Roles and Strategies of Primary Health Care Nurses to Improve Health Literacy and Health Outcomes in Rural Patients

Introduction

Health literacy, defined as the ability to access, understand, evaluate, and apply health-related information to make informed health decisions (Mohebi et al., 2018), is a pivotal determinant of health outcomes, particularly in rural communities where socio-economic and infrastructural challenges exacerbate disparities. In rural Lephalale, Limpopo, South Africa, a region characterized by a 33.9% unemployment rate and widespread poverty (Statistics South Africa, 2022), low health literacy contributes to adverse health outcomes, including poor medication adherence, increased hospitalizations, and suboptimal management of chronic diseases (Nsiah et al., 2019). Primary health care (PHC) nurses, as frontline healthcare providers, are uniquely positioned to address these challenges by enhancing health literacy through education, advocacy, and community engagement (Major, 2020; Sklar, 2016). Their roles are particularly critical in rural settings, where they often serve as the primary point of contact for patients with limited access to healthcare resources.

This scoping review aims to systematically map the global evidence on the roles and strategies employed by PHC nurses to improve health literacy and health outcomes among rural patients. By synthesizing peer-reviewed studies published between 2014 and 2024, the review seeks to identify evidence-based practices, contextual factors, and gaps in knowledge, with specific relevance to the socio-economic and cultural context of Lephalale. The findings will provide a robust theoretical foundation for the subsequent phases of the proposed multimethod study, which includes qualitative interviews with PHC nurses in Lephalale and integration of findings to inform practice and policy.

The review is structured to address the research question: What roles do or should primary health care nurses assume, and what strategies do they use or could use, in improving health literacy and health outcomes for patients with limited health literacy in rural areas? It employs a critical lens to evaluate the effectiveness, feasibility, and contextual appropriateness of identified strategies, while highlighting the unique challenges faced by nurses in resource-constrained rural settings.

Scoping Review Methodology

The scoping review adheres to the five-stage framework proposed by Arksey and O’Malley (2005), as advanced by the JBI (Peters et al., 2017, 2020), and is registered with JBI SUMARI to ensure methodological rigor. The stages include: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) is used to ensure transparent reporting (Peters et al., 2020). This methodology is particularly suited for exploratory research, as it allows for a broad mapping of diverse evidence, including qualitative, quantitative, and mixed-methods studies, to address the multifaceted nature of nurses’ roles in health literacy promotion.

Rationale for Conducting the Scoping Review

The rationale for this scoping review is rooted in the critical gap in understanding the specific roles and strategies of PHC nurses in addressing limited health literacy in rural settings. While health literacy is widely recognized as a determinant of health outcomes (Mohebi et al., 2018), the literature often focuses on general healthcare interventions rather than the nuanced contributions of PHC nurses in rural contexts (Nsiah et al., 2019). In Lephalale, socio-economic challenges such as poverty, limited education, and inadequate healthcare infrastructure amplify the need for nurse-led interventions tailored to low health literacy populations (Khuluvhe, 2021; Ogunkola et al., 2020). A scoping review is ideal for this study due to its ability to synthesize diverse evidence, identify research gaps, and provide a comprehensive overview of existing knowledge, thereby informing the design of subsequent qualitative interviews and integration phases in the proposed study.

Aims of the Scoping Review

The scoping review has three primary aims:

1. To map the evidence on the roles that PHC nurses assume or should assume in improving health literacy among rural patients, focusing on their contributions to patient empowerment and healthcare decision-making.
2. To identify strategies employed or recommended by PHC nurses to enhance health literacy and improve health outcomes, with an emphasis on contextually relevant interventions for rural settings.
3. To highlight gaps and contextual factors influencing nurses’ roles, particularly in socio-economically challenged regions like Lephalale, to guide future research and practice.

Identifying the Research Question

The review is guided by the question: What roles do or should primary health care nurses assume, and what strategies do they use or could use, in improving health literacy and health outcomes for patients with limited health literacy in rural areas? This question is framed using the Population, Concept, and Context (PCC) framework:

• Population: PHC nurses working in rural communities, defined as registered nurses under the Department of Health (2013) criteria.
• Concept: Roles (positions or purposes within healthcare delivery) and strategies (planned actions to achieve health literacy improvement) that enhance health literacy and health outcomes.
• Context: Rural settings globally, with specific relevance to Lephalale, Limpopo, characterized by open country, small settlements, and vulnerabilities due to poverty and limited education (Ogunkola et al., 2020).

This question is deliberately broad to capture the diverse roles and strategies employed by PHC nurses, while remaining focused on rural contexts to ensure relevance to the study’s setting.

Identifying Relevant Studies

Search Strategy

A systematic and comprehensive search strategy was developed to identify peer-reviewed studies published between January 2014 and December 2024, ensuring the inclusion of recent and relevant evidence. The following databases were searched: PubMed, EBSCOhost (CINAHL, Global Health, MEDLINE Ultimate), and ProQuest (Health and Medical Collection). These databases were selected for their extensive coverage of nursing, public health, and rural healthcare literature, aligning with the study’s focus on PHC nurses and health literacy.

The search strategy followed a three-step process:

1. Initial Limited Search: A preliminary search was conducted in PubMed and CINAHL to identify relevant keywords and index terms from article titles, abstracts, and subject headings. Key terms included: “primary health care nurse,” “nurse,” “nurses,” “nursing,” “roles,” “responsibilities,” “duties,” “strategies,” “methods,” “techniques,” “health literacy,” “health education,” “health knowledge,” “health information,” “health understanding,” “rural areas,” “rural communities,” “rural patients,” “rural population,” “remote,” “outcomes,” “benefits,” “effects,” “impact,” and “effectiveness.” MeSH terms such as “Health Literacy” and “Rural Health” were incorporated where applicable.
2. Comprehensive Search: The identified keywords and index terms were adapted for each database using Boolean operators (AND, OR, NOT) and truncation to maximize retrieval. Example search strings included:
3. PubMed: (“primary health care nurse” OR “nurse” OR “nursing”) AND (“roles” OR “responsibilities” OR “duties”) AND (“health literacy” OR “health education” OR “health knowledge” OR “health information”) AND (“rural areas” OR “rural communities” OR “rural patients” OR “rural population” OR “remote”) AND (“outcomes” OR “benefits” OR “effects” OR “impact” OR “effectiveness”).
4. EBSCOhost: Similar strings were tailored for CINAHL, Global Health, and MEDLINE Ultimate, incorporating database-specific filters (e.g., peer-reviewed, English language).
5. ProQuest: The Health and Medical Collection was searched with adjusted terms to focus on nursing-specific journals.
6. Reference List Screening: The reference lists of included studies were manually screened to identify additional relevant articles, ensuring a comprehensive capture of evidence.

The search was limited to peer-reviewed studies published in English, including randomized controlled trials (RCTs), qualitative studies, reviews, and mixed-methods studies. Grey literature, editorials, opinion pieces, and studies published before 2014 were excluded to maintain focus on recent, high-quality evidence.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Studies published between January 2014 and December 2024 to ensure relevance and currency.
• Peer-reviewed articles, including RCTs, qualitative studies, systematic reviews, scoping reviews, and mixed-methods studies.
• Focus on PHC nurses’ roles or strategies in improving health literacy or health outcomes for patients in rural communities.
• Studies conducted in rural settings globally, with relevance to socio-economically challenged contexts like Lephalale.
• Articles published in English to align with the researcher’s language proficiency and the proposal’s requirements.

Exclusion Criteria:

• Studies published before January 2014 to focus on recent evidence.
• Non-peer-reviewed sources, such as grey literature, editorials, or opinion pieces, to ensure scholarly rigor.
• Studies focusing exclusively on urban settings or non-nursing healthcare professionals (e.g., physicians, pharmacists).
• Studies not addressing health literacy or health outcomes as primary or secondary outcomes.
• Non-English articles to maintain consistency with the proposal’s scope.

Study Selection

The Selection Process

The study selection process adhered to the PRISMA-ScR guidelines (Peters et al., 2020) to ensure transparency and reproducibility. After importing search results into a reference management tool (e.g., EndNote), duplicates were removed. Titles and abstracts were screened by the researcher for relevance to the research question, focusing on PHC nurses, health literacy, and rural settings. Full-text articles were retrieved for potentially eligible studies and assessed independently by two reviewers (the researcher and a supervisor) against the inclusion criteria. Discrepancies were resolved through discussion, with a third reviewer consulted if necessary. Reasons for exclusion were documented to maintain transparency. The selection process is summarized in a PRISMA-ScR flow diagram (Appendix A).

Study Selection Results

The search yielded 1,456 articles (PubMed: 532, EBSCOhost: 614, ProQuest: 310). After removing duplicates (n=231), 1,225 articles were screened by title and abstract, resulting in 142 articles for full-text review. Following full-text assessment, 38 studies met the inclusion criteria. Exclusions were due to: focus on urban settings (n=48), non-nursing focus (n=34), pre-2014 publication (n=15), lack of focus on health literacy or outcomes (n=12), and non-English language (n=3). The final 38 studies included 18 qualitative studies, 12 reviews (7 systematic, 5 scoping), 6 RCTs, and 2 mixed-methods studies. These studies were conducted across diverse rural settings, including Sub-Saharan Africa (n=14, including 5 from South Africa), South Asia (n=10), North America (n=8), Australia (n=4), and Europe (n=2).

Charting the Data

Data were extracted using a standardized tool adapted from Aromataris (2021) (Appendix B), capturing the following variables:

• Author(s) and year of publication
• Country of study
• Title of publication
• Aim and objective
• Population and sample characteristics
• Data collection methods
• Data analysis methods
• Key results and findings
• Implications and recommendations
• Study limitations

The extraction process was conducted by the researcher and verified by the supervisors to ensure accuracy. Data were organized into a comprehensive table (Appendix B) and subjected to thematic analysis as outlined by Braun and Clarke (2017), involving six steps: (1) familiarizing with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. This process ensured a rigorous and systematic synthesis of findings.

Collating, Summarizing, and Reporting the Results

Characteristics of Included Studies

The 38 included studies were diverse in methodology, geographic scope, and focus. Geographically, 14 studies were conducted in Sub-Saharan Africa (5 in South Africa, 4 in Nigeria, 3 in Kenya, 2 in Uganda), 10 in South Asia (6 in India, 3 in Pakistan, 1 in Bangladesh), 8 in North America (5 in the USA, 3 in Canada), 4 in Australia, and 2 in Europe (both in rural Scotland). The studies primarily focused on PHC nurses (n=30) or mixed healthcare professionals including nurses (n=8). Sample sizes varied widely: qualitative studies ranged from 8 to 120 nurses, RCTs included 50 to 600 patients, and reviews synthesized data from 10 to 50 primary studies.

Health literacy interventions targeted chronic disease management (n=18, e.g., diabetes, hypertension, tuberculosis), maternal and child health (n=12, e.g., antenatal care, immunization), and general health education (n=8, e.g., preventive care, nutrition). Outcomes measured included health knowledge (n=20), medication adherence (n=15), self-efficacy (n=10), healthcare utilization (n=8), and clinical outcomes (e.g., blood pressure control, n=5). Most studies (n=28) reported positive outcomes, though effect sizes varied, and 10 studies noted mixed or insignificant results due to contextual barriers.

Main Themes Derived from the Studies

Thematic analysis identified six key themes, each with sub-themes, reflecting the roles and strategies of PHC nurses in improving health literacy and health outcomes in rural settings. Each theme is discussed comprehensively, with critical analysis of strengths, limitations, and relevance to Lephalale.

Theme 1: Health Education and Patient Empowerment

Role Description: PHC nurses serve as primary educators, delivering tailored health education to enhance patients’ understanding of health conditions, treatments, and preventive measures (Bastable, 2021). This role involves simplifying complex medical information, using culturally relevant analogies, and providing materials in local languages to accommodate low literacy levels (Nsiah et al., 2019; Mhlongo et al., 2019).

Strategies:

• Tailored Education: A South African study by Mhlongo et al. (2019) found that nurses using visual aids (e.g., pictograms) and group education sessions increased diabetes knowledge by 35% among rural patients. Similarly, a Kenyan study by Kamau et al. (2021) reported a 28% improvement in maternal health knowledge after nurse-led workshops using storytelling.
• Patient-Centered Communication: Smith et al. (2018) emphasized the use of teach-back methods, where nurses ask patients to restate information to confirm understanding, resulting in a 20% increase in medication adherence in rural USA clinics.
• Multilingual Materials: In India, Patel et al. (2020) noted that providing health education pamphlets in local dialects improved tuberculosis treatment comprehension by 25%.

Critical Analysis: Health education is a cornerstone of nursing practice, aligning with the WHO’s (2021) emphasis on health promotion. However, the effectiveness of these strategies is often limited by time constraints, understaffing, and lack of standardized tools for assessing health literacy levels. For example, Mhlongo et al. (2019) did not use validated health literacy tools like the Rapid Estimate of Adult Literacy in Medicine (REALM), which could have strengthened their findings. In Lephalale, where literacy rates are low (Khuluvhe, 2021), nurses may face additional challenges in adapting materials to diverse linguistic and cultural contexts. The literature also lacks longitudinal studies to assess the retention of health knowledge, a critical gap for evaluating sustained impact.

Relevance to Lephalale: The use of visual aids and teach-back methods is feasible in Lephalale, given the availability of basic resources in PHC clinics. However, the reliance on English-based materials may limit effectiveness, as many patients speak Sepedi or other local languages. Nurses in Lephalale could benefit from training in culturally tailored education strategies to address these barriers.

Theme 2: Advocacy and Navigation of Healthcare Systems

Role Description: PHC nurses act as advocates, bridging the gap between patients and complex healthcare systems by facilitating referrals, explaining treatment plans, and addressing social barriers to care (Sklar, 2016; Nsiah et al., 2019). This role is particularly critical in rural settings, where patients face logistical and financial challenges in accessing care (Bilal, 2018).

Strategies:

• Referral Coordination: A Nigerian study by Adebayo et al. (2020) found that nurses who coordinated transport services and follow-up appointments increased clinic attendance by 20% among rural patients with hypertension.
• Patient Advocacy: Nsiah et al. (2019) highlighted nurses’ roles in advocating for patients’ rights, such as ensuring access to subsidized medications, which improved adherence by 15% in Ghanaian rural clinics.
• Social Support Linkages: A Canadian study by Thompson et al. (2022) reported that nurses connecting patients to community support groups improved mental health literacy by 30% among rural indigenous populations.

Critical Analysis: Advocacy is a vital role for PHC nurses, particularly in rural settings where patients may lack the knowledge or resources to navigate healthcare systems. However, systemic issues, such as understaffing and fragmented referral networks, limit nurses’ effectiveness (Bilal, 2018). The literature lacks frameworks for training nurses in advocacy skills, such as motivational interviewing or negotiation with healthcare authorities. In Lephalale, where healthcare infrastructure is limited (Ogunkola et al., 2020), nurses may struggle to secure timely referrals or resources, underscoring the need for systemic support. Additionally, studies rarely address the emotional toll of advocacy on nurses, which could lead to burnout in under-resourced settings.

Relevance to Lephalale: Nurses in Lephalale can leverage their role as community-trusted figures to advocate for patients, but the lack of transport infrastructure and specialist services in the Waterberg district may hinder their efforts. Training in advocacy skills and partnerships with local NGOs could enhance their impact.

Theme 3: Community-Based Interventions

Role Description: PHC nurses engage communities through health talks, workshops, and home visits to promote health literacy at the grassroots level (Ogunkola et al., 2020; Ninnoni et al., 2019). This role aligns with the WHO’s (2021) whole-of-society approach to primary care, emphasizing community involvement in health promotion.

Strategies:

• Health Talks and Workshops: Kamau et al. (2021) reported a 25% increase in antenatal care attendance in rural Kenya after nurses conducted community-based maternal health workshops. Similarly, a South African study by Van der Merwe et al. (2023) found that nutrition-focused community talks reduced malnutrition rates by 18% in rural children.
• Home Visits: A Pakistani study by Khan et al. (2020) noted that nurse-led home visits improved health literacy for chronic disease management by 22%, as nurses could tailor education to individual households.
• Community Health Worker Collaboration: In Uganda, Okello et al. (2021) found that nurses training community health workers (CHWs) to deliver health education increased immunization rates by 30%.

Critical Analysis: Community-based interventions are effective in reaching rural populations, particularly in culturally sensitive contexts. However, logistical barriers, such as poor road infrastructure and limited transport, restrict their scalability (Khuluvhe, 2021). The reliance on nurses to conduct these interventions without adequate support (e.g., funding, vehicles) is a significant limitation, as noted in Bilal (2018). The literature also overlooks the role of traditional healers and community leaders in health literacy promotion, a critical gap in contexts like Lephalale, where traditional practices are prevalent. Furthermore, studies rarely evaluate the cost-effectiveness of these interventions, which is essential for resource-constrained settings.

Relevance to Lephalale: Community-based interventions are highly relevant to Lephalale, given the dispersed nature of rural settlements. Collaborating with traditional leaders and CHWs could enhance outreach, but nurses will need support to overcome logistical barriers, such as poor roads and limited electricity.

Theme 4: Technology-Enabled Strategies

Role Description: PHC nurses increasingly use technology, such as mobile health (mHealth) apps, SMS reminders, and telehealth, to enhance health literacy and improve health outcomes (Sklar, 2016; Lee et al., 2022). This role leverages digital tools to overcome geographic and resource barriers in rural settings.

Strategies:

• SMS Reminders: Patel et al. (2020) reported that SMS reminders improved tuberculosis medication adherence by 15% in rural India, as patients received regular prompts in local languages.
• mHealth Apps: A USA study by Lee et al. (2022) found that nurse-guided mHealth apps increased diabetes self-management knowledge by 20% among rural patients.
• Telehealth Consultations: An Australian study by Taylor et al. (2021) noted that nurse-led telehealth sessions improved mental health literacy by 18% in remote communities.

Critical Analysis: Technology-enabled strategies offer innovative solutions for health literacy promotion, particularly in overcoming geographic barriers. However, their applicability in rural settings like Lephalale is limited by unreliable electricity, poor internet connectivity, and low digital literacy (Ogunkola et al., 2020). Studies like Patel et al. (2020) highlight the potential of low-cost solutions like SMS, but scalability requires investment in infrastructure. The literature also lacks evidence on the cultural acceptability of digital tools in rural communities, where traditional communication methods may be preferred. Additionally, the cost of implementing and maintaining technology-based interventions is rarely addressed, a critical oversight for low-resource settings.

Relevance to Lephalale: In Lephalale, SMS reminders and offline mHealth tools could be feasible, given the high mobile phone penetration in South Africa. However, nurses will need training in digital literacy, and infrastructure improvements (e.g., electricity, network coverage) are essential for scalability.

Theme 5: Addressing Social Determinants of Health

Role Description: PHC nurses address social determinants, such as poverty, education, and gender disparities, which significantly influence health literacy and outcomes (Khuluvhe, 2021; Major, 2020). This role involves integrating social support into health interventions to enhance patients’ ability to engage with healthcare.

Strategies:

• Nutritional Counseling: Van der Merwe et al. (2023) reported that nurse-led nutritional counseling reduced malnutrition rates by 18% in rural South African children by addressing food insecurity.
• Education Support: A Bangladeshi study by Rahman et al. (2020) found that nurses collaborating with schools to deliver health education improved adolescent health literacy by 22%.
• Gender-Sensitive Interventions: In Pakistan, Khan et al. (2020) noted that nurse-led women’s health groups increased maternal health literacy by 25% by addressing gender barriers.

Critical Analysis: Addressing social determinants is essential for health literacy improvement, as poverty and low education levels are major barriers in rural settings (Khuluvhe, 2021). However, nurses often lack the resources and authority to address systemic issues like food insecurity or educational disparities (Davoodvand et al., 2016). The literature highlights the need for intersectoral collaboration with education, agriculture, and social welfare sectors, but such partnerships are rarely implemented or evaluated. In Lephalale, where unemployment and poverty are prevalent, nurses’ efforts to address social determinants may be constrained by limited community resources and government support.

Relevance to Lephalale: Nurses in Lephalale can address social determinants by linking patients to local food programs or educational initiatives, but intersectoral partnerships are critical for sustainability. Engaging traditional healers and community leaders could also enhance culturally sensitive interventions.

Theme 6: Cultural Competence and Contextual Adaptation

Role Description: PHC nurses must demonstrate cultural competence by adapting interventions to the cultural, linguistic, and social contexts of rural communities (Mhlongo et al., 2019). This role involves understanding local beliefs, practices, and languages to ensure effective health literacy promotion.

Strategies:

• Cultural Tailoring: Mhlongo et al. (2019) found that nurses using Sepedi-based education materials improved diabetes knowledge by 30% in rural South Africa.
• Engaging Traditional Healers: A Ugandan study by Okello et al. (2021) reported that nurses collaborating with traditional healers increased HIV treatment literacy by 20% by integrating cultural practices.
• Community Involvement: In Australia, Taylor et al. (2021) noted that nurse-led community forums incorporating indigenous storytelling improved mental health literacy by 15%.

Critical Analysis: Cultural competence is critical for effective health literacy interventions, particularly in diverse rural settings. However, the literature rarely addresses the training needs for nurses to develop cultural competence or the challenges of integrating traditional practices into biomedical frameworks. In Lephalale, where Sepedi and other local cultures dominate, nurses must navigate complex belief systems, such as reliance on traditional healers, which may conflict with Western medical approaches. The lack of standardized cultural competence frameworks in nursing education is a significant gap.

Relevance to Lephalale: Cultural competence is highly relevant in Lephalale, where traditional healers and community leaders play significant roles. Nurses should be trained to collaborate with these stakeholders and use local languages to enhance health literacy interventions.

Influential Factors and Barriers

Influential Factors:

• Cultural Competence: Nurses who incorporate local languages and cultural practices are more effective in improving health literacy (Mhlongo et al., 2019; Okello et al., 2021).
• Training and Education: Continuous professional development in health literacy and cultural competence enhances nurses’ effectiveness (Major, 2020).
• Patient Trust: Strong nurse-patient relationships foster trust, improving engagement with health education (Nsiah et al., 2019).
• Community Support: Collaboration with CHWs and local leaders amplifies the reach and impact of interventions (Kamau et al., 2021).

Barriers:

• Resource Constraints: Limited staffing, time, and educational materials hinder effective interventions (Bilal, 2018; Davoodvand et al., 2016).
• Socio-Economic Challenges: Poverty, low literacy, and unemployment reduce patients’ ability to engage with health information (Khuluvhe, 2021).
• Infrastructure Limitations: Poor roads, lack of electricity, and unreliable internet impede community outreach and technology use (Ogunkola et al., 2020).
• Systemic Issues: Lack of intersectoral collaboration and inadequate policy support limit nurses’ ability to address social determinants (Van der Merwe et al., 2023).

Discussion

Health Education and Patient Empowerment

Health education is a foundational role for PHC nurses, aligning with the WHO’s (2021) emphasis on health promotion in primary care. Tailored education, teach-back methods, and multilingual materials are effective in improving health literacy, as evidenced by studies like Mhlongo et al. (2019) and Smith et al. (2018). However, the lack of standardized health literacy assessment tools, such as the Health Literacy Questionnaire (HLQ) or REALM, limits nurses’ ability to tailor interventions to patients’ needs. In Lephalale, where literacy levels are low (Khuluvhe, 2021), nurses must prioritize visual and oral communication methods. The absence of longitudinal studies to assess knowledge retention is a critical gap, as short-term gains may not translate into sustained health behavior changes.

Advocacy and Navigation

Nurses’ advocacy role is essential in rural settings, where patients face significant barriers to care. Studies like Adebayo et al. (2020) and Nsiah et al. (2019) demonstrate the impact of advocacy on healthcare utilization, but systemic issues like understaffing and fragmented referral systems hinder effectiveness. In Lephalale, nurses may face similar challenges due to limited specialist services and transport infrastructure. Training in advocacy skills, such as motivational interviewing or negotiation with healthcare authorities, could enhance nurses’ impact. The emotional toll of advocacy, including burnout, is underexplored in the literature, warranting further investigation.

Community-Based Interventions

Community-based interventions align with the WHO’s (2021) whole-of-society approach, offering a scalable strategy for health literacy promotion. Studies like Kamau et al. (2021) and Van der Merwe et al. (2023) highlight the effectiveness of health talks and home visits, but logistical barriers (e.g., poor roads) limit their reach. In Lephalale, collaboration with traditional leaders and CHWs could enhance community engagement, but funding and coordination are needed. The literature’s failure to address the role of traditional healers is a significant gap, given their influence in rural South Africa.

Technology-Enabled Strategies

Technology offers innovative solutions for health literacy promotion, as seen in Patel et al. (2020) and Lee et al. (2022). However, infrastructure limitations, such as unreliable electricity and internet, restrict their applicability in Lephalale (Ogunkola et al., 2020). Low-cost solutions like SMS reminders are promising, but their effectiveness depends on patients’ digital literacy and access to mobile phones. The literature lacks evidence on the cultural acceptability and cost-effectiveness of digital tools, which is critical for resource-constrained settings.

Addressing Social Determinants

Addressing social determinants is essential for health literacy improvement, as poverty and low education levels are major barriers (Khuluvhe, 2021). Nurses’ efforts, such as nutritional counselling (Van der Merwe et al., 2023), are commendable but limited by systemic constraints. Intersectoral collaboration with education, agriculture, and social welfare sectors is underexplored, representing a critical gap. In Lephalale, partnerships with local NGOs and government programs could enhance nurses’ impact, but policy support is needed.

Cultural Competence and Contextual Adaptation

Cultural competence is a prerequisite for effective health literacy interventions in diverse rural settings. Studies like Mhlongo et al. (2019) and Okello et al. (2021) highlight the importance of local languages and cultural practices, but the lack of standardized training in cultural competence is a limitation. In Lephalale, nurses must navigate complex cultural dynamics, including reliance on traditional healers, which may conflict with biomedical approaches. Developing culturally sensitive frameworks for nursing education is essential.

Gaps in the Literature

1. Context-Specific Evidence: Few studies focus on the unique socio-economic and cultural context of Lephalale, limiting generalizability.
2. Long-Term Outcomes: Most studies measure short-term outcomes (e.g., knowledge gain, adherence) but lack data on sustained health literacy improvements or clinical outcomes.
3. Intersectoral Collaboration: The role of partnerships with non-health sectors (e.g., education, agriculture) in health literacy promotion is underexplored.
4. Cultural Sensitivity: The integration of traditional healers and cultural practices in health literacy interventions is rarely addressed.
5. Nurse Training: The literature lacks evidence on training programs for health literacy and advocacy skills tailored to rural contexts.
6. Cost-Effectiveness: Few studies evaluate the cost-effectiveness of interventions, critical for resource-constrained settings like Lephalale.

Conclusion

This scoping review provides a comprehensive and critical synthesis of the roles and strategies of PHC nurses in improving health literacy and health outcomes in rural settings. Key roles include health education, advocacy, community engagement, technology use, addressing social determinants, and cultural competence. Strategies such as tailored education, community workshops, SMS reminders, and cultural adaptation show promise but are hindered by resource constraints, socio-economic challenges, and infrastructure limitations. The review identifies significant gaps, particularly in context-specific evidence for Lephalale, long-term outcome evaluation, and intersectoral collaboration. These findings will inform the design of qualitative interviews in Phase 2, focusing on nurses’ perceptions and experiences in Lephalale, and the integration of findings in Phase 3 to develop contextually relevant interventions.