When Noncompliance Isn’t the Problem: The Invisible Barriers Facing Immigrant and Indigent Patients

By Kathryn Keaton

Originally published, May 2025

“Carmen” had waited months for her shoulder procedure. But when she misunderstood her pre-op instructions and thought she had to stop her diabetes medication for a week, she nearly canceled the surgery. Afraid and unsure, she called the Project Access office for help—confused, not defiant.

Stories like Carmen’s are often reflected in medical charts with a single word: noncompliant.

Everyone reading this article knows the interpretation of these instructions—stopping her diabetes medication—was incorrect. But if Carmen had canceled her procedure without explaining her concerns, she could have easily been labeled as “noncompliant”—a patient lost to follow up rather than one navigating miscommunication and fear.

Too often, patients are labeled as noncompliant when they miss appointments, fail to adhere to medication regimens, or do not follow care plans. But for many residents of Tarrant County, particularly immigrants, the indigent, and other marginalized populations, these behaviors are not a reflection of defiance or indifference—they are symptoms of deeper, structural challenges rooted in the social determinants of health (SDOH).

Low health literacy is a major contributor in perceived noncompliance. Immigrants and low-income individuals often face challenges navigating a complex medical system, understanding terminology, or recognizing the importance of ongoing disease management. The 2022 Tarrant County Public Health Community Assessment noted that nearly 25 percent of residents have limited proficiency in health-related decision-making, and there is an even higher rate in non-English-speaking households.1

The term “noncompliance” places blame on the patient, ignoring the complex interplay of economic, cultural, educational, and systemic barriers that make following medical advice difficult. Reframing noncompliance as a response to SDOH helps us better understand the lived experiences of patients. In an effort to combat patterns of “noncompliance” among our patients, Project Access is taking a deep dive.