Housing Instability Linked to Cost-Related Medication Nonadherence and Financial Hardship in Adults with Uncontrolled Diabetes

Introduction

Housing stability is a critical social determinant of health profoundly affecting chronic disease management. In adults with diabetes, consistent access to medication and healthcare is essential for glycemic control and prevention of complications. However, when individuals face housing instability—characterized by frequent moves, inability to pay rent, or living in inadequate conditions—the financial and psychological burdens can impede adherence to prescribed treatments. This study explores the relationship between housing instability, cost-related nonadherence to diabetes treatment, and financial toxicity (the economic burden caused by healthcare costs) among adults with uncontrolled diabetes.

Objectives

The primary objective was to assess how prevalent housing instability is within a sample of adults with uncontrolled diabetes who experience cost-related barriers to care. Furthermore, the study aimed to analyze the associations between housing instability and two key outcomes: 1) cost-related nonadherence to medication and care, and 2) financial toxicity affecting their overall wellbeing.

Methodology

The research utilized baseline data from a randomized controlled trial involving 600 adults diagnosed with uncontrolled diabetes, defined typically by elevated blood glucose levels despite treatment. These participants reported facing cost-related barriers to their medical care. Logistic regression models evaluated the likelihood that those experiencing housing instability also demonstrated cost-related nonadherence to diabetes medications or appointments. Linear regression models measured the degree of financial toxicity associated with housing instability. Adjustments were made for confounding factors including symptoms of depression, anxiety, and diabetes distress to isolate the impact of housing issues.

Results

Half of the participants (n=298) reported housing instability, indicating a significant prevalence within this population.

• Cost-related nonadherence: Those with housing instability had a 64% higher odds (adjusted odds ratio 1.64; 95% CI 1.05, 2.56) of missing medication doses or not filling prescriptions due to costs compared to those with stable housing.
• Financial toxicity: Participants experiencing housing instability reported significantly worse financial toxicity (B = -4.64; 95% CI -6.20, -3.09), reflecting greater economic hardship related to their medical expenses.

However, after further adjustment for psychological factors—such as diabetes distress and symptoms of depression and anxiety—the association between housing instability and cost-related nonadherence was no longer statistically significant, suggesting mental health influences play a mediating role. Importantly, the link between housing instability and financial toxicity remained robust even after these adjustments.

Sensitivity analyses highlighted that worry specifically about housing costs, rather than unmet housing or utility needs per se, was associated with greater financial toxicity, indicating the psychological stress of housing affordability directly impacts financial wellbeing.

Discussion

These findings underscore housing instability as a significant factor linked with economic hardship and challenges in managing diabetes treatment costs among adults with uncontrolled diabetes. The disappearance of a significant relationship between housing instability and cost-related nonadherence after accounting for mental health factors suggests psychological distress may be an important mediator or confounder and deserves further attention in clinical care.

Financial toxicity—representing the strain of healthcare costs on individuals—remained significantly associated with housing instability independent of mental health effects, highlighting the tangible economic burden faced by this population. The study’s focus on worry about housing costs further emphasizes the importance of addressing perceived financial stress alongside actual material deprivation.

Clinical and Public Health Implications

For healthcare providers, understanding that housing instability contributes to financial toxicity and may indirectly affect medication adherence through mental health is crucial. Screening for housing insecurity and associated stress in diabetes care settings could help identify patients at risk of poor outcomes due to financial and psychosocial challenges.

Interventions need to be multidimensional, combining diabetes management support with social services connecting patients to housing assistance programs, financial counseling, and mental health resources. Policymakers should consider integrating healthcare and housing policies to mitigate these social determinants and improve diabetes control and overall health outcomes.

Limitations and Future Research

The study analyzed cross-sectional data at baseline, limiting causal inferences. Longitudinal studies with nationally representative samples are necessary to validate these findings and understand the temporal relationship between housing instability, cost-related nonadherence, financial toxicity, and mental health factors.

Further research might explore tailored intervention strategies that address housing insecurity as a pathway to reduce financial and psychological burdens, thereby improving diabetes management and reducing healthcare disparities.

Conclusion

Housing instability is prevalent among adults with uncontrolled diabetes and closely linked to financial toxicity and, initially, to cost-related nonadherence to diabetes treatment. The interaction with mental health underscores the complex web of social and psychological factors influencing diabetes management. Addressing housing affordability and associated financial stress is essential for improving adherence, reducing financial hardship, and enhancing overall outcomes in this vulnerable population.

Reference

Davis VH, Mehdipanah R, Patel MR. Housing Instability Associated With Cost-Related Nonadherence and Financial Toxicity in People With Uncontrolled Diabetes. Diabetes Care. 2026 Aug 13:dc261152. doi: 10.2337/dc26-1152. Epub ahead of print. PMID: 42594248.