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December 1, 2014

Ageing involves many challenges for health and well-being. One under-recognised problem is that of declining literacy skills. While we are familiar with general issues of ageing such as loss of eyesight or physical mobility, what happens to literacy skills during ageing is much less well understood. Literacy is important to health during ageing because literacy is fundamental to managing health. For example, proper taking of medications, understanding what the doctor says, and understanding of written medical information all rely on having adequate literacy. When literacy is used in health contexts such as these, we refer to it as ‘health literacy’. The American Institute of Medicine defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (1).

The consequences of low health literacy include poor self-care of chronic disease, unnecessary use of emergency services, low use of preventive health services such as cancer screening, and increased risk of mortality (2–4). Health literacy declines during ageing. This is thought to be caused by the normal ageing-related decline in cognitive abilities such as mental processing speed and memory (5,8).

In our study, we were curious to see whether cognitively stimulating activities would help older adults to maintain their health literacy skills, regardless of any cognitive decline they experienced.

In particular, we examined whether internet use and engagement in several different types of social activities might help older adults to maintain health literacy. We used data from almost 4500 men and women aged 52 years and over in the English Longitudinal Study of Ageing (ELSA). The ELSA is a population-representative longitudinal study of English adults aged 50 and over, which aims to capture the experience of ageing in England. Since 2002, the study participants have been interviewed every two years about their health, economic, and social conditions. Data on health literacy were measured in 2004 and again in 2010 using a basic reading comprehension test of a medicine label.


At the start of the study, we found that nearly one-third of adults had low health literacy, and that 18% of the study sample experienced a decline in their health literacy skills during the study follow-up period (9). People who were most at risk of declining health literacy were older, had no educational qualifications, had relatively low wealth, were ethnic minorities, and had difficulties with activities of daily living. On the positive side, consistent internet use over the six year study follow up period and engagement in cultural activities such as attending the opera, theatre, art galleries, museums, concerts, or the cinema appeared to protect against health literacy decline (9). The other types of social activities that we looked at were civic activities including being a member of a trade union, environmental group, neighbourhood group, and volunteering, and leisure activities including being a member of a sport or social club, or attending educational or musical classes. Alone, participating in civic or leisure activities had no effect on health literacy during ageing.

When we looked at the combined effects of engaging in none, one, two, three, or four of internet use and each of civic, leisure, and cultural activities, we saw an additive effect where the more activities adults engaged in, the more likely they were to maintain health literacy skills (9). People who engaged in all four of internet use, civic activities, leisure activities, and cultural activities over the study follow-up period had half the odds of losing health literacy skills as people engaged in none of these activities (Table). Importantly, all of these associations were independent of cognitive decline and other factors that might influence internet use and social activities such as wealth, social class, and health status.

Table. Additive effects of consistent engagement in any of internet use, civic activities, leisure activities, and cultural activities, the English Longitudinal Study of Ageing, 2004-11 (n=4368)


95% CI

Per additional activity


(0.81, 0.94)

Number of activities engaged in







(0.76, 1.14)



(0.63, 1.02)



(0.53, 0.94)



(0.33, 0.79)

*Adjusted for age, sex, ethnicity, educational attainment, net non-pension wealth, having a limiting long-standing illness, experiencing an IADL limitation, baseline executive function, baseline memory, executive function decline, and memory decline


What does this study mean? Well, first of all, that it is not inevitable that older people lose literacy skills as they age. It appears that internet use and social activities help with the maintenance of literacy skills. Even adults who experienced cognitive decline appeared to gain a benefit from using the internet and engaging in cultural activities. However, the main concerns are social inequalities in access to the internet and that cultural activities require time, money, and transportation. Older adults who are in poor health, have low wealth, and are from deprived backgrounds are the least likely to take advantage of the internet and to participate in cultural activities. They are also the most vulnerable to the loss of literacy skills as they age. Future research is needed to improve our understanding of how internet use and social engagement promote literacy skills, and to develop strategies to enable the most vulnerable individuals to benefit from technological advances and full participation in society.

This research was conducted at the Health Behaviour Research Centre at University College London, and funded by a Doctoral Foreign Study Award from the Canadian Institutes of Health Research, an Overseas Research Scholarship from UCL, and by programme grant funding from Cancer Research UK.


1.        Institute of Medicine. What is health literacy? In: Nielsen-Bohlman L, Panzer A, Hamlin B, Kindig D, editors. Health literacy: a prescription to end confusion. Washington D.C.: National Academies Press; 2004:31-58.

2.        Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011;155:97–107.

3.        Kobayashi LC, Wardle J, von Wagner C. Limited health literacy is a barrier to colorectal cancer screening in England: Evidence from the English Longitudinal Study of Ageing. Prev Med 2014;61:100–5.

4.        Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ 2012;344:e1602.

5.        Wolf MS, Curtis LM, Wilson EAH, Revelle W, Waite KR, Smith SG, et al. Literacy, cognitive function, and health: results of the LitCog study. J Gen Intern Med 2012;27(10):1300–7.

6.        Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med 2005;20(2):175–84.

7.        Gazmararian JA, Baker DW, Williams M V, Parker RM, Scott TL, Green DC, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281(6):545–51.

8.        Federman AD, Sano M, Wolf MS, Siu AL, Halm EA. Health literacy and cognitive performance in older adults. J Am Geriatr Soc 2009;57(8):1475–80.

9.        Kobayashi LC, Wardle J, von Wagner C. Internet use, social engagement and health literacy decline during ageing in a longitudinal cohort of older English adults. J Epidemiol Community Health 2014;epub ahead of print. doi: 10.1136/jech-2014-204733

All images: Wikimedia Commons


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