The Effects of Economic Scarcity on Health Behaviors in Older Adults With Chronic Disease

Summary

Chronic diseases are the leading causes of death and disability in the US, accounting for the majority of health care spending. Among adults with chronic illnesses like hypertension, diabetes, or HIV, adherence to daily oral medications is essential but often below 50%. Why do medication adherence and preventive health service engagement remain stubbornly low? Scarcity theory offers a novel explanation in the context of poverty. It posits that economic hardship imposes a cognitive burden that shifts attention from long-term goals to immediate needs, reduces future orientation (the relative value placed on immediate vs. future outcomes), and limits mental bandwidth (the cognitive resources needed for decisions), thus undermining behaviors like daily medication adherence and service engagement. To address these gaps, our objective is to rigorously test whether and how economic scarcity affects medication adherence and preventive service uptake among older adults with chronic disease, leveraging the naturally occurring monthly fluctuation in scarcity created by the Supplemental Nutrition Assistance Program (SNAP) benefit cycle as a natural experiment. There are three aims: 1. We will measure daily medication adherence objectively for four months with wireless electronic pill bottle caps (CleverCaps). We will test whether, when, and by how much adherence changes as scarcity fluctuates during the SNAP benefit cycle. 2. We will conduct two easily implementable RCTs to test whether scarcity affects participants' engagement with beneficial services requiring navigation of administrative burdens. In one trial, participants will be randomized to receive an invitation during either a high- or low- scarcity period (i.e., before vs. after SNAP receipt) to a personalized preventive health review that identifies gaps in US Preventive Services Task Force Grade A/B recommendations.25 In the second, participants will be invited to free financial counseling provided by the City of Philadelphia during a high- or low-scarcity period. We hypothesize invitation response rates will be \>15% higher during low-scarcity periods. 3. We will examine potential mechanisms that link scarcity with health behaviors by randomizing timing of validated measures of mental bandwidth and future orientation during a period of high- or low-scarcity (i.e., before vs. after SNAP receipt). Our hypothesis is that we will find differences in several measures between participants who are randomly assessed during high- vs. low-scarcity periods (i.e. before vs. after SNAP receipt). Impact: Demonstrating that scarcity helps to explain low medication adherence and beneficial health-related service uptake can inform patient-centered adherence interventions, clinical care-delivery approaches, health-system strategies, and public health approaches to improve these health behaviors and promote healthy aging.