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. 2022 Nov 9;30(6):e3921–e3933. doi: 10.1111/hsc.14101

Understanding the role of financial health literacy in midlife and old age: A scoping review

Angela Y M Leung 1,2,3,✉, Laurence Lloyd B Parial 1,4, Stephanie S Szeto 1, Adwoa O Koduah 1
PMCID: PMC10100128  PMID: 36350147

Abstract

As global population ageing persists, understanding older adults' capacity to navigate the financial and healthcare system is essential. This scoping review examines how the concept of financial health literacy (FHL) is described and measured in the existing literature, the factors that may affect it, and its potential outcomes in middle‐aged and older adults. The review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analysis) extension guidelines to synthesise the available evidence on this topic. We utilised electronic databases and hand searching to identify relevant literature published between 2010 and 2022. A total of 29 articles were included in this review. The results showed that FHL involved accessing, understanding and utilising financial information for planning/management of healthcare expenses and selecting appropriate health services. However, FHL is not particularly depicted as a concept in the current literature, as most studies investigated health literacy, financial literacy and health insurance literacy as separate domains that were interrelated to one another. No validated measurement tool was developed for FHL. We propose five domains to indicate the concept and measurement of FHL in middle‐aged/older adults: money management, management of medical bills, understanding health insurance, deciding on appropriate health services, and planning for long‐term care needs. Demographic variables, such as sex (females), advanced age, cognitive impairment, low education and income and racial and ethnic minorities, were found to be related to low FHL. The reviewed studies also showed that FHL was related to several outcomes, including healthcare decision‐making, physical health and psychological well‐being. Hence, future studies to develop and validate assessment tools of FHL, together with the involvement of vulnerable groups, are imperative to understanding the concept of FHL. This could also facilitate the development of appropriate interventions that could enhance this capacity in the ageing population.

Keywords: financial, financial literacy, health literacy, health literacy, healthcare decision‐ making, middle‐aged, older adults, scoping review

What is known about this topic?

  • Supporting middle‐aged and older adults' capacity in financial and health decision‐making is vital to healthy ageing.

  • Health literacy and financial literacy are individual constructs that may impact healthy ageing.

  • Financial health literacy is a new concept that may involve intersections between the domains of financial literacy and health literacy.

What this paper adds?

  • Financial health literacy involves money management, medical bill management, understanding health insurance, deciding on appropriate health services, and planning for long‐term care needs.

  • Financial health literacy is an emerging concept that could impact healthcare decision‐making and health outcomes, particularly in middle‐aged and older adults.

  • Appropriate measures to assess financial health literacy are lacking, with existing research disparities between high‐income and low‐ and middle‐income countries.

1. INTRODUCTION

Population ageing is a phenomenon occurring in most countries, as people aged 60 years and above surpassed the number of under‐five children globally (World Health Organisation, 2021). As this demographic shift could introduce demands in the health and social systems, supporting older people and their families is crucial. However, financial insecurity is one of the present challenges to healthy ageing (McMaughan et al., 2020). A recent study noted that 80% of US households with people aged ≥60 years are financially struggling or at increased risk of economic insecurity (e.g. financially able to meet current needs but not major/unexpected expenditures) due to rising costs of necessities, healthcare and long‐term care services (Popham et al., 2021). Notably, financial vulnerabilities may begin early in midlife due to several factors, such as job loss/difficulty finding employment due to age discrimination, unpaid mortgages/debts and continued financial contribution to other family members (Infurna et al., 2020). Despite the assumption that pre‐retirement is associated with wealth accumulation to support the needs of late life (Mitchell & Lusardi, 2022), this may not be the case for some older adults. According to the National Council on Aging (2021), about 50% of people aged ≥50 years may have no job security or retirement savings. Hence, some older adults may rely on pensions or financial support from children to manage their needs while also continue paying off outstanding debts (Mitchell & Lusardi, 2022).

While some older people can remain independent and have intact functional abilities, others may also suffer from chronic diseases and degenerative conditions, leading to increased disability, hospitalisations and healthcare costs (World Health Organization, 2021). Moreover, older people could experience greater challenges navigating the healthcare system than younger adults. They could have more difficulties in understanding their health conditions and related treatments, identifying professional care providers/services needed to address their health problems, and making informed health decisions based on information provided (Funk, 2019). Notably, financial difficulties in older adults could further complicate their problems in accessing appropriate healthcare services (Leung, 2021). Older adults may also have lower education and income than younger populations, which may result in poorer financial decision‐making (Fong et al., 2021). Hence, in addition to offering direct financial support to older adults, enabling their abilities to successfully manage their financial and healthcare choices is important.

Health literacy, or the ability to access, understand and use health information, is a vital resource that could guide people in making appropriate healthcare decisions (Nutbeam & Lloyd, 2021). Previous studies indicated that health literacy is a significant predictor of health outcomes, including quality of life, adoption of healthy lifestyle and clinical parameters (e.g. lipid profile, body weight and blood pressure; Stormacq et al., 2020). Hence, health literacy has been widely investigated, with several studies involving assessments and interventions in the ageing population (Chesser et al., 2016). However, healthcare decisions also depend on one's financial resources, understanding of treatment options and individual preferences (Leung, 2021). Hence, financial literacy is another competency that requires considerable attention, since older adults may also face economic challenges in planning and managing their healthcare needs. Financial literacy is a broad concept that involves knowledge of financial information to promote economic prosperity (Lusardi, 2008). Notably, making treatment‐related decisions based on financial resources, planning for insurance coverage to manage future health issues, and balancing medical and household expenses require not only health literacy but also financial literacy. These two concepts may influence middle‐aged and older adults' healthcare choices through distinct pathways. Particularly, being able to understand and apply health‐related information (health literacy) could influence intentions to seek health‐promoting actions, diagnostic examinations or treatments (Nutbeam & Lloyd, 2021). Meanwhile, the ability/inability to analyse and manage financial resources/expenses (financial literacy) could affect the decision to avail or not avail such health services (Chan et al., 2020). With the increasing healthcare costs, mounting medical debts and varying insurance programs, the integration of financial literacy with health literacy are important in making informed health decisions (Harnett, 2019). Hence, the intersection between these two concepts is worth exploring.

We propose to further understand and assess the concept of financial health literacy (FHL), which involves the application of financial knowledge to facilitate planning and managing health expenses or treatment decisions (MacLeod et al., 2017). Given the vulnerability of middle‐aged/older adults to health and financial constraints, exploring the current evidence about FHL is crucial in this population. Since FHL is an emerging topic in literacy, we propose a scoping review approach to comprehensively search for relevant literature that will help identify the current evidence, clarify key concepts and recognise knowledge gaps in this area (Munn et al., 2018).

This study aims to identify what is known about FHL among middle‐aged and older adults. Specifically, the review targets to answer the following questions: (1) how is FHL described and what are the key components/domains?; (2) what measures are used to assess FHL among middle‐aged/older adults? and (3) what factors (including predictors and outcomes) are related to FHL in middle‐aged/older adults?

2. MATERIALS AND METHODS

2.1. Design

This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis extension for scoping reviews (PRISMA‐ScR; Appendix A; Tricco et al., 2018) and the Joanna Briggs Institute (JBI) guidelines for scoping reviews (Peters et al., 2021). The scoping review involves the systematic search, selection and synthesis of existing knowledge to comprehensively answer the question: “What is known about this concept?” (Tricco et al., 2018). As the concept of FHL is not clearly defined in the literature, the scoping review approach facilitated the exploration of existing knowledge from a wide range of literature sources and research designs (Munn et al., 2018), which enabled the researchers to clarify the key constructs in FHL, explore the factors/outcomes related to FHL, and identify existing gaps in this topic. This review involved the following steps: definition of the objectives/questions; alignment of the inclusion criteria with the objectives/questions; searching, selection, extraction and analysis of evidence; presentation of results; and summary of the evidence, with conclusions and implications (Peters et al., 2021).

2.2. Search strategy

An initial literature search was conducted in PubMed and CINAHL using a set of pre‐planned key terms (i.e. financial health literacy AND health literacy AND financial literacy AND older adults). Search results were noted to be broad and non‐specific (Appendix B1), prompting further amendments in the methods. We consulted a medical librarian to refine the search strategy (Appendix B2), which also enabled the identification of additional electronic databases based on the scope of studies and topics they contain. We used the following key terms: (financial literacy OR financial management OR financial knowledge) AND (health literacy OR financial health literacy) AND (health insurance literacy OR Medical insurance literacy OR Medicare) AND (older* OR senior OR elderly OR aged). The following databases were searched for relevant literature published from 2010 (January 1) to 2022 (January 15): ABI/INFORM Collection, Academic Search Premier, CINAHL, PsychINFO, PubMed, Google Scholar and Scopus. The reference lists of the extracted articles were also manually assessed for relevant studies. To fully scope the available evidence, grey literature was also included through ProQuest Dissertations & Theses, MedNar and Trove databases. The literature search was conducted from August to September 2021 and was further confirmed in January 2022 to ensure an updated pool of studies.

2.3. Study selection

The inclusion criteria for the articles were: (1) discussed concepts related to financial knowledge/behaviours in healthcare; (2) explored the factors related to financial and health literacy, such as predictors or outcomes; (3) involved participants aged ≥50 years and (4) published in English. According to the US Health and Retirement Study (HRS), the age of ≥50 years is crucial since this is considered the final stage of working years for most adults, wherein they transition to decreasing participation in the labour force and experience health changes (Lusardi & Mitchell, 2012). Declines in functional abilities and progression of chronic diseases also begin at this age, leading to reduced life expectancy and increased healthcare utilisation (Brown et al., 2017; McGrath et al., 2019). These situations could influence the health status and financial security of older people. Hence, including the perspectives of middle‐aged adults related to health and financial decision making could help in understanding the concept of FHL in the ageing population.

To obtain a broad range of relevant literature in this scoping review, quantitative and qualitative papers, including mixed‐method studies, were included. Articles involving other age groups were also considered if they presented information about financial/health literacy in the older samples. Meanwhile, articles were excluded if they explored aspects related to financial or health literacy but did not discuss any relationships between the two. Conference abstracts, letters, study protocols and papers with unavailable full text, which could not provide adequate information about the topics of interest, were also excluded.

The articles from the literature search were pooled into EndNote 20 to facilitate the removal of duplicates. Two research team members (SS and AOK) independently screened the titles and abstracts to identify relevant articles, while a third member (LLP) was involved in resolving any discrepancies. This facilitated the extraction of full‐text versions of the articles.

2.4. Data extraction and synthesis

The JBI template for scoping review evidence synthesis (Peters et al., 2021) was used as a guide to facilitate data extraction from the retrieved articles. Particularly, the author/year, study design, objectives, participant characteristics, FHL concepts, measures and factors related to FHL were included. Two members (SS and AOK) independently extracted the relevant information from each article, while the other two (LLP and AYML) reviewed the papers to verify the completeness and accuracy of the gathered data. The entire team discussed to address any differences in the extracted data. We made sense of the complex data by focusing on the conceptual descriptions of FHL and related ideas arguing how financial knowledge/management affected health outcomes. Findings that addressed each research question were highlighted and summarised, which served as the basis for narrative synthesis. The initial analytical process was undertaken by SS and AOK, followed by validation and confirmation of the key findings by AYML and LLP.

3. RESULTS

The search yielded a total of 1698 articles (1689 from database search and an additional nine through hand search). Of these, 795 were duplicates, and 859 were considered irrelevant after the title and abstract reviews (Figure 1). Forty‐four full articles were screened, and 15 were excluded due to unmet criteria. Hence, a total of 29 articles were included in this review: 18 cross‐sectional, eight longitudinal, two mixed‐methods and one commentary.

FIGURE 1.

FIGURE 1

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PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analysis) flow diagram of article search and selection.

The majority of the reviewed papers came from the United States (n = 24), while others were from Spain (n = 2), Australia (n = 1), and other European countries (Austria, Italy, France, Denmark, Israel, Czech Republic; n = 1). Only one developing country (Togo, West Africa) had a study related to concepts of FHL in older adults. The samples in the primary studies ranged from 21 to 63,626, with a total of 91,621 respondents. The mean age of the participants ranged from 53.5 to 90.9 years, and most of them were females (pooled % = 68.2%). Notably, more than half of the primary studies involved participants from the Rush Memory and Aging Project (n = 16), a cohort study about ageing and cognition in the US (Bennett et al., 2012; Boyle et al., 2013; Han et al., 2015; James et al., 2012, 2018; Kapasi et al., 2019; Lamar et al., 2019; Stewart, Boyle, et al., 2018; Stewart, Yu, et al., 2018; Stewart et al., 2020; Weissberger et al., 2019; Wilson et al., 2017; Yu et al., 2017, 2018, 2020, 2021). These studies account for a combined 11,631 participants in this review.

Some studies described their participants having an average of 0 to 2 chronic medical conditions, but did not specify the illnesses (Bennett et al., 2012; Gillen et al., 2020; Gousia, 2016; James et al., 2012, 2018; Sivakumar et al., 2016; Stewart et al., 2020). Other studies reported the participants' comorbidities, which included hypertension, diabetes (n = 1026; Lamar et al., 2019; Patel et al., 2016), cancer (n = 1053; Patel et al., 2016; Zhao et al., 2019) and cognitive impairment (n = 1427; Han et al., 2015; Kapasi et al., 2019; Stewart, Boyle, et al., 2018; Wilson et al., 2017; Yu et al., 2017, 2018, 2020, 2021).

3.1. Current descriptions of FHL

Financial health literacy is a concept that is not clearly depicted in extant literature. Most studies discussed financial literacy and health literacy as distinct subdomains of literacy. Appendix C presents how the included studies defined these two constructs. For instance, financial literacy involved skills for obtaining, understanding and applying financial concepts to facilitate better financial decisions/outcomes (Bavafa et al., 2019; Bennett et al., 2012; Gousia, 2016; James et al., 2018; Palací et al., 2018; Patel et al., 2016). This definition can be compared to health literacy, which posited that health‐related knowledge and skills could promote better healthcare decisions/outcomes (Bennett et al., 2012; Lamar et al., 2019). Meanwhile, seven studies discussed the two concepts together, noting that health literacy and financial literacy are interrelated skills to access, comprehend and utilise health and financial concepts to function in medical and economic contexts (James et al., 2012; Stewart, Yu, et al., 2018; Stewart et al., 2020; Weissberger et al., 2019; Wilson et al., 2017; Yu et al., 2020, 2021). However, none of the primary studies specifically identified the concept of FHL.

MacLeod et al. (2017) proposed a definition of FHL, which is the “capacity to understand and apply financial information to plan for healthcare expenses and to make sound healthcare and treatment choices while managing other household finances effectively.” Apart from financial and health literacy, they also proposed health insurance literacy as a component of FHL (MacLeod et al., 2017). Health insurance literacy is described as the knowledge, skills and confidence for obtaining, appraising and using medical insurance information (Zhao et al., 2019). MacLeod et al. (2017) asserted that FHL is a multifaceted concept that cannot be characterised by merely combining financial literacy and health literacy. They proposed four domains related to FHL, which included skills for management of medical expenses, payment of healthcare bills, understanding healthcare needs and related treatment options, and making appropriate healthcare decisions with the available financial resources.

Eight studies confirmed the complementary relationships between the two concepts—financial literacy and health literacy. Financial literacy was related to increased retirement planning behaviours (Chambers et al., 2021; Palací et al., 2018; Topa et al., 2018); availing private long‐term care insurance (Gousia, 2016); obtaining additional health insurance other than government or employer‐provided insurance plans (Bavafa et al., 2019; Topa et al., 2018); and preventing delays or non‐fulfilment of therapeutic regimen due to costs (i.e. cost‐related nonadherence; Lamar et al., 2019; Patel et al., 2016). Meanwhile, one study noted that health literacy could play a role in financial security in ageing by facilitating more income/savings through chronic disease prevention, health‐promoting practices and better healthcare spending (e.g. use of health/long‐term care insurance and lower out‐of‐pocket expenses; Gillen et al., 2020). Health literacy was also associated with knowledge of government health insurance programs (e.g. Medicare, a US‐based health insurance program for individuals aged ≥65 years and people with disabilities; Sivakumar et al., 2016) and having long‐term care insurance coverage in older adults (Gillen et al., 2020). Moreover, adequate health insurance literacy was suggested to minimise healthcare debts in people aged ≥50 years (Wiltshire, Liu, et al., 2021) and alleviate problems or worry in paying medical bills (i.e. medical financial hardship) among patients diagnosed with cancer (Zhao et al., 2019).

Without formally identifying the concept of FHL, four studies explored the problems and experiences of older adults in managing healthcare‐related financial matters. In a multi‐country study, Gousia (2016) noted that financial literacy and long‐term care insurance coverage are low among older adults in Europe. This previous study also indicated that a high financial literacy was positively associated with obtaining a private long‐term care insurance. While the ability to process financial information may influence the decision to hold a medical insurance (Gousia, 2016), health insurance literacy involves more than being financially literate. Rather, it requires the capacity to understand and evaluate medical insurance plans and utilise them to seek appropriate health services (Edward et al., 2019). Meanwhile, a study in Togo observed that older adults, regardless of the type of health insurance they held, avoided utilising referral hospitals and private health centres due to high service costs (Atake, 2020). In a study in Australia, Chambers et al. (2021) learned that retirees were inclined to spend their money on leisure and health‐promoting activities, but not on preparing for future healthcare needs (e.g. allocating budget for possible hospitalisation or long‐term care services). The participants also shared that it was difficult to anticipate healthcare costs due to uncertainties in the outcomes of their future health issues. Meanwhile, Wiltshire, Garcia Colato, et al. (2021) noted that older adults in the US perceived medical billing as a complex process, with challenges in understanding bill details, transparency and resolution procedures. Their study also noted that participants expressed concerns about medication costs, including gaps in prescription drug coverage, unaffordable prices and overprescribing by physicians.

3.2. Assessment of FHL among middle‐aged and older adults

There was no single validated measurement tool for FHL. In all the reviewed articles, financial literacy and health literacy were measured separately. Financial literacy was assessed via questionnaires involving numeracy (e.g. mathematical calculations and discounts), knowledge of financial concepts (e.g. interest rates, inflation, stocks and mutual funds) and financial behaviours (e.g. planning, saving, spending within means and managing debts; Bavafa et al., 2019; Bennett et al., 2012; Boyle et al., 2013; Gousia, 2016; Han et al., 2015; James et al., 2012, 2018; Kapasi et al., 2019; Lamar et al., 2019; Palací et al., 2018; Patel et al., 2016; Stewart, Boyle, et al., 2018; Stewart, Yu, et al., 2018; Stewart et al., 2020; Topa et al., 2018; Weissberger et al., 2019; Wilson et al., 2017; Yu et al., 2017, 2018, 2020, 2021); while health literacy was assessed through various aspects, including confidence in filling medical forms (Bavafa et al., 2019); healthcare‐related numeracy/reading skills (Gillen et al., 2020; Sivakumar et al., 2016); and knowledge of Medicare, medication use instructions and risks, and common causes of mortality in older people (Bennett et al., 2012; Boyle et al., 2013; Han et al., 2015; James et al., 2012; Kapasi et al., 2019; Lamar et al., 2019; Stewart, Boyle, et al., 2018; Stewart, Yu, et al., 2018; Stewart et al., 2020; Weissberger et al., 2019; Wilson et al., 2017; Yu et al., 2017, 2018, 2020, 2021). On the other hand, health insurance literacy was partly assessed in those studies that included Medicare knowledge in the evaluation tools. Other studies had specific assessment tools for health insurance literacy, which involved confidence in understanding the Medicare program (Sivakumar et al., 2016; Zhao et al., 2019); perceived (subjective) and actual (objective) knowledge of Medicare benefits/coverage (Sivakumar et al., 2016); and familiarity with insurance terms (e.g. premium, co‐payments, deductible and out‐of‐pocket spending; Wiltshire, Liu, et al., 2021).

Without a valid tool to measure FHL, studies utilised other methods to assess this concept. Fifteen studies averaged the combined scores of financial literacy and health literacy measurement tools, which was indicated as total literacy (Bennett et al., 2012; Boyle et al., 2013; Han et al., 2015; James et al., 2012; Kapasi et al., 2019; Lamar et al., 2019; Stewart, Boyle, et al., 2018; Stewart, Yu, et al., 2018; Stewart et al., 2020; Weissberger et al., 2019; Wilson et al., 2017; Yu et al., 2017, 2018, 2020, 2021). Meanwhile, MacLeod et al. (2017) suggested using a screening question for identifying the extent of a person's confidence in managing health‐related expenditures (including paying bills) to rapidly identify people with low FHL.

Seven studies explored some aspects potentially linked to FHL. For instance, Chambers et al. (2021) investigated the financial preferences/behaviours related to retirement planning and healthcare management. Two studies assessed middle‐aged and older adults' financial planning for retirement (Palací et al., 2018; Topa et al., 2018). Four articles explored problems in following healthcare instructions/paying medical bills due to financial difficulties, utilising the concepts of cost‐related nonadherence and medical financial hardship (Atake, 2020; Patel et al., 2016; Wiltshire, Garcia Colato, et al., 2021; Zhao et al., 2019).

3.3. Determinants of FHL and outcomes on middle‐aged and older adults

Eleven studies identified several variables related to some FHL components, including sociodemographic factors and information‐seeking behaviours. Particularly, increasing age and female gender were associated with lower financial/health literacy (Bavafa et al., 2019; Boyle et al., 2013; James et al., 2012; MacLeod et al., 2017; Stewart, Boyle, et al., 2018; Stewart, Yu, et al., 2018; Wilson et al., 2017; Yu et al., 2017, 2018). Higher education and income/wealth were noted as protective factors against poor financial literacy or health insurance literacy in older people (Bavafa et al., 2019; James et al., 2018; Stewart, Boyle, et al., 2018; Wilson et al., 2017; Wiltshire, Liu, et al., 2021; Yu et al., 2017). People from racial and ethnic minority groups, such as Blacks and Hispanics, were noted to have lower financial/health literacy than White non‐Hispanics in the US (Bavafa et al., 2019; James et al., 2012). Compared to Whites, racial and ethnic minorities in the US encountered more problems in paying medical bills, with patients unable to pick up/fill their prescriptions due to unaffordability (Wiltshire, Garcia Colato, et al., 2021). Poor health status was also associated with lower financial literacy or health insurance literacy in older adults (Bavafa et al., 2019; James et al., 2018; Wiltshire, Liu, et al., 2021). Notably, an increased online search for financial and medical information was shown to positively influence financial/health literacy (Bavafa et al., 2019).

Twelve studies explored the relationship between cognitive function and financial/health literacy. For studies involving participants with normal cognition, increased cognitive test scores were associated with higher financial/health literacy (Boyle et al., 2013; James et al., 2018; Stewart, Yu, et al., 2018; Stewart et al., 2020; Wilson et al., 2017). Meanwhile, participants with mild cognitive impairment (MCI), APOE4 allele (a genetic risk factor for Alzheimer's disease), and TDP‐43 pathology (a protein related to neurodegenerative disease) were noted to have lower financial/health literacy compared to people with normal cognitive function (Han et al., 2015; Kapasi et al., 2019; Stewart, Boyle, et al., 2018). Two studies found that high financial/health literacy was linked to a slower decline in cognitive functions, including global cognition, memory and perceptual speed (Wilson et al., 2017; Yu et al., 2020). Hence, an increase in financial/health literacy was negatively associated with the risk of developing MCI and Alzheimer's disease (Wilson et al., 2017; Yu et al., 2017, 2018, 2020). Nevertheless, one study suggested that literacy and cognition might be partially dissociable constructs that did not always influence each other, given the impact of some demographic variables (e.g. sex and income) on these factors (Weissberger et al., 2019).

Two studies recognised that adequate financial/health literacy could facilitate independent living and successful ageing (Kapasi et al., 2019; Lamar et al., 2019). Several studies explored outcomes associated with financial/health literacy, including decision‐making, psychological well‐being and physical health. Financial/health literacy positively influenced decision‐making (financial and healthcare‐related) in older adults (James et al., 2012; Stewart, Boyle, et al., 2018; Yu et al., 2021). Notably, James et al. (2012) observed that compared to health literacy, financial literacy had a stronger relationship with healthcare decision‐making. In addition, financial/health literacy had negative associations with depression and loneliness (Bennett et al., 2012), such that declines in these literacy components correlated with lower psychological well‐being (Yu et al., 2021). In terms of physical health, several aspects were investigated. Higher financial literacy (e.g. knowledge of financial concepts and numeracy) was associated with lower risk of hospital admission (James et al., 2018), while lower financial/health literacy was linked to higher mortality risk among older adults (hazard ratio: 1.02; Stewart et al., 2020). Moreover, lower financial/health literacy was related to higher levels of diabetes indicators in older people (Lamar et al., 2019).

3.4. Identification of FHL domains

We synthesised the findings of the included studies in this review by extracting the key concepts, measures and relevant results that pertain to FHL. The gathered information was clustered based on their similarities and differences to indicate the specific skills/capacities related to FHL. These skills were further sorted to establish the domains contributing to the concept of FHL.

Based on the evidence presented in this review, we propose five key domains to be included in developing the concept and measurement tools for FHL among middle‐aged and older adults (Table 1): (1) money management, which is necessary to understand healthcare/insurance expenditures and balance savings with expenses; (2) management of medical bills, which involves identification of the charging items and processes involved; (3) understanding health insurance, which comprises knowledge of insurance types, premium and out‐of‐pocket spending; (4) deciding on appropriate health services, which is based on resources available and it includes knowing appropriate health service options and who/where to seek assistance and (5) planning for long‐term care needs, which involves retirement planning, availing options for long‐term care insurance, and saving for healthcare needs in advanced age. Figure 2 shows the proposed conceptual framework of FHL, which highlights the relevance of its various domains at different times in a lifespan.

TABLE 1.

Key domains of financial health literacy (FHL) and their related skills

FHL domains Specific skills
Money management Understand interest rates and discounts, in relation to healthcare expenses
Balance savings/income (e.g. pension) with household expenses and health care expenses
Management of medical bills Understand and interpret medical bills (basic items and its meaning; procedures involved)
Familiarise with the process of medical billing
Handle the payments
Identify contact persons/agencies for assistance
Understanding health insurance Understand premium, deductibles, co‐payments, co‐insurance, maximum annual out‐of‐pocket spending and provider network
Select health insurance plans (e.g. self and supplementary) that are appropriate for individual situation
Establish a coverage for drugs and long‐term care
Modify insurance plans as needed
Deciding on appropriate health services Identify health services/facilities that can be utilised within insurance and out‐of‐pocket resources
Select treatment options (e.g. medical consultations and filling prescriptions) that match the resources available
Identify agencies that could extend assistance for financial and health concerns
Planning for long‐term care needs Determine the importance of retirement or long‐term care planning
Identify resources that can be utilised for financial planning for retirement/long‐term care
Identify potential healthcare needs and allocate budget for long‐term care expenses
Understand options for long‐term care
Select appropriate options for long‐term care insurance
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FIGURE 2.

FIGURE 2

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Conceptual framework of financial health literacy.

4. DISCUSSION

This scoping review summarised the existing knowledge on FHL and its associated determinants and outcomes in middle‐aged/older adults. The conceptualisation of FHL is still at its early stage, with most studies investigating financial literacy and health literacy as separate constructs that are closely intertwined. Financial literacy may impact older adults' healthcare decision‐making, planning for retirement, obtaining health insurance, adherence to treatment plans and health status; while health literacy and health insurance literacy can affect their economic security and management of medical bills. Although some middle‐aged/older adults are functionally independent, others could have multiple chronic conditions or functional limitations (De Wit & Schuurmans, 2017) with healthcare needs ranging from risk reduction, early detection, treatment and rehabilitation. Coinciding with these issues is their need for support in making financial decisions, such as managing daily expenses, calculating savings and distributing income/wealth (MacLeod et al., 2017). Ensuring the capacities of middle‐aged/older adults to manage their healthcare/financial needs is vital to address the potential problems of diminishing financial resources despite increasing health issues that are associated with ageing (Popham et al., 2021).

However, FHL is not regarded as a distinct domain of literacy but is conceptualised as a simple combination of financial literacy and health literacy. This may influence the advancement of FHL in the knowledge field and the implementation of relevant actions to support FHL. Existing tools assessed financial literacy and health literacy separately and averaging the combined scores in these measures may not accurately depict FHL. Although MacLeod et al. (2017) proposed a single‐question screener (i.e. degree of confidence in independently managing medical expenses) to rapidly identify people with low FHL, a comprehensive assessment tool is warranted. This review indicated that FHL involves more than managing health‐related expenditures. Thus, a single question may not encompass the multidimensional concept of FHL, since the latter comprises skills for management of daily finances and healthcare expenses, understanding health insurance, choosing appropriate health services and planning long‐term care services. The five domains synthesised in this review also indicate the significance of FHL at the several points in the lifespan of middle‐aged/older adults, who have different healthcare/financial concerns than other groups. Given the importance of health literacy and its extended domains in public health promotion, the WHO recommends developing comprehensive tools to investigate these concepts across populations (Rowlands et al., 2019). Moreover, assessing health literacy should include some objectivity, apart from asking about people's perceived confidence/knowledge on the topic (Liu et al., 2018). These findings support the significance of developing future FHL assessment tools that could reflect the needs of particular ageing populations.

Since low financial/health literacy is associated with poorer health outcomes, identifying people at risk of inadequate FHL is vital to provide adequate support to such vulnerable groups. Increasing age seemed to be related to having a lower FHL. Age‐related cognitive decline has been noted as a significant risk factor for poor financial/health literacy, since adequate mental skills are crucial for understanding financial and health information (Geboers et al., 2018; Mitchell & Lusardi, 2022). The reviewed studies supported this claim, highlighting the association between cognitive impairment and lower financial/health literacy in older people (Han et al., 2015; Kapasi et al., 2019; Stewart, Boyle, et al., 2018). As people with lower education and income levels may have potential limitations in processing health and financial concepts (Chesser et al., 2016; Fong et al., 2021), they were also more susceptible to having inadequate FHL. In the US, where most studies in this review came from, females and racial and ethnic minorities also had lower financial/health literacy than their male and racial and ethnic majority counterparts. However, such group comparisons were not explored in the studies from other countries. Factors contributing to the financial literacy gap include the greater involvement of women in traditional roles of childrearing and domestic labour, leading to work interruptions and limited opportunities to accumulate financial resources (Bucher‐Koenen et al., 2017). As women tend to outlive men (World Health Organization, 2022), problems related to their financial needs and resources may become more prominent in late life. Meanwhile, racial and ethnic differences in financial literacy are also evident in the literature, as these groups commonly have disparate access to economic opportunities and financial information/services (Angrisani et al., 2020). These findings imply the importance of FHL education focusing on women, those with low income and racial and ethnic minority groups. However, some middle‐aged/older adults may be more interested in investing in promotive and preventive healthcare, instead of allocating financial resources for future healthcare expenses (Chambers et al., 2021). Health promotion and disease prevention might delay disease onset/progression, which in turn could decrease medical costs (Gillen et al., 2020). Hence, health promotion aspects could be integrated in FHL programs, enabling middle‐aged/older adults to understand the role of financial well‐being in healthy ageing.

Promoting FHL should consider an individual and group approach, as middle‐aged/older adults may have common yet varying needs and limitations related to financial/health information. The promotion of FHL could take guidance from health literacy, which is conceptualised as an individual capacity requiring a tailored approach, while also being influenced by people (e.g. family members and caregivers) and societal factors (e.g. reinforcing community and organisational practices to improve access to relevant information/services; Levin‐Zamir et al., 2017). For instance, microfinancing programs (e.g. providing financial services to low‐income individuals or those without access to banking/credit services) are suggested to promote active ageing (European Microfinance Network, 2012). By facilitating better access to financial resources, microfinancing could allow middle‐aged/older adults to have self‐employed work or explore means to reinforce their financial security. Microfinance groups are also conducive platforms for financial education for people at risk for inadequate financial literacy, such as women and racial and ethnic minorities (European Microfinance Network, 2012). It might be advantageous to start FHL training at midlife, as this is when people commonly prepare for retirement and set goals for healthy ageing (Solhi et al., 2022). Apart from FHL programs in the workplace of pre‐retirees, there is a need for concerted strategies in communities to reach more vulnerable populations. Community health centres and senior centres could serve as conducive venues for providing free and accessible FHL programs that are calibrated to the literacy level of the target population. These agencies could also link with financial and health organisations that could provide tailored assistance for women, low‐income people and racial and ethnic minority groups, who may have lower confidence and fewer resources to manage healthcare expenses (Taylor et al., 2012).

With the increasing technology utilisation by middle‐aged/older adults, developing digital tools to promote FHL is valuable. For people with adequate access to these tools, using technology could provide a more efficient means to reinforce FHL. However, program developers should consider the digital literacy of the ageing population when conceptualising and designing relevant platforms. Given the multiple FHL concerns among older adults, web‐based tools should facilitate easier navigation by consolidating relevant information into a single platform (Manjiyani et al., 2021). An example of this is the National Council on Aging (2019) Savvy Saving Seniors financial education toolkit, which covers various topics to assist community‐based older adults and caregivers in learning strategies for economic security. Nevertheless, the integration of FHL is important for a more holistic platform, as financial literacy in ageing is closely linked with health management and outcomes. It is also imperative to have human touchpoints (e.g. customer support agents and chatbot) embedded in web‐based platforms, which could provide immediate support to older people for financial questions or recommendations (Johnson & Gdalman, 2020). Moreover, customisation of FHL information in digital tools is important as older adults' financial and health needs evolve over time. This could be possible by including relevance assessments in the websites (e.g. questions about the user; preferred financial and health topics) so that the topic recommendations match the older adults' interests and goals (Manjiyani et al., 2021).

The role of social support in these FHL programs cannot be overemphasised, as families/caregivers are key partners of older adults in decision‐making (Bunn et al., 2018). Family caregivers could assist older adults in financial and healthcare management, especially those with low FHL due to cognitive or functional disabilities. Promoting FHL among families would benefit not only older adults but also family members who will be involved in planning/managing their own healthcare expenses in the future. For older people living alone or without familial support, social workers could support budgeting resources, preventing financial exploitation (e.g. fraud and scams), understanding/choosing insurance plans and planning long‐term care services (Frey et al., 2017). Social workers could also help in the FHL education of older adults' relatives or caregivers who could provide direct assistance when needed. Home health aides, which are generally expected to assist in basic/instrumental activities of daily living (D'Cruz et al., 2022), are also in the unique position to help older people utilise financial and healthcare‐related information. Nevertheless, home health aides may require further training to promote their readiness in promoting FHL in older people. As bridges between communities and health/social agencies, community health workers could fill gaps in FHL promotion as they could facilitate local adaptation of interventions based on the needs/preferences of the communities they serve (Thompson & Borson, 2021).

The role of professional healthcare/financial workers is also essential in promoting FHL in middle‐aged/older adults. Primary care practitioners and nurses could contribute to screening people at risk for financial challenges in healthcare. Strategies to achieve this may include asking patients about difficulties paying for their medications or following treatment regimens due to costs (Arora et al., 2015). Physicians' and nurses' engagement in cost conversations with their patients could also enable the latter to manage out‐of‐pocket spending on health services (Perez et al., 2019). While these conversations may be uncomfortable to some people due to feelings of shame or perceived inappropriateness of discussing financial difficulties with care providers (Warth et al., 2020), these are valuable entry points to assist patients who may experience financial harm due to healthcare. However, it would be impossible for clinicians to accurately estimate the out‐of‐pocket cost of medications and procedures, given the variety of the plans offered by insurance companies. Patient navigators, who are responsible for guiding patients through the healthcare system, could help older people understand their medical bills and identify financial services to effectively manage healthcare expenses (Mailloux & Halesey, 2018). Financial planners, who are currently trained for personal financial investments, should also be trained to understand FHL to support older people's choices in health insurance. Other than individual personnel, health facilities can also play a role in supporting FHL. Health facilities are encouraged to develop a patient‐centred billing system, in which the terms in medical bills are simplified for easy understanding, bills from various care providers/diagnostic centres are consolidated, and real‐time cost information (estimation/final invoice) are provided to before discharge (Semigran et al., 2016). These strategies require collaborative efforts among health agencies, patient advocate groups and government offices, so that middle‐aged/older adults and their families can financially navigate the healthcare system.

This review also revealed a disparity in research about financial/health literacy between high‐income and low‐ and middle‐income countries (LMICs). Twenty‐eight (out of 29) studies were from the US (more than half were conducted by the same team of researchers) and other developed countries, where there are established national health insurance. Nevertheless, it is also worth noting that there are individual differences in the healthcare system of developed countries in terms of service delivery, insurance coverage, private sector involvement and percentage of out‐of‐pocket spending (Wagstaff et al., 2018). Only one study from Togo (Atake, 2020) represented the LMIC cluster, which showed older adults' avoidance of utilising health services due to perceived costs. In Togo, government health financing is low, with most medical expenditures shouldered by households (World Health Organization, 2016). LMICs have significant limitations in insurance provision, manpower resources and health facilities (Wagstaff et al., 2018), requiring more tailored strategies to assess and promote FHL in the ageing population. Despite the considerable differences in the healthcare system of each country, the main findings and implications of this review could serve as launchpads for future investigations of FHL assessment and interventions in the ageing population. Such undertaking could enable the development of appropriate strategies to promote FHL across countries, based on their existing financial/healthcare resources and policies.

4.1. Study limitations and future directions

This scoping review has some limitations. First, only articles published in English were included, thereby excluding other articles that might have also contributed significant perspectives on the topics. Second, the reviewed articles focused on middle‐aged (≥50 years) and older adults, so the findings may not be applicable to other populations. Most of the included studies were from developed countries, such as the US, which accounted for the majority of participants in this review through the Rush Memory and Aging Project. However, due to the longitudinal nature of the said project, this number may involve some overlap or inclusion of some participants among the studies, as subject recruitment was updated in the more recent articles. Only one study (from Togo, Africa) represents the LMICs, which limits the generalisability of the current findings to other settings. Nevertheless, this study could serve as an entry point for assessing and improving FHL in the vulnerable group of middle‐aged/older adults.

Since FHL is not yet fully explored in the literature, the included studies in this review discussed the related domains about financial knowledge/behaviours, health literacy, health insurance and health‐related decisions/outcomes. The next step for the authors is to incorporate the findings from this review to develop and validate a tool that can assess FHL in middle‐aged/older adults. To obtain a more comprehensive picture of FHL, we recommend involving the stakeholders (e.g. laypersons, financial retirement planners, health service providers, etc.) who could link the theoretical concepts to real‐life practices. Long‐term directions include designing tailored interventions and evaluating the existing programs that seek to reinforce FHL in ageing populations. To facilitate these efforts, it is important to develop a validated instrument to assess FHL.

5. CONCLUSIONS

Financial health literacy is an emerging concept, yet understudied, that has relevant implications in facilitating health services for middle‐aged and older adults. This review showed that FHL is not fully explored as a particular domain of literacy, but rather as a combination of different financial and health literacy parameters. Hence, we proposed five key domains of FHL that could be considered when developing the concept and measures of FHL, particularly for the ageing population, which include money management, management of medical bills, understanding health insurance, deciding on appropriate health services, and planning for long‐term care needs. People with advanced age, cognitive impairment, low education/income, females and racial and ethnic minorities are at risk for low FHL, making them important targets of future interventions. Promoting FHL among older people should also be considered a priority, as the current findings noted that this could positively impact healthcare decision‐making, physical health and psychological well‐being. As the ageing population continue to experience financial and health resource constraints, future studies contributing to knowledge and strategies in FHL enhancement are highly warranted.

AUTHOR CONTRIBUTIONS

Study design: Angela Y. M. Leung; Data collection: Stephanie S. Szeto, Laurence Lloyd Parial, Adwoa O. Koduah; Data analysis: Angela Y. M. Leung, Stephanie S. Szeto, Laurence Lloyd Parial, Adwoa O. Koduah; Manuscript writing: Angela Y. M. Leung, Stephanie S. Szeto, Laurence Lloyd Parial and Adwoa O. Koduah. All authors read the manuscript for important intellectual context and approved the submission.

FUNDING INFORMATION

This study was funded by Internal Research Fund (Project number: P0031062; P0043000) and Postgraduate Studentship Programme of the Hong Kong Polytechnic University.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

CONSENT FOR PUBLICATION

Not applicable.

Supporting information

Appendix S1.

Click here for additional data file. (76.3KB, docx)

ACKNOWLEDGEMENT

We acknowledge the assistance provided by the Hong Kong Polytechnic University Library through Ms Lydia Ngai, particularly in the literature search for this scoping review.

Leung, A. Y. M. , Parial, L. L. B. , Szeto, S. S. , & Koduah, A. O. (2022). Understanding the role of financial health literacy in midlife and old age: A scoping review. Health & Social Care in the Community, 30, e3921–e3933. 10.1111/hsc.14101

DATA AVAILABILITY STATEMENT

The data that supports the findings of this study are available in the Appendices/Supporting Information of this article.

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Supplementary Materials

Appendix S1.

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Data Availability Statement

The data that supports the findings of this study are available in the Appendices/Supporting Information of this article.

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