Background
Historically, literacy referred to the three technical skills of reading, writing and calculating. Over the past half century, a plural notion of literacy has evolved such that literacy is now considered a multi-dimensional construct involving a host of skills essential for optimal functioning in society and the achievement of one’s personal goals. The United Nations Educational, Scientific and Cultural Organization (UNESCO) defines literacy as “the ability to identify, understand, interpret, create, communicate and compute, using printed and written materials associated with varying contexts. Literacy involves a continuum of learning in enabling individuals to achieve their goals, to develop their knowledge and potential, and to participate fully in their community and wider society.” [
1]. In this context, many Americans display low levels of literacy. About 90 million adults scored poorly on the 2003 National Assessment of Adult Literacy [
2]. Low literacy is a particularly significant problem among persons over age 65, the majority of whom score below basic competency levels [
2]. This represents a particular challenge since late life is a time at which some of life’s most significant and influential health and financial decisions must be made (e.g., health insurance plan selection, complex medical options, retirement savings, inter-generational transfers). Literacy, therefore, encompasses a wide range of competencies, including the domains of health and financial literacy, both of which have important implications for the health and well-being of older persons [
3‐
15], the fastest growing segment of the population in developed countries [
16,
17]. We define health literacy as the ability to access, understand, and utilize health information and concepts in ways that promote good health outcomes, and we define financial literacy as the ability to access, understand, and utilize financial information and concepts in ways that promote good financial outcomes, as previously reported [
18] and consistent with prior work [
19‐
21]. Our definition of health literacy is consistent with the definition used by the Institute of Medicine which is “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” [
20]
Recent studies of older persons have shown that low health literacy is associated with poorer self-rated health and increased all cause mortality [
3‐
6]. Persons with low health literacy also have higher health care costs and are less efficient in their use of health care services [
7,
8]. However, there is limited data on the relation of health literacy to health promoting behaviors such as social, physical, and cognitive activity. Studies have reported associations with physical activity [
6] and use of preventive services [
9], but other health promoting behaviors have not been examined.
Further, whereas studies of older persons have shown that financial literacy is important for financial planning in old age [
22], very little data from older persons are available regarding the relation of financial literacy with health promoting behaviors and measures of health status. However, evidence from younger persons suggests that financial literacy may also have important health consequences, especially with regard to mental health. For example, the British Household Panel Survey (BHPS) found that higher financial capability was associated with better self reported mental health and better self reported physical health [
23].
Most prior studies of the relation of literacy to health in older persons used screening tests of cognition or functional abilities or medical record review to exclude persons with moderate to severe dementia [
6]. However, they did not perform clinical evaluations to exclude persons with dementia, and specifically mild dementia. Thus, it remains unclear whether mild dementia accounts for some of the associations of literacy with health outcomes. In this study, we examined the correlates of literacy among more than 550 community based persons from the Memory and Aging Project, all of whom were clinically evaluated and determined to be without dementia. We collected data on health and financial literacy and created a total literacy score based on the average of these two domains. Then, in a series of analyses adjusted for age, sex, and education, we examined the relation between total literacy and health promoting behaviors, including cognitive, physical, and social activity, all of which have been associated with adverse health outcomes. We then examined the relation between total literacy and several indicators of health status, including cognition, functional status, and mental health. Additional analyses considered potential confounders. We then examined these associations separately for health and financial literacy.
Discussion
We examined the relation of literacy with health promoting behaviors including cognitive, physical, and social activities, and indicators of health status including cognition, functional status, and mental health in a community-based cohort study of over 550 older individuals clinically evaluated and determined to be free of dementia. We found that total literacy was associated with participation in cognitive and social activities. It was also associated with better cognition, less impairment in instrumental activities of daily living, less mobility disability, and less loneliness. In additional analyses of the two domains of literacy separately, similar associations were frequently present for both health and financial literacy. However, in general, health literacy was more strongly associated with health promoting behaviors, whereas financial literacy was more strongly associated with indices of mental health. Overall, the results suggest that literacy is associated with participation in health promoting behaviors and indicators of health status. Our findings raise the possibility that strategies to improve health and financial literacy may have the potential to improve public health, even in advanced age.
Most prior work on the relation of literacy with health has focused on the domain of health literacy. One prior study showed an association between health literacy and physical activity [
6]. Prior studies also have reported an association between health literacy and indices of health status, including cognitive function [
12] and functional status, including ability to perform instrumental activities of daily living [
9,
13]. Health literacy has also been related to indices of mental health, with one study showing an association between health literacy and depressive symptoms [
4], while another did not [
45].
While there has been less focus on the relation of financial literacy with health promoting behaviors and health status, data from several studies have shown direct and indirect associations between financial literacy and health. For example, cognition, a component of health status, has been related to indices of financial literacy [
14]. One study also reported an association between numeracy and self-reported health [
12]. A recent study found that the presence of real estate owned properties (2005–2009) in a neighborhood, an indicator of foreclosure rates, was associated with increases in medical visits for a variety of mental health conditions such as anxiety among persons 18–64 [
46]. In addition, the Greek minister for health reported an increase in suicide rates of about 40% in the first months of 2011 that were thought to be attributable to unemployment [
47].
The present study builds on prior literature in three important ways. First, we excluded persons with dementia based on a detailed clinical evaluation. It is well accepted that dementia is associated with impaired medical and financial competence [
48,
49]. An important limitation of prior work is that screening methods for dementia consisted of excluding persons with a MMSE score below 18 [
10], impairment in basic activities of daily living [
6], or exclusion based on medical record review [
7]. These approaches may identify moderate to severe forms of dementia but will not eliminate many persons with mild dementia. Our findings restricted to persons without dementia suggest that the previously reported associations with health and financial literacy are not due to the confounding effects of dementia. Second, we extend previous research by showing that health literacy is associated with participation in cognitive and social activities, in addition to physical activity. Cognitive and social activities, like physical activity, are health promoting behaviors associated with a wide range of adverse health outcomes, including disability, dementia and death [
29,
31,
32,
34,
36,
37] and are targets of intervention studies actively underway in the elderly. Third, we found that financial literacy, a domain not well studied in older persons in relation to health, was also associated with cognitive activity and indices of health status including cognition, functional status, and mental health. In fact, the findings with mental health were more robust for financial literacy than for health literacy. As there were many more items in the financial literacy scale, it is possible that these findings were the result of a psychometrically more stable measure rather than being specific to financial literacy. By contrast, it may be that financial literacy has a relatively selective effect on mental health. Financial literacy may make individuals more confident and secure about their future, particularly in later life when there are limited opportunities to overcome financial mistakes. It has been suggested that lack of financial literacy may contribute to financial stress and lead to poor mental health [
50], and our findings support and extend this idea in the elderly. There is also data suggesting that higher financial capability and higher financial literacy are associated with better psychological wellbeing [
10,
11]. In this way, financial literacy may affect indices of health indirectly through its impact on mental health. Some studies report that mental health is associated with a variety of adverse health outcomes in older adults [
35,
36,
40,
42,
43]. Furthermore, one study found that communities with higher foreclosure rates, which may be indicative of lower financial literacy, experience higher hospital admission rates [
46]. Thus, our data are consistent with the hypothesis that financial literacy impacts health status through an effect on mental health. However, further prospective studies will be needed to clarify these associations.
The finding that literacy is associated with health promoting behaviors and indices of health status is novel and has important public health policy implications. About 90 million adults scored poorly on the 2003 National Assessment of Adult Literacy, and the majority of persons over age 65 scored below basic competency literacy levels [
2]. In addition, persons over age 65 suffer a disproportionate burden of disease and are faced with some of life’s most significant financial decisions. It certainly is the case that greater financial literacy is associated with better financial outcomes, and financial status is related to access to and utilization of healthcare services. Financial literacy most likely also is related one’s knowledge of the important role of lifestyle factors as determinants of health outcomes, and persons with greater financial literacy (and financial status) may be more likely to have the opportunity and resources needed to engage in health promoting behaviors (i.e., access to and resources to pay for fruits and vegetables and gym memberships). Further, the Foresight Program in the United Kingdom Government Office for Science recently issued a report on mental capital and wellbeing [
51] which found strong links between mental health problems and debt. One of the recommendations was better financial management training to help break the cycle between debt and mental illness. Our findings extend previous research and raise the possibility that strategies to improve health and financial literacy have the potential to improve public health even in advanced age. That being said, there is increasing evidence that the seeds of age-related chronic diseases are sown in early and mid life [
52]. Thus, efforts to improve health and financial literacy should not only target older persons, but also persons of younger ages [
15].
There are several strengths to this study. We used a structured multistep process to diagnose dementia, and those with dementia were excluded from analyses to reduce confounding. Our participants were older than participants in most prior studies resulting in a cohort at greater risk for adverse health outcomes allowing examination of literacy and health in later life. We assessed a range of novel health promoting behaviors. We also measured cognitive function using a detailed cognitive battery that yields a global measure and measures of five important domains of cognition. We also assessed a broader array of indices of functional status and mental health. Finally, we assessed associations with financial literacy, a topic not well studied in relation to health among older persons. The study also has important limitations. MAP participants are a volunteer cohort, and findings based on their health and literacy levels may not be representative of the general population of older adults. Thus, studies in more representative populations are needed. In addition, the study is cross-sectional and we cannot determine the direction of causality. For example, it is possible that literacy is related to or a function of cognitive decline even among persons without dementia. Longitudinal studies of the relation of literacy to health will be important to determine the causal directions and will inform on the likelihood that interventions to improve literacy will result in improved public health. Finally, we did not use common measures of health literacy such as the Rapid Estimate of Adult Literacy in Medicine (REALM), which measures the ability of adults to pronounce and recognize medical terms [
53], or the Test of Functional Health Literacy in Adults (TOFHLA), which measures the ability of adults to perform basic reading tasks needed to function in the health care environment, such as reading prescription bottle labels, understanding appointment slips, and completing health insurance forms [
54]. This makes it difficult to compare our findings to prior work in the literature and it is possible that our results would have differed had we used one of these other measures. While the REALM and TOFHLA have strengths, we believe our measure also has strengths in terms of identifying the ability to understand and process health concepts specifically relevant to older persons; assessing literacy in this manner may provide novel information about the knowledge older persons need to make decisions that promote good health outcomes consistent with the 2004 Institute of Medicine’s definition of Health literacy [
20].
Competing interests
None of the authors have a relevant competing interest.
Authors’ contributions
JSB drafted the manuscript. PAB helped manage the data and edit the manuscript. BDJ helped performed the statistical analysis and helped edit the manuscript. DAB helped to coordinate the study, manage the data, and edit the manuscript. All authors read and approved the final manuscript.