers, especially within the homeless community. Research indicates that higher levels of health literacy were associated with being housed and with lower levels of drug use. In addition, a 2006 study conducted in central North Carolina, examining medication barriers among homeless women, revealed that those with low health literacy faced greater challenges in administering medication to their children compared to those with higher health literacy. This finding underscores the dangers of low health literacy, extending beyond individual consequences to affect the health and well-being of family members, particularly children. Finally, individuals with limited health literacy frequently struggle to comprehend health education materials provided by healthcare professionals or pharmacists. This difficulty may extend to monitoring their symptoms effectively. Also, they may have concerns about developing dependency on long-term medications and hold misconceptions about the efficacy of medications over prolonged use. With better health literacy education, knowledgeable patients could be more inclined to follow through with treatments and take control of their own health.
Furthermore, the homeless population faces additional
barriers contributing to non-adherence including limited
or no prescription insurance coverage, lack of storage
space for medications, limited privacy, and lack of
transportation to pick up their medications. More
factors include younger age, illicit drug use, and
depression or stress. These challenges underscore the
complex social, economic, and psychological factors
affecting medication adherence.
Finally, an overwhelmed patient often struggles with self-care, particularly when facing complex and stressful life situations such as homelessness. These situations can leave individuals feeling exhausted, unable to fully manage a chronic illness, and alone, with disaffiliation from social networks worsening non-adherence challenges among homeless individuals.,
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