The Factors that Prevent the Adherence to TB Treatment among Homeless Persons

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The research topic is majorly on the factors that prevent the adherence to TB treatment among the homeless persons. The above topic is concerned with finding an analysis of the reasons behind TB infections among homeless persons. The above research will specifically adopt a more cynical approach to developing, controlling and even managing the methods of TB management. The research will adopt a different system of controlling and the research that will use primary data collection methods to enhance the authenticity of the research outcomes. Further, the study system will be important in enhancing better research results through qualitative and quantitative data analysis methods.

The researcher will use primary data analysis approaches as the major means through which they will achieve accurate results. The research will be done on an experimental basis and will include an approach that is well defined by more accurate means. Further, the research will be used to accurately define the research questions through a proper analysis of the results. Coming up with more defined and accurate conclusions and findings will be used in the process of controlling and enhancing results on the reasons why homeless people are more susceptible to TB attacks and do not find an easy cure or even management of the disease. The research will be since the people who are considered homeless always have very limited access to proper healthcare and areas such always not able to fully adhere to the treatment of TB. Much of the previous research has always been focused on the general management and treatment of TB.

Key words: Homeless, drug abusers, medication, treatment and adherence


I am grateful to God for the opportunity to undertake the above study research. I would also wish to express my gratitude to my professor and the rest of the faculty for the understanding and direction that they gave me in the process of taking part in the above study. Lastly, I would also wish to register my appreciation to all my parents for the encouragement that they gave me while undertaking the assignments and research above.

1: Introduction/background

Tuberculosis is an infectious disease produced by the bacterium Mycobacterium tuberculosis, which is inhaled in respiratory droplets and spread from person to person (Skrahina, et al., 2013). Although rates are falling as a global incidence, it remains an important public health problem in industrialized countries especially among vulnerable groups (WHO, 2018). The World health organization (WHO, 2015) reported 9.6 million of new TB cases and 1.5 million TB deaths worldwide have been estimated. Despite improvements in the problem of TB has been observed in high-income countries, many barriers to TB control and treatment still exist especially among the homeless (Ramani et al, 2016). The homeless are at increased risk of developing TB and have worse treatment outcomes than any of the public (WHO. 2018).

Tuberculosis (TB) is an infectious disease that goes back over 17,000 years ago (Sandhu, 2011). Despite better qualities of diagnosis and treatment of TB available in the world, it is unfortunately still among the top ten killer infectious diseases worldwide and the development of drug-resistant forms of the disease is a major risk to global health security (Lönnroth, et al. 2015). According to World Health Organisation (WHO), TB is still the leading cause of death among HIV positive people. TB is a disease that is indistinguishably linked to poverty and socially disadvantaged. It is a problem in London which often described as the TB capital in Europe (PHE, 2016).

With tuberculosis, it is an elevated risk in homeless people and is underserved by conventional health series such as the National Health Services (NHS) (Mugwagwa, 2018).

In England in 2015, over 5,700 cases of TB were notified (PHE, 2016.) of which 4.4% had a history of homelessness (PHE, 2016).

Description of the condition

When infected, most people do not develop symptoms as Mycobacterium tuberculosis are controlled by the immune system and lie dormant in a state known as latent TB. Active TB is when the bacterium is no longer controlled by the immune system and can occur at any given time following infection and most commonly affects the lungs resulting in chronic coughs, which then spread the disease (Harris, 2006).

The most frequently used method of diagnosing latent TB is in Mantoux test, which involves the injecting of a purified m. tuberculosis protein under the skin of the forearm (Millet, et al, 2013). A swelling occurs in the area injected if the individual has been exposed to TB due to the localized immune response which is measured from 48 hours to 72hours later (CDC, 2010). The treatment of latent TB is known as chemoprophylaxis which involves the use of isoniazid for 6 months, where it aims to prevent the later development of active disease and reduce transmission (NICE, 2016).

In both active and latent TB, effective treatment requires regular medication to be taken from up to six to twelve months. Adherence to this treatment is particularly difficult due to prolonged schedule resulting in treatment failure (Narayanan 2003: Volmink 2000). Homelessness is a major factor that leads to the non-adherence of the treatment in the long term. Whereas the treatment would be necessary through a proper follow-up the process, homeless people provide difficulty in terms of patient follow-ups. Homeless people are always exposed to dynamic and changing environments, a factor which increases their physical mobility and thereby reduces long terms access for the treatment of their TB cases.

Definition of homeless

Currently, there is no known standard definition of homelessness as the terms largely vary depending on the conditions and situations that are driven by the psychological feelings of homelessness. As a result of the lack of consensus on the definition, there are many ways through which the term homelessness has been described. For this study, however, the term homeless may be used to refer to the situation where a person or a group of people literally do not have a roof under their heads (Skrahina, et al., 2013). The term may also be extended to mean the condition in which people may be forced to stay within areas that are unsafe, illegal, overcrowded and where there is only a temporary form of accommodation such as a relative’s house, hostels or even refugee camps. The above definition describes how diverse the term homelessness may be seen to exist beyond the idea of only not having a house.

Research Question

What factors prevent adherence to TB treatment among homeless people and drug users?

The aim of the review

The main aim of the study is to carry out research and use the figures and data obtained from the study in elaborating the various factors that prevent the adherence to TB treatment among homeless people.

The objectives of the review

i. Come up with the factors that prevent the adherence to the treatment of Tuberculosis Treatment among the homeless people.

ii. Develop a theoretical understanding of the relationship between Tuberculosis and homelessness.

iii. State the various factors that influence vulnerability to TB among homeless people.

iv. Investigate why the homeless people are more vulnerable to Tuberculosis attacks.


Many homeless people and drugs abusers find it difficult to access TB treatment. Those lucky to visit the hospital fail to follow and adhere to the doctor’s prescription. These social factors have become a key obstacle in management of TB, especially at the latent stage. Therefore, this research will help to gain insights into TB prevalence among the homeless and drug abusers. The study is also useful as it helps to identify the best solution towards improving adherence of homeless and drug abusers to TB treatment, especially through enhanced social care.

Definition of key terms

Tuberculosis- According to Young, et al., (2014), Tuberculosis is defined as an infectious disease that may be majorly caused by a bacterium that is known as Mycobacterium Tuberculosis

(MTB) and which mainly influences the functions of the lungs.

Homelessness- Nahid, et al., (2015) asserts that homelessness may be generally defined as the state of not having a roof over one's head or even not being able to have a permanent residence such as a refugee situation.

Adherence- May be used to referring to the act of being able to keep up with the necessary and laid down procedures and plans (Story, et al., 2016).

Treatment – Is the process of providing medication through the assistance of well-trained and qualified medical personnel (Abubakar, et al., 2013).


TB- Tuberculosis

CDC – Centre for Disease Control

WHO- World Health Organization

NHS- National Health Services

HIV- Human Immune Virus

Chapter 2: Methodology

The chapter begins with the presentation of the various research strategies, the analysis of the database used, the search terms and the inclusion and exclusion criteria. Further, the chapter gives the critical description of the study which is presented through a flow chart. Lastly, the study carries out critical appraisal.

Search Method

To find the studies for this review, a broad systematic literature search was needed to be conducted (Aveyard, 2010). The literature review was undertaken by using the EBSCOhost tool were four databases were selected CIHNAL complete, MEDLINE complete, PsycINFO and Academic search complete. The use of different databases helps to broaden the ranges of references produced and the choices of databases depend on interest and potential coverage (Grewal, 2016). A search was carried out with the aim of finding a broad range of results regarding factors that contribute to non-adherence in tuberculosis treatment.

The main search term used was ‘tuberculosis’, this was then combined with using Boolean operator ‘AND’ with the truncate terms ‘Treat*’, ‘integr*’, ‘Homeless*’ and ‘Rough sleep*’, asterisk (*) at the end of each character, this helps to broaden the search by looking for relating terms. For instance, enter* will search for terms i.e. integration or integrates. These were then utilised to gather relevant research and the search obtained was 38 results.

Furthermore, the following limiters were then applied. The articles needed to be from the year 2007 onwards. This was to ensure that relevant up-to-date articles were obtained for inclusion. Also, the articles were limited to those that were peer-reviewed to ensure that they were considered as academically high-quality studies and that the articles reflected the latest research on treatment adherence of tuberculosis. Once the limiter was applied the results obtained was 12 articles that were deemed relevant to the review. Then duplicate was removed this resulted in 11 articles remained.

Moreover, the title and abstract were screened in this literature review for eligibility using the inclusion and exclusion criteria. The inclusion included primary research studies, on the disease of tuberculosis, homeless people or some referred as hard-to-reach groups or vulnerable people and which focused on the factors influencing non-adherence in treatment. The exclusion included a general population that was non-homeless, systematic reviews, articles with non-English language, adherence to diseases other than TB. Below Table 2 shows the inclusion and exclusion criteria.

Table 1. Inclusion and exclusion criteria.




o Primary research studies

o Factors influences non-adherence in TB

o Homeless people

o Specifically, TB only

o 2007 onwards

o Peer-reviewed

o English language

o Systematic reviews

o Non-homeless people (general population)

o Adherence to other diseases (non-TB).

After reviewing the title and abstracted 5 were excluded, this then resulted in 6 articles being selected and was assessed for eligibility. The main criteria for the selection were an emphasis on factors influencing non-adherence in homeless people focusing on social determinants. The quality of researchers was then evaluated using the CASP appraisal tool and only ones that demonstrated a high-quality research and mainly answered ‘Yes' in the appraisal tool regarding their methodology was used in the review, this lead to 3 articles to be rejected. Two studies (Potter et al, 2015 and Sagbakken et al, 2013) were removed because of poor design. A further study (Moreau et al, 2012) was removed because it did not identify factors influencing non-adherence in depth.

Three studies were selected for the review. This resulted in a hand search to be conducted was finding relevant literature were difficult to find through the databases. Accordingly, searching is an important strategy when conducting a review as not all journals are indexed in databases. Relevant journals such as the Journal of Public health, the lancet: infectious diseases were used to obtain further 3 studies. This lead to a total of 6 articles to be selected for this literature review.

As Craig & Alimuddin (2015) used a qualitative design, therefore, it was appraisal using the CASP qualitative checklist (CASP, 2013a). The remaining articles apart from one or two, all fit in the category of a cohort study and was appraised using the Cohort Study Checklist (CASP, 2013b). One of the studies is a retrospective chart review it meets the criteria of a quantitative study (Malejczyk et al, 2014). For this reason, it was evaluated using the cohort study checklist (CASP, 2013b).

The CASP appraisal was summarised in a table (see appendix 1). Also, one for the case-controlled study is summarised in Appendix 2. A full CASP appraisal was used is included in Appendix 3.

Fig. 1 Preisman Flowchart

Chapter 3: Findings


The chapter presents the researcher's adoption of the different research methods, research study regions and even the study designs and methods of measurements adopted by the researcher. The main objective of the research was to come up with the most appropriate data, while still considering the possibility of coming up with the best ways of relating the rate for tuberculosis and its treatment among the homeless people. The research also undertook an in-depth exploration of the different available options for the understanding of the relationships that are found between TB and the rate of infection among the homeless people.

The CASP table which has been given under the appendix provides a platform through shuck the research study adopted the use of both quantitative and qualitative data. The qualitative aspect of the research study was majorly used as the best means of exploring the various research options. Additionally, both approaches were very useful, especially in finding and establishing a strong link that would be useful in the process of sharing a commonality point I the process of examining the phenomena of homelessness and TB. Both approaches are also very useful as they operate with the required data. The process of gathering data during an interview to gain information from the study would, for example, ensure that there is adequacy in the focus that is given to the topic and even the subject of the study.

The key characteristics of the research study were marketed by a convergence of the study which gave the author a very valid understanding of the contents of the study. The research utilised a well elaborated referencing systems which comprised of the author-date format. The use of such references was to help in validating the research using secondary data materials. The research was conducted in the United States since the country provided a very good platform for a diverse group of people and even institutions to give clear information that was relevant to the research. Additionally, the country provided a unique opportunity to undertake the study since much of the past research related to homelessness and TB infections have majorly been done within the US.

Research design

The study also adopted both observational and experimental research in accomplishing the aims and details of the study. In implementing the experimental research methods, the study used the manipulation of the data by using quantitative analysis to influence the dependent and independent variables and has a feasible research outcome. The achievement of the above method was accomplished through proper statistical data analysis which was used as a means of coming up with properly evaluated data. The use of experimental research was also advocated and utilised due to the degree of accuracy which it always seeks to achieve and accomplish in the long run.

On the other hand, the study also adopted the use of observational research as a major research design. In seeking to increase the relevance and the reliability of the research, the researcher used ethological studies, case studies and even adopted the use of ethnographic studies. The researcher ensured that the process of observation and recording of the available data was accurate and timely. The accomplishment in the use of observational research was also carried out using research surveys which were conducted accordingly. The study also adopted the use of questionnaires which were primarily for giving more value to the research and increasing the level of research reliability and authenticity.

Research sample

The research mainly focused on a sample which included homeless persons who had suffered from TB infections in the past. The total number of homeless persons who were put under the study was 100. In addition, the sample also included medical personnel and other caregivers who had a previous experience in dealing with TB patients, especially those who are homeless.

Key Themes

Six studies were selected because they had information relating to the research question. The first theme is factors contributing to non compliance with TB treatment. Two studies, Malejczyk et al. (2014), Goetsch (2012), Dias et al. (2017) and story et al. (2007) express this theme by focusing mainly on imprisonment, drug use and homelessness. The second theme from three of the studies is benefits of collaborative care for marginalized patients (Dias et al. 2017; Craig et al. 2008; and Craig and Alimuddin (2015). The last theme expressed by two studies is lack of access to healthcare, which evaluates the challenges faced by many people, especially in urban centres, seeking medication for TB (Dias et al. 2017; and Craig et al. 2008).

Factors Contributing to Non-Compliance with TB Treatment

Four of the reviewed studies have factors contributing to non-compliance to TB treatment as the main theme. In two of the studies, researchers establish the impact of homeliness, drug use and alcoholism on adhering to TB treatment. In one of the articles, Malejczyk et al. (281) identify factors such as unemployment, drug use, alcoholism, and homelessness make it difficult for T patients to follow the doctors’ guidance or even seek for the necessary treatment. In their study aimed at identifying the impact of these factors, Malejczyk et al. (282) found at that homelessness was the leading factor in non-compliance to drug as 60% of the homeless patients failed to follow the treatment protocol. Incarceration, alcoholism, and drug use were also among the leading factors for poor adherence to TB treatment By comparison, related research by Story et al. (667) investigates the factors leading to poor TB treatment adherence among the patients in London. In their findings, Story et al. (668) show that homelessness and drug abuse are the leading factors for non-compliance with TB treatment. These articles have relevant information supported with data and example, thereby making them to be highly valid and reliable.

Another major concept discussed in three of the studies is on relationship between imprisonment and adherence to drugs. For instance, In their research, Malejczyk et al., Goetsch., Dias et al., and Story et al. examine the impact of incarceration on TB treatment. In their findings, all the authors agree that these factors affect negatively TB treatment since they make it difficult for patients to adhere to their prescription. According to Goetsch et al. (391), homelessness and drug abuse lead to noncompliance with TB treatment. Males contributed to a large percentage homeless and drug users in this study (Goetsch et al. 391). In a retrospective cohort study, Dias et al. (328) report that the incidence of TB among homeless persons in Portugal was high. For instance, in 2011, Portugal had 9205 homeless persons and 2609 TB cases, from which 112 affected those without homes (Dias et al. 328). Then, during the same year, unsuccessful TB treatment between homeless and non-homeless patients was at 26.8% and 9.9% respectively (Dias et al. 329). Furthermore, Dias et al. (329) show that mortality rate due to TB infections among the homeless patients was 14.4% compared to 5.4% in those with homes. Similarly, Malejczyk et al. (282) report that homeless and imprisoned patients were at high risk of developing latent TB and recording high mortality rates due to non-compliance with treatment. Malejczyk et al. (282) also indicate that patients who abuse drugs were likely to forget following the doctor’s prescription. Furthermore, Story et al. (668) reveal that drug abuse and imprisonment made it difficult for TB patients to stick to their prescribed medicines. The findings in all the four studies are highly transferable since all the authors make a clear description of the method used to collect and analyse data.

Collaborative Care for Marginalized Groups

Majority of marginalized groups find it difficult to access treatment to TB, a factor that leads to a high mortality rate. A high population of the marginalized people is found in urban centres, hence difficult to access proper treatment. In their studies, Craig et al., Craig and Alimuddin, and Dias et al. investigated on the best strategies for treating TB in marginalized populations. Using a qualitative cross-sectional study, Craig and Alimuddin (107) indicate that drug abuse, alcoholism, and homelessness were the leading factors that affected TB treatment among the marginalize groups. Therefore, providing quality social care was the effective approach towards enhancing compliance with TB treatment in the affected population (Craig and Alimuddin 108). In a similar study, Craig et al. (414) investigate the role of collaborative care through social outreach model on helping TB patients’ access and adhere to their treatment. In their findings, Craig et al. (416) show that offering social care to marginalized groups increased their adherence to TB treatment. Equally, Dias et al. (331) note that a change of strategy towards social care for marginalized groups was the best solution for increasing their compliance with TB medication.

Summary Table

Author and Year


Type of Study




Data Collection

Key Findings

Craig et al. (2008)

Journal of advanced nursing

Qualitative Interview

To establish the effectiveness of social outreach model of care including collaborative care pathways

100 patients

Mixed Methods Approach

Prospective cohort studies and interviews

Providing social care improves adherence of patients to TB treatment.

Mitigation of some social risk factors such as poor housing promotes adherence to medication.

Craig and Alimuddin (2015)

International Journal of Infectious Diseases

Qualitative Cross-sectional Study

To describe the social context of adhering to TB treatment in the marginalized population in London

17 participants

Semi-structured Interviews

Semi-structured interviews involving analytical frameworks

Homelessness is a key obstacle towards adherence to TB medication.

Provision of social care acts as an incentive towards adherence to TB medication.

Dias et al. (2017)

International Journal of Tuberculosis and Lung Disease

Retrospective Cohort Study

To determine the outcome of TB treatment among homeless patients in Portugal.

To establish the impact of homeliness towards TB treatment.

100,000 homeless patients

Data analysis

Logistic regression

Homelessness has a positive correlation with high TB incidence.

Homeless patients had a high incidence rate of drug abuse and alcoholism

Goetsch et al. (2012)


Field Experiment

To establish a sustainable X-ray screening program for homeless TB patients and drug users

3477 TB patients

Mixed Methodology

Direct observations

X-ray screening for the chest was effective at improving health outcomes among homeless and drug abuser TB patients.

Story et al. (2007)


Cohort Study

1995 patients

Quantitative design

Direct observation

In a population of 100,000, the prevalence of TB among homeless, drug users and prisoners was at 788, 354 and 208 respectively. Hence, this population encounters a high prevalence rate of TB compared to other people.

Malejczyk et al. (2014)

." Canadian Journal of Infectious Diseases and Medical Microbiology

A retrospective study

To determine the ability of inner city latent TB infected population to complete the required treatment in Alberta

77 patients

Quantitative design

Direct analysis of collected data

Homeless and drug abusers in the inner city of Alberta had low completion rates of their TB treatment compared to the non-homeless.

Review of the CASP Table

In all the six articles selected, the statement provided a clear aim. The investigators described the research goals, importance, and relevance. Then, the appropriateness of the quantitative method was highly visible.

The research design was highly appropriate since it described the methodology used to collect data, analyse and interpret. With this design used in each study, it was possible to relate the findings to the topic or aim.

The recruitment strategy in all the study had the highest level of appropriateness. All authors described the method used to identify eligible participants and include them in the study. Besides, the investigators provided adequate factors that led to exclusion of some participants.

Chapter 4

Discussion & Recommendations

After completing the data gathering and analysis, the researcher came up with specific data facts that majorly aimed at answering the research questions. The findings of the study were majorly related to the literature review of the study and sought to provide concrete answers to the research questions (Lönnroth, et al., 2014). Majorly, the discussions of the findings were related to providing an insight into the knowledge gap that exists in seeking to understand the various factors that acted as the major blockers to adherence to medication and treatment among the homeless tuberculosis patients. The results were limited to the findings that were arrived at after the research focused on a study population of 100 homeless persons. The findings below are based on the logical sequence that the study also followed in seeking to answer all the questions that came up in the research.

Causes of homelessness

Firsts, the study confirmed the assertion that homeless persons have a large degree of non-adherence to medication related to TB. The study analysis concluded that there are numerous factors that contribute to the interruption of the TB medication process that is always undertaken by the homeless patients (Story, et al., 2016). Additionally, the study noted the constant medical concerns that are raised because of the increasing number of homeless patients who continually miss and forego medication processes because of their status.

The findings of the study revealed that much of the contribution of non-compliance to TB treatment was mainly seen in the case of the male persons as compared to the female. The above observation was mainly drawn from the fact that most of the homeless population are mainly made up of males. Additionally, medical research reveals that the male sex has a lower level of immunity to TB infections as compared to the females. The above study revealed the reasons behind the high number of male infections with TB and the high number of homeless patients suffering from the conditions.

The study also revealed that the mean age for homeless persons stands at 39 years. The above explanation was drawn from the findings of the research which indicated that homeless patients between the ages of 31 to 50 years made up 60% of the homeless patients’ population. The above reasoning could be explained from the point of view that younger homeless persons are not fewer in the study as most of them are always either put under the foster care of taken up for adoption (Habteyes and Gholamreza, 2015). Additionally, at the young age, most of the young people are actively engaged in their education process and that are not left to wonder about while contributing to the population that may be considered homeless.

In seeking to establish the causes of homelessness, the study also found out that unemployment was one of the biggest contributors that made people lack a roof over their heads. In undertaking the study, it was found out that 98% of the homeless people who were incorporated in the research had no active jobs or even a means of earning an income. The above explanation could be taken to mean that homeless persons mainly lack the financial support and the monetary income that may enable them to either rent a, build or even buy a permanent residence (Tankimovich, 2013). Most of the homeless people are other cashless or even lack the basic education that may easily secure them any meaningful job. The study also found out that the homeless people spent much of their time idling and thus they did not have any kind of monetary income to support their lives. Due to their disadvantaged economic situation, homeless people were mainly subjected to poor medical conditions as they are unable to afford even the basic medical expenses. The above reading could be extended as one of the major causes of non-adherence to medication by the homeless persons.

The relationship between Homelessness and TB infections

As part of the research questions, the researcher sought to establish the existing relationship between homelessness and the level of TB infection. In undertaking the study, the researcher examined the homeless person in relations to their level of infection, especially with Latent TB contact, latent Tb fibrosis and even the effect of other opportunistic diseases such as HIV. After an extensive research, the study revealed that there is a great connection that always exists, especially for persons who are undergoing a homeless experience

January 19, 2024




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