A social care programme’s impact on quit-smoking intention in multi-problem households: exploring the scarcity theory 261 8 Introduction Overwhelming evidence exists of a higher prevalence of unhealthy behaviour in lower as compared to higher socioeconomic groups.1, 2 The effects of such behaviour on mortality make it tempting to design interventions aimed at improving health behaviour in lower socioeconomic groups for the purpose of reducing socioeconomic health inequalities. However, with some exceptions, results are generally disappointing thus far.3 While there may be many reasons for the limited evidence how to improve health behaviour in lower socioeconomic groups effectively, one important potential reason is that interventions insufficiently put health behaviour in the wider context of daily life, despite recommendations to do so.4 Indeed, it seems crucial to link health behaviour with the more unfavourable circumstances lower socioeconomic groups are often in, and the psychosocial stress resulting from these circumstances. Poverty, for example, is often accompanied by stress caused by uncertainty about the availability of food, shelter and employment and instability in one’s environment.5 Dealing with such stressors is often prioritized over less pressing issues, such as health behaviours with potential advantages in health later in life. Decision making patterns in deprived individuals are often characterized by a focus on the present and on the actual, as opposed to the future.5 Such decision patterns, deliberate and unconscious, could explain the preference for a stress-relieving cigarette now over a healthier future. One theory connecting poverty and health behaviour is the theory of scarcity by Mullainathan and Shafir,6 according to which human cognitive capacities are limited and making deliberate and healthy choices takes up “cognitive bandwidth”. Stressful circumstances as experienced in poverty take much of this cognitive bandwidth, and can even lead to an actual decrease in cognitive performance.7 What would this imply for health interventions? Effectively removing scarcity may create in the end more “space” for making healthy choices. It implies that tackling problems outside the health domain, such as upstream material living conditions, may increase an intrinsically motivated intention to change behaviour. Moreover, it emphasizes that health problems can and should not solely be tackled by health professionals, but that a truly intersectoral approach is required. In a social care program in Rotterdam and Nissewaard (the Netherlands) for families facing problems in multiple domains, an app was developed registering
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