Literacy is described as an individual’s competency to read, write, and speak a language with understanding and show the ability to solve problems to sufficiently function in the working environment and in society, achieve goals, and develop knowledge and individual potential.¹ Globally the literacy rate for those 15 years and older is currently at 86.3%.¹ This leaves 13.7% of the world illiterate. Developed nations such as countries in Asia, Canada, Russia and Poland have literacy rates of 96% and higher. Developing countries such as Chad, South Sudan, Somalia and Afghanistan have literacy rates as low as 27% – 45%.¹ According to the United Nations Educational, Scientific and Cultural Organization (UNESCO) report, sub-Saharan Africa has one of the lowest adult literacy rates in the world with a 61% average literacy rate.² According to the National household survey conducted in 2020, South Africa has a literacy rate of 87%, leaving 13% of the country functionally illiterate.³ Low literacy is defined as the inability of an individual to read and write.³ Low literacy and low health literacy (HL) are closely related.^4,5,6,7

Health literacy is defined as competencies and skills that individuals need to find, comprehend, evaluate, and use to make knowledgeable choices to improve their health and well-being.^8,9,10 According to the Institute of Medicine (IoM) model of HL, HL has four major components, namely cultural and conceptual knowledge, print HL (reading and writing), oral HL (listening and speaking), and numeracy.¹¹ The IoM model of HL has a strong focus on the required skills for people to obtain, process, and apply information for the purpose of healthcare.¹¹ An important component of HL is basic reading skills. Basic reading skills are necessary to function in everyday situations in healthcare, for instance reading prescription labels and health education materials.¹¹ Reading also forms part of the ability to process and use health information in various formats in relation to health and healthcare.^11.

Low HL has been found to affect people’s ability to take care of their own health and follow the principles of disease prevention and this as a result contributes to the spread of disease and health disparities.^1,12,13 It has also been reported that some patients may feel embarrassed to admit that they have low literacy and as a result do not comprehend and therefore do no follow health education and healthcare instructions as they should.^9,14 As a result of incomprehension of health education and healthcare instructions, patients’ ability to make correct choices and decisions regarding their health and well-being are compromised.¹⁵ These incorrect choices in turn lead to several adverse health outcomes because of non-compliance to treatment and treatment failures resulting in an increased morbidity and mortality rates.^1,12

The incomprehension of health education and healthcare instructions because of low HL is often because of information given at a level that is above the patient’s level of understanding^6,12,16 or in a language that is not well understood by the patient. Patients with low HL often find it difficult to follow health education and healthcare instructions such as how to take their medications and how to apply disease preventative measures.^1,6,17,18,19 As basic reading is an important component of HL, patients with low HL may often lack the ability to read and to understand written healthcare instructions and health education materials.¹²

In South Africa, Primary Health Care (PHC) clinics are the first entry point for accessing healthcare services for the people in the community.^20,21 It is therefore important for patients at PHC level of care to understand the health education and healthcare instructions given in either written or oral form, to avoid adverse health outcomes and the need for referral to higher levels of care.^22,23.

Health education in written and oral form is the cornerstone of health promotion, disease prevention and improved health outcomes, especially at PHC level.^24,25,26 Health education materials such as posters, pamphlets, and booklets, are mostly written in English.^15,28 Oral health education is also often given in English as English is the dominant language for communication in the public sphere in South Africa.¹² The lack of availability of health education materials in all 11 official South African languages may be a challenge for patients with low HL, as they might not be able to read and understand the information written in a language that they are less familiar or unfamiliar with.^12,27,28 People in the community who are accessing PHC facilities also come from different socio-demographic backgrounds. This implies that some patients lack education while others have at least completed certain levels of education. As a result, some patients often find it challenging to understand health education and healthcare instructions if not given at their level of understanding or in a language that they are familiar with.^6,12 A South African study found that patients’ level of understanding is four school grade levels below the highest level of schooling completed.¹² Patients might also understand health education and healthcare instructions better when it is given in their native language or a language that they more frequently read, write, and speak.^29,30,31

It is paramount for PHC providers to determine the HL levels of PHC patients to ensure that health education and healthcare instructions are well understood by patients in the PHC facilities.^1,12. One component of HL that should be tested includes the patient’s ability to recognise and pronounce health-related words that are frequently used in the PHC setting.¹² If patients understand the health education and healthcare instructions given to them by PHC providers, patients might adhere to and comply well with treatment and this would assist in reducing rates of defaulting on treatment for conditions such as diabetes, hypertension, Human Immunodeficiency Virus./Acquired Immune Deficiency Syndrome (HIV/AIDS), and tuberculosis (TB), and improving overall health outcomes.^32,33

The Rapid Estimate of Adult Literacy in Medicine–Revised (South Africa) or the REALM-R (SA) is the tool currently available to determine one component of HL, which is, word recognition and pronunciation of health-related words commonly used in the PHC context.^12,34,35 The tool was only validated in the English language. The availability of this tool in only English was found challenging, as South Africa has 11 official languages for communication.^34,36 Although English remains the dominant language in the country, many patients do not understand or have limited understanding of English in either written or oral form. Recognising and pronouncing health-related words in either English or in a native South African language therefore only forms part of the one component of HL; however, this remains the foundation of HL.

Assessing PHC patients’ health-related word recognition and pronunciation as a component of HL in their native language may give a more accurate indication of the patient’s ability to read and comprehend health care instructions and health education. If this can be determined, health education can be tailored to the needs of the patient and given to patients on their level of understanding that may increase PHC patients’ ability to understand and execute health education and healthcare instructions. In turn, patients may also be more likely to manage their medical conditions more effectively and to adhere to prescribed medication and improve their health outcomes when they understand what needs to be done to achieve this.^9,12 These improved health outcomes may also be the right step in achieving the Sustainable Developmental Goal (SDG) 3: ‘Ensuring healthy lives and well-being for all’.³⁶ This article gives a comparison between the health-related word recognition and pronunciation levels of PHC patients in English and in the patient’s native language.

Health literacy is defined as the skills and competencies that people need to find, comprehend, evaluate, and use health information. Health literacy also involves concepts to make informed decisions to reduce health risks and improve the quality of life.³² In this study, we only assessed one component of HL, which is to recognise and pronounce health-related words as part of print (reading and writing).¹ Reading and writing is the foundation of HL and therefore forms an important part of the assessment of HL.¹¹ Although also important components of HL, comprehension, evaluation, and use of health information were not assessed in this study. These components rather form part of cultural and conceptual knowledge, oral HL (listening and speaking), and numeracy.¹¹ Assessing PHC patient’s ability to recognise and pronounce health-related words commonly used in the PHC context remains an important aspect of HL as comprehension and evaluation are higher order skills stemming from word recognition and the ability to pronounce health-related words correctly.¹² Improving patient’s ability to understand health information is an important aspect in empowering patients in the PHC context to take responsibility for and manage their own health, and that of their families.³² A low or inadequate ability to recognise and pronounce health-related words as a component of HL is associated with inadequate knowledge about health and the healthcare system, the use of health services, and increased hospitalisation.³² The findings of the study gave a comparison between the health-related word recognition and pronunciation levels of PHC patients in English and in the patient’s native languages.

Increased age, educational levels, poor socio-economic status, and poor English proficiency and reading levels are major barriers to components of HL.^8,28 In our study, more than half of the respondents were between the ages of 30–40 years (53%) and 18–29 years (32%). The ability to correctly read and understand medical information declines with age.²⁷ Few of the respondents were older than 50 years (14.1%). With older age, the risk for incorrect taking of medication, poor chronic disease management, low use of preventative health services, and the risk of mortality increase.^4,37,38 Lee and Lee⁴ have reported that the components of HL levels drastically decline over the age of 40 years. The authors also mention that the level of understanding of medical text declines in older patients as compared to younger adults.⁴

It is well established that educational levels are a key determinant of health.⁶ It is also reported that a higher level of education is linked to higher total HL levels.^4,27,37 In our study, 54% of the respondents completed a grade 12 level of schooling, while 42% did not complete high school but only completed some high school level education. It has been reported that there is a positive correlation between school grade levels and total HL levels in younger and middle-aged patients (40–65 years).⁴ However, although 54% of the respondents completed grade 12 and would be expected to be literate in English, only 19.5% of the respondents showed adequate health-related word recognition and pronunciation levels in English. These results are worrisome as health-related word recognition and pronunciation are important in the PHC context as patients often need to read prescriptions, medication labels, patient education materials, medical forms, and appointment slips for follow-up visits.⁹ Healthcare providers (HCP) often assume that when a patient is literate or come across as literate, they can understand health information and have high total HL levels.⁸ This is often not the case, as even patients with high literacy skills may have trouble recognising health-related words and understanding health information in either written or oral form as the demand in the healthcare context is often more complex than in the context of everyday life.¹ Janse van Rensburg reported that the health-related word recognition and pronunciation as a component of HL levels of PHC patients are as much as four school grade levels below the highest level of schooling obtained.¹² The authors also mention that some patients may also lack the ability to comprehend what they hear or read because the average person’s English comprehension level is five grades below the highest level of schooling.¹² Considering the finding by Janse van Rensburg,¹² none of the respondents in this study can actually be declared as health literate in the component of having the ability to adequately recognise health-related words and reading. There is a clear mismatch between the patient’s highest level of schooling, English comprehension levels, and their ability to read and pronounce health-related words.¹² It is also reported that patients, even those with high literacy levels, are often too embarrassed to indicate that they do not understand healthcare instructions and health education given by the HCP.¹²

Although HCP assume that health information and health education is understood by patients, this is rarely the case.¹² Health education in either oral or written form is often given at a level much higher than the patient’s understanding.¹² The benefits of giving health information and healthcare instructions at the level of the patient’s understanding, including giving health information in the patient’s native language, includes increased patient knowledge, reduced patient anxiety, and better adherence to treatment.¹² Low HL can be managed by closing gaps between health information and health education given, and the health information/education provider by using simplified language and giving information in the patient’s native language.²⁷ In our study, English was not the native language of any the respondents. It is reported that in South Africa, English is the native language of only 8.2% of the population. Even though English is the dominant language spoken in the public sphere in South Africa, the country has 11 other official languages.^15,27 Malik²⁷ emphasises that people with low or inadequate HL often misunderstand information in the English language. Although only 19.5% of the respondents showed adequate health-related word recognition and pronunciation levels in English, the results of the levels in the respondent’s native languages were far better. Posiliti and Cilliers³⁸ also reported a significant difference in English HL levels and IsiXhosa HL levels in a study conducted in South Africa. Du et al.⁸ and Hargis et al.³⁹ confirm that HL levels are often lower in people whose native language is not English. Patients in the PHC context need to actively engage in the management of their health and need to be able to make healthcare decisions.¹ To do so, information needs to be appropriate and on the patient’s level of understanding.¹ This does not only refer to HL levels but also to giving health education in the patient’s native language and taking into consideration the patient’s cultural and social backgrounds.¹ Inappropriate understanding of health information because of low HL levels and language barriers substantially impact patient’s health behaviours and health outcomes.^1,9 Most HCP in PHC usually speak the local native language and understanding the language might not be a problem for most patients; however, further emphasis should be placed on determining the HL level of the patients and the level of understanding at which the health information and health education is provided.³⁹

Evidence shows that poor HL is associated with more hospitalisations, greater use of emergency care, poorer overall health status, and higher mortality rates.⁹ Patients with adequate HL levels, on the other hand, were shown to be more likely to comprehend health information, identify medication names, better access to health services, and maintain good health.^8,10

Healthcare providers in the South African PHC context provide care to patients of a diverse cultural and linguistic background. For PHC patients, language specifically plays an important role in HL levels. A significant difference in the health-related word recognition and pronunciation levels in English and that in the native language were observed in this study. The significance of this is that although patients indicate that they have completed high school, this may not be a true reflection of their ability to read and understand health-related words used in the PHC setting. Providing health information and health education in the patient’s native language and on a level of the patient’s understanding may therefore improve the health outcomes of the patients and prevent referral of PHC patients to higher levels of healthcare. The complexity of the South African healthcare system and an increasing burden of disease demand a greater participation of PHC patients in self-care, further emphasising the importance of HCP’s awareness of the HL of PHC patients in the PHC context of the country.