Consistent with our interest in the 'hidden population', few participants had disclosed or sought help with their low literacy within health services.
There is a need to explore the previously neglected perspectives of people with low literacy to help explain how low literacy can lead to poor health, and to consider how to improve the ability of health services to meet their needs.
Many communities in developing countries are geographically dispersed with poor access to health services, have low literacy levels, and commonly do not receive information about the prevention, control and treatment of diseases, including NCDs.
A further study limitation is that external factors not explored in this study, such as lack of time, a high crisis situation for visiting the non-government social and community service organisation, and low literacy levels, may also contribute to non-participation.
On the contrary, the poor and those with low literacy are less likely to use health services [ 16], especially preventive services, leading to worse health outcomes and subsequently increased need for OOP expenditures [ 40].
Approximately 2 out of every 5 women identified with low literacy levels eventually received any related services, and fewer than half of the women with confirmed periodontal disease ever had any follow-up treatments.
Other socio-cultural factors such as low literacy and a lack of awareness of service availability also play critical roles.
"The situation we face in rural South Africa is the same in any other African country – low literacy compounded by lack of access to services and affordable healthcare," says Wilson.
We have also highlighted the potential negative implications of literacy-related stigma for people's mental wellbeing which could perhaps be seen as an example of a 'direct' (i.e. not just service-mediated) impact of low literacy on health.
Our study provides a quick reference point for MMR in a rural poorly developed area with a particularly low literacy rate and poor access to health services.
