The Effects of Economic Scarcity on Health Behaviors in Older Adults With Chronic Disease
| Registry | NCT07862452, acronym TIDES |
|---|---|
| Status | Not yet recruiting |
| Phase | Not applicable |
| Study type | Interventional; randomized, factorial, masking: none, health services research |
| Enrollment | 400 (Estimated) |
| Sponsor | University of Pennsylvania (Other); collaborators: National Institute on Aging (NIA) |
| Conditions | HIV, Hypertension, Hypercholerolemia, Type 2 Diabetes |
| Interventions | Preventative health review invitation early in SNAP cycle, Financial counseling invitation early in the SNAP cycle, Aim 3 follow-up call early in the SNAP period, Preventative health review invitation late in SNAP cycle, Financial counseling invitation late in the SNAP cycle, Aim 3 follow-up call late in the SNAP cycle (Other) |
| Dates | start 2027-03-01 (estimated), primary completion 2029-07-01 (estimated), completion 2029-07-01 (estimated), first posted 2026-10-07, last updated 2026-10-19 |
| Locations | 1 site in United States |
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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, the study's 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. Daily medication adherence will be measured objectively for four months with wireless electronic pill bottle caps (CleverCaps). The investigators will test whether, when, and by how much adherence changes as scarcity fluctuates during the SNAP benefit cycle.
2. The investigators 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. In the second, participants will be invited to free financial counseling provided by the City of Philadelphia during a high- or low-scarcity period. The investigators hypothesize invitation response rates will be >15% higher during low-scarcity periods.
3. Potential mechanisms that link scarcity with health behaviors will be examined 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). The investigators hypothesize that there will be 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.
| Arm | Type | Interventions | Description |
|---|---|---|---|
| Early preventative health review, early financial counseling invitation, early aim 3 follow-up call | Experimental | Other: Preventative health review invitation early in SNAP cycle; Other: Financial counseling invitation early in the SNAP cycle; Other: Aim 3 follow-up call early in the SNAP period | |
| Early preventative health review, early financial counseling invitation, late aim 3 follow-up call | Experimental | Other: Preventative health review invitation early in SNAP cycle; Other: Financial counseling invitation early in the SNAP cycle; Other: Aim 3 follow-up call late in the SNAP cycle | |
| Early preventative health review, late financial counseling invitation, late aim 3 follow-up call | Experimental | Other: Preventative health review invitation early in SNAP cycle; Other: Preventative health review invitation late in SNAP cycle; Other: Aim 3 follow-up call late in the SNAP cycle | |
| Early preventative health review, late financial counseling invitation, early aim 3 follow-up call | Experimental | Other: Preventative health review invitation early in SNAP cycle; Other: Aim 3 follow-up call early in the SNAP period; Other: Financial counseling invitation late in the SNAP cycle | |
| Late preventative health review, early financial counseling invitation, early aim 3 follow-up call | Experimental | Other: Financial counseling invitation early in the SNAP cycle; Other: Aim 3 follow-up call early in the SNAP period; Other: Preventative health review invitation late in SNAP cycle | |
| Late preventative health review, late financial counseling invitation, early aim 3 follow-up call | Experimental | Other: Aim 3 follow-up call early in the SNAP period; Other: Preventative health review invitation late in SNAP cycle; Other: Financial counseling invitation late in the SNAP cycle | |
| Late preventative health review, late financial counseling invitation, late aim 3 follow-up call | Experimental | Other: Preventative health review invitation late in SNAP cycle; Other: Financial counseling invitation late in the SNAP cycle; Other: Aim 3 follow-up call late in the SNAP cycle | |
| Late preventative health review, early financial counseling invitation, late aim 3 follow-up call | Experimental | Other: Financial counseling invitation early in the SNAP cycle; Other: Preventative health review invitation late in SNAP cycle; Other: Aim 3 follow-up call late in the SNAP cycle |
Sex: All, ages: 50 Years to any
Inclusion Criteria: * Age ≥50 years * SNAP beneficiary * Resident of Philadelphia, Bucks, Montgomery, Chester, or Delaware County (all with the same SNAP disbursement schedule) without plans to leave in the next 4 months * Diagnosis of hypertension, diabetes mellitus, hypercholesterolemia, or HIV (without advanced immunosuppression) * Prescribed a once-daily oral medication for the qualifying condition * Self-report missing ≥2 doses of this medication over the prior 30 days (i.e., <94% adherence) Exclusion Criteria: * Does not meet all of the inclusion criteria * Unable to provide consent * Non-English speaker * Cognitive impairment, per PIs discretion * Receives cash assistance through the Temporary Assistance for Needy Families (TANF) program * Daily medication produces immediate symptomatic relief and thus provide a strong and immediate incentive to be adherent. Daily medication has common short-term side effects (e.g., sulfonylureas, which can cause hypoglycemia).
| Facility | City | Country | Status |
|---|---|---|---|
| Penn Medicine, 3535 Market St. | Philadelphia, Pennsylvania | United States |
NIH grants: R01AG103431